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HomeMy WebLinkAboutApp, License, WC & Certificcations T-1 c YGf>-,b + FtooSe `,of....►,n4i-,, TOWN OF YARMOUTH BOARD OF HEALTH 0 g 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: \00 YrfOtA J-�Piu, ,P f�,e .>t kra -, TAX ID: LOCATION ADDRESS: 33 S MO,C.n 6- TEL.#: 6Z4 ?1 I-S-1 VI MAILING ADDRESS: E-MAIL ADDRESS: iav A a i ,_ >°$-kt.�,r�c. ��m� a`l�OY1n OWNER NAME: EVa ejt� Zctrr t s V CORPORATION NAME (iF PLICABLE): nci tS �Y ./prices c MANAGER'S NAME:r✓GwtS S KaotR s' TEL.#: �}/ -- fl/- 5Y sit MAILING ADDRESS: 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 the employees below and attach copies of their certifications to this form. The Health Department will not use papt years' records. You must provide new copies and maintain a file at your place of business. 1. 2. DEC 2 2 2020 3. 4. HEALTH DEPT. 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. SIC,( . 2. fir:. i8� / G70 '{ f4 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. i. &1 r�. 6(i)ra8 2. jawed Bra tel ci 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. AcitArkAl (cpIrO( 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 tbrm. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. I=V a al,leA &-- 2. GAY5 3. CAA r'51D 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE I'i RMI"f It LICENSE RI QIIIRI I) [H PERMIT ll LICIENSI'. REQUIRED FEE PERM IF II O2.0 CCC . nniw ace ...,. 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 NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or 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. 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 I Icalth Department prior to opening. Contact the I Icalth 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 Icalth 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) clays of closing. FOOT) SERVICE SEASONAL FOOL) SERVICE OPENING: All food service establishments must he-iusi,CLted by the Health Detriment 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.yarniouth.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 Iealth 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 !bud service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has {-ailed 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 1. IT IS YOUR RESPONSIBILITY TO RETURN Trrr"` nIlk Anr CTCV III CRIC\LA 1 A 11111 If,ATIC 1k1i0 AXIrl nn.r\r tmnr\ rnnim nv r1CnnAAEI CTI Io "n^1/1 The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-14-0332-07 Issue Date: 1/1/2021 Mailing Address: Location Address: KOUNADIS ENTERPRISES 335 ROUTE 28 THE YARMOUTH HOUSE WEST YARMOUTH, MA 02673 335 ROUTE 28 WEST YARMOUTH, MA 02673 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: 264 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 111 Bruce G. Murphy, PH,R.S., k HO ( allory R. Langler, R.S. Health Director/Assistant Health Director Awa CERTIFICATE OF LIABILITY INSURANCE DATE(M10/07/2020 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 CONTACT NAME: STANDISH INSURANCE GROUP INC. PHONE 7/4.283.4425 FAX --7742834243- - 303 COURT STREET UNIT 1B E-MAIL Extl: (AJC,Nolo._______ ADDRESS: ANDYR@STANDISHINSURANCE.COM , PLYMOUTH,MA. 02360 INSURER(S)AFFORDING COVERAGE NAIL p INSURER A:AIM MUTUAL INSURED INSURER S:EAP-SPECIAL-MY __ _ KOUNADIS ENTERPRISES INSURER C: THE YARMOUTH HOUSE INSURER D: 335 MAIN ST INSURER E WEST YARMOUTH MA 02673. — — 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. .._ ___.