Loading...
HomeMy WebLinkAboutApp, WC, Licensing & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-16-0124-05 Issue Date: 1/1/2021 Mailing Address: Location Address: SEA DOG BREW PUB CAPE COD LLC 23V WHITES PATH UNIT I SEA DOG BREW PUB SOUTH YARMOUTH, MA 02664 23V WHITE'S PATH 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: 140 Seats; 18 Bar Stools Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 111 ruce G. Murphy, MPH, R.'.., C.✓ allory R. Langler, R.S. Health Director/Assistant Health Director S e=. c7vc3 o, TOWN OF YARMOUTH BOARD OF HEALTH 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. (7ESTABLISHMENT NAME: C Jo �� 1 TAX ID: LOCATION ADDRESS: '33 L4 ) C �Q4i TEL.#:S-58-65Lt -66w MAILING ADDRESS: ,,,..t, E-MAIL ADDRESS: 1 p ® Sec ?S a-pc CDC C6� OWNER NAME: �(-' l ( Lu C t plb CORPORATION NAME (IF APPLICABLE): MANAGER'S NAMErp CK 11 A G.e� C�kj4 TEL.#:c - 7 -�g9 3 MAILING ADDRESS: �c� L 4)rYt r V OW S /LIP 616A/ 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 :,ttach a copy of the certification to this form. 1. 2. Pool operators must list a mil mum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscit .on (CPR), having one certified employee on premises at all times. Please list the employees below and attac copies of their certifications to this form. The Health Department will not use past years' records. You m i rovide new copies and maintain a file at your place of business. 1. 2. 3. AMER 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 Establishmelpts, 105 CMR 590.001. Please attach copies of certification to this application. The Health Department will not use past years' record You must provide new copies and maintain a file at your establishment. DEC 0 0 2020 („.P1NE 2. PERSON IN CHARGE: Each food establishment must have at least one /Person In Charge (PIC) on site during hours of operation. 1. d [tel A C` t'1�`r.�1�..11`l.� 2. 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. V rCS( V �Y T-2- � 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 . ' ovide new copies and maintain a file at your place of business. 1. �.:)••- _ q iI 2. 3. 4. RESTAURANT SEATING: TOTAL # /S1 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# .•.. .n�� �.r..wi JCC KACTC1 QI I,l 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 X NO jj 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 colilorm 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: -Alt-food service establis - - ' ed by the IIcalf t)epar inent 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 3 I. IT IS YOUR RESPONSIBILITY TO RETURN THF (`ru.iDi FTCrI D CAIC111 A T A DDI In A Mit-VAI/ON A 70r1 n r./-NI lin 17rN 17rr,n\ m1 I". • , The Commonwealth of Massachusetts Department of Industrial Accidents r q11111,.• Office of Investigations . —=ist p 1 Congress Street, Suite 100 -14= l • 4•— Boston, MA 02114-2017 "k2P_.,�„.a www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Or anization Name: - `--" ' 3---C -C Address: (--IJ ,+:-C 'c <1--- -1-‘) City/State/Zip:S ,, �.,-‘0- 'V) t\,-D Phone #: cO09 -6o 2` Are you an employer? Check the a propriate box: Business Type (required): 1. I am a employer with 3"c employees (full and/ 5. ❑ Retail or part-time).* 6. testaurant/Bar/Eating Establishment 2.E 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. E Nonprofit 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.[- We are a non-profit organization, staffed by volunteers, 11.0 Health Care 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 providing1workers' compensates insurance for my employees. Below is the policy information. ' Insurance Company Name: ) 'N•{ 11 e-.,----t C( Insurer's Address: /0 i0 S_ t U rvm f v,, City/State/Zip: `N a 1 / (:--T---- � Q /S Policy # or Self-ins. Lic. # ---)C7 �-r C�ILJ��L Expiration Date:10 I 2) Attach a copy of the workers' compensation policy declaration page (showing the policy number and piration 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 ce ' •,• e pains a d penalties of perjury that the information provided above is true and correct. Sienature: diDate: l -219/7-1 7- Phone #: ��� /CO `—' 91 -C) Official use only. Do not write in this area, W 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#: THE — HARTFORD November 13, 2020 Account Policy Information: Agency Name PAYCHEX INSURANCE AGENCY INC Agency Code 76210755 Recipient Information SEA DOG CAPE COD LLC DBA SEA DOG BREW PUB 23 WHITES PATH SOUTH YARMOUTH MA 02664-1221 SUMMARY OF INSURANCE Account Policy Number Policy Premium Policy Recap Term Worker's Compensation Hartford 76 WEG AJOTML 10/15/2020 to Accident and 10/15/2021 $3,293 Indemnity Company Sum of Insurance