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HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-19-0880-02 Issue Date: 1/1/2021 Mailing Address: Location Address: T.N.T. ENTERPRISES INC. 908 &928 ROUTE 28 ROPES END SOUTH YARMOUTH, MA 02664 908 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 39- Inside; 12- On Deck Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric WestonIII „/. . _____„.. Bruce G. Murphy, (7, CHO/Mallory R. Langley, R.S. / Health Dire , /Assistant Health Director • • " ► TOWN OF YARMOUTH BOARD OF HEALTH 0• . 'A 1 APPLICATION FOR LICENSE/PERMIT - 2021 ; ' * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: X 'f5 Z�,44 /sig � TAX ID: -- LOCATION rLOCATION ADDRESS: 90k ,24.4- "s- TEL.#: fo5.5 o5. 3 'S-'& €F- MAILING ADDRESS: gas ;. .,-,- E-MAIL ADDRESS: i//f4kitA94,Com OWNER NAME: ''34/ A/11-44.40€.46' CORPORATION NAME (IF APPLICABLE): /1.1-7—' "iOr/ /,v4'p41,15 MANAGER'S NAME: --/'f , r.«. TEL.#: s--�- 7-/ ?3's-€7 MAILING ADDRESS: ,9 ,1744.,i )c— POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. 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 le employees below and attach copies of their certifications to this form. The Health Depa tment will not use p, st years' records. You must provide new copies and maintain a file at your place of s usiness. 1. 2. DEC 2 2 2020 3. 4. 111. 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. r--�� // PERSON IN CHARGE: Each food establishmentmustmust have at least one Person In Charge (PIC) on site during hours of operation. 1. 0' /v`-,vA 2. *73 it// M1/4,w 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 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. /0/P1 AA G A 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. 1. U.�t �/l�t %�� 2. `----73),..1/i „44Z 3. 4. RESTAURANT SEATING: TOTAL # S l OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# a R'rQ ycc !'A DIAI J'fc The Commonwealth of Massachusetts Department of Industrial Accidents II =rt. .� Office of Investigations 1 Congress Street, Suite 100 Boston, M4 02114-2017 -►-� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: /< fl/ Fid /97" / .&s Address: lva- /� City/State/Zip: SJ tdead‘ Phone #: c(4- 3 Are you an employer? Check the appropriate box: Business Type (required): 1. .1 am a employer with 3 employees (full and/ 5. ❑ Retail or part-time).* 6. Restaurant/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. ❑ 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 4.1 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: l 6 A-- Insurer's Address: C S O I A4-S City/State/Zip: n- e 44" 5,2C s is Policy # or Self-ins. Lic. # S.',g e>b —7 r a—U Expiration Date: 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. Ido hereby certif er th ains nd penaft' s of perjury that the information provided above is true and correct. Sienature: �— �/ Date: l ,��v Phone #: fie' F' f V V v1 3 S G 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#: -4 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 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 'VNO 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. FOOL) SERVICE SEASONAL FOOD SERVICE OPENING: _ AlLfooLL_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 CAFES: 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 Artr f)CAIC\l/A T A EMT 10 A T!( l'JIQ\ A Fnt ►tR Fn FFF(S' RY DECEMBER 18. 2020. 4. ir I. is �� r ir r,� r ��, .z r ,y .-.i gt t =yw, 1i R t : ..., 11--t• t4.Z�_,.s A t.i, , ws 1i n q t.n : �, fl C 1.2• - --- - - .� --- •174414 . . E O ›.. qAY ‘4,'S r.r. 3 1 S,1/44fe' -i a. � en,� Tb C.I i*'2?�C o 1r S. 0 Jl {K !. � OI z , e � 4... c.. r ,... 1 41>!leis t7 l a o ^�• �^ h' z l y sziO N ti 1 t-. V Mill 4S I 3 "--• '706"'A .-; '1.41 ,7. L_AP:ilj r 4 _ m !'S � CoIt1 ,4. )-' . 7:1 �. �. co" • le k'tE� '. w w N l u K •:i N 2 til r) `. , m co v o �'1 t o j m D Z >1',..__i !c:.. 4 i [nen Z „ � o CA urn • n n b •/ d 5 gl C) I v � -A, C = .�,r s=gam op 1 M r c1., . G v N O • 14 n>. �1 r n ^ '} H • w, O ' ,. 1 rr • I; s >• ZZ r � Co 111 , 4 g v�� 40> - AV) " ? ' (-)6 �I `cam g ? >1D• • :'r D {'F� pq.1 bN Oz—irk". ' y }•WA: •I Z I N��Y. 4r41 •U iOtt r,'r1 U 7 t;XVI;y u t-giny7pry U sv nr U I +Wy)r.-4 U FOODS NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® 76 CERTIFIES F�r1 . trf c1..110" T,ONI NICKINELLO HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE CERTIFIED FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS A x rr 4r x ' PRESIDENT: ..***er, aNS� 111 LAWRENCE J. LYNCH.CAE ACCREDITED PROGRAM Amer�wn Narma�slanaaraemstt fe ` ISSUE DATE: JUNE 22. 2015 Ana Ore Conference to"Foca ProtecD "-. ft. ,v � =0656 EXPIRATION DATE: JUNE 22. 2020 CFRTIFIr ATF IIID• 7 112 i Cr Q p�F00DS NATIONAL REGISTRY OF 4 � FOOD SAFETY PROFESSIONALS® CERTIFIES ori TOM NICKINELLO HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE I t! SpippriNIIIIP FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH,CAE ANSI ISSUE DATE: DECEMBER 4,2019 ACCREDITED PROGRAM EXPIRATION DATE: DECEMBER 4,2024 AmermanearAnalstaRaamslmcwlc CERTIFICATE No:21651491 antl IAC Conference Icr Foetl Proleclion #0656TEST FORM: EXE85 6751 Forum Drive,Suite 220,Orlando,FL 32821 This certificate is not o alio for more than five years from date of issue P(800)446-0257 F(407)352-3603 www.NRFSP.com N.,r:....�1 Dor.:o��„„G t..,.,i c..t...n_..t......:......t..• TNTFAMI-01 ASANZO ACORO TE(MWDDNYYY) CERTIFICATE OF LIABILITY INSURANCE DA12I8 2020 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 License#1780862 CONTACT NAME: HUB International New England PHONE 508 945-0446 FAx 508 945-9136 266 Orleans Road (ac,No,Ext):( ) (A/c,No):( ) North Chatham,MA 02660 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B:Massachusetts Retail Merchants Workers'Compensation Group,In 34355 TNT Family Enterprises,Inc.DBA Route 28 Diner INSURER C: 908 Route 28 INSURER D: South Yarmouth,MA 02664 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 EXP LIMITS LTR INSD WVD (MM/DD/YYYYL(MkVDD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7620076620 8/1/2020 8/1/2021 DAMAGE TO RENTED 100,000 PRFMISES(Ea owirrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ $ AUTOMOBILE LIABILITY Ec a act idem,INGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS p BODILY INJURY(Per accident) $ AUTOS ONLY _ AUUTOS ONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N 014006034637119 1/1/2020 1/1/2021 600,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 600,000 If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD