HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 � TOWN OF YARMOUTH BOARD Q�-�.T'��� �l'.�' ':����� �i��''
��� APPLICATION FOR LICENSE/PERMt�-2'OO�y , � �
�a13� ` JAN 2 8 1009
* Please complete form and attach all necessary dcrbum��y Dece DEPT.
Failure to do so will resuk in the return of your applicahon pac
NAME OF ESTABLISHMENT:�Q�,�a(� L=5 C��7�.1(/ E.tdl: RAtC.L-7L�-STEL. # 5��-7�5-g��2--
LOCATIONADDRESS: 3S I{U�J(I�JCnTadJ fYUr S, Y MOU77f� N/� C�2<ala`F
MAILING ADDRESS:
OWNER NAME: � ��a�i�� TAX ID FEIN or SSN :
CORPORATION NAME (IF APPLICABLE}: �p(L« WG�b� nuG.
MANAGER'S NAME: /}L GAP��L� TEL. # Sb�-227-v�25
MAILING ADDRESS: SA�(E
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 certification to tlus form.
i. �'�H" 2.
Pool operators must list a minimum of two employees cun•ently certified in basic water safery, standard First Aid and
Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies ofemployee
certifications to tlus 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 requued 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 Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Heaith Department wiil not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. N�� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIG) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service estabiishments with 25 seats or more must have at least one employee trained in the Hennlich
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 maintain a file at your piace of business.
1. ��� 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI�iG:
L[CENSE REQIDRED FEE PERMIT s? LICENSE REQUIRED FEE PERNIIT 's` LICENSE REQUIRED FEE PERMIT#
_B&B S55 _CABIN S55 _MOTEL S55
_INN S55 _CAMP S55 � _SVJIMMINGPOOL SSOea.
iODGc S55 TRAII,ERPARIi SI05 WHiRLPOQL 5fi0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMII-#
0-100 SEA'IS SSS _CONTINENTAL 335 /NON-PROFIT S30
_>100 SEATS %160 _COMMON VIC. 560 ✓ WHOLESALE S80 ����
REtAIL SERVICE: � —RESID.KITCHEN 580
LICENSE REQLJ[RED FEE PERMIT# LICENSE REQI.IQLED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_<SOsq.B. S50 _>25,OOOsq.ft. 522� _VENDING-FOOD S25
_<25,OOOsq.H. S80 _FROZENDESSERT 540 _TOBACCO S55
�.a�iE cxnrcE: sio AMOUNT DLTE _ $ �o . 00
""*""pLEASE TURN OVER AA'D COA4PLETE OTHER SIDE OF FOR�i""*••
. ,
ADNIINIS'I'RA'ITON
Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTt'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth tases and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHII-IENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transiern occupants must haue and be able to demonstrate that they maintain 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 Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days
pnor to opening. PLEASE NOT'E:People aze NOT allowed to sit m the pool azea until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total colifonn and standard plate count
by a State certified lab, 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 SER�'ICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department 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 Pemut 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 Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking, prepazation, or display of any food product by a retail or food service establishmern is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.TI'1'TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQilIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO t1ND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATLTRE: �To+tN Su-tA�FE'2_.
PRINT NAME&TITLE: D�R c c/� .S'.4UfS
10/21�O8
DATE(MM/DD/YVYY)
A CORDTM O1/08/2009
PRo°°ceR Tf�S CER77F[CATE IS LSSUED AS A MAITER OF INFORMATTON ONLY
AOn RiSk SefVices Centfa�, InC.
Phi 1 adel phi a PA Offi Ce AP1D CONF'ERS NO RIGFI'IS UPON 7HE CER'17F'[CATE HOLDER THIS
One �iberty Place CER1TFiCATEDOESNOTAMEND,EXTENDORAI.1'ERTHE
1650 Market Street COVERAGEAFFORDEDBYTHEPOLIC�SBELOW.
suite 1000
rhiladel phia PA 191�3 USA $$A�'ORDINGCOVERAGE NAIC#
rao�ve- 866 283-7122 F�- gq7 953-5390 ECENED
wsuxcu . wsursFaen: uri h erican'�ns co 16535 :
seorge weston eakeries inc. on behalf JA �� - ' . i
of its subsidiaries, units & divisions, �
incl Stroehmann aakeries, mc, stroehman �vsursEna � ^o
aakeries PA LLC & Stroehman aakeries �C ^�
� 255 ausiness center orive, suite 200 TOWN �aRATOR r-�-- ,�,
Horsham PA 19044-3424 u5a � �� =
wsuxEae: x
THE POLICffiS OF INSIIRANCE LLSiFD BII,OW HAVE BEEN ISSUm TO'fHE INSURID NAbffiD ABOVE FOR THE POLICY PERIOD A]DI ATED. NOTWITHSTANDING
ANY REQUIILEMIQ�]'I',TIItM OR CONDTIION OF ANY CONTRACT OR OTHEIt DIX;[1MENT W1TH RESPEC7 TO WFllCH 7HIS CEIt71FICATE MAY BE ISSUED OR MAY
PERiAAI,iHE WSURANCE AFFOADID BY THE POLICIES DESCRIDID FIE2EIN IS SUBlECT 70 ALL THE'f'ERMS,EXCLUSIONS AND CONDTIIONS OF SUCH POLICIES.
