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' TOWN OF YARMOUTS BO L -
� � APPLICATION FOR LICENSE t' -, ��: "� JAN 1 � '+ �
; � t.���w 111�
* Please complete form and attach all necessary documents by Decem r f�IQ� Utt'�-►_
Fai�ure to do so will result in the return af yaur applicat�on pac .
NAME OF ESTA�LISHMENT: ^ti�rvr S TEL. # 54f�' 34�'���0
LOCATION ADDRESS: �3 I CYIQ t� �T 12 T �.,_
MAILING ADDRESS: '',R�n
OWNER NAME: � D FE or �' ;
CORPORATION NAME(IF APPL CABLE),:
MANAGETt'S NAME: �1 d TEL. # �{".�.r�:������Z�
MAILING AD►DRESS: ��4 F� �3��-�1 Z 2�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two emp loyees currently certified in basic water safety,standard First A.id and
Commuwty Cardiapulmonary Resuscitation(CPR). Please list these employees below and attach copies o�'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�vIANAGERS - CERTIFICATIONS: �
All food service establishments are required to have at least one full-time employee who is certified as a Food i
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 145 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use p�st years'records.
You must provide new copies and maintain a file at your establishment. ;
1. �J v �i v� p � 2. �cT-i.c�" (Gi� �,C�b� i
PERSON IN GHARGE:
Each foad establishment must have at least one Person In Charge (PIC) on site durin�hours of operation.
" �i vn�c�Gj�t ��S�t�4l �
l. �vl'w� �l�hY 2. '
HEIMLICH CERTIFICATIONS: 'i
All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich ;
Maneuver on the premises at all times. Please list your erYployees trained in anti-choking procedures below and ,
attach copies of employee certifications to this form. The Health Department will aot use past years' records.
e of business.
rovide new co ies and maintain a file at your plac ,
You must p p
1. 1.��h 2. �c�a-��.�J � �/
3.� � 4.
RESTALJRANT SEATING: TOTAL# �� _
OFFICE US� ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
BdcB $55 �CABTN $55 r...MQTEL $55
�� $55 __,_CAMl' $55 �SWIMMING POOL $80ea.
�LODGE $55 �TRAII.ERPA.RK $105 WI3IRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUI1tED FEE PERMIT# LIC£NSE REQUIRED f£E PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $$5 �(O�(`f� ._.GONTINENT'AL $35 NON-PROFIT $30
>100 SEATS $160 _ �COMMON VIC. $b0 ��� WHOLESAL£ $8�
" —RESID.KITCHEN $80
RETAII.SERVICE:
LI�EN$E REQUIItED FEE PERMIT# LICENSE REQUIItED FEE pERMIT# LIC�NSE REQUIRBD FEE PEitMTT#
>25,000 sq.ft. $225 VENDING-FOOD $25
�<50 sq.ft. 550 -- �
.._FROZEN DESSERT $40 _ �TOBACCO $55 _,__,____
,.�<25,000 sq.ft. $$0 _ $ ��� ��"�
; AMOUNT DUE _
' NAME CHANGE: $15
1 ,►rwev
pLEASE TURN OVER AND COMPLETE O'THER SIDE OF FORM"**"*
ADNIINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WUItKER'S COMPEN5ATION INSU1tANCE
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 pernuts. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES J NO
MOTELS AND OTHER LUDGING ESTABLISHMENTS
TI2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the tetnporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate tha.t they maantain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous accupancy of not more than t�ixrty (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, sha11 generally be considered Transient.
POULS
POUL OPENING: All swimmin�,wading and wlurlpools which ha.ve been closed for the season must be itisp�t�i
by the Health Department prior to opening. Contact the Health Departmerrt to schedule the inspection three(3)days
pnor to opening.PLEAtSE NOTE:People are NOT allowed to sit m the pool area.until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform asld staudard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or cove�red within seven(7)d�ys of
closing.
FOOD SERVICE
CATERING FOLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmou�h Health Departme�t by filing the requir�ed
Temporary Food Service Application form 72 hours prior to the catered event. These£arms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the He�1th
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 ofHealth.
