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Home My WebLink About16-9385 Cape Cup ��5�� TOWN OF YARMOUTH BOA�.��E & TH APPLICATION FOR LICENS�E: "�'- � �� ; �iAR 15 `1016 * Please complete form and attach all necess�.ry c�yr�e�� y em r 1 DEPT. Failure to do so will result in the return of your application pa.c . ESTABLISHMENT NAME: �G.�. T LOCATION ADDRESS: Sou��lJ�.�'f- D/.`� r��'�i /j?a- O • ��/2 � O� 2 MAILING ADDRESS: �Q�t- E-MAIL ADDRESS: C /��L u-��+ 6�'�CtGf" OWNER NAME: %lt- GJa��or� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: ��i�- GtJ4fC/�h TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: !� °v The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy o e certification to this form. 1 ��5� � 2. -_ _ _ Pool operators must list a minimu t��,,,`$7S : �"� ified in standard First Aid and Community Cardiopulmonary Resuscita.tion / :.� �y� : ��f, emises at all times. Please list the employees below and attach cop' �' � ��i ,h Department will not use past years' records. You mast pro G 1�� -�'� : lace of business. 1. � � t 3. � VS� �� _�_� FOOD PROTECTION MA� ,�,� ��•- ^�S All food service esta.blisha' a�� e employee who is certified as a Food Protection Manager, as d/ �� ice Establis�unents, 105 CMR 590.000. Please atta.ch copies of ce ��r�, -►��; . �rtment will not use past years'records. You must provide new=�.� <��► �� - nent. 1. �/�S� �aldr., �,�`�C' �: �� PERSON IN CHARGE: ��"' Each food establishment must have at least one Person In Char�� 'IC)on site during hours of operation. ' 1. ��i�'c �'4/d�U., 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, ' as defined in the Sta.te Sarutary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. �%r� CcJa�lf I�d n 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. , 3. 4. i ; RESTAURANT SEATING: TOTAL# i The Commonwealth of Massachusetts Fee ! Town of Yarmouth $i2s.00 '; Food Establishment License � ! Number: BOHF-16-9385 Issue Date: 03/15/2016 ; j Mailing Address: Location Address: f ELISE WALDRON 144 OLD TOWNHOUSE ROAD � CAPECUP SOUTH YARMOUTH, MA 02664 4 SOU'WEST DRIVE HARWICH, MA 02645 i IS HEREBY GRANTED A 2016 LICENSE TO OPERATE: Food Service; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2016 unless sooner suspended or revoked and is not transferable. Conditions *RESTR/CTION: Precooked chicken only. Use for Farmer's Market Only. SEAT/NG:0 Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman Of Charles T.Holway,Clerk Tanya Daigneault Health Evelyn P.Hayes Bruce G.Murphy,MPH,R.S., CHO/Amy L. von Hone,R.S.,CHO Health Director/Assistant Health Director j � :� OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED � PERMIT# B&B S55 CABIN $55 MOTEL $tn INN $55 CAMP $55 SWIMMING POOL$1 l0ea. ' LODGE $55 �TRAILER PARK $105 _WHIRLPOOL $110ea. � — k FOOD SERVICE: i �LI ENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 —WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# <50sq ft. $50 ' >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,(�0 sq.R �150 _FROZEN DESSERT $40 TOBACCO �110 NAME CAANGE: $15 AMOUNT DUE _ $ K sI , *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � , � [ � ; .�.�,�-.�_.�..�� -_ -.A._. ......_._ _. ... ---_�...�.__._�:��_�_.._v.�... .,� _.v - ___-a,._.