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��� TOWN OF YARMOUTH BOARD OF HEALTH ��`�`- �� �`-'='
APPLICATION FOR LICENSE/PERI�IFI`--�� � ^ ,.,
, � � � _�i��
... �,„,{ 11� �„��%'; �
* Please complete form and attach all necessary d6l�Ixm D�c ber 1 S 2012.PT
Failure to do so will result in the return of your application ck
ESTABLISHMENT NAME: Alec�e0 ��ellle TAX ID: �
LOCATION ADDRESS: 8/ �nas Grr ect-� � ��rrr�.,��z�i l�lF1 TEL.#: �6�3l0�7— �'%�3D
MAILING ADDRESS: „2�? V h� '3 � , �Se���aA(-/ � ME7 0.,�-lob�l
OWNERNAME: Tosf,� T'tmiP�
CORPORATION NAME (IF APPLICABLE): .J��ej rla.Qi�y C u
MANAGER'SNAME:3Qcp� �'�nieJ � TEL.#: �S' 760�i360
MAILING ADDRESS: 01 sV Wh��c's Y�dfi , Siufh �¢rmle-Jf, hrA 6a66�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Onerator{s) and attach a copy of the certification to this form.
1. 2.
Pool operatars 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 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 � copies d maintain file at your establishment.
1. � �R1 i ' i� 2.
PP:RSON P,�I�.iIARGE: _
Each food establishm nt must have at least on erson In Charge (PIC) on site during hours of operation.
1. �J ��' 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must haue 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 mainta' a file at your place of 6usiness.
1. ,�� � 2.
3. 4.
RESTAURANT SEATING: TOTAL# � Z
OFFICE USE ONLY
LODGING:
LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# [,ICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMING POOL $80ea
_LODGE $55 TRA[LERPARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
UCENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-�100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
/ >IOOSEATS $160 ��3-oS7 I COMMONVIC. $60 #f�j-07S _WHOLESALE $80 �
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERM[T# 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 _ $ 2 2�,o0
**"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•***
ADMINISTRA'TION .
Under Chapter 152,Section 25C,Subsection 6,the Toum af Yannouth is now required ta hold issuance ar renewal
of any license or permit to operate a business if a person or company does nat hr�ve a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLL+"TED A1VD SIGNED,OR
CERT. OF tNSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens musY be paid prior o renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES N(}
MQTF,LS AND OTHER LtJDGING ESTABLISHMEAI�S - - -
TRANSIENT OCCUPANCY: For purposes af the timitations of Matei ar Hatel use,Transient occupancy sha(i be
lirnited to the temparary and short term occupancy,ordinarily and customarily associated with motel and hote]use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transiezit accupancy shall generally refer to continuous occupancy af not more than thirty{34}days,and
an aggregate of not more than ninety{90)days within any six(�)month period. LTse pf a guest unit as a residence or
dwe]ling unit shall not be considered transient. Occupancy that is subject to the colleckion of Room Occupancy
Excise, as defined in M.G.L. a b4G or 830 CMR b4G, as amended, shall generally be considered Transiettt.
FOOLS
POOL OPEriING:All swimming,wading and whirlpools which have been closed for the season must be inspeoted
by the Health Depar'tment prior to apening. Contact the Heaith Department to schedule the inspection ihree(3}days
prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pooi azea until the poal has been inspected
and opened.
POOL WATER TESTING: The water must be tested far pseudomonas,tatal caliform 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 swirnming pool rnust be drained or covered within seven(7)days of
closing.
FQQll SEFlVICE
SFAS4NAL H'40I}SERVICE 4PENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Fiealth Department to schedule the inspection three (3}days prior to opening.
CATERING POLICY:
Artyone who caters within the Tawn of Yarmauth must notify tlae Yarmauth Health Deparhnent by filing the
reqmred Temporary Food Service Application form 72 hours priar ta the catered event. These forms can be
obtained at the Health Department,ar from the Town's website at www.yazmauth.ma.us under Health]7epa,rtment,
Downloadable Forrns.
FROZEN DESSERTS:
Frozen desserts must be tested by a State eertified lab pzior to opening and monthly thereafter,with sampla results
submitted to the Health Departtnent. Failure to do so will result in the suspension or revocation af your Frozen
Dessert Permit until the above terms have been met.
OiJTSIDE CAFES:
_ . {)irtside cafes(i.e,,�utcloar seating-urith waiterlwaitxess service),mtzst have prior appr�Yali'r�m th�Bo���f H��lth.
OUTDOOR C40KING:
Outdoor caoking,preparation,or display af any food product by a retail or food service establishment is prohibited.
NQTI+CE:Permits run annually fram January 1 to December 31. IT IS YQUR RESPONSIBILIT"Y TO RETUftN
THE COMPLETED RENEWAL APPLIC',ATTON(S) ANTa REQUIRED FEE(S) BY DECEMBER 15, 2012.
