HomeMy WebLinkAboutApplication and WC `�� �
°� TOW�1 OF YARMOUTH BOARD OF HEALTH �
� � APPLICATION FOR LICENSE/PERMIT-2017 '
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`'� *Please complete form aud attach all necessary documents by Deeember 16 2016. �
Failure to do so wi�l result in the retum of your application pac et.
ESTABLISHMENT NAME: C. 0.G�n o�r TAX ID: � (�
LOCATION ADDRESS: o � -k- • TEL.#: ' �( (P
M.a,iLnvGaDD�ss:�oo Pro�°;c�e.►�ce l-�wy 'D�d aw� M� oZo� �
E-MAILADDRESS: Lby-}{,�ra�..1 C� (�.�0.'�ctq�nos e C'arl I
OWNERNAME: Qg�a �r�,,;a� �h�
CORPORATION NAME(IF APPLICABLE): P�p�(',�na S T"_ f
MANAGER'S NAME: Elr�L �`p�,r�tcs�•., TEL#• `7�'(+{V � ('Z Vp
MAILINGADDRESS: �p(5 (�,�� , ��,�,y 'I� dhaN-. ��} o2ozc
POOL CERTIFICATIONS: i
The pool supervisor must be ce ' �ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a copy o e certification to this form. i
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Pool operators must list a minimum of two e ees currently certified in standard First Aid and Community � O �`"
Cardiopulmonary Resuscitation(CPR), ng one rtified employee on premises at all times. Please list the -`" w �,�.,`""
employees below and attach copie eir certification o this form.The Health Department will not use past � rv �:r '
years' records. You must �de new copies and main 'n a file at your place of business. -�j o ��� �
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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.
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PERSON IN CHARGE: ""Q '
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � ��
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ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification, �
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach i
copies of certification to this appiication. The Health Department will not use past years'records. You must ;
provide new copies and maintain a file at your establishment. ;
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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. '
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RESTAURANT SEATING: TOTAL# 9�o
OFFICE USE ONLY
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 _TRAILERPARK $105 _WHIRLPOOL $110ea. i
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $200 �Z� �COMMON VIC. $60 �9 =WHOLESALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
=<Z5,000 sq.ft_ $150 =FROZEN DESSERT$40 TOBACCO $110
NAME CHANGE: g15 AMOUNT DUE _ $_��c0.OO ,
*R*k*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**• p,O��t����'^O 2
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ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now reyuired to hold issuance or r�n�wal
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 V
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taYes 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 OPENING: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
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.
FOOD SERVICE
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. ;
CATERING POLICY: ;
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
obtained 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 De
artment. F '
ailure to
do so wi
P Ilr
. esult in the sus
ension
Dessert Permit until the above terms have been met. P or revocation of your Frozen
;
OUTSIDE CAFES: j
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:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLIRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
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 REQUIRE A SITE PLAN.
DATE: I�2..'Zal - �(,. SIGNATURE:_�- ���,�-- '
^ PRINT NAME&TITLE: ��YT �-{,Qy��v .}- �C c o v,,�+;,,.,r (-�,h a e.r.�
Rev.10/]2/16 ` '.
� The Commonwealth of Massachusetts
Department of Industrial Accidents
� � Office of Investigations .
600 Washington Street �
s Boston,MA 02111
s� www niass gov/dia
Workers' Compensataion Insurance Affidavit: General Businesses
A�plicant Informaf�on Please Print LeQiblv
Business/Organization Nam e: �Q.�G �i�n v�s
Address:_ �,k2� Z� t, `�Q � �r� S�t'• S, `f�l.�r-r,o��z-, .
City/State/Zip: .�. `(o,�-w,o..�, �`'l� 6'21�(�� Phone#: ���g" 3�� � �`� �
Axe ou an employer? Check the appropriate box: Business Type(required): �
1'�I am a employer with �O employees(full and/ 5. ❑Retail
or part-time).* 6. �estaurant/Bar/Eating 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 capacity. �
[No workers' comp.insurance requiredJ 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.Q Manufacturing
no employees.[No workers' comp.insurance required]*' 11.0 Health Care �
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insuranee req.] 12.� Other ' '
*Any applicant that checks box#1 must also.fill out the secrion below showing their workers'compensation policy informa6on. ',
**If the corporate officers have exempted themselves,but the corporation has other empioyees,a workers'compensation policy is required and such an.• ',
organization should check box#L '
I atri an eniployer f1:at is providing wot kes s'compensation insr�rance for n:y entployees Below is tl:e policy i�iforntation. '
Insurance Company Name: �_� .�.c,r-� ,,.� ,y �.S
Insurer's Address: '`Za�' 1v���s�,.� Q�v-c� �
Ciry/State/Zip: i�o,-Y:��vv,,_,..1 . � b�-9„6� ;
Policy#or Self ins.Lic.# �.o$'�-�f�'�a-6� Expiration Date: �, �3o i 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 l:et eby certify under tl:e pains and penalties of perjiny tl:at tlie inforr�:ation provided above is frue�nd co�rect
Si�nature: �•�v�-,� Date• �"Z.-��"l�v
Phone#: �C� � � � '� � Z,�O
Official rrse only. Do r:ot wj•ite irz tlsis area,to be cos�:pleted by city o�•tow�:officia�
City or To�vn: Permit/License#
Issning Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
�� SPECBRA-01 DLEE ',
'�'�'�R�� CERTlFtCATE OF LlA61LITY INSURANCE °�'�`M"°°°�"""' '
7/1/207 6
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 TNE COVERAGE AFFORDED BYTHE POLlC1ES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'IWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOIDER. '
iMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the po(icy(ies)must be endorsed. if SUBROGATlON IS WAIVED,subJect to
the terms and condiftons of the policy,certain policies may require an endorsemenL A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement{s).
PRODUCER ���
Krauter&Company a NN E,�,1 (212)596-3400 c No:1(212)596-3460
1350 Avenue of the Americas
18th Floor nno��ss:
New York,NY 10019
INSURER S)AFFORDING COVERAGE NAlCl�
INSURERA:United Sfates Fire Insurance Com an 21113
n�sur�o INSURERB:Charter Oak Fire insurance Company 25615
Speciatty Brands Hoidings�LLC iNsu�c:Nationai Union Fire Ins.Co.of Pittsburgh PA 19445 ,
600 Providence Highway . iNsu�o:
Dedham,MA 02026 iNsu�a 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 FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEtJT WITH RESPECTTO WHICH THIS
CERTIFICA'fE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREINISSUBJEC7TOALLTHETERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�1R 7YPE OF INSURANCE INSD POLICY NUMBER MI�Wu00 EFF �P�p� LIMRS
A X COMMERCIAL GENERAL UABILIIY EACH OCCURRENCE 5 'I�000�000 ,
CLAIMS•MADE a oCCUR 543-997995-3 06/30/2016 06I30/2017 pREMISES Ea��ee 5 1,000�000 ',
MED EXP(My one person) S ,
PERSONAL S ADV INJURY S 'I�000,000 '
GEN'LAGGREGATELIMITAPPUESPER: GENERALAGGREGATE S 'IO�OOO�OOO I
X �u�❑JEC�'f ��� PROOUCTS-COMP(OPAGG 5 � 2�000�000 I
OTHER: • S ',
AUTOMOBILE LIABILlIY COMBINED SINGLE LIMIT ',
Ea aaidenl 5 1�000,000
B ANYAU70 BA-3D545189-16-AUF 06f30/2016 06/30/2017 BODILYINJURY(Perpecson) 5 �I
UTOS�E� X A OSLED BODILY INJURY(Peraeddenq 5 �i
X HIREDAIJiOS X NON-0WNED PROP DAMAGE S I
AUTOS Peraacfdent i
S �
X 0M8���^B X ocCUR enCH occut�NCE S 25,000�000 '
C accEss ups CwMs-MAOE BE023355181 06/3012016 06/30/2017 pGGREGATE 5 25.000,00 ',
OED X RETENTIONS �O�OOO S ',
WORKERS COMPENSA'flON X �'�p,�,E EOTRH- I
AND EMPLOYERS'LIA9IUTY �
A ANYPROPRIETORIPARTNERIEXECUTNE Y�N OH T29-OHO-7 06/30I2016 06I30/2017 E,LEACHACCIDENT S �iOOO�OOO '
OFFICER/MEMBER EXCLUDED? �N�A
(Mandatory In NH) E.L�SEASE-EA EMPLOYE S 'I,000,000 '
If yes,desaibe under
UESq21PT10N OF OPERATIONS below E.L DISEASE-POLICY LIMR 5 1�O00�000
p Liquor Lfability 543-997995-3 06/30/2016 06/30/2017 Common Cause 1,000,000
p Liquor Liability 543-997995-3 06/30/2016 06f30/2017 Aggregate 2,000,000 ',
DESCRIPitON OF OPERA'iIONS/LOCATIONS/VEHtCLES(pCORD 101,Addlponai Rematks Seheduie,may be alfaohed tf more space Is requlred) ',
Thirty(30)days written notice of cancellation.Ten(10)days wriften notice of canceilation due to non-payment of premium. ',
Evidence of insurance '
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRfBED POUCIES BE CANCELLED BEFORE '
Evidence of Insurance THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN
ACCORDANCE WI'f'H THE POLICY PROVISIONS.
aunioru�o r�rt�s�ramre
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O 1988-2014 ACORD CORPORATION. Ail rights reserved.
ACORD 25(2014/01) 7'he ACORD name and logo are registered marks of ACORD
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AGENCY CUSTOMER ID:SPECBRA-01 DLEE
� LOC#: 1
ACORO"
�../ ADDITIONAL REMARKS SCHEDULE Page � of �
Ar'�� NAMEDINSURED
rauter&Company Speciatty Brands Holdings�LLC
, 600 Providence Highway
POUCYNUMBER Dedham,MA 02U28
� EE PAGE 1
CA�� NAIC CODE
EE PAGE 1 SEE P 1 EFFECTiVE DA'iE:SEE PAGE 1
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM iS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 25 FORM TITLE: CertiHcate of Liabilltv Insurance
The foilowing are included as Named Insured:
Speciaify Brands Hoidings,LLC
PGHC Holdings,lnc.
Papa Gino's Hoidings Corp.
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 Hospifalify,inc.
ProjecE Griil
ProjecE Gri1F II
Pap Gino's/D'Angelo Card Services,lnc.
D'Angelo Sandwich Shops Advertising Fund,Inc.
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ACORD 101(2008/01) O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD