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TOWN OF YARI4IOUTH BpARD OF HEALTI3
APPLICATI4N FQR LICENSEJPERMIT-2@17
'Please complete form a�l attach all necessary doaunents by Dw.ce�b�er 1 16.
: Fail�e to do�w�1i resalt ia�r�m of your a�licahon pac cet.
ESTABLISfIlN1EI�'T NAME• K� !� �r�-r rrr / D' G
L.00ATI(}1�TADDRESS• T�?I..#: — 7p
MAiLWG ADDRESS:_�,�,�
�ArIAIL ADDRESS:�19 k�`-B��«,A����G
OWNERTIAME:_CI�,�,�E`"� ,r'.d.s'-'`�c�.t'!
coxraRn�arr x� ��acas � � -
MANAGER'S NAME: TEL.#: �
MAILING ADDRESS:
POdL CERTI�7CATIONS:
'I'6e laol saPcsv�►r��t be eerfiT�Cd ss a F�1{�ra#er,�re9eired L3'Stste Ia�r. P�se list the d� 2 p m
Pa>1 Operator{s)ared attach a cxepy of tbe cer�on to tltis form � --C7-�
1.�1 C K. fL Gd'�P�-ti 2. _ �v m
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Pool operators must list�minimum of two emp}�yses c�ently cectifi�in st�rd First Aid arni Commimity � ,� C
aPu�y Resusci#atian(CPR},2utveng or�ceatified �on �es at all tenAes. Piease list tl�e � � Cbl
employe�below aud attach oopies of their catif�to this�'i'�e�Depart�t�vill aot��t � � (7
ysus'r�. Y��t gravi�aew cop�a sad�ta�a fde at yaar prace af 6�aa.
�.f/� �l'c, ('�2 o��r, p.�. 2., �� f F ��f,�' .
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FOOD PROTECTION MANAGF1tS-CERT�ICATIONS: �'"��l
All fcaod se.rvice es�blish�r�er►ts ere required to have�le�t c3ue full-ti��Ic�e who�s c�fied as a Fo�d �
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3ne
P�tection Manager,as defined in the State Sanitary Code for Food Service Estabiishmeats, 105 CMR 590.000. �,_.� .�
P2ease�tach capies ofce�'cfie�`an ta this e�c�ion.'�e I�c��art�e�t�v�t eat�tse}�st Y�ra'recee+�. ,., ,:
Yeu mnat pro mew copiea gnd mAietain n file st yonr es#ablishuisn� k � a
1_—��!L`� � L �,�
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PERSON It�T°GHARGE: _ . �: _ ,
Each€ocid ' , �mst�ac�e at teast one Ferson�►C�arge{PIC)en site d�ng h�urs of oper�tio�s,
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2. � ,
AF.I.ERGEN CERTffICA�'it3NS: _ _
All food service esrablishmeais are required to have ai least one fuli-tirne employee wl�1�Is Allergen certificaaioa,
as a�fi�ea�n the state s�Ea�y r„c�afe€or Fooa savice�ishm�ts,Ios cMS.34o.c)aS�(Gj{3�(a;. P2�e a�c�
copies of certification to this application. Tl�c Health Depnrt�at.rill not�e p9at ye.lu�a're�rds. Yoa muet
pruvide new ce ' asd�is�a�si ya�r ests6��me�.
1._�� /� 2,
HEiA�lLiCH CERTfFiGA3T�'lNS:
A11 fuod�ice e�ablishments wi#�25 seats or mare must have�t kast ene empioyee#reined in t�Heimlich
M�itv�on tl�pnamises 8t atl t�es. Pleage list yo� trained in anti-Choking�ures below a�
atigch copies of em�oyee ce�ific�s tci llus form. The�l� t�1 eot ose praat years'r+oc�rds.
Y�� new�a�d�s�e a#yoer pta�ee b�.
l. /"" / �`� �_
3. 4.
