HomeMy WebLinkAboutApplication and WC� \ ' ' TOWN OF YARMOUTH BOARD OF HEALTH a�c�r�a d�o
APPLICATION FOR LICENSE/PERMIT-2010,,_ �`aB NOV 2 0 �R09
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* Please complete fom►and attach all necessary tiocuments by�ecemb � h i.1tr i .
Failure to do so will result in the return of your applicat�on pac
NAME OF ESTABLISHMENT: l7�a1/� ���� cc/' /IFSGcI TEL. #���- 7]�
LOCATION ADDRESS:
MAILING ADDRESS: 1/ �fi 5 �- Az'ZWt ✓�� .
OWNER NAME: O ` D FE or N - -.�
CORPORATION NAME I APPLICABLE):
MANAGER'S NAME: � TEL. # ,�3•Z�U• 7�33
MAILING ADDRESS: t�ltil�l
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State lew. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to ttus form.
1. 2.
Pool operators must list a minimuw of two employees currently certified in basic water safety,standard First Aid aud
Community Cardiopulmonary Resuscitarion(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 maintafn a �le at your place of business.
i. a.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fizll-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Piease attach copies of certification to this application. The Health Department will not use past years' records.
You mnst provide new co ies and aintain a file at your est�blis�� C'�
2 �-m l �
PERSON IN CHARGE:
Each food establi ymenf must have at 1 st one Person In Charge (PIC) on site during hours of operation.
1. b � . 2. �-C)�j «��
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 enployees trained in anti-choking procedures below and
attach copies of employee certificarions to tlris form. The Health Department will not use past years' records.
You must provide new copies a maintain a file at your place of business.
�. � � '� z. � �'lC7
3.�{� ),P � 4.
RESTAURANT SEATING: TOTAL #�. S�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQ[IIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOIEL $55
�INN S55 _CAMP $55 _SWIMI�9�IGPOOL S30es.
_LODGE $55 �7RA[LERPARR $105 W$[RLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIItED FEE P$TtMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_4100 SEATS $85 _CONTINENTAL $35 NON•PROFIT %30
�>IOOSEATS $160 ����3?� �COMMONVIC. $60 0�0�') _µ�pLESAL� �80
RETAII.SERVICE: —RESID.KITCHEN S80
LICENSE REQUIItED FEE PERMIT# LICENSE REQUDtED FEE PERMIT# LIC£NSE REQUIRED FEE PERMIT#
_�SOsq.ft. $50 _>25,OOOsq.B. 5225 VENDING-FOOD $25
_QS,OOOsq.R $80 _FROZENDESSERT $40 . TOBACCO S55
NAMECHANGE: S15 AMOUNTDUE _ $ 2Zo. oc�
••«"'pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'*"*
\
ADIYIINISTRATION
LTr+der Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pemrit 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 COMPLET'ED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior t ewal or issuance of your pennits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHM�NTS
TRANSIEN'T OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transieirt occupancy shallbe
limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they mairrtain 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 Transie�rt.
POOLS
POOL OPENING: All swimming,wading and whirlpools wlrich have been closed for the season must be ins
by the Heatth Department prior to opening. Contact the Health Depazhnettt to schedule the inspecrion thr�( )days
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area 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 Depariment 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
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmoufh Health Departmeat 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.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 Board ofHealth.
OUTDOOR COOHING:
Outdoor cookin�,preparatioq or display of any food product by a retail or food_service establishmetrt isprohibited._
NOTICE:Pemuts run annually from 3anuary i to Decembet 31. TT IS YOUR RESPONSIBIIdTY TO RET[7RN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.),MUST BE REPORTED TO AND APPRO BY O OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS M REQ E L 1 .
DATE: d � f ��� SIGNA
PRINT NAME&TI s �(
09/25/09
� The Commonwealth of Massachusetts
pepartment of Lnilusdxa!Accidenxs
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b00 Woshin,gton Strect, �"Ftoor
Boston,Mass. 021.(X
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IP}Ff}RMATIftN PAC;F. REPIL'WiiZ, AGP,�k;�ME:tO'P
Producer: Anenti! 548
I9A katai]. i�terchants wG i�roup Inc. Thomas E Keefe Insurance Agency. 1
li? i3ririeh Amarican SZ�,d. 51 West C�ntral Street PO Sox R
Latham, NY 12110 Franklin, MA 02035
(Carrier Code: 34355} CertiEicate �: 014005030285109
Prior Gertificata #: 4I4005034285108
1 . The Emplo_ver: Ardeo
South Side Tavern, LLC
Mailing Address: ?,3V Whites Path
South Yarmouth, MA 02664
Fein:
Other workplaces npt shown abava: Type af Business: Limited Liability Co
SEE SCFIEDULE OE QPERATIONS Risk IA.
2. The certi£icate period is from 12:fl1 a.m, an�� to 12:01 a.m. on
1/O1/2� at the insured's mailing address.
3. A. Workers Compensation Coverage: Part One oE the certi£icate applies to the
Workers Compensation Law o£ the states listed here:
MA
B. Employers Liability Gaverage: Part Twa of the certificate appiies to work in
each state listed in Item 3.A. The limits of our liability under Part 'hao are:
Bodily Injury by Accident $ SQ4 Q�.__ each aceident
Bodily Injury by Disease $ 5p�00 certi£icate limit
Sodily Injury by Disease $ 500 OQO _ each employee
C. Other States Goverage:
D. This certi£icate includes these endorsements and schedules:
WCOOOOOOA(04/92) WCOOQ308(04/84) WC000414(07/90) WCOOd422A(Q9/08) WC200301(04/84)
WC20p3Q2(05/8b7 WC204303Bt47199) �7C200405(4b101} WC200601(d6/92}
4. The contribution £or this certi£i.cate will be determined by our Manuais of Rules,
Classi.fications, Rates and Rating Plans. All information required below is subject
to verificatian and changa by andzt.
Glassifications Gode Contribution Basis Rate Per Estimated
No. Total Estimated $lOQ of Annual
Annual Remuneration Remuneration Cuxitribution
SEE SCHEDULE pF OPERATIONS
Total Estimated Annual Contribution 10,187.00
Minimum Contributiqn $ `L6$.OQ Expense Ge�nstant $ 00
WC 00 00 O1 A Tssue Date: 1/06/?.009 Counter,i�ned by _._._--_—_—_________._
SCHEBULE OF OPERATIONS FOR: FAGE: 1
niucv LeL�LlL1CdL2 � : U14UU5U3ULtl51Uy
South Side Tavern, LLC Fein:
23V Whites Path
South Yarmauth, MA 02664
OTHER WOftKPLACES :
Ardeo
Sa�zth Side Tavern, LLC
Kings Way
$1 Kings Circuit
YarmouLhpart, MA Q2675
WC QO �0 03 n