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HomeMy WebLinkAboutApp-License-Certification TOWN OF YARMOUTH BOARD OF HEALTH r E '; 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: - r►ufN x 3a-0,91 TAX ID: LOCATION ADDRESS: 324 Pxoi ill) TEL.#: S% g £HZ- MAILING ADDRESS: S. 'A P'J J D4-6 tr E-MAIL ADDRESS: 'DKOS'I eGt.L S( C4(mt, of -- OWNER NAME: P-00^41-t" Co44..04--t -13+"4 u • CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: i.,kJ1 -k1 16)s C"(,4". TEL.#: S4 S& 2 €1 IL MAILING ADDRESS: 3'2k 1J.i, ) a- ' J TN 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 past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. uta a Lupi I,EALTW DEPT. 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. Ge4L�4<► c (~ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ( at,1.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 provide6€"1111^- , _ new copies and maintain a file at your establishment. 1. 111 t^`. 111C Ca V-41 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. Aij 1. t+i�V� uf L, 5 2. AN''► 3. (I'LL COC;t 4. —1),v01�,, La . RESTAURANT SEATING: TOTAL# 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 $l l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125NTINENTAL $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 = $ cg(e,(� *****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 v 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 he 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: 11 I - SIGNATURE: 41 �w5 • PRINT NAME&TITLE:Tb 1�'�+ J �( ��` �U S�n/ S C/A-1 Rev. 10/15/19 The Commonwealth of Massachusetts ..,� Department of Industrial Accidents . =.47. 1••t. gi, Office of Investigations o �'_' 1 Congress Street, Suite 100 � € I = Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: - AA -' Address: c r 4. >� -4 City/State/Zip: cSi Cru J - Phone #: b` -c (7 t l'2 Are u an employer? Check the appropriate box: Business Type(required): I I. I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no • 7. 0 Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 1SNon-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]* 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 if I 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#I. - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: M, ( ,(tc e-1,i- tt^SLf' L . C `tir Insurer's Address: CC Pp.o.aleS -b✓ , City/State/Zip: I) CIA.;`-' 4'GL 'i i 14" O Z I Gt Policy#or Self-ins. Lic. # )000002.0 Z Expiration Date: 3 I 1 202 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 2SA of MGL c. 152 can lead to the imposition of criminal penalties of a fine un to$1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP LYIORK 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#: io .'9 k ( [ 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 The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-14-0467-08 Issue Date: 1/1/2022 Mailing Address: Location Address: ROMAN CATHOLIC BISHOP OF FALL RIVER STATION AVE (OFF) ST. PIUS X SCHOOL SOUTH YARMOUTH, MA 02664 321 WOOD ROAD 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: 130 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston I. Z. uce G. Murp, , � ,R.S.,CHO Hea th Director ACRO® l `-----T COlifleDATE(NN/DDMM') �lig O� LIABILITY INSURANCE 11/29/2021 till /� OR ALTER THE COVERAGE CERT FICATEUTHORIZED IERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERIFICATE HOLDER.THI ED BY THE POLICIES CERTIFICATETHIS DOES NOT TE OF INSURANCE EN NEGATIVELY AMEND, EXTEND THE ISSUING INSURER(S), BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEENprovisions be endorsed. