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HomeMy WebLinkAboutApplication and WC i �Qg) v1cT TOWN OF YARMOUTH BOARD OF HEALTH 106'3 _/ " APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessarydocumentsbycc lS 2 NOTE:ALL BUSINESSES to do Eso wITHL result the reICrn of your TRE UFOion eMSBYNWI fBER 1546. Failt. ESTABLISHMENT NAME: /1,41 rm. 6-") TAX ID: LOCATION ADDRESS: 'o eck $-4' a 1,141• .cin*-a k TEL#: S.: 398 11.I4, MAILING ADDRESS: 46 P2vv,42) i., i<'�,Ii /.r ill a-. ;OP E-MAIL ADDRESS: , ' ►a 'A- - `ikas •Ga 0-+c OWNER NAME: ' /A-40_,5 -t9 C. , CORPORATION NAMEQF APPLICABLE): Pu 44.•; Qs /NC- MANAGER'S NAME: 1-)411-,N-1`< . S y/✓et-f� TEL.#: Co? 378'1/410 MAILING ADDRESS: 5 Y'o µA.-1" St sa,r+s- yw.r"o.r-1r1---- POOL CERTIFICATIONS: The pool supervisor must be ce fied as a Pool Operator,as required by State law. Please list the designated Pool Operators)and attach a c••% the certification to this form. 1. / 2. m ' a Pool operators must list a •i'.1 um of two employees currently certified in standard First Aid and Community r---1- 5? Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the = ---.1 employees below and attach copies of their certifications to this form.The Health Department will not use past a Iv years'records. You must provide ew copies and maintain a file at your place of business. m o M 1. 79-- 2. : 0 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 . 1 Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. q 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.P9Aii F t 5 / yG U£ 2. I/01 7 14/04 vi PERSON IN CHARGE: Tn Each food establishment must have at least one Person In Charge(PI4zAJ 9 ite during hours of operati n. >�1✓/ 1. E L 5y/ i 2. F%; a rHP,,,,,,,,-T4 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(GX3Xa). 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..P LG 67/IA57-yiC�J— 2i/,,,,i41. 7-,‘J /9/ ' 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. n , .l 6cbx1: g4.„.....) (5. ...,p,54, 4. ,5 ii",../...3g4.1.5i,Aic, _ . RESTAURANT SEATING: TOTAL# / 136 1f'-,(4--b Li4 t 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 TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 J_>100 SEATS $200 Q J__COMMON VIC. $60 �c '-' 7 =WHOLESALE $80 ���I cI _RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 scat. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 -<25,000 sq.ft. $150 =FROZEN DESSERT$40 —.TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 260.00 PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 ATTACHED v/ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes 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. 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.640 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 Department. Failure to do so will result m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress 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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. 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 QUIRE A SITE PLAN. DATE: I�/7/ SIGNATURE: L5i if ✓ /�� PRINT NAME&TITLE: 9r , �'r 9i.i I ,bei,-25- (�E/ek�f TO . Rev.10/23/18 The Commonwealth of Massachusetts Department of Industrial Accidents � ,z'`; Office of Investigations 600 Washington Street -` - Boston,MA 02111 ^,..s ,0,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leg bly Business/Organization Name: //53P/?67AJtL5 Address: 9G/o re/") JT City/State/Zip:5 Pe C7 7 Phone i...,!O2`3'1 ill y� , Are yo an employer?Check the apsropriate box: Business Type(required): 1. I am a employer with itifYir P employees(full and/ 5. 0 Retail or part-time).* 6. N'kestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees.[No workers'comp.insurance required]** 11.0 Health Care 4.0 We area non-profit organization,staffed by volunteers, with no employees. [No.workers'comp.insurance req.] 12.❑Other *Any applicant that checks box#1 must also 61l out the section 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 organization should check box#1. I am an employer that is.providing workers'compensation insurance. or my employees. Below is the polic -in ormation. Insurance Company Name: ( / j � �7 t. ..c. Insurer's Address: 3DS -2) AJ '1 City/State/Zip: 11610,570c,"/ /t ,020 f f r Policy#or Self-ins.Lic.# / e //tlr'"' Expiration Date: ,/ Attach a copy of the workers'compensation policy declaration page(showing the policy number an 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 herebyrti under th5e pains and penalties ofperjuty that the information provided ab ve true and correct Signature: • t2' Date: Phone#: -753/ ' Li,7 ,k/oi Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www:mass.gov/dia SPECBRA-01 WASSAI AC-COREY 07/02/22018018 CERTIFICATE OF LIABILITY INSURANCE DATE`MM/ ) 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 THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE 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 certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER SACT Kreuter&Company PHONE FAX 260 Franklin Street (A/C,No,Ext):(617)8614330 I lac.No):(617)861-8334 16th Floor Miss: Boston,MA 02110 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:United States Fire Insurance Company 21113 INSURED INSURER B:Pilgrim Insurance Company j Papa Gino's Speciality Brands Holdings INSURER c:XL Catlin 600 Providence Highway INSURER D: Dedham,MA 02026 INSURER 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 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPO INSD WVD (MM/DDIYYYY1 (MM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR 543-221501-4 06/30/2018 06/30/2019 DAMAGE TO RENTED 1,000,000 MED EXP An one•=rson PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL A REGATE 10,000,000 X POLICY ja LOC PRODUCTS-COMP/OPAGG 2,000,000 OTHER: B s AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO _ CSC-00001002881 06/30/2018 06/30/2019 BODILY INJURY Per•- • S A�URTEO�S ONLY X SCHEDULED BODILY INJURY Per accident S X AUTOS ONLY X AUTO ONLY F rO t AMAGE S S C X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 25,000,000 EXCESS UAB CLAIMS-MADE US00079103LI18A 06/30/2018 06/30/2019 A RE TE S 25,000,000 DED X RETENTIONS 10,000 A WORKERS COMPENSATION X PER DTH- S AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 408-734416-8 06/30/2018 06/30/2019 E L.EACH ACCIDENT S 1,000,000 FFICER/MEMBEPEXCLUDED? N/A 1,000,000 andatory In NH) E.L.DISEASE-EA EMPLOYE:S If yes,describe under DESRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 A Liquor Liability 543-221501-4 06/30/2018 06/30/2019 Aggregate 2,000,000 A Liquor Liability 543-221501-4 06/30/2018 06/30/2019 Common Cause 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) This certificate is issued as evidence of insurance coverage only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:SPECBRA U1 MERMYI AC R Loc#: 1 1...� ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Krauter&Company Specialty Brands Holdings,LLC 600 Providence Highway POLICY NUMBER Dedham,MA 02026 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance The following are included as Additional Named Insured: Specialty Brands Holdings,LLC • 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 Corporation South Point Hospitality,Inc. Project Grill Project Grill II Pap Gino's/D'Angelo Card Services,Inc. D'Angelo Sandwich Shops Advertising Fund,Inc. ACORD 101 (2008/01) ®2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD