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HomeMy WebLinkAboutApplication and WC , ���E.:�s��� � � TOWN OF YARMOUTH BOARD OF Ati.'�1'� �'a �� g ��� APPLICATION FOR LICENSE/� , �'I'�a " li,, �� OEC 15 2010 * Please complete form and attach all necessaYy�oc�u��b�y b�(2�ribe �r� u��T. Failure to do so will result in the return of your application packet ESTABLISHMENT NAME: e� .s, 1A, �1 l TAX ID:�� LOCATION ADDRESS: TEL.#� � � 7 0 � � MAILING ADDRESS: ��� OWNERNAME: �l� l,Li Ya-vV� Si,�fp�•Q,Y1 K11� CORPORATION NAME (IF APPLICABLE� MANAGER'S NAME: �d�o �J � (�k TEL.#: " D ' MAILINGADDRESS: t�1� R� a.� ��Rf� tJll�� q� �)r�(O�v�/ POOL CERTIFICATIONS: The pooi supervisor must be certi�ed as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certification to this forni. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard Fnst Aid aud Community Caz•diopulmonazy Resuscitation(CPR). Please list these employees below and attach copies ofempioyee certifications to this foim. The Health Department will not use past years' records. You must provide ne�r copies and maintain a 61e at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requu-ed to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'ui the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of ceiYification to this application. The Health Department�vil(not use past years' records. You must provide neFv copies and maintain a file at your estabiishment. i. 2. PERSON IN CHARGE: Lach food establisiunent must have at least one Yerson In Charge (PIC) on site during hours of operation. I. 2. HEIMLICH CERTIFICATIONS: Ali food service establislunents with 25 seats or more must have at least one empioyee trained in the Heimlich Maneuver on the premises at all tnnes. Please list your employees trauied in anti-choking procedures below and attach copies of employee certifications to this foim. The Health Department will not use past years' records. You must provide new copies and maintain a �le at��our place of business. l. 2, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER'�IIT a LICENSE REQUIRED FEE PER�fIT F LICENSE REQUIRED FEE PER'�IIr� _B&B S55 CABIN 555 D40TEL S55 ��� _INN S5� CAMP Si� Slt7bL\31NGPOOT. SROea. .. _LODGE S55 IRAILERPARK 5105 ��7-IIRLPOOL S80ea. FOOD SER\'ICE: LICENSEREQLnRED FEE PEIL�41I'= LICENSEREQUIRED FEE PER\4Ir= LICENSEREQUIRED FEE PER�1Ii= _0-100 SEA'IS S85 _CONI'INENTAL 535 NON-PROFIT 530 �>IOOSEATS S160 (�IIg I C0�40NVIC. S60 �kU-n�SO _��''HOLESALE S80 REt.1IL SER\10E: —RESID.HITCHEN S80 LICENSEREQL7RED FEE PERbIIr= LICENSEREQUIRED FEE PER�41T- LICENSEREQUIRED FEE PERbII7< _60sq.T'c S50 _>ZS,OOOsq.R. S?25 VENDING-FOOD S25 _<25,000 sq.ft. S80 _}ROZEN DESSERT SAO TOBACCO S55 �.��zE c�scE: sis AMOUNT DUE _ $ 220 �0 0 """*•pLEASE TtiR\OVER A\D CO�IPLE'IE O'IHER SIDE OF FOR\I**"** S' ' 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � � �� Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO Mf)'TELS A1V71 aTHr:Ti'c i..aDGII�IG ES"TABLISHMENTS TRANSIENT OCCUPANCI': 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 ofresidence 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 pnor to opening.PLEASE NOTE: People are 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 Department to schedule the inspect�on three(3) days prior to opemng. 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 obtazned at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health DepaRment,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 Boazd ofHealth. 