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HomeMy WebLinkAboutApp, License & Certification w0K u Roil --.^ IF.. TOWN OF YARMOUTH BOARD OF HEALTH ti g'1 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: OK- )C(- k OLi-- • TAX ID: LOCATION ADDRESS: / 3/9 RO(A4e c:;) /-s ( find+-rr1 sq ), TEL.#: .teg-.7 O -ooh ( MAILING ADDRESS: /3 /n , RoUfie- aC,i 8 Cil S-74 j E-MAIL ADDRESS: t1 I Ovt ® CSO/•C on') _ OWNER NAME: V Yoo nf S'- L-OLA) - CORPORATION NAME (iFPLICABLE : $i'Ol nd ori Tel c . L�n'i MANAGER'S NAME: 2u e-1 rho TEL.#: 78i--888 - 1772 MAILING ADDRESS: 117 , d Za•i L-n , Caton , tY) Oa Q2/ 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 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 Dcpartmedrwill not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 00 1 9 /-0 .3 JAN 0 4 2021 HEALTH DEPT. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. YO0 SI 1-01-0 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. I. Yeo - Loo ) • 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. 2. 3. 4. RESTAURANT SEATING: TOTAL # /0 . OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT II LICENSE=REQUIRED FEE. PERMIT-tl LICENSE REQUIRED FEE PERMIT it _.. _ .�, ace nnn-r=i Vain ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the"town ofYarmouth 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 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)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 I lealth Department prior to opening. Contact the I lealth Department to schedule the inspection three (3) clays 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 I lealth 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 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 I lealth 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 lood 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 3 I. IT IS YOUR RESPONSIBILITY TO RETURN TU[: r`r1AADI CTCrI The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-6065-06 Issue Date: 1/1/2021 Mailing Address: Location Address: BRANDON INC. 1313A ROUTE 28 WOK-N-ROLL SOUTH YARMOUTH. MA 02664 1319 ROUTE 28 SOUTH YARMOUTH, MA 02664 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: 19 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston • Bruce G. Murphy, M'H, R.S., C ti<aTlory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts `_, Department of Industrial Accidents I_ t--- ./. _ Office of Investigations _ ff ^�1= 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: ?).1O0✓tjk'1 G - Address: (9 , Yak. Opt in 9+ (0 c8‘) 3 , kotyve( 1A0 0) 66 City/State/Zip: Phone #: c.)(1)_ 16 0 . r° e Are yo n 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.❑ 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 10.17 Manufacturing no employees. [No workers' comp. insurance required)* 11.0 Health Care 4.nj We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.11 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 41. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 7 Q A V f_ g Insurer's Address: QIl e. fb vJ(-r gat GILt�rQ,- , 4-Po E' Off` 1U1 City/State/Zip: (oft f CL /OO 6 r Policy 4 or Self-ins. Lic. + 3 Expiration Date: 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, u der the pains and penalties of perjury that the information provided above is true and correct. r- S i mature: r Date: 1213 3 a1Zi Phone #: 513Z. -1()O . ) Oa' 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 S. Selectmen's Office 6. Other Contact Person: Phone #: 0.0r - � Cril, ri - .c.,.;: 6.1. fo y ~ '.4. 4 11 Fa ,LN J 7 0 N 47; Z 4. Zi t'.L.fi:./1 C'''' ..: .(.0 aM ;� Qz 44r44v Y • ,e,r 17�j :. —3O rV i '� CCS MI s Q' 7 O 1 • ^• a �Eii y, �y�•, M� '-" 'ris. r "� , con w0 t c Mcg . in , . ,..,,,. .. , , ,.. ,..,., , , z 0 C1I ,N1 J 1f1 O ..„,s iiiiic-4..p il ilm*_..000 411 X P ci° 5 1 ) 1 /r `y Z N 1,�' 2:, OQ Q N •• . 'f►4-t-ak i rN OHO 44E+.:• 'S 0M1.4 (14 t.:02 Gce.. r . a •, y +r G meq; r ; - , --.., z. :..,.., ,,z, ,,...2 1 ::;,1"C.'"' $1111.sC 4.0 (....) Z ,.... .. .... , _ . „. -,- :,.. , , .,„ 4... .4144., ..'.:. '... '-' ''' ''''', : as ,. .,,,, ,1 LI.J .., ... ,-, ,..... ,.._ z3' yrs ° '\` v ^C yr 4` A „rte . 4.. lt-fet �, A , ---a, w. A +S �, sem' A Cut Here 6 Prometrec Score Report Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 88 PASS 11/26/2019 CZ tit PROMETRIC e•'ifyth-, 0659 YOONG S LOW Has met ih, ;utter.._. YOONG S LOW 117 INDIAN LANE FOOD AGERajIFICATIO\ CANTON, MA 02021Il7Lfl Exam 7701 Recognized By Con erence For Food Protection 009368729 11/26/19 to z Exam Date Greater Lowell Tech-Sarasin 2079766 11/26/24 Cert t Fxpres On `P Cut Her 6 DATE(MM/DD/YYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 12/21/2020 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 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 Zachary Tonello NAME: Murray&MacDonald Insurance Services,Inc. (A/C.NN,Ext): (508)540-2400 FAX X No): (508)289-4111 550 MacArthur Blvd. E-MAIL zach@riskadvice.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Bourne MA 02532 INSURER A: Phoenix Insurance Co. 25623 INSURED INSURER B Brandon,Inc. INSURER C: 1319 Route 28 INSURER D: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 Master 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 ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DO/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREM SESO(EaENTED occurrence) $ 300'000 MED EXP Any one person) $ 5,000 A 6803R526623 09/03/2020 09/03/2021 PERSONAL&&D'/INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PET LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Medical payments $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVENIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Yarmouth Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 41!„,,c.c, ri=4 ,ErPti ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD / 1 ® DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 12/21/2020 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 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 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: Sharen Rabesa MURRAY& MACDONALD INSURANCE SERVICES INC (A/C.No. (508)2894160 (A/C,No): E-MAIL saren rsadvice.com hik ADDRESS: � 550 MACARTHUR BLVD INSURER(S)AFFORDING COVERAGE NAIC# BOURNE MA 02532 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: _ BRANDON INC INSURER C: INSURER D: 1319 ROUTE 28 INSURER E: _ SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 606620 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 I -__ ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ,MMIDD/YYYYI (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE $ CLAIMS-MADE OCCUR PREM SESO(Ea occurrence) $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E T LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE I DED I RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A AWC40070253722020A 02/03/2020 02/03/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yarmouth Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD