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HomeMy WebLinkAboutApp, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $225.00 Food Establishment License Number: BOHF-15-1019-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SPARKLE FOOD CORP. 465 STATION AVE WENDY'S SOUTH YARMOUTH. MA 02664 66 PONDSIDE CIRCLE CENTERVILLE, MA 02632 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Frozen Dessert Manufacturer; 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: 96 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 4111 Bruce G. Murphy, MPH, RI, C 0/Mallory R. Langler, R.S. Health Director/Assistant Health Director e..,....mo_c.. TOWN OF YARMOUTH BOARD OF HEALTH 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: W/4":" y'.S TAX ID: LOCATION ADDRESS:-3Z 4D-A_ T-Nr -,b//Yde> ' •� c-,c . v8--Ji-a9&3 MAILING ADDRESS: hes -.s-zz---...447-e.....:7 {va -E' —7.9 v 2 e.;;'� E-MAIL ADDRESS: o-/-i7z� . --2:',..--",44"z-7---v-47 OWNER NAME: r*T � 'Q CORPORATION NAME(IF PLICABLE): G., -- -C- MANAGER'S NAME: ^'7,-f 'y , .c'' / V TEL.#: So g •_37/ -29&i MAILING ADDRESS: •es'4" /��-- lZrry�Ei‹v.�u c. /77.'1F 4-2 ,3a POOL CERTIFICATIONS: / \/,7• The pool supervisor must be certified as a Pool Operator, equired 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 qew copies and maintain file at your,place of business. 3. 4. DEC 01 2020 FOOD PROTECTION MANAGERS-CERTIFICATIONS: STH DEPT. All food service establishments are required to have at least one full-time employee who is certifie as Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMit 590.006 Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and m • tain a file at your establishme ,/pr 1. %v7ro--rv� r/�� v.-in/ 2. />,17-2,404,--r,ii \,,..11,7'yGi PERSON IN CHARGE: Each food establishmenttamust have at one Person In Charge(PIC)on • during hours of operation . / '.- 1. /v-mes vy v...4.1/v...4.1/ 2. A9 .�--7✓.c- V �.eilg... 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 r: :t your establishment. / 1. .77("/7/7•0--"JA •• ,W zv 2. --- o<r'- .c \�v' `� / X 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 ' fain a file at your place of business, 1. �'S'7/'/o-..v/ � \Ain. 2. .C.- rv,c /5`-..1J�.dn' 3. 4. RESTAURANT SEATING: TOTAL# Y1 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT it B&B $55 _CABIN $55 _MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. —LODGE $55 _TRAILER PARK $105 —WHIRLPOOL $110ea. FOOD SERVICE: REQUIRED LI ENSE 00>100 SSEATUIRED FEE WRMIIvA.EATS $225 LICENSE S/CONT N TALVIC. $35 D FEE PE LI—CENSE H_RES-D OFIT E $0 PERMIT# RETAIL SERVICE: ���"���"� ��1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 25,000 sq.ft. $150 FROZEN DESSERT $40 1 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2 2 S "oQ i *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION kic _ \6.1 C tC't 04' 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 ✓ 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 MG,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. 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 1 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 APPRO :OARD OF HEALTH PRIOR TO COMMENCEMNCT. RENOVATIONS MAY ' -"" - . DATE: -'d-// SIGNATURE: PRINT NAME&TITLE: ,.4<>'1•'"-- ----37 77 '-7-7—'":.>1 Rev.10/15/19 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents _• f Office of Investigations 410 S-71111:-.--- 1 Congress Street,Suite 100 Boston, MA 02114-2017 ' vs*. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Sparkle Food Corporation dba Wendy's Address:32 Old Townhouse Road City/State/Zip:South Yarmouth MA 02632 Phone #:508-394-2985 Are you an employer? Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 27 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:MA RetaailMerchants WC Group Inc. Insurer's Address:P.O. Box 85922-9222 City/State/Zip: Braintree MA 01285 Policy#or Self-ins.Lic. #014005030559120 Expiration Date:01/01/2021 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 cern t i ins and enalties of perjury that the information provided above is true and correct. 