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HomeMy WebLinkAboutApp-License-Certifications - The Commonwealth of Massachusetts Fee /IP. Town of Yarmouth $185.00 Food Establishment License Number: BOHF-19-0880-03 Issue Date: 1/1/2022 Mailing Address: Location Address: T.N.T. ENTERPRISES INC. 908 &928 ROUTE 28 ROPES END SOUTH YARMOUTH, MA 02664 908 ROUTE 28 SOUTH YARMOUTH, MA 02664 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: 39- Inside; 12- On Deck Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston . , / fr. ,. Bruce G. Murp y, MPH,R.S., CHO _.....) Health Director , The Commonwealth of Massachusetts =+; -- Department of Industrial Accidents =,ti' t Office of Investigations 0 _= e= � 1 Congress Street, Suite 100 —I ,,�= - Boston, MA 02114-2017 `r' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 72‘.11-e S. �,1-e'l 6/7 171,41,/ltAriVI .4,s'' Address: 9°S-- ,/� - City/State/Zip: - z-g }4t44-44-/L p3 'iiione #: c'e4 79J-- 5 .w Are you an employer? Check the appropriate box: Business Type(required): 1. I am a employer with '3 employees(full and/ 5. ❑ Retail or part-time).* 6. estaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 0 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *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'compfnsation insurance for my employees. Below is the policy information. Insurance Company Name: ,/V-1 /` .714'L cHe't c- 44-tr%S � Insurer's Address: -3 -S 419 " 4.-e- /74 ,S'c--/, /r .?-e4 City/State/Zip: /�'-t4�,4et.._ . b )/ Cy Policy#or Self-ins. Lic. # 0 /C/4 , 3 '3 LI 6 3 -2/i y / (.9-aa 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. i 52 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,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 ��...,41 TNTFAMI-01 ASANZO ACORO DATE(MM/DD/YYYY) k..-------- CERTIFICATE OF LIABILITY INSURANCE 11/19/2021 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 License#1780862 !, NONTACT HUB international New England PHHOONN1 508 945-0446 Fax 508 945-9136 266 Orleans Road (A/C,�No,Ext):( ) (a/c,No):( ) North Chatham,MA 02660 AD�REss: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B:Massachusetts Retail Merchants Workers'Compensation Group,In 34355 TNT Family Enterprises,Inc.DBA Ropes End INSURER C: Family Restaurant 908 Route 28 INSURER 0: South Yarmouth,MA 02664 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 CLAMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY). A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X I OCCUR 7620076620 8/1/2021 8/1/2022 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 _ OTHER: $ AUTOMOBILE LIABILITY (Ea accidentSINGLE LIMIT $ 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$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N 014006034637119 1/1/2021 1/1/2022 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEN N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Liquor Liability 7620076620 8/1/2021 8/1/2022 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 26(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � 4FOODS� NATIONAL REGISTRY OF �� �� FOOD SAFETY PROFESSIONALS® CERTIFIES TOM NICKINEL,LO HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH,CAE ANS/ i ISSUE DATE: DECEMBER 4, 2019 ACCREDITED PROGRAM EXPIRATION DATE: DECEMBER 4, 2024 amerlcan u�ronaistandams mssWie CERTIFICATE NO:21651491 and the C:,rference for F,wtl Protection 40656 TEST FORM:EXE85 6751 Forum Drive,Suite 220,Orlando,FL 32821 This certificate is nor sahm for more P(800)446-0257 F(407)352-3603 www.NRFSP.com than five years from due of issue National Registry of Food Safety Professionals' ,OFOODs 4,?, NATIONAL REGISTRY OF c) �A FOOD SAFETY PROFESSIONALS® '° 7c6::, CERTIFIES Ali, tri al Irat. o TONI NICKINELLO HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE CERTIFIED FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: ANSI p LAWRENCE J.LYNCH,CAE ACCREDITED PROGRAM ISSUE DATE: JUNE 22, 2015Amencan National Stdodards Institute andthe ConferencemrEaodProection EXPIRATION DATE: JUNE 22, 2020 N065G CERTIFICATE NO: 2 i 121039 7680 Universal Blvd..Suite 550,Orlando,FL 32819 TEST FORM: EXE55O P(800)446-0257 F(407)352-3603 www.NRFSP.com This certificate is not valid for more than five years from date issue. 