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� APPLICATION FOR LICENSE/PERMIT-2004 ���
a Y��? pv�bs�IJ��R. (�cr-�
* Please c�lete form and attach all necessary do0►,.�lents by December 31, 2003. ���
Failure to do so will result in the return of your application packet. ��
L�IAME OF ESTABLISHMFNT: 5T�2/P�S Svn/St'7�'/Ae/LL TEL #SOFl 2�//Of�3y
L N • SOVY'ff ST�l�BT' .f�T �/�/L�G Blc�lsi! S_ `
MAILING ADD F : � 36 �'/Y�✓/!lu O� s. y.9�2 �.�- OL66
OWNER/CORPORATION N M : p/A��/�' � Gd G�'7t/3 cC�
MANAGER'S NAME: _�/A'i✓�� � Gd c-tA7�s TFT, #6"Z7� O ��
MAILING ADDRESS• 3( lts✓!�✓/��l bR S �'�i.e �9ff- �Z6(af� -
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POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as require ' �i$t@��i ated
Pool Operator(s) and attach a copy of the certification to this form � ,
1.
� JUN 3 0 2004
HEALTH D P .
Pool operators must list a minimum of two employees curren ertified in basic wa e , s ust Aid
and Community Cazdiopulmonary Resuscitarion (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Deparhnent 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 ANA R - CERTIFI ATION :
All food service establishments 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 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. ,
1. D�i /V� -�GOGL�",I�S 2.
PERSON IN CHARGE:
Each food establishxnent must have at least one Person In Charge (PIC)on site during hours of operation. '
1. Dl�Na� F Gol,�fi'7�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 trained in anti-choking pmcedures 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 place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# O�-�� U
OFFICE USE ONLY
LODGING:
UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE PERM[T#
B&B $50 CABIN S50 _MOTEL ��$50
INN $50 CAMP S50 _SWIMMING POOL S75ea
_LODGE $50 _TRAILER PARK $50 _WI-�RLPOOL S75ea
FOODSERVICE: �- '
�—�,� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
., �/ �0-100 SEATS $75 �� _CONT[NENTAL $30 NON-PROFIT S25
�/ _>100 SEATS $150 _COIvllNON V[CT. S50 _WHOLESALE � S75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�t LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 >25,000 sq.ft. 5200 _VENDING-FOOD S20
_<25,000 sq.ft. $75 _FROZEN DESSERT S35 _TOBACCO $25
NAME CHAIVGE: S10 AMOUNT DUE _ $ 7S_O�
'+•'*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*••••
�
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. . ADI�IINISTRATION
Under Chapter 152, Section�, Subsection 6,the Town of Yaimouth is now requirad to hold issuance or renewal
of any license or peraut to operate a business if a person or company does not have a Certificate of Worker's
Compensa6on Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
#: AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
� � �
'"' CERT. OF INSURANCE ATTACHED
r:: _
` , _ �
f.; WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACFIED
�`
` Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yow permits,' PLEASE CHECK
APPROPRIATELY IF PAID:
YES �C Np
NUTIC�':Permits ivn annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETCJRN
Tf�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31; 2003.
SEASONAL ESTABLiSHIvIIIdTS ARE TO CONTACT Tf�HEALTH DEPARTME'NT FOR 1NSPECTIO 7-10
DAYS PRIOR TO OPENING FOR Tf� SEASON:
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVTING, NEW
EQUIPIv1ENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEi1LTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A S1TE PLAN.
ti
; _
'' AI?DITIQN i. F. ii.ATION
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� POOLS
� POOL OPENING:All swimming,wading and whirlpools w}uch have been closed for the season must be inspected
i by the Health Department pnor to opemng.
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 grotmd swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
C�0�4iTMFR A�VISORY•
Each food establishment which serves or sells ready-to-eat,raw or undencooked animal products are required to post
Consumer Advisories.
�,ATT iN PO .IC�i_�
Anyone who caters vv� the Town of Yarmouth must notify the Yarmouth Health Department by filing the
reqwred Temporary Food Service Application form 72 hours prior to the catered evern. Thses forms can be
obtained at the Health Deparcmen�
FRO .F.N D .SCF.RT •
Frozen desserts must be tested on a monUily 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 Fmzen Dessert Permit until the
above terms haue been met.
OiTTCID FN'C•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),g�have prior approval from the Board of Health.
OUTDOOR OOKIN .:
Outdoor cooking,PrePara�on,or d'ispley of azry food product a retail or. ent is proltibited.
