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HomeMy WebLinkAboutApp-License-Certifications E"�, TOWN OF YARMOUTH BOARD OF HEALTH NO) 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: 1}(kf,7 4 n !,;(0e., l<491)--4v fold- TAX ID: LOCATION ADDRESS: /(114, }1''(n .YJ y4r 1Y1Q114 TEL.#: 3 y(( 9)-1-2- MAILING ADDRESS: E-MAIL ADDRESS: blJ e Win((h 1g(/4l( ' h1 OWNER NAME: CORPORATION NAME (IF APPLICABLE): • + ( G ,� ( �' 1 ` CYZ`L/' MANAGER'S NAME: /-11/11,.1111OTEL.#: j' 6D Cri— MAILING ADDRESS: /( M/10✓44i A H`l�'I ri'J .A (' it 0��iO 1 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 times. Please list the employees below and attach copies of their certifications to this form. The Health Depa tment will not use past yearsrecords. You must provide new copies and maintain a file at your place of usingges UE.0 22 2020 1. 2. 3. 4. HEALTH DP-r. 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 Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. (id i l((( ��c Ks4 2. r4r( OIS J PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) n site during hours of operation. 1. biliM ,i1l 2. (4- 191) a t f 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. 0 f/'C A( I�(1r 2. t!( f/I ( 1-4(k. s611 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. 144 rvi 2. LW"4nl ctSt1) 3. ill ,M s ► 4. C4o b 491J PCT ATTRANT CFATTNCI. TOTAL ft 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio 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 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 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 CAFÉS: 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. The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-14-0314-07 Issue Date: 1/1/2021 Mailing Address: Location Address: CATANIA HOSPITALITY GROUP 1196 &1198 ROUTE 28 HEARTH 'N KETTLE RESTAURANT SOUTH YARMOUTH, MA 02664 1196 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: 200 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health41Eric Weston truce G. Murp y, MPH, R.'f., ' O/Mallory R. Langler, R.S. Health Director/Assistant Health Director CATAHOS-01 CROY ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/22/2020 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 434 Rte 134 (A/c,No,Ext):(800)553-1801 FAX No):(877)816-2156 South Dennis,MA 02660 E-MAILDSS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NorGUARD Insurance Company 31470 INSURED INSURER B: Catania Hospitality Group,Inc.,ETAL INSURER C: 141 Falmouth Road INSURERD: Hyannis,MA 02601 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY _ $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ POLICY PEST LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY (Ea accident)INGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOSBODILYRINJURYp (Per accident) $ AUTOS ONLY AUUTOS ONLY (Peri acEcident)AMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N CAWC181851 1/1/2020 1/1/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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) Locations: 141 Falmouth Road Hyannis,MA 02601 149-151 Main Street Sandwich,MA 02563 151 Main Street Weymouth,MA 02188 1225 lyannough Road Hyannis,MA 02601 1196-1198 Main Street South Yarmouth,MA 02664 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Informational Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVETI�IV7j(rt7Zf� L ✓/ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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C f/y This recognizes that uV) 2 m Shaun S•+t'ni f11111 has completed th. requirements for 16 Cho e Saver 4 CZ c nductr`d by CAPS OD .HAPTER Date comp ' d 04108/2002 The America Red Cross recognizes this certificate as valid for,n/a yearts)from completion date This certifi at cd O Sean Mel. en p \ has ar ended e C.) CI) course o •truction s;.onsored by CA"E COD CHAPTER Date course completed DEC 19 1936 . + )�o paaaldx uao3 anoa arra 1131dVHD GOD 3. D .gli This certifies that .4q pasosu.'•s uotp �asui 3o asano.) i p 1i'; Sean Mclaxen r"` at{a p.plain .•4 8 E5sC) has attend/the avzd ui ax P-1 course •'instru•.on sponsored by iELir sarii.taa s!qy iel 4-.4 AP COD CH'PIER ►.-te course completed 9351 6 1 OM + - + DEC 1 9 19% L3idVH3 GOD 3dV.3 ?z, This certifies that Aq pas• ..s uopatviq ,3o asrnoa / LI r•`:V. • /1 Rollie Handraha alp pap • is req 8 e .� has =tcend•. the CD F.4 0 4,4, course of i struction,rpo•cored byTO I sagniaa sttu CA . 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