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Home My WebLink AboutApplication and WC In11s C�;�s U V Is l� TOWN OF YARMOUT'H BOARD OF HEALTH pr,� � 0 2010 " APPLICATION FOR LICENSE/PERMIT-2010 NtHL I f-i i.3t��f. * Please complete form and attach all aecessary documents by Dece Failure to do so will result in the return of your applicat�on pac cet. NAME OF ESTABLISHMENT: /¢ (',,,��e �p f�� TEL. #SoB-,39�-9D7,9 LOCATION ADDRESS; (v P2 !�/G.vrS.o,dK Raaa � Y� ��r .,TLo. O.�lGr�r MAILING ADDRESS: OWIVER NAME: ____%w,u e,e �,o�a,,,,a�v _ `r TAX ID (FEIN or SSNZ CORPORATION NAME (IF APPLICABLE):' MANAGER'S NAME: �Q4rt, Nav�� TEL. # Sc8-398-907� MAILING ADDRESS:_ G R Nieaeay.r-.�o.vo S'odTN ,e,,�,..�.v� �le o��b y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State 1$w. Please list the designated Pool Operator(s) and attach a copy of the certification to ttris form. 1. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety,standard First Aid and Communiry 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 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 Protecrion 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 new copies and maintain a file at your establishment. t. a� /,�eu�i,�5 2. F,ee,o �'�•a�o PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �om Nerur.s�s 2. F.�o C/�,.�o 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 mained in anri-cholnng procedures below and ' attach copaes of employee certificarions to this form. The Health Departroent will not use past years' records. �� You must provide new copies and maintain a file at your place of business. f i ; 1. Ren Ntww�s 2.��eso G{mro ' 3. � a.....r..�,.,.T 4. � RESTAURANT SEATING: TOTAL#_��rio i OFFICE USE ONLY LODGING: LICENSE REQUQtED FEE PERMIT# LICENSE REQUIRED FE6 PERMIT# LICENSE REQUIRED FEE PERM[T# _B&B $55 _CABIN $55 _MOtEL S55 _1NN $55 _CAMP�t $55 _SWIMNIINGPOOL 580en. _LODGE $55 �TRAILERPARK $105 _WI;IRLPOOL SSOea. FOOD SERVICE: LICENSE REQUIltED FEE P6RMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS S85 �0��7y _CONTINENTAL S35 _NON-PROFIT 830 _>100 SEATS 5160 � WMMON VIC. S60 � I � 0`I �WHOLESALE 580 RETAII.SERPtCE: —RESID.KITCHEN S80 LICENS6 RbQiJIItED FEE PERMYI# LICENSE REQUIl2ED FEE PERMlT# LIC£NSE REQiJIRED FEE PERMIT# . _60sq.ft. $50 _a25,000sq.ft. 5225 _VEND[NG-FOOD S25 _QS,OOOsq.ft. $80 _FROZENDESSERT $40 TOBACCO S55 xnn�canxGE: sts AMOUNT DUE _ $ l� . o0 •"""•PLEASE TURN OVER AND COMPLETE OTFIER 5IDE OF FORM"*•"* �� _ g�N� �� 'y �� 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. T'H� ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V �R . -� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pemrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be liraited 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 ofresid�ce elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more thait thirty (30) days, and aa 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 wlrich have been closed for the season must be ins by the Health Departmem prior to opening. Contact the Health Department to schedule the inspection thrce( )days pnor to opening.PLEASE NOTB: People aze NOT allowed to sit m the pool area until the pool has bcen inspe.cted and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifotm aad 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('n days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departtnem by the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be o ' ed 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 revocarion of yoar Frozen Dessert Pennit 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 ofHeahh. OUTDOOR COOHING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILiTI'TO RET�IRN TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY bECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTF.L OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), M[IST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE A SITE PLAN. DATE:�iL ,�l� �� SIGNAT ' PRINT NAME&TITLE: orJ u .Dl�IPCTrlJ oF (y'oCf ��-PT��$ 09/25/09 MIIA Property And Casualty Group, Inc. One Winthrop Square WORKERS COMPENSATION AND Boston, MA 02110 EMPLOYERS LIABILITY I . DECLARATIONS CONTRACT#09-210 #1 MEMBER NAME AND ADDRE S: YARMOUTH,TOWN OF TOWN HALL, 1146 ROUTE 28 SOUTH YARMOUTH, MA 02664 #2 CONTRACT PERIOD: PROM 07/01/2009 TO 07/01/2010 AT 12:01 AM STANDARD TIME AT THE ADDRESS SHOWN ABOVE #3 SCHEDULE OF COVERA ES: A. Workers Compensation Coverage: Part One of the contract applies to the Workers Compensation Law of the Commonweal�of Massachusetts. B. Employer's Liability Coverage: Part Two of the contract appiies to work in the Commonwealth of Massachusetts. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident � Bodily Injury by Disease $1,000,000 Contract Limit Bodily Injury by Disease $1,000,000 Each Employee Note: ConUibution: The Contribution for this contract will be determined by our Manuais of Rules, Classifications, Rates, and Ratlng Plans. All infortnation on the extension of information page is subject to verifica6on and change by audit. #4 FORMS AND ENDORSEMENTS ATTACHED TO THIS CONTRA T: DEC 9, EXTENSION OF INFORMATION PAGE, MWC 001 (0799), MWC 002 (0799), MWC 003(0704) � (07/01l2009) DEC PAGE 9 ' ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT , PERMIT NUMBER: #10-174 FEE: Waived In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of ihe Grneral Laws,a permit is hereby granted[o: Town of Yarmouth, 62 HiAhbank Road, South Yarmouth, MA Whose place of business is: The Grille at Bass River Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2010 BOARD OF HEALiH: �KllUt �AtI�IItfOIt-Sfttl�, C'/�av�nurn ,l l7cugneau[t, `tlice ClFaixrnan sEn7ma: 78 Inside; 112 Outside. 2UQFIP ��4t1L C. SftUlUl�¢tt III� �RJl�t � Not to exceed 190 seats rotal. Jk�� ¢d xEsrxicnoxs: Disposable Senice Oniti. �Od � ./�.`�. Apri130.2010 Bruce G. Mucphy, , .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #10-104 FEE: Waived This is to Certify that Town of Yarmouth d/b/a The Grille at Bass River 62 Hi�;hbank Road, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2010 unless sooner suspended or revoked for vialation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomury with the authority granted to the licensin¢ authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersisned have hereunto affixed their official signatures. BOARD OF HEALTH: .`.(3xian `.l3a�a�intaet-Smit�, C'/Eninnura se.a7it:c: 78 [nside; t(Z Outside. J 17QLgR1¢p{lQt� �ICC C�QI![/ItIYtE Not[o exceed I90 sea[s total. �Q��e. SftQUlC�Cft�� RJL� ��a��. ;� ./�.�. Apri130.2010 Bruce G. Murphy,MP .5.,CHO Director of Health