�
DATE: 6 .�� D SIGNATURE:
,
PRINT NAME Bc 11T'LE:_.__ Z�/�4,r�.v� G G'OG�..y yr�-�
10/22/03
� u The Commonwea/th ojMassad.,.lsetls
� Deparrment ojlndustrial.-Iccidents
; 0/llceaJlsrsstlestliis
600 Wnshington Street
� Bnston, Mass. 02111
"� '` W'orkers' Compensation Insunnce Affidavit
Aoolicant informallon: P►easePRiN7'Tes�Tt
namv 5�����5 �(/�� ��L�
luc�tion� s0✓� $ .�L�1-'� A� 6/j$`7 ����X' g(�'f.' � . .
��� 5. Y//F�i/�! �� O7.f7�� � ehonep� S�Z���7�� .
� I am a homeowner pertortning all work myself.
, � I am e sole propriecor_-d ha�e no one «orkin_ in an} capaein�
' � I am an employer pro�iding workers' compensacion for my employees u,orkine on[his job.
eomnan� namr 5�/�L�iS .�J/✓.�f%� �/QLC/Li
��Jdress• p0. '�� �G7 .'�
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� I am a sole proprie[or. general contractor, or homeowaer(circle ontl and ha�e hired the contrattors listed below uho ha�e
the follu�cin_ ��orker," ,ompensation polices:
companv n+me• � � � -
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{�tr:. . . . phone 8• � � —
insur�ncc co yolicy q
iqmoanv namr �
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ritw . . � � nheee M• . .
insaronee eo � ��n'M � -
Failurc ro ueure coren`e�s requfrcd under Seeaoe 25A o(MGL 152 w Ind to�Ye i�paitlo�otuidW pndtln o!�G�e vp m SI�00.00��d/or
oae yean'fmprimnment��wxll u eiril peeNtla io the fcrm of�STO�WORK ORDER t�d a Me off100.00�d�r K�imt�e. I��denu�d HN a
rnpy o(thy sn�rmrnt m�r be for.nrded to the 011fee of Inve�Ug�uom of 16e DIA for eoren{e veri8adoa
!do hereby cenijp und�ins art rn �rhat the injormallon providad abnve!t mte and rnrrcei
Signaturc -� �� � �� �
Print name Phone M
olTicial use onl. do not rrite in�his arca to be eompleted by eiM or town ollieial �
ci�y or towa• Y�DTQ _ .peneiNieeox M nBuildio�Department
pLiemsiee Bo�rd
p eheek if immedia�e r�spoese i�required 261 ❑Stlet�meo'a Olflee
. �HwItA Dep�nmeet �
contact persan: pdant N:_ �508� 398�2231 eat. nOther
A.�D CERTIFICATE OF LIABILITY INSURANCE °"'�""'"°°'""''"'
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P�oueER (508)656-,1400 FAX (SOS)656-1499 TXI$CERTIFICATE IS 13SUED q$A MATTER OF INFORMATION �
Menbers First 7nsurance BPOklPS IOC ONLY AND CONFER$NO RICiFITS UPON THE CERTIFlCA7E
4 Standi sh Rd HOLDER THIS CERTIFICATE DOES NOT AIAEND,EXIEND OR '
ALTER TIIE COVERAGE AF�ORDED BY THE POUCIES BELOW. �
Bridgarater, MA 02324
IN3URER8 AFFOf301NG COVERAOE NAIC# .
ixsuneo U�anne Co atos ir�=�nean: Guard Insurance Conq�y .
DBA: Stripers Sunset Grill IN9URERB:
I36 Coveview Dr �rvsurs�Rc
S. Yarenuth, MA 02664 inisuitereo: .
INSLIRER E: �
C01/ERAGFS �
THE POLIGIES OF INSURANGE LISTED BELOW HAVE 6EEN ISSUEO 7p 7H6�NSUREO NAMED A60VE FOR TNE POLICY PERIOD INDICA7E�,NOTMTNSTANDING
ANY REQU�REMENT,7EIiM OR CONDITION OF ANY CAMRIICT OR OTHER DOCUMENT NRh1 RESPECT TO WHICH 7HI3 CERTIFIGI7E MAV BE 135UED OR �
MAY PE/iTAIN,Tt1E INSURANCE AFFORDEU BY T11F POLIqES OESCRIBED I1QtElftl IS SUBJECT TO ALL THE TERMS,EXCLUSION6 ANU CONDITION9 oF SUCH'
POI.ICIFS.AGGREGATE tJMYY$SMpWN MqV IiAVE BEEN RE WCED BY PND CWMS.
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ACORD 26(2001I08) FAX: (SO$)398-0836 �pCORD CORPORATION 7888
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