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HomeMy WebLinkAboutApp, License WC & Certification T,,,t- ,, 7 3.k • ";+�. TOWN OF YARMOUTH BOARD OF HEALTH it`d• ii. APPLICATION FOR LICENSE/PERMIT- 2021 * Please complete form and aesulthn the return necessary all documents by 18, 2020. Failure to do TAX ID: °1 5 "� ��'���{Co ESTABLISHMENT NAME:� 7` 13 TEL.#: 1 •.. LOCATION ADDRESS: R-ou a g MAILING ADDRESS: E-MAIL ADDRESS: 9�6.B 'LW' 6) 60 I. C) ar^ OWNER NAME: T �t'n 5 2t, L C.. C CORPORATION NAME (IF APPLICABLE): TEL.#:J'�b�lo�r��� J MANAGER'S NAME: `G I � a 'n MAILING ADDRESS: 5'&We a-7 ab ovt POOL CERTIFICATIONS: The pool supervisor must be certified as a Po to this as orm uired by State law. Please list the designated Pool Operator(s) and attach a copy of the certification 1. 2. d n ard First d nd Com Pool operators must list a minimum of two employees certified employeetcertii onipremises at all timiesa Please 1st thy Resuscitation (CPR), having on employees below and attach copies of their certifications and maithisn aorm.file at yourHealth pcDeo rtmentusinessswill not use past years' records. You must provide new cope 1. 2.4. 3. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time Service Establishments, 105 CMR 590.000. certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Please attach copies of certification to this application. The Health D partment will not use past years'records. You must provide new copies and maintain a file at your ment. 1. VN,Q.' " 1-ca v,. ` 2. r- t PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Iv\Athat I lra A 1 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one h lentrsn 105 CMR 590.009(G)(3)(a)n Plealse attachas defined in the State Sanitary Code for Food Service Estab 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. l Owe t Icci r 1 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more employeest have trained leastonn anti-choking l procedures below and ch Maneuver on the premises at all times. Please list your attach copies of employee certifications to this form. The Health eah De artme st will not se past years' records. You must provide new copies and maintain a file at yourplace 1. V\k(_h GT I <<G n/ 2. 3. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: - -- -r LICENSE REQUIRED FEE PERMIT# .,rn, r.T++ i.T[F.NSEREQUIRED FEE PERMIT# MCITRI, $110 ' r - cJ_ . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renews of any license or permit to operate a business if a person or company does not have a Certificate of Worker' Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCI 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: V YES NO 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 coliform 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: All food service establishments must be inspected by the Health 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.varmouth 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-0- s of permit expiration date is considered an expired license, and the tobacco licensaps dreducedthe previous year's NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY Tn P PT!TART THE COMPLF.TFn u PMP\ �A T A TIM r� . ..,r� __._- The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-14-0316-07 Issue Date: 1/1/2021 Mailing Address: Location Address: 71 MAIN STREET, LLC 731 ROUTE 28 TAVERN 731 SOUTH YARMOUTH. MA 02664 P.O. BOX 370 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 *RESTRICTION: Total 99 persons per Fire Department(68- Tables & Chairs; 19- Bar Stools; 11 - Standing at Bar) Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston ql Bruce G. Murphy, MPH, R.S., C • /Mallory R. Langler, R.S. Health Director/Assistant Health Director .Alk-•r e DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/27/2020 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: THE OCEANSIDE INSURANCE GROUP 08084400 PHONE (508)771-1660 FAX (508)775-1135 (A/C,No,Ext): (A/C,No): PO BOX 38 WEST DENNIS MA 02670 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B: , SKP1M,LLC.,731 MAIN STREET LLC,277 S.SHORE INSURER C: DRIVE LLC DBA SKIPPY'S PIER 1 PO BOX 370 INSURER D SOUTH YARMOUTH MA 02664-0370 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 8 ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PR°- LOC — JECT PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED — AUTOS _AUTOS BODILY INJURY(Per accident) 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 08 WEC AD1A4A 05/30/2020 05/30/2021 OFFICER/MEMBER EXCLUDED? 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. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1146 ROUTE 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED S YARMOUTH MA 02664 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 5 u� 03‘.2aaT-.74,V'—a.-> ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 0 o � O U U c N N o, U Et�O z O7 W 'E = � CfJ c - 'm c7/ a �-+ cn 0 .c o y.4 v i U W U r im- o c C5! 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