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HomeMy WebLinkAbout2022 App-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH !MM.to. 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: -77-1e- al-- fS UI�`�tl TAX ID: LOCATION ADDRESS: 03, %y .y/9f47 v . 1,44_ . TEL.#: �$-77,?/SS MAILING ADDRESS: / • , �' n/1orni . /1/l . 0,)4,7'3 E-MAIL ADDRESS: SI t jil' Y '1 �'l?LC01,M. OWNER NAME: kei . ti •la;W/1f D CORPORATION NAME (IF APPCABLE): MANAGER'S NAME: J €tiih ib5 TEL.#:4'17••-/y- yr'/L) MAILING ADDRESS: . / e1)S <. I, m M H11°r 0 Z(D Yg 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 a Ltimes_.__PleaseJist{ •e employees below and attach copies of their certifications to this form. The Health Depa meOt will4mtiuse p. t yearsrecords. You must provide new copies and maintain a file at your place of b siness. ULi.; 2 0 2021 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. N 1. '/►/ I1i"jitJ 0,090 2. / ' i /C i 4q,/ PERSON IN CHARGE: , Each food establishment must have at least one Person In Charge (PIC) on site during hoursrof operation. 1. KQIf4fryn49747,0 �°( fl ki 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 provi e ew copies and maintain a file at your establishment. 1. iniA/n livgipa 2. Pam Saii/VG6 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 b siness. 1. )91'injn ? 1' 2. ' 02Nl o' l 3. 4. RESTAURANT SEATING: TOTAL# 1% 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 $110ea._ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 ,/>1o0 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 = $ �.(g�,`)v *****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 p id 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 whoJas failed to renew his or her permit within thirty des 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 R UIRE A S ► PLAN. DATE: 1111S)).4)0 / SIGNATURE: iitN7) PRINT NAME &TITLE: /6141/1ri ' ammo 1 I ff Rev. 10/15/19 The Commonwealth of Massachusetts Fee /*I Town of Yarmouth $260.00 Food Establishment License Number: BOHF-16-10284-06 Issue Date: 1/1/2022 Mailing Address: Location Address: ROURKE'S TOP OF THE COVE LLC 183 ROUTE 28 THE LOFT WEST YARMOUTH, MA 02673 183 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 SEATING: 194 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston i Bruce . 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Q Pum ".1 •"171 it 1U Pmfm ll ttooPraidElOS490NW3W +parg00Z°°NW"�°7'w4°Iou9Poylyu"wmpm'°°u! 9990# $uognjos uaNaposcVpwusissit Iou°IWN"dAS sj".......3.7r4618 IMUUMIS .01 ISN •slUowonnboj u090199Jo30J Jot dwoen"Ggpl iku poq,na; quip•iddb 1119 poi NOIlVbIdX3 10 3Iva NO11VNIWyX3 10 31Va ZZOZ/9Z/17 L 60Z/9Z/t7 1136Wf1N W2101 WVX3 8ci81nl,,np,I 311/D1111113D L£Z9 .176991705. '(dD)UDpalad poN xi scuaJaGUo)-OSNV)alnoul 9pJDpUDls IDUDIIDN UD7ldewtf ey/(9 pelipe o sl LPIgM 'uoipu!wox3 uoyDayµle,J0BouoW uo_lpelad p0D1 oa1DSNas Byi.1O1 4P1011es spJopuDp,elµSugeldwoo,f(njsso»ns Jot SaeIVH3I2:I NIA )1 NOI1VDI111113D eiDS4UGS : .. ..,.__:.__„ - --;-,:: - elesAJes .......,. ,: .. ______ __,.. ,,., " AC�RIC) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/15/2021 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 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 00509-001 Nni€1CT Branch 509-1 pp Baldwin Krystyn Sherman Partners LLC dba RogersGray Inc, RogersGray Inc 1ARM/CNNo ): (800)553-1801 (AIC.No.: (508)398-0246 434 Route 134 ADDRESS: mail@rogersgray.com South Dennis,MA 02660 — - INSURER(S)AFFORDING COVERAGE NAIC# NSURERA: Associated Employers Insurance Company 11104 INSURED Rourke s Top Of The Cove LLC INSURER B INSURER C• 183 Route 28 INSURERD: West Yarmouth, MA 02673 --- — __ LINSURERE: INSURFR 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. INSRR TYPE OF INSURANCE INSRL$U.BR POLICY NUMBER POLICY EFF POLICY UP. WAD (MM/DDIYYYY) (MM/DorMrY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE 3 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY : PRO- JECT I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE — AUTOS , 1Per accidenU $ _ UMBRELLA LIAB OCCUR ,EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ y�pRKDEERDg�pry�pER�EgTpENN1TIION $ y�,�g 7H 3 AND EMPLOYERS LIABILITY — X I TORY LAMITS ¶ A AOFFIC� 25T3 'Pf TNEF RECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000.00 rvmt r t�c�LUDt ryi N/A WCC-500-5024258-2021 A 4/7/2021 4/7/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) PROOF OF COVERAGE Kathryn Gianno is not covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Rourkes Top Of The Cove LLC 183 Route 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE West Yarmouth,MA 02673 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts -�-� ..:_..0 Department of Industrial Accidents • :� _,....... Office of Investigations 1 Congress Street,Suite 100 ,,; w Boston, MA 02114-2017 L www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N•ame: [1IA tdijf j? / 4J • Address: 10 /4'jI1Sl . • `City/State/Zip: �i�// t /.�/ 4 4 U_ 4/ . oe #: '2 )l S�i1 ) Are you an employer?Check the appropriate box: Business Type(required): -1:p I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6.A Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity.. ❑ Office and/or Saks(incl. real estate, auto, etc.) ['Nu wvulkors' comp. insurance required] 0 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 100 Manufacturing 11•❑ Health Care no employees. [No workers' comp. insurance required]** 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. "lithe 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' ompensation insurance for my employees. Below is the policy information. Insurance Company Name: Ain/ mwilikd . Insurer's Address: c 3 11.1 ,aid (e 1 City/State/Zip: tt!)�1/JIM •F cm�� 3--0 / 76 PolicyJ � (� �nl f� #or Self-ins. Lic.# fti i. C 6 O 7�' F� c)5 -,1`+�)/ Expiration Date: Y �7`��" �. 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 0f;:f,iu n25O.O0 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. r Ido hereby cert y,under the pain and.penaltles of perjury that the information provided above is true and correct. Signature: ,' A ./• Date: l/ ( )1 Phone#: 6 t '7)--C V 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