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Home My WebLink AboutApplication and WC , • � �{sE>3soNs ' �� TOWN OF YARMOUTH �. "-`'. '� " � APPLICATION FOR LIC 1��1�� `` `��20 �. �"' �� * Please complete form and attach all ecessary docutnehts b December 15, 20I2. Failure to do so will result in r��o�y��li tion packet. �� ESTABLISHMENT NAME: �v i' S�C?S'£JJ'! S `(/'L/��!'JYrq �i1C=TAX ID• � �� LocaTiorr.�D�ss: /0�'7 ��e �28 g yu•��{-F� h�vz�� TEL.#:.SoB- 7 d o0 MAILINGADDRESS•/07�J k'ov � ` � S yn�mvu ti d7� �t6�. � OWNER NAME:�u�S' � i�c'�i1�7rr t'� ' CORPORATION NAME (I�' APPLICABLE): �o��r .�c'c�S�n J T�✓�l Lz`C�✓i� h G MANAGER'S NAME: �(U e S (; �rn�1 n P-t TEL.#: MAILING ADDRESS: f 1 /4� ��cr ,��r ff`f4'��rl t 1' 11/+ '�Z � 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. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deparhnent will not use past years' rewrds. You must provide new copies and maintain a f►le 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 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. Z• PERSGN IIr CHf��:iE. __ _ -- - - — _ : Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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-chokmg 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. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT!k B&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWIMMING POOL $80ea. LODGE $55 _1RAILERPA2K $105 _WHIRLPOOL $SOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100SEATS $85 �OZ`'� _CONTINENTAL $35 C NON-PROFIT $30 >100 SEATS $160 I COMMON VIC. $60 7h 3 'O(7 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 � LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 � NAME CHANGE: $15 AMOUNT DUE _ $ l45. �� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . � 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 WORK�R'S COMPENSATION INSURANCE 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMEPFTS TRANSIENT OCCUPANCY: For purposes ofthe 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 far the season must be inspected by the Health Department priar to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool azea 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 Departsnent 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 Deparhnent 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 ar revocation of your Frozen Dessert Permit unfil the above terms have been met. OUTSIDE CAFES: Outside cafes{i.e.,outdoer seating with waiter/waitress serviee�,�u.�t liaue pric�a}�pr�cal frnmShe Board of Health. _ _ OUTDOOR COOHING: 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 RE"I'URN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND AP.g E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M A TE PLAN. DATE:.