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HomeMy WebLinkAboutApp, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-16-1385-05 Issue Date: 1/1/2021 Mailing Address: Location Address: NEW YARMOUTH CORP. 330 ROUTE 6A YARMOUTH PORT VILLAGE STORE YARMOUTH PORT, MA 02675 1 PATRICKS WAY FORESTDALE, MA 02644 IS HEREBY GRANTED A 2021LICENSE TO OPERATE: Food Service; Retail; 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: 0 RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston C Bruce G. Mum MPH,R.`., f"0/Mallory R. Langler,R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-16-1388-05 Issue Date: 1/1/2021 Mailing Address: Location Address: NEW YARMOUTH CORP. 330 ROUTE 6A YARMOUTH PORT VILLAGE STORE YARMOUTH PORT. MA 02675 1 PATRICKS WAY FORESTDALE, MA 02644 IS HEREBY GRANTED A 2021 LICENSE 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 If ruse G. Murphy,MPH,R.S., i /Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents 'Lv Office of Investigations 1 —Fie1m 0 y 1 Congress Street, Suite 100 == .=, Boston, MA 02114-2017 `�i=.�s W W.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le4ibly Business/Organization Name: ►f eu° ucts-rnoL1 1 (Sp ,i�P)P+ LAet2sRlOtXM i I 1 ceLcf e_ 3-fra€ Address: 330 ibil;.1 e 60- . City/State/Zip: Oo-rop ppz- miN 6264 Phone #: So g.S 24,31 PSP Are you an employer? Check the appropriate box: Business Type (required): l.5] I am a employer with 2. 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.E Manufacturing no employees. [No workers' comp. insurance required]` ' 11.0 Health Care 4.[l 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 4:1 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 kl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: TGs Saa 0PI 1... Insurer's Address: LA'3)---t Liz 14 /u •s,� * City/State/Zip: SOU* .1/t en_95N1 s. (mc - Ca 2_6 A O Policy k or Self-ins. Lic. # 0 I .14 00, 0 3 Lt. 1 23. 2..c) Expiration Date: I I —202 I 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 certif, under t pains and penalties of perjury that the information provided above is true and correct. Sig-nature: V IP Mr.MAWDate: .�- i 0 , 2o2O Phone: 50 s•'.S 2N4-31....t 1.1 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 #: NEWYARM-01 MROSS ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �� 11/9/2020 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 NAME: RogersGray,Inc. .PHONE FAX 434 Rte 134 (A/C,No,EM):(800)553-1801 (NC,NO(877)816-2156 South Dennis, MA 02660 n pRIEs,mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Vermont Mutual Insurance Company 26018 INSURED INSURER B:Massachusetts Retail Merchants WCSIG,Inc.00000 New Yarmouth Corp/New Yarmouth Realty LLC INSURER C:Mount Vernon Fire Insurance Company 26522 330 Route 6A INSURER D: Yarmouth Port,MA 02675 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 (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR BP11046844 10/31/2020 10/31/2021 DAMAGE TO RENTED PREMISES(Ea occurrence) $ _ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY 1,1EI9 LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ ACOMBINED SINGLE LIMIT AU LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED 'SCHEDULED AUTOS ONLY AUTOS yy Ep BODILY INJURY(Per accident) $ AUTOS ONLY AUUTOS ONLY (Peri accidentDAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO RETENTIONS $ B WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE ERH 014005034124120 1/1/2020 1/1/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEgEE.L.EACH ACCIDENT $ (Mandatoryiin NH)EXCLUDED? N/A 500,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Liquor Liability CL 2704946D 10/28/2020 10/28/2021 Liquor Liability 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Liquor store CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth BuildingDept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .:Y ..to } I) Ilt 11 a% A �� n t 1 1 C .i...UI) D ire milli i 1 ". z rli 0 Q.> ..., ,, N o '" 1 —1 fl ......, - il Z pz (e) 1 5- > C 6.11.1 II< el, ,.. . z n_ i r I [ i _in> > Irin 5 ieNNO i i _,,, 4041 imme a 1 Ii r:, - ,r zOI > M a I 3 y›. -- x T.,,,4- '5: ,-.; 1 Z (111) rn N AR '+ p qC mx, 4 D ii I _ 0 z cr n w a y . ' N •..p., E ... .4414!. !4; i Yy ****Nuit******************** ......•iufsafrw!!!aaaasasania. tf Y • ** w I :-•-•111,.:0. i > • ' • I !'•;.►: Q .may,,. f ` i i aa • r Y X11„ •a • rr;+ ' . n .... . i i , .... ' D (• � !�• CD Z , , , 04 0 ; } „, : -,*. 3 > 1 m C) C 0 t 6• _ -zON INa _ ,. ? ! CD O 0 2. l .... rir ri.) .c..c.., : O >.. skk : 1 zi) : cico.c a N 5. zsfr 3 V 1 rirl n KJ C.3 C -,...3.} N N VD ;. . —a .0 42. 111.11.1111.11 I f+r T _ ~ _ a 4:-;` omoot • Z • 4,,, ..,". '`. ..G.:,,7.9 4(4? : Z i • 3 `� fi~. • O CI) . `! . I5, • `a . pro <sxfaf4li4'!!Ax'.1°d►lf►.abra ar!