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HomeMy WebLinkAboutApp-Licemse-Certifications TOWN OF YARMOUTH BOARD OF HEALTH �• �'\ ``: 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: The Grill at Bayberry Hills TAX ID: LOCATION ADDRESS: 635 West Yarmouth Road TEL.#: 413-786-0257 MAILING ADDRESS: PO Box 498 East Windsor CT 06088 E-MAIL ADDRESS: Lhaley a chezhospitality.com OWNER NAME: Marc Sparks CORPORATION NAME(IF APPLICABLE):Chez Hospitality Group, 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. 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# 41 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$110ea. 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 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 <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 = $ *****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 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.varmouth.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 REQUIRE A SITE PLAN. DATE: 3-21-2022 SIGNATURE: c 400-rvad, PRINT NAME& TITLE:Marc Sparks, General Manager Rev. 10/15/19 The Commonwealth of Massachusetts Fee (...' Town of Yarmouth $185.00 Food Establishment License Number: BOHF-22-3628 Issue Date: 03/31/2022 Mailing Address: Location Address: CHEZ HOSPITALITY GROUP, LLC 635 WEST YARMOUTH RD THE GRILLE AT BAYBERRY HILLS WEST YARMOUTH. MA 02673 P.O. BOX 498 EAST WINDSOR, CT 06088 IS HEREBY GRANTED A 2022 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 41 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 4111P / Bruce G. M(rp , PH, R.S., CHO Health Director CHEZHOS-01 DALDRICH ACCHRo CERTIFICATE OF LIABILITY INSU DATE(MM/DDYYYY) RA N C E 3/21/2022 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 Haberman Insurance NAME: 95 Ashley Ave PHONE (A/c,No,Ext):(413)781-7000 ,No):(413)733-9545 West Springfield,MA 01089 E-MAIL info@habermaninsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:Sentinel Insurance Company 11000 INSURED INSURER B: Chez Hospitality LLC INSURER C: PO Box 498 East Windsor,CT 06088 INSURER D 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/DO/YYYY5 IMM/DD//YYri] LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ g CLAIMS-MADE I OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL A.ADV INJURY __ $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ OTHER AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT _ (Ea accident) ANY AUTO $ OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS ONLY AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) g UMBRELLA LIAB OCCUR $ _ EACH OCCURRENCE g EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTIONS g A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY SPER TATUTE X I EORH Y/N 08WECALIFGD 3/29/2022 3/29/2023 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y N/q E.L.EACH ACCIDENT g 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 Grille at Bayberry Hills THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 635 West Yarmouth Road ACCORDANCE WITH THE POLICY PROVISIONS. West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE V r 'Y ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD the Alwa1, t company Anne Wright • c6 kr/lie.dcccre Crsgs7r f" O' The Always Food Safe Company Allergen Awareness Apprpyyi{t:163594 Employee Food Safety Online Course & Exam Date: 12/17/2019(valid+until 12/17/2022) Course reference: AA Learner reference: 344274 This training is approved for 1 continuing edt.cation hour toward the initial or recertification application for ACF certification ANSI . ACCREDITED Nick Eastwood The Always Food Safe Company President 899 Montreal Circle,St. Paul, MN 55102. #1203 The Always Food Safe Company www.alwaysfoodsafe.corn Congratulations!Go ahead and frame t:he big copy--you've earned it! Keep in your wallet for anytime,anywhere proof you passed! For your manager to keep and admire the tne Always Always Safe Safe company company /�.d�fJ�/nI d/`c C�/fri•rrl..rvr/vJ nln.y�rl/ :;c.1 00.// he..Srirr4✓p �eln'eerrn /r•v Anne Wright Anne Wright Xerrr.r.rrrr+i:/l 'ewer/.e/ 1/,Aver Too Always FoodSafe Company / .,ameae. Me Always Food Sale Company Allergen Awareness Allergen Awareness Employee Food Safely Online Course 0,Exam Employpu Food Safely Onane Cause 8 Exam Pate; 12/17/2019(valid!'tmt7 12(17/2022) Date. 12/17/2019(varrdf until 12/17/2022) Course coherence. AA course reference: Al. Learner refertrc<: 344274 learner reference: 344274 This training is approved for 1 continuing education This training s approved for 1 continuing education hour toward the initial or recertification application for ANSI hour toward the inttiat or recertification application for ANSI: Nick cortwwaa ACF ceftifica[ion Amman The Phraya Food sere Comwn ACF certification .sMOS President 699 Montreal Circle,Sv Pool.MN 55102. ef2US President lwood 699 Montreal Ot20S The Alereyi Food Sale Company ww..opo.ysfootware.mm Th,MWya Food ore Company 899.c a ysl odsafee Petr{,MN SS1OL www-0M+ayslooasalP.tom 6 0,-.z-i.. I c 4V — . .44 , lif•11,Ci 1 O - t ./ .-- `,,' a ,..K -.,:, 'S ..., — , t= ... . x — V tu = c 0 o • c o - 0-; 2fLo CC z P, R 8 1.1.1 CO 0 e c 5 — I-- i 0 .,- < .T. 0 z 0 u E: 1 ct 1 x s. •,-.,. . -"i` 75 .-*,- LL. W SAIL ........... (7) 0 to L L w, --- =am -1, =am ' .,- -47. ,.., ---.7., ,,S•..."3„:• -- . 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