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Home My WebLink AboutApplication and WC Edit Record By Single Page 1 of 4 Menu Save Reset Caneel Help �� `�- " "—^ " '� �{`�� t�� A " � �-- Zo �7 (ZEU�kJior-L Record Detail ' (T is section is 2quired.) Case# � rT.,7(�e,...�_.___�. .,.._.».__,� Status Opened Date BO -4167-� `BoardOfHealth/Food EstablishmenVApphcatioNNA mm�.N��Appl�wUon�Subm 05/17/2017 � � lication Name� ��mp . �..,��x .�� Smu lers Beach Concessionse, ;.-�, Deseription � ' Concession stand at Smugglers Beach /f�� i 220 South St � �o'�'�" � � � J South Yartnouth,MA 02664 � �� `-��^�� ShfCk soeillna ' Total Invoieed Total,Pa�d _ Balance Assigned to Department Curron!Depar6nenfAssigned to Staff Current UserChannel Re orted ,18500 s18500 ,j �0.00 „ .,� -Select-- v -Seled-- v --Seled-- v Address • (This section is requiied.) New Search Delete SeS Primary GIS ❑ Primnr�( �4�gt� pjlg�tiqp §ye� Street Tvoe �y State �jg Addresa SUtus Sheet Suffix(Directionl Uni Unit# sta Name Code (startl � � 220 SOUTH ST SOUT... MA 02664 < s�-.�-;,<.:.a,�stt>v :i- cs�G,�s, ��_� ," �;�:4:.?" , �-:..�a .�:,3��.,i. ._ �__�"-.-_� x-*;N`:..�u.a a.t.!`.s.ia,rrt!..��i,.3i.� .�",.::_..�I;.;kI-+it?�?�� . . . .. . . . . . Paroel • (This sedion is required.) � Searoh Delete Get Address 8 Owner Set Primary GI3 ❑ Paroel M Primarv oo Block � Leaal DeseriMion Paroel Ana Land Value TOWnbMiO ve �. Value � 026.116 � 1153 116 220 SOUTH ST 479160 1194800 Yartnouth 444100 � Owner � (This section is 2quired.) � Searoh Delete Set Primary GIS � ❑ EU��p( IlLmg Address Line 1 Address Line 2 Addresa Lina 3 Mail CIN Mai1 State F�x Mail Zip Coc ' � � TOWN OF YARMOUTH MUNICIPALFOR RECPLYGRNDPARK 1146 ROUTE 28 SOUTH YARMOUTH MA 026644463 �. Applicant � (This section is required.) � Seareh As Owner As CoMact ' Type� Primary ��.. �licant�.� �.. .. v, Yes v �.. Full Name V d N A 1 T�FSN FYIV��'Y�� . '7/IG + 1✓� —+� �� -+ ��O� . /J � O anization Name Home Phone xxxpcxx-xxxx� O � Fireand WaterConcessions Inc. 508 479-9481 � � • Address Line 7 Mobile Phone��xxx�xxu-xxxx� 129 Weybosset St 0 Address Line 2 Business Phone xxxpcxx�xxxx� ^r (506)47&9481 /�� \ 1 � Address Line 3 � U �� Ci State Zi Code � ` � • �� . Providence RI v 02903 � l , E-mail• 'onathan fireandwate rou .com Fortn Designer:Single Entry Applicant Form APPLICATION . Unit# Applicant Address New Look Up DeacSivate Remove ❑Contact Address Line 1 City State Zip Country/Region Recipient Stalus Address ID https://av3.accela.com/portlets/cap/CapBySingle.do?mode=edit&fromModel=myCap&mo... 5/17/2017 Edit Record By Single Page 2 of 4 Responsible Party (This section is not required.) Searoh As Owner As ContaeS Type,,,_ Prima I iResponsiblePaA��. ..�._. ._.�.._ ...,�..v� No v � Full Name�O N{h l CCi�c� F�/�(�1�'FW Home Phone��xxx xxx�xxxx� '� 508 47&9481 �:� O anizatlon Name Mobile P�—I xxx.xxxxl . Fire and Wafer Concessions,Inc. DBA/Trade Name Business Phone xxx�xxx-xxxx� 508 479-9481 Etnail Preferred Channel jonathan fireandwate roup.com --SeleG-- v FEIN � Fqm DBsigMr:Singk EnlryContaet Fortn . Responsible Party Addresa New Look Up Deactivate Remove ❑5gat3� Address Line 1 '�-yt S�a ZIp Countrv/Reaion Recioient SGtus gddrese ID ❑3 9990 129 Weybosset St. Providence RI 02903 United States Adive Business Owner � (This section is requi2d.J . Searoh As Owner As Contac! TY.�?__��. m.____ ,m__ _.. Prima (Business Owner.._. ............ .