HomeMy WebLinkAboutApplication and WC ��.�-� F�TCArG�
•� d TOWN OF YARMOUTH BOARD OF HEALTH ` -
� � APPLICATION FOR LICENSElPERMIT-2 1 ¢`� '��j�'��'M A ;% �"
� �� ` �=� �. ����� . � �.�
* Please complete form and attach all necessary doc� s t r�5�'��I(�.� �011
Failure to do so will result in the return of yc�t�ap�e� n pac��et.y
.. y a y�.
ESTABLISHMENT NAME: l�c G v j- TAX ID: -
LOCATIONADDRESS: jl' /ll /J'lc��h s�; S'. i/a•-,mo��'!1 /�'I,� G t�'r(TEL.#: S'G�-SG� — Z�,Q'�'
MAILING ADDRE S: .5�6,_� �
OV�TNER NAME: �.�s� r
CORPORATION NAME F APPLICA E): � G p 'S L � G
MANAGER'S NAME: �i .�,-- ° TEL.#: ' — f` - �-
MAILING ADDRESS: .5��n-, .�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated
Pool Operator(s) aud attach a copy of the cei-tification to this foiYn.
1• 2.
Pool operators must list a muiimum of two employees cui-�ently certified in basic water safety, standard First Aid a�id
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
. certifications to tlus form. The Health Department will not use past years' records. You must provide ne�v
copies and maintain a file at 3�our place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined ui the State Saiutary Code for Food Seivice Establislunents, 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 establishment.
1. •-- � �l"�L ��� 2.
PERSON IN CHARGE:
Each food establislunent must have at least one Person In Charge (PIC) on site dui-ing hours of operation.
l. 2,
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must haee at least one employee trained 'ui the Heunlich
Maneuver on the premises at all tinies. Please list your employees trauled in anti-chokmg procedures below and '
attach copies of employee certifications to this foini. The Health Department will not use past years' records.
You must provide netiv copies and maintain a �le at `�our place of business.
1. 2_ '
3. 4.
RESTAURANT SEATING: TOTAL # D �- F,a--r Ca� _ (o
� � S�J l.C.� OIV�I, .
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERMIT?� LICENSE REQUIRED FEE PER\2I7� LICENSE REQUIRED FEE PER'�IIT� '
_B&B S» _CABIN S» �IiOTEL SS�
_INN S55 _CAMP S�� _S�t'L1�I:vIINGPOOL S80ea.
_LODGE S�5 �TRAII,ERPARK S105 ��VHIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQL�IRED FEE PERMIT=' LICENSE REQUIRED FEE PER�IIT= LICENSE REQUIRED FEE PER�ZIT�
LO-100 SEATS S8� - I�� �CONTINENTAL S35 _NON-PROFIT S30
_>100 SEATS S160 �COMNIQN VIC. S60 �'�/—Qf/� _��4�OLESALE S80
RET�II.SER�'ICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PER�r1IT.� LICENSE REQ[JIRED FEE PER'41IT�
_<50 sq.ft. S50 _>25,000 sq.ft. S2?5 VENDING-FOOD S2�
I <25,000 sq.ft. S80 I!-66a _FROZEN DESSERT S40 TOBACCO S»
��1vIE CHt1\GE: sis AMOUNT DUE _ $ o'22S.p0 �
I
*****PLEASE TtiR`O�'ER A�D CO�IPLETE OTHER SIDE OF FOR�1"***� '
f ) �
ADMINISTRATION � � ;
�
k
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 Certiflcate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, �R �
CERT. OF INSURANCE ATTACHED Y
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 I
APPROPRIATELY IF PAID: ;
YES NO `
MOTELS AND OTHER LODGING ESTABLISHMENTS
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 De�artment to schedule the inspection three(3)days
pnor to opening. PLEASE NOTE: People are NOT allowed to srt m 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.
i
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: II
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. I
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 obtamed 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 ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohi6ited.
_ NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. REN4VATIONS MA UIRE A SIT LAN.
DATE:����f� SIGNATU : �.../� �
PRINT NAME&TITL . .� �l �r k O��� o ,�r�-7a
10 06�10
�
I
�
'I � . _. ` l
�\ The Cominonwealth ofMassachusetts .
