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Home My WebLink AboutApplication and WC ,� � G[Ak.Din10 S �rawx oR��azr�$o�o��.� arrr.�ca,�ox�o��cEr�s�rn��x-zo�� ; "`Flease complete farm and attach all necessaiy doam�i��s }� ece ber I 2009. Failure to do so wilI result in the return of your appticahon pac et. — NAME OF ESTABLISHMENT:_'s.�211�./�,l2/N�✓ �/�r �,�,�eu�TEL. #t�i�l�"w�i��' D� LQCATION ADDRESS: a'},.,� �1�.nJ �ST'---YK T ,�1 6"O <..��C�',,,rT..71„�,+�'t-�'...�.c{,l'� MAILING ADDRESS: QWNER NAME: ' o✓ � E r ' CORPORATION NAME (IF APPLTCABLE): MANAGER'S 1vAME: TEL. � MAILING AIlDRESS: t (,�/� �' ,y�y� POOL CERTIFICATIC}NS: The pao(aupervisor must be certified as a Pool Operator,as required by State law. Please list the designated Paol C3perator(s} and attach a copy ofthe certificarion to tlsis form. I. 2. Pool aperators must list a mrnimum of two employees currently certified in basic water safety,standazd First Aid and Community Cardtopulmanary Resuseitatian{CPR). Please list these employees below and attactt capies afemploye� certifications ta this form. The Health Department will not use past years' records. You must provide new capies aed maintatn a fi�e at yanr place of business. 1. 2. 3. 4. FOOD PROTECTTON Iv1ANAGERS - CERTIPICATIONS: All food service establishments are required to have at feast one full-time empioyee who is certified as e Food Protectian Manager, as defined in the State Sanitary Code for Foad 3ervice Establishments, 105 CMR 594.004. Please attach copies of certificarion ta this application. The Health Department will not nse past years'records. You must provide new copies and maintain a !"ile at your estab6shment. 1. �r r ,,,P (r.rl�.OrNr7 2. D/� �/�,f_./�l/L-/ � PERSCIN IN CHARGE: —.._— ----- _ – __— ach oodestablishment must haue at least one Person In Charge (PIC) on site during hours of operation. 1._ l D�! �,�.2/�/sr !� 2. �D � �r�,�/4Q/�G� F3EIMLICH CERTIFICATI(?NS: All fopd service establishments with 25 seats or more must bave at least one employee trained in the Heimlich Maneuver an the premises at all times. Please list your ennaployees trair�ed in anri-chokwg pracedures belaw and attach copies of employee certificarions to this forxn. T6e Health Department will not use past years' records. Yon must provide new copies aud maintain a file at yuur place of business. i, �,� Gi�iifl/i✓1L , 2. �ei4y_�i�f��/.r 3. 4. RESTAURP.NT SEATING: TC?TAL#�� _ _ L4AGi�'G: OFF�ICE USE C1NL�1' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# �B&.B $SS �CABIN $55 ,_,_MOTEL S55 �INN $55 �CAMP S55 _SWIMMINGPOOL �80ea. _LODGE S55 �'FRAILERPARK 5105 _WT�llRLPOOL $SQea. FOOD SERVICE: LTCENSE RE!QUIRED FEE PERMIT# LICENSE REQUIRED f�E PERMIT# LICENSE REQUI1tED FEE PERMIT# rt0-100 SEATS S85 _CONI'INENTAL S35 � �NON-PROFIT S30 _ ! >iao sEnts �iea �lU-�[�7 Y �con�ax vlc. ��a �4–O�O _wxo�,ssnr.� �aa �T�tt,s�xvlc�: ��s�n.�rcz�x sso LICEN5E REQIA3tED FEE PEI2MTI# LICENSE REQUll2ED FEE PERMIT# L10EN5E REQiJIRED FEE PERMCT it �c50sq.ft $50 , >25,OOOsq.R. 5225 _VENDiNG-FOOLI $25 „_,.QS,WOsq.ft $80 .,_FRpZENDESSERT 540 TTOBACCO S55 __ x.a�canxsE: sis . ' . _AMaUNTDUE = s 22.0._00 _ '"""•PLEASE TURPi OVER AND CONiPLE1'�OTHER SRSE OF FORM•"*" � � anm�s•rxAzzoN _ -�'""" Under Chapter 152, 3edian 25C, Subsection 6,the Tawn of Yazmauth is now required to hald issuance or renewal vf any license or pernrit to operate a basiness if a persan or company does not have a Certificate of Worker's Compensation Insurance. 't"HE A'1'i'ACHED STATE WOT�2KER'S COMPENSA'1'I�t� TNS�ItANCE . A£+FIDAYIT MUST BE COMPLETED AND SIGNED,QR CERT. OF IlVSURANCE ATTACI�IED QR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens znust be paid prior to renewai ar issuanae of yaur germits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTIiER LODGING ESTABL,ISHMENTS TRANSIENT OCCUPANCY: Far purpases af the limitations of Matel or Aotei use,Transient occupancy shaii be limited ta the temporary and short term accupancy,prdinarily and custamarily associated with motel and hotel use. firansient occupamts must have and be able ta demonstrate that they maimain a principal place ofresidence elsewhete. Transient occupancy shall geaeraily refer to cantinuous occupancy of noE more tban thirty {34} 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 dweiling unit shatt not be considered transient. Occupancy that is subject to the collection of ltoom Occupancy _ . Excise, as defitted in M.G.L. c. 64G or 830 CMR 64G, as amencfed, shaiF generaliy beconsidered'I'ransient.- POOLS POUL QPENING:All swimming,wading and whirlpools whiah have been closed£or Yhe season must be inspected by the Health Departmem rior to opening. Contact the Health Departmem to schedute the inepection three(3)days pnor to opening.PL�, '.AS NO :People are NOT allowed to sit sn the goal azea until the pool has been inspected and opened. POOL WATER 1`ESTING: The water must be tested for pseudomanas,total coliform attd standard plate cawrt by a 3tate certified tab, and submitted to the Health Departmeat three (3} days priar to opening, and quarteriy thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained ar covered within seven(�daqs of cIosing. FQOD SEItYICE CATERING POLIL`Y: Anyone who caters within the Town of Yarmouth must natify the Yarmauth Health DeparfinerXt by filing the required Temporary Fcu�d Service App2icatian farm 72 hours priar to the catered event. These focros can he abtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be#ested on a monthly basis by a State r,erpfled#ab. Test results must be sern to the Health Department. Pailure ta do so will result in the suspension or revocadan af your Prozen Dessert Permix until the above terms have been met. CiUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwa'rtress service),must have prior apgroval&am ihe Boazd ofI�ealfih. QITTDOOR CQOHING: Outdaor cooking,preparatinn,or displaq of any food product by a retail or food service eskablishmart is pra6ibited. NOTYCE:Pernrits run annually from 3aanary 1 ta December 31. IT IS YOUR 1tESPONSIBII,TTY TQ ItET[71iN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIR�.D FEE(S)$Y DECF.M$ER 15, 2009. ALL RENOVATICaNS TO ANY FOOD ESTABLISHMENT, M01"EL OR POOL (i.e., PAINTING, N�'W EQUIl'MF;NT,ETC.},MUST BE REPORTED TO AND APPROVED BY THE BOARA QF HEALTH PRTOR TO CC?MMENCEMENT. RENOVATIQNS MAY REQUIRE A SITE PLAN. DATE:�pP/��'`— � f SIGNATURE: PRINT NAME&TITLE:_ ��L1�f1 fL,�, l�.l��'-�//v� `�°;' o9rzs�og ��L�-S�`�P�/� ■ ■ . • �' � ■ Juty S, 2009 Giardino's Tastee Tower Inc 242 PAaireStreet West Yarmauth, MA 02673 Deartnsured: Thank you for selectitig AIG for your Workers' Comperisation coverege. Please firni endosed the A1G policy inform8tlon kit providfng you qrrter contacts, daim reportirig informa6on and required posting noti�es. For your corneni�ce, we have out8ned below the ir�formation needed on your posting nonce: Name of Ins�uancs Gompany: AK's 3paciaity Workers'Compensetian Address af Insurance!Company: 5 Wood Hotiow,PO Box 409, Parsippany, NJ C7064-0449 Policy Number. WC98736U1 Effective Dates: 08lG1/09 to 08l04t10 Insurence Agent: Johrt R.Germani Ineurance f�genYs Ptione Numbe�: 508-4F8-S088 Thank you again for your business. Sent on behaff of AfC�and your Independent insur�nce Agen# WC Department Number One insurence Agency, tnc. 91 Cedar Street Milford,MA Qt757 (800)742-6383 Enclosure 91 Cedar Screet,Mrifoxd,MA Of 757� 5t)8-6342902 �1-8W-742-6363!Fax:5Q8-634-2930 e VpC Fax: 5�-6342931