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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH �� + & ►� APPLICATION FOR LICENSE/Man 2I:n 2 CU14 ai * Please complete form and attach all necesscedoc°w:,ii't', ; I e ... be -C. ;, pt Failure to do so will result in the return of your application p. - - ESTABLISHMENT NAME: P I c C-ADI1.Ly CAc'C d-DEL I TAX ID: LOCATION ADDRESS: ) 1 nS Roark' o1 SO.lii.,rmo /whc�T`EL.#: 3O3 /'1-Of? MAILING ADDRESS: se, n,,e. E-MAIL ADDRESS: Gape.. ,-IFO'd5 Q QOI I . Corn OWNER NAME: v_ L,�e4 i re.es -tr)C.- CORPORATION NAME' APPLICABLE): �r-2. DJ, �GY'iats T MANAGER'S NAME: �rA-i-r1 e,G (,(,a 1s1TEL.#: 5O 3q /.-p97 MAILING ADDRESS: / I D c 2-F .56 74err)0 1 f ,4L) -€ 6t-/ / / 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. 1 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified 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 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 establishment. 1. Et, Gtiel rd t I5 y 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 1. Pa fri c_i cx_ ( U 2. cpAe= /—) I ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. I. I CI er U41 Ink 2. HEIMLICH CERTIFICATIONS: G. cr i_ G0 IA ",CA7 C'4AR_ otOS be '"`T"'t' 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. 1. EG, UVOt_ k 2. l n % w. Is K 3, 4. Q e'''1. s6-= bo RESTAURANT SEATING: TOTAL# O U s OFFICE USE 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$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LIc CENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 / --0 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 i COMMON VIC. $6015—O3S 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. $150FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 - AMOUNT DUE = $ 185.00� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** L101 �/t` 6"Oo 044-411661i qd4 a . 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›c 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_ y 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 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 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 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 CAFÉS: 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 prohibited. 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, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: /1/ a a SIGNATURE: / S PRINT NAME & TITLE: PAe-rl -IC 14 0 ALS E1 r( AAk( 2_ Rev.11/03/14 11/25/2014 15:01 Dryden and Sullivan Donna Seviour-►Beth 01/12 e BERKSHIRE HATHAWAY Worker's Compensation and Emolover's Liability Policy f*h� UA R� INSURANCE COMPANIES NorGUARD Insurance Company-A Stock Company Y Policy Number CAWC584903 Renewal of CAWC459 NCCI N^ r Policy Information Page [1]Named Insured and Mailing Address Agency Cape Deli Foods Inc. THE FAIRWAY AGENCY 1105 Main St. 479 Turnpike St.Unit 6 South Yarmouth,MA 02664. So.Easton,MA 02375 Agency Code: MAFAWA10 Federal Employer's ID Insured is Corporation Additional Names of Insured (N2) Piccadilly Cafe&Deli [2] Policy Period From August 1,2014 to August 1,2015,12:01 AM,standard time at the insured's mailing ad' • [3] Coverage A. Workers'Compensation Insurance-Part One of this policy applies to the Workers Law of the following states: Massachusetts B. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed in item[3]A. The limits of our liability under Part Two are: Bodily Injury by Accident-each accident $500,000 Bodily Injury by Disease-each employee $500,000 Bodily Injury by Disease-policy limit $500,000 C. Other States Insurance-Part Three of this policy applies to all states,except any state listed in item[3]A.and the states of North Dakota,Ohio,Washington,and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page-Schedule of Forms [4] Premium The Premium Basis and,therefore,the premium will be determined by our Manual of R.,iee. Classifications,Rates,and Rating Plans. All required information is subject to verification ar;d audit. (Continued on another page) Total Estimated Policy Premium S $ 4,721 Total Surcharges/Assessments $ 244.00 Total Estimated Cost $ 4,965.00 • INTERNAL USE XX Page-1- In`ormatior Pane MGA :CAWCSS4903 WC 00000_;=. - Date :07/31/2014 • MANOTE Issuing Office:P.O.Box A-H,16 S.River Street,Wilkes-Barre,PA 18703-0020•www.guard.com