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Home My WebLink AboutApplication and WC .; , ��.��Ary� ;ry�� ► � TOWN iOF YARMOUTI�BOA ,� , A � �` �' � � NOV (�7 2Q11 � � APPLICATION FOR LICENS � � �� a. �,. � � """` � * Please complet�form and attach a,ll neces� � t� y ��em �. � �� Failure to do so will result iri the return of your application i:�� ESTABLISHMENT NAME: l � TAX ID: � -' LOCATION ADDRESS: � L.#: MAILING ADDRESS: Sa.�,.� I E-1VIAILADDRESS: �'�„o(�QL,�a�s �ao��- �em OWNER NAME: -�� ' CORPORATION NAME (IF APPLIC;ABLE): �s MANAGER'S NAME: 'a� LUO�. TEL.#: �p -� 7•1� MAILING ADDRESS: P r ' Q- . POOL CERTIFICATIONS: ' The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of�he certification to�his form. 1. ' 2. Pool operators must list a minimum o�two employees c;urrently certified in standard First Aid and Community. Cardiopulmonary Resuscitation (CPR), having one certif ed employee on premises at all times. Please list the employees below and attach copies of their certifications to this form: The Health Department will not use past years' records. You must provide new copies and ma�ntain 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 lState Sanitary Coc�e 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 establishment. 1. ��,t.�ia rGr .� VlJcc,(gl�---� 2. PERSON 1N CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � � �Q�► '✓� 2, Pa'��i c,[a (��s �5� ALLERGEN CERTIFICATIONS: All food service establishments are req�ired to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Es�ablishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicatian. The Health D�partment will not use past years' records. You must provide new copies and maintain a f le at your establishment. 1. �d wa �a� �I �i(Ja �,s!;.— ' 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 t''�:� ; � �- ' 2. �d n r�o� �i�G-�r�rr�. 3. . ��i- 4. - RESTAURANT SEATING: TOTAL# ' OFFICE U5E ONLY LODGING: LICENSE REQUIRED FEE PERMIT# 'LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN : $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$1 l0ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $11Dea. FOOD SERVICE: ' L CENSE REQUIRED PEE P RM LICENSE REQUIREDI FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � � 0-100 SEATS $125 ��j CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $200 �COMMON VIC. ' $60 �� _WHOLESALE $80 , —RESID.KITCHEN $80 RETAIL SERVICE: '� LICENSE REQUIRED FEE PERMIT# :LICENSE REQUIRED� FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. � $285 VENDING-FOOD $25 <25,000 sq.ft. $150 —FROZEN DESSER!T $40 TOBACCO $1I0 NAME CHANGE: $15 , AMOUNT DUE _ $ !SS•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** '; �60��`r�-0325-6� ... ,. � ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is mow 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 i CERT. OF 1NSURANCE ATTACHE� 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 LQDGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel c�r Hotel use,Transient occup�ncy 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 shall generally refer to continuous occupalncy of notmore 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 be�n closed for the season must be inspected by the Health Department prior to opening. Contact th�e Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to si�in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water muat be tested for pseudomona$,total coliform and standard plate.count by a State certified lab, and submitted to the Health Bepartment three Q3) 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 establishments must be inspected by tl�e Health Departm�nt prior to opening. Please contact the Health Department to schedule the inspection three (3)days prior to operning. 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 p.rior to opening an�monthly thereafter,with sample results submitted to the Health Department. Failure to do so'will result in the 5uspension 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 hav�prior approval from the Board of Health. OUTDOOR COOKINGs ' Outdoor cooking,preparation,or display of any food product by a retail or Ifood service establishment is�rohibited. _ ______-__ __ — _ _ __ __ __ _ _-- — _ __ ____ _ _ _--- -- ---- - � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD DF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE . DATE: �� a� SIGNATURE: PRINT NAME& TITLE: �jc� Rev. 10/12/17 t � 11/7/2017 15:32 Bryden & Sullivan Donna Seviour� 1/1 _��'� PICCA-1 OP ID: DS ACORO" CERTIFICATE OF LIABILITY INSURANCE oATECMM`°om'"� `-� 11107/2017 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS. �' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEE": T�� !SS'J!"�.^s-lNSL'P.�r-R�3}AL'T�-lrJP��'�3 - REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. PRODUCER �MEA� Hyannl50ffiCe - � . Bryden&Sullivan Ins Agency PHONE 88 Falmouth Road ,vc No e�:508-775-606Q �y,rc,Noa:508-790-1414 Hyannis,RflA02601 ADDRESS: I Hy8f1f11S OfflCe INSURER(S)AFFORDMG COVERAGE NAIC#. � � wsuReRa:Guard InsuranceGroup INSURED CapeDeliFoodS,InC.dba INSURERB: Piccadilly Del i 8�Cafe INSURER C: 1105 Main Street ' South Yarmouth,MA 02664 INSURERD: INSURER E: � I INSURER P: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE LIMITS � LTR INS� POLICY NUMBER MMIDDlYYYY MMl�D1YY1'Y � COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE � $ � . CLAIMS-MADE �OCCUR PREMISES(Ea occurrence � $ ' . MED EXP An one erson l Y P ) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIh11T APPLIES PER. GENERAL AGGREGATE $ � � POLICY �jEa �LOC PRODUCTS-COMPIOPAGG $ � � OTHER $ AUTOMOBILE LIABILITY � COMBINED SINGLE LIMIT �$ . � (Ea accident) ,4NY AUTO . . BODILY INJURY(Per person} $ � ALL OWNED SCHEDULED � BODILY INJURY(Per accitlent) $ AUTOS AUTOS NON-OWNED . $ � HIREDAUTOS AUTOS � (Peraccident) $ � UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE A6GREGATE $ DED RETENTION $ $ � WORKERS COMPENSATION � X STATUTE ERTH- AND EMPLOYERS'LIABILITY A ANYPROPRIETORIPARTNERfEXECUTIVE Y�N CAWC$Z73�J OSJO'IIYO'IT OH/O�IZO�$ E.LEACHACCIDENT $ SOO�OOO OFFICERJMEMBER EXCLUDED7 �N�A (Mandatory in NHJ E.L.DISEASE-EA EMPLOYEE $ � SOO,OOO ,If yes,descnbe under '�ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO�OO � DESCRIPTIDN OF OPERATIONS 1 LOCRTIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if moro space is required} � � Certificate issued for insurance verification CERTIFICATE HOLDER CANCELLATION YARM003 SHOULD ANY OF THE ABOYE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTIGE WILL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN ST qUTHORIZE�REPRESENTATIVE S.YARMOUTH,MA02664 HyannisOffice O 1988-2014 ACORD CORPORATION. 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