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HomeMy WebLinkAboutApp-License-Certification (2) 11 .._. ..\_‘..5...1_ -3,_-D TOWN OF YARMOUTH BOARD OF HEALTH (1:0151APPLICATION FOR LICENSE/PERMIT - 2022 � X021 Ple• e complete form and attach all necessary documents by December 18, 2021. HTM pEp-r, Failure to do so will result in the return of your application packet. EAL ESTABLISHMENT NAME: / 7 QSoNS AW.E'F;•"- TAX ID: LOCATION ADDRESS: We AMA'v GGr, .rte-,. 0 Zr TEL.#: ,99 •. •,9/4/7 MAILING ADDRESS: - S4,7F - E-MAIL ADDRESS: PgrRSwl/44Q,QG-,E116'//04 Gtw OWNER NAME: germ/ r Lrmral CORPORATION NAME(IF APPLICABLE): Smi-014-Etjuetory ywavric i UC. MANAGER'S NAME: JgFF //,,q// TEL.#: MAILING ADDRESS: MS- /1641047 oewb MeL>rsch; 1414 .4,g6c/,S 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. /U/,4 2. /141 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 b siness. 1. N& 2. /v 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. 13030 `77- SmirtY 2. /j'12? //Ea ieriV/OS PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. (% �W /1,� 2. aen14) 04/4420,2 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. 84 ''- �iZ/4 2. 3 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. i/1 / 2. Zil ' 3.— — -- ------ 4. - - RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55$ _CAABIPN $55 MOTEL $110 INN $55 —SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $1 l Oea. 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 _WHOLESALE $80 RETAIL SERVICE: RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 _>25,000 sq.ft. $285 VENDING-FOOD $25 Z<25,000 sq.ft. $150 _FROZEN.DESSERT $40 ,/TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ ae0 *****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 CAFES: 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 RE IRE A SITE PLAN. DATE: A2/ SIGNATURE: /zTc-77� PRINT NAME &TITLE: &DM/ Da././W Rev. 10/15/19 The Commonwealth of Massachusetts Fee rt.' Town of Yarmouth $150.00 Food Establishment License Number: BOHF-14-0323-08 Issue Date: 1/1/2022 Mailing Address: Location Address: SMITHFIELD MARKET OF YARMOUTHPORT, LLC 918 ROUTE 6A PETERSON'S MARKET YARMOUTH PORT,MA 02675 918 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail 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 RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston II Bruce G. Murp , so'R.S.,CHO ........0°) Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-14-0573-08 Issue Date: 1/1/2022 Mailing Address: Location Address: SMITHFIELD MARKET OF YARMOUTHPORT, LLC 918 ROUTE 6A PETERSON'S MARKET YARMOUTH PORT, MA 02675 918 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE 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 1111 Bruce G. Murph , H,R.S.,CHO Health Director The Commonwealth of Massachusetts Print Form Department of Industrial Accidents _- _ __.��� _-rya+._ Office of Investigations t. Ali!1 mit 1 Congress Street, Suite 100 NOV 18 2021 VLI Boston,MA 02114-2017 .— HEALTH DEPT. '•r•.,= www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: f 7JZI/ZK j1/4.€, 6 Address: %l 0 /10 S i r City/State/Zip: /' ii' ice' I/4 i. . J Phone #: 3 c1 ?(,,,„2 - .2/V7 Are your an employer?Check the appropriate box: Business Type(required): 1.ad I am a employer with I/O employees(full and/ 5. E Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* ' 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 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'compensation insurance for my employees. Below is the policy information. Insurance Company Name: An G 46!6A6 ,41 (4/c �rQo&i, Insurer's Address: /"0. Roy g -9= City/State/Zip: segpi e / "kg 0./ Policy#or Self-ins.Lic.# oiVoaSo3o 999/.2/ Expiration Date: /7//.2.2 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 certi nder the pains and allies of perjury that the information provided above is true and correct. Signature: Date: dt_c/1 Phone#: .000' 360 • 0/4/2 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 Workers Compensation and Employers Liability NOV 1 0 2021 Insurance Policy Insurer ID No (s): 34355 HEALTH DEPT. MA Retail Merchants WC Group . Carrier Policy#: I Policy Period PO Box 859222-9222 014005030998121 I 01/01/2021 to 01/01/2022 Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 205023052 Carrier Prior Policy#: 014005030998120 stern 1: Named Insured and Address Agency Smithfield Market of Yarmouthport, LLC Dowling&O'Neil Insurance Agency Peterson's Market PO Box 1990 c/o Barnstable Market Hyannis, MA 02601 3220 Main St., PO Box 323 Barnstable, MA 02630 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Limited Liability Company(LLC) Federal ID#: 205023052 Risk ID: 000000000 NCCI/Bureau#: 34355 Unemployment ID#: File#: 014005030998121 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2021 to 12:01AM on 01/01/2022 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA 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: Bodily Injury by Accident $500,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $500,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000308(04/84),WC000406(/),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14), WC200301(04/84), WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $276.00 $21,277.00 $21,277.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: ' �` � Braintree MA 02185-0000 01-15-2021 !� 17 Form#WC 00 00 01 C ) ._ Pana 1 of 1 +�'�r'�� hi '�X� r ,,Y'� t,y '�Y y�_.Y� 47 V c \ :" a . n 2 1 V� �``�,�� 6.-1 K A VO) 't, ,-) 44. C Ye- 1, °" 1 rtl qit ;-÷..3"::::.'r ti,,� ; IC :6Z Va. may� ••i VVII/ �kn ' b A k 442, Q. , -, Et.; . q O A r�rrt fiLZ till • V 1 0 �D !y v :Vce1l1! Ixa ; ` � 5' X ' —PoX � a :E73 ' r;yie C -7. �: "7A,,47 R rt ori fori o• 0 —. „ DVN Cpvv :-� 0CD MI m 1.1 = Z VVy. Y ITS -4, .,a, cr = .-1 N V JMI �.. 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X 111 y D R D m Q_B m N T E 3 Z • a - Z 1111111114 � Q < C m co IMMO 1111 o c D o, D m N W Min N o O 0 Q 0114 - o Z Q C CO T C C Q co N ri vs F D • )12°P o O 0 > z o Q O m n z o n ii 11.11.111 o ° 9 t V MEM CI A n p -IN w > W rn C33 x cr' m m —{ -71 Z Z M N D -� D m p 3 y R a- 3 O a) T T o o a 0 = R 7 9 a Z ^m 8 > �jC ° cc y p \p++\ gT -4 3 -n G ( ) _ Z v Zco ', o m Q O \\\ O u T7 l m 'nQ 0. 3 iga rsNCHOrF Commonwealth of Massachusetts Letter ID:L1595545152 .f Department of Revenue Notice Date:September 1,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10955026-006 7tArr3�''• f4 oF4 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES nIIihIIiIiI�ililuiIiiiIIIIiIIlsli,iIiutlinilliliIIiulIIiiIili SMITHFIELD MARKET OF YARMOUTHPOR PETERSONS MARKET PO BOX 323 3220 MAIN ST !Ewa BARNSTABLE MA 02630-0323 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. Nov 18 2021 HEALTH DEPT DETACH HERE • MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 f, 1 Retailer License for Sale of Cigarettes ir:11t0Arr'-'of*. cense musPThis lit be osted and visible at all times.The sale of tobacco - products to anyone under 18 years of age is prohibited. SMITHFIELD MARKET OF YARMOUTHPOR T LLC Account ID: CGL-10955026-006 PETERSONS MARKET License Number: 1697568768 918 MAIN ST RTE 6A YARMOUTHPORT MA 02675 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30,2022