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Home My WebLink AboutApplication and WC � �^° TOWN OF YARMOUTH BQAR� � k�i.�'H, -YT� , y �� APPLICATION FOR LICENSE/P��VI T ��11 '� , * Please complete form and attach a11 necess��ocu�ments by cember IS Z *-j Failure to do so will result in the retum of your applicat� n � ESTABLISHMENTNAME: GYd�r CaoL C✓r-,o-s.-�a✓�, TAXID•�� LOCATIONADDRESS: S -t1�,�,0-�� C.,I,,,,, G�� S= I/�� TEL.# S?r�-35�- �yao MAILING ADDRESS: t ,�.,,.,� � OWNER NAME: /�//�,.�, t�A�,'c CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /�/,o,n ,�✓�..,n; TEL.#: MAILING ADDRESS:__ _,� POOL CERTIFICATIONS: The pool supervisor must be certiGed 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 forni. 1. 2. Pool operators must list a minimum of two employees cun•ently certified in basic water safety,standard Fnst Aid and Community Caz•diopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past y�ears' records. You must provide new copies and maintain a Gle at your place of business. 1. 2_ 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislvnents u•e required to have at least one fiill-time employee who is cenified as a Food Protection Manager, as defined 'ui the State Sa�utary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of ceitification to this application. The Health Department will not use past gears' records. You must provide new copies and maintain a file at your establishment. 1. �A✓��a�� /Zcve,ic... 2. �'�.� �/�+�i`t PERSON IN CHARGE: Each food establislunent must have at least one Person In Charee (PIC) on site during hours of operation. �. /�/�.., �,9-�,� 2. Be-„s�... � .q-�,j HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee n•ained in the He'vnlicl� Maneuver on the premises at all times. Please list your employees trained in anti-chokine procedures below and attach copies of employee certificatiovs to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1._ ��✓3.i %�/�-✓i� 2. 3. 4, RESTAURANT SEATING: TOTAL #� OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER�III# LICENSE REQUIRED FEE PER�III = LICENSE REQUIRED FEE PER�SIT r _B&B 555 _CABIN S55 _\407EL S55 _INN S55 _C.41�IP S55 _SI�INLVIINGPOOL S80ea. _LODGE S55 �TRqII,ERPARK 5105 \l��'fiIRLPOOL S80ea. FOOD SER�-'ICE: LICENSE REQUIRED FEE PE&bIIT= LICENSE REQUIRED FEE PERbIII'r L[CENSE REQUIRED FEE PERbiff= . ( 0-100SEA2S S8i �'"I��.�" _CON'IINENI'AL 535 NON-PROFI7 530 _>I00 SEAiS 5160 � �CO'vLtiION VIC. S60 ��"bs(� _�y'HOLESALE S80 REI'.11L SERVICE: —RESID.KIICHEN S80 LICENSE REQUIRED FEE PERvtIT# LICENSE REQUIRED FEE PERvtIT- LICENSE REQUIRED FEE PER�iIT� _<SOsq.ft. S50 _»S,OOOsq.B. 5225 4'ENDING-FOOD- S29 _<25,000 sq.fl. S80 �FROZEN DESSERT S40 "�'�(-�� iOBACCO S55 \�1�1E CHA\GE: SIS AMOUNT DUE _ $ I8S .00 ***`"PLEASE iLR�OVER A\D COSIPLEtE OTHER SIDE OF FOR}I*•"** ADMINISTRATION • 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 Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taz�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have 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 OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depamnent prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POUL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Heaith Department to schedule the inspechon three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmecrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta�ned at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocat�on 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 Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII.IT'1'TO RET[7RN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: //- �p -/v SIGNATURE: �/',,� iy,.� � �,,,,,i— PRINT NAME&TITLE:��, � ��,,,,f �'i w,,,.� 10 06']0 • ' Clienl#:46785 . CCCRE �ACORD,� CERTIFICATE OF LIABILITY INSURANCE °"�;��o""""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS , CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER?HE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certifiwte holder is an ADDI710NAL INSURED,the policy(ies)must be entlorsed.If SUBROGATION IS WAIVED,subjed to the terms and conditions of the policy,certain policies may requfre an endorsemenl A sWtement on fhis certificate dces not confer righls to the - certificate holder in lieu of such endorsement(s). : PRODUCER' �E; DEf115E D2L@O Rogers&Gray Ins.So.Dennis PXONE 508 7605745 508-258-2129 qIC No Ert: NC.No: 434 Route 134 ' deleode@rogersgray.com � RDDRE55: P.0.Box 1607 cusrorers io s: South Dennis,MA 02660-1601 INSURER�S�AWORDINGCOVERAGE NAICp iNsurseo � iNsuRERA:CNA/Continental Casualty Compan Cape Cod Creamery,LLC ixsurscne:National Pire Insurence Co.of 5 Theater Colony Way INSURER C: � South Yarmouth,MA 02664 - INSURER D: INSURER E: INBURER F: COVERAGES CERTIFICATE NUMBER: � REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIO�J INDICATED.NOTWITHSTANDING ANY RE�UIREMENT,TERM OR CONDITION OF ANY CONTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$ . . . EXCLUSIDNS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CIAIMS. � TYPEbFINSURANCE � POLIGYEFF � POLICYEJ� LIMRS N R POLICYNUMBER MMIDD/YYYY MMIDD GENERALLIABILRY FJ�CHOCCURRENCE $ ' REN E COMMERCIALGENERALLIABILRY PREMISES Eaoccurrence $ CLAIMSMADE ❑OCWR ME�cXP(Myoneperson) $ PERSONAL 8 ADV INJURY $ . GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-GOMVIOPAGG $ � . FOLICY PR6 LOC s . AUTOMOBILELIABILITY COMBINEDSINGLELIMIT . s ' (Ee accidenp ANVAUTO BODILVINJURY(Perperson) $ � AILOWNEDAUTOS BODILYINJURY(Peraccident) $ SCHEDULEDAUTOS PROPERNDAMAGE $ HIRED AUTQS (Per accitlent) NONOWNED AUTOS � E $ UMBRELLALIAB pCGUR EACHOCWRRENCE $ EXCE55 LIAB QAIMSMAOE AGGREGATE $ DE�UCTBLE $ RETENTION $ A WORKERSGOMPENSATION WC2077173819 5/01/2070 OS/01/2071 X WCSTATU- OTH- . AND EMPLOYERS'LIABILRY ANVPROPRIETOR/PARTNERIFJ(ECUTIVEyIN E.L.EACHACCIDENT $SOO�OOO OFFICERIMEMBEREXCLUDED? � N�A (MantlabryinNH) E.L.DISEASE-EAEMPLOVEE $SOO�OOO If yes.tlesaibe under ' . OESCRIPTIONOFOPERATIONSbHow E.L.DISEASE-POLICVUMIT $SOO�OOO DESCRIPTION OF OPERATIONS/LOLATIONS/VEHICLES(Attxh ACORD 101,AJtlitional Remarts Sclwduk,if moia apace is requi�etl) retail ice cream operation CERTIFICATE HOLDER � CANCELLATION 70 D3 s for Non-Pa ment - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES eE CANCELLED BEFORE . THE IXPIRATION DATE THEREOF,NOTICE WILL BE DELNERED IN ' TOwfl Of YBRIlOUt11,Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main St�eet,Route 28 � , South Yarmouth,MA 02664 AUTHOR�D REPRESENTATNE i 0798 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009I09) 1 pf 7 The ACORD name and logo are registered marks of ACORD iIS60174IM54024 DD