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HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2022 NOV 1 9 2021 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application paLTH DEPT. ESTABLISHMENT NAME: Yar mcvt..'tvl k-kiu RveSket A.ree-nom TAX ID: LOCATION ADDRESS: ;�3S S .0 t TEL.#: 1fr'111-c I St/ MAILING ADDRESS: E-MAIL ADDRESS:_(arneva_tnhouc-exrS4eutrttrdCQ . cUrYN OWNER NAME: L V U. ?Am bei�S CORPORATION NAME (IF?APPLICABLE): Y CAu rNC1.S -der • L s-e S MANAGER'S NAME: KAey✓y (•--(-t a.I i TEL.#: 513 (4* ) `-k(A(.0 MAILING ADDRESS: (' Co(LY (2-D 1A- tM 132-4,15' POOL CER'I'th'ICA'1'IONS 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 ast years' records. You must provide new copies and maintain a file at your place of bL smegEa i L: 1. 2. NOV 19 2021 3. 4. HFAI TH DFPT 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. ( aj 2. �lA .i(\ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. C aYy s'YC �U2 2. SSQ.v 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. C7 / Spfa _ 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. Q 1. Avu.),L,e_ Lot,yy), J2's 2. .$)eur roct Kairwk 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 $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ONTINENTAL $35 NON-PROFIT_ $30 7>100 SEATS $200 �OMMON 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 V 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 hagled—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: \\i(e I SIGNATURE: /2, PRINT NAME & TITLE: Ke(ZRy r ec,loio C(\4(\4- Rev. (\aRev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-14-0332-08 Issue Date