HomeMy WebLinkAboutApplication and WC . . ' TOWN OF YARMOUTH BOARD OF HEAL'TH [�C� ���v � °
APPLICATION FOR LICEIV'5�/PERMIT-2010
, �#i�� �, : 0 9 2ens
* Please complete form and attach all nece�ssazy documents by�Y ember 1
Failure to do so will resuk in the return of yow applicario p � s �
NAME OP ESTABLISHMENT: A �P TEL. # �!`JR '��L (QS,�'�
LOCATION ADDRESS: �-i I(o !� Y� �Lk i2�'�5�� l r.l O�YYL� M(3 C'(,�dn'��
_.... _�r.—� — - - __
MAILING AAD S: '` " �
OWNER NAME: ��.+� ,;j, ki. T ID(FEIN or SSNI:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: ' r TEL. # �X �,�X -C,��`i l�
MAILING ADDRESS:��44 12�1 �8 ��� S �al'k.CY���-� i�.l��(n�^�
POOL CERTIFICATIONS: •
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to tlris form.
L 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and
Comtnunity Cardiapulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certificarions 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• � z
.�rFOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents 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 certificarion to this application. The Health Department will not use past years' records. �y
You must provide new copies aad maintain a file at your establishment.
1. 2• � �
PERSON IN CHARGE_ - --
_ - --- -- -- - .
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. P
7
1. 2' �
"� 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 employees trained in anti-cholung procedures below and �,
attach copies of employee certificarions 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. 3 �
i.�: ��r�r�. X°�,�IC�. 2.C� �'Ir� r-�-o I��c;�b�C� �- 2
3.��(1�� n��nPv -a. . a ���r� c-�„�r-��e" _ � �
P
RESTAURANT SEATING: TOTAL # Q' �
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
g�g $55 _CABIN $55 _MOTEL $55
�t $55 _CAtvR SSi _SWIMMING YOOL $SOea. �
LODGE S55 _'TRAILERPARK 5105 ,_WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMIT# L[CENSE REQt1IRED FbE PERMIT# , LICENSE REQZJIItED FEE PERMIT H
0-100 SEATS $85 —CONTINENTAL S35 / _NON-PROFIT S30
�>IOO SEATS $160 la''0�� J_COMMON VIC. S60 ���03J TWJ-IOLESALE $$�
RETAII.SERVICE: —RESID.KITCHEN S80
LICENSE REQ1JIItED FEE PERMIT'ti LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT#
<SOsq.B. S50 _>25,OOOsq.ft. 5225 _VENDING-FOOD E25
QS,OOOsq.ft. $80 _FROZENDESSERT $40 `TOBACCO $SS
NpME CgArTC>E: $15 AMOUNT DUE = S 220.o0
••�••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM«*'""
, . .
ADMIlVISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernrit 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 COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED -
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth talces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
� MQTELS AND OT�R-TADGIN�ESTABLISffiV�NTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transietrt occupancy shall be
limited to the temporary and short term occupancy, ordinarilq and customarily asaociated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than t}vrty (30) days, and an
aggregate of not more than ninety (90) days within any sut(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 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 aznended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be insp�
by the Health Departmem prior to opening. Contact the Health De�azYmern to schedule the inspection thrce(3)days
pnor to opening.PLEASE NOTE: Peopie 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 coutrt
by a State certified lab, and submitted to the Health Depaztment three (3) days prior to opening, and quarterly
thereafter._
POOL GZOSING: Every outdoor in ground swimming pooi must be drained or covered within seven('7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters witlrin the Town of Yarmouth must notify the Yarmouth Heaith Departrnetrt by Sling the required
Temporary Food Service Applicarion 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 Iab. Test results must be sant to the Hea1th
_ Department. Failure to do so will result in the suspeasion or revocarion of your Frozen Dessert Petmit until We
, above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromtheBoard ofHealth.
OUTDOOR COOHING:
. .
- ���-0r di�plap of any food nroduct by a retail or foo�i service establishmart is rahibited.
— p— —__
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN
THE C�MPLETED RENEWAL APPLICATION(S)AND REQUIRED gEg(g�gy DECEMBER 15, 2009.