�v� No v . �ME Pis p�PPL 1 c:�A�NT' Full Name Home Ph0.xnx�q �'' i Organization Name Mobile Phone��xxx�xxx�xwcx� � 0 ! DBAITrade Name Business Phone xxu�xxx-xxxx� ( I Address Line 7 i Addreas Line 2 �, Address Line 3 City 3tate Zip Code . 0� Etnail SSN FEIN 00 Single Entry Contact2 Fortn Business Owner Adtlress New Look Up Deactivale Remove ❑Contact Address Line t City State Zip CouMrylRaqion Recipient Shtus AddrQu ID 0 record�s�found. � i, Direet or Regional Supervisor (This section is not iequired.) . Search As Owner As Co�Wct Type Prima 'Direct or Regional Supervisor �v� No v � _. https://av3.accela.com/portlets/cap/CapBySingle.do?mode=edit&fromModel=myCap&mo... 5/17/2017 r Edit Record By Single Page 3 of 4 Pull Name Home Phone��x�oqxxx-xxxx� ' 0 O anization Name Mobile Ph�xxxxl . DBA/Trede Name Business Phone��xxxZmcx-xxxx� 0 Address Line 1 Preferred Channel --Selecl-- v Address Line 2 Address Line 3 Cit �Zi Co� E-mail � Form Desi9Mr:Slnpk Eniry COMadl Form � Direct or Regional Supervisor Address I New Look Up Deactivate Remove 0 Contact Addnss Line 1 City State Zip CouMrylReQion RecipienS 8tatus Address ID . . . ' 0 record(s)found. . � Eslablishment Infortnation Q � SewageDisposal �G�C J�� . Town Se V Produets H ' Location� Driver Name Vehicle Plate Telephone Number i Permanent Structure v Length Of P ��a�emporary From Date � w„..M.,m.o,.,.b�nm�... Seasonal/Temporary To Date • .a.».�e,n.ew„�w�aa.rro�.. N18CksoaNlrw ; Seaso �/ 05124l2017 �` � � i i' ❑Retail � Number of Seats-Inside• Number eats-Outside• ��, �FoodService-Seating o �o Wak Staff Provided for Outside Dining^ Is an Air Curtain/Screen Door Provided at Wait staff Service Door(s) • . �Yes 8 No �Yes�No � ❑Caterer ❑Residential Kitchen for Retail Sale ❑Frozen Dessert Manufacturer ❑Non-Pr�t ! ❑Continental Breakfast ❑Wholesale ❑Vending Food ❑Bakery ❑Farmers Market Retail Food Event ❑Other Food Operations PHF-potentially hazazdous food(time/temperature controls required) Non-PHFs-non potenfiatly Maisrdous food(not time/temperature controls roqu'ved) RTE-ready-tocat foods(Ex.sandwiches,salads,muffins which need no further processing) ❑Delivery of Packaged PHFs �PHF Cooked To Order ❑Sale of Commercially Pre-Packaged PHFs ❑Preparation Of PHFa For Hot And Cold Holding For Single Meal Service. ❑Sale of Commercially Pre-Packaged Non-PHFs ❑Sale Of Raw Animal Foods Intended to be Prepared by Consumer ❑Customer Selt•Service ❑Preparation Of Non-PHFs � ❑Ice Manufactured and Packaged for ReWii Sale ❑Customer Self-Service Of Non-PHF and Non-Perishable Foods Only ❑Juice Manufactured and Packaged for ReWil Sale ❑Reheating of Commercially Processed Foods For Service Within 4 Hours ❑Offers RTE PHF in Bulk Quantities ❑Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑Retail Sale of Saivage,Out-of Oate or Reconditioned Food https://av3.accela.com/portlets/cap/CapBySingle.do?mode=edit&fromModel=myCap&mo... 5/17/2017 Edit Record By Single Page 4 of 4 ❑PHF and RTE Foods Prepared For Highly Susceptlble Populatfon Facility ❑Vacuum Packaging/Cook Chill ❑Other ❑Use Of Process Requiring A Variance AndlOr HACCP Plan ❑OHers Raw Or Undercooked Food Of Animal Origin ❑Prepares PoodlSingle Meals for Catered Events or Institutional Food Service Custom Lists ' OWNERS/OFFICERS/PARiNERS �Add �DeIMe �CSV ExpoR ❑ Name Texl1 TitlelTextl Home Address(Teutl Pho�re NumbeATeutl '�� ❑ Jonathan Owner 373 Wickenden St.Provi� 5084799481 '� i FOOD PR07ECTION �Add �Delete �CSV ExpoR � MANAGEMENT ❑ CeRifled Emolovee(Textl Certification ProvidarlTextl ❑ Jonathan Kaufman National Registry of Fooc FOOD SANITA710N (1.1 Add Y...