HomeMy WebLinkAboutApplication and WCr
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. TOWN OF YARMOUTH BOARD OF H�ALTH
APPLICATION FOR LICENSE/PEI2MIT="2010 fo�
* Please complete form and attach all necessary documents by Dec���Z009.
Failure to do so will resuk in the retum pf your applicatiott pac et.
NAME OF ESTA$LISHMENT: ���.e C.,,,Z Gv�c,.a.,,,,ci, TEL. # 32 j�-3 9Y-Y�/up
LOCATIONADDRESS: C— -t'�,.<,,1,.. ,Ir_,, l-.�.., .�
MAILING ADDRESS: 5,4,,.,,�
OWNER NAME: l��ii.-, �,�,�C TAX ID �FEIN or SSNI� �
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME:___ /j/r� `��,n� TEL. # sZ P-7G u- ���3
MAILING ADDRESS:. S/a-w..�
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 this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain e file at yonr place of business.
1. a.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
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 Seivice Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You mnst provide new copies and maintain a file at your estab6shment.
1. J'� �i'�.-1 ' Jl�-�3 2. i'�'1/dr�n,�3.�L.. /�a(�e..c.i
���,
PERSON IN CHARGE:
-- - - _ __
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1._ /�'l Y� t�f-Y�-3 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich
Maneuver on the premises at all tunes. Please list your enployees trained in anri-choku�g procedures below and
attach copies of employee certificarions to this form. The Iiealth Department will not use past years' records.
You must provide new copies and maintain a file at your place ot business.
i. 2.
3. 4,
RESTAURANT SEATING: TOTAL# 7
OFFICE USE ONLY
LODGING:
LICkNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'1'# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL %55
_INN $55 _CAIv*3 S55 _SWII�IMING POOL $80ea.
_IADGE $55 _T1tAILERPARK 5105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUQtED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
�0.100SEATS S85 �fn-Qga- _CONTINENTAL $35 NON-PROFIT S30
_>IOOSEATS 5160 I COMMONVIC. S60 . ¢ (d�b(o0 �W(-IOLESALE 580
RETAII,SERVICE: —RESID.KITCHEN S80
LICENSE REQUIkED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# LIC£NSE REQiJ(RED FEE PERMI I#i
_<50 sq.R. S50 _>25,000 sq.ft. 5225 _VENDING-FOOD S25
_QS,OOOsq.ft. $80 �FROZENDESSERT $40 I(��DON TTOBACCO $55
NnME caax�E: sts AMOUNT DUE _ $ I 85.o0
"`"'"PLEA5E TURN OVER A1VD COMPLETE OTHER SIDE OF FORM*•«•*
ADMINI5TRATION
Under Chapter 152, Section 25C, Subsection 6,the Town oFYarmouth is now required to hold issuance or renewal
of any license or permit 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CI�CK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiem occupancy shalt be
limited to the temporary and short term occupancy,ordinarilq and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresid�ce�lsewh�e.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) daya, 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 i
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 inspected ',
by the Health Departmecrt prior to opening. Contact the Health Departmem to schedule the inspection thrce(3)days ',
pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected
and opened. ',
POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standard plate count '
by a State certiSed lab, and submitted to the Aealth Department three (3) days 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 ',
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health I3epartment by the required ',
Temporary Food Service Application form 72 hours prior to the catered event: These fornis can be o ' ed at the ,
Health Depattment. ',
FR07.EN DESSERTS:
Frozen desse►ts must be tested on a monthly basis by a State certified lab. Test results must be sern to the FIealth
Department. Failure to do so will result in the suspension or revocation 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 Board ofHealth. '
OUTDOOR COOHING:
Outdoor cooki�prepararionz or display of any food product by a retail or food service establishmart isprohibited. !
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTTY TO RET[JRN
TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER I5, 2009:
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e,'PAINfING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A 3ITE PLAN.
DATE: SIGNATURE: ,!�� �� = �,,.,--
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PRINT NAME&TITLE: �'I,�,-, vl'1• � .a-.�7 a c..H-�
09/25/09
�\ The Coinmonwealth of Massachusetts
Depariment oflndustrialAccidents
NNCIN�d�s
600 Washington Street, f"Floor
Boston,Mass. 02111
Workers'Compeasation iesera■ce Aftidavit:gei�diug/p�embieg/Eleetrical Coohactors
Ap��ept f�f�fdw: Pkne PR_�1'kp161t
oame:
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work site locatia�/Culi addressl� ` �
❑ i am a homeowcer perfumumg all work myself. Project Type: ❑New Cmshvcti��Remodel
❑ I mn a sole propridor and have no une wodcing in miY�����Y- ❑Bwlding Addition
❑ I am an eanployer providiog w�keas'compensapion for my employces wodcing�tLis job.