ALL EtENOVATIQNS TO ANY POOD ESTABLISHMENT, MOT QR P L {i.e., PATNTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO D V H OF HEAL"1"H PRIOR
TO COMMENCEMENT. RENOVATIt7NS M RF S .
DATE: 1 I ` I � �j C�-- SIGNA
FRINT NAME& TITL,B:�V r'�`7/ /t.,Q�
Rev. 10/09/12 . .
ti
� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Legiblv
Business/Organization Name: I�/�-s+��O �p(�I�LSL �GClY�IP�C IT�f�%7�r� (� �
Address: � I^�( ( C�1
City/State ip: � G .Phone#:__�f3 � 7(pd• lJ (�.�
Are yo u em{�loyer?CLeck tJts appropriate box:_ ._ , _, Busine_ss Txype(required):
1. I am a employer with�employees(fiall and/ 5. ❑ Retul
or par[-time).* 6. estaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have I 0.❑Manufacturing
no employees. [No workers' comp.insurance required]* I 1.❑Health Caze
4.❑ We aze a non-profit organization,staffed by volimteers,
with no employees. [No workers' comp.insurance req.] 12.❑ Other
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infortnation.
•'If the corpora[e officers have exempted themselves,but the wrporation has other employees,a workers'compensa[ion policy is required and such an
orga�ization should check box N l.
I am an emp[oyer that is providing workers'rcompensation�iqns�u�ra�n� c/eJ�or my emp[oyees. Below is the policy information
Insurance Company Name: �(� �.(Ip�P/'�. IVll.al.G�
Insurer's Address: �I,i �.,EIIX.,e'/�`/ �TR'.f:r"!;
c�ri�s�t�z�p: ���m r, , r�q O�i�7
PQ��y#or se���.�:«.# inK-�531538�tYJ`{-oo� E��r�: �'�"�'-i�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$I,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigaf of the D r ins verage verification.
I do ereby ce er 'es ojperjury that the information provided above is true and correct
Si e: Date: ����2 ` � �—
Phone#: � ���'
Official use on[y. Do not write in this area,to be completed by city or town o�ciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board oFHealth 2.Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Oftice
6. Other
Contact Person: Phone#:
� www.msss.gov�d;a � .
ncoRo• CERTIFtCATE OF LIABILITY INSURANCE �"'� „�"���'
nr�aso�s
THIS CERTIFICATE IS ISSUED AS A MATfER OF INFORMA710N ONLY AN�CONFERS NO RIGHTS UPON THE CERTIPICATE HOLDER TFfIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE �OES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,A1JD THE CERTIFICATE HOLDER.
IMPORiANT: Ii the eertifiGate holder is an ADDITIONAL INSURED, fhe policy(ies) must be entlorsed. If SUBROGATION IS WPJVED, su6Ject to
tM1e terma antl co�Mitions of the policy,eertainpaltcies may rcquire anentlorsemeM. Aatatement onthiscertificaMEcesnotconferrigMs tothe
certlflcate holtler In Iieu of sueh entlorsemenqs�.
caooucex rnme: (aot)253-5soo Fax: (am)zss-sass c«rtncr JaneAlegria
A N NUNES AGENCY,INC
549 HOPE STREET PNONuo e , (40'1)2533300 F m , ,. (401)253-9485
PO BOX BD E'`""'� . janea�fullchannei.net
BRISTOL RI 02809 INSIIRER(5)AFPOROING COVERAGE NAIC C
Ax�r��:�oasa�e inwAenn : I�uurance Innovators Ageney of New England Inc
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ARDEO TUSCAN TAVERN '"��e :
C!O JOSEPH JAMIEL JR wsuReac :
23 V WHITE'S PATH
INSURER D:
SO YARMOUTH MA 02669
INSUNER E :
WBURERF :
COVER4GES CERTIFICATE NUMBER: 5734 REVISION NUMBER:
THIS IS TOCERTIF`!THATTHE POIICIES OFINSURANCE LISTE� BELOW HAVE BEENISSUED 70THEINSUREO NAMED ABOVE FOR THE POIJCY PERIO�
INDICATED. NONIITHSTANDING ANY REOUIREMENT, TERM OR CONDfi70N OF ANY CONTR4CT OR OTHER �OCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MhY PERTAIN, THE INSURANCE AFFOR�ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
EXCLUSIONSAND CONDfTIONS OF SUCH POIICIES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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DESCRIVTI�N OF OPERA71pNS/LOCpTqNS/VEHIGLES�AWch ACOR�f0�,AGdNonal Remsrke Se11e0We,If mora spxe is rpuind)
Soufhside Tavern,LLC d6a Ardeo Mediterrenean Tavem,23 V Whites Path,South Yarmouth MA
CERTIPICATE HOLDER CANCELlAT70N
Town ot Yarmouth Ma SHOULD ANY OF iHE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE
THE EXPIRATION DA7E THEREOF, NOTICE WILI BE OELIVERED IN
ACCOROANCE WRH THE POLICY PftOVISIONS.
I AVTIORQm REPftESEMATNE �� <'`;—/I V
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Attention:
Jane A Aiegna
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