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Home My WebLink AboutApplication and WC a. . i� TOWN OF YARMOUTH BOARI� F H��T� Q G C�L 0 M C�D APPLICATION FOR I,IC{. �' �A�'� A10� •Please complete form and attach all nec�ssarigdo'cw�ients"�'"6y 1Tec�� 1 DEC � 8 2�Q9 Failure to do so will result in the rehun of your apphcatton pac H Ut"r i . i NAME OF ESTABLISHMENT: G'J O K - � - ��-�- TEL. # �S-T60 �D�Z) I LOCATION ADDRESS: J.� i�"� � ; �P • 7��r�r1 o c.�d�h l�'1 Oc��y�� MAILING ADDRESS: S A- OWNER NAME: �f' O .4 • LE TAX ID (FEIN or SSN)• . - �/ CORPORATION NAME (IF APPLICABLE : RR�N,DON IIVG . MANAGER'S NAME: �n'1 U�L �h O�� TEL. # MAILINGADDRESS: .G39lY)� ,AsS' �9$t�✓� POOL CERTIFICATIONS: The poo!snpervisor must be certified as a Pooi pperator,as required by State law. Please list the designated _____P4o1_Qgeratoi(s�and attacha c9py of the certificarion to this form. - - 1. 2. Pooi operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Commumty Cardiapulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintafn a f�le at your place of bnsiness. �. 2. 3. 4. FOOD PROTECTION IvfANAGERS - 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 Heait6 Depardnent wiil not use past years'records. You mnst provide new copies and maintain a file at your establishment. 1. YK�OI�/(� .� . /—�i.t� - 2. PERSON IN CHARGE: Each food establishment must have af least one Person In�harge (PIC) on sife during hours of operation. L �00/�L'G �- L-!� � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar more must have at least one employee uained in the Hennlich Maneuver on the premises at all times. Please list your enployees trained in anri-chokmg procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. I You must provide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FE£ Pf.RMl7# LICENS&REQU(RED FEE PERMIT# � _BBcB S55 _CABIN $55 _MOTEL $55 IIVN $55 CAMP S55 �SWIMNIING POOL �uSOea. _LODOE $55 _TRAII.ERPARK $105 _WHIItLPOOL SSOea. FOOD SERVICE: ' LICENS$REQUIltED FEE PERMiT# LICbNSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS %85 !0- _CONTINENTAL S35 �NON-PROFIT S30 _>I00 SEATS $t60 �COMMON VIC. $60 �O J� ��'HOLESALE S80 ��. RETAII.SER�'ICE: —RESID.KITCHEN S80 LICENSH REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT i� <Strsq.ft 850 _>25,000sq.R. " 5225 _VENDING-FOODS25 ' ,Q5,000 sq.ft. S80 _FROZEN DESSER7 $40 TTOBACCO $55 ' xa�cantv�E: sts AMOUNT DUE = S /�S. 00 •'"••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""=• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuanee or renewal of any license or permit to operate a business if a person or company does not have a Certificste of Worker's Compensation Insurance. TH� ATTACHED STATE R'ORKEIt'S COMPENSAITON INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR / CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY 1F PAID: / , YES %� NO MOTELS AND OTHER LODGING ESTABLISHM�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiem occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transiem occuparns must have and be able to demonstrate that they mairnain a prinapal place ofresidence eLsewh�e. Transient occupancy shall generally refer to corninuous occupancy of not more than tfirty (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 Faccise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient. POOLS POOL OPENING:All switnming,wading and whirlpools wlrich have been closed for the season must be ins by the Health Departmentpnor to opening. Contact the Health Department to schedule the inspectionthree(� pnor to opening.PLEA5E NOTE:People are NOT allowed to sit m the pool area untii the pool has baen inspecEed and opened. POOL WATER TESTING: The water muat be tested for pseudomonas,total coliform and standard plate coum by a State certified lab, and submitted to the Health Depar�ern three (3) days prior w opening, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n daya of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heaith D byfi�the required Temporary Food Service Application form 72 hours prior to the catered event. These or�ins�tcan be o6tained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certifi6d lab. Test results must be sem to the Health Departmern. 