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HomeMy WebLinkAboutApp, WC, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $125.00 Food Establishment License Number: BOHF-15-6410-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SUB ACQUISITION LLC 2 WHITES PATH SUBWAY #12312 SOUTH YARMOUTH, MA 02664 930 WATERMAN AVENUE EAST PROVIDENCE, RI 02914 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service 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: Zero (0) RESTRICTIONS: (1) Maximum daily water usage not to exceed 247 gallons per day; (2) Maintain a weekly water usage log and submit an annual report to Health Department; (3) No cooking or frying on site. Baking bread is allowed: (4) Single service/paper items only. No dish washing on site; (5) No clothes washing machines; (6) No seating allowed. Take out only; (7) No public rest rooms. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 40 Bruce G. Murphy, MPH, •.S,.' O/MallorY Lang ler,Lan ler, R.S. Health Director/Assistant Health Director ... TOWN OF YARMOUTH BOARD OF HEALTH 12312. .t'J') j e 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: ' Jb 0) AS (fin -�' TAX ID: LOCATION ADDRESS: g7k kip"tNTEL.#: ,e MAILING ADDRESS: Clojp (J30A4.c. � V'--C- P> tiv 42-31 OCAe/ 1'l E-MAIL ADDRESS: ! r. ' S k•.- rs •co OWNER NAME: jl1M 4Lau vl-e CORPORATION NAME (iF APPLICABLE): MANAGER'S NAME: 'MAS NV(jeD _ TEL.#: MAILING ADDRESS: COON.A-- 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. i 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 the employees below and attach copies of their certifications to this form. The Health Depar ut.will..ust- se-p nst years' records. You must provide new copies and maintain a file at your place of business_. 1. 2. JAN 0 4 2021 3. 4. HEATH PrP T. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments arc 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. `e Liv ' 2. 0\(JO N\&c PERSON IN CHARGE: Each establishment must have at least one Person In Charge (PiC) on site during hours o operation. 1. . �wu5 Jxü 2. J( ALLERGEN CERTIFICATIONS: All.food service establishments are required to have at least one lull-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. 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. I. 2 3. 4. RESTAURANT SEATING: TOTAL # L J OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT IJ LICENSE RI Qt1IRED FEE PERMIT If LICENSE. REQUIRED FEE PERMIT ti RX.R q:SS (`A 12I1\1 ,LSS nn(1TI:I 'YI III f 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 Ni O/1 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 ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or I lode 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 I lealth 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 I Iealth Department three(3) clays prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must he drained or covered within seven (7)days of closing. FOOD SERVICE SEAS ONA-L-FOOD-SE RV-t€t 0-1 NING:-- All food service establishments must be inspected by the I lealth 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 I-Iealth 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 I lealth 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 3 I. IT IS YOUR RESPONSIBILITY TO RETURN TUC r IAADI CTCr' D I:KICl1/A I A n01 IC'ATl/Inlie\ A xir1 11 CC\I IID ell CCC/C\ Dv r1Cr'1_7.1\ADCr) 10 ,1n'n • - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations —�i11= p _;• 1 Congress Street, Suite 100 • -A if— • Boston, MA 02114-2017 �,�,r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ' '` A (-- Address: p,k \ WVA\r“S \c1-- City/State/Zip: J ( V`I\/ ti`e\-t— P Phone #: ‘61 -ik3u Are you an employer? Check the appropriate box: Business Type(required): 1.' I am a employer with (p employees (full and/ 5. ❑ Retail or part-time).* 6. n Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. E Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. n 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.[7 Manufacturing no employees. [No workers' comp. insurance required]* ' 11.7 Health Care 4.[ I We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.n Other 'Any applicant that checks box 41 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 rl. I am an employer that is providing workers' compensation insurnce for my employees. Below is the policy information. Insurance Company Name: Cl Insurer's Address: ` ! `-' City/State/Zip: S�'ti � 12 Policy z or Self-ins. Lic. # CT Ac expiration Date: I (-24 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 51,500.00 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, un i er the pains an penalties of perjury that the information provided aboveis " is true and correct.l Sig.-nature:ature: ��.�: . �� Date: 1, W1'v Phone n: rVl' -I9k{' )) 2 I 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 #: °r' DATE(MM/DD/YYYY) "AMR/4 ' '�" CERTIFICATE OF LIABILITY INSURANCE 12/22/2020 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 be endorsed. If SUBROGATIONIS 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 NAME: PAYCHEX INSURANCE AGENCY INC/PHS PHONE (800)472-0072 FAx 76210756 (585) 7894 (A/C,No,Ext): (A/C,No): 150 SAWGRASS DRIVE ROCHESTER NY 14620 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B: SUB ACQUISITION LLC DBA SUBWAY INSURER C: 45 PINEHILL DR EAST GREENWICH RI 02818-1905 INSURER D: 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/Y YYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO- LOC PRODUCTS-COMP/OP AGG JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED BODILY INJURYPer accident) AUTOS AUTOS ( HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY Y/N E.L.EACH ACCIDENT $1,000,000 A PROPRIETOR/PARTNER/EXECUTIVE — N/A 76 WEG ACIWPF 11/25/2020 11/25/2021 — OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. For Informational Purposes only. CERTIFICATE HOLDER CANCELLATION Sub Acquisition LLC DBA Subway SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 45 PINEHILL DR BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED EAST GREENWICH RI 02818-1905 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Y- Ate kfr y T nre A 4. s - 1 Z n1 e 33.` ., n s !<'b. 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Date of Completion: December 13, 2017 eA- Gam+-: �.�,.... .YDate of Expiration: December 13, 2022 � ,,�4 4 el V 1 Issued By: 61S,, t 7Th nhove-rrnmerl rson is herelTy issued tllis cert rata J, � �.•, K. �S�+,} fhr completing an allergen nzuarerress training prosrarn k� /% recognized by the Massachusetts Department ofPublic Health Berkshire d C in accordance with 105 CAM 590.009(0(3)(4 AHEC . ("? - Area Hca1th Education Center G 4 e.. .. " ?his artyieate will be x rrlal for five(5)years from date o,j completion.N i Pittsfield,atnmsac6naettc K' (//. VW .nIAi,S,,dsil,�iTflinIu.c)1. +E J y'� 01,%Yum i } u�i v4 rr'> Q 1 , Y- t , i', t,:6------3„ ;^t'et , c c` fid?as.,1 i!+} U 4i1 <vt.t"r1 r U )'