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HomeMy WebLinkAboutApp, License & Certification The Commonwealth of Massachusetts Fee /...' Town of Yarmouth $300.00 Food Establishment License Number: BOHF-15-1916-07 Issue Date: 1/1/2021 Mailing Address: Location Address: BEACHVIEW INC. 152 SOUTH SHORE DR THE SKIPPER RESTAURANT SOUTH YARMOUTH. MA 02664 152 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Frozen Dessert Manfucturer; 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 *TOTAL SEATING - 144: Inside - 100; Upper Outside Deck- 44 *FROZEN DESSERT: Regulation 105 CMR 561.009 requires monthly plate count and coliform tests. Board Hillard Boskey, M.D.. Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston J 4I))1Bruce G. Murph , MPH, R.S.. • allory R. Langley, R.S. Health Director/Assistant Health Director THESKIF-01 DATTRIDGE AC'eCAliCr DATE(MM/DD/YYYY) �.. CERTIFICATE OF LIABILITY INSURANCE 2/1/2021 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 CONTACT NAME: Deland,Gibson Insurance Associates,Inc. PHONEFAX (NC,No,Ext): (781) 237-1515 I(NC,No):(781)237-1805 36 Washington Street Wellesley Hills,MA 02481 AD AIL info@delandgibson.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Mass Retail Merchants Workers Comp Group INSURED INSURER B: The Skipper Restaurant Beachview,Inc. INSURER C: 162 South Shore Drive 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/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) _$ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ _ OVVNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE _. ER_ _ Y/N 014006032678121 1/1/2021 1/1/2022 600,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 600,000 If yes,describe under 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $• DESCRIPTION OF OPERATIONS/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 TowTown of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . Tow of Yam ACCORDANCE WITH THE POLICY PROVISIONS. 1146 28 South Yarmouth,MA 02664 — AUTHORIZED REPRESENTATIVE I j _ ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved.' The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts &tier Department of Industrial Accidents p!=';'t.. Office of Investigations = f-4p 1 Congress Street, Suite 100 =�mg== Boston, MA 02114-2017 -;._= www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Please Print Legibly Applicant Information � � •, �`1 �9rC: �< S}hti r.:.� � L1 r�L� CLlu.:�,r Pluut � Business/Organization Name: t k� v� �� Address: I Ss S' h ore. pr;vc- City/State/Zip: So„,fh fi� �M • •. (� Phone #: 5o - 3 q Y 7 Yob Are you an employer? Check the appropriate box: Business Type (required):5 [1] Retail 1. I am a employer with I On employees (full and/ _ 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. 8. Non-profit [No workers' comp. insurance required] 3.,_ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* ' 11.❑ Health Care 4.1 1 We are a non-profit organization, staffed by volunteers, 12 n Other with no employees. [No workers' comp. insurance req.] 'Any applicant that checks box 41 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. e r pi 4,14S WQr Vers �d trip 6 Insurance Company Name: nil � C,� g,.+ 4.11 4SS����«mss �h t. 9e l e n d �J 1J 501 l,�15;n ci Insurer's Address: 5 City/State/Zip: lrv&I I e5 j c y 14;1 S , /Gl A O 4-Li e• ). 6-7 . Expiration Date: i/ t/ ) Policy # or Self-ins. Lic. # 01 '1 00 S 3 � 19 �� 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 hereby certify, under the pains and penalties of perjury that the information provided abpve is true and corrct. Date: � ' Sipnature: ' 1 Phone#: 7 1 LI ? C ,A? 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. 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' ,.a:••., . li) . 1 ,7 13.1'''J Inc): © �c4 ' Lawm,,,,,,v,,,,,,,,, 1 ..G���C- �:-Gam,=.3.C� c .-G-~-.DCy:."- Th-(// ��� +1'. iii rf ' .: It�� T!1? �'"`}� til �: x•moi; C \ a gyp` S NSC CPR Course 2 �c eoliouNo' Adult, Child, Infant, Choking & AED OSHA CPR 1910.151 Name: Aidan Delaney Security Control No. Address: Skipper Chowder House Address: 152 South Shore Drive -3648 City, State,Zip: South Yarmouth,MA 02664 Course Completion Date: 3110J2020 Training Center: Cape Cod Safety Training Expiration Date: 311012022 Instructor Name: Rick Todd Instructor Number: 1040918 Aidan Delaney has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work,in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining I \ -I THIS DOCUMENT IS VOID IF REPRODUCED e0„��. Security Control No. O100 O Aidan Delaney ........ Cs' x ',,,, `` has completed the 'S. NSC CPR Course We want your feedback! AdultChild,Infant CPR,Choking&AED Training Center: CapeCod Safe Training Please visit nsc.org/firstaidevaluation to Completion Date: 311012020 take a brief survey and share your opinions Ex fires. Instructional Hours: about the NSC course you completed. �- �p 3/10/2022 : i;.49 1040918 Instructor Signature Instructor No. ',NSC-in it for life) nsc.org/fatraining_) » .talY:-'tai race ii. Diff ii e ratf to 70M04032019 1015 900008130 02016 National Safety Council /91(4-0000 i /.°11.° 11°1 - �a r&=c "' ;`: ^tee's 9. ,.r-1.vtt`�4;rt i n, r"rlrn • gyp` S NSC CPR Course c°""`�® Adult, Child, Infant, Choking & AED OSHA CPR 1910.151 10 Name: Security Control No. ,11°°'Address: Niamh Delaney Skipper Chowder House d 3 b 4 U Address: City, State, Zip: 152 South Shore Drive South Yarmouth,MA 02664 Course Completion Date:3/1012020 Training Center: Cape Cod Safety Training Expiration Date:3110/2022 Instructor Name: Rick Todd Instructor Number: 1040918 Niamh Delaney has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities,and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED r0.,..:, Security Control No. ilf `• °° Niamh Delaney m,°„ � has completed the NSC CPR Course We want your feedback! Training CerlJit,Child,Infant CPR,Choking&AED Please visit nsc.org/firstaidevaluation to Completion Date: take a brief survey and share your opinions Cape Cod Safety Training Expires 3!1012020 Instructional Hours: about the NSC course you completed. 311012022 P--f Instructor Signature Instructor 4040918 \�NSC-in it for life' nsc.org/fatraining_) 70M04032019 1015 900008130 02016 National Safety Council 79174-0 :,. .:\V`: `.Capecodsa etvti'iinin2.com NSC CPR Course 2 c°""e Adult, Child, Infant, Choking & AED OSHA CPR 1910.151 Name: Amy Delaney Security Control No. Address: Skipper Chowder House Address: City, State, Zip: 152 South Shore Drive South Yarmouth,MA 02664 Course Completion Date:3/1012020 Training Center: Expiration Date: Cape Cod Safety Training 3/1012022 Instructor Name: Rick Todd Instructor Number: 1040918 Amy Delaney has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED "Q� Security Control No. C- 858073 Amy Delaney has completed the We want your feedback! N CPR Course Training Cen4O utt,Child,Infant CPR,Choking&AED Please visit nsc.org/firstaidevaluation to take a brief survey and share your opinions Completion Date: Cape Cod Safety Training Expires: 3�10l2020 Instructional Hours: about the NSC course you completed. A 3/10/2022 Instructor Signature Instructor 10918 NSC-in it for life' nsc.org/fatraining 70M04032019 1015 900008130 02016 National Safety Council 79174-0000 Sl rj p.e,t (,€st• • TOWN OF YARMOUTH BOARD OF HEALTH oF....rg4 " 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: Sup i)pi,— R•s+,...."„ ./ ( d - i40.,$.4..- TAX ID: `/ LOCATION ADDRESS: 1 S a. So,.441 Shot- D r, TEL.#: 5'd ir ? ? Y 7 Yo d MAILING ADDRESS: lS' a S(M4-A S'Ihs.e, Dr. , 5o -.#1, Y4rmuN4-', ,✓44 / 0a66(/ E-MAIL ADDRESS: 5 K:•nPcr- (ape Cad & 6,0l,(owl OWNER NAME: 4loin tle Ca4ei CORPORATION NAME (IF APPLICABLE): (?,a 4L 4 1.;1,. T n c MANAGER'S NAME: Rye �Gi� TEL.#:7 71/ g-3 S- y a MAILING ADDRESS: I, ,s - S,,-,3- s k Of-.<1, - 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. I. 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 Healt rtment will use past years' records. You must provide new copies and maintain a file at your pl ce of-business.-,-, 1. 2. APR 2 8 2021 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. PI I Gel Jle 14,17 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PICn/) on site during hours of operation. 1. Amy Oz lti,+e 7 2. A;d,etIk1447 ALLERGEN CERTIFICATIONS: 3) 141,x„ 1� 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. I. PI 4.7 Del,ne/ 2. 14 / De i4,,,. HEIMLICH CERTIFICATIONS: ?' ,d.�n, be I ti t7 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. A;et4n 11.14nc j 2. Om/ D. /40,7 3. 1Whnt4 Dz Ic.ntY 4. (4. 16,7 l7el4nc, RESTAURANT SEATING: TOTAL# I CI-7 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 00.o OCt atc ...�-.,.-. .n.... 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 V 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/ 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-open-ing. 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 mutually fioutiunuary I-to December-3 I. IT S-PONSIBIL 'Y TO RETURN--