Loading...
HomeMy WebLinkAboutApplication and WC r � i , � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December l6.2016. Failure to do so will result in the return of yow application packet. ESTABLISHMENT NAME: `u� I • -- LOCATION ADDRESS: U1aa.� �-+� - TEL.#: �-- �i -�-�2� : MAILING ADDRESS: C� Q.r�.e..e. = .�-.--- c..�..�� m-Ia.._.c��-e�-6 E-MAILADDRESS:�.�-b.,-v,J tv ����aoS _ ra:�. OWNER NAME: CORPORATION NAME(IF AP LICABLE): "��(E,,,s T�•c � MANAGER'S NAME: TEL.#: '�r(-��i—+'�-q� MAILING ADDRESS:C,fx: Qrvv+.�-c.-�� �.��� ,� Ey�..c�ss�-L . OOL CERTIFICATIONS: T e u ervisor must be certified as a Pool Operator,as required by State law. Please list the des' �-� Pool Operator ttach a eopy of the certification to this form. 1. 2. D Z � Pool operators must list a minimum of two employees i ed in standard First Aid and Community � C' Cardiopulmonary Resuscitafion(CPR),having one ' e e ee on premises at all times. Please list the � w �`� ` employees below and attach copies of their carions to this form. alth Department will not use past � '"' ' years'records. You must provi copies and maintain a f�le at your p business. � o �.�C� i 1. 2. --I � � � 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 certificarion to this applica6on. T6e Health Department will not use past years'records. `' '` You must provide new copies and maintain a fde at your establishment. �. �,.�.-� �. e�-��..- 2. �.�� ; . ..C;� PERSON IN CHARGE: �C's�` � ` Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. -,--�-; 1. � lJ�r=�--S 2. � ' i �rzc��� ' I ALLERGEN CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who has Allergen certification, i as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach ; copies of certification to this application. The FIealth Department will not use past years'records. You must � provide new copies and maintain a file at your establishment. ; , 1, Y s�._.. „ a) � �--��- 2. � � HEIMLICH CERTIFICATIONS: I All fo9d service establishments with 25 seats or more must have at least qne 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 aot use past years'records. You must rovide new co ies and maintain a file at oar lace of business. P P Y P 1. U a!"'rn�.`i h �It�,-r-,c�S 2. � 3. 4. i ; RESTAURANT SEATING: TOTAL# � 'Y OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT M LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# BBcB $55 CABIN $55 IvIOT'EL SI10 IP1N S55 —CAMP $55 SWIMMING POOL SI IOea —IADGE $55 TRAILERPARK 5105 WHIRLPOOL S110ea. FOOD SERVICE: ' L[CENSE REQUIRED FEE P�R7MIT� LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# ' �0-100 SEA�'S SL2S � � CONTINEIJTAL S35 NON-PROFIT S30 >100 SEATS $200 �,COMMON VIC. S60 ��$( —I�VHOLESALE S80 —RESID.KITCHEN a80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# <50sq ft. S50 >25,000sq ft 5285 VENDING-FOOD S25 =<25,000 sq.ft. S 1 SO � _FROZEN DESSERT S40 _TOBACCO $I 10 NAME CHANGE: S15 AMOUNT DUE = S �iS.�_ , ""**«pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*t"*" �a�3�-c�-- 1353-6 Z � _ � t � 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 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 ATTACI�ED ✓ � OR ' 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 purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shatl 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 '' elsewhere.Transient occupancy shali generally refer to continuous occupancy of not more than thirty(30)days,and j 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 shail not be considered transient. Occupancy that is subject to ttie collection of Room Occupancy € Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. j I POOLS i r POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected ` 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 k by a State certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly � thereafter. ' I POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ' closing. I FOOD SERVICE ' f SEASONAL FOOD SERVICE OPENING: 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. i � f CATERING POLICY: Anyone who caters within the Town of Yannouth 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 obtained at the Health Department,or from the Town's website at www.vannouth.