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. is ies must have ADDITIONAL INSURED Pr A (tions of the policy,certain policies may require an dorsement. or statement on IMPORTANT: If the certificate sub ect is an theDterm�sand condiNAL tions the poi Yl endorsement(s). If SUBROGATION IS WANED, 1 __ ACT this certificate does not confer rights to the certificate holder in lieu of such EMIIIIIIIIIIIIIIII PRODUCER ' EAI( Certificates@Ratiorisk.comMIMI Ratio Risk Services AppREs3: CORDING COVERAGE - MISURE' 66 Brooks Drive issu A, Massachusetts Catholic Self Insurance Group MA 02184 - Braintree INSURER e : 111111111111 INSURED INSURER C INSURER O 321St.Pius X School BISURER E : WINO Wood Road MA 02664 INSURER F: REVlS10N NUMBER: ABOVE FOR THE POLICY PERIOD South Yarmouth DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE NSU NUMBER: IIIIIIIIIIIII CE CE LISTED BELOW HAVE BEEN ISSUED TO T1'i THE NANIED COVERAGES ANY CONTRACT OR THAT THED OR MAY OF INSURANCE THE TERM OR CONDITION OF CLAIMS. IR FORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER THIS IS TO CERTIFY INSURANCE AF BEEN REDUCED FF PND EXP ■ INDICATED. NOTWITHSTANDING ANY REQUIREMENT, _-- ICY EFF POLICY Via EXCLUSIONS MAY BEO DIISTION OR MAY PERTAIN, "-ICY YNUMBER " EACHOCCURRENC' nIIIIIIIIIIIIIII EXCLUSIONS AND CONDITIONS OF SUCH PIES,LIMITS SHOWN MAY TYPE OF INSURANCE ■COMMERCIAL GENERAL LIABILITYlli MED EXP(Any one ■■ CLAIMS-MADE [13 OCCUR person) IIIIIIIIIIIIIII PERSONAL&ADV INJURY _ GENERAL AGGREGATE' a ■ 101111111111111111 PRODUCTS-COMP1OP Ac' GEM%AGGREGATE LIMIT APPLIESPER: geptSlN LE LIMB PRO- LOC EMillini . POLICY JECT BODILY INJURY(Per person) ■OTHER INJURY(Per accident) AUTOMOBILE LWBILITYli ll PROPERTY DAMAGE a ANY AUTO •1111 Per BODILY INJURY accident LED III ■ µ0pSWNED ■HUROS ONLYME CEs,atv 100011111 IIIIIIIIIIIIII ■ AUTOS ONLY AUTOS ONLY EACH OCCURRENCE .UMBRELLALIAB ■ OCCURii ■� a CLAIMS"MADE 03131121 03131122 ©� = 1,000,000 a EXCESS LIAR rOval E.L.EACH ACCIDENT 1 000.000 RpITION$ Certificate of APP EJ.pigFJ+SE- Cpl°YEE S 0 iiiis Neill RS COMPENSATION 3000002021 1,000,00 Ya E .DISEASE-POLICY LIMrr s iiiiMa I EMPLOYEORSS� BILITY ECUTNE CEIMEMtRIPTI M RS, in undeS RIPnON OF OPERATIONS bellow _ required), Application. `ham sFood License f'ermlt APP LES ACORD 101,Additional Rl for Town f marks Schedule, th 2022 s i LOCATIONS I VEHra �or St Pius X SC oEscmPTi of�fOPERATION nSatlOn Insurance Evidence CANCELLATION D PO JCIEg BE CANCELLEDBEDELIVEREDE 32 BEFORULD ANY OF THE TM�OF�NOTiCE �-L I St. CERTIFICATE HOLDER TMSHOE EXPIRA�ON HTHE DATEABOV�LICY PROVISIONS. Pius X School ACCORDANCEwIT 321 Wood Road MA 02664 AUTHORIZEDREPRESENTATNE South Yarmouth, Amanda Taillon --\--)tk,h-A*Alus4 p 1988.2015 ACORD CORPORATION. All rights reser . _ _a M r]RD 'Ir ,- r,is r v{; . r ir , r r , .1- r �'� �`S t.14=aew i' :_Ali t (w/ ,* It m _-„_..•.f r_<t,,�s p. ems= ' . .( S 4 _ V _1,0 — p� ?2,4,:j Lai, % � 4 se 40 3” '� .. O '•3• Z`2 O 73 ' segS 0a ,!Sk1/4V% 4":rw �. � '), `- ►" Cill) -, 0 r ^t , t T: ZisIt .1 Lri A 7.0-'„..Co 0 ,. , J so ^* : I• d 1, � •�„: . rrt p �-+� F., liii " (tr,:(p� 1.1111.1 r) :, ,, . , , .., N N N ., , . _ Cn L r ^tz 1 Z., A frit >'',..___j ''I l ).4. ilr.