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HomeMy WebLinkAboutApp-License-Certificationsv TOWN OF YARMOUTH BOARD OF HEALTH t-, -- L��iL) APPLICATION FOR LICENSE/PERMIT -2022 / 19 2021 * F lease complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. HEALTH DEPT. ESTABLISHMENT NAME: Alm 'G E^ Auer ie. la,- PBRTI A6-470'$ TAT ED#(, LOCATION ADDRESS: RID �A VP Slikkr MAILING ADDRESS: LPD 0 rrAL tai WCti I11'6M'A f tXIIAn lin Oa 2-, E-MAIL ADDRESS: ����,����A�U7�4N�C- �,A� LLC OWNER NAME: CORPORATION NAME (IF APPLICABLE): NEw £IAA /11)17,C67)6 &S TEL.#: SOP-3V— I/1(4,MANAGER'S NAME: LA ;IUA nob MAILING ADDRESS: &O a (-W €eci- hYktvAza-, .pe-Z1/AM, MA 0.6�(, 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. ,jlP 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 2. 2. 4. 3. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is cert fied s5a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 0. 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. ALAiiJA frl,4)'D 2. V1'C Detre LAPP-4 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 2. Viab Rt4 " F ej' 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 590.00 - _,. -h` >� copies of certification to this application. The Health Department will not use past years' "+ �• -�t mst provide new copies and maintain a file at your establishment. NOV 1 9 2021 1. ALA1'NA CtAID 2. OA NtALTH DEPT. 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 certi and maintain form.ile The at yourHealth Department will nott use past years' records. a You must provide newcopies 1. 4 LAillA ilA1'D 2. tilt fOld LA FLAY1 j 3. aInh P1' 4. hA/WW/ln MVR.Pd RESTAURANT SEATING: TOTAL# (1 lD OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSMOTE REQUIRED FEED PERM[ B&B $55 —CABIN $55 —SWIMMING POOL$110ea. _INN $55 — —TRAILER PARK $105 CAMP $55 —WHIRLPOOL $1 IOea. LODGE $55 — FOOD SERVICE: LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICSE REQU IRED FFEOE PERMIT# /0-100 SEATS $125 ONTINENTAL $35WHOLESALE NON-PROFIT SALE $80 >100 SEATS $200 COMMON VIC. $60 _RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED $25 PERMIT EN <50 sq.ft. $50 —>25,000 sq.ft. $285 =VENDING FOOD$$25 —<25,000 sq.ft. $150 _FROZEN DESSERT'$40 110 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 Atobacco 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: /)'1 1 ' 9— SIGNATURE: 8 )m ViGy J PRINT NAME & TITLE: m 60(1.04- C F ,d�l2ltilS�i�L Rev. 10/15/19 The Commonwealth of Massachusetts Fee ill' Town of Yarmouth $185.00 Food Establishment License Number: BOHF-19-2662-03 Issue Date: 1/1/2022 Mailing Address: Location Address: NEW ENGLAND AUTHENTIC EATS INC. 932 &940 ROUTE 28 SOUTH YARMOUTH. MA 02664 PAPA GINO'S 600 PROVIDENCE HIGHWAY DEDHAM, MA 02026 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances evoked sarelating thereto, and expires December 31, 2022 unless sooner suspended or d is not transferable. Conditions SEATING: 98 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge . Health Eric Weston I , vBruce G. Murphy,M' , R.S., CHO Health Director Nov 19 ?021 HEALTHpT. -a The Commonwealth of Massachusetts v- . !, Department of Industrial Accidents sir .l 1 Congress Street, Suite 100 iNti Boston,MA 02114-2017 www.mass.gov/dia .. Affidavit: General Businesses. Workers' Compensation Insurance TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: New England Authentic Eats LLC DBA Papa Gino's Address: 9 yD /1,4 ,0 S “/ City/State/Zip:Ano(fiiIll 0(2..66y Phone #: SOF- 3 578°-//416 Are you an employer? Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 20 employees(full and/ 5• 0 Retail or part-time).* 6. ['Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real state_,VpJ employees working for me in any capacity. 8. Non-profit [No workers' comp. insurance required] NOVg 2021 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 HEALTHDEPT. no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.[] We are a non-profit organization,staffed by volunteers, 12.0Other with no employees. [No workers' comp. insurance req.] *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:Crum & Forster Indemnity Company Insurer's Address: 100 High St#1350 City/State/Zip: Boston, MA 02110 Policy#or Self-ins.Lic.