____-_ --------------- IADDL SUBR!, -'- ---- rPOUCY EFF POLICY EXP I Ih R TYPE OF INSURANCE UMITS LTR INSD WVO POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY)! X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 OOO CSI8001925024/01/2020 B •f__i `X 1 ! 4/01/2021 FRE PREMISES occurrence) $ 100,000 CLAIMS-MADE L OCCUR MED EXP(Any one person) I$ 5,000 !PERSONAL&ADV INJURY j s 1,000,000 GENII_AGGREGATE LIMIT APPLIES PER ;GENERAL AGGREGATE I$ 2,000,000 I PRO POLICY )JECT LOC ! PRODUCTS-COMP/OP AGG I$ 2,00Q-QQ . OTHER I ' I$ AUTOMOBILE LIABILITY I f COMBINED SINGLE LIMIT $ I(Ea acclden1)_._ ANY AUTO II BODILY INJURY(Per person) I$ _- OWNED SCHEDULED ~ j BODILY INJURY(Per accident)j$ ;AUTOS ONLY AUTOS . I HIRED NON-OWNED i ;(pe�accident DAMAGE $ AUTOS ONLY -AUTOS ONLY ) ) I '$ UMBRELLA LIAB ! OCCUR • EACH OCCURRENCE I$ EXCESS LIARCLAIMS-MADE I AGGREGATE I$ ,DEC ! RETENTION$ $ WORKERS COMPENSATION WCC5005022314 • • AND EMPLOYERS'LIABILITY Y/N 6/08/2020; 6/08/2021 i STATUTE I I ERH ANY PROPRIETOR/PARTNER/EXECUTIVE !E.L.EACH ACCIDENT I$ 500,000 A OFFICER/MEMBER EXCLUDED? N/A — -- (Mandatory In NH) , '•,E.L.DISEASE-EA EMPLOYEE$ 500,000 I If yes.describe under — i i DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT I$ 500 000 3 LIQUOR LIABILITY ' CSI800192502 4/01/2020 i 4/01/2021 PER OCCURRENCE$9,000,000 GENERAL AGGREGATE$2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is required) OUTSIDE DINING IS ALLOWED UNDER THE GL&LL CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 ROUTE 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©19 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD BASIC LIFE SUPPOR BLSAmerican Heart Provider Association. Angie zambelis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Training Center ID Instructor ID 02112303145 MA00640 eCard Code Training Center City, State 205503338082 Pembroke, MA Training Center Phone QR Code Number o ?r.o • (781)826-2011 �l""; `. 0444 yy To view or verify authenticity,students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 ServSafe National Restauran`.Ass;:-,-iat- ServSafe AIIergen ;.TM Certificate of Completion Awarded to GARY SPRAGUE Provided by the National Restaurant Association Certificate Number 4165637 Date 11/20/2019 (ii?isi Expiration Date 11/20/2022 ACCREDITED / miss O"f_ � .S11,,(2659 / •� W ierrt Sherman Brown Executive Vice President,National Restaurant Association Solutions r C \\ 22 { Cui. . § � ° _ kr @ � � a \ / MN o } } < flU 0)$ \0 E, \ LW)i / L (} ( }� A,r_ , / 2 {Ei , (.)\)......00)0 / (i + g , {} } ~^ 0 � \ \ / / f g z : / i ƒ j Ii: Fr 0 IV{\ƒ ' \ O / 3 2 > gtn E 2 q « _ A ® n % \ �r > am , ~ n x A� -1 ƒ § f 73 Xiii 0 , E .< -I } \ CD ^ lf Z �� 9 ( / Z / cd f ¥ t / jC/) \ // §. [ MIII=M 4 ( \Z k ƒ lj CD E ) � " n 0 7:1 { - . ƒ \ i_ ° H \ ± @ = / 6- n / ƒ \ MM. a F a, "Illi { \\ c / k ii. ] / k ƒ LZ 0 } co \ 06 ƒ m C ƒ x & . § / Z CD 0 EIi /_ I ƒ %\ CT 0- /Z m -0 a\ 0\ \ 0. n ƒ \ a• \ •. ! . D.Em ®' B ))ServSafe ServSafe CERTIFICATION JARROD BRAND for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 185907 5184 HUMBER EXAM FORM NUMBER 9/20/2016 9/20/2021 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply.Clitt with your local regulatoryagency For recertification requirements. own ism" •iona1 Restaurant Association Solutions 46655 1 a a¢arrJwo with Mamma 1� Nim "'... N 068-2017 tltminism 3 2%mlord °° OiolS Nod i" .. ,feundwo.NRAFFI AM ri¢n ree.,at 5..Srf4 and 6w e o badnvlsdl.DiAEF A Al Ae ac deign ore ead.no44 olive Naeorol 166 aN Anna on 16:6 document wwol 6e reproduced Of ohered 16102901 v.1401 Canoe w with qumtions at 1751.111.1=n Died.51.1500,CMicogo,11 60606 a S.n5dn6r.+ouo*.ag HEARTSAVER 0,4R Heartsaver° American First Aid CPR AED Assaociation. Christos Kounadis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Optional modules completed: Issue Date Renew By 12/10/2020 12/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Training Center ID Instructor ID 02112303145 MA00640 Training Center City, State eCard Code 206007614321 Pembroke, MA Training Center Phone QR Code Number a; •;:^ o (781)826-2011 �4 o�kJ o�n• To view or verify authenticity,students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3002 R3/20 l (tis tt 4)1 1 a1'lil(►utiiis i ;iiddlii2 I ;=. I4,di 1 146 lztr;ticF ?ti. 'south \ at mouth '‘I '. l t1. t114.b li '. 2 -) 'q 1.\i I ',Li g--.1-c_ct \ 1-7-1 , i ct \ 1-7-1 Gni �cs�s _ b F��=z- Imo• 1oQ P -17(936, Tem Temporary Outdoor heating/ � S p fi(i ---- Alcohol Alteration of Premises Application Date: p 2 2. I 1 u-u ti A 7)( S E_lV7€R 1'R 1 CE- S' BusinessName:d e ` (A-gVY1QU(-k- Ifi)0% RLL7cf\---ctk'. 6 /';I Business Address: 335 'Y161 AJ S j W fcrr'io (-,i /IV Unit#: Applicant Name: CVech50 lcC. 2?moi , 1 ( S Applicant Address: 12 -(. COL)-47t( act . ' S+ \/Ct.c v uA-tf li i i Al t`1 E-mail Address:`iarmotl-}l,hcx.150 es uqu "' Applicant Phone: (,Su o b 1( - 7 2 LI e 5iM0.(1• (vvv. ABCC License #: Common Victualler #: 0 0 0 17 - 15- I51E: Manager: i 12_ Neto A-) Current Hours of Operation: etc)0 -- f r)°o 0 d a't I l Requested Hours of Operation: Request for Outdoor Seating Only (Y/N): \le S Request for Outdoor Seating and Outdoor Alcohol Service (Y/N): \1 ) S Occupancy and Seating: Complete the Table below. Description Existing Proposed Occupancy Load of Building 1 i?ancY Load of Outdoor Areas "— t: C,ppacity of Building . �� 2--0 y 180 durlhyI .�(QRAlc `1,-5;..:_- : C-apacity of Outdoor Areas L a are Footage of Outdoor Area }O o ` ~ `° a*t'�=available on site - -'- ':'",::-.:srViits7 ncy.of 50 orgreater is shown on your Certificate of Inspection which should be displayed at your `killii6¢ etit F 3 XOccupancy<50 is displayed on your Use &Occupancy Permit. Access to these documents is available °ti te_.: of rr}Website under the Building directory at . y "li' s/WebUnk/Welcome.aspx?cr=1. ._ igiv . ou r septic plan and also noted on your Food Service Permit.tF -, ,, o !ii ii a, r nnot exceed the total number allowed under you Certificate of Inspection, or . ' establishments is 1 space per 3 occupants per Section 301.5 of the Zoning x - T - : 'i o tE S PLEASE SUBMIT COMPLETE APPLICATION MAT ERI Ai °- 4 a 1 7{ , $ ," ;' ",.,r0. 0 , armouth.ma.us