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 DepaRment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. ' OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER I6,2016. ' ALL RENOVAT'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINI'ING, NEW F,QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE RE A STI'E PLAN. DAT'E: ����I 1 r. SIGNATURE: � �j„y�� �� PRINT NAME&TITLE: I,.���- �y���. �-Q �ArS�c��-�'e-- '! � ' Rev.10/22l16 � � :�����c.'�"�: . 1 • • p � � �'.,'9� . . , . ��`'� C GRtLtED SAHDWICHES , I i COI17I'AI�F�S ' PGHC HOLDINGS INC PA.PA.GINO'S HOLD7NGS CORP PAPA GINO'S TNC PAPA G1N0'S PRANCHISING CORP D'ANGELO'S SAND�WICH SHOPS INC DELOPS INC PROGRESSIVE FOOD INC � � � { o�xc�s � . i Mr.�D�x.ors � i 184.FOREST STREET � � SHERBORN,MA OI770 ' PRESIDENT,CHIEF OPERATING OFFICER ' � . COREY�1ENDLAND ! 4Y FIELDSTONE LANL . FALIVIOUT�ME 04I05 � CHIEF FINANCTAL OFFICER ' �k c F Papa Gino's Inc. 600 Providence H�ty. Dedham,�IA 02026 � Pl�one 751-=�61-1�00�Fax 751-�6I-tS96 � f � The Commonwealth of Massachusetts Department of Industrial Accidents � Office of Investigations . 600 Washington St�eet Boston,MA 02XII y� " www�aass.gov/dia Workers' Compensahon Insurance Affidavit: General Businesses � Applicant Information Please Print Le�ib1Y Business/Organization Name: '�� ,� s �.-.c _ d �1��� °�'l1`�.,.�. _� C����Q 5�.�.�.�.�.�s Address: 1�9� ��..,...� �r��- City/State/Zip: Phone#: e�,�- ���t-a��-� € Are yoy�-an employer?Check the appropriate box: Business Type(required): � ; 1.�I am a employer with ��� employees(full and/ 5. ❑Retail or part-time).* 6. �taurant/BarBating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) � employees working for me in any capaciry. � � [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 10.0 Manufacturing � no employees. [No workers' comp.insurance required]* � 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care � with no employees. [No workers' comp.insurance req.] 12.0 Other ' *Any applicant that checks box#1 must also.fitl out the secNon below showing their workers'compensation policy information. ! **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an•• ! organiza6on should check box#1. � I attz an etn lo er tliat is rovidi�: workeJ s'co»: e�:sation i�:surance or m en: lo ees. Selow is tlte olic ut of�tation. f P Y P g P .f Y P Y P Y�f f Insurance Company Name: ��� �c,� ,..� � �s ' { , . � , Insurer's Address: `�ts� 1��-�s�� 0..�-��-�. � J� � � City/State/Zip: t'�.o,--,�-:��ow.--. b�'q.6� ! Policy#or Self ins.Lic.# �f o�f'�-��,,�o�-�� Expiration Date: 6 �'30 � l"� , Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). � Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a � fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ! Investigations of the DIA for insurance coverage verification. I do lzereby cef7ify uude�•thepai�ts a�tdpe�:alties ofperjuiy t/:at t/ze i�tforntatio�:provided above is irue and cor�•ec� Si ature: `-�---� Date: t �� � Phone#• � �t- 4�(�1 —� �-e�� Official irse o�:ly. Do not write irz tltis area,to be conspleted by city of•town of�cial. City or To�vn: Permit/License# ,. Issuing Authority(circle one): 1.Board of Health 2.Building DeparEment 3.City/Town Clerk 4.Licensing Board 5.Seleciamen's Of�ice 6.Other Contact Person: Phone#• �� SPECBRA-01 DLEE ACORO� DATE(MMiDD(YYYIn �� CERTIFtCATE OF LIABILITY INSURANCE ?�v2o�s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFHRS NO RIGHTS UPON THE CERTIFICA'fE NOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER 'f'HE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CON7RACT BETWEEN THE ISSUING INSURER(S),AUTNORIZED REPRESENTATIVE OR PRODUCER,AND THE CER'f'IFICATE HOLDER. IMPORTANT: If the certifcate hoider is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject fo the terms and condittons of the policy,certain policies may require an endorsemen� A statement on this certificate does not conier rights to the certificate holder in lieu of such endorsement(s). - PRO�UCER CONTACT NAME• Krauter&Company �CNN E,�;1 (212)596-3400 a N,;1(212)596-3460 1350 Avenue of the Americas ENIAIL 18th Floor ADDRESS: NewYork�NY 10019 INSURER(S AFFORDING COVERAGE NAICl� INSURERA:United States Fire Insurance Company 21113 wsuReo INSURERB:Charter Oak Fire Insurance Company 25615 Specialty Brands Hoidings,LLC INSURERC:National Union Fire Ins.Co.of Pittsburgh PA 19445 600 Providence Highway . msu�n: Dedham,MA 02026 iNsu�E• � INSURER F• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH'�HIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJECTTOALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��jR TYPE OF INSURANCE POU EFF POLiCY EXP V�� i 1 SD NND POLICY NUMBER MMIDD MMIDDlYYYY A X COMMERCIALGENERALLIABII.ITY EACHOCCURRENCE S 'I�000�000 CWMS-MAOE Q oCCUR 543-9979953 06/30/2016 06130/2017 pREMISES Eaoaurtence 5 1,000�000 i MED EXP(My one person) S � PERSONAL&ADV INJURY S 'I�000�000 4 GEN'LAGGREGATEUMITAPPLIESPER GENERALAGGREGATE S 'IO�OOO�000 i X POLICY�jEC �LOC PRODUCTS-COMPlOPAGG S � 2�000�000 OTHER: ' S AUTOMOBILEUABIUTI' W eBI�,NeDSI GLEUMIT S ��00p���� i B ANYAUTO BA-3D545789-16-AUF 06J30/2016 06/30/2017 BODIIYINJURY(Perperson) 5 � ALLOWNEO SCHEDULED AUTOS X AUTOS BODILYINJURY(Peraeddenq S � X HIREDAUTOS x AUi08�E0 Pe�a�den°�"GE S 5 �( UMet�w►ua6 X ��R enCH occu�utENCE S _ 25,000,000 � C excess uns cwMS.�no� BE023355181 06/3012016 06/30/2017 pGGREGATE 5 25,000�000 DED X REfEMIONS �O�OOO S WORKERS COMPENSATION X �TUTE ERH� AND EMPLOYERS'LIABIU7Y A ANYPROPRIEfOR/PARTNEWEXECUTNE Y�N 08-729-0807 06/30/2016 06/30/2017 E,LEACHACCIOENi S �i000���� � o�ic�m�+enne�Fxc�u�eoa �H r a (MandatoryinNH) ELOISEASE-EAEMPIOY 5 1�000,000 � lf yes,describe under OESCRIPTION OF OPERATIONS below EL DISEASE-POUCY UMR S 9,000,00 q Liquor Liability 543-987995-3 06►30/2016 06/30/2017 Common Cause 1,000�000 i A Liquor Liability 543-997995-3 06/30/2016 06f30/2077 Aggregate 2,000,000 � ( DESCRIP'iION OF OPERA710NS I LOCA710NS/VENICLES(ACORD 101,AddiUonal Rematks Sehedute,may be attaehed it more spaee Is required) ' Thirty(30)days written notice of cancellation.Ten(10)days written notice of cancellation due to non-payment of premium. Evidence of insurance CERl'IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ' Evidence of Insurance THE EXPIRA710N DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH SHE POLICY PROVISIONS. AU7NORIZED REPRESENTA7NE ../9�� O 1988-2014 ACORD CORPORATtON. Ali rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD . I AGENCY CUSTOMER ID:SPECBRA-01 DLEE /'� LOC#: 1 ACORO" L,�.� ADDITIONAL REMARKS SCHEDULE Page � of � AGENCY NAMEDINSURED tauter&Company Speciatly Brands Hotdings,LLC 600 Providence Highway POIJCY NUMBER Dedham,MA 02026 EE PAGE 1 CARRIER NAlC CODE EE PAGE 1 SEE P 1 eFFEcnve na�:SEE PAGE 1 � ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CertiBcate of Liabilitv Insurance The following are included as Named Insured: Specialty Brands Holdings,LLC , PGHC Holdings,Inc. Papa Gino's Holdings Corp. i Papa Gino's,Inc. Papa Gino's Franchising Corporation Delops,Inc. D'Angelo Sandwich Shops,Inc. Progressive Food,lnc. D'Angelo Franchising Corporation � South Point Hospitality,Inc. Project Grill I Project Grill II Pap Gino's/D'Angelo Card Services,Inc. D'Angelo Sandwich Shops AdverEising Fund,lnc. � G i I I f � I €` 6 I I � I � I ! I ACORD 101(2008/01) O 2008 ACORD CORPORATION. AU rights reserved. ', The ACORD name and logo are registered marks of ACORD i � i c�s�`�Us� MASSACHIJSETTS DEPARTMENT OF REVENUE Letter ID:L0766198784 j � � � PO BOX 7044 Norice Date:August 2,2016 � � BOSTON,MA 02204-7044 Case ID:0-000-083-798 �' CONTACT CENTER ' �r�.oF4 (617)887-6367 � CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE � , ���nl���uillllliln���llllu��ni�lli�i����i������nl�l�nli��� „�� e� DELOPS INC o� 600 PROVIDENCE HWY �� DEDHAM MA 02026-6804 W/zy.did you:receive this nohce� �-� The Commissioner of Revenue certifies that,as of the date of this certificate,DELOPS INC is in compliance with its tax obligations under Chapter 62C of the Massachusetts General Laws. This certificate doesn't certify that the taxpayer is compliant in taxes such as unemployment insnrance administered by agencies other than the Department of Revenue,or taxes under any other provisions of law. This is not a waiver of lien issued under Chapter 62C,section 52 of the Massachusetts General ' Laws. Where can you find additional informahon? f Visit our website at mass.gov/dor for one-stop access to taxpayer information. You can learn more about state tax laws and DOR policies and procedures,including your Taxpayer Bill of Rights and the appeals , process. � You can file most business tax returns,make payments and manage your account at mass.gov/masstaxconnect. You may also contact us by phone at(617) 887-6367 or toll-free in Massachusetts at(800)392-6089,Monday through Friday,9:00 a.m. to 5:00 p.m. i � Charlene Hannaford Acting Deputy Commissior..er:� � _. , A ` ! r �s,, � �F �.�.