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Home My WebLink AboutApp-License-Certifications /oF TOWN OF YARMOUTH BOARD OF HEALTh g`; APPLICATION FOR LiCENSE/PERMIT - 2021 Please complete tinm and attach all necessary documents by December Ib, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: T`i/nr� /wile l/c k,4 & TAX ID: �, LOCATION ADDRESS: J38/&icy 7 _ ' ) '- ' ��-o "ITL.#: 96'0 7/7 fo42 MAILING ADDRESS lox al? /u.r-% ✓0. c1264. E-MAIL ADDRESS aciy® ',47. /1 �,b,/ etoW� /7e•cd --------------.-- -- --- OWNER NAME:/ 17 / 4c CORPORATION NAM.f4IF APPILiCABLE):,S(Aso MANAGER'S NAME: 4i Gr/hei`'/r TEL.#: /-f95-70 MAILING ADDRESS:,. 8 7; r ,-.4 a4J ",.. hi"//s M 6- c 64 POOL CERTIFICATIONS: /v/e 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. '. 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. a 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. =,_T=;-i`7:41 1._,... 6.; 4 e%` 2. AUG 0 3 2021 PERSON IN CHARGE: HEALTH DEPT, Each tbod establishment/ must have at least one Person In Charge (PiC') on site during hours of operation. I. .J�/), U1iv/ -e// — '. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one lull-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. 712i // ike'/r- 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 fbrm. The Ilcalth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 2 3. 4. RESTAURANT SEATING: TOTAI. 8 ADM INIS'FRATION 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 ATTACI IED Olt ---- 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 oldie 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 POO1. 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 People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL.WATER'I'ES'I'ING: The water must be tested liar pseudomonas, total coliform and standard plate count by a State certified lab, and submitted to the Health Department three(3) clays 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 FOOL) SERVICE OPENING: All Heid service establishments must be inspected by the I lealth Department prior to opening. Please contact the I lealth 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't'own's website at www_y_armouth_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 food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAI' A tobacco permit holder who has Tailed 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 $30.00 Food Establishment License Number: BOHF-21-0377 Issue Date: 8/10/2021 Mailing Address: Location Address: FAMILY TABLE COLLABORATIVE, INC. 1338 ROUTE 28 P.O. BOX 643 SOUTH YARMOUTH. MA 02664 HARWICH PORT, MA 02646 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Non-Profit 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. Seating: 200 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 411, Bru4e G. Murphy, . CHO Health D rector The Commonwealth of Massachusetts lei y Department of Industrial Accidents Lr Office of Investigations :r „ t Top-- w 1 Congress Street, Suite 100 it SONY Boston,MA 02114-2017 "`-1-•.;.,� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Le, ; Business/Organization Name: ��/ ( lU ' � �M�h'r« Address: 1-0 f3/X 6-13 City/State/Zip://-C-w.`(4 c"/. 62‘)1 Phone#: 26° 7/? CFVV?-- Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, 0 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 10.0 Manufacturing ' no employees. [No workers' comp.insurance required]* 11.0 Health Care 4. We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# 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 -er the p,i s and penalties of perjury that the information provided above is true and correct. Sit ature: ll Date. 262/ ` Phone#: � / eo‘/ 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 Z, * XX} 4I ` ) .. T '�ZY ' p . ..:� wry g .:4r:i>j�.e ''-(,1 :1,-. *.. .Jr ` t ' p s1 { iI �• .4.. JA.. , '�` �+=Asa•.::,:nitrsr1:,.:. . ..a1....t► '� ..tw: air .,iR►.-wtr► :r -= CERTIFICATE OF E .. ,,,,\ i` :; ALLERGEN AWARENESS TRAINING 1. 44. : y ` 4ei \,tmr of Recipient:ewxrr oerti r.ticmtr Number.'"'", I}atc.rt C ompkctnxi."ter rs q Ifaec ui k xpitaturr 44 l tZi i. 44t• .} v„,,..„,„,,,---,,,IM`AiS .%f it let:lN4110 Z `,� �i'�' tm. as Ningwe ,,1-+. f.i'. j ii , 1: .. c n59 � a :... y ;k 1 ,y z Pr k ! 0'. c..... 4.1 . _ . „:.„,,_.,... ,,,,:.,..,,, '.±.- ,..r, r.T., rri ,,, ,„. ,, ,c, 1.-- — ...sem 7„, 4:11, .. _. ,. ..„.„.0, § ,,,, y __ * ..... ,,.,.. , ‘,.m10111111111111 n f It .�rw. Umry m _ C c c L- ,...-: 1111111111111111v • z a:„ ,_, , ,...„ >_ ,.„. _ 27 0 CD c- N Z ! & C'- a pqc (g+ r.c 4 m 1tt E D w t PmiiMumA "wl's° INSURANCE COMPANIES A Member of the Tokio Marine Group One Bala Plaza,Suite 100,Bala Cynwyd,Pennsylvania 19004 610.617.7900•Fax 610.617.7940•PHLY.com 05/12/2021 Family Table Collaborative Inc PO Box 643 Harwich Port,MA 02646-0643 Re: PHPIC2272719 Dear Valued Customer: Thank you very much for choosing Philadelphia Indemnity Insurance Company for your insurance needs. Our first class customer service,national presence and A++(Superior)A.M.Best financial strength rating have made us the selection by over 550,000 policyholders nationwide. I realize you have a choice in insurance companies and truly appreciate your business. I wish you much success this year and look forward to building a mutually beneficial business partnership which will prosper for years to come. Welcome to PHLY and please visit PHLY.com to learn more about our Company! Sincerely, John W.Glomb,Jr. President&CEO Philadelphia Insurance Companies JWG/sm Philadelphia Consolidated Holding Corp.•Philadelphia Indemnity Insurance Company•Tokio Marine Specialty Insurance Co•Maguire Insurance Agency,Inc. J0`�/4 PHILADELPHIA One Bala Plaza, Suite 100 air" INSURANCE COMPANIES Bala Cynwyd, Pennsylvania 19004 610.617.7900 Fax 610.617.7940 A Member of the Tokio Marine(;roup PHLY.com Philadelphia Indemnity Insurance Company Commercial Lines Policy THIS POLICY CONSISTS OF: - DECLARATIONS - COMMON POLICY CONDITIONS - ONE OR MORE COVERAGE PARTS. A COVERAGE PART CONSISTS OF: • ONE OR MORE COVERAGE FORMS • APPLICABLE FORMS AND ENDORSEMENTS BJP-190-1(12-98) 1111/ One Bala Plaza,= PHILADELPHIA. Suite 100 N Bola Cynwyd, Pennsylvania 19004 A INSURANCE COMPANIES 610.617.7900 Fax 610.617.7940 A Niember of ti e I okio Niarine Group PHLY.com Philadelphia Indemnity insurance Company COMMON POLICY DECLARATIONS Policy Number: PHPK2272719 Named Insured and Mailing Address: Producer: 15927 Family Table Collaborative Inc Hilb Group of New England LLC dba Dowlin PO Box 643 PO Box 1990 Harwich Port, MA 02646-0643 973 Iyannough Rd 2nd Fl Hyannis, MA 02601 (508)775-1620 Policy Period From: 05/05/2021 To: 05/05/2022 at 12:01 A.M.Standard Time at your mailing address shown above. Business Description: Non Profit Organization IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part 100.00 Commercial General Liability Coverage Part 1,122.00 Commercial Crime Coverage Part Commercial Inland Marine Coverage Part Businessowners Total $ 1,222.00 Total Includes Federal Terrorism Risk Insurance Act Coverage 6.00 FORM (S) AND ENDORSEMENT(S)MADE A PART OF THIS POLICY AT THE TIME OF ISSUE Refer To Forms Schedule *Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations CPD-PIIC MA(09/17) Secretary John W.Glomb,Jr. President&CEO Philadelphia Indemnity Insurance Company Form Schedule — Policy Policy Number: PHPK2272719 Forms and Endorsements applying to this Coverage Part and made a part of this policy at time of issue: Form Edition Description WHY MyPHLY 0000 WHY MyPHLY? CSNotice-1 0120 Making Things Easier BJP-190-1 1298 Commercial Lines Policy Jacket PI-FEES-NOTICE 1 1119 Notice Late/Non-Sufficient Funds/Reinstatement Fee PP2020 0220 Privacy Notice For Commercial Lines CPD-PIIC MA 0917 Common Policy Declarations Location Schedule 0100 Location Schedule PI-BELL-1 MA 1109 Bell Endorsement PI-CME-1 1009 Crisis Management Enhancement Endorsement IL0017 1198 Common Policy Conditions IL0021 0908 Nuclear Energy Liability Exclusion Endorsement IL0130 0121 Massachusetts Changes - Intentional Loss IL0952 0115 Cap On Losses From Certified Acts Of Terrorism PI-ACL-001 1218 Absolute Cyber Liability And Electronic Exclusion PI-HS-029 0220 Exclusion - Adoption and Foster Care Operations PI-SAM-018 0519 Absolute Abuse or Molestation Exclusion PI-TER-DN1 MA 1220 Disclosure Notice Of Terrorism Ins Coverage Rejection Page 1 of 1 Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2272719 Prems. Bldg. No. No. Address 0001 0001 1338 Route 28 South Yarmouth, MA 02664-4427 Page 1 of 1 vole Coi °0 C ro Community Kitchen Description of Operations The Family Table Collaborative is a Cape Cod based 501 c 3 non-profit focused on feeding those in need across Cape Cod. With a home base of operations at the Riverway Lobster House we look to using the facility to provide some commercial food services to generate profits that can support our non-profit mission. We have a goal of becoming a self-sustaining non-profit operation. The major operations at the Riverway will be educationally focused on food operations where: • Our team will be generating cooking lessons focused on showing the community how to cook healthy and nutritionally focused meals using basic foods available in food pantries. • We work with a large team of volunteers— many of them are looking to get into the food industry and start their own business, so there are training opportunities where we will provide training preparing meals. We are actively working the Cape and Islands MassHire in this effort. • One aspect of the food operations will feature locally made products made by local, Cape Cod food businesses. We have created a business curriculum for food entrepreneurs to help them learn all the aspects of running a business— beyond the food they make. • The local food makers will also have the opportunity to sell their food products on site as part of a "Makers Market" we are creating in the building. Food makers will learn about pricing, marketing, retail sales and customer relations by selling their products directly. P.O.Box 643 Harwich Port,MA 02646 781-248-5753