ALL RENOVAT'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN't'ING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TFIE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT'E PLAN.
DATE: � �- U �I � SIGNATURE: � �:;�����/ "" _
/ 4
PRINT NAME&TITLE: I�V',!-� �� r� � � � � � � n I�
0925/09
. _ �
The Coinraonwealth of Massachusetts
Department of lndustria!Accidents
Mi�elN�
600 Washington Sheet, 7t°F/oor
Baston,Mass. 02I11
Workers'Compeesatioa iasaraace q(6davrt;gei�diug/p�embiag/EkayeMal Cootnctors �
Aoolieaot i<f�.matin• Mease PRQ�T leei6h•
name: '�/�OU (.CO�
am�: �F( c� (Z�
ci�Y L�1J '/��'(IiYV` A' ]61,4- sfa[e M�- zio vU6 L 7 ohone# t JCJ 7 7 � 6 l >/
woik site location(fiil(addrtssY. . � . .
❑ I am a hom�wcer performmg all work myself. Project Type: ❑New Constn�.�tion QRemadel
❑ I arn a sole�proprietor aod have no one woiking in mry�����Y• ❑Buildiog Addition
�am an empbyer Jaovidiog walceas'compensati�fa my empioyees wodcing�this job. �
wem�v.sme• � � � � � . : . .
� address. . . . � .
eity: . � . . . . - . oYa.e M: . . . . .
co.
-;:- :.�. . r �:..� : ,�, a a� „ , . :,.. „. . . . . .
❑ I am a so(e proprietor gaeral co�tractor,or Yomeowwer(cirde ane)aod have hired the ��conhactas listed below who have�
tLe following workeis'compensa�on polices: -
�r�me• '. �. . . . . . .. . . .
ad�ea�. , . _ . ' . . . . , . .
etn• . . . � . . . � - nre.sM- ... . . . . _ � . . .
iuea�oece. . .. . � . .� . , . . � � . , .
-o..,.-�.aera,Y , �. . . .
.. :. . .. _. ..� .N - - . ...� .x...��: :Y. ,.2,�b,
n�me:
add�rw• . . .
ellv:. . � . . .- . . . . . � - _ . . � . . . .
. __ . _— _:. — . _ . ... . __ � ___--- -_.----� . . .
. .:- . -.;: .. � -. 8. . —. -�- � -- --
Eail�re rxeae.. .. .�.a , ..;:_„. , ;_ , .'�: z t :i< t ��`#.�;' d ..ac-,s� �;"s�rr. <�. ,:;�'u.#'��:'#`aa .'s�� .""s,�'...; �.
�Yn�'�F��mt n wd a dN�v SeeW�2SA NMC.L�152 e�Ied M IYe�daldal p�16n d��e q�b S7,3MM asdNr
penitld h IYe Hr�Ka 31�7 WORK ORDBH nd�me dS1B0.N�dry q��e. 1 udenh�d tYN a
n17�[W6�fa1e0ntr�hetarwardrAbtOeOmaedL�ealgWsnK6eDlAtre�aOexr�yryw, - - � .
/blYers6ycerafyrsle e� �PeNu�ry' aMefefo�allen/rovlde/alace�bv��e_a� id�on�rr,r,�et� . .
� � %%��.��'>" �i."j/-Z ce � � � ���1�U�
— �t,�
, . ��--��c/� �
\/ r°°r n� rno�u `
J`
�d�l�seaaly tle�NsnkeiWsarcabhena�Irfed69dlYKywe�a�id .
dboreowc . .�S ��-��t
❑tYat If f�1e�psme 6 Rq�eA .. .. �� . . - -. ��g Bntd
�d�f's O�oe .
(.p'.�� M� ��,. .. . - . '..��t�t
. FrQm:Debbie Kleponis FaxID:781-444-0090 Rodman Date: 12/10/2009 03:24 PM Page: i of
2
� !�
ACORD CERTIFICATE OF LIABILITY INSURANCE OPID DK DA�����YYrr�
ACAPUI9 12/10/09
PROWCER
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
aodman iasurance agency, xnc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
145 [wsemaxy st. , aldg. a ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO .
Needham MA 02494-3238
ehone:781-247-7800 Bax:781-944-0090 INSURERS AFFORDING COVERAGE NAIC#
INSURED iNsuaean: PubliC SeiviCe Mutual
INSl1RFR B:
LaPlaya dba Acapulcos iNsuaeac.
West Yatmouth Location
705 W 7th Ave Suite A-3 iN�RERo�.
Spokane YII� 99209
INSt1RQi E' �
COVERAGES
7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEF1J ISSUED TO THE INSURED NAMED ABOVE FOR 1HE POLICY PERIOD INDICATED.NOTNI7H5TANDING
ANV REOUIREMEM.TERM OR CONDITION OF ANV COMRACT OR OiHER DOCUMEIJ�WR}7 RESPECTTO WHICN 7HIS CERTIFICA7E MAY BE ISSUED OR
MAY PERTAIN,7HE INSURANCE AFFORDEO BY 7HE POLICIES UESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTfl SR TYPE OF NSIIRNNtE POLICY NURHHt DATE(��D/TY) OAl£(N�NODMI) LMRS
ceEauuq��rtr EncHoccwaEr1cE S 100000
A X coMnEacir�cweanLuraiuTv CP010932 06/18/09 06/18/10 prteMises(eaoccua�ce) f 10000Q
CIAIMSAMfIE �OCCUR MEOEXP�MrymeDerson� SSOOO
aErzsorw.BnnVlrauRY f IOOOOOO
X Liquor Liability GENEPPLAGGREGAIE E ZOOOOOO
GENiAGGREGATELIMRPPPLIESPER'. PRODUCTS-COMP/OPAGG SZOOOOOO
PaICY ,j�d LOC o
���LE��� CCMBIl�ED SINGLE LIMR
!wY NJ�o (Ea xcitlem) S
���„�os DEC 1 1 2009
BODILY INJLRY $
SCHEDULED PAR�S (Per persan)
„„�o,,,�� HEALTh1 Utr � .
BODILY INJURV $
NOKOWNEDAlJ�pS �Pe�eccl�eM)
FHOPERTY DPM4GE s
�PereccideM)
GARAGELN&LffY N.Jr00NLY-EAACCI�ENT $
PNYP4R0 OlF¢RhWJ EAACC $
PUr00NLv: A� $
E%CESSftIIBFELLALl4&LRY EACHOCCURf�NCE S IOOOOOO
A occua �cuinnsr.noe UM010678 06/18/09 06/18/10 ���.� S 3000000
a
oEoucne� 3 —.
X RElEMION $ $
WOPo(ERSCOMPENSATONOND TORYLIMITS FR
A enxovaes•�weam {�03329608 08/15/09 08/15/10 E�.EncHnccioEnrt 8500000
PNY PROPRIEfOWPPRINER/E%EGf�NE
oFFicEannEineFa�cc�wmv E�.oisEnsE-EnExv�ove� 5500000
Ii yas.Jescnbe unEer
SPECIPLPROVISIONSbelav ELDISEhE-POLICYLIMIT SSOOOOO
onisi
DESCRWIpN OF OP9EATONS/LOCATIONS/VEHCLES/E%CLUSIONS PDOE�BY ENDORSEMCN!I SPEC141 PROVISIONS
Restaurant
CER IFICATE HOLD R CAN L ION
SADSPLE— SIqULDONYOFTIETBOVEDE3CRB�POLILESBECPNCELLEDBEFORETXEE%PIRAII(+:�.
DAIE TFEREOF,TIE ISSIING INSURH2 W1LL BIDEAVOit TO MAA IO DAYS Wfi11lEN
NOTIGE TO 11E GERIIFlCAIE IqLDHt NPMED TO 1XE IEFf,&lT F➢1LUHE TO DO 30 SH4LL
IMPOSE NO OBLIGRTON OR LIA8ILIIY OF ANY KND UPON 1XE INSUFlER�AGF.YfS JR
*kR�#irA*�}*y`j�]e�f�kd#R�##R##M REPRESEMATIVES.
A
5 2007 988