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HomeMy WebLinkAbout2022 App-Permit-Certifications ?��, TOWN OF YARMOUTH BOARD OF HEALTH � ►t1 ° APPLICATION FOR LICENSE/PERMIT - 2022 - * Please complete form and attach all necessary documents by Dec- be :_. l,' '021 Failure to do so will result in the return of your application pal ket. HEALTH DEPT, ESTABLISHMENT NAME: COI be0. t f �-C. TAX ID: , LOCATION ADDRESS: 1114, S jziON ANPh,U Sall laf4'►iOl,tth. TEL.#: SIT- 39�i-0401 MAILING ADDRESS: ca)W P I eit etd o I Ke ,Cshcia1`ler Od$a 1 E-MAIL ADDRESS: Q hl,Q Ort40� eSearid'•CP_Mei 'C. CO 01 OWNER NAME: COI GL Plies"erlfg,)t CORPORATION NAME (IF APPLICABLE): CU!l i-, palerp���py U-C- MANAGER'S NAME: Lisa- Lz 11 ( "`" TEL.#: '77(f aij- 0/ MAILING ADDRESS:20119 17 litn6>Ad Al ge > t rail00pi t r4 Oaf . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pohl Operator(s) and attach a copy of the certification to this form. N ( 11- 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. N ( Vi 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. I`tr (1- 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 14 '' 1 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 maintain a4 I �file at your establishment. • 1. 1'-1 / 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. N i fig- 2. =; J (s 3. 4. 1`:T\' 21 ?C21 RESTAURANT SEATING: TOTAL# I P• 19 - 9j5'J -c- ,G\ `�N n GST?- 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 >100 SEATS $200 COMMON_ VIC. $60 _REB LESALE $80 _ ID.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 ENDING-FOOD $25 7<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 , NAMF.CHANGE: $15 AMOUNT DUE = $ O(4/0•00 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 MOTEL_SANI)OTHER LODGINGEST*BLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limiteo the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupa s 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 j 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 AN P A PPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' ' Q ' A SITE PLAN. DATE: l/p & RI SIGNATURE: At/ — *****1/0103 30 SUIS 113E10 3.131d11103(INV 1I1A0 A1I[11,3Sd4'Id***** The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-19-3534-03 Issue Date: 1/1/2022 Mailing Address: Location Address: COLBEA ENTERPRISES, LLC 446 STATION AVE STATION AVENUE SHELL SOUTH YARMOUTH. MA 02664 2050 PLAINFIELD PIKE CRANSTON, RI 02921 IS HEREBY GRANTED A 2022 LICENSE 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. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bru eG. Murp , .S., CHO Heal Director The Commonwealth of Massachusetts Fee Town of Yarmouth $150.00 Food Establishment License Number: BOHF-19-3531-03 Issue Date: 1/1/2022 Mailing Address: Location Address: COLBEA ENTERPRISES, LLC 446 STATION AVE STATION AVENUE SHELL SOUTH YARMOUTH, MA 02664 2050 PLAINFIELD PIKE CRANSTON, RI 02921 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail Food Service 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 RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET RESTRICTIONS: Soda, chips, candy,juice. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston J \ Br.ce G. Murp y, H, R.S., CHO Health Director The Commonwealth of Massachusetts == Department of Industrial Accidents --Y—ter v.�: — 1 Office of.Investigations 13 Viir r_ 1 Congress Street, Suite 100 AS Boston, MA 02114-2017 _,:•p.,:-/50-• www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �.0t wQ. ' ("alr . Cc— ,eA / e i et0 C ) Address: o?OW P lolin fid Pf j City/State/Zip: OirtilINO J 1 Oa'd j Phone #: i/b/—'y -QQo Are y an employer? Check the appropriate box: Business Type(required): 1. I am a employer with 6 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] 0. ❑ Non-profit 3.E 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, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.gOther / I t; h i# 44 J l(ke *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 00-e_ **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. Iam an employer that is providin workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: O 1 bli it rail(e e tote a kuj Insurer's Address: P. 0, e X L#(ego I 1 City/State/Zip: 5111, &lipk7to JTeKaf ltd 4(4) Policy#or Self-ins. Lic. # 4c/01'7(1 5=) Q TT Expiration Date: 1 /I l' a"•••• 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 c'rti y 'der the pains and penalties of perjury that the information provided above is true and correct. Signature: _ _ p Date: 11 /f / j Phone#: hlb F /y�" Official use only. Do not write in this area, to be completed p ed by city or town official. NOV��� � 4 1 U�1] City or Town: Permit/License# HEALTH DEPT. 