-Co,P i K II.1 ‘ c,,„,..,,..) ,,,,,,, 0 t4 G. o 0” '' ado O ° ai ~` CA till � r I Oe , 1 4 Pim ' 0 ` p ., d .1 a $�LJ a N o R. .rv li W. . p re 3 I' • i i r -fel ›. zZ S iftz i00 CArri> Z i i.F>1.2i- 0 �cz r ,I " N �z •rte.,i.. ,T lil Nom. ,i Zc...) y •`O�f'• .l (rte r `� � _ . . -.. 's. 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'•,.";-''..4,11,',f,(M,Y4.--t-Na-7.-..F.,0,4-,- 14'.4 n) 1 0 a) g WatiNerfftir 0* 3 > 0 ,-,Alovriout,_-A2:*414;rt: 4?..7 410.14,4vai41,ANtwogt. 0 IA: = a) li-44-riteN044,4; 'WI -' Ommi ' -,,-r1-0,1C-K04-,-*.431V-0,--,e w,2400,,,,,,,,,K,viroo..,,,o;/440,9,4,,,q t 4-v--Pe-05,44,,g_in4.0,5vAtti-,4.,11, Mk ---i " - ,.. tt 1.Vte4.01-voiVro.4,-A4,-4-vp.o, ----tol- '' cc) hatim_ovitmom v,:, ....1 ..,,, -1:,,,1„*.iilyx%rit.ki.treolomot ;.;;!;-oetAthettaiR,Tkti* ,r '•:',„4,PoW,..4*-ifr1*-5,707 kiEVIitiV- .3-4.40,41000.0'Ve,,grA4:tt=% •,,,rp., . ki.fo T v-kii • BASIC LIFE SUPPORT BASIC LIFE SUPPORT BLSege Training Institute For Emergency Medical Education American Center Name Provider Asseart socciation Training MA20277 Ann Agurkis Center ID has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association IC City,State Marstons Mills,MA Basic Life Support(CPR and AED)Program. TC Phone (508)759-9055 x301 Issue Date Renew By eCard Code p.'< :yci Imector Richard Todd 10/23/2020 10/2022 205506514635 r Lys Instructor ID 09180718187 To view or veify authenticity,students and enployers should scan the OR code with their mdlie device ago b wwwheartorgi pf/myCaldS. I b 2020 American Heart Association 15-3001 R3/20 Directions 1. Cut along dotted lines 2. Fold both halves together 3. Use adhesive to combine halves www.capecodsafetytraining.com 4,041. Si. NSC CPR Course a 2 fr °°"`s ® Adult, Child, Infant, FBAO & AED Name: Nick Corsi Security Control No. Address: St Pius X School 858101 Address: 321 Wood Road City, State, Zip: South Yarmouth,MA 02664 Course Completion Date: 10/23/2020 Training Center: Cape Cod Safety Training Expiration Date: 10/23/2022 Instructor Name: Rick Todd Instructor Number: 1040918 Nick Corsi has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work,in homes and communities,and on the road through I leadership, research,education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining 1 THIS DOCUMENT IS VOID IF REPRODUCED www.capecodsafetytraining.com 641NSC CPR Course i e ° ® Adult, Child, Infant, FBAO & AED Name: Ann-Marie Shaw Security Control No. Address: St Pius X School 85810 Address: 321 Wood Road City, State, Zip: South Yarmouth, MA 02664 Course Completion Date: 1012312020 Training Center: Cape Cod Safety Training Expiration Date: 10123/2022 Instructor Name: Rick Todd Instructor Number: 1040918 Ann-Marie Shaw has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED www.capecodsafetytraining.com "C"`y$ , NSC CPR Course a 00, °°"`'� Adult, Child, Infant, FBAO & AED Name: Dorothy Kostecki Security Control No. Address: St Pius X School 858106 Address: 321 Wood Road City, State, Zip: South Yarmouth,MA 02664 Course Completion Date: 10/23/2020 Training Center: Cape Cod Safety Training Expiration Date: 1012312022 Instructor Name: Rick Todd Instructor Number: 1040918 Dorothy Kostecki has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. The National Safety Council eliminates preventable deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy. For more life-saving courses from NSC please visit nsc.org/fatraining / J THIS DOCUMENT IS VOID IF REPRODUCED