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HomeMy WebLinkAboutApp, License, WC & Certifications -rhe Le— oF..... 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. ESTABLISHMENT NAME: 'TI� Lefr jtmi! . TAX ID: 4.-Clr1 a'' y/3 LOCATION ADDRESS: J 3 1111-4111 SI- . - Y/SJr/Y)O4fi►MHT EL.#: 5c,2-21�7 MAILING ADDRESS: S) I1 . E-MAIL ADDRESS: lyi rt)0 `ItiC ('We , ('um OWNER NAME: Kett ILy/lJ 6i N/t1 N'D CORPORATION NAME (iF APPLICABLE): DLl t TO cF 7/tr`.Cwt` Lc(. G/ MANAGER'S NAME: k144M✓ 1J 6,4n/u) IZ( cIi4r5fs - , -.' /• i‘y/C MAILING ADDRESS: SAyl POOL CE TIFICATIONS: The pool s, pervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operat,r(s) and attach a copy of the certification to this form. I. Pool operators ,ust list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonar Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below nd attach copies of-their certifications to this form. The Health Department will not use past years' records. Y u must provide new copies and maintain a file at your place of business. 2_ DEC is 2 2020 3. 4. HEALTH DEPT FOOD PROTECTION M NAGERS - CERTIFICATIONS: All food service establish' tints are required to have at least one full-time employee who is certified as a Food Protection Manager, as deft 'ed in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of=till ition to this application. The Health Department will not use past years' records. You rust provide new copie and maintain a file at your establishment. I. 2. li4iivL PERSON IN C LARGE: ---P-1923111-261:14 Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. i. • fi � SIL 11 681)/1 t 2. tali g.f4,f-V f � ALLERGEN CERTIFICATIONS: � �/ i '/4 Alt 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. 6-1144 1/0 2. Ptili L`/t(/ S 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 iew copies and maintain a tile at your place of business. 011101 Pqn4/1) 2. ?-tliki , / 3. 4. —151.11 RESTAURANT SEATING: TOTAL // OFFICE USE ONLY LODGING: LICENSE REQUIRED PLL PERMIT N LICENSE: REQ1 FEE PERMIT II LICENSE_ REQUIRED PLL PERMIT II r,o-r, u,cc i'AI)ini 4'cG M(1TF1 4;110 e • ADMINISTRATION Under Chapter 152, Section 2.5C, 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 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. 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 he inspected by the I 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 lealth Department'three(3) clays 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 Icalth 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 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 food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or !ler 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 l to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN rt-'t--iR r'nnnnt r,Tr rl D C Ki CU/A I A nnr I/'"'A Trllxli[,\ A XIV, r•r• T. �r�.-..�. .,-..... f. ........ The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-16-10284-05 Issue Date: 1/1/2021 Mailing Address: Location Address: ROURKE'S TOP OF THE COVE LLC 183 ROUTE 28 THE LOFT WEST YARMOUTH. MA 02673 183 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: 194 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, R! ., HO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents r=- Office of Investigations MSL' _�+�1= p 1 Congress Street, Suite 100 � .;`1� Boston, MA 02114-2017 =►-�,, www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: g - ■ itiili4) Address: ) KJ 1fi*\ STM'+f. City/State/Zip: 1,kJ. \ hi 1'Y N41 f . CMZ( W Phone #: 7'21537 Zi 7 7 . Ar• to an employer? heck th appropriate box: Business Type(required): 1.1:1 I am a employer with employees (full and/et 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. ❑ Ngn-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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.E1 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' cope ation insurance for my employees. Below is the policy information. Insurance Company Name: (-11/0 1(( 4( Insurer's Address: /,9 h'i, '/'7' S I _ G City/State/Zip: 's i , - 8 2, yP Policy # or Self-ins. Lic. # 0��-31 5 tot 14?I " Op • Expiration Date: U —7 –d 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 Ido hereby cert_ify? unde the pai arld penalties of perjury that the information provided above is true and correct. Signature: '11 �4 Date: � J c .11_1 ' Phone #: 9g-10 (1(‘'- q Y 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 #: iv NORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY \ ; Liberty Mutual. INSURANCE INFORMATION PAGE 175 Berkeley Street Boston, MA 02116 sued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-621418-010 Issuing Office 016C RENEWAL OF: WC5-31S-621418--019 Issue Date 03-04-20 Account Number 1-621418 Sub Account 0000 1. Insured and Mailing Address ROURKES TOP OF THE COVE LLC RISK ID 001058718 183 MAIN ST WEST YARMOUTH,MA 02673 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 04-07-2020 to 04-07-2021 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 215 (MA) Total Estimated Annual Premium $ 2,273 Premium will be billed ANNUAL Producer 0004-005707 ROGERSGRAY, INC 434 RTE 134 SOUTH DENNIS MA 02660-3433 WC 00 00 01 A © 1987 National Council on Compensation Insurance,lnc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Broker Copy s ii44111 nit - I 1 I 1 ._ ..,„,_. _ _ - < 7 -,. 4..ritri ... in t i - a)._ _ i i .0,_.-,- _ i ,,, , ...._. . I.. ,1J....) i k3 F rcn1 1. cr 0 A 3 -> '' (1 " A 70 CAI '--4- Nri tot If, f,o�� fl O r N 72 w ® ;',1�" D N Pa 0 0 D m E. 3 �� Z - -a M 3 imill { onal o D-I m m 03 r mum IIIII :.. ' N . ..,_ � -Z QN rill til 3 D O QT o )1211° t i MUNIII a 7.. r s ' RF..„ i - r r. i i 3' .a... en 0 lift r T > ▪ z 92 m 3 D N x a, —y -„ • a .fix rn O 41. D . 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RTIFI KEVIN RICHARDS for successfully completing the standards set forth for the ServSaF®° which is ssaccredited le the to stand National Stan Food Protection Ma Standards Institute(ANSI)-Conference fot Food Protection actio E(CFPJ. ion, Proteetion(CPP), • 15045594 CERTIFICATE NUMBER 5237 EXAM FORM NUMBER 4/26/2017 DATE OF EXAMINATION 4/26/2022 Locd laws Checkwtth l bed DATE O F EXPIRATION reatlsaoryoge„n,For reca►iRca8on feauirmnens. (NSI 8VP #0855#0855 � ' � teuraMgy oven Sohei enc #80151######16._ ..embas•Araftsai Egurakedlasdaigs_08#01### 1 comotiorop,dy�et aa�dsar4 N �asdlig6s (�sarenadanvlsefhSN F. a:U01 Great wdh quell as at DI W larisan ted.Sta 1509,Chitaga,tL O&M ar SawSar0 \4 . . A i .vt ;.". fr 14 ;„e, _•,,,,, .,_ _.. • - ,_, , - „. ..-.:!.' 'tc — .,V , ,- )'”( L),,•, , '- :-'_ '. 41la 1:Alt '- , ,,',I.,-' 4 i,flrAi T ,Intr-FA.: Y 3.•-• .,--('; .. ,. . - , •--" 61hi..._----'C. =:' . .-,-)'(_,'*- -(')''ci -—-)'''/:' ;tr '- 10' ''.' n .'' 41.1' '‘St ''' ' . I rt*rm.- ..' 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V...) 1 A ''4'h , ,..... • • A tk L. 1 c).: s t' C.) es .•(,(, WU lit'' - z).-c"----• - 4(1)7;(f")' ' „,•3 c __--vs .,r„...„,_,,•,.,,,,,,..,,,,,,,,,,. . -,--- _,, ,., c•,,,.. --_-..,-,_)c .-----m.r--------- .-)c ----, ' ' .. W • -; ' . ' )11*'-- lir - Pae 1 of 2 7117 ZiAlifiGVit@R r o Certificate of Completion II Kathy Gianno has successfully completed requirements for Adult and Pediatric First Aid/CPR/AED- valid 2 Years conducted by American Red Cross ❑ ❑ Date Completed: 04/23/2019 fj,' ca".. Instructors: Richard A.Stabile Certificate ID:15RJ35 To verify,scan code or visit • https://classes.redcross.org/Saba/Web/Main/goto/FullCertificate?t=15R.T1i .— .� l • ; i it • • li ServSafe : -111101110110. e ry a e CERTIFICATION KATHRYN GIANNO 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). glimmimilioitti • 24077 5268 KATE NUMBER EXAM FORM NUMBER 5/15/2017 5/15/2022 DATE OF EXAMINATION Coad laws apply.Chi��local regulatory D A T E OF E X P N agency for recertification roqulromeste.onn, ANSI taiii 1 AL.4.4. 111.1, .., j161111° , Sherman Brawn ® SVP,National Restaurant Association Solution i " 80 ''i in aocanlonce with Maritime Lime Ceteed.3504 Itmefiekte*eked aralamatAisackliaria a�t,ao 11��I��,9ot, as eo.aa<,nsat !et,,;rIC] Mk dOCAVAIS ameart�asr eb�a arc askp� Imono%ti the Iddq�moral Smear*�hplego ma haetemorks eifha NRAEF. i , -i . t-; I .--- — __ Contact Contact us v411 avec ions of 175W !admen Bbd.Ste Ina chime,L d0.104 or SQ^'Sa iatoodare •