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{ , , TOW1Y OF XARMOUTEI BOARD OF FIEALTH
� APPLICATION N'QR LtCEN5�/['ERM[T-2017
� , 'Please compiete form and attach alt necessary documu►ts by ► b, 201 .
, Failurc to do so will resuit in the rotum of your applicaLon pac ct.
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� : BSTABLiSHMENT NAME: `� • • � � �
LOCATION ADDRESS:_(�i.'� t►�.�a.--. 5-�-�.e_..e.L S. �f TEL!#: eti�-- `5�i.f—,..,.��'
M°�II.ING ADDRE5S• �i T`""_�
•Sts�_ �✓rs..y,l�.�_.,,�„ —S� �..�,..��,� m.-� �,-e�.�j
E-MAII.ADDRESS:__�.1-4.�-�..� tv n.•�n...,.e..�..., . ��r,_,...
• OWNBR NAME: "�'—V-
CORPOItATION NAME(IF AP LICABLE�` �����` ..�, �
MANAtiER'S NAME; ` TEI..#� �. —�'.�
� MAII,ING ADDRESS: � ^ ..n�. �y ;
�OOL CEitTffICAT[ONS:
Th�p u ervisor must ba cerNlied as a Poo!Operator,as required by State lnw. Plcase list the des'gciet�!"—
Poo!Operator ch a copy of the ccrtification to t6is form. �
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Poo}opecators must Iist a minimum of two employe ed in standerd First Aid end Community � C) �
! Cardiopulmonary Rcsuscitation(CPR),having one rf! c Ic�ee on promiscs at att times. Please list the r
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emp loyees b e tow en d atta c h copies of their '►cations to this nn.Th a-H�alth Dopartment wltl not use past . _ � I�
yeare'rccords. You must provf ew copies end maintain a tile at yovr'pta buslneas. � �
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3. 4, -1 —ra (�
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FOOD PROTECT(ON MANAGERS-CBRTIFICATIONS:
.All#'ood scrvice estabGshments are required to have at least one full-time employee who is certified as a Food
�, Protection Menager,ss dcfincd in t6e State Sanitary Code for Food Service Esteblishsmnts,105 CMR 590.000. G`" i
I Please attach copies of certification to this application. The Health Departtpent wit!not use paetyeera'records. �
iYou muat provide new copies snd maintain a ille at your estabtiahmen� ��
�._P1�t�,� 1�.��—��c.`� z. , �� ��
PERSON'INCHARGB: ��� ���
F,ach food establishment muat have at feast one Petson In Charge(PiC�on site during hours of operation. +i�,:
1, Q M-.�'.�0 �ti..\�.Q�'� 2 ':r. �':i
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ALLERGEN CfiRTIFICATI0N5: ��t'
AlI food sarvice estabtishments erc required to havo at least one full-timc employee who has/Ulergen certificatiotl, <��
as defined in the State Sanitary Code for Food Service 6stablishrrtents,l05 CMR 590.009(G)(3xa), p1ease sttaeh �"
co ics af certification to thi e �
P s ppi►cahon. T6c Health Depai'tmel1t WIII f10t QSC gBSt ye81'g�CeCO!'de. You must ()ln�
provide new copies and m8iritalri 8 CIC 8t y0ur CS�b]j9�lment� �
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HEIMLICH CERTIFICAT[ONS:
A!t food service estabiishments with 25 seats or more must havc at 1eas;one emptoyee trained in the Eleimiich
Maneuver on ihe premises et a!!times. Plcase list our em lo ec.c trai
attach eo ies of em lo y ��' ned in ana-ahoking proeedures below end
P p yee certifications to this focm. The 4h Departmemt wUl not use paat yeara record�.
