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HomeMy WebLinkAboutApp, License, WC & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $410.00 Food Establishment License Number: BOHF-14-0298-07 Issue Date: 1/1/2021 Mailing Address: Location Address: DAVENPORT REALTY 237 NORTH MAIN ST THIRWOOD PLACE SOUTH YARMOUTH. MA 02664 20 NORTH MAIN STREET SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Retail; 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: 145 RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 110 Bruce G. Murphy, MPH, R.SI CHS Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-14-0398-07 Issue Date: 1/1/2021 Mailing Address: Location Address: DAVENPORT REALTY 237 NORTH MAIN ST THIRWOOD PLACE SOUTH YARMOUTH. MA 02664 20 NORTH MAIN STREET SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE 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 WHIRLPOOL/VAPOR BATH Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway. Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, R.S., CHO/ •(allory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-14-0397-07 Issue Date: 1/1/2021 Mailing Address: Location Address: DAVENPORT REALTY 237 NORTH MAIN ST THIRWOOD PLACE SOUTH YARMOUTH, MA 02664 20 NORTH MAIN STREET SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE 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 INDOOR SWIMMING POOL Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston / Bruce G. Murphy, MPH, R.S., CHS / /ory R. Langler, R.S. Health Director/Assistant Health Director 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: Thirwood Place TAX ID: LOCATION ADDRESS: 237 North Main St., South Yarmouth, MA 02664 TEL.#: 508-398-8006 MAILING ADDRESS: 20 North Main Street, South Yarmouth, MA 02664 E-MAIL ADDRESS: mpurrier@davenportcos.com OWNER NAME: Blue Water CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Michael Ceku TEL.#: 508-398-8006 MAILING ADDRESS:20 North Main St., South Yarmouth, MA 02664 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. Attached 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. Attached 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, 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. Attached 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Eric Bright 2. 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. Attached 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 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. Attached 2. 3. 4. RESTAURANT SEATING: TOTAL # 145 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110_ INN $55 _CAMP $55 I SWIMMING POOL$110ea. —r nnnr~ QGG --TR All PR PARK g1n5 1 WHIRLPOOL $110ea. 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 X 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 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.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 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 (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 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020. ATT T1T'ATlvTATTc\KTO Tr\ AATAT TVA/AT T'.ClTATIT TOT TXAT?ATT 11,TrTLT (\D T)(\CT /: ,. DATRTTTRTI`_ ATL'UT The Commonwealth of Massachusetts Print Form Department of Industrial Accidents iiiW ,, , ,gt Office of Investigations SSI , 1" i 1 Congress Street, Suite 100 sktrt.„, : Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Thirwood Place Address: 20 North Main Street City/State/Zip:South Yarmouth, MA 02664 Phone #:508-398-8006 Are you an employer? Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 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. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. n Entertainment their right of exemption per c. 152, §1(4), and we have 10.n Manufacturing no employees. [No workers' comp. insurance required]** 11.0❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, Retirement Community with no employees. [No workers' comp. insurance req.] 12.0 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 Name: Zurich American Insurer's Address: Attached City/State/Zip: Policy #or Self-ins. Lic. # WC8196035 Expiration Date: 3/1/2021 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 herebilif nder the pains gild penalties of perjury that the information provided above is true and correct. Signature: a)-(/ /-i Date: 12/9/2020 Phone#: 508-760-9261 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#: www.mass.gov/dia -...411 DAVEREA-01 NCANUSO '4�-R0 CERTIFICATE OF LIABILITY INSURANCE DA2/26/2020 I 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 CAME: Valley Forge Captive Advisors 630 Freedom Business Center Drive lacc°,NN,Ext):(610)458-3659 FAX No(484)965-9627 Suite 203 E-MAILDRESS: King Of Prussia,PA 19406 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B: Thirwood Place L.P INSURER C: c/o Davenport Realty Trust 20 North Main Street I 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR GLO8196255 3/1/2020 3/1/2021 PREMISESO(EU RENTEDnce) $ 1,000,000 MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 X POLICY JECT I LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: 5 D A AUTOMOBILE LIABILITY COMEa acccidentSINGLE LIMIT 5 1,000,000 X ANY AUTO BAP8196256 3/1/2020 3/112021 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOSpBODILY� INJURY(Per accident) 5 AUTOS ONLY _ AUTOS ONLY PPerr acudent?AMAGE $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED 1 RETENTION 5 5 A WORKERS COMPENSATION TH- X STATUTE R ERH AND EMPLOYERS'LIABILITY YIN WC8196035 3/1/2020 3/1/2021 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ (Mandatory in NH)EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below I I I 1 I DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Aa. I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r l'F' i 8 11 tri r :, . ... ,,, o0D N , , s rn F "1Ifl g Er` o Ont A I77:1 M , _.. .... .,-..1.- _...s.,... r2 Dliasirim im°11 MI w l iil 0 {J N CI0 ,- ' \ rn m .1.11.11 T. g 1 �_ , C mqpi Q o' 3, a , - 2 iL Z M R, m W N3 X `n 1 ° W o it O rn Z 77 0 n 7, O -TI 0 a g g `TJ ::','w' ok' CI Ir • a CERTIFIED eTIP^r On Premisr;3.0 Issued: 3/6/2i...,8 . Expires 3/6/2021 1134:4744183 . Michael M Ceku • j 5 Ridgehill Ln>. Saganiore Beach, MA 02562-2544 { For service visit us online at www.gettips.com • ri i tf 037 (. 9k4r hx pYl t _ d •e>xs :. ter.. P.. !e ..^f,�^ .. •".. .fin f tr N a� � �x'w`y b a"S - �1: � { � : .A' CZ i 7iii '- E Yi„ .. ...-34 I. { - ,�4 ."m> �{ f F } i1➢` f,q«W,. Y## '� Yrs 'i a' k . .: ffht r £ a :.� _ 7" . 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'I ;; ^s•.— .y•i* £' icti wgata. c�, ; I44 y -?'i., » \_ ,- 5 } -.< rF a; �f r:•k` � ( 'd'tea!:ar{r .��a'. +i: S.Iz'c f'k7" �.:+; k.� 3- <>jf�fs �r .� .* �..< g: �F r : ;{1 zw y rr ati (xa S i � �e�tt iw>u:�'_... _Jxl� r^;Pow't �', • . .., ... . ,.,. IC..STE_PHEi :BRIGHT I • who has Met•all the ANSI 'j ration in .. rtifit. 'r I'C.E' requirements ft • lt; 1 .. e� ire P R O M,E T R I� ::•••• proFesslon,�t I lu' �'" food seiyl{F� Lj cl.elend old 11ltation'.• .40,c00.•.ceforr•aAPr•tacl0- teitani193;1 Recogrilz• 41 By.. Ofifet'ence Fo;Fpocl.f!.r ott ctioti• • . ; <rk. .; f;:r. ::Crtificate No:....hoop: r;; ;; : ,I ••Exam:Da e.: 07/21'/2Q2Q: r 1,4 ,,,,,, • • ,,,... t •.i;•. ;ti> •,;. �z;.-0: 1 ss•1.in i•5 >` ;•.. °r• • r 1-6§�}CodetA20.80511931 i..,:• ...., ,:,., •r ' •. t cgyiillio '•Client Seivl g ai • Y`,:. . ,.• ces Manager 'u IkT- . - Ryan M tl. � `• � .IFIX�71t'e O �.07�21/2�25 i I3 236 l',.ab0b24:2 36' :a, :?4v r t ' I;romeirp`�7841 Cod(ate Driye,;I�totgnghalil„f,A � I•. � •. '.., S.. •i F'. :¢ r- F kMATIAWr.% ,4. ` .s' -3��.au+�.. ar .– - — O Glu Hem Prometric Score Report Congratulations! You passed the Certified • Professional Food Manager examination. Your Score is as follows: Score Status Exam Date • 94% PASS 07/21/'1020 • •11NS• •Amt,, I P.ROMETR '1C:sr, Ttusasto.certify IIiet . 1 , Sr. -10659 -I I . .' ERIC STEPHEN BRIGHT .i • - : .Has mel the nacesssry Iepkxrarnsnis for 11 1.4 --JiE gili,, DMiaANAGER CERTIFICATION I Exam 1931 Recognized By Conference For FoodProtectiotl IID# 1038532 Exam Date” •07/2112020 1 Cert# 1000Expires On 07121/2025 j • Cut Here z RR °f' U) y 2 I Dov ^R0 9 o'n R O 3 a 1•i. n al: �� N' tD 1 a- oi m rill o m N • N, a t101$ C) mQ �O (.0 '-< C , * 7Z1 (IC/ 0--FL_ > MIMI 9 0 (171 T o inTI 4 mN Y ) MIMEO Z ° C� D )::01' 1111°11) Q T Q� fl 6-. * Milli C:io N 1111111111111 3irl 9-. 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