# WC 408-740677-2 Expiration Date: 02/11/2022 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,under the pains a d penaltie of perjury that the information provided above is true and correct. Signature: i M/09 Date: //47' --/ Phone#:781-467-1647 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 ® DATE(MM/DD/YYYY) A►�R 0 CERTIFICATE OF LIABILITY INSURANCE 02/12/2021 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 CONTACT Certificates NAME: The PLEXUS Groupe LLC ('I NE,Ext): (847)307-6100 FAic,No). (847)307-6199 21805 W Field Parkway,Ste 300 E-MAIL certificates@plexusgroupe.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Deer Park IL 60010 INSURER : United States Fire Insurance Company 21113 INSUREDINSURER B: The North River Insurance Company 21105 New England Authentic Eats LLC,DBA:Papa Gino's/D'AngeloINsuRER c: Crum&Forster Indemnity Company 31348 600 Providence Highway INSURER D: XL Insurance America,Inc 24554 INSURER E: Dedham MA 02026 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW`HAV1 BEEIR'ISSUE19 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 AWL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGED CLAIMS-MADE X OCCUR PREM SESO(EaEoccurrrence) $ 1,000,000 MED EXP(Any one person) $ Excluded A 543-227191-2 02/11/2021 02/11/2022PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY JEOT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 C OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE 5821158006 02/11/2021 02/11/2022 AGGREGATE $ 5,000,000 DED RETENTION$ $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY /� STATUTE OTH- ER YIN 1 C ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A 408-740677-2 02/11/2021 02/11/2022 E.L. ( EACH ACCIDENT S , , OFFICER/MEMBER EXCLUDED? (Mandatory In n NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below ___ ___ E.L.DISEASE-POLICY LIMIT $ , Per Occurrence $1,000,000 Liquor Liability A 543-227191-2 02/11/2021 02/11/2022 Aggregate` $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Sc Fed,le,may be attached If more space Is requlred�, ?�s.',2�C SLS Certificate is issued as evidence of coverage. NOV 19 2021 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. ~AUTHORIZED REPRESENTATIVE aK ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and Togo are registered marks of ACORD AGENCY CUSTOMER ID: 00005588 LOC#: AC" RD ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED The PLEXUS Groupe LLC New England Authentic Eats LLC,DBA:Papa Gino's/D'Angelo POLICY NUMBER CARRIER NAIL COD_ EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes Excess Liability Policy Term:2/11/2021-2/11/2022 Policy Number:US00089484L121A Carrier.XL Insurance America,Inc. Limit:$1OM x$5M Named Insured Schedule: New England Authentic Eats LLC(DBA Papa Gino's/D'Angelo's) WC PG Franchising LLC(Papa Gino's Franchising Corp.) WC DA Franchising LLC(D'Angelo Franchising Corp.) D'Angelo Sandwich Shops Advertising Fund,Inc. NEAE card services LLC .�. G°slAC5l�U t OV I 7071 HEALTH DEPT. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. 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I 4lmsachuxtts Restaurant Assoc anon 600.765.2122 i�^ 1.s.:5 333 Turnpike Road,Suite 102 w,%i¢saeaurant.org +i+t; 45 ggqq Tis cern rate will be valyd r ve tart from date,,Prem Teti+1 Southbomngh,T1A 01772 n' A .f f ()y' f 9 p 506-303-9905 19d+ M ssac.org ��. r 4VWN'.mareShV[anrt 61:7- Ai t M1 • • nU U ”Vy� cV .- it ,-. ''P U 'a .R »y'S U 7'.`sAa 'A UX .�.1 'i Y R M k 6f. .r. 1 ,? ` ���a�s�� ria�t - � „� ;' � n t'''* ' < s s+r'i .a 1 chr 1i ? 1 09(4. Qy`19Gt el S NOV 19 2021 HEALTH DEPT Scanned by CamScanner r cu "I N 0 Mil _ .0 N Li; C -0• -§ 22 in i 3 W u .I N i V 0cL E Z ( a o = z u � o c in a O o L Z LU v c U c O J o O vi a) a) c co J of o a > >, �, in NI c O - O ° a, NI ® UM x J Q _C 2 N u 2 0 D i u w O4-1 � -0Q 1\ LL LI- 4aut ------ ___ i +-J >- (5 -o 0) > c L o C CU c I n3 • 0 W U. 4- 41 =O G 7) c O C > 0 O U 0 a, a_ cn = U D LY73 >. > -0 U Q w lc- (23 u Q o a) L W O OoC 1- LL -- ccC 6411111 Z V W v = v o O - U -p a) N m C cn +O+ D I— z ---- < w ~ -0 — ° � � u°. 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