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HomeMy WebLinkAboutApp, License, WC & Certfications The Commonwealth of Massachusetts Fee /I..' Town of Yarmouth $185.00 Food Establishment License Number: BOHF-21-3057 Issue Date: Mailing Address: Location Address: CHEZ HOSPITALITY GROUP, LLC 635 WEST YARMOUTH RD THE GRILLE AT BAYBERRY HILLS WEST YARMOUTH, MA 02673 P.O. BOX 291 WILBRAHAM, MA 01095 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: 41 *RESTRICTION: Paper service only, excluding bar glasses, coffee cups and utensils. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • - Bruce G. Murphy, MP ', ' CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMfT-2921 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: The Grille at BaYbeffY TAX ID: LOCATION ADDRESS: 03st rar mouth Road TEL.#: 413-786-0257 MAILING ADDRESS: PO Box 291 wihraharn MA 01095 E-MAIL ADDRESS: rialeYechezhosPitalftY.com OWNER NAME: Town of Yarmouth CORPORATION NAME(IF APPLICABLE):Chez Hospitairy Group,LLC MANAGER'S NAME: Marc Sparks TEL.#: 413-786-0257 MAILING ADDRESS: Po Box 291 Wilbraham MA 01095 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. N/A 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.N/A 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. l.Noah Hiersche 2.Anne Wright = _ PERSON IN CHARGE: APR .I 2 2021 Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1.Noah Hiersche 2.Anne Wright - HEALTH DEPT. 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(GX3Xa). 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.Anne Wright 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. Haley Mathieu 2. Marc Sparks 3. 4. RESTAURANT SEATING: TOTAL# 40 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $ILO —INN $55 CAMP $55 _—SWIMMING POOL$llOea. —LODGE $55 --TRAILER PARK $105 WHIRLPOOL S110ea FOOD SERVICE: L CENT QUIRED $ PERMIT# LI�� REQUIRED FEE NON-PROFIT PERMIT# LICENSEREQUIRED 0 FEE PPERMIT# SEATS >100SEATS $125AI,$200 COMMON VIC. $60 —WHOLESALE $80 —REM.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq R $50 >25,000 sq t. $285 VENDING-FOOD$25 _25,000 sq.R $150 =FROZEN DESSERT$40 'TOBACCO nit.... NAME CHANGE: $15 AMOUNT DUE = S �Lf PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM 2-l . ? 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 X 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 N/A 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.646 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 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 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 I to December 31.IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 18,2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:4-7-2021 SIGNATURE: C/ " PRINT NAME&TITLE: Marc Sparks, anager Rev.10/15/19 N_ • 1 — c � _zm o =dT ac£ D ® ` O • a 4114 cn . 0 D r N a' r) ut ` n C —1 S A m ` w AEN - N n H 1 rn et.?.T- > \• nX • E. 3 XI (111) T -T2 _ MIMI illi 1 m m IHrrlI<- ° N xiQ. . .3. I. 2 3 a' RU y ulo -uul Mall ��' -5; -n Z 0 N a. CN o F U. at a, X45: ,' n e — go a 41� ' . .. 3 . a- -' _ ' ` . a- n ett..S: • z yj ` II 3 i ,.... Q . 3 .: R. in i. 1'G t ".;.?,,y,i.r,t,,,L...„ . f,,,,,,,:t_.4,1,1,,Fli„,:, . 3. h"i yyew�l AdVli i _ 40 f o , -t � e . ..''' 4.rg -Y � k . . ___... o .r )„. ,...... E.... r › eil in . .. . _ .. T F z �� ,... .. m COco M E {; m Q __712 (1101) F. i5-- �-U X WNW a al CP ➢ m Mirri momp m 3 i ---1 rill till .:,, 1 F .„ c A -I- Q , E Z n = a s 1� Ft > a O CI Q WFa% a_ ='m c' a 0 (111) CDZ T ©. $ m N m g I. c m -a X gp 43) cl ik ® in o n T ID * n T d 11n a Zi _ m o n x or e' g Q. 3 0 0 CZ a • 1 ne Always fa,.'4) , _. .. Q Food Safi .