RESTAURANT SEATING: T'OTAL#
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r.oncrt�r�:
OFI�IGE U5E dNLit
L��uu�u � �re tF��n r� r�x�r� �� �
� 555. �IN S53 l M03Fd: STlO
�� �S c�e ass �sw�m�Poo�,suo�. �o
. �u.�t�a� sios _�r.800a, siia�
Foon se�tv�: _. _
t�t��Q[�Ea � ratbnr� �w.a � rc�n�rra �sE� cnx£u � r�r�
fl,i90 SFi�TS f123
- >1DBSEATS, . SE04. _ . ',`�flM�04�FYiC. , 960. . :.. �yy��pE�hi:�. �
BLTAH:SEEVK�:t —RFS1D.KiTCFI�N 3'EO
i1[�E&�E�T�� PERMII'� �RH(jI1IRED� PERMIT IV L VII�DING-�Ft�D S23 PERM11'�
_Q3,000 sq.6. S150 �tROZEN D�AT S10 TOBACGO
s�to
�ce,�vc�: sis AMOUIVTDUE = S 22o.Ob
••,�••rl.L:asE T[lRi�t aVBR wND�'Oli3P[.ETE tkt'H�R&IDE vF FORM•••••
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ADMINISTRATION
U�Chaptcr 152,Section 25C,Subsectior►6,�he'�'awcf of Y'a3mouth is nvw reqe�is�edta hald issu�ee or r�wat
of any iicense ar permit to operate a busirxss if a person or campany does not have s Ce�tificate of Wo�ker's
Compeosation Insurance. THE ATTACHED STATE RiORKER'S CQMPErI3ATi4N 1TISURANGE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.�F INSUR�A�Iti1eL A'I"Tt4CNEU�
OR
RtORKER'S CAMP.AFFIDAVTI`SIGNED APFn AT'PACHED
Towa of Yarmauth taaces and liens must be paicl prior W renewai or issuance of yoiu.permits. PLEASE CHECiC
APFROPRIA'fEi�3t'IF PAiG:
YES� NO
MOTELS AND OTHER LODGIt�TG ESTABLLSHMEI�TS
TRANSIENT OCCUPANCI': For purposes of thc limitations of Mo�i or Hotci use,Tiansient occupaucy shaii be
lunitad to the tsmporary and slmrt term occuPancY,orc3insrily and custom�iIy associated witt►mQteI aad hotel use.
Transient occapants must have s�d be ebk to de�nons�e ffiat they meintain a principal place of resi� . .
e�SCW�1CiC.TI�tBt�O�3Cy S�18���£IIC£�y ie�Cl't0 COAtIt}uOt7S4CC[ip8ilCy 4�At?�#llOEC�#�liifj`��}}t�&}�Ss�
an aggregate of not more tha�i uinety(90)days within any six{b)month period. Use ofa guest unit as xresid�ce or
dweIting�mit s�all�ot be�onsid�ct tr� Qccupaacy that 3ss subjixi ta tise sstlectiau of Rs�om 4)cr�y .
Excise,as defined in M.G.L.c.b4G or 830 CMR b4C,as amended,shall geaerally be considered Transient.
POULS
POOL OPENIPIG:AIl swimming,v�diag aod whidpc�ol4vs�hich have be�clased fi�rt�seasonm�be inspec�
by the Hesiih� cor tn o ai� CoIItact the EIealth to scl�dale t�e' ' It6ree(3)
daya prier to�pe�ug. � SE] ' :Peopie are NOT at1oW��the p�arl a�until pool l�as bar,n ;
���. �
POOL WATER TE5IZNG: 'i'he w�r must be tested for p�eetdomonas,wtal c�o�sfcxm and standari ia#e count
by a State certified iab,a�submitted to t'he Heatfh Department three{33�3'�P��bP�I►Ss�4��y
t�er. ,
I'OOL CLOSING.Every wkdoor ia gra�nd swimming pool must be drained or coverai wit6in seve.n(?)days of
closing.
