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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-22-3626 Issue Date: 03/31/2022 Mailing Address: Location Address: CHEZ HOSPITALITY GROUP, LLC 62 HIGHBANK RD THE GRILLE AT BASS RIVER SOUTH YARMOUTH. MA 02664 P.O. BOX 498 EAST WINDSOR, CT 06088 IS HEREBY GRANTED A LICENSE TO OPERATE: Food Service; Common Victualler 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. CONDITIONS: SEATING 125 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston111 A / Bruce G. Murp,"y, MPH, R.S., CHO Health Director CHEZHOS-01 DALDRICH ACORN CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 3//21 21/2/2022 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: Haberman Insurance PHONE FAX 95 Ashley Ave (A/C,No,Ext):(413)781-7000 (A/C,No):(413)733-9545 West Springfield,MA 01089 ADDAIL RESS:info@habermaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Sentinel Insurance Company 11000 INSURED INSURER B: Chez Hospitality LLC INSURER C: PO Box 498 INSURER D: East Windsor,CT 06088 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 LTRINSD WVDIMM/DD/YYYYI IMM/DDIYYYYI 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 $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ $ A WORKERS COMPENSATION PER X 0TH- AND EMPLOYERS'LIABILITY Y/N 08WECALI FGD 3/29/2022 3/29/2023 STATUTE ER 500,000 ANY OFFICER/MEMBER EXCLUDEDPROPRIETOR/PARTNER/EX?ECUTIVE Y N/A E.L.EACH ACCIDENT $ (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 I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Marc Sparks is excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Grille at Bass River ACCORDANCE WITH THE POLICY PROVISIONS. 62 Highbank Road South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Vitt ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,gyp 'Y...� it r ,.1 '41 _ t�,ti• + �A .ir •4 ,' ' . 11 . ;. �l+f A i , , :/. I .(1 .-. 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'G�7 C/ (p4, �r� V V ` t 1'! , : ,11 ` `y + S, v i 1 1�`rit,at N 1 • �' � , v 1 , r 7 ' u �F '.i, 1� 111 4.,, x . .t ,�.J .# t TOWN OF YARMOUTH BOARD OF HEALTH • APPLICATION FOR LICENSE/PERMIT-2022 a * 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: The Grill at Bass River TAX ID: LOCATION ADDRESS: Fit Highhank Rnaci, Yarmnuth 02664 TEL.#: 413-786-0257 MAILING ADDRESS: PO Box 498 East Windsor CI 0_6088 E-MAIL ADDRESS: 1 , - 6.) 1 - 1 . I. . . .i OWNER NAME: Marc Sparks CORPORATION NAME (IF APPLICABLE):Chez Hospitality Grcup, LLC MANAGER'S NAME: Marc Sparks TEL.#: 413-786-0257 ext 24 MAILING ADDRESS:PO Box 498 East Windsor CT 06088 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. N/A 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: 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. Raymond Arias 2.Anne Wright PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I.Raymond Arias 2.Anne Wright 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 Anne Wright 2. Raymond Arias 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. Haley Mathieu 2. Marc Sparks 3. Cameron Lebeau 4. RESTAURANT SEATING: TOTAL# 125 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 REQUIRE A SITE PLAN. DATE: 3-21-2022 SIGNATURE: 01,1 .c. G!J c6echvd. PRINT NAME& TITLE:Marc Sparks, General Manager Rev. 10/15/19 t. /!l .'Ii.�♦.�/. X1' t (L!;:it.........,;111„;;\.):,,,7•4i11:1;:,;,iii.,',,11; :h':••/;,0; ::•ihff.t :'ti .'ti�'N,,,y) !'/:titii:•;l,1••i'/ :� ft.',;ii!.",4;i;.4: ..i::''riir. .%•ti1t§,;1"//ii�i!,; ? 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