OUTDOOR COOKING:
Outdoor cookxng,preparation,ar display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YpUR RESppNSIgILITy TO RETURN
THE COMPLETED RENEWAL,AppLICATION(S)AND REQiJIRED FEE(S)BY DECEMBER 1 S,2009.
ALL RENOVATIONS TO ANY FOOD ESTABLIS��vtENT, MOTEL OR POOL (i.e., PAINTING, NEy�
; EQUIPMENT,ETC.), MUST BE REPORTED TO AND AppROVED BY TI-�BOARD OF HE,ALTH PRIOR
� TO COMMENCEIviENT. RENOVATIONS MAY REQUtRE A SITE PLAN.
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DATE: '��� SIGNATURE: �
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; Departme�rt of Iadastriul Accidents
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,4co' I LITY I N RAN C E DATE(MMUDDMfYY)
�.,..-- CERTIFICATE OF LIAB SU 9/2/2009
PRODUCER (866)380-7007 FAX: (866)648-0916 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ne�vtek Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
�' HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
! 301 Mexico Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
1 3uite H4-A
Brownsville TX 78520 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:UIIlt@CZ St3t@8 L3.3b1�.].ty
Brockton Johnny's Inc. INSURERB:Sp3rt3 Insurance Company
199 Route 28 INSURER C:
+ INSURER D:
� WEST WICH MA OZ671 INSURERE:
I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIMTHSTAN DING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�� POLICY NUMBER P0L1�EFFECTNE POIJCY EXPIRATION ����
' GENERALLIABILITY EACHOCCURRENCE $ 1 OOO OOO
+ X COMMERCIAL GENERAL LIABILITY PREMISES Ea oxurtence $ lOO OOO
A CLAIMS MADE �OCCUR L1551984 9/5/2009 9/5/2010 MED EXP(My one person) $ rJ ��0
PERSONAL&ADV INJURY $ 1 OOO OOO
GENERAL AGGREGATE $ 2 OOO OOO
� GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Z OOO OOO
X POLICY PR� LOC
AUTOMOBILE W►BILtTY COMBINED SINGLE LIMIT
ANY AUTO (Ea accideM) $
ALL OWNEDAUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
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' HIRED AUTOS BODILY INJURY
j NON-0VNJED AUTOS (Per accidenQ $
PROPERTY DAMAGE $
(Peracadent)
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GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
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ANY AUTO OTHER THAN �ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILiIY EACH OCCURRENCE $
OCCUR �CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION T RY T M T ER
AND EMPLOYERS'LIA�LITY
ANY PROPRIETOR/PARTNER/EXECUTIVE� E.L.EACH ACCIDENT $ 1 OOO OOO
OFFICER/MEMBER EXCLUDED?
(Mandffiory In NH) 03�PK03639 9/5/2009 9/5/2010 E.L.DISEASE-EA EMPLOYE $ 1 000 000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1 OOO OOO
OTHER
DESCWP'170N OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS AD�D BY ENDORSEMENT f SPECUIL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Brockton Johnny's II1C. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
199 Route Z B NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 80 SHALL
West Harwich, MA 02671
IMPOSE NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHOPoZED REPRESENTATIVE' �J' _�,,L
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ACORD 25(2009/01) O 7988-2009 ACORD CORPORATION. All rights reserved.
INS025�2ooso�> The ACORD name and logo are registered marks of ACORD
'4�� CERTlFICATE OF LIABILITY INSURANCE °"'�`""'�"
9/2/2009
r�o� (866)380-700T FAX: (866)646-0916 THIS CERl'�iCATE IS iSSttED AS A MATTER OF N�ORMATIQN
Ne�otek Insuranca Aqency ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE
HOLdER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
301 Maxico Hlvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BE�OW.
Suite H4-A
Srownsville TX 78520 INSURERS AFFORDING COVERAGE NAIC#�_ _ _
--- - - - - - - -
� naursERnLTnited States Liabi7.ity
Brockton 3ohnny's 2nc. ����;Sparta Insurance Ca�paay
731 Main St Rt 28 SO. INSURER C:
iMsuR�a. �
Yarmou MA 02671 INSURER E:
�OYEFiAGES
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