�Delete �CSV ExpoR ..�y� � ❑ CeRi£ed Staff Name(TeMI Fxpiration Date of Certi(cadon Certifieation ProvideAText1 HEIMLICH ... Add .;Delete CSV Expok CERTFICATON � � ._� ❑ Emolovee NamelTextl ExRintion Date of CertNication CeRification Provider/Textl ALLERGY �Add �DeleM �CSV Export CERTFICATON ❑ Emolovee NamefTaxtl Exniration Ds(gQf G�ution Certifieation ProvideATextl ❑ Jonathan Kaufrnan 05/18/2020 J ServSafe Submk Gncel https://av3.accela.com/portlets/cap/CapBySingle.do?mode=edit&fromModel=myCap&mo... 5/17/2017 ' , � ,�fe��4�d r�Y�y _ i � . .._ _ _ ___ _,._ ._._. n�e r_ _ _ _._. ��C�....'�'�` � Workers' Com ' pensat�on o and Em �o � . . . 0 � p yers iability � � �, � Business Insurance Policv a + � � > � 1 { � � � I < rE � � �'' D' �d.. 4 �� :� . �. � . . � , '' �s- � � . ! r, K � Form WC 99 00 02 (03/14j Page 1 of 1 �. . � _ -Q�e.�_ ^^prn. . �,__ � ib (PolicyProvisions: wC 00 00 00 C) 15 xz INFORMATION PAGE WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY 1NSURER: �EE ATTACHED ENDORSEMENT 46 THE RD NCCI Company Number: 10 s H,AgTFO Company Code: 9 r N ei $U�iX O LARS RENEWA � 02 o POLICY NUMBER: 76 WEG Kz1516 �'' Previous Policy Rlumber: 76 WEG Kz1516 0 1O HOUSING CODE: 76 � ,n F'IgE AND WATER CONCESSIOZ3S IN N 1. Named Insured and Mailing Address: � (No.,Street,Town,SYate,Zip Code) r c� 129 WEYBOSSET ST 0 PROVIDIIVCE, RI 02903 �+ FEIN Number. � * State Idenfification Number(s): � '= The Named lnsured is: C��TI�N Business of Named insured• Concessionaire with no cooking � Other workpfaces not showrt above: SEE ATTACHED SCHEDULES � I � 2, ppiicy Period: From 0 5/O 1/17 To 0 5/01/18 = 12:01 a.m.,Standard time at the insured's maiting address. — Producer's Name: PAY�xEX INS�RANCE AGENCY INC/PAC s � p0 BOX 33015 ..�� gp.t�T ANTONIO, TX 78265 � Producer's Gode: 250881 �i -= THE HARTFORD � issuing Office: �, 3600 W=SEMAN BLVD• Tx 78251 n = Sp,N ANTONIO :c � (877) 287-1312 $1�753 � Total Estimated Annaai Premium: � Deposit Premium: $526 Rz � Policy Minimum Premium: -= Audit Period: �AL Instalfinent Term: = The poticy is not binding unless countersigned by our authorized representative. � �J'�-R„� C�a��.�� oaia6�i� — Countersigned by Date Authorized Representative Page 1 (Continued on next page) Form WC 00 00 01 A (1) Printed in U.S.A. po��cy Expiratian Date• �5J01/18 Process Date: ��26/17 ' I ORIGINAL , INFORMATION PAGE {Continued) 3.A. y4tarkers Compe�tio�n�insurance: Fart one ofthe policy appfies fo the Wor�Cers Comp��sat�on� � � siates listed here. � woF;�G � g, Empfoyers Liabitity Insurance: Part Two of the policy applies to work in each siate listed in lterr�3.q, The fimits of our tiability under Part Two are: Bodily injury by Accident $100,000 each accident Bodiiy irc�,ry by Disease $SOQ,000 po��Y��m� Bodify injury by Disease $1�0,000 each employee C. Other States insurance: Part Three of the paficy app�ies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA� WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. 