AGGREGAIELIMITSSHOWNMAYHAVEBEENRIDUCIDBYPAIDCLAIMS. LIMITSSHOWN ARE AS REQUESTED
OVSR DD' PoLICYEFFE POLICYEXPIR.1'I[ON
LiR rn5 '1'1'PE OF INSIIRANCE PoGCY NUhIBEA LNiI'CS
OATE(MFMD\n) DATE(MM1MD\W)
A Eav,uwBwrs� GL0837475611 O1/O1/09 O1/O1/10 EACHOCcursnENCE Y10,000,000
X COhA�RCIALGENERALLIABR.CfY DAMAGE'IOREN]ED S1OO,O00
CLARdS MAD2 � OCCUR PR£t�9SES(Fz occurence)
( oneoason
O
PsxsONu.ffinnVmnmY E10,000,000 �
.i
GEr�ui wccaEcwrE $10,000,000 �
GENL AGGREGATE LQ.SfC APPL�S PEA-. �
PROWCTS-COMP/OPAGG $10�000�000 m
❑X POUCY ❑ ��- ❑ �p� O
�
A AUTOMOBn.e Lusarrr eAP837475211 Ol/Ol/09 Ol/Ol/10 COt.mm�n SmG�Lmvr p
X �A�.�.� A05 (Fa ecddem) El,000,000 ,'�
Y
V
ALL OWNED AUTOS BODR.Y INI[1RY �
SC}�DlJL6D AITf05 (Peepmson) 47
.L
X E�tF.DA[ITOS � BODD,YWMtY V
X NONOWNEDAUTOS (Paecadatt)
X 5500 Ded Collision PROPEftTY DAMAGE
X 4500 oed Comorehensive (P«scodmi)
GARAGE LIABII,ITY AUiO ONLY-EA ACCmENT
B ANYAUTO
OTFIFR'1'FiAN EA ACC
AUTO ONLY:
AGG
EXCESS NMBRELLA LIAB�.I'1'Y EACH OCCURRENCE
❑OCCUR ❑ CLAIMSI.IADE AGC.REGA1'E
BDEDUCItB�.E . . . . .
REIEM ION
A WC 4 ,�( C STATU- OiH-
WORI�RSCOhIPENSATIONAND (q05)
A E���� �Ba�� E.L.EACH ACCIDEM $1,OOO,O00
ANYPROPRIETOR/PARTNF.R/EXECVCIVE W�0837475109 01�01�09 O1/O1/10 =
MA�WI�OH,WA.1W
OFEICEftMtEM1ffiEREXCLUDED? E.L.DISEASE-EAEMPLOYEE $1,000,000 �
Ifya,dacribewderSPECIALPROVISIONS � E.L.DISEASE-POLICYLRvLT E1,OOO,000 �
below
Oi9ER �
DESCRIPiION OF OPERATIONS/LOCAilONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSFMENi/SPECW.PRONSIONS �
any ndditional insured status granted to certificate Nolder is limited to the specific terms and conditions
contained in the contract and/or agreement currently in effect between insured and Certificate Holder as of the
date this certificate is issued. �
Town of varmouth eoard of tiealth sxouinnmoert�aeoveoescxmmeouc�saec.wcecceoseFoner�e�amnnoN �
1146 Route Z$ DATE THEREOF,THE ISSUWG INSURER WIl.L ENDEAVOR TO MAIL �
varmouth rnA 02664 USA 30DAYSWRITTENNOTTCETOTHECERTTYICATEHOLDERNAMEDTOTHELEFL �
B[TI FAQ.URE TO DO 50 SHALL IMPoSE NOOBLIGAT[ON OR GABILITY a�
OF ANY KIND UPON THE WS[1RER,ITS AGENTS OR REPRESF.N'1'ATfVES.
t k"
AUTHORIZEDREPRESEMATIVE ..9 /7f ..C-pN� CO S g� �
c�dmrs :92"isE J (a�vLes<✓
�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-147 FEE: 80.00
In accordavice with re�u]ations promulgated under authority of Chepter 94,Section 305A and Chapter
I 1 l,Section 5 of ihe�'ieneral Laws,a peimit is hereby ganted to:
George Weston Bakeries Inc. 35 Huntington Avenue, South Yarmouth, MA
Whose place ofbusiness is: Amold Sales Co. Inc./G.W. Bakeries
Type of business: Wholesale Food Service
To operate a food estabGshment in: Town of Yarmouth
Permit expires: December 31. 2009 BOARD OF HEALTH: .�felea Sl�a�t, �J2..lv., �atixnta�t
e� .� x� v�e�,�
�es. �, el�
���., r�..�v.
January 28.2009
iuce G. Murphy, ,R.S.,CHO
Director of Heal