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HomeMy WebLinkAboutApplication and WC Florio, Mary Alice From: Florio, Mary Alice Sent: Wednesday, November 6, 2019 1:27 PM To: 'license@papaginos.com' Subject: 2020 License Renewal - Papa Gino's, 940 Route 28, South Yarmouth, MA Importance: High Good morning. In October we received a food service and common victualler license application for the Papa Gino's located on 940 Route 28,South Yarmouth.The check enclosed (#010649)for the fee was in the amount of$185. That amount would be for a food service/common victualler establishment with 0-100 seats. Please be advised that this particular Papa Gino's has 160 seats,so the total fee amount should be$260. Would you please forward the$75 balance due at your earliest convenience,so that we may finish processing the 2020 renewal license. If you have any questions regarding the above, please feel free to call. Thank you for your attention to this matter. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 78t.M(7- 1(x'1 P a<<l e-{ -- l t — g2ct.ol . t-e_s---t--exoAzA" 110 (44.- ,. (O0 es;r b - -�v2O' ak c lb0 (‘os ose.L cJ4'1 scc. 3r) Town of Yarmouth Receipt No.: 51167 ittAtsti 1146 Route 28 South Yarmouth, MA 02664 Receipt Date: 11/06/2019 508.398.2231 RECEIPT RECORD&PAYER INFORMATION Record ID: BOHF-19-2662-REN-01 Record Type: Food Establishment Renewal Property Address: 932 ROUTE 28,SOUTH YARMOUTH,MA 02664 Description of Work: FOOD SERVICE AND COMMON VICTUALLER LICENSE RENEWAL Payer: PAPA GINO'S Applicant: JIM POIRIER,LICENSE ADMINISTRATOR NEW ENGLAND AUTHENTIC EATS LLC 600 PROVIDENCE HIGHWAY DEDHAM,MA 02026 PAYMENT DETAIL Date Payment Method Reference Cashier Comments Amount 11/06/2019 Check 010649 MFLORIO $185.00 FEE DETAIL Fee Description Invoice# Quantity Fee Amount Current Paid Food Service Establishment by Seats 54243 160.00 $200.00 $125.00 Common Victualler License 54243 1.00 $60.00 $60.00 $260.00 $185.00 AA_Receipt Template.rpt Print Date:11/06/2019 Page 1 TOWN OF YARMOUTH BOARD OF HEALTH Iiitl. APPLICATION FOR LICENSE/PERMIT 26+9- 2020 * Please complete form and attach all necessary documents by December 15, 3i$Zo l cl NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15`h. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 1}4-U :ozdA V b F.rilic u AT ti-C, De4 rA X ID: LOCATION ADDRESS: 9 C/0 /(11,' IN 3i (5):_ae 'I TEL 5' ?- _� /AY. MAILING ADDRESS:f 0(i) ell Grr1i De)/ciL, L, G/,INA'* b . bivA 1/1 '5, C 7,0 E-MAIL ADDRESS: L,l'C't r';..° _, 03('4 iiC i A,D.S, Ci')IA OWNER NAME: pc Li (..*PI, v L ; ;it) ;-ti 1 i(' iii' .S li't d" CORPORATION NAME (IF APPLICABLE): ,U f A) t,t1 Gln- ,D All'";'f%/17 e: c/17-c /.z'_.('. MANAGER'S NAME: TEL.#: Seib' n - i '-f L MAILING ADDRESS: . /u AV,i ,,1 J eIJL 3'?7, VlV 1ref^rj' ,474 /, G, (71/ POOL CERTIFICATIONS: j ' D The pool supervisor must be certified as a Pool Operator,as required by State law. P1 ase J.j t.th1 higated Pool Operator(s)and attach a copy of the certification to this form. U U �UII 1. /V 1;4\I 2. HEALTH DEPT Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past yearsrecords. You must provide new copies and maintain a file at your place ofkauiihesF", 7r2;,--).-), MO 1. iJIA 2. , - cf4v. ' p tiiitt ,;- Iv,., L , , , . „v„,,„, 6 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 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. ALA !fiJP .1.1 ti i O 2. _ _ , PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ,LA1AJA /Ir it, 2. it f C 4A) /4/vD.1 S/Ni' 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 copiesof 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. AL/\y ?1✓6 h A10 2. 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. Wv 3. Ve.'Fop^ LA WI Ihfi 4. MiE&f Al ''1` .N ))YR RESTAURANT SEATING: TOTAL# (7 (r OFFICE USE ONLY 6644-R1-'2-CC 1-C)( 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: LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# J- a' - ' $125 ZD-00 t CONTINENTAL $35 , NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 -031 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 —<25,000 sq.ft. $150 FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $/.. *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ..2--G.01,00 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 X. 