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HomeMy WebLinkAboutApp, WC License & Certifications T7-71/ oX "4.... TOWN OF YARMOUTH BOARD OF HEALTH ` `fir 9`g1 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:THUAN LOI CO,INC dba THUAN LOI RET TAX ID: LOCATION ADDRESS:1 300 main st S.Yarmouth, MA 02664 i'EL.#: (508) 398-55 92 MAILING ADDRESS: 156 SEA ST QUINCY MA 02169 E-MAIL ADDRESS: tonytran198119@yahoo.com OWNER NAME: TONY ANH TRAN CORPORATION NAME (iF APPLICABLE): THUAN LOI CO,INC MANAGER'S NAME: TONY ANH TRAN (ceo) TEL.#: MAILING ADDRESS: 156 SEA ST QUINCY, MA 02169 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 foim. 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 the employees below and attach copies of their 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. 2. 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, 10.5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years"-reeords. You must provide new copies and maintain a file at your establishment. . DEC 1 1 2020 I. 2. HEALTH DEPT. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (I'IC) on site during hours of operation. 1. 7 ALLERGEN CERTIFICATIONS: All food service establishments arc 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. I. 7. 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. 3. 4. RESTAURANT SEATING: TOTAL # 23 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT I/ LICENSE REQUIRED FEE PERMIT// LICENSE REQUIRED FEE PERMIT/1 B&B 4;55 r•n flim ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town ofYarmouth 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. TI-IE 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 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or I lotel 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 640, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must he inspected by the I lealth Department prior to opening. Contact the Ilcalth Department to schedule the inspection three (3) days prior to opening. PLEAli NO'T'E: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER'FESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, and submitted to the I lealth 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 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 Health Department, or fiom 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 1-lealth. 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 trom January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN __ . 1 nnr rr n-rrr-%niic\ n Nin D rni tip rn FT:Flgl RY nICEMBER 18. 2020. The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-1317-06 Issue Date: 1/1/2021 Mailing Address: Location Address: THUAN LOI CO., INC. 1300 ROUTE 28 THUAN LOI RESTAURANT SOUTH YARMOUTH. MA 02664 156 SEA STREET QUINCY, MA 02169 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: 23 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston111/ Bruce G. Murphy, MPH, R.' fi 0/Mallory R. Langler, R.S. Health Director/Assistant Health Director 4 - - TE ..PROF . SIONAL FOOD MANAGER „__ Designation Has Been Confor 1 ed Upon TONY TRAN Adak Who has met all the SAFETY professional requirements for certification in 1( 61 food service safety and sanitation. ACCREDITED Exam 6901 Recognized By Conference For Food Protection #0659 Certificate No: 1987732 J ...LI,�;_,...., Exam Date: 01/31/18 Ryan McMahon,Client Services Manager Test Code: 6203096901 Prometnc ! 7941 Corporate Drive Nottingham MD 21236 j 800 624.2736 Expires on: 01/31/23 c = + © » . } I ` � \ 2 \ f - - - - - - i - ƒ \ 1 I\ J ! : \\ � � � k 4-4 / \ � \ | I ' . k } « j 2. | 1 w CO ; < %« 2 I CI ~ I 18 II 3 & I ƒ '0 . di - 1 2 /\// -< ! ]/ » m ` < I Fye , oz ®: : . / ! ,P 1m 2 : :' : \ B � ` . 7 11 ( � ' @ } :j I C. « § { 1 o o ƒ §/may § � \ } 1 8 \ .