FOOD SEttViCE
SEASONAI.FO(}D S�RVICE UPENiNG:
All food servioe e.4tablishm�ts must be�by tlu Health Dep�rmzent prior to o�g.Please cantact the �
Health D�nt to s�the iaspectton tf�ree(3?aiaps prior to aP�n6•
c��E�vc ro�cv:
Aayone wt�caters within ttre Toa�n of Y��h must�tify tl�Yarmouth� t ti�
req�red T Food Serric;e Ap�uation frnm'72 hours priar to tl�e catcred�f ms�be
oMained�t1�e�m�H�h Dep�riment,or�om t�e Towa's vvebsite at www.varmouth.�s.us.vndcx He�itt�D�#,
Dawnlo�ciable F�. '
FRQZEN DESSERTS:
Fmzen d�ts mvst be ta4ted by a St�e catified lab prior ttc�o and monthly t�fier,with sample results
submii�ed ta the Heslth Dep�rm�t. Fa�iue to de so vvitl rewilt��n ac�+evvc�tion of yonr Froz�
Dessert Permite�!the a6ove tr�havt{seea ar�et.
flU'i'SiDE GAF�S:
Outside cafes(i.e.,ouWoor seatingwith waiter/waitress service),must have priorapproval from tl�Board ofHealt�.
� OiJTD�UOR C{}f3K1NG:
; �'��,PT�P�ti�4 or display of aay food prod�by a retail oz food secvice estabHshment is proLibfted.
�
? NOTICE:Pecmits nm sanually from January 1 to December 31. TT IS YOUR RESPONSIBILiTY TO RET[JRN
; THE?COMPLETED i2ENEWAL APPLiCATION(S)A�ND REQUIRED FEE(S)BY DECEMBER 16,2016. j
�
' ALL RENOVATfONS TQ ANY FOOD ESTABLISFII�IENT, M�TEL OR POQL ('�.e., PAINTING, NEW �
I EQUIPMENfi,ETC.},MUST BE REP()RTED TQ AND APPRO TH PRIOR
' TO COMMEN RENOVAITUNS MAY A I
DATE:��n2A� /� SI4NATURE: `"`'��
�
FRIl�}T N�8c TITL.E:� �d���.. "
Rav.tallltb
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMAT�ON PAGE
A.l.M. MutuaE fnsurance Company
54'ffi�ird Avenue,8ur{ington, Massachusetts t#�i 803-097fl '
.,
{800)876-2765 �vcci n�o 2si sa
��`�'�`,� � _-
- � - poucv n�o. wMz-soa-sooas7�-2o�sa
F T� ���� ;;:,f� : _; � PRIOR NO. WMZ-f300-8003576-2015
TEM
' 1. �lresure� Sabina Fam#y T�u,si k�fiael�Satur�a Trsrs�e
! C3B�1: Winct�rrttr�er M<� -
; _.
i Maiiir�addr�ss: 123 tAl't�Rvad FEIN;:"-••,.t)Q5U
j So�h Ya�,�AA�
Legal Entity Type: Corporation
►ther workpfaces not shown abave: See Location
2. The poticy period is firom 04/Oi/20f6 to Odld1/2017 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation insurance: Part One of the poli+cy applies to the Workers Compensation La+nr of the
siates listed he�;: MA
B. Ernployers"Liabitity insurance:Part Two af the paiicy sppties to work in eaah state lis#ed in item 3.A.
The timits ofi liabitity under Part Two are: Bodf(y tnjury by Accident $ 500,000 each ac�ident
Bodily injury by Disease $ 500,000 poiicy limit �
Bodily lnjury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Repiac�d by Endorsement WC 20 03 O6 B
D. This Policy includes these Endorsements and Schedules: SEE SCHE�ULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
Ail in#ormation required below is subject to verification and change by audit.
`�s �r�Basis Rates
Ct�de Estirraated f'er$il�(f E '
R�to. I',�tal J1iux�ai pf qn�at
Re�une�a�u► t�on PtecnMnn
�tTRA 342t?15
t�7'ER �CODE SCt�
Ninirrwrn Rremium $284 Total Estimated Annual Premium $g49
GU1! Gt}V �epvs�Prern�m $989
STAT� CLASS
�t, � S�te Asses�nenls/Surdra[r�es
$6.48.4f!x 5.7�0% $4p . �
this po�,i�g atl endorse�►en�s,�hereby coun#efsigned by '`�-'"� ���'`�'��''``... �� fl2/�l201fi
nuthorized s�e �
�
���� Miiter McCartin dba Dowling&O'Nei!Ins Agcy
3r►e Lak�st�ore Center 9731yannough Raad
3t'idgewater MA Q2324 Hyann€s,MA f?2601
NC 00 00 U'! A{7-11)