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Datev 12/2/2009 Time� 2:31 PM To: 9,1508-398-7253 Rogeis S Gray Ins. Pape: 001
� � Clientl1:46785 CCCRE
ACORD,u CERTIFICATE OF LIABILITY INSURANCE ;Zov�°""'"'
rrsooucers � THIS CERTIFICATE IS ISSl1ED AS A MATTER OF INFORMATON
Rogers 8 G2y Ins.So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
434 Rou[e 734 HOLDER.THIS CER7IFICATE DOES NOTAMEND,EXTEND OR
ALTER THE GOVERAGE AFFORDED BY TH E POLICIES BELOW.
P.O. Box 7607 ,
South Dennis,MA 02660-1607 INSURERS AFFORDING COVERAGE NAIC# �
wsunEo wsur�Ra: CNA/ContineMal Casualty Company
Cape Cod Creamery,LLC �
INSURER B',
5 Theater Colony Way -
WSURER C
South Yarmouth,MA 02664 iNsuaeao:
INSURERE'. �
COVERAGES
THE POLICIES OF INSURPNCE LISTED BELOW HAYE BEEN ISSUED TO THE INSURED NPMED ABOVE FOR THE POLICY PERIOD INDILATFD.NOTWRHSTANDING
ANY RE�UIftEMENT,TERM OR CONDRION OF ANY CIXJTRAGT OR OTHER pOCl1MENT WRH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS Sl18JECT70 ALL THE TERMS,EXCLUSIONS PND CONDRIONS OF SUGH
POLICIES.AGGREGATE LIMRS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS.
LTR NSR T'�PEOFINSURFNCE PpLICYNUM9ER Pa� YEFFECTIVE POl1CYEXPIRATION
MTE fTVOO/YY OATE M1TVD LIMRS
GENERALLw61LrtY ERCHOCCURREKCE $
COMMERCIlLLGENERALLIABILITY OPMMG�ETOREMEO $
CLAIMS MME ❑OCCUR MEO EXP(M me person) S
. PERSONPIBPDVINJURY $ �
GENERALAGGREGATE $
GEN'LAGGREGATELIMRAPPLIESPER: PROOUCTS�COMPIOPAGG §
POLICV PRO-
JECT LOC
AUTOMOBILE W BIfIY
GOMBWEDSINGLE LIMiT
M11"AIJ�� (EaecdOeM) $
FLL ONRJEO Alfr05
BOOILVINJURY
SCHEOULEOAUTOS (Perperson) $
� HIRE�AUTOS �
NON-OWNEOAUTOS BOOILYINJURV $ _
(PeraatltlmQ
� PROPERTVOMWGE 5
(Pe�acdtlen�)
GNUGEIJqBLITY AIJ�OONLV-EAACCIOEM S
MIYAlJ�O
OTHERTHPN EAACC $
AUTO ONLY: qGG S
EXCESSNMBRELLP.LWBLLJTY EACHOCCURRENCE §
OCCUR �ClAIMSMrV]E AGGREGNTE y . �
5
DEDUCTIBIE
$
REfENTiON $ $
A wonKeascaxreumnounr�o WC2077173879 OS/01/09 OS/01/10 X wr.srnTu on�-
EMPLOYERS'WiBiLITY �
ANVPR�PRIRORIPPRiNEWEXFCUTIVE ELEACHACCIOEM SSOO,OIIU
OFFICEPoMEMRFREXCLlIDFp9 ELDISEASE-EAEMPLOYEE SSOO�OOO
If yes,tlesaibe un0e�
SPECIALPRpVI510N5G&ow 6LOISENSt-POLICVLIMIT $SOOOOO
OTHER
OESCRIF�ION CF OPERqTqNS/LOCATIONS/VEHIClESI EXCWSIONS AOOEO BY ENOpRSEMENT/SPECIAL PRONSqNS
ice cream shop
CER7IFICATE HOLDER CANCELUITION -
SHOUID qNY pF T1�E ABOVE OESCRBEO POLICIES BE CANCELLEO BEFORE THE E%PIRpT10N
TownofYarmouth OFTETHEREOF,THE65UNGINSURERWILLENDEAVORTOMpL �� OAYSWqRTEN
HealthDept NOTICETOTHECERTi1CATEXO(DERNAMEOTOTIIELEFT,BUTFpLURETO00505HqLL �
1146 Route 28 IMPOSE NO OBLIWTION OR llpglLRY OF ANY qN0 UPON TNE INSURER�pGENTS OR
SouthYarmouth,MA 02664 ItEPRESEH�ATIVES.
AIrtMOR1iE�REPRESEH�ATIVE
/
ACORD 25(2001/OB)7 af 2 #47365 DD O ACORD CORPORATION 1988