�('{/�I 3 'OZ 0 ( 2. SIGNATURE: �J� PRINT NAME& TITLE: Rev. 10/09/12 CERTIFICATE OF LIABI�ITY INSURANCE °"'�'�'�°°"""' oziz3lzoiz THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION ON�Y AND CONFERS Nq PoGMFS UPON THE CERTIPIGATE HQLDER. THU . CERT�FlCATE D6E5 NOT AFFIRMATVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORLIED BV THE POLICIE' � BELOW. THIS CERTIFICATE OF IN$URANCE [10ES NOT CONSTITUTE A CpNTRACT' BETNEEN THE ISSUING INSURER(S}, AUTNORI2EI R6ARESENTATtVE OR PRODUCER,ANO THE CERTIPICATE HOLDER. ' � IMPOftTANi: It �the certiflcate �Oltler i9 an AODITIONAL IN URE , the poliCy�ies) must 6e enCorseC. If SU ROGATION IS WAIYED, su6ject t the terms and conditions af the paiicy, certain poiicies may reqaire an endorsement. A statemeM on tFis certificate dces not confer rights to th certificate holder in lieu of such endorsemenqs). PROWCER NAME; 5chlegel & Schlegel InsurBnce Brokers Inc PXON — tac xo.ens: (Sp8J 771 – 6381 _,....._ tac.em1:t50$) 771 – 0€ 34 MAIId STREET e-maa _ "—'. — . ADORE35: PROOUC£R� ��- � C�ATOMER I00: __..--r- ..___...___. ... Wk35t Yarmauth, MF1 �2�7$ INSURER�S�AFFORUINGCOVERAGE NAICk _ •�_. ____. ..__..___—.�,�._.___.�.�__ .—._.__. _�._..._.�_ .._____.. ir:;.VREO ' INSURERAMOUN�A' VERNON FZRE INSQRANCE C�ANY LtJis G FERNANDEZ DBA 4 Season'S Trattoria - �� "'�--—"""�'�—i"—"��-- ws�ataeMODNT VERNON FIRE INSIIRANCE C�ANY 1677 RODTS 28 ixsuReacAIM MO'�'ON+ ... . �'�.. ... R .._.�..._�_......._._____.___�. INSUftER 0: .�__ ..._...._..—.. _�__..—___. ._ South Yarmouth, MA 02664 INSURERE: � .—.�.___�'__..�_.... _..__ wsunEac: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO GERTifY THAT THE PQI,ICIES OF INSURANCE tiSTEO 6ElOW HAVE BEEN i$SUED TO THE INSUftEO NAMED ABOVE FOR TFIE POUCY PERip� iNDICATEO. NOiWITHSTANDIN6 ANV RE�UIREMENT. 7ERM OR CONOIiIpN OF ANY CON7RACT Oft OTHER DOCUMENT WITH RESPECT T4 WNICH THI f.ERTIFICATE MAV BE ISSUED OR MAY PER?AIN, TNE iNSURANCE AFFORDEp BY TkE POLIC�ES DESGRI&ED HEREIN IS SUBJECT t0 ALl THE TERM; . EXCtUS70NS AND CpNDITiQNS QF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN ftEOUCED BV PAID C[A�MS �rNSR ..... _..__._ .._.. �...._ . PSC�fF IIbY ._ .� —.... . .. _ �iR n'PEOFiNSURANCE �NSR yyyD PO�ICYNUMBER (MMl�ONYTY) (MN1DOfYYYY) CiMRS � A ��cErvErsnWn&uiv EACn OCCURRENCE E 1�OOO�OOO I CL 2612906 Ol/13/2tl1201/13/2013 ORMAGE TO RENTED S SOO�{JOO '':][ COMMERCIALGENERAIt�AHLLiTY , . 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FR __ _ aNYPROPRiEiOftiPARTNEWE%ECUiIV� I E.LEACMACCIOENT S SOO�OOO OFFiGER/MEMBERE%CWOE01 ❑ N�A --- {manaaroryinNN� ElOtSEASE-EREA�PI.OYEE E 2OOrOOO � � '.if yee.tlescnb@ Vtqer ..'— � DESCftIiTIONOFOPERATI0N5below E.L.OISEASE-POLICTUMIT 5 SOO�OOO B LIQUOR I,IABILITY CI,2fr14173 02/09J201202J04j2012� 1,000,400 CFSCRIPTpN O£OpERAT10NS 1 tCCRiX#!5 t V£HICI.ES{AtMch AC01lD 1M,A1ftlNanel RemaM4 SMeEuk,fim0(e'Space H.(eQuiYeli CER7IFICATE HOLDER CANCELLATION � TOWN QF YRRM(}IITH ' 1146 RO9TE 2B SH6ULD ANY OF TNE ABOVE dESCRIBED p4LICIE$ BE CANCELLE� BEPOftI THE EXPIRATION DATE THEREOF, NOTICE VALI 8f DEl1YER£D it SOUTH YARMOUTH� Mk 02GB9 ACCOftDANCEVNTHTXEPOLICYPROVISIONS. AUTIORQfURFPRESENTp1NE ' � Fax a x-soa-ssa-oe�s , � .� � �1988-2069 ACORO CdRPqRATIdN. Ai7 rigMs tese AqORD 25(2008109� The ACORD name and logo are registered marks of ACORD