Loading...
HomeMy WebLinkAboutApp, License & Certification • 'HDY2,-- TOWN OF YARMOUTH BOARD OF HEALTH 1 tf g' APPLICATION FOR LICENSE/PERMIT - 2021 �"' * Please complete foim and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Mn QtcA*ury .PoDS, LLC TAX ID: 23- 129 21 3.5— LOCATION ADDRESS: Cl WktrEt Porrr( , s.acr/t yARreKrW, MA *UPI TEL.#: 5413-322.--6516 MAILING ADDRESS: *OO I-ham STS HAN-aveie,, M /7331 E-MAIL ADDRESS: ,CI;{>Fie- ktZSPNAC- _co OWNER NAME: (Irz Qui.tart - DSS CORPORATION NAME (iF APPLICABLE): U12- Ce 414ry 'Foil ILL MANAGER'S NAME: 'A-7,A s wAics TEL.#: Vol - 6q2—oIQ MAILING ADDRESS: jolu«.4S a NttzShadeS,Cow� 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. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments arc 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 CN4R 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. kI4fJ / LITE1, JAN ub1 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. 1. -VME-s Lt MIS 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 I-Iealth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 10,MrS )6LCDy,t r 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. I 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE I'I?RMI"I If LI( I NSI? REQUIRED FEF. PERMIT If I.1(1:NSE REQUIRED FEE PERMIT If 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.pe-son 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 O/1 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 ofthe limitations of Motel or I lotel 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)clays,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. 640 or 830 CMR 640, 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 I lealth Department prior to opening. Contact the I lealth 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 WA'T'ER'TEST'ING: 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)clays prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)clays of closing. .—E00-11-SERVI Cid SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the I lealth 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 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 tobacua-p rmit _flakier who has failed to renew hi-s or her pct7nit within previ-otrs year's permit expiration-date is-eotrsidered an expired l ense, and the tobacco license cap is reduced. NOTICE: Permits run annually from January l to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN mr rr rr��Ar rmr r- ri U x xx r A I A nnr ic' A mr fl w it OA A K I TN 11 r.r i lint71-1 Cr rr c.'\ DV r'cn r Ti AD on 1 0 'nVn The Commonwealth of Massachusetts Fee Town of Yarmouth $80.00 Food Establishment License Number: BOHF-18-1748-03 Issue Date: 1/1/2021 Mailing Address: Location Address: UTZ QUALITY FOODS, LLC 57-67 WHITES PATH UTZ QUALITY FOODS SOUTH YARMOUTH, MA 02664 900 HIGH STREET HANOVER, PA 17331 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Wholesale; 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. Board Hillard Boskey,M.D.,Chairman Mary Craig,Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . nice G. Murphy, MPH,R.S., C 4 / allory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee /.°' Town of Yarmouth $80.00 Food Establishment License Number: BOHF-18-1748-03 Issue Date: 1/1/2021 Mailing Address: Location Address: UTZ QUALITY FOODS, LLC 57-67 WHITES PATH UTZ QUALITY FOODS SOUTH YARMOUTH, MA 02664 900 HIGH STREET HANOVER, PA 17331 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Wholesale; 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. 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/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents i.._._, Office of Investigations =��►i- y 1 Congress Street, Suite 100 • = _ Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 2 d(ANA - ffi !— Address: Address: G7 W k/lE ' P4-rf City/State/Zip: 5)(4.7-14 iffe-mom111, MA 0160/Phone #: 5D8 — 822, — ( 5't Are you an employer? Check the appropriate box: Business Type (required): 1.[(1 am a employer with 3)40D employees (full and/ S. ❑ Retail 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. [No workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ 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.