Loading...
HomeMy WebLinkAbout2022 App-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH Oft 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: ' %� /A-'«-- TAX ID: LOCATION ADDRESS: 9,,qs- TEL.#: $ 3 5dr a�cF a MAILING ADDRESS: E-MAIL ADDRESS: (9 /404 , e47r"1 OWNER NAME: "7-a,a'�'� /v«t4Nei�6 CORPORATION NAME (IF APPLICABLE): -27,A", �ia+►./r f ^/»it�1 __�-c MANAGER'S NAME: '�"1 /(�I z.ieb4,e/¢j TEL.#: ,rc.� S'-"/ 3.ro MAILING ADDRESS: 7.7(1-- POOL 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 plac waD 2. 3. 4. urC 0 3 2021 mgAli M ®PPT. 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. 2,,m /M440,4416 2 � i6te f4 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. / i VaGI f,ve/ll2 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 afile at your establishment. 1. ZiAG/ ‘1//6 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. 1. /""f � ''`// 2. `_'7 ,4"' 3. 4. 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 $125 _CONTINENTAL $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 CHANCE: $15 AMOUNT DUE = $ V2.5 *****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 A✓ 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. DATE: /2- 3 c) ) SIGNATURE: PRINT NAME&TITLE: 44,e—PC--- Rev PC—Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-0990-07 Issue Date: 1/1/2022 Mailing Address: Location Address: T.N.T. FAMILY ENTERPRISES INC. 908 &928 ROUTE 28 ROUTE 28 DINER SOUTH YARMOUTH, MA 02664 928 ROUTE 28 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, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 45 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 1111 Bruce G. Mushy, PH, R.S.,CHO Health Director lOs � The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-0990-07 Issue Date: 1/1/2022 Mailing Address: Location Address: T.N.T. FAMILY ENTERPRISES INC. 908 &928 ROUTE 28 ROUTE 28 DINER SOUTH YARMOUTH. MA 02664 928 ROUTE 28 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, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 45 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman Of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G. Mu shy, PH,R.S., CHO Health Director The Commonwealth of Massachusetts Department of Industrial Accidents ti Office of Investigations Tillt - 1 Congress Street, Suite 100 _ "lz�= 1 Boston, MA 02114-2017 ` - www.mass,gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: .-----?-6,---4c„)--S--- --P/4/t0"____. Address: 9ccF i ; City/State/Zip: _.(:,,,,,le ..1'€� en 0?6 c one #: .SJ- 19 c- ? 144— Are you an employer? Check the appropriate box: Business Type(required): 1.LTJ tam a employer with 3 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 1 1.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#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#1. I am an employer that is providing workers'rcompensation insurance for my employees. Below is the policy information. / Insurance Company Name: ' � c �e 4/14'"5. k./ ell Gi. ' c-� '�' Insurer's Address: 3 S 6,4fr`ite 11I// j&I L. .7GG �.4,,,U''hee Mil D 7i It/ City/State/Zip: f ''4-'0'"t'`{L Gai4- y Policy #or Self-ins. Lic. # d/1100 sc'3 LVt 3 `7"/ Expiration Date: J -2r 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. Ido hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: NA,vv w.mass.gov/dia _____•...4110 TNTFAMI-01 ASANZO ACRO CERTIFICATE OF LIABILITY INSURANCE DA10/5/2021 Y) 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 License#1780862 co it TACT HUB International New England PHONE 508 945-0446 I FAX 266 Orleans Road (EA/C,No,Ext):(508) (A/C,No):(508)945-9136 North Chatham,MA 02660 ADDREss: INSURER(S)AFFORDING COVERAGE NAIC# _INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B:Massachusetts Retail Merchants Workers'Compensation Group,In 34355 TNT Family Enterprises,Inc.DBA Route 28 Diner INSURER C: 908 Route 28 INSURER D: South Yarmouth,MA 02664 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 7620076620 8/1/2021 8/1/2022 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY EO M(EaED LIMIT $ ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OVyNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ _ Ill II $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ , DED RETENTION$ $ B WORKERS ' I PER H D EMPLOYERS'LIABILITY STATUTE I ER Y/N 014006034637119 1/1/2021 1/1/2022 600,000 ANY EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500'000 If yes,describe under 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 04FOOD NATIONAL REGISTRY OF 44 FOOD SAFETY PROFESSIONALS® 0 CERTIFIES TOM NICKINELLO HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE P FOOD SAFETY MANAGER ,, UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS fr PRESIDENT: LAWRENCE J. LYNCH,CAE ANS/ II ISSUE DATE: DECEMBER 4,2019 ACCREDITED PROGRAM EXPIRATION DATE: DECEMBER 4,2024 A nerrean Halm:Al Standards Ins`''Into CERTIFICATE NO:21651491 and the Cantu, In,Fcaa Protection #0656 TEST FORM:EXE85 6751 Forum Drive,Suite 220,Orlando,FL 32821 This certificate is not valid for more P(800)446-0257 F(407)352-3603 wwNRFSEtom than five years from 3aze dome w National Registry of Food Safety Professionals' -VOODS ��� NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES Z 111171 Ip 0 TONI NICKINELLO a„ r HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE CERTIFIED F 8`' 4P C#R i Q FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH,CAE ANSI III .410 ACCREDITED PROGRAM Amerman Habana'Standards Institute ISSUE DATE: JUNE 22, 2015 and the Conference for Food Protection #0656 EXPIRATION DATE: JUNE 22, 2020 CERTIFICATE NO: 21121039 7680 Universal Blvd.,Suite 550,Orlando,FL 32819 TEST FORM: EXE5O P(800)446-0257 F(407)352-3603 www.NRFSP.00m This certificate is not valid for more National Registry of Food Safety Professionals© than five years from date of issao. u tit S.ar L4 t4 f 41 3irim r 'o K :� Vi. It - ; '1 _ •; �, o 'a i b PI:i v Cilli) ......, ; ..,..,..„ ..: .... so ., , .... z n ., _....; A 't' o a a Z d Z ;! Ohi '''rfa Z,. C)' .:.• n a. i..-- ' it ENS •,J o t ,_„h C O <10>11. i____37:41 r•r 1' ! Z ! po--- ,i s.„. 4., CD' o oII 1/4e.7 i e 7 W —11 44.1P t. K •;i CD --N CO iI r D ›i' !I fAk:cf ., cnw - y o � �1 �, H • h .� � � m o \ VJ Iril m ..iF3 7 c o 2 \ r^ �K `r/J Y „ n If: �Wp 2 2 ra=� C.) 41 AN ' 4 R ,= ; 60 «. ' ^2 A i Cod c '., ^ ., 4 +t9 44,4 v o "• a TN 0 .S H 44-3* td •t" 1• t • r ^,•fel oo (J1CTlz ! 4 i D ado, ..���� ,z g ' Ocz1 H ��� p N ��D1 0.. r _0 N , "D�`rE^� c OZ •+rte C.) Op. ,� _L �..a,c, -.6��c .�,.,%" r -26-s:-..„,),e,, ,6-�.7��. .. v c r� v .? :+ � r, 4 v a, c. , T. U s : r> uA �, fi v * _____ Heartsaver® AmericanAmerican CPR AED Heart Association Heartsaver® PrR aA E D Association Nancy Lee Nickinello Nancy Nickinello This card certifies that the above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AID This card certifies that the above individual rias successfully completed the obiect,ves Program Optional completed modules are those NOT marked out and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AE: Mid CPR AED Infant CPR Written test Program Optional completed modules are those NOT marked Out 12/20111 12/1/2013 t Child CPR AED Infant CPR Written test v 1112015 Issue Date Recommended Renewal Date a 11/2511 _ - Issue Date Recommended Renewal Date Strike through the modules completed. This card contains unique security features to protect against forgery. 90.1813 Heartsaver® Pt American .. CPR AED tioHeart Heartsaver® Association., American CPRart AED Association Kt Toni Nickinello This card certifies that the above individual has successfully completed the objectivesToni Nickinello and skills evaluations in accordance with the curriculum of the AMA Heartsaver CPR AID __ __—______. Program Optional completed modules are those NOT marked out This card certifies that the above individual has successfully completed the objectives Child CPR AED Infant CPR Written test and skills evaluations in accordance with the curncutum of the AHA Heartsaver CPR AED /2/20111 12/1/2013 Program.Optional completed modules are those NOT marked out Issue Date Recommended Renewal Date Child CPR AED Infant CPR Written test --------11/25/13 _ ___ 11/2015 Issue Date Recommended Renewal Date Strike through the modules completed. This card contains unique security features to protect against forgery. 90-1813 3/1 Heartsaver® American Heartsaver® '� American CPR AED A socation. CPR AED Heart Association Pt,, . e Tom Nickinello Torn Nickinello This card certifies that the above individual las successtuily completed the objectives This card certifies that the above individual has successfully completed the ob;ectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED Program Optional completed modules are those NOT marked out Program Optional completed modules are those NOT marked out Child CPR AID Infant CPR Wntten test Child CPR AED Infant CPR Written test 12/20111 12/1/2013 11/25/13 __1 ino15 issue Date Recommended Renewal Date Issue Date Recommended Renewal Date