You muat provide new copies and maintain a tile at yoar place o[busineas.GP R
1. ��.��t n �..s�--i�C.e� 2. •
3. 4.
ltESTAURANf SEATMC3: TOTAL# 1�
�.oacnvG: � OFFICE USE UNLY
LICENSE REQUI[tED FfiB PERMlT N LIC6N9E REQUIRRD FEQ PBRMIT q LICEN$&REQUIRED FEE P&Wr11T N
,_„_ARD Sss CABIN S33 �M07EL S11U
• `_LODQE SSS �!'RA(�ER PARf( S OS --S�M�►�'�G POOL SI 14ea.
— _.WHIRLPOOL St l0ee.
FOQD S£RV1L'E;
LiCENSB REQ�U1RED FEE J1' UCENSE REQUIRED F6E PERMIT N LICENSE!�p UIRED PE6 pERM(7'N
1O�IODS�AIJ 5125�� COMINENTAL S75 �� _NON•PROPtT S30
>IOOSEATS 5200 =CON(MONVIC. S60 �WHOLCSALB S80
RESAIL SERV[CE: —RESID.KSTCHEN t80 •
LiCENSEREQ(J1RED FEE pERMfFN L[CENSEREQUIREb FEH PEitMRtl UC$NSEREQUIRED FGE P�RMITN
`�S s9•_ft• SSO . >25 000 R. 5285 V&NDTNCI-FOOD T25
uw sq,ft, SiSO =FRd7.EN�6SSERT T40 ;I'OBACCO SI10
NAME CE{AiYGE: SIS AMOUNT DUE g S {�„�Op
••'••PLEASE TIiRN OVER ANp COMPLET6 OTNBR 9ID$OF FORM"*�••
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` ADMINISTRA'�'ION
Under Chapter!52,Sectjon 25C,Subsection 6,ti�e Towu of Yatmouth is now requited to hold issuance or renewal
of any license or pemut to operate a business if a person or company does not have a Ccrtificate of Worker's
Compensation Insurance. THE ATTACHED STA7'L WORaCER'S COMPENSATION IIVSUR4NCE
AF�JDAViT MUST BE COMPLETED ANB SIGNED,OR �
CERT.OF iNSURANCE ATTACHEO.I '
OR =
� WORKER'S COMP.AFF[DAVI1'SIGNED AND ATTACHED
Town of Yarmouth taxcs and liens must bC paid prior tv rencwal or isauance nf ynur pemrits. PLEASE CHECK
APPROARIATELY IF PAID:
• YES_� NO
MOTELS AND OTHEIt LODGING I�STA$LISHMENTS
'I'RANSIENT OCCUPAIVCY: For pwgoscs oCthe timitations of Motel oc Hotel use,Transient occupancy shetl be
limited to tl�e Eemporary and short term occupancy,ordinarily and customarily associated with rriotc!and hotcl use.
� Transient occupants must have and be ablc to dcmonstrate that they maintain a principa!place of residence
eisewhere.Transient occupency shell generally rcfer to continuous occupancy of not more thaan thuty(30}days,and
an aggregete ofnot more than ninety(40)days withie any six(6)monUi period. Uae ofa gueat unit as e residencc or
' dwelling unit ahall not be cons;daed trensient. Occapancy that is subjeet to tlie collection of Room Occupency
Excise,as defined in M.G.L.c.64C3 or 830 CMR 64t3�as amended,shall generally be considered Translent.
POOLS
POOL OAENING:All swim�ning,wading end wliirlpoots which have baa closed for the aeason mwrt be inspected
by the Hcatth.Departrnent or to o eniog. Contact the Heslth Departmenk to achedute t6e jnepect[on three(3}
days prlor to openipg.��Q,�;p�p�e�NOT ellowed to sii in the pool area until the pool has been
inspected and opened.
POOL WATER TESTitVG: The water must be tested for pseudomonas,total caliform and standard plete count '
by a State ced�ed lab,end submitted to the Health Department three(3)days prior to opening,and querterly
thereafier. '
POOL CLOSINC:EVCIy OUt�00T iri grOWd SwtiCUllittg ppol must be drained or covered withitt seven(T)days of
closing,
ROOD 5ERVICE
SEAS03YAL FOQD SERVICE OPENING:
, All food service esta
blishmcnts must e
b inspected by the Health Department prior to opening. Pleese contact the
Health Uepartment to scBedule the Inapection tlu�ec{3}days prior to opeoing.
