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Home My WebLink AboutApplication and WC � y TOWN OF YARMOUTH BOARD OF � '` •� � APPLICATION FOR LICENSE/PE � ` � � � � e,,,,. ��: , �v��i L�w`� �.�� * Please complete form and attach all necessary do'�i�nen � ecem er 5 2 ., _ Fai lure to do so will result in the return o f your application pac et. _�,_ �� "�`��' �--'�=�°�� ESTABLISHMENT NAME: 7a2wtocl T�1 t��2� U��C/1G C S TZ)2 ETAX ID: �� ¢ � LOCATION ADDRESS: �3C> �O U T� ro /� �d 2 r°rcv c��Irl/�D rL T' TEL.#: SOg I 36 Z- Z q� MAILING ADDRES5: S ,�.x•t� OWNER NAME:_ U t[�TU i2 2 v k�d�S K� CORPORATION NAME(IF APPLICABLE): Lv E IGl!S 2�/� ✓� �V L��G e CD 2 P , MANAGER'S NAME: t>!fG't� 12 2 UK/.�-u s lc,Q-s TEL.#: ��C�h' 36 Z�Z 9�U MAII.ING ADDRESS:�_�o �o v 3� G,Q Y��2.wu�v Tb! Po 27� 1�� POOL CERTIFICATIONS: 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 of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. 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 file at your establishmen� 1. (Jll�TDl2- Zv1G�-uSKv1� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1, v l lL y7'l2. Z.ci��t,�S l�i1� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich 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. 1. 2, 3. 4, RESTAURANT SEATING: TOTAL# d OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea _LODGE $55 _TRAII,ER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $85 ��[� _CONTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 �Q5,000 sq.ft. $80 �/�� _FROZEN DESSERT $40 �a� 1.TOBACCO $95 NAME CHANGE: $is AMOUNT DLTE _ $_a�,O.�a *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION ` , Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED v . 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 MOTELS AND OTHER LODGING ESTABLIS�IlVIENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall 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 shall 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 shall 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 Department 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: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLO5ING: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 establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to opening. CATERING POLICY: � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required 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 in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPON5IBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2011. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PIiIUR -- TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A S E PLAN DATE: ��z�r�Z-- SIGNATURE: � PRINT NAME&TITLE: Ut(�TI1 2v I��-w11�'�$S `�/L�3 U!2�Iz Rev.10/25/ll � � �.;:./ �'"�r� YARMO-1 OP ID:AD '4�� CERTIFICATE �F LIABILITY INSURANCE °A�`MM,°°""'"' 07112I12 THIS CERTiFICATE IS ISSUED AS A MATI'ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAl1VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES �ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED EPRESENTATIYE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subJect to ' the terms and conditions of the policy, certain policies may requlre an endorsement. A statement on this certiflcate does not confer rights to the ' certlflcate holder in lieu of such endorsernent s. PRODUCER 781-293-6331 ryq�E� WM.F.Borhek Insurance Agency PH01� 311 Plymouth Street 781-293-2171 C No E : A!C No: Halifax,NIA 02338 A��ss: Scott C Casagrande INSURER(S)AFFOR�ING COVERAGE NAIC! iNsu�Rn:Selectivelnsurance 19259 ;� �r,su�o Yarmouthport Village Store wsu�Rs:Massachusetts Retail Merchants Blue Marlin Beverage Corp �su�Rc: 330 Route 6A Yarmouthport,MA 02675 wsu�Ro: INSURER E: IPISURER F: COVERAGES GERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTUVITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WtTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE TERMS, ; EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR �� TYPE OF INSURANCE POLICY NUMBER MMtDD1YYYY MMAD LIMI7S GENERAL LIABILIN EACH OCCURRENCE $ 'I,OOO,OO A X COMMERCIAL GENERAL LIABILITY 2021461 07/16/12 07I16/73 pREMiSES Ea occurrence $ 30��0� CLAIMSMADE �OCCUR MED EXP(Any one person} $ �0,�0 Business Owners PERSONAL&ADV INJURY $ �,��,�0 � � GENERALAGGREGATE $ S,OOO�OO GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $ $,QOO�OO i X POLICY PR� LOC $ G , AUTQMOBILE LIABILITY CAMBINED SINGLE LIMIT Ee acdden[ $ �,�DD,Q� RNY AUTO 2021467 07/16I12 07116l13 BODILY INJURY{Per person) $ ALLOWNEO SCHEDULED � AUTOS AUTOS BODILY INJURY(Per acddentJ S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Peraccident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERSCOMPENSATION WCSTATU- OTH- At�EMPLOYERS'�IABiLITY TORY X B 0 FICERIMEMBER EXC UDED�n�Y❑ N f A B� 07/16I12 01/01l13 E.L.EACH ACCIDENT $ g�O�Q� (Mandatory in NHJ E.L.DISEASE-EA EMPLOYEE $ rJ��,�O If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO,OO � A Property S 2021461 07/16/12 07H6/13 BUILDING 300,00 , PROPERTY 200,00 , DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEFACLE3 (A&ach ACORD 101,Additlonal Remarks Schedule,If moro space is requircd) ! The above certificate holder is named as Second Mortgagee Concerning the I roperty coverage on the above mentioned policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE US Small Business Admin- TME EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN ACCQRDANCE WITH iHE POLICY PROYISIONS. � istration,clo SEED Corp ,� ISAOA ATIMA qUT�.{p�ZEpREpRESENTATNE 8Q Dean Street. Scott C Casagrande Taunton„ MA 02780 O 1988-2070 ACQRD CORPORATION. All rights reserved. ACORD 25(2010l05) The ACORD name and logo are registered marks of ACORD