[—j We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.n Other 'Any applicant that checks box k l 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Locg,t. CiPnAfA-N tE-S" Insurer's Address: 3 Gs7 +BAAAPAiie. btAtiE Sum-- 7oo City/State/Zip: ilIOWS7VN i "7704 Policy 4 or Self-ins. Lic. 1412-48'0 Expiration Date: o y/411, Ay 24 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Sipnature: Date: /Z 29_____ Phone 4: 7/7 —9e Z -- 304,4' Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone r: K ' Jam: v @ CI±;§ : ) o 3 \\ CoC \ O 2 / . / ƒ ƒ w Z \ 3 8 to 0 - 1 \ /ƒ / \ e u - x .& w 2 = 2 \ \ ks \ \ ( 7 \ R \ 7 0 Z -§ 2 « f L { m ~ LO \ 4 § \ % ƒ & � % 4 - "MI 0 a 2 \ it/ 0 \ \ ; 0 (1)Limi � � 0 \ } 2 ƒ v) b } in n 7 .J . g 7 § 2 H ) § / § ®e > OMNI k ` /$ cc \ ° ® ` ƒ 1 0)/ \ �� • / . \ Avila' I--• E-0 Z 7,. )/ lir 1W _ / . � � $ >..I?) 4 r x } k % ? % \ � �j� \ \ §• .- / / % u § §.! � % 41) taj n _c � V CO � � / j LU « ƒ / CO cz & o ± \ƒ j / A # : zt { R. ! E :> 2 \ ( 7k B § } 1111 0.1 0 2-__L _2\ k / .2 t - \ $7 # L \ i »» § HJi_g 3 inZ.'. : a04. i 1 o . U U L O 0 � ? 5 �LL \t v -4- r CEO 1 .co O Y Z OO Q O = in-0 issi o u clo Q Eu z V 'v = iL ( J CZ a) 0 E z V Q 0LV CoOH 1 O � 2ii w . ce o Z 4.1 .�O H y O > w p m c 010 'ff co LU- Z O U d +-'i. - C N C"loo O Z7 v O Z3�7 V ° • an > a. a/ > 0 —I a)CIz 41Cn E1.4.11 ,' �� �o o Q E Oa" LI) > wh-CD CD (;)P a. t > a) '° scoiii . 30 u (1/4) n isCC 4- 0- :4= > -. ..9 I tf) Lu- wd k‘ p = i+ 0 1111111M1111111 tn CD Im VI LINN= 0 c a. ® ` LLQ = .0 0— W . 13 cziQ (13 140 a_ Z,‘ = .. 412r t � ..Y O co ll ii c L Y Y ` O COd 1 ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 1/41......--"-- 4/1/2021 3/23/2020 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 BT 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 LOCKTON COMPANIES CONTACT 3657 BRIARPARK DRIVE,SUITE 700 PHONE- - FAX HOUSTON TX 77042 a MA L ,Ext): (ac,No): 866-260-3538 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Travelers Property Casualty Co of America 25674 INSURED Utz Quality Foods LLC INSURER B: The Phoenix Insurance Company 25623 1426897 900 High Street Hanover PA 17331 INSURER C: The Travelers Indemnity Company 25658 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 15816468 REVISION NUMBER: XXXXXXX 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY)(MM/DD/YYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY y y TC2J-GLSA-9367B352-20 4/1/2020 4/1/2021 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE piOCCUR PREMISES(Ea occurrTO ence) $ 500,000 MED EXP(My one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000000 poLicyr-1 Ira n LOC OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y TC2J-CAP-9367B364-20 4/1/2020 4/1/2021 COMBINED SINGLE LIMIT {Ea accident) $ 2,000,000 X ANY AUTO BODILY INJURY(Per person) $ XXXXXXX - OOUTOS ONLY _AUTOS SCHEDULED BODILY INJURY(Per accident $ XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX ONLY AUTOS ONLY (Per accident) $ XXXXXXX A X UMBRELLA LIAB X OCCUR Y Y ZUP-21N89705-20-NF 4/1/2020 4/1/2021 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED X RETENTION$10,000 $ XXXXXXX B AND EMPLOYERS'LIABILITY Y UB-8M243987-20-51-K 4/1/2020 4/1/2021 -v WORKERS COMPENSATION PER OER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A UB-9K943894-20-51-R 4/1/2020 4/1/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION See Attachment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 15816468 AUTHORIZED REPRESENTATIVE Elizabeth Sherman 67 White's Path South Yarmouth MA 02664 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATI 4All rights reserved The ACORD name and logo are registered marks of ACORD Attachment Code : D547352 Master ID: 1426897,Certificate ID: 15816468 All policies (except Workers' Compensation/EL) include a blanket automatic additional insured [provision] that confers additional insured status to the certificate holder only if there is a written contract between the named insured and the certificate holder that requires the named insured to name the certificate holder as an additional insured. In the absence of such a contractual obligation on the part of the named insured, the certificate holder is not an additional insured under the policy. All policies include a blanket automatic waiver of subrogation endorsement [provision] that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. In the absence of such a contractual obligation on the part of the named insured, the waiver of subrogation feature does not apply. All policies (except Workers' Compensation/EL) contain a special endorsement with "primary and noncontributory" wording.