CATERING I'OLICY:
Areyone who catecs within the Town of Yarmouth must notify the Yermouth Health Aepariment by filIng the
required Temporary Food Servico Application focm 72 hours prior to the catered event, These forms cen be
obtained at the Health Department,or from the Town's website at wwwy�4� .ms.us under Health Depaztment,
Downloadable Forms.
I�ROZ�N DESSERTS:
Pcozen desserts must be tested by a State cerlified lab prior to opening and monthly thereafter,with sample tesults
submitted�o the Health Depsrtment. Failure to do so will result in the suspension or nvocation of your Frozen
Dessert Pcrmit until the above terms have been met.
ou'�'Sin�Ca��s:
�Ut3ide CQ�e3(i.e.,outdoor seating with waitcr/waitress service),must have prior approvat from We Boerd af Health.
OU'i'DOOR COOKiNC:
Outdoor cooking,pteparation,or display ofnny fvad producl by e recail or food servlce establishnnent Is pwhtbited.
NOTICE:Peanits run annually ftom January 1 to Decembcr 3 I. IT IS YUUR RESNONSIBILITY TO RETURN
THE COA�LETEA RENEWAL APPLICATION(S)AND REQU(RED FEE(S)BY DECEMBER l6,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLiSHMENT, MOT$L OR POOL (i.e., PATNTIN(3, NEW •
F.QUIPMENT,ETC.),MUST BE REPORTED TO ANA APPROV$D BY THE BOARD OF I�ALTH PR10R
TO COMMBNCEMENT. RENOVATtONS MAY RE 1RB A SITE PLAN. '
DATE� � � �t�\�" SIONA7'URE:_ ~ �j„t��„_
PRiAlT NAME 8c TITLE• �.=—�—o'Q+— �y}�t�� �-e
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� . QAiLLBp BpNOWICHFS .
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PGF.�C HOI,D]NGS INC .
PA,PA GINO'S HOLD]NGS CORP
' PAPA GIlsO'S�NC
PAPA GINtJ'S FRA,N'CHISIl�TG CORP
U'ANGBL4'S�AND"4�TICI3 SHOPS lNC
DELOPS ll�IC '
PR4G�SNB FOOD lNC �
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' � CU�tREN'�'0�'�ZC;�S
MARZ�DEBLOZS '
. 184.FOREST STREET -
SHBRBORN,MA OI770
PRBSIDBNT,CHIBF OPER,ATING 4FFTCSR ' .
• CORB'�'�'BNDLAND
4X FIELDSTONE LANE
. FALMOUT.�MII 041.05
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. G�IIEF FZN'AI�'GIAL OFFZCBR
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Papa Gino's[na
G00 Prov�dence Hny,
Dedham,i�IA 0�4?6
Pl�oae 78 t-�6I-I200°Fa,�781-d6f-I S9G
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' The Commonwealth of Massachusetts
i Department of Industrial Accidents
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� , ; 1 Congress Stree�Suite 100
; Boston,N.�4 02114 201 7
' www mass.gov/dia
�� Workers'Compeasation Insurance Affidavit:General Businesses.
TO BE FILED WITH TH�PERMITTTNG AUTHORTTX.
� Applicant Information Please Print Legiblv
Business/Organ.ization Name: � ��.��d 5 �'�,,.�„,c� ��,,,��
Address:__ 134� M��-� 'Sk.t� �
City/Sta.te/Zip: . ✓,� Phone#: �pB-— `39� — ���'�
Are you an emgloyer? eck the appropriate bog: Business Type(required):
1.�I am a employer wi�^Is=..� employees(full and/ 5. ❑Retail
_���
orpart-time).* �}�, 6. �estaurantlBaz/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no �. �p�ce and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.�nc��rance required] g• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑Enterta.inment
I, their right of exemption per c. 152,§1(4),and we have 10.Q Manufactuzing
j no employees.[No workers'comp.incr,�.,ce r�quired]* 11.0 Health Care
� 4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees.[No workers'comp.in�,�*a.,ce req.] 12.0 Other
� *Any applicant that chec,ks boz#1 must also fill out ihe section below showing their workers'compensatioa pohcy mfoimahon.