Deparhnent of Indastrial Accidents
MUe'iNrw�
600 Was/ri»gtoa Street, 7"�Floor
Bostoa,Mass. 02111 '
Workers'Compensatios Insaranee Affldavit:Baildiog/Ptambing/Ekctrical Cowtnctors
P
narue: �-- � ` ,
�aa�s: �' ,l�—��_��__
citv��� i?/I�f�(- state- �� zio D��/p� ohone#
wnrk site lceation full address: //� `Gt s C • �� o'I�?Gvf�7 /'/ Q Go,�o�
❑ I am a homeowner performing all work myself. Project � ❑New Construction ORemadel
❑ I a so(e proprietor and have no one working in any capacity. ❑Bwlding Addition
I atn an employ viding workers'compensation for my employees working on this job. '
com �e: ��r l/ �f � � G
addre�s• �� ��l � //! � �d't S �
��e�- .�' �/�.✓' rr/IG c��L� /��t ,Z/'G�1 �� f d� -S la ZS'�T
Ins�t�oe ca �# '
❑ I am a sole ' —�""_"'. ..,_.
propnetor,geaeral co�tractor,or 6omeowner(circl�nn�)and have hired the contractors listed below who have ;
t6e following workers'compensation polices:
comoa�v e�a�e• ��O/`� /�/.r� �i �,/ y' S
a
address• !3 /!'f 177 t�/'G !Q � L /�!1 Y� ���j l C1'4r�ren d/` Li L' rG�� �i'G�t �(/J f�
ci O /rt hoee AE: �— ��a
� i
�.�.n.��. �+�#-� �GI/� �1�i a�v!o' -y—// ;
�.�: �
�
ya�,.: ;
eten• o�e k
I
I
i9��Ce C0. DoLirv!F '
w�.++1�I�.N+ilio.e r�
Fail�re 0�secve crrva;e as reqdred�edv 3eetio�2SA�f MCL 132 eu lad b IYe . . I
�'�crloi�d Pe�aNks�[a A�e�p b f1,SN�M a4d/�r
°k Ya*'s'�n�tro��eet�a wdl as dv�pesaNies le the fora�el a 3TOt WORK ORDBR aed�Ane ef f10s.Os a day�aimt me. i mdast�ud that a i
cepy a[t�h flahmt�t may be ferwarded ro tAe Odlce e[InvestlpWm ot tYe DlA far e�reraae verldatlw. !
/�o ber+eby ader Mie paJaf and �hler ofPerlr�r�'tk�t Nie iafonw�tloe prov�ded abot+e Is lrwe awd co►rect i
s; .a.� �— '
"`_`'—c Date ��/� �/� I
Ptint natne � .,� �^ � I
� Phone# _�lG�" y �i� "'_7JC��► i
i
ofBelal ase only ds aot wrMe(a thh area ta 6e eadpleted Dy dty or�awn oBiciH !
�
eity ar towp• ���e�#
• QHnYdina Depar�ent
❑ched[Kimmediale respeme h reqaired �l�°�t��
�'s cxe«
�w�a„o.: ��a; OH�r n�.�.� '
��.:�d s�,.mao, DotAQ 4`
I
j
_ I
s
�
I
I
i
01l03�'2811 12:06 7192723625 ST PAUL TRAVELERS PAGE 01 �
J • . , �
Aco� CERTiFICATE 0►� LIABILI'i"Y IN3URANCE °�o�
i
Yn�s ceRnFicnr��s �ssu�o�w a �rr�R oF in�aaWwwn� o�Y�►t�ro � tro�x�s uPow�n+�c�re�icw� Ko�o�R.�r+a�
CERTIFICATE a0la NOT AFF�lNtATNE1.Y OR NE�A'flVELY AM�ND, EXTEND OR AL'fdt 'iME C0IRRARiB.AFFORD� BY TME POLICES i
BEL.OW. 71M�S CERT1FlCl1SE OF MiL1RA1'IC� a0E8 N07' COI�TITl1TE A i50�17RAC7'BETYYEBN THE 1$�INfi M�UI�!!(�). I11J7'11aR�p
REPR�SEM'+A4'111�OR PRaDIJCE'R.AND TEfE CEFt'11l�fCATE MOl�L1ER.