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 Bo��d ofHeahh OUTDOOR COOI�NG: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishment is pro6ibited. NOTiCE:Petmits rutt annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTF,L OR POOL (i.e., PAINI�IG, NEW I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ A SITE PLAN. DATE: I,� O� . _ SIGNATURE: ' PRINT NAME&TITLE: - S . �O � ovnsio9 � I _ , 3/1 / 10 9 : 28 : 23 AM 4170 � 03/03 ,�co' CERTIFICATE OF LIABILITY INSURANCE °"�`MM'°°",�"" , �—�' 3�i�2oio vRaaxen (508)590-2400 FAX: (508)289-4111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mux�ray 6 Mac�oaald Insuraace Services, Iac. ONiY AND CONFERS NO RIGWTS UPON THE CERTIFICATE ��. HOLDER. THIS CERTIFlCATE DOES NOT AMEND, E%TEND OR � 550 MacArthui Hlvd. ALTER THE COVERAGE /1FFORDED BY THE POLICIES�BELOW. '�. Hourne bF� U2532 INSURERS AFFORDING COVERAGE NAIC# ��. ireuaeo NwR aA:Phoenix Easurance Co. zseza� � �� HRANDON, INC. DHA GPOR-N-AOLL Nsua=ae:�=aaite State Iasuranm CO � �1319 AOIITE 28 NSUR-RC NSUR°R D �'. SOUTH � �� H M9 02664 Nsurr=_rxe� � COWERAGES � ' THE POLICIES OF WSURANCE IISTED BELOW HAVE BEEN ISSUE�TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEO.NOiWITHSTANDIN6 � ANY REQUIREMENT,TERM OR CIXJOITION OF ANY CONTRACT OR 07HER OOCUMEN7 WIT}i ftESPECT TO V4HICH THIS CERTIFICATE MAY BE ISSUED OR ' MAYPERTAIN,THEINSURANCEAfFORDEDBYTHEPOLICIESDE5CRI8EDHEREINI55UBJECTTOALLTHETERMS,EXCLU510NSANDCONDITIIXJSOfSUCH � POLICIES.AGGREG4TE LIMITS SHOWN MAYHAVE BEEN REIXICED BYPAID CLAIMS. �. IN 'L POUCY EFFECTIVE POLICV E%PIRATION �'� � POUCY MJMBER D O TE M IDDI � LINJTS '�. GENEML LIh6LL17Y ERCN OCCURFENCE 5 I� OOO�OOO �I. X COMNERCWLGENERPLLW8ILRT FREMISES Ee zwrence 5 300,000 A cwiMs�nn� �occua 68o8795a.5o9 9/3/2009 9/3/2010 MEDEXP�Myonepersonl 5 5 000 '��. FEPSONo1 BICV IN.AIRY 5 S,OOO.,O00 II . GEHERPLAGGREGATE. E P 000,.000 ( GENlAGGREGA"ELM9TAPPLIESPER: FRODUCTS-C9MPoGPWG S 2 000 000 X COLIGY Pp0 . LOC li AUTOMOBILE IIABILI7V � COMBINEDSMGLELMIT S PNY PoJ�O IEe ecciOaN) �� PLLONNEDAUTOS EODILY IN,UP1' S SCHEWLEDAUTOS IPe�paRJnj YIF[D.WTOS EODILY IN,A1R1' I NON-O�M1fiE�WITOS IPerattidenl� 5 I LROPERIY pAW1GE � �Per attiCan�l 5 I GARACELIABI�Itt PAIr00NLY-E4ACGDENi 4 . I �1�e OTHERTHHN EAACG S AUTOONLY: q�G S EXGESSIUPoBRELL0.LUBRIN EaCHOCCURRENCE 5 OCCUR �Ci,WMSMPDE AGGREGaTE 5 _ I S � � OEWCTIBIE 5 I FETEN-ICN y 5 � B WORKERSCOMPENSIITIDN �YSATU- OTH- I ANOENPLOYERS'LIABILITY y�N T RV IMIi R , [NY vPOPRIE10RiPPRTNERrXE�UtIYE❑ EL EAC�ACimENT 5 SOO�000 �� OFFlCEWMEMPFR FXCLI�DED'� �. (MantlazoryinNH� 002355977 9/3/2009 9/3/201D EI.D�EasE�ea.E�+FLOrE 5 100 000 ''� r�s.ae;�eee Mee� � $PECIPLPRDVIS�NS.Celow . E1.DISEASE-POLICYLIMIT $ SOO OOD OTHER OESCPoVTION OF OPERATIOIS f LOCATION51 VEHICLES I E%CLISIONSA W EO BY ENOORSEMENTI SiEQI1 PROVISIONS . I I CER7IFICATE HOLDER CqNCELLATION - I'� (508)398-0836 SHOU.OAPTOFTNEABOVEDESCPoBEOPOLICIESBECANCELLEDBEFORETHEEMPIRpTION � TOWII OE Yd2IDOUYA DATE THEREOF,TME ISSUING INSURER N1LL B.mEAYORTO MAIL 1� OAYS NRITfEN - '� 1146 ROIItB '1$ NOTICETOTHECER'fIFWFTEHOLDERNAME�TOTHEIEFf,BUTFMIURETO�O503H0.11 - � SOIIt7l Yarmouth� �1 02664 IMiOSE ND OBUGNTION OR IWBILIN OF ANY NINO UPON T1E INSURER ITS AGENTS pt � REPRESENTATIVES. � AUTiORIZEO REPRESEM�TIVE � I S Harrincton, �IriSh[H ��r•�r_ f'�wc.-�� ..�ii ��,,. ACORD 25(2009/01) 01988-2009 ACORD CORPORATION. All rights reserved. ' IN5025 Roomi� The ACORD name and logo are registered marks of dCORD !� 5754 '