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Nancy Lee Nickinello _.__ _...___ _ ___ Nancy Nickinello This card certifies that the above individual has successfully completed the objectives and skills evaluations in accordance with the cumcutum of the ANA Heartsaver CPR AED ( This card certifies that the above individual has successfuity completed tri_0:-„E:,:, r:= Program Optional completed modules are those NOT marked out. and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AE. Child CPR AED Infant CPR Written test Program Optional completed moduies are those NOT marked out 12/20111 12/1/2013 N Child CPR AED Infant CPR :"''nt*en ter ...-__ _ _____. 11/2015 Issue Date Recommended Renewal Date A ___!__1�./25>!1 .___. _ Issue Date Recommended Rene.va Date Strike through the modules completed. This card contains unique security features to protect against forgery. 90-1813 4- •lO'.<,knit Heartsaver® American ciq E A. I S, ' VF .i '� ' `°`"` CPR AED Heart H e a rt s a v e re American Association Heart C% PR AED Association Toni Nickinello This card certifies that the above individual has successfully completed the objectives Toni Nickinello and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED _________ __- Program Optional completed modules are those NOT marked out. This card certifies that the above individual has successfully completed the objectives Child CPR AED Infant CPR Written test and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED 12/20111 12/1/2013 Program.Optional completed modules are those NOT marked out Issue Date ~� Recommended Renewal Date Child CPR AED Infant CPR Written test _ 11/2%3_--_ 1112015 --- Issue Date Recommended Renewal Date Strike through the modules ' completed. This card contains unique security features to protect against forgery. 90-18'13 3/) • Heartsaver® American Heartsaver l 4 American CPR AED Aeon atiDn. CPR AED Hart Association Tom Nickinello Torn Nickinello This card certifies that the above individual has successfully completed the objectives TMs card certifies that the above individual has successfully completed the otrectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED and skills evaluations in accordance with the curriculum of the AHA Heartsavcr CPR AED Program Optional completed modules are those NOT marked out Piogram Optional completed modules are those NOT marked out Child CPR AED Infant CPR Written test Child CPR AED Infant CPR Written test 12/2011112/1/2013 11/25/13 11/2415 Issue Date Recommended Renewal Date issue Date Recommended Re^r..a'Date 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: /` o/tes- .r, / .r.,�-'/1 /?esi, TAX ID: 7/ 7/ 7/a JJ LOCATION ADDRESS: 9901— a r TEL.#: SoS-3 9v4-0 MAILING ADDRESS: fair- -)$ E-MAIL ADDRESS: ` 7 M 4- 4:2 go/. OWNER NAME: pig/ /l4i�/4''1/% CORPORATION NAME (IF APPLICABLE): -7-A,7-,m-,1), f.� ^Aise-f -�• MANAGER'S NAME: i o� �s.l'l—//o TEL.#: / •frO MAILING ADDRESS: 9a4- k �-,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 all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use ast years' records. You must provide new copies and maintain a file at your place of ayaD 1. 2. HU 03 ?n 3. 4. WGA1T1.1 DSD 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. �'' /v<�1�'� 2. / G '1 A4 c!l/s s PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. v►9 "ayLl.Li/rli 2. /�ivi ,4%e/4 /i 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 fileat your establishment. 1. 4-./ ' 2. 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. 7M /Medrew/4 2. P/1// /VGi‘e/P6 3. 4. RESTAURANT SEATING: TOTAL# c OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55MOTEL $110 _ INN $55 CAMP $55 _ SWIMMING POOL$1 l0ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $1 l0ea. FOOD SERVICE: LI ENSE 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 WHOLESALE $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 = $ / *****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.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 REQUIRE A SITE PLAN. DATE: /a' 3"a SIGNATURE: PRINT NAME &TITLE: / d .4-1 Ali 4 c:76444"—• Rev. 10/15/19