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 RESPONSIBILTI'Y TO RETURN TF� COMPLETED RENEWAL APPLICATION(S) AND REQUIRED PEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPOR'I`ED TO AND APPROVED BY TI�BO OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA . DATE: ( V C, OSIGNATURE: PRINT NAME&TITLE: 10�06�'10 � DaLe: 12/75/2010 Time: 11:o9 AM To: @ 9,150B7603972 Paqe: 002 CI ient#: 1 fi383 2DOYLES RE1 . ACORD,M CERTIFICATE OF LIABILITY INSURANCE ;;;5 0,0"" eaooucea TXIS CERTIFICATE IS ISSUED AS A MAITER OF INFORMATION Dowling 8 O'Neil Insurance ONLV AND CONFERS NO RIGHTS UPON THE CERTIFICATE NOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR Agency . . qLTERTHECOVERAGEAFFORDEDBYTHEPOLICICt58ELOW. 973 lyannaugh Rd., PO Box 7990 � Hyannis, MA 02507 INSURERS AFFORDING COVERAGE NAIC k wsanEo . � msuReaa: Mt. Hawley Insurance Company. ZDOM,Inc. D(81A Doyle's Restaurant irvsuaeas: The HarNord A/O Bisque Hoy Realty Trust �insuReac: Mount Vernon Fire Insurance Co t329 Route 28 irvsuaeRo: � . South Yarmouth, MA 02664 INSURERE: COVERAGES � TNE POLICIES OF INSURANCE LISTED BELDW HAVE BEEN ISSUEDTOTHE INSURED NAMED ABOVE FORTHE POLICV PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT.TERM OR CANDRION OF ANY CIXJTRACT OR OTHFA OOCUMENT WITH RESPECT TO VJHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBFD HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIDNS AND WNDff IONS OF SUCi POLIGES.FGGREGATE IIMITS SHOWN MAY HAVE BEEN REDUCEDBV PAID CLAIMS. POIICV EFFECTIVE POLICY E%PIRAPON LTR�NS. � T�'PEDFINSUqANCE PDLICYNUM9ER OATEhIIv1l0 OPTEmmmom �1MR5 /{ GENEMLLIRBILITY MPR0502329 OSIO�I�O OSIO�I�� EAGHOGGURRENGE 5� OOOOOO X CIXAMERCIAL GENER0.L LIpBIL17V p�aCE TO RENTED SSO OOO ClAIMSMhDE �OGCUR MEDEXP Anymepersor) S� OOO PEFSONAL&ADVINJURV E� OOO.00O � cenEaniAeGREcaTE E2 OOO OOO GEMLAGGREGATELIMITAPPLIESPER: PROOUGTS-COMP/OPAGG EYOOOOOO POLIGV ,�� LOL AUTOMOBIIE LIkBILITY COMBINEDSMGIE�IR q ANV AlJrO (Ea actltleM) ALL OWNEO AUT�S BDDILV WJURV SCHEDULEDAUTOS �p��rs�� S H.REOAUi05 80DILV PJJURV s NON-OlMJEO AUTOS (Per actltlmp � GROPEFTVCAMAGE 5 �Pe!attltlenf) GAMGELiABRITY ' AUi00NLV-EAACCIDENT $ ANVNUtO OTHERTMHN EAACC 8 AIJr00NLV' qGG S EXCESSNMBRELLAWBILITY EACHOCCUftRENGE S OGCUR �GLAIMSMADE AGGREGATE S S DECVQIBLE S RETENTION $ S B WbRRERSCOMPENSATIONANO 08WECNL4872 QB/O�I�O OBIO�H� X �NGSTATU� OTH- EMVLOYERS'IlABR1TY qNVFROMiIETOR'PARTNEWE%EQRNE E.LEAGHACGIOENT S�OOOOO OFFICEWMEMBERE%0.UOED? NO E.L.DISEASE-EAE�dROVEE 1�00,000 11�ms,tles�'iip�urcer SFEGWLPROVISIONSONow El.D6EA5E-POLIGVLINIT E$����� C oTxEa Liquor liahi BIN�ER311333 09f01/10 08107/11 §1,00�,000 per occur. ;1,000,000 aggregate oESCRIFTION OF OPERhTIDNS/LDCPTIONS/VEMICLES/E%CLUSIDNS�O�EO BY ENDORSEMENT/SiEC1AL VROVISIONS Operations performed by the named insured suhject to policy conditions and exclusions. CERTIFICATE HOIDER CANCELLATION SN Wl0 ANY OF TNE ABOVE DESCR�ED POLILIES 9E CNNCELLEO BEFOqE THE EXPIRATION TOWOOfY3ffllO0tI1LILEfISBDBPS. OATETNEREOF,THEISSUWGINSURERVALLENOEAVORT�MAIL 70. �AYSWRRiEN 1146 Route 28 NOPLE TO TME CERTFIL�TE NOLOEft NAME�TO THE LEFf,BUT FNILURE T�0�50 SHALL South Yarma uth, MA 02664 IMPOSE N�OBIIGATION 011lIhBIIRV OF ANV KIND UPON TNE INSURE0.,ITS AGENTS OR REPRESENTFTIVES. AIITHORI�PRESE NTATIV�E�.+ � m �� � ACORD 25(7001108)� pi 2 IR574754/M74753 L57 O ACORD CORPORATION 7988 �a[e: 12/15/2010 Time� 11:09 AM To: @ 9,15087603472 Paqe: 003 IMPORTANT Ii the cerlificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certifcate does not conFer rights to the certificate holder in lieu of such endorsement(s). � Ii SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may . require an endorsement A statemenl on this certificate does not confer rights to the certiflcate � holder in lieu of such endorsement(s). � DISCLAIMER The Certificate of Insurance on the reverse side of this form does nof constiWte a contract between the issuing insurer(s), authorized representative or pmducer, and the certifcate holder, nor does R affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORU 25-5(4001/08) y Oi 2 #574754/M74753 �. � � .