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HomeMy WebLinkAboutApp-License-Certifications "" TOWN OF YARMOUTH BOARD OF HEALTH C)' J I. 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: (. 1r11NA ('rj+e_ d0� \ TAX ID: LOCATION ADDRESS: yo /20,,i-c, yir ive S C`M1 oal,11 0 27....3 TEL.#:So d LC/)- rs MAILING ADDRESS: jcv►i t_ G3 CA Ot./e E-MAIL ADDRESS: iv;sr �ca . Y ,2-3 a I1 J i 4 �l, Cam OWNER NAME: L cvr 1 31ari you/ CORPORATION NAME IF ATPLICABLE): ( MANAGER'S NAME: . V y Car 1 0 ' TEL.#: -5 G 6P q() . O MAILING ADDRESS: g Fp ret 6/'r yWIs 00-60 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. 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 w' •..:•-.• •- • • ecords. You must provide new copies and maintain a file at your establishment. a LiOY -S..) 1. V ( ( O ((AEI e., 2. NOV 222021 PERSON IN CHARGE: HEALTH DEPT. Each food establishment must have at least one ne Person In Charge (PIC) on site during hours of operation. 1. ( 1 Ci\V C\ CrA\C-C \A CM() i 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 mintain a file at your establishment. 1. t-U iS pot.j ()(AV 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 nnewt (copies and maintain a file at your place of business. 1. 6 CI�.�O �--G'�l t2. 1iu CCATJ CAI 3. 4. RESTAURANT SEATING: TOTAL# q'7 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 $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# /0-100 SEATS $125CONTINENTAL $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. SIGNATURE: DATE: /it/G off- I �- ------ PRINT NAME &TITLE: c�1S I G, ()tnv 0W/10 V Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-17-4319-05 Issue Date: 1/1/2022 Mailing Address: Location Address: LUIS P. PAGUAY 80 ROUTE 28 GRAND CAFE WEST YARMOUTH, MA 02673 34 CIRCUIT ROAD NORTH WEST YARMOUTH, MA 02673 Q\oSE .2//G/? 2-/ 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: 95 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, R.S., CHO Health Director The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Plc ' 7t Office of Investigations 1— y 6 ! 1 Congress Street, Suite 100 €111111 Boston, MA 02114-2017 www.mass.gov/dia • Workers' Compensation Insurance Affidavit: General Businesses Applicant Information a Please Print Legibly Business/Organization Name: 6 1---MCI k a��i-aff r- „-- Address: eO A0 cr\-. �� �V�'-� yarmo 44- © 6/-3 City/State/Zip: 6U0 Yaivô(/-I/A 0 01-6 j-3 Phone #: S p g 0L CO- g_j Are ygu an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with G( employees(full and/ 5. ❑ 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]** 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. **[f 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: 72 e ,</i a t) Insurer's Address: 467/6'l "d.1/e— Seilk men 9' 4cJ City/State/Zip: /V2,011 / T z4,1 /V )/ /.3Y/3 Policy#or Self-ins.Lic.# (5g a'-6' AA JSc2 O Expiration Date: t/1 d 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: 4Z Date: ////672_0 Z( Phone#: c d d : 90- f$/Li Official use only. Do not write in this area,tobe 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 _/" PAGUA-1 OP ID:JA AkCCNRCY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/22/2021 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 suchpoendorsement(s). PRODUCER 508-775-6060 NAMA CT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 FAX )508-790-1414 88 Falmouth Road (ac,No,Ext): (A/C,No): Hyannis,MA 02601 E-MAIL Bryden&Sullivan Insurance ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Scottsdale Insurance Company 41297J INSURED INSURER B:The Hartford Grand Cafe Restaurant Inc. 80 Rte 28 INSURER C: West Yarmouth,MA 02673 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 I TR TYPE OF INSURANCE .INSD WV• POLICY NUMBER „„ .• e I IMM/DD/YYYYt LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPS734184904/25/2021 04/25/2022 DAMAGE TO RENTED 100 000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 X Liquor CPS7341849 04/25/2021 04/25/2022 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG_$ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ AUTOS ONLY AOTNNOSppONLD PROPERTY DAMAGE (Per accident) $ . $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'UABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 08WECAA2S20 05/04/2021 05/04/2022 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 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) CERTIFICATE HOLDER CANCELLATION TOWN-02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF YARMOUTH 1146 ROUTE 28 S.YARMOUTH, MA 02664 AU D REPRESENTATIVE B den Sul(jvan Insurance .. ----\__. , �A i -. -�\ � I t � V , ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are re st d marks of ACORD 31 2 g 3 i 1 l`i§ aft B g g 61") 13 12 n O f! ! fl n T 'w F nXr- Xi M t, [ S yrn � 0 0n DIi / AP.4.. C 7-,-.33 c) • MOM -•1 rn co a nom .111‹ . a a•••— 70 ---A- = > 7 z 7 Q a 414 Z a- 1--- el tin K r a a ar N 4- rn Z R = ., 111111111111 a ao • 3. 0 apt R r_ r . 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U r m D CD a c n Ili" S' ` n Cp ♦J o PO Q m CD m a mieli 7) C 0v, CD cn CD w 13 o x P CD m CD rn "1'c a N �;D r+ C • PO .1 > 3 co .» w was 5-cD FIT CD ODO 3 rap Cot I .-t- mitt _ -- Q O February 16th, 2022 Luis Paguay 34 Circuit Road North West Yarmouth, MA 02673 - Yarmouth Town Hall 1646 MA-28 South Yarmouth, MA 02664 Dear Yarmouth Town Hall, _ I am writing this letter to inform you that as owner of Grand Cafe Restaurant, which is located on 80 Route 28, West Yarmouth, MA 02673, have decided to close the restaurant. Unfortunately, the landlord and I did not come to an agreement to extend/continue with the lease. Not only that but, the building was in an extremely bad condition due to the extreme weather conditions within the past few years. The landlord did not want to repair these issues, even after being notified by the Yarmouth building department. These are some of the reasons I have decided to close the restaurant. For now, I would like to know how I can cancel all the permits that were attached to the restaurant. You can call me at 508-292-8584 or 508-292-8583. Thank You for your help. Sincerely, G`3t0YCi] Luis .I 7 2022 Paguay HEALTH DEPT. /c__,p_f_—.)2.-_ – _--A-,e-er----- MONWEALTH OF MASSACHUSETTS ✓J is Poluctui personally apps bef me,the undersigned notary public.,and - f proved t e his/her identity through satisfactory evidence,which rte,,. — were Y(J47 S r T to be the person J^ whose name is slgrjed on the preceding or attached document in my ;`,� -^0!—",..-a ill dayf t"e•brl,Qr,!� t:1 3' �� i �• .. presence on this _ WEDNAMAR M A UZ Notary PublicMy Commission Expires October 6,2028 -,