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Home My WebLink AboutApplication and WC O � ' ' �e�'"�' ,� s:a.��zs °`�"�. TOWN OF YARMOUTH BO ALT$ ` 3= ` APpLICATION FOR LICENS �2 ' G� �`' "C�x :� � � �; �"� �� ✓I %� ie *Please complete form and attach all necessary do �� ents by December 31,�@b�42 6 Z 005 Failure to do so will result in the retum of your application pack . HEA T NAME OF ESTABLISHMENT: .�TR/P�725 SU�rlS�T F�/L L- TEL. #S�f3.2 /,o .3 f� LOCATION ADDRESS: Z�ZO 56U17f 5 S. �rQUT-h/ MAILING ADDRESS: P.G• �"JX 6rf3 S, D�/.r//S oZ/�4 a OWNER/CORPORATION NAME: 1�/�i � f GOL�/f 7��-. �6G MANAGER'S NAME: D/ilX/.r/-�F GOGG�S . #S/.t�Zs%/.OYvTy binII,ING ADnitEss: � O, ��Y 6y3 S��i��s.sJ� dZlo(ol7 . POOL CERTIFICATIONS: T6e poot 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 this form. 1. 2. Pool operators must list a m;n;,m�.r� of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of empioyee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. � 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Al! food service establishmerns are required 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 Establishme�s, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Healt6 DepaRment will not use past years' records. You must provide new copies and maintain a fde at your establishment i i. �lAa�l�f/� �. GOG�S 2. PERSON IN CHARGE:- - Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �/�.l� � G0�2�1 S 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 uained 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£de at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItID FEE PERMI'I'# LICINSE REQi7IItED FEE PERMI'1'# _B7CB S50 _CABIN � $50 _MOTEL � E50 _INN $50 _CAMf' S50 _SWIIvi[vIINGPOOL$75ea. _LODGE $50 T'RAII,F,RPARK S50 WIDRi.POOL S75ea. FOOD SER'VICE: - LICENSE REQUIItED FEE PERMIT# LICINSE REQUIItED FEE PERM[T# LICENSE REQUIItED FEE PERMIT# 10.100SEATS S75 �6S'18S _CON1'INENTAL $30 NON-PROFIT $25 >100 SEATS SI50 COMMON VICT. S50 WHOLESALE S75 RETAII.SER�'ICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQiJIl2F.D FEE PERMIT N LICENSE REQlJIl2F.D FEE PERMI1'# _<SOsq.ft $45 >25,OOOsq.R. $200 VENDING-FOOD S20 '� _Q5,000 sq.ft. S75 _FROZEN DESSERT $35 _TOBACCO S25 �. NAME CHANGE: S10 AMOUNT DUE _ $ �ZSI.O� ••"•'PLEASE TURN OVER AND COMPLETF OTHER SIDE OF FORM••"'• , � - . � . ADMINISTRATION ' Under Chapter 152, Section 25C, Subsecrion 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to ope�ate 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 I CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTl' SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RE$PONSIBILITY TO RET[JRN Tf�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTME1dTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTfI PRIOR TO COMIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I ADDITIONAL REGULATIONS I POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departmem prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform 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 SERVICE CONSUMER ADVISORY: Each food estaU'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post , Consumer Advisories. ' CATERING POLICY: ', Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the ; reqwred Temporary Food Service AppGcation form 72 hours pnor to the catered event. Thses forms can be , obtained at the Health Departmem. F�E1�fi�ESSER3'S:- — -- _ _ 