Summary of Insurance (Continued) Workers' Compensation Summary of Insurance with Hartford Accident and Indemnity Company A member company of The Hartford 10/15/2020 - 10/15/2021 Policy Detail: Worker's Compensation Policy States: MA Location 1 Premises Address: 23 WHITES PATH SOUTH YARMOUTH MA 02664 Worker's Compensation Coverages: Employer's Liability Limits Limit Disease- Policy Limit $500,000 Bodily Injury—Accident $100,000 Disease- Each Employee $100,000 Class/Payroll Class Description Class Code Payroll Detail Location 1 - MA RESTAURANT NOC 9079 $350,000 This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions, limitations or exclusions. Please refer to the actual policy forms for detailed coverages, limits and deductibles. Sum of Insurance AQ SEADO-1 OP 1D:K; LC --- CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) 06/08/2020 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(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 508-398-6060 COIV TACT Bryden&Sullivan Ins Agency IJpME: Bryden&Sullivan Insurance Of Dennis Inc. PHONE (NC,No,Ext):508-398-6060 I FAX 508-394-2267 485 Route 134,PO Box 1497 (A/C,No): So.Dennis,MA 02660 ndREss: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIL# INSU ED INSURER A:SCOTTSDALE INSURANCE COMPANY 41297J Sea Dogg Brew Pub Cape Cod LLC INSURER B: South Ya mouth,MA 02664 INSURER C: INSURER 0: INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER: NUMER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NVAMEOD 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 ADD.SSUBR POLICY EFF POLICY EXP u• A POLICY NUMBER X COMMERCIAL GENERAL LIABILITY LIMITS CLAIMS-MADE X OCCUR CPS7103950 EACH OCCURRENCE $ 1,000,000 05/02/2020 05/02/2021 DAMAGE SS TO occcurrence) $ 100,000 X Liquor$1m/$2 MED EXP(Anyone person) $ 5,000 GENII AGGREGATE LIMITAPPLIESPER: PERSONAL&ADV INJURY $ 1,000,000 X POLICY_jECT LOC GENERAL AGGREGATE $ 2,000,000 OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE UABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ OWNED __SCHEDULED AUTOS 1/ AUTOS BODILY INJURY(Per person) $ AUTOS ONLY q�TOS ONLY BODILY INJURY(Per accident) $ PROP cadent MAGE (Peraccident $ UMBRELLA LIAR OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ DED RETENTION$ AGGREGATE $ WOAND EMPLOYOERSENLWBILOITNY ANY PROPRIETOR/PARTNER/EXECUTIVE Y N PER ETM_ OFFICER/MEMBER EXCLUDED? STATUTE (Mandatory in NH) N/A E.L.EACH ACCIDENT byes,describe under $ DESCRIPTION OF -E-•TIONS below E.L.DISEASE-EA EMPLOYEE$ E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Certificate Holder Named as Additional Insured if required by written contract. Liquor Liability restricted to designated premises. CERTIFICATE HOLIER CANCELLATION OSCAR T U THE EXPIRATION H DE ABOVE HEREOF, NOTICE IE WISLL BE CDELIVERED RE Oscar Taylors, LLC a/o Union ACCORDANCE WITH THE POLICY PROVISIONS. Station Condo Assoc 23 Whites Path--Unit M AUTHORIZED REPRESENTATIVE South Yarmouth,MA 02664 Q" � ,,: , ;, ACORD 25(2016/03) @ 1988-2015" "b '�'^ `� The ACORD name and logo are registered marks ofACORD CORPORATION. All rights reserved. ACORD 02 bib. I Ift°3 : '1 tU ))) to I ki 0 im ‘J n ..._ ,. 1 ilt" g) B Fil F3 CO ElCO MilliM mai 2 tze 51.--, tii xagi p NI03til 4 iti 0 trz) , . i, . 0.3 , i ggi © E = , � F 3a0 i NM ``0 �:L�. J'G n , ti '; .......--... �.. ,i .LTJ G��`, 3 ----=•mow..__. 9 1 ›Is -. ... I r •'1- , ', ).# .,.., rt. >, Ati r...., �a )�r c 0:7 ,n .;") 0- C \ tori / , ..... •Lt. .„...tV ...,^, .4.2 I 1.... z 2 is-«a..1 a `t7i ` ,s, Irri Cr fD .J �?. ti Al il \. 0 ...4., „....01 ti) > p741 I c!,--,2-._ I ., rt kz __........_ ___.____ P 0 f§ 4 rill n- ,,,a-Al 1 g g E o ���` ' S fw ri I 4 al 0 I ten iir• �y k,._a � Cry'"T v� `�g ' -•- O a �• Et i CO I Y Oil :Pull i)''' �^ a CJ- 1 ''Z NL.: •_,�Yr 1 ga, 3- • -. 1 V T \�.s 'i' �:�1� ��.?,!,C., J�.�A. M1} /--.. zz R, �..2'.„ -„_.Ri..4B•w1,.'4.e 1 at i�� } 1\`„ ,.V •,` iu , •._ Gam'• --,,.C------b J i It r 1 + i, �jj c �v ` 'x 1�� f: b ��� 7 e \ k--k • , \ . , . r (I/1) • ' , . . • %.: - CA M , .. . . / - . , if . i . ..... 0 . (r) ‘ 1 ' / I w i . I 1. I I F...- •••,.. i al ,1 r m _Li: :..... ..... -. ,_ _,,..„.,: > et 0 co .:'* '"ilk, 0 o g =ra- iw _. R vcA . < . ..- „ OIL -II NT /--..1 , ...."/ E7,1 in ..-, . ' rn , ioj g * n A '44 rof 0.) 0.... PD 111D g Pi ,, r 8 Cr 133 , '.< E I mil 1 I r<8! > . 1 \... • ,.. t . . rn t 0 MI a L M am= g. , .• 11- z ri tit ,.. . 1 ,,, ,.:, . _ ...: = 9_ r c =,.. )211111.4 .54' ---. 0 = cl R `?. .4=. r;c1 cri 13- „, r- • a m 0 11411 trr, - 1 . __Ji Zki) C rT1 i E Z ° a' x 0 f T i a -0 l 3 po a 07 5, 5 m I } t . F -ra i 9. a th . a_ i • ,. ,„ ? . . n -.i 5 -0 . . . . 5 ..?a 4 . r . : .?.. 4 .