0�' THE INFORMATION PAGE. ' D. This poticy inctudes these endorsements and schedufe: '; i�C 99 00 U5 WC 00 04 21D WC OQ 04 22B WC 00 04 24 WC 2p 03 03D SEE ENDT � 4. The premium for this poiiry wilt be detemt�ned by our Manuais of Rufes,Classifi . � Plans. Ait information re uired beiow is sub' ct to verification and chan e b �ations, Rates and Ratmg Classifications Premium Basis g y�ud�. Code Numbe�afld Total Estimated Rates Per Description Annual Estimated Remuneration $�00 of Annua! Remuneration Premium (SEE ATTACHED SCHEDULES) TOTAi, ESTIMATED AN�}u�, STA1��D p�I� EXPII3SE CONSTANT (0900) TOTAL ESTIASATED STATE 1,446 �'ERRORISM (9740) �C�G� 250 CATASTR.OPHE {9741) 31 TOTAL ESTIMATED 21 AI�IUAL PREMI(3M 5 1,753 Total EsNmated Annual Premium: $1,753 �posit Premium: Policy Minimum Premiurn: $526 RI tnterstatp/irrtrastate lderit�fcation Number: Labor Carrtrdc�ors pa�� NAICS: 453996 y Number: SIC: �999 Fon►i WC�0 00 01 A (1 f printed in U.S.A. Process Date: 02/2 6/17 Page 2 Policy Expiration Date: 05/OI/16 _ __ r�rr � •,,�� 8�� dnce "/// ' FI, ; ��`e; cO�p '�'��►, ._ l _ � �_ Qs._ _ �y �o�,.��..._. _. 3CHEDULE OF OPERATI4NS fhis Schedule of Operations forms a part of the policy efFective on the inception date of the paticy unless another date is ndicated below: NSURER: TWIN CITY FIRE INSURANCE COMPANY :ompany Code: � �oficy Number: 76 WEG KZ1516 Schedule Number: 01-20-01 �ffective Date: 05/01J17 Effective hour is the same as stated on the Information Page of the policy. 1lamed Insured and Location Address of operations covered by this schedufe: FIRE AND WATER CONCESSIONS II3C [�i0 SPECIFIC LOCATION IN STATE OF MA 1�TAICS: 453998 FEIN: UIN: SIC: 5812 NO. OF EMPL: 000006 4. The premium for this policy will be determined by our Manuals of Rutes,Ciass�cations,Rates and Rating Plans. All information required befow is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Descriptfon Remuneration Remuneration Premium 8017 15,300 1.07 164 ST4RE: RETAIL NOC Cou�tersigned by Authorized Representative Form WC 99 00 OS (1) Printed in U.S.A. po{��y Expiration Date: 05/01/18 Process Date: 02/2 6/17 . , SCHEDULE OF OPERA710NS a art of the�licy effedive on the inception date of the policy unless another date is This Schedute of Operatwns fiorrns p indicated below: lNSURER: TWIN CITY FIRE INStJRAIJCE CdMPANY Company Code: 7 Policy Number: 76 WEG KZ1516 Schedule Number: 01-20-02 Effective Date: OS/01/17 Effective hour is the same as state�on the Information Page of the policY• Named)nsured and Location Address of operations covered by this schedute: FIgE AND WATER CONCESSIQNS INC 220 S STREET � 02664 YARMOUTH NAICS: 453998 StC; NO. OF EMPL: FEIN: UIN: 4, The premiam for this policy will be determined by our Manuals of Rules,Ctassifications, Rates and Rating ; Plans. Atl information required below is subject to veri�cation and change by audit. ; Premium Basis Classifications Total Estimated Rates Per Estimated � Code Number artd Annual $100 of Annuai � Description Remuneration Remuneration Premium I :8017 36,600 1.07 392 j :STORE: RETAIL NOC t , " � :TOTAL CLASS PREMItTM 556 °TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 556 'EXPII�TSE CONSZ'ANT ('0 9 0 0) 2�� '-MASSACHUSETTS DIA ASSES5MENP 5.bQ0 PERCENT 31 ;TERRORISM (9740? 51,900 .030 16 �TOTAL ESTIMATED ANNUAL PREMIUM 853 Countersigned by Authorized Representative Form WC 99 00 OS (1� Prinied in U.S.A. Process Date: 02/26J17 Policy Expiration Date: 05/01/18 -.. ' -��nS4 ance c e e�j� . po1i� e� : �ai� �''I� _ �te'Qs,._ ��y _ _ _ _ �� _ �# � , �, fiCHEDULE OF OPERATI4NS �;`�This Schedule of Operations forms a part of the policy effective on the inception date of the po{icy uniess another date is ,1 indicated below: �` INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY Company Code: ( Policy Number. 