HomeMy WebLinkAboutApplication and WC .a TOWN OF YARMOUTH BOARD OF HEALTH -� �
� � APPLICATION FOR LICENS - ' . �t� �E � �U��
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* Please complete form and attach all neces �. � o n , : y� r 1 S 201 S.
' Failure to do so will result in the ret 'of ��p�a�b ac et. HEALTH DEPT.
ESTABLISHMENT NAME: ' TAX ID: �- '�-
LOCATION ADDRESS: �..._ � . ..,_.,.k+.`._TEL.#: ��3� -a���
MAILINGADDRESS: ►�"�- a�� '
E-MAIL ADDRESS: .. s � ,
OWNER NAME:
CORPORATION NAME (I APPLICABLE): Zj.e��,� �.�
MANAGER'S NAME: TEL.#: `�-�-�{�.�-t�Q�
MAILING ADDRESS: {�-. D.,,�r.A - .� � ��.t,�,_ Y►.-✓.L- o��ra
PO L CERTIFICATIONS: .--- " '
The po u ervisor must be certified as a Pool Operator,as required by State law. Pl 'st the designated
Pool Operato d attach a copy of the certification to this form.
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1. 2
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Pool operators must list a minimum of two currently certified in standard First Aid and Community '
Cardiopulmonary Resuscitation (CPR), havin e c �employee on premises at all times. Please list the
employees below and attach copies of t ' certifications to this . The Health Department will not use past '
years' records. You must provi ew copies and maintain a file a r place of business. ,
1. 2. '
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 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. �--��--•--•-�--� �^-'' S<�.--�--� 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1 __�-�----=��,;:.-�,.�µ -__�__�__-___ .�_ -.-^_� _ -_ _- -_ ��---------, __ - - _ _
ALLERGEN CERTIFICATIONS:
Al�food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. a
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1. i;� ���.-..LSS ta:
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 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 place of business. ;
1. t......-ri.�...._ lu.� ,,.� .._ 2.
3. 4.
RESTAURANT SEATING: TOTAL# � 4�
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_ ur'r'ic:;�:u��;-uNTi.� -- -
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea. '
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
LO-100 SEATS $125 ��I� CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC. $60 �63 =RES�ID.TCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $li0
NAMECHANGE: $is AMOUNTDUE _ $ /$S.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION t i
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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
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WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes 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 rurposes 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. I
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence j
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and I
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 inspected I
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) ,
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been �,
inspected and opened. '�,
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count j
by a State certified lab, and submitted to the Health 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.
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FOOD SERVICE I
SEASONAL FOOD SERVICE OPENING: II'�I
All food service establishments must be inspected by the Health Department prior to opening. Please contact the ,
Health Department to schedule the inspection three (3) days prior to opening. '
CATERING POLICY: �'I
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 i
obtained at the I�ealth Department,or from the Town's website at www.varmouth.ma.us under Health Deparhnent,
Downloadable Forms. I
' FROZEN DESSERTS; I!
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results 'i
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen j
Dessert Permit until the above terms have been met. ',
OUTSIDE CAFES: I��
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
� �__ Outdoor cookin�,preparation,or display of any food product by a retail or food service establishment is prohibited. ,
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. I
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN.
DATE: �,-��zi� �� SIGNATURE: `� Ii
PRINT NAME&TITLE: L�.��9� Pa.,�,�� 1� � t�F-ss���k�.
Rev. 10/O 1/15
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CUMPANIES
PGHC HOLDINGS INC
PAPA GINO'S HOLDINGS CORP j
PAPA GINO'S INC i
PAPA GINO'S FRANCHISING CORP
D'ANGELO'S SAND'O�TICH SHOPS INC . ;
DELOPS INC i
PROGRESSIVE FOOD INC
,
. CURR�NT OFFZCERS
MARK DEBLOIS
184 FOREST STREET
SHERBORN,MA 01770
PRESIDENT,CH�F OPERATII�IG OFFICER -
. COREY WENDLAND
41 FIELDSTONE LANE
FALMOUTH,ME 04105
� CH�F FINANCIA.L OFFICER
Papa Gino's Inc.
600 Providence H�vy.
� Dedham,�riA 020�6
Phone 731-=�61-1200�Fax 751-461-1396
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Illl�������t��� ,P�����IIIII '
MASSACHUSETTS DEPT.OF REVENUE '
PO BOX 7021
BOSTON,MA 02204 .
- ;
MARK E. NUNNELLY, COMMISSIONER i
CHARLENE HANNAFORD,ACTING DEPUTY COMMISSIONER f
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osoc Notice 80619 OP i
o DELOPS INC T/P ID f
� 600 PROVIDENCE HWY Date 10/03/15 ,
� DEDHAM MA 02026-6804 Bureau CERTIFICATE
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CERTiFICATE OF GOOD STANDING AND10R TAX COMPLIANCE " "
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The Commissioner of Revenue certifies as of the above date,that the above named individual or f
entity is in compliance with its tax obligations payable under M.G.L. c. 62C, including corporation
excise, sales and use taxes, sales tax on meals, sales and use tax on Boats/RV,withholding '
taxes, room occupancy excise and personal income taxes, with the following exceptions.
This Certificate certifies that individual taxpayers are in compliance with income tax obtigations
and any sales and use taxes, sales tax on meals, withholding taxes, and/or room occupancy
taxes related to a sole proprietorship. Persons deemed responsible for the payment of these
taxes on behalf of a corporation, partnership or other business entity may not use our automated
process to obtain a Certificate.
This Certificate does not certify that the entity's standing as to taxes such as unemployment ,
insurance administered by agencies other than the Department of Revenue, or taxes under any
other provisions of iaw. Taxpayers required to collect or remit the following taxes must submit a
separate request to certify compliance:Alcohotic Beverage Excise; Cigarette Excise, International
Fuels Tax Agreement, Smokeless Tobacco or Ferry Embarkation.
THIS IS NOT A WAIVER OF LIEN ISSUED UNDER GENERAL LAWS, CHAPTER 62C, '
SECTION 52.
Very truly yours,
Charlene Hannaford,Acti eputy Commissioner
r
� The Commonwealfh ofM'assachusetfs
r Departmenf oflndustt�ialAccide►�ts
. '� ; X Congr�ess S`freef,Suife X00 �
� Bosfon,MA 021I4-20X7'
�y >�.`'' www.massgov/dia
Workers'Compensation Insarance Affidavit:General Businesses.
TO B�RILED WITA TSG PFRMITTING AIJTHORITY.
A Iicanf Informaiion PIease Prinf I,e�iblv
�
Business/Organiza�ion Name:���� -�—,,,� ��z ����n ��z 1�� ����
Address• �a�� W1.�.� �„�.� $
City/State/Zip: 5,.� .�,t,... � � Phone#: S�-- �t—�.���
Are you an empIoyer?Check the appropriate box: Buseness Type(reqairetn:
1-l� 1 am a employer with a�-� empIoyees(full andl 5• ❑RetaiI '
Z.� or part time).* 6. faurant/BadEating EstabIishment
I am a soIe proprietor or partnership and have no
employees working for me in any capacify. 7• ❑Offcce and/or Sales(incl.reat estate,auto,etc.}
[No workers'comp.insurance required] 8• ❑Non-profit
3•❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c.152,§1(4),and we have 10.[]Manufacturing '
4.❑ no employees.[No workers'comp.insurance required]* 11.[]Health Care
We are a non-pmfit organization,staffed by voIunteers,
with no empIoyees.[No workers'comp.insurance req J 12.[]Other
tAny applicantthat chec�box#1 must also fill outthesection 6elo�vshowing their�vorkers'compensation polioy infocmation.
•*Ifthe corporate officers have exempted themselves,but lhe cotporation has other employees,a wor};ers'compensation policy is required and such an
organi�ationshould checkbox#L
Xanz mz e�nployer iliaf isprovidingworkers'co»rpensation insurar:cefor t�iy eri�ployees Belosv is tliepolicy iuformatio�r.
Insurance CompanyName: Unifed States Fire Insurance Company(Crum and Forsfer)
Insurer's Address: 305 Madison Ave,PO Box 1960
City"/State/Zip: Morristown,NJ 07962 • ;
PoIicy#ar Self-ins.Lic.# 5439959829 Expiration Date: 6/30/20'[6
Attach a copy of the�vorkers'compensation policy declaration page(shotiving the policy number and expirafion date).
� Failure to secure coverage as required under Section 25A of MGL c.152 cati lead to the imposition of criminal pena(ties of a
fine ap to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form o£a STOP WORK ORDERand a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to fhe Offiee of
Investigations of the DIA for insurance coverage verification.
