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HomeMy WebLinkAboutApp-License-Certifications - 1st Floor The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-17-4361-05 Issue Date: 1/1/2022 Mailing Address: Location Address: MAPLEWOOD SENIOR LIVING 164 ROUTE 28 MILL HILL RESIDENCES WEST YARMOUTH. MA 02673 164 ROUTE 28 WEST YARMOUTH, MA 02673 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 FIRST FLOOR KITCHEN SEATING: 62 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston V Bruce G. Murphy,MPH, • .,C /James G. Gardiner 00.) Health Director/Assistant Health Director tziria TOWN OF YARMOUTH BOARD OF HEALTH I s F Ioor 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. ESTABLISHMENTISHMENT NAME: Maplewood at Mill Hill(f/k/a Mill Hill Residence) TAX ID: DEC 1 7 , LOCATION ADDRESS: 164 MA 28, West Yarmouth, MA 02673 TEL.#:(774)470-5174L MAIADDRESS:164 MA 28, West Yarmouth, MA 02673 HEALTH DE E-MAIL' 'ADDRESS:millhilled@maplewoodsl.com r1kVNER NAME: CORPORATION NAME(IF APPLICABLE): Maplewood Mill Pond, LLC MANAGER'S NAME:Joanna Lovely TEL.#:(774)470-5174 MAILING ADDRESS: 164 MA 28.West Yarmouth, MA 02673 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 will not use past years'records. You must provide new copies and maintain a file at your establishment. 1.Kimberly Dixon 2.Jose Nunez PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1.Kimberly Dixon 2.Jose Nunez 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.Kimberly Dixon 2.Jose Nunez 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. Jose Nunez 2.Madison Lemire 3.Denise Malcolm 4.Merla Florestal David RESTAURANT SEATING: TOTAL# 62 LODGING: OFFICE USE ONLY 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 SI I0ea. FOOD SERVICE: LI ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125ONTINENTAL $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 4 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 = $ 156 *****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 1/ 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 d 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 REQUIRE A SITE PLAN. DATE: \;\q\a SIGNATURE: (5- — PRINTNAME&TITLE: Soconk\ 1-.0veI_ Fyrec„Kv& -V(pc-1L Rev.10/15/19 ✓') The Commonwealth offMassachusetts _=t _r+/� Department ofIndustrialAccidents 41 Office of Investigations � 1 Congress Street,Suite 100 - t = Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Maplewood Mill Pond, LE..0 Address: 164 MA 28 City/State/Zip:West Yarmouth, MA 02673 Phone#: (774)470-5174 Are you an employer?Check the appropriate box: Business Type(required): I II,/I am a employer with 56 employees(full and/ `i• 0 Retail 2.0 or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 1 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, 0 Entertainment their right of exemption per c. 152,§I(4),and we have no employees.[No workers'comp.insurance required]** 10.0 Manufacturing 4.0 We are a non-profit organization,staffed by volunteers, 11 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'compensation insurance for my employees. Below is the policy information. Insurance Company Name:MEM IC Indemnity Company- Insurer's Address:650 Elm St, Ste 401 City/State/Zip:Manchester, NH 03101-2551 Policy#or Self-ins,Lic.#3102804908 _ ration ate:6/1/22. Attach a copy of the workers'compensation policy declaration page(showing the pol policynumberand 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 K tit nd,penalties ofperjury that the information provided above is true and correct. Signature: (JMyvKjtsL 644.411/Ce_ 12/6/21 •Phone#: C z3) $f 1-1>77 -7 _ Date: Official use only. Do not write in this area,to be completed by cit:,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 A!^�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/29/2021 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 M&T Insurance Agency, Inc. PHONE Commercial Lines Service Team FAX 285 Delaware Avenue, Ste 4000 (A/c.No.Eat):716-853-7960 (A/C,No):855-595-4605 Buffalo NY 14202 ADDRESS: CLServicing@mtb.com INSURER(S)AFFORDING COVERAGE NAIC# — INSURER A:TDC Specialty Ins Co 34487 _ INSURED MAPLE-5 INSURER B:StarStone Specialty Ins Co 44776 Maplewood Mill Pond LLC Go One Gorham Island INSURER C:Federal Insurance Company 20281 Westport, CT 06880 INSURER D:National Fire&Marine Ins Co 20079 . INSURER E:American Empire Surplus Lines Ins 35351 INSURER F: COVERAGES CERTIFICATE NUMBER:1712100207 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DO/YY/1') (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY LTP-01015-21-01 6/1/2021 6/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 — MED EXP(Any one person) _ $5,000 — PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO- v _ POLICY JECT ^ LOC PRODUCTS-COMP/OP AGG $ X OTHER: Shared Aggregate Policy Aggregate $10,000,000 C AUTOMOBILE LIABILITY 73594041 6/1/2021 6/1/2022 COMaBIINdEDISINGLELIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ B UMBRELLA LIAB OCCUR 82176D210AHL 6/1/2021 6/1/2022 EACH OCCURRENCE $13,000,000 DE X EXCESS LIAB X FNSC100124 6/1/2021 6/1/2022 - CLAIMS-MADE XS E717399 6/1/2021 6/1/2022 AGGREGATE $13,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYY/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability LTP-01015-21-01 6/1/2021 6/1/2022 Per Incident 1,000,000 CLAIMS MADE Aggregate 3,000,000 retro 6/1/20 Policy Shared Aggr 10,000,000 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZ D REPRESENTATIVE South Yarmouth MA 02664 I ©1988-2015 ACORD CORPORATION. All rights reserved. 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