76 WEG RZ1516 Schedule Number: 01-38-01 N Effective Date: 05/01/17 Effective hour is the same as stated on the Information Page of the poticy. � Named Insured and Location Address of operations covered by this schedule: o FIRE AND WATER CONCESSIONS II3C 129 WEYBOSSET ST .� PROVIDIIJCE RI 02903 � NAICS: 453998 0 � FEIN: UIN: 0000000002 SIC: 5812 N0. OF EMPL: 3 � � 4. The premium for this policy wiil be determined by our Manuals of Rules,Classifications,Rates and Rating .o Plans. All information required below is subject to verification and change by audit. N Premium Basis o Classifications Total Estimated Rates Per Estimated � Code Number and Annuaf $100 of Annual * Description Remuneration Remuneration Premium �80�� 16,400 3.27 536 �STORE - RETAIL NOC �. � �� s � �� i� �� o� � �� a �� _ �..:.. � � � Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 02/2 6/17 Policy Expiration Date: 05 J 01/18 . r �I' _ �.,S�s,��Qs._ `V��d!!ir /�o�y�I�-�. _ ' I�r , 3 SCHEDULE OF OPERATIONS ' � f � n � This Schedu{e of Operations forms a part of the policy effective on the inception date of the policy untess another date is indicated betow: t � 11�1SURER: HARTFQRD (TNDER�ITERS INSURANCE COMPANY Company Code: b Policy Number: 76 VAEG Rz1516 �� Schedule Number: 01-38-02 °D Effective Date: OSl01/17 Effective hour is the same as stated on the Information Page of the poticy. � Named Insured and Location Address of operations covered by this schedule: �' F'I12E AND WATER CONCESSIONS INC 254 GREAT ROAD o NARRAGANSETT RI 02862 � � FEIN: UIN: 0000000002 NAICS: 453998 � SIC: 5812 N0. �F EMpL; 6 � d. The premium for this policy will be detennined by our Manuals of Rules,Class�cations,Rates and Rating � Plans. Alf information required below is subject to verification and change by audi� � Classifications P�emium Basis � Total Estimated Rates Per Estimated * Code Number and Annual a100 af Annual _Description Remuneration Remuneration Premium =8017 S,400 3.27 177 �STORE - RETAIL NOC � � � � � � � �� _ �_ � � • � � � � _ � � �: � ..�. � � � Countersigned by Au#horized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 02/2 6/17 Policy Expiration Date; p 5 J 01/1 S v � � at�a� ''�y /�r..�� Fr� ��'� �.� _ _. r. �' �' �� ,6CHEDULE OF OPERATIONS � This Scheciuie of Operations forms a part of the policy effective on the inception date of the policy untess another date is indicated below: . {11lSURER: HARTFORI3 tJNDERWRITERS INSURANCE COMPANY Gompany Code: b Policy Number: 76 WEG KZ1516 Scheduie Number: 01-38-03 Effective Date: 05/01/17 Effective hour is the same as stated on the Information Page of the policy, Named Insured and Location Address of operations covered by this schedule: FIRE AND WA`PER CONCESSIONS INC 950 SUCCOTASH RD S RINGSTON RI 02881 NAICS: 453998 FEIN: UIN: 0000000002 SIC: 5812 NO. OF EMPL: 6 4. The premium�or this poticy will be determined by our Manuals of Rules,Classif�ications,Rates and Rating Pfans. All information required below is subject to verification and change by aadit. Prernium Basis Ctassifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium � 8017 5,400 3.27 177 eSTORE - RETAIL NOC 890 °TOTAL CLASS PREMIUM 890 �TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 27'Z00 �Zp 5 =TERRORISM (9740) 27,200 .020 5 'CATASTROPHE (9741) 900 ;TOTAL ESTIMATED ANNUAL P1tEMIUM ! : i Countersigned by � Author�zed Representative Form WC 99 00 05 (1) Printed in U.S.A. policy Expiration Date: 05/O1/18 Process Date: 02l26/17