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 A 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. 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 Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: 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. 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 REQUIRE A SITE PLAN. • DATE: / n a `) j SIGNATURE: 6--- -rr, ...(7 --),(0.722 PRINT NAME&TITLE: }I"l.�� '6 Z 1 - /� Rev.10/23/18 L/VQ/1 3—e ,v 7J/4f✓V1 ✓l TR /(J The Commonwealth of Massachusetts _*-,1hl•_ 1,,t Department of Industrial Accidents _'Vii, 1 Congress Street,Suite 100 =_ _f= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: New England Authentic Eats LLC DBA Papa Gino's Address: 9 q0 flj I l+) 31-w56 City/State/Zip:S OA 'A(u/1 O ffi I A O Z L IA Phone#: 6 () SI— 3? 52— /fl/C Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 20 employees(full and/ 5. 0 Retail or part-time).* 6. ElRestaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. EI 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]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, -with no employees.[No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill 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 for my employees. Below is the policy information. Insurance Company Name:Crum& Forster Indemnity Company Insurer's Address: 100 High St#1350 City/State/Zip: Boston, MA 02110 Policy#or Self-ins.Lic.#WC 408-850450-2 Expiration Date: 02/11/2020 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 hereby certify,under the pain and pen 'es of perjury that the information provided above is true and correct. / t Signature: (r)11-/r° Date: /o 0 3-/j7 Phone#:781-461-1200 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 Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia ® '`� OR[�' CERTIFICATE OF LIABILITY INSURANCE dITE(MMA7D/YYyY) 02/03/2019 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(les)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 CONTACT Certificates The PLEXUS GroupeNAME° LLC PHONE 47 21805 W Field Parkway,Ste 300 �AfC,No,EMI: (8 )307-6100 F Ne) (841)307-8199 ADDRESS: certificates@piexusgroupe.com INSURERS)AFFORDING COVERAGE NAIC it Deer Park IL 60010 INSURER?.: United States Fire Insurance Company 21113 INSURED INSURER B XL Insurance America,Inc. 24554 New England Authentic Eats LLC - aasoRERc; Crum&Forster Indemnity Company - 31348 DBA:Papa Gino's/D'Angeto INSURER D: 600 Providence Highway INSURER E: Dedham MA 02026 INSURER F COVERAGES CERTIFICATE NUMBER: 19/20 GL,WC,UMB,EXCS, 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. INLTR TYPE OF INSURANCE ADWEIR R POUCY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYTY) UNITS X COMMERCIAL GENERAL LIABILITY _ EACH OCCURRENCE 1,000,000 I CLAIMS-MADE a OCCUR oaDAMAGE 10 RENTED 1,0,000 PREMISES(Ea oerenee) a MED EXP(Any one person) a Excluded A GL 543-850449-3 02/11/2019 02/11/20201,000,000 PERSONAL a Am IN IURY a GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE a 10,000,000 POLICY ri j�a 0 LOC PRODUCTS-COMP/OP AGO a 2000,000 I OTHER a AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO Ma aodde� a OWNED __ SCHEDULED BODILY INJURY(Per person) a AUTOSONLY _ AUTOS BODILY INJURY(Per Ioddenl) a HIRAUTOS ONLY _ AUTOS ONLYY PROPERTY DAMAGE (Perscddenn a a X UMBRELLA LIAR X OCCUR 25,000,000 B EXCESS UAB OCCURRENCE a CLAIMS-MADE US00089484LI19A 02/11/2019 02/11/2020 AGGREGATE 25,000,000 DED (XI RETENTION a 10,000 WORKERS COMPENSATION a AND EMPLOYERS'LIABILITY YIN Xl 8 ATUTE I ERH- C ANY OFFICERIMENTOR EXCLLrRD7 CURVE El N/A VVC 408-850450-202/11/2019 02/11/2020 E.L.EACH ACCIDENT a 1,000,000 (Mandatory In NH) If s,deserles underEL DISEASE-EA EMPLOYEE a 1,000,000 DESCRIPTION OF OPERATIONS below1,000,000 EL.DISEASE-POLICY LIMIT a A Liquor LiabilityPer Occurrence $1,000,000 GL 543-850449-3 02/11/2019 02/11/2020 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) SEE LOCATION SCHEDULE PROVIDED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1f r ®1986-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD