HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee
Town of Yarmouth $80.00
Food Establishment License
Number: BOHF-19-3289-03 Issue Date: 1/1/2022
Mailing Address: Location Address:
CAPE COD COOKIES LLC 23T WHITES PATH
23T WHITES PATH SOUTH YARMOUTH. MA 02664
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Wholesale
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 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 . /
V , . ,
Bruce G. Murphy. MPH, ' .S., CHO
......
Health Director
t ne commonwealth of Massachusetts
—...t.e.
Department of Industrial Accidents
=70mi= Office of Investigations
..,ti! -;,_ 1 Congress Street, Suite 100
�w�- ,= Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information
Please Print Legibly
Business/Organization Name: CAe_ Cc[ Coo r_`
� t£'S, L. C.
Address: 2,37 (A)k t 5 Pte..\-L
City/State/Zip: Soul 4r0t0t.‘,41,t,Lk A Ott( Phone #: 3 .. - 3- - Z9 2
Are you an employer? Check the appropriate box: Business Type(required):
1. I am a employer with LI employees(full and/ 5. 0 Retail
or part-time).*
2.❑ I am a sole proprietor or partnership and have no 6. El Restaurant/Bar/Eating Establishment
7 ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. 0 Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]** 10.0 1.0 Manufacturing
4.❑ We are a non-profit organization,staffed by volunteers, 11 ❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.1 Other _ 6 o
*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: C k!'( , 1 j
Insurer's Address: 15-0 Sck tip • •('s 5 ( t^)x)'
City/State/Zip: P-OC ,QS 4-e r L 20
Policy#or Self-ins. Lic. # 5 ' I '7j 7 5-//0
Expiration Date: 2
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 cert' under the pains d penalties of perjury that the information provided above is true and correct.
Signature: ,.------ /20722_
j' Date: I lo/ZZ
Phone# ,r W 1Aida,
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
NP 131073513
Security National Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 5
INSURANCE POLICY INFORMATION PAGE
Ncci Code:40533
1. Insured: Policy Number: SWC1375110
Cape Cod Cookies LLC
23 Whites Path
South Yarmouth,MA 02664 Individual Partnership
Other workplaces not shown above: _Corporation or X LLC
Nom Federal Tax ID: 873863150
Producer: Risk Id:
AmTrust North America,Inc. Renewal of: New
c/o Paychex Insurance Agency,Inc.(B)
150 Sawgrass Drive
Rochester,NY 14620
2. The policy period is from 1/7/2022 to 1/7/2023 12:01 a.m.at the insureds mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of
the states listed here:Massachusetts
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:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$100,000 each accident $500,000 policy limit $100,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
All states except ND,OH,WA,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans.All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 1,717
STATE ASSESSMENT 71
TOTAL ESTIMATED COST 1,788
Minimum Premium 450
Deposit Premium 1,788
Issue Date: 1/7/2022 Countersigned by:
Authorized Representative
n
" ...._`_ TOWN OF YARMOUTH BOARD OF HEALTH
E• +\ ' APPLICATION FOR LICENSE/PERMIT -2022
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: C2 C 4 ('oD Kle5 , LLc. TAX ID: 77- ,W63/5C%
LOCATION ADDRESS: 2 2,i lAA 4-e5 Pk4-1, , 40. iletottenevA TEL.#: 695-833-/21/2
MAILING ADDRESS: 23 k:te5 reCH 6o0-k VaiMo1.1.4t 1 /4A Olbb9
E-MAIL ADDRESS: C4peCod Caok4e5 LLC &AA' ( < cow
OWNER NAME: 3o.4 & cknd L-Qak Let t,r
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: Lee,k Le4!c TEL.#: ^r7'/- 122 0890
MAILING ADDRESS: Aja► -e.
POOL CERTIFICATIONS: WA
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.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: UM
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. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
I. LP&h ia.) Q ±c 2.
ALLERGEN CERTIFIICATIONS:
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. Le,(IL Ze el y( 2.
HEIMLICH CERTIFICATIONS: /
Pv
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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$1 l0ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 7WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
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 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ ?0 •00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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 prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES I 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.
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 APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY ' •UIRE A SITE PLAN.
DATE: 112.612i SIGNATURE:
PRINT NAME& TITLE: I-656cc, . i.-4.C(34$ OI�.JY�e
Rev. 10/15/19 U