„:„... de, company .. � szteediz Anne Wright �/,. ,C7,fe" ,g........./ The Always Food Safe Company .. Allergen Awareness Approval#-163594 Employee Food Safety Online Course & Exam Date: 12/17/2019{valid}until 12/17/2022) Course reference: AA Learner reference: 344274 This training is approved for 1 continuing education hour toward the initial or recertification application for ACF certification S . CED Nick Eastwood The Always Food Safe Company #1203 President 899 Montreal Circle,St. Paul,MN 55102. The Always Food Safe Company www.alwaysfoodsafe_com Congratulations! Go ahead and frame the big copy--you've earned it! Keep in your wallet for anytime,anywhere proof you passed! For your manager to keep and admire J AlwaysfAlways oodSde Safe e0iivany ,. �� , tnilinEty' eL f"i• jr/.1:r4,tpp srust../-.a on... l/o: ?Tiriw 6ntl . Sic.,,;..r...we'is er... .(/o: //Anne Wright Anne Wright The Alloys Food Safe Company The Malay$Food Sate Company enewee new rroa arrt,, Allergen Awareness Allergen Awareness Employee Food Safety Online Coarses ft Exam Employee Food Safety Onitte Course 8 Exam Deem 12/172019(raifid't until 12!772022) Date: 12/17/2019(yartdT ma 12/1712022}Coarse reference, , Course reference: AA Learner reference: 344214 teamster refeceece_ 344274 This training A approved for 1 continuing education Q Stcontinuing �/c tour tcmafd the unlet or appion This toward is approved for 1 education ANS1- ACF certiscafion her toward the inthat or recertification appfffafnon for Hldl eesiwoPd ..-:rcertm. ACF cer06eaUon +ccefa�c. Preodent me Montreal refood safe Pauly alms i'11a Eastwood me Mlaays Food sok comyany rico W.myg rood Sate M PMx+cal Circle Si Paul MN SSID2. Preddent 050 Montreal Onto,St.Paul MN 55107. 111203 -aj aY400 ie,, The 1.p Food Sale Conduce a nonnewaystoodsetecorn i--"N CHEZH-1 OP ID: DA ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ Y) 04/01/2021/2021 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 413-781-7000 N NTS M KevinMayo Haberman Insurance Group Inc PHONE 413-781-7000 I FAX 413-733-9545 95F Ashley Avenue (A/C,No,Ext): (NC,No): West Springfield,MA 01089an la Kevin Mayo INSURERS)AFFORDING COVERAGE MAIC S suR�n INSURER A:The Hartford 29424 Chez Hospitality LLC 8c 1N PO Box 498 INSURER c East Windsor,CT 06088 — INSURER D: 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 PAD CLAMAS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ISD YND POLICY NUMBER IMINDEINYYY1 IMMIDDNYVV1 UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ _ CLAIMS-MADE OCCUR P ) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY _ $ GEN'L AGGREGATE LIMIT APPLES PER: GENERAL/AGGREGATE $ POLICY -ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COIABINED SINGLEIANT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ UNON-OWNED e �ATOS ONLY ONLY ( r $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB i CLANLS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE X BIER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 08WECALIFGD 03/29/2021 03/29/2022 1,000,000 OFFICER/MEMBEREXCLUDED? Y M I w EL EACH ACCIDENT ; Mandatory in underEL DISEASE-EA EMPLOYEE$ 1,0001,000,000,describe , DEESSCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Marc Sparks is excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWNYAI 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. 1146 Route 28 South Yarmouth, MA 02664 AUTHORED REPRESENTATIVE Kevin Mayo ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All riuhts reserved. Hi Phil, Enclosed are the two applications for food permits for Bayberry and Bass River. I have included everything I believe you will need except for the Heimlich certifications,which will be hand delivered on Wednesday at Bass River when you conduct the inspections. Warm Regards, Lynn At'R 12 2021 HEALTH DEPT.