__ ,_____- _ l � r I i ! � � � ! � i i , ; , ' ADMINISTRATION Under Cha.pter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to opera.te a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �/� { ' CERT. OF INSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED /� '� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO M4TELS AND OTHER LODGING ESTABLIS�IlViENTS �� i _ _-- _. TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS ,� (� POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count by a Sta.te certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE ' SEASONAL FOOD SERVICE OPENING: All food service esta.blishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)da,ys prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the i requ�red Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: f Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. � f OUTDOOR COOKING: (1nt�Innr nnn�rinrr r�rararatinn nr�ienlav nf anv�fnn�r�rnrinr•t l�v�rAtai�nr fnn�ecare�ir+a Pe}ahliel�mc.nt io rrnhihitaa f or � ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2015. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ! EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY QUIRE A SITE PLAN. DATE:� (`'1 �� SIGNATURE: PRINT NAME&TITLE: �I�St �alC�r'a►� —O cs�^ e.r' Rev. 10101115 � l � � 1 � � f � F �1��'!) g1W� `�'�--�'.:,:� ' � dt�,t��SldC�idt��S �� ',�"1�� eJn ,Ptt(df� � I��tle6B�S �,�'f`ue o,�'I�v�ctig�a�a� ' I�ongress S�e�,�ui�e df10 �vstv�, 1d211'4-2ft1� ��a��ers'�c�a�p�nsatia�n I��r�e�.��vit: ��usi�esses �nlisa�a��,n�r�a�tin� ' h'Iease�r�� 1�Iv Bus�esslQrganization Name: � ` i .Adciress: �F� .�t��r �,l�(�N..t;� �',`cF'�..� I ' ' CatylStatelZip: %'�.��;�� ,� �� Phone#: ,��,�.,�7.CC��f�... r�re yoa a�entplayer?Check t#�e a�prEapriate box: , p' B�ness Type(r�aired): � l.� I am a employer with____.__,��layees(ft�i2 anr�t 5, []Reta9i ' ar Part ti�no).* IZ<[] i am a sule pragrietc�r or partnership and haue no �' �RestaurantlBar/Eating F.scablishment i EITI�)ICf�L'ES WOTI{IIIg�flP 7218 17!8t3�Cg�aC3�, �• ❑U�ice andlor B�Ies{incl.resI�tat�auta,�tc.) � � �/� jNo wt�rkers'camp.insurance requiredJ 8, [�Non-profit au 3.[] i+V'e are a corpora.tion a�a its c�#i�cers have e�cercised 9. � t�tair right of exemptic�n per e. 152,§i(4),and we�ave ��ter�ainr,nent ,,� c,,,� no emplayees.{IVo wurkers'com .' ,� IO.�Manufacturing �.� Wa�rre a non- fit c� aniz�on sta�ff��uired� �' �° � iry v�lunt�sr �1.�Health Care with no employees.�1�+10 wr�rkers'camp.insurance req.] 2�.�Other �`�+ny applicani thai checks bc�c�I must also fifl aut ifie section betow showing theit warkers'campensateoa Polic�'infosrrratina, **tf the carpor�te of�ic�e:s have c�cemp#ed theatselves,but fite orgatli�tiott shnnld check box�I. �FPo�tion has other emplayees,a workers'comgensstion�licy is requsre�l and s�h an I ur�a a�a empd�y�er t�ite�t ds pr�i�irig workers'eo�a�r►a�irrsrarance far rny e Insuru�ce Company Name: �.�e� Bel�sw fs ghePa,�Y lnforrt�c�tnaa. Insurer's Address: CitylStatetZ#p. Poticy#or Self-ins.Lic.# ��c6 a rapy e►f�6c workers'eom �satian E�tpiration Date; F� �►dic+y declarst�a p�ge(s6owi��tf�e�1�u��ber sac8 expsra�os�d��e}. FaiIure to secure caverage as requir��ier Se,�tdon 25A of MGL c. 2 52 can Iead ta tha imposition af crimina.t �Sn�up ro�1,5€�(3.UQ anu3{or cane-yEar impriscsnment,as weI1 as civai inat penaitie.s ofa c�f up�ci$25[t.Q{}a P�na3tie.s in#he�iarcn af a STOP WORK{�RDER an�a�ine �yY��sr the violator. Be aduised that a oapy c�f tttis statem�nt may be forward�tc�i�se C?ffice of Investigatians t�f t�e DIA far ins�ararace coverage verif�catiQn, l.l Lw_..a�__ _ � �.w nrrsay c.et[`!'�j`�y !dlltliT't112 ""�� ' .��781ffQ111E'S 6f,�JeTfl�'lllfF!�'/d�Il�(1 -. ,f rftiQ�dG!!jil(tVJ�QItOV�TS tl�B Qit�ClfT/'L'C� $3�#1$'�'i72�' j �� '• $� �,,,,,�,,..,,,. P one�• ��i —�'.� ;� — ��#�.,� r3a�e: � .� /5` +F3.f�eta[use oatly. IM rrvt writ�i�t�ic rtre�tu be cnmptetedhy c�,vr tnrv�e rr,/,�c� Ci#y e>r"Y'a�wu: Yssui ha�tori �'ers�it/�,icense# � t�'(circie arsaej�; 4.Boaa a�af�ea�t6 2.Suil�ding Y�part�eaa� 3.Ciifyyl°d'aa�n�lerlc 4.�,�ce � fi.E}t�a�r �i�►g�oard 5.S�ic�te�e�o s U�ce : i iCsantaet P�rsc�r�: Phaat�#: ' � www-snass.gavtdia i