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 �. � � .