I do Itereby cerli ,utzder tlie pai�ts and pertatties of perjttry tliat tlte itiforntation provided above is irtte and correcf.
Si ature• Date• b - ''
Phone#: "��,—t— 4,(�� — ��,�
Offreial use oiily. Do nof�vrite in fliis area,fo be complefed by cify or fo�v�z official.
Ci€y or Town: Permit2icense#
Issuing Authority(circle one):
1.Board of HeaIfh 2.Buiiding DeparEarent 3.CiEy/To�m Cterk 4.Licensing Board 5.SeIecfinen's Office
6.Other '
Contaet Person• Phone#•
�nvw mass.gov/dia
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AC�° SPECBRA-01 EBORTNIKER
�,...! CERTtF[CATE OF LtAB[L[TY fNSURANCE DAYE(MMIDDIYYYYJ
7l151201v :
THIS CERTIFICATE IS lSSUED AS A MATtER OF INFORMA710N ONLY ANQ CONFERS NO RiGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NIEGAI7VElY ANfEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES
BELOW. TH[S CE(ZT�FICATE OF INSURANCE DOES NOT CONS7'1TUTE A CONTRACT BETWEHN THEISSUINGINSURER(S],AUTHORIZED
REPRESEN7ATIVE OR PRODUCER,AND THE CERTtFICATE HOCDER.
IMPOR7'ANT: If the cerEiBcafe holder is an ADD[TtONAL INSURED,the pol[cy(ies)must be endorsed. If SUBROGAT[ON IS WAIVED,suBjecEto
the terms and condifions of the policy,cerEain policies may require an eadorsemenE. A stafemenE on this cerEifccafe does notconfer righfs fo the
cerfificafe 6older in lieu of such endorsement(s).
PRODUCER CONTpCT 4
Kraufer&Com any NAM�
4350 Avenue o�ti�e Americas pNCNNo E�:'1 �242)596-3400 ��N,;4(212)596-3460
48fh Floor ADD�RESS•
New York,NY 40019
INSURER(S)AFfOR�IN6 COVERAGE NAIC#
INSURED
INSURERA:Unifed Sfafes Fire Insurance Company 24143 (
wsus�s:Charter Oatc Pire Insc�rance Company 25645
SpeciatEy Brands Holdings,LLc iNsuR�c:Nationaf Union Fire lns.Co.of PiEfsburgh PA 19445 I
26o Frantclin St
suite 78so INSURERD:Crum&Forster Indemnity Company 34348
Bosfon,MA 021Q0 tntsut�ee•
INSURERF:
COVERAGES CERTIFICATE NUMBER: REV(SION NUMBER:
'PEIIS IS TO CER7!!-Y THAT THE POUCIES OF INSURANCE L(STED BELOW HAVE BEEN(SSUED l'�THE INSURED NAMED ABOVE FOR'iHE POUCY PERtOD
INDICA'i'ED. NO7 Wfl'HSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI'i'F�RESPEC7T0 WF11CH THIS '
CER'PIFICATE N►pY BE ISSUED OR MAY PER'i'AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRtBED HEREIN IS SUBJECTTOALLTHETERMS, �
IXCLUSIONS AND CONDI'f10NS OF SUCH POlICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �
L7R 'fYPEOFtNSURANCE POUCYEFF POUCYEXP i
INSD WVD POLtCYNUMBER fdMfDD MNfIDD LIMtTS
A X COMMERCIALGENERALUABILIiY EqCNOCCURRENCE S 'I�OOUi000 �
I
CtAtMs•MAOE X oCCUR 5439959829 06l30/2045 06f30l2016 pREMISES�Eaoaurte�ee s 'I,000,000 f
MEDIXP(Myoneperson) S
PERSONAL&ADVINJURY S 'I�000�000 �
GEN'LAGGREGA7ELIMITAPPUESPER: GENERAIAGGRF�A7E S 'IO�OOO�OOO �
X P�u�❑JEC �LOC
PROOUC7S-COMProPAGG S 2i000�000
OTHER: S ''i
AUTOd10HfLELIABILITY W aB�f.NdF.D�SINGLELIMIT S 'j�000�000
B ANYAltTO BA3D54S1$915AUE 06/80/2045 0613DI2016 800ILYINJURY(Perpersory S
AILONMED �( SCyEOULED
AUTOS p�p5 • BOOILYINJURY(Peracddenq S '(�000�000 '
X HIREOAUTOS X NON-0WNED PROpERiYDAMAGE '
Al1TOS PeracddeN S :
S
X UMBRELLAUAB X p�CUR EACHOCCURRENCE S 25�000�000
C IXCEssuae CLAIMS•MApE BE035625562 06/30/2095 06►30/2046 p,�,R�-,p� 5
nEo X RETENTIONS '��,000 Aggregafe S 25,000,000 '
WORKERS COMPENSATION PER O7H-
AND EMPLOYERS'LIABILITY STATUiE ER
� ANYPROPRIEfORlPARTNERIEXECUTNE Y�� 087267Z63 06/30/2045 06/30l2016 EL.EACHACCI�ENT S '��000�00�
OFFICERlMEMBERIXCLUDED? � N!A
(MandatoryfnNH) ELEIISEASE-EAEMpLOY S 'I,000,000
Uye�s,descnbe under
DESCRIPTIONOFOPERATIONSbetow ELDISEASE-POLICYUMtT S 4�00�,000
OESCRIp7iON OF OpERA710NSlLOCAtiONS!VEEIICLES(pCaRD t01,Additlonaf Remarks Schedute,may 6e aNached tf mocc spacc is requfred�
PeoplesBan[c is named as additional insured with respe�E to the operaEions oF the named irtsured and as required by wriffen contract
CERTlPICATE HOLDER CANCELLATION
SHOULD ANY OF'CEiE ABOVE oESCRIBED POLIC[ES BE CpRCELLED BEFORE
Evidence 'fHE EXPIRA7(ON DATE THEREOF, NOtiCE WIlL BE DE4NERED IN
ACCORDANCE WITH 7HE POLICY PROVISIONS.
AUSHOFtiZEO REPRESENTA'[iVE
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O 1988 2014 ACORD CORPORATfON. AU righfs reserved.
ACORD 2S(2094101j The ACORD name and tono are reaistered martc��f ncnRn
�
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AG�HCY CUS'tO1VfER ID:SP�CBRA 04 ASMITH i
LOC#: 2 �
/"�� �"'�n • i
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� aDD[T[orii�►L, �.Et�ARi�s SCH�aU[�� • Page �t o� � �
AGENCY NRMEDINSURED �
KCaufer&Cottlpatty,Ll.0 5�ecialEy Brands HoIdings,LLG
600 Providence Highway
PouctrHUMseR • Qed6am,MA 02026
S��PAGE 4
CARRIER NAICCOGE
S�E PAGE�i SE�P 4 EFFEC7NEDAIE:S��PAGE'I
ADDiTIONAL.REMARKS '
THIS ADDiTtOKA[.REMARKS�ORM tS A SCHEDULE TO ACORD FORM,
;FORM NUMBER: AcoRD 25 �ORM 7li'LE: Cect[6cate oFLTa611ttv Insurence �
I Remarks: ':
I Addifionai t�iamed Ittsureds:
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Papa Gino�s,Inc. ;
Pa�a Gino's Hotdings,Corp. ';
Pa�a Gitto's�ranchising Gor�oration �
Papa Gino'sID'Angelo Card Services,[nc.
D'Angelo Franchising Corp. ;
Q'Angeto's Sandwich Shops,[nc. '
The Smith&WoltensEcy Resfaurant Group,Inc. � i
S&W of Miami,L.t,.C,(DE)
S&W�.C.,L,.L.C.(pE) '
Smifh&Wol[ens[cy of Bos�on I�LG(DEj
Smifh&WoI[ensky of Housfon Ll.0(DE)
1Afo![ensky Beverage,inc.
Housfon S&W,C.P. '
S&tt1!of Las Vegas,L..L.C.(AE) -
S&W of Phitadelphia,L.LC(DE)
Smifh&Wol[ens[ty of Ohio LLC(D�)
Smit6&Woltensky of America I.LC :
�Washing�ott Avettue Cor�. '
Projecf Grit[I
PGHC Hotdings,Inc. • •
Delops,Inc. . i
SouEh Poin�e Hnspitality,Inc. I
Pro,jec�Gritt lt i
Progressive Food,lnc.
Smith&Wol[ensky Afiantic Wharf[.[.0
S�W Ghecago,L.L..C.
i
ACORD�[��[[20I18fdd1 020UB ACbRD CORPORATI(]N_ Alldnhic ra_aenrPd.