•aw s •.at+afkaaUw++("• "�• iifflr.rrrarf•!lfwrfl:llf f►w1lll.fwfx!!!wylf:f•w fitt+tfalkittk€+b1kfD-* +r4slfk* _ .. k l z• r � ' , rig +trr Commonwealth of Massachusetts Letter ID:L0516045888 r t� Department of Revenue Notice Date:May 7,2020 ' Geoffrey E.Snyder,Commissioner Account ID:EDL-11347648-013 4N7 os* mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS n111111linliiillIIIiIIillitIIIII11110Iil'IiIIiIlniiiillililli NEW YARMOUTH CORP o= YARMOUTHPORT VILLAGE STORE MIMM 1 PATRICKS WAY FORESTDALE MA 02644-1030 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE sNCHe s MASSACHUSETTS DEPARTMENT OF REVENUE r•fi , " Retailer License for Sale of Electronic Nicotine Delivery Systems ,, -4 This license must be posted and visible at all times. The sale of v. tobacco products to anyone under 21 years of age is prohibited. NEW YARMOUTH CORP Account ID: EDL-11347648-013 YARMOUTHPORT VILLAGE STORE License Number: 1491150848 330 ROUTE 6A YARMOUTH PORT MA 02675-1818 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 7,2020 Expiration Date: September 30, 2022 0 ,0i.rq,`sa j Commonwealth of Massachusetts Letter ID:L0279892288 Department of Revenue Notice Date:November 30,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-11347648-010 'KA-T 'r` mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO inIIII111111IIIii11111111119lnl NEW YARMOUTH CORP 1 PATRICKS WAY FORESTDALE MA 02644-1030 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE s #`"``S�f MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a; ,t. :, Retailer License for Sale of Cigars and Smoking Tobacco =14� v• This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. NEW YARMOUTH CORP Account ID: CRL-11347648-010 330 ROUTE 6A License Number: 1293092864 YARMOUTH PORT MA 02675-1818 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 PA �h„`411E:rp j Commonwealth of Massachusetts Letter ID:L1177309504 �i Department of Revenue Notice Date:November 30,2020 4 Geoffrey E.Snyder,Commissioner Account ID:CGL-11347648-007 AT kli a mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES II,IIIIItIII111111t'InliiIIIIIIIl IlhillIIIIiii911uIiiiI NEW YARMOUTH CORP o 1 PATRICKS WAY FORESTDALE MA 02644-1030 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE sNcli s�, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 I. Retailer License for Sale of Cigarettes ,yF yr"k ,�e: This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. NEW YARMOUTH CORP Account ID: CGL-11347648-007 330 ROUTE 6A License Number: 588785664 YARMOUTH PORT MA 02675-1818 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30,2022 ycv...1 Pork V I110 t TOWN OF YARMOUTH BOARD OF HEALTHSt-crCsL o.r- L g' APPLICATION FOR LICENSE/PERMIT - 2021 y * 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 NAM E:'HUts-t`npu-hpoak— 0 j ( qae o TAX ID: $I — 216O0l • LOCATION ADDRESS: 33o c o(t-1e 6R.14Cnr11)ote po>-t'• erviN. O2 -S TEL.#: .56a-,362.-29a MAILING ADDRESS: 330 Rotate 6 A- Ucxar-mou+en pow m A- 02_69:S E-MAIL ADDRESS: V.Shed. 29-6 Ltaiioo-oni- OWNER NAME: 0 t99haaL Sht.t,1.1&- CORPORATION NAME (iF APPLICABLE): NI pup lka.2r-ncyzt-en Com . MANAGER'S NAME: \J i,o,h c4 51101414 TEL.#:50g-_sap -334<0 MAILING ADDRESS:1. PaAL-1-ic.K5 LO ay - --M Je rnfv D26( / 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. i 1. 2. , •i i nn , 3. 4. VtU ' I £ULV I) HEALTH DEFT. I FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one hill-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. N ITi In VA.4 Mtrr P C -%- 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. 1. lel S Ari ,r is kA m4 yr P ccs 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. \I ( 5\r)aL 51,,tA[k 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 # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PI{RMIT!! LICENSE REQUIRED FEE PERMIT II LICENSE REQUIRED FEE PERMIT II 00.0 Q•cc /•A DIM UI CC KAMYTCI 101 111 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 V Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES V NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or t 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.[,. 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 Icalth 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 liar pseudomonas, total colilorni and standard plate count by a State certified lab, and submitted to the I leallh 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)clays of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Ilealth 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 I-lealth 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 waiterlwaitress 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 3 I. IT IS YOUR RESPONSIBILITY TO RETURN Tri rtifl• wnr rmrn n V.I 1--•111 A 1 a nnr 1e, A mrn1,I i(-1 A A I ri n r•is I ern I-,I, r r r i fl, nv r'sr r,r•e n rn t n n(snn