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HomeMy WebLinkAboutApp, License & WC The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-15-1589-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SHREE GANESH STORE INC. 845 ROUTE 28 YARMOUTH MINI MART SOUTH YARMOUTH, MA 02664 845 ROUTE 28, UNIT 5 SOUTH YARMOUTH, MA 02664 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 Bru G. Murphy, MPH,R.S., CHO/ allory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-15-1588-06 Issue Date: 1/1/2021 Mailing Address: Location Address: SHREE GANESH STORE INC. 845 ROUTE 28 YARMOUTH MINI MART SOUTH YARMOUTH, MA 02664 845 ROUTE 28, UNIT 5 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: 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 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 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 Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 A wwwemass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: YA'rn►ill M l 14,4 Address: f3' Rov tgm►+ '_ 5 City/State/Zip: S)4rn r,.1 , , (11 a 0266 Y / Phone #: '-gS 'C3 Are you an 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.E We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l(4), and we have 10.111 Manufacturing no employees. [No workers' comp. insurance required]` ' 11.E Health 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 14 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 ar. organization should check box#l. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: J,05 Ity,,c (a Insurer's Address: City/State/Zip: Policy # or Self-ins. Lic. # ti 6 15 37i 6:7- Lf 9 Expiration Date: It I l.6 12(51 J 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. Sionatur-: Date: 1.2- _� r Phone #: 93 02 — 6 3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License k —�1 uIp/AOn'SSMM.MA1 CIOZ/L pas!/tab ACC7RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �...- 11/19/2020 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 CONTANAME: Elaine Donoghue McShea Insurance Agency, Inc laic°.No€xt) --(508)420-9011 FAX 1645 Falmouth Road, Rt 28 BLDG D (A/C,No): (508)420-9010 E-MAIL elaine@mosheainsuranoe.00m Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# �NSUR : Travelers Ins Com. 25682 INSURED INSURER B: Shree Ganesh Store Inc Subodh Basnet INSURERC: 845-851 Route 28, Unit 5 INSURER D: South Yarmouth, MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00003155-7468 REVISION NUMBER: 3 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 EFF POLICY EXP ! LIMITS LTR INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ I PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY � _AUTOS ONLY '(Per accident) $ _ ' UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE ! !AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- A ' UB1J326749 06/1612020 06116/2021 STATUTE ER !AND EMPLOYERS'LIABILITY YIN - - ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? n N/A -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If ydescribe underes, OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BOARD OF HEALTH AUTHORIZED REPRESENTATIVE /e.Ar, (ESD) ©1988-2016 ACORD CORPORATION. All rights reserved. %j/irrcl, /V) ,1 l /14,1-21- oF.. 'TOWN OF YARMOUTH BOARD OF HEALTH (:tE.. `g'; 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: 9 4-Rmutirril ftr'/ i/ At)g12 - TAX ID: — LOCATION ADDRESS: et/6- agr aty4e.fcr5larmoigi ,44t7 o2. 6 it TEL.#; --a5g�038y MAILING ADDRESS: S hble xyS c 4"Q E-MAIL ADDRESS: tlerYleut•eowk_ OWNER NAME: PUP)aryl 6411.0arv1 CORPORATION NAME (iF APPLICABLE): SArte G5arle61A 5* re_ C MANAGER'S NAME: 4c,g - ii 6 4'sm+ TEL.#: 5re, 2s8 - c3gy MAILING ADDRESS: fay Ruu.k. , unS e -S, '. jafmct-44, , MR 0260{ 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. '. Lin, 22 2020 3. 4. 1.-14=.1!TN DEPT 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 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. PERSON IN CHARGE: Each food establishment must have at least one Person in Charge (PiC) on site during hours of operation. 1. 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. 1. 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. _ - 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEL PERMIT/I LICENSE REQUIRED FEE PERMIT// I.ICE.NS! REQUIRED PEE PERMIT If �t1 ADM INISTRATION 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 0!? 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. 640 or 830 CMR 646, 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 Ilealth Department prior to opening. Contact the Ilcalth 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)clays prior to opening, and quarterly thereafter. - )POOL-CLOSING: Every outdoor in-ground swimming pool ii Ust be drained or Covered witlrin seven (7) clays of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must he 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 (lealth 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 Ilcalth Department. Failure to do so will result in the suspension or revocation of yours 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 tailed to renew his or her permit within thirty (30) days of the previous year's - - pernlit 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 • . ,.-. . . IA nr•f-st rnni[•x Tl\7 rlcrCAAOCD IQ 'Imn