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 revocauon of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAFES: ' Outs►de cafes(i.e.,outdoor searing with waiterlwaitress service),mnst have prior approvai from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: _�O�o ' �� SIGNATURE:C� ��G%��„ PRINT NAME& TITLE: �'�DGt�� LiJ��- I 10/22/04 I I � ':, � =d�, CERTIFICATE OF LtABILITY INSURANCE o�ioiizo°"""'oa =R (SOS)656-1400 FAX (508)656-1499 TNI3 CERTIFICATE IS ISSUED AS A p1ATTER OF INFORMATION � .mbers FirSt YnsurdlfCO BrokBrS Ztl[ ON�Y AN�CONFERS NO RIGXT$UPON THE CERTIFlCA7E 4 StandiSh Rd � HOLDER.THIS CERTIFICATE DOES NOTqMENO,EX7END OR ALTER THE COVERA6E AfFORDED BY Tt1E PO ICIE3 BELOW. � Bridgerrator, MA Q2324 INSURERS AFFORD�NG COVERAGE ' NqIC# Id9URE0 Dianne C0��8Z05 . IN6lJRER4: (�pj�rQ TOSIJMAIIC6 Co�any DBA: Stripers Sunset Gri71 I.VSURER@ 36 Coveview p� rtiSURERC' - S. Yarnouth, MA 02664 INSunEMp: I.V$VRER L � OVERA i HE POLIC�H6 OF INSURANC6 uSTED BELOW HAVE BEBN ISSUEp TO THE tN3URED NAMED A80YE FOR TM8 POLICY PERI00 INDICATED.NOTMTHSTANOING� ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRpCT OR OTHER DOCUMENT W1TH RESPEC'f TO WHICH THIS CERTIFICATEMAY BE ISSU6D OR M/1Y PERYAIN,7HE INSURANCE AFFOROHD BY THE POUCiES OESCRIBED NEREW IS SUBJECT SO ALL THE TERMS,EXClU310NS ANA CONDITIONS Of SUCH POLICIES AC+GREGATE UMI75 SMOWN MAV HqVE BEEN REDUCE�8Y PAIO CLAIMS. �n� ar TAEOFIN{{fRpNG[ PoLIGYNUMBER ` bUCYEFfE G POLICYEXNRIITON V�� GENBNb4LUl81L(7Y EACH"�CURRENC� S COMMFRCWICaENERAI.LIA01tiTY GRMAGETOREMfO 6 CWMSMA� �OCC'Ja ME7E%P(MroMpMaon) � S PENSQYtit>WINJUAY S GENERa�AGGRCGATE : � Gf.rxi.AGGqEAnTE UMR APPL�ES PER: �P,�pp'�75.COMP/OC A6G $ POLICV 1� �� LOC i r— . �AUTONOBi�,{,IppRITY � C04t31Nf�5tN.::E.DA1T ANYauip !EeflaYca+!) $ ALL OYMED A(J�(�5 0071LYItUURY .S SCFIEOU4EOAtJfQS � I (PNpnml� "_ � HIREGA:ITOS BOJ�IYIYJURY b NONONNEDAUTp$ — I I (P9rBc0p9iv) PROPERTI'Dw1eaGE S (Px BCciMM) CNR�GELI�91{ATY � AU�OONLr-ewq��DEnT •5 WVAUTO � � — ' O?F15RTH.11 �FCC S ` � AUTOONLY: �I s E][CE56f�MlREILALI►91YTY pqCnxWRRErK'< 3 ' I �GW �CLNMS M�ACE �AGGRECKTE f I � DEIX1C7181.E I 'S i 3 RETENTIpH $ s won��aco'nrcns.rannno STYK536486 0�/Ol/2004 O7/41/20U5 X ��8�A� oTM- -- �urwresr iueam A oF�icert°m�"�"Eia'�Excuoc�Ecunve EL tqCM RCG9pN{ S 100 000 ppppa�y� I fl.L.�1&ENSE�E7EMM.OYf S lOO O Si'EGULVNpviS10M30Nav E,L�1SElu�-aOLICYLIMiT S SOO OO OTNER I I , DESC��p7bMMO►ERATONC/lOCA7WND�yEry�CLEEfEXRUS10NSqODEDBYENoOasGN1FN}�906[IALPAOVIp,qNS CE IFIC XOL CAN LATI � � ... RHOULOAhVOFTNE�H7VEDLSCMBEDPOLICIF7BEGNCElLED9�TORfTHE � E%7�WA710N D4TE TXEfHOF,TNE 19SUHIp IMSURFR YNLLENpFAVON TO MI11L ._OAYE WRI77pN NQT�CE 70 TXE CEMtIq�p}�Np�,pEp NpMEO M 7kE LEF7. TOtrn Of Yanippth Heaith Office BuicW��0.ErOM1WLlyGNNOnCEJHa��iMPo3E[IbO8L16LTONORLIA&UiY David Flaherty OiAt�yWN�UPONTMEIp��p[p,�TyAGENT9WlpEp�gpyfAMEy Yarnputh, MA 02664 numo�oxevq�,ternamrt i. ncorto25�2ootro8) FAX: (SO8)398-0836 � �ACORD CORPORA710N 1988 � � Make check payable to InterGUARD, Ltd. GUARD INSURANCE Remittance /�►ddress: G R O U P P.o. BoX 41658 www.guard.com Philadelphia, PA 19101-1688 FINAL AUDIT BILLING STATEMENT Workers' Compensation Premium STRIPERS SUNSET GRILL Agent: 508-697-0700 P.O. Box 643 MEMBERS FiRST South Dennis, MA 02660 INSURANCE BROKERS 4 Standish Road Bridgewater, MA 02324 Statement Date: il/14/2004 Polity Number: STWC536486 �.,..;,... ni...r_i ievn rr,��ranra C'.mm�anv PolicY Period: 07/Ol/2004 - 07/01/2005 