*"If the cocporate officers have exempted themselvex,but the coiporation has other employees,a workers'compensation policy is required and such an
organizadon should check box#1.
�
I am an emp[oyer that is providing workers'compensaiion insurance for my employee� Below is the policy information.
InsuranceCompanyName: �J�y�;.�.r. �#t :�,�k�,� �'�'r—e "��, ��
' Insurer's Address: '�J�� �-ii S�---. G1.J-�c.---,.}=_
City/State/Zip: 1�/'�,a~-�'$S�-� ��� ��'r'l '�.�
Policy#or Self-ins.Lic.#_ `{Ca�'^ �-�,i �„�f'�`3 '�'""�'�' Expiration Date: fo � '
Attach a copy of the workers'compensation policy declaration page(showing the policy numbe�ezp ation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminai penal6es of a
fine up to$1,500.00 and/or oae-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 covenge verification.
I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct
SiQnature• /�� Date• I r�- ' �-�"f'�
Phone#: ��— ����— (��
Official use nnly. Do not write in this arery to be completed by city or town official
City or Town: PermitlLicense#
Tssuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfi'own Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person• Phone#:
� www.mass.gov/dia
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����� SPECBRA-Q1
' A'�c.._�--'�`Q� CERTIFICATE OF LIABILITY INSURANCE DATE�MMND/YVYY)
� 06/27/2017
� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
! BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
{ REPRESENTATIVE OR PRODUCER,AND THE GERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certtftcate does not confer ri hts to the certificate holder in Neu of such endorsemen s).
PRODUCER C CT
Krauter&Company PHONE
1350 Avenue of the Americas ac No,e:e:1 (212)596-3400
18th Floor e�No:1�212)596-3460
New York,NY 10019
INSURER S FfORDIN(i COVERAOE NAIC#
iNsur�Rn:United States Fire Insurance Com an 21113
INSURED xvsuRER e:Pil rim Insurance Com an
Speciaity Brands Holdings,LLC wsuReRc:XL Catlin
600 Providence Highway IN URERD:
Dedham,MA 02026
INSURER E•
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVlSION NUMBER:
� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD
� INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TypE OF INSURANCE A��SUBR POLICY EFF POIJGY EJtP
� POLICY NUMBER V�
A X COMMERCIAL 6ENERAL LIABILITY EACH OCCURRENCE S 7,000,000
J CLAIMS-MADE a OCCUR DAMAGE TO RENTED
543-217454-1 O6/30/2017 O6l30/2018 ��y , 1,000,000
� MED EXP M one rson S
j PER L 8 ADV INJ RY S ��OOO,OOO
i GEN'L ACaGREGATE LiM1T APPLIES PER: EN RAL AGGRE TE S �O,OOO,OOO
� X POLICY❑j�� ��pC PRO TS-COMP/OPAC3G 2rOOO,OOO
j OTHER:
a Included
! B AUTOMOBiLE LIABIUTY COMBINED SINGLE LIMIT 'I�OOO�OOO
i s
+ �wY AUTO GSC-00001002881 06/30/2017 06/30/2018 eODiLY IN,x/RY Per enon 5
1 OWNED SCHEDUIED
� AUTOS ONLY X AUTOS BODIIY INJURY Per acddent g
j X AUTOS ONLY X A3f'o�`�'�g �OeE�R��AMAGE a
5
, C+ X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 25,000,000
� EXCESSLIAB CLAIMS•MADE US00078103LI17A Os/3�/20'�7 06/30/2018 A REGATE 5 25��00,���
oe� X RETENTIONS 10,000
A WORKERg COMPENSATION PER OTH-
AND EMPLOYERS'LIA8ILITY X
ANYPROPRIETOR/PARTNEWEXECUTIVE Y�N 08-731603-4 06/30/2017 06/30/2018 ��000,00�
FFICE M R EXCLUDED7 �N N/A .L.EACH ACCIDEM S
� �anda�ory�n�i�) 1,000,000
If yes,describe under E.L.DISEASE-EA EMPLOYE S
OESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S �,OOO,OOO
A Liquor Aggregate 543-217454-1 06/30i2017 06/30/2018 Aggregate 2,000,000
A Liquor L(ability 543-217454-1 06/30/2017 06/30/2018 Common Cause 1,000,000
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHIC�ES(ACORD 101,Additlonal Remarks Schedule,may be atqcbed if more space ta required)
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� CERTIFICATE HOLDER CANCELLATION
SHOULO ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WIIL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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AUTHORIZED REPRESENTATIVE
� `���"�`
� ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved.