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 09/08/2021 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 Kim Cabral,AAI,ACSR NAME: The Hilb Group New England,LLC PHONE Ext): (800)232-0582 FAX X,No): (888)505-9300 2000 Chapel View Blvd E-MAILDDSS: kcabral@hilbgroup.com Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# Cranston RI 02920 INSURER A: Motorists Commercial Mut Ins Co 13331 INSURED INSURER B: Beacon Mutual Insurance Company 24017 Colbea Enterprises LLC INSURER C: 2050 Plainfield Pike INSURER D: INSURER E: Cranston RI 02921-2062 INSURER F: COVERAGES CERTIFICATE NUMBER: CL216287:3645 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 ADUL SUHH POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCEDAMAGE T $ 1,000,000 _ CLAIMS-MADE X OCCUR PREM SESO(Ea occurRENTErence) $ 500,000 MED EXP(Any one person) $ Excluded A 5000124237 07/01/2021 07/01/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY JECT PRO X LOC PRODUCTS-COMP/OPAGG $ 3,000,000 X OTHER: Deductible$10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED ' 5000124237 07/01/2021 07/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X Garage X Ded$5,000 $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5000000 A EXCESS LIAB CLAIMS-MADE5000222437 07/01/2021 07/01/2022 AGGREGATE $ 5000000 DED RETENTION$ $ WORKERS COMPENSATION XI STATUTE I 100TH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? Y N/A 890510-Rhode Island 07/01/2021 07/01/2022 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 _DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Limit 600,000 Garage Keepers Legal Liability A Deductible$2,500 5000124237 07/01/2021 07/01/2022 Limit-Hope St 150,000 All Car Washes Limit 10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation-MA&NH-Per Statue Policy#AIC928768759054 Effective 7/1/21-7/1/22,Limits: 500,000/500,000/500,000.Carrier: Argonaut Insurance Company 1,01 2 4 X021 HEALTH DEPT, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN For Informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD t,,y,C11-4 Commonwealth of Massachusetts Letter ID:LI58244204843- Department of Revenue Notice Date:September 4,2020 PO �r v_ Geoffrey E.Snyder,Commissioner Account ID:CGL-11710146-060 ' 4 r©ti mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 111'IIIII�III�IIIIIII��IIIIIIIIIIIiuI�IIiiIuIuiI"IIIIIIiIu�IIIi COLBEA ENTERPRISES LLC EAST SIDE ENTERPRISE 2050 PLAINFIELD PIKE CRANSTON RI 02921-2062 • Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. • DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes �t� This license must beposted and visible at all times.The saleof tobacco Iry ob eco products to anyone under 18 ye; If age is prohibited. COLBEA ENTERPRISES LLC Q 1c21 • ccount ID: CGL-11710146-060 COLBEA ENTERPRISES, LLC NOv 2 i ocation ID: 11710146-0103 446 STATION SOUTH YARMOUTH MA 02664-1208 HSP\-%H EP-C. cense Number: 1508513792 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 ssu=r-%s.6Commonwealth of Massachusetts Letter ID:L1504667200 ,r 1, Department of Revenue Notice Date:September 2,2020 b ;`.4,�, Geoffrey E.Snyder,Commissioner Account ID:CRL-11710146-066 fx�T�F � mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO COLBEA ENTERPRISES LLC COLBEA ENTERPRISES,LLC 2050 PLAINFIELD PIKE CRANSTON RI 02921-2062 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut • along the dotted line and display at your business.location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE • acxc,&e MASSACHUSETTS•DEPARTMENT OF REVENUE • Form CT-3T , Retailer License for Sale of Cigars and Smoking Tobacco 11L K. xrog��' This license must be posted and visible at all times.The'sale of tobacco products to anyone under 18 ', of age is prohibited. • COLBEA ENTERPRISES LLC J � Account ID: CRL-11710146-066 COLBEA ENTERPRISES,LLC 2 p 1. Location ID: 11710146-0104 446 STATION AVE '�N O�P-� License Number: 196473 8560 SOUTH YARMOUTH MA 02664-120: • • This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to • sell at.retail atthe address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. . Effective Date:October 1,2020 Expiration Date:September 30, 2022 ;,shett�s� Commonwealth of Massachusetts �' � ji. Letter ID:L1776503360 l� x Department of Revenue Notice Date:May13,2020 `; GeoffreyE.Snyder, l y er,Commissioner :,•;,, 4: Account ID:EDL-11710146-090 i��Tt7��c mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS liIiIIItiiuIi viii III1�nntIPIiiilillliInlllliulllnii11 COLBEA ENTERPRISES LLC COLBEA ENTERPRISES,LLC 2050 PLAINFIELD PIKE CRANSTON RI 02921-2062 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE SSCIf 4;\ MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems . tJ. y 'l This license must be posted and visible at all times. The sale of �7 OY tobacco products to anyone under 21 years of age is prohibited. COLBEA ENTERPRISES LLC Account ID: EDL-11710146-090 COLBEA ENTERPRISES, LLC rZ 4 Location ED: 11710146-0137 446 STATION AVE a p" License Number: 1301239808 SOUTH YARMOUTH MA 02664-1208 �A This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 13, 2020 Expiration Date: September 30, 2022