12/01/2020 Signature: -7 Date: Phone#:568-207-6322 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#: www.mass.gov/dia • Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030559120 01/01/2020 to 01/01/2021 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN:861176398 Carrier Prior Policy#: 014005030559119 Item 1: Named Insured and Address Agency Fashion Food LLC HUB NE Association Programs Wendy's 300 Ballardvale Street 66 Pondside Circle Wilmington, MA 01887 Centerville, MA 02632 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 861176398 Risk ID: 000000000 NCCI/Bureau#: 34355 Unemployment ID#: File#: 014005030559120 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $ 100,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000406(/),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14),WC200301(04/84), WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $215.00 $28,893.00 $28,893.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: I / (� � Braintree MA 02185-0000 01-16-2020 �/b-/U-1 -2147�f 4��� 7 Form#WC 00 00 01 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 • Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. _ Carrier Policy#: Policy Period PO Box 859222-9222 014005030559120 01/01/2020 to 01/01/2021 Braintree, MA 02185-0000 Information Page Renewal Poli FEIN:861176398 Carrier Prior Policy#: 0140050305591' Item 1: Named Insured and Address Agency Fashion Food LLC HUB NE Association Programs Wendy's 300 Ballardvale Street 66 Pondside Circle Wilmington,MA 01887 Centerville, MA 02632 �..- Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 861176398 Risk ID: 000000000 NCCI 1 Bureau#: 34355 Unemployment ID#: File#:014005030559120 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $ 100,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000406(/),WC000414A(01/19), WC000422B(01/15), NOE(01/01),WC200102(01/14),WC200301(04/84), WC200302A(09/08), WC200303D(08/10),WC200306B(06/13),WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $215.00 $28,893.00 $28,893.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: Braintree MA 02185-0000 01-16-2020 Form#WC 00 00 01 C (Ed. ) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 • Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s):34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030559120 01/01/2020 to 01/01/2021 Braintree,MA 02185-0000 Information Page Renewal Policy FEIN:861176398 Carrier Prior Policy#: 014005030559119 Item 1: Named Insured and Address Agency Fashion Food LLC HUB NE Association Programs Wendy's 300 Ballardvale Street 66 Pondside Circle Wilmington,MA 01887 Centerville, MA 02632 Schedule of Covered Workplaces Other Workplace Fashion Food LLC Effective Date: 01/01/2020 Wendy's NAICS Code: 722511 554 Route 28 Division#: 0 Hyannis, MA 02601 Workplace#: 0000000001 State Risk ID#: 000072530 Mailing: 66 Pondside Circle Centerville, MA 02632 Fashion Food LLC Effective Date: 01/01/2020 Wendy's NAICS Code: 722511 15 Canal Road Division#: 0 Orleans, MA 02653 Workplace#: 0000000008 State Risk ID#: 000072530 Fashion Food LLC Effective Date: 01/01/2020 Wendy's NAICS Code: 0 45 Commerce Way Division#: 0000000004 Plymouth, MA 02360 Workplace#: 72530 State Risk ID#: Fashion Food LLC Effective Date: 01/01/2020 Wendy's NAICS Code: 0 69 Long Pond Drive Division#: 0000000005 Plymouth, MA 02360 Workplace#: 000072530 State Risk ID#: Form#WC 00 00 01 C (Ed.) or 7 L_. ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 2 Workers Compensation and Employers Liability Insurance Policy Insurer ID No (s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005030559120 01/01/2020 to 01/01/2021 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 861176398 Carrier Prior Policy#: 014005030559119 Item 1: Named Insured and Address Agency Fashion Food LLC HUB NE Association Programs Wendy's 300 Ballardvale Street 66 Pondside Circle Wilmington, MA 01887 Centerville, MA 02632 Schedule of Covered Workplaces • Other Workplace Fashion Food LLC Effective Date: 01/01/2020 Wendy's NAICS Code: 722511 32 Old Townhouse Road Division#: 0 South Yarmouth, MA 02664 Workplace#: 0000000007 State Risk ID#: 000072530 Form#WC 00 00 01 C (Ed. ) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 2 of 2 MASSACHUSETTS DEPARTMENT OF REVENUE REVENUE ENFORCEMENT and PROTECTION (REAP) ATTESTATION I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. / may ✓ .f�GC * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicafble) // 7 '3 ** Social Security No. (Voluntary) or Federal Identification Number * This license will not be issued unless this certification clause is signed by the `4-' Applicant. ** Your Social Security Number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. GL c. 62C s. 49A. U:\HealthDept\health\2018 Permit Renewals\2018 Permit Renewals\2018- #3 Mass. 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A -. 2 .,\ , • It.. 3r ��1 .Nem * \--IS c,,,,,) i :>, , pcc: , ((iv - , • %Cd v v U ;,,• .,p,,,,,1 ,. t`..n•V.e s it, t'�. :y U. m ,=0 yi,7; e -U- w.-.1eJ Certificate of Completion Certificate of Completion Nina Daigle Brittany Gosselin 4..___•-,has completed requirements for — has completed requirements for American American Restaurant Emergency Training for Red Cross Restaurant Emergency Training for Red Cross Massachusetts Massachusetts _ _❑ conducted by 0 conducted by it American Red Cross American Red Cross 4 Date completed: 12/12/2019 r f•or Date completed: 12/12/2019 c'�rt-o�, Validity Period:2 Years Validity Period: 2 Years Certificate ID: GYU4CY Scan code or visit: Certificate ID: GYU4CZ Scan code or visit: redcross.org/confirm redcross.org/confirm Certificate of Completion Certificate of Completion + , 11111 : Nikki Tasker Tony Brown has completed requirements for has completed requirements for Restaurant Emergency Trainingfor American 5 American g y Restaurant Emergency Training for Red cross Massachusetts Massachusetts _❑ conducted by El o 0 conducted by {•� 4 American Red Cross �� American Red Cross 'E.1 Date completed: 12/12/20190 Date completed: 12/12/2019 •o Validity Period:2 Years 0 Validity Period:2 Years 0 Certificate ID: GYU4D0 Scan code or visit: Certificate ID: GYU4D1 Scan code or visit: redcross.org/confirm ! redcross.org/confirm Certificate of Completion Certificate of Completion Sharlene Walker + , Lance Legrange ' has completed requirements for has completed requirements for American American Restaurant Emergency Training for Red Cross Restaurant Emergency Training for Red Cross Massachusetts Massachusetts _ - : 0 conducted by u conducted by 0 7T;•❑ American Red CrossAmerican Red Cross k ,y 4 CI Date completed: 12/12/2019 Ott,f Q.. Date completed: 12/12/2019 ;.e.•o•i Validity Period:2 Years - Validity Period: 2 Years - Certificate ID: GYU4D2 Scan code or visit: Certificate ID: GYU4D3 Scan code or visit: redcross.org/confirn redcross.org/confirm Certificate of Completion Certificate of Completion 40Waleed Ali Travis Griswold + . has completed requirements for has completed requirements for American American Restaurant Emergency Training for Red Cross Restaurant Emergency Training for Red Cross Massachusetts Massachusetts conducted by 0'V. 0 conducted by 0 • .• •EI American Red Cross • of + American Red Cross —er,F%-67 Date completed: 12/12/2019 + ''o; Date completed: 12/12/2019 '' o Validity Period:2 Years Validity Period: 2 Years Certificate ID: GYU4D4 Scan code or visit: Certificate ID: GYU4D5 Scan code or visit: redcross.org/confirm redcross.org/confirm Certificate of CompletionCertificate of Completion Watson Oscar 41 . Tracey Rudlin 4 has completed requirements for has completed requirements for American American Restaurant Emergency Training for Red Cross Restaurant Emergency Training for Red Cross Massachusetts Massachusetts conducted by 01 conducted by ❑� American Red Cross 9d t American Red Cross 4 Date completed: 12/12/2019 ti• . ot_ Date completed: 12/12/2019 FiTor Validity Period:2 Years ❑� ' II Validity Period:2 Years i Certificate ID: GYU4D6 Scan code or visit: Certificate ID: GYU4D7 Scan code or visit: redcross.org/confirm redcross.org/confirm