IMPORTIIHT: It tlfR CoetlReab I101ds►i=an A01a1'�IOrIAL IN�URI[D,i1M polle�{�S)mYst b�Mdor+Nd. N SIl9ROmA'1'101!1Sf WAIVED.iYbl�to th!
arms M�d�onditlona of!ho polfay.oertaln pdkias maY nequtrs sn endoreamerd. A�nt 4n pMs�oi�dae3 nd�ripM�to tha
MI'lifl�at!lltlidlr In tl�u L#iYCh�Idolsllmllt�i�
r��ooucee
PAYCFIBJC A�iEMCY INC .�8T7-dT7-0447
150 SAWGRIt�S DRiV�
ROCFIESTER,NY 14820-48�8
.�. �onrooa� wacs
j�o �n TRAVELEtZB�I V NITY t.�OMPANY
CARLUCC108 LLC a:
6q OR�EENVY.L.E CRIVE '
FOR�STUALE,MA OZQ44 p.
F•
cau�w��s c��c�►r� MUMs�t:
TMIS IB TO CE1RTlFY THI1T THE POLICI�S OF 1N�Ut4AN4��IBZEO bE40�N HAVE�EN ISSUED TO THE INBUF�NALIED A90�FOR TME POLICY PERIOb
1NL177CAA7FD. NO'TWITNSTN�DINf9 I4NY RQQVIR�NT�TERM CR t�NDITIaN OF ANY COMi'fu4CT OR O'iMBR DOGUMEKT W1TH RESPECY TQ WMCH TlitS
CERTIFIGITE MAY dG 19S1IE0�t MAY PERTpIN�TME INgURANC$AfFOR�D 9Y�HE POUd�B OESCRI�D HEREIN 18 l9UBJECT Tb AI.i.THE TERMS,
EXC:UlSION��1R�tD�CF suCN*OLIG�s.tMYMTs BHP�MM MAY W1vE BEEN R�DIJCED BY PA10 t�J51M8-
yY►EOF W�NCE UM15
Yl41BM�u1101Nf1f �ACiIOCGJR� �
GM�iRC4LL A!q!ltAL WWIrtY �� . � !
�LXMA�W►DE ❑OCG�R 1A��iv ans e�em ! ,
P�ObN1L d�A4N MlJURY =
� fil�1ML�78 !
GG1�1'LI�GI►TfLIMRAPaLI[8P� Fl10oUCTe•t�IIAP�o1�AOQ 3 .
PQLIl1Y LOC `
AuiCNO�IL[WMLTf OOM�INriDEI�IIMR :
t�+�i
/WYAUTO lODILYRIAIRY{PrPrpnJ S •.
� _....
N.L OVMNi9�►t�'OS ebolLY MIJURY I��d�) f
�CfImUL�AUTiQS PRO�TYDA1ilA0E `
N�EI7.14�t106 ���
�n�rnoa a .
s
uw�uwwe �pq� rr►a+aocuweenc�t ,�
�� � r.. ,�,,,�
� _
A �O°��� uB-2Z91X084 011�1�2011 411�1/2012 X
�Nr rhpM�TOp/P��ERIl7�1CUTIVE� N!A i.L.iACM A�ENT 1 ,
��� -- EL.WSEA�E-!AlMP i�_„� ,
il.p{3EA0!- YUNtT f
O.SCRIPflOMOFOP�7�ONilLDCA710Ni/YWCI.CG WHtl►ACOND1MrAd�Ma�YAR�MM�11iS1ANd11b�M�1ev�l�qlt1�q11Y�d{
CERTIFlCAI'E N
TOWN GF YARMOU71-1 �o �wr C�'n�E Arava orawav ►ouG6s rr r.�a� �FoaE r�
e�nw►�na�w1�sMwo�Notioe v�q.�M eaMn�o ur�aoo�a�CE v�t�e
BUILOEN�3 DEPT f0�0Y MeanwoNs.
9146 ROtJT6$8 A� • '
SOVTM YARMOUTH.MA 028E4
oas�e-saco coapoR�noH. An�ona�...«,►.a.
ACC1eD a6�Og) Th�wCORD�and loqo an�opis'I�rsd m�ks c�f ItCORD
- I