i The ACORD name and logo are registered marks of ACORD
^ AGENCY CUSTOMER ID:SPECBRA-01 MERMY1
'' 7 LOC#: 1
ACORt7R
1.....� ADDITIONAL REMARKS SCHEDULE Page. � ot �
� AGENCY -
NAMEDINSURED
rauter 8�Company Specialty Brands Holdings,LLC
600 Providence HIghway
POLICY NUMBER Dedham,MA 02026
EE PAGE 1
CARRIER NAIC CODE
EE PAGE 1 SEE P 1 EFFECTIVE OATE: EE A 1
� ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liabilkv Insurance
The following are inciuded as Additionai Named insured:
Specialty Bra�ds Holdings,I.LC
PGHC Holdings,inc.
Papa Gino's Holdings Corp.
Papa Gino's,Inc.
Papa Gino's Franchising Corporation
Delops,Inc.
D'Angelo Sandwich Shops,Inc.
Progressive Food,inc.
D'Angelo Franchising Gorporation
South Point Hospitality,Inc.
Project Grlll
Project Grill 11
Pap Gino's/D'Angelo Card Services,Inc.
D'Angelo Sandwlch Shops Advertising Fund,Inc.
ACORD 101 (2008/01) �O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are reglstered marks of ACORD
a�p
� ��� Commonwealth of Massachusetts Lctter[D:L1344750848 �° "�
� �, � ,�� Dcpartmcnt of Rcvcnuc Noticc Datc:Octobcr t2,2017 ��
� � '��`�� Christophcr C.Harding,Commissioncr Casc ID:0-000-172-788
� ��� mass.gov/dor
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; CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE
�
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����li�l���ill�lli��i����ll�lli�illl����l�����l��li�l�llll�l�i�ii
DELOPS INC
0 600 PROVIDENCE HWY
o—
� DEDHAM MA 02026-6804
�
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�Why did I receive this notice?
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.
� 3'his certificate doesn't certify that the taxpayer is compliant in taxes such as unemployment insurance
j administered by agencies other than the Departrnent of Revenue,or ta}ces under any other provisions of
j law.
�
This is not a waiver of lien issued under Chapter 62C,section 52 of the Massachusetts General
Laws.
K'hat if I Itave questiuns?
If u h v - -
o a e uestions call t 1
us a 6 7 887 6367 r 11- 'n a
o to free i Mass chusetts at 800 2
Y , � )
39 6089 Monda
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through Friday, 8:30 a.m. to 4:30 p.m..
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T'isit us online!
Visit mass.gov/dor to learn more about Massachusetts tax laws and DOR policies and procedures,
includin our Tax a r Bil
e 1 of Ri hts and M T x onnect f r a
ass a C o e s access to our t•
gY P Y g , Y Y
accoun .
• Review or update your account
• Contact us using e-message ,�
• Sign up for e-billing to save paper
• Make a ments or set u auto a
PY P PY
�'�..�,,4._.� �- ��
�
Edward W. Coyle,Jr., Chief
Collections Bureau