� II U / f ƒ § � E yy i�' � The Commonwealth of Massachusetts Department of Industrial Accidents —T. Office of Investigations =1111= A 1 Congress Street, Suite 100 • :42-9 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_ THUAN LOI CO,INC DBA THUAN LOI REATAURANT Address: 1300 MAIN ST RT 28 City/State/Zip: s. YARMOUTH MA 02664 Phone #: ( 508 ) 398-5592 Are you an employer? Check the appropriate box: Business Type(required): 1.i I am a employer with 02 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. n Non-profit 3.(1 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]* ' 11.E1 Health Care 4.1 1 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] l2.❑ 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 Nie: MA RETAIL MERCHANTS WC GROUP INC Insurer's Address: . PO. BOX 859222-9222 City/State/Zip: braintree, ma 02185-0000 Policy # or Self-ins. Lic. # 01400034677119 Expiration Date: 01 /01 /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 certi under the pains and penalties of perjury that the information provided above is true and correct. Sig.-nature: , ___ Date: 12/09/2020 Phone#: ( 508) 398-5592 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 #: ' ' i ‘A;,., , ‘A ..r, , %A.4.d. # 'A ..d' • ,'),,4 4 t Ai, , %. ; . tv 1•1 .."-^.'we, ill ,.....\ 10 , .....,,....-• 41 :63,4 r-,,,,, 4. s. z,'" ),... _ f i t '' 4• ,.- . 4 'A t, - .. .• 4 I .. _ 4 ' - 4 ' 1 ,-,... ' 4 ' 1 ta , -, -,-,ch - .Q.__ I C _ ' ••-,... -- -3 0-•—9-' - l'C '_.9 --•-:)*C , c•.e --- *) `-- c.42. - at-',,...9 k : I i 4, CERTIFICATE OF ei '6a ; ''''' ALLERGEN AWARENESS TRAININGI -st ! / 1 1 r)i i g \ i,/,t ,•t Recipient: : t_Crtiticate Number: 24'8917' ' tdi I) te•4( Mpletl(In: 12144" : : I)ate of Expiration: 1242" 1 411 ' k.): t I li •-•,.. • OM *ell' i t1 r 11+A,..",i•141 t.. ko,44,0401 A-4,,7 V SI : ' .14.4'../0‘ V/\ ...PA .si 'CI 1 s 4 t fttArr4f pstmtafoo,., ,•k % •6 -'‘..).,c,-. zr6-- ,----.,-.4er , ,..).C-,-- 2- .1.., , it ' , 4 1, 4. • ' ., ,i ' - ' tio li .._Iiid;i ...a. fil , A * ' ".• • C-____......440____......440THUALOI-01 ASANZ( AC7F?O DIYYYY) (MM/D `,..,— CERTIFICATE OF LIABILITY INSURANCE DATE(MM!D2o 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 ri•hts to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 CO TACT HUB International New England • PHONE FAX 265 Orleans Road (A1C,No,Ext):(508)945-0446 (Arc,No):(508)945-9136 North Chatham,MA 02650 Miss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Ohio Security Insurance Company 24082 INSURED INSURER B:Massachusetts Retail Merchants Workers'Compensation Group,In'34355 Thuan Loi Co,Inc.DBA 1 INSURER C: Thuan Loi Restaurant 1300 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 IADDLISUBR� I POLICY EFF POLICY EXP - - LTRW INSD4 V �D POLICY NUMBER 1(MM/DD!YYYY);(MMIDDIYYYYI; LIMITS A X ; COMMERCIAL GENERAL LIABILITY 1,000,000 000000 - ' EACH OCCURRENCE $ CLAIMS-MADE 1 X i OCCUR IBLS58036396 6/14/2020 6/14/2021 j_PR M$ES Ea PNCu enGe) - $ 300,000 • MED EXP(Any oneperson) $ 15,000 I j PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: 1 I GENERAL AGGREGATE i_$ 2,000,000 I X ! POLICY' JEIQT . LOC , 2,000,000 I I PRODUCTS-COMP/OP AGG +$ OTHER $ _. I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .LEa aGGigQnt} s. ANY AUTO !. 1 BODILY INJURY(Per person $ OWNED - AUTOS ONLY i AUTOS )'' ---- HIRED I 1 NOHNEpDWNEDp BODILY INJURY Per accident $ L . AUTOS ONLY r1 AUTOS ONLY PROPERTY DAMAGE i (Per accident) ,$ r UMBRELLA UAB l I OCCUR ' EACH OCCURRENCE 4_ EXCESS UAB CLAIMS-MADE AGGREGATE DED RETENTION$ ---$ B ANYWORKERS COMPENSATION 1 STATUTE I___-LOTH PROPRIETOR/PARTNERiEXECUTIVE YIN! 1 X14005034677000 1/1/2020 1/1/2021 OFF{ER/MEM ER CBLUD D7 N!A E.L EACH ACCIDENT $ DENT 100+000 (Mandatory in NH) - 100,000 DESCRIPTION:If gN OF OPERATIONS gD058036396 6/14(2020 6/14/2021 E.L DISEASE- EMPLOYEE:, yes, 500,000 OF below A !Liquor LiabilityE.L DISEASE POLICY- LIMIT $ 1,000,000 • • i DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is re uirled P 9 ) 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 1146 Route 28 ACCORDANCE WITH THE POUCY PROVISIONS. South Yarmouth,MA 02664 ___ AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. 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