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HomeMy WebLinkAboutApp, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-15-5951-05 Issue Date: 1/1/2021 Mailing Address: Location Address: ABOVE THE HARBOR INC 21 ARLINGTON ST TUGBOATS WEST YARMOUTH. MA 02673 11 ARLINGTON ST 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 RESTRICTION: Maximum Capacity Total = 324, per Board of Appeals #3688, April 26, 2001 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston GA Bruce G2 Murphy, MPl, R.'.,CHO/Mallory R. Langler, R.S. Health Dire tor/Assistant Health Director foo. El@CEUV-LJ MAR 0 9 2021 TOWN OF YARMOUTH BOARD OF HEALTH HEALTH DEPT. 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:.__. 6�L /-'c 4e LOCATION ADDRESS:. 1 1 '{111 1 n 3tVJ 194 \'k m° n 1 2 MAILING ADDRESS; 1 1 ,r11 J In E-MAIL ADDRESS: T'CD ct0 ivboa-t Cave rod,CIm OWNER NAME: h K u r K?Y CORPORATION NAME(IF APPLICABLE):_ -e 1—i b}I,1,( U71 MANAGER'S NAME 1"e U n'i �_l 2 s TEL.#: O -3/,/9 77 LO MAILING ADDRESS 11 /7-'11( 110)--1/Y1)-j1y1 t ). '-J( n'1 Vlij MA (2L), "7 3 • 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. 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. 2. 3.— F. t5 . 51 FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food A— Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. CIL,\ `7 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.t� Of1 i Fin ll Int 2. Sat, I PERSON IN CHARGE: Each food establishment *must have at least one Person In Charge(PIC)on site during hours ofoperation. 1 Ta I. .�/" 1 _ 2.114111_____2t0112-00 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' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 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. .. 1 DATE(MM/DD/YYYY) ACc RL CERTIFICATE OF LIABILITY INSURANCE 03/09/21 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 CONTNAME: PAUL PAUL SCHLEGEL Schlegel&Schlegel Ins Brokers, Inc. PHONE No,Ext): 508-771-8381 (AIC,No): 508-771-0663 34 Main Street E-MAIL ADDRESS: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: HOUSTON SPECIALITY INSURANCE CO INSURED INSURER B: GUARD INSURANCE ABOVE THE HARBOR,INC. DBA INSURER C: SAFETY INSURANCE TUGBOATS INSURER D: 21 ARLINGTON ST WEST YARMOUTH,MA 02673 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 ADDTYPE OF INSURANCE IVSD wBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,00 MED EXP(Any one person) $ 1,00 A Y HOSPK1044054 06/10/20 06/10/21 PERSONAL&ADV INJURY $ 1,000,00 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PE� LOC PRODUCTS-COMP/OP AGG $ 1,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ • C OWNED SCHEDULED AUTOS ONLY AUTOS Y COM5535672 06/25/20 06/25/21 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER B ANY OFFICER/MEMBER EXCLUDED?ECUTIVE -YNN N/A Y ABWC183736 06/08/20 06/08/21 E.L.EACH ACCIDENT $ 100,00 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under 500,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ EACH OCC 1,000,00 LIQUOR LIABILITY A Y HOSPK1044054 06/10/20 06/10/21 POLICY LIMIT 1,000,00 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reservec ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD BASIC LIFE SUPPORT BLSAmerican Heart Provider Association, Kristen Bardsley has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 eCard Code Training Center City, State 205503338081 Pembroke, MA Training Center Phone QR Code Number .; o;."+13 (781)826-2011 • To view or verify authenticity,students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 {�. 1 J timiml el • •o I a `l xA� c A ct ' ' c ,-7..S. 4. ' c, 6sifr, P: cr- *N. Nk. • A rte„ n `S o �. Cill)MI 7.; ^h A 4,,,, irni 7. 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CD oIA faa W: I,, 4, y """"'1F�f National Registry of Food Safety Professionals � CERTIFIED FOOD SAFETY MANAGER 1 CHRISTOPHER GRAY 6751 Forum Drive Suite 220 Orlando,FL 32821 Celliticate:NO:2/477055 Toll Free(800)446-0257 Phone(407)352-3830 Issue Date:June II,2018 Pax(407)352-3603 Expiration Date:June 11,2023 www.NPFSP.com This recognizes that Ct0 U O Christopher Gray Lhas completed the requirements for Chokesaver w//Restaurant Emergencies Q a conducted by Cape Cod and Islands Chapter Date Completed 10/25/2010 The American Red Cross recognizes this certificate, as valid for N/A year(s)from completion date. I www.RedCross.org Instructor's Signature (9f5,e:4‘ U.:ezta'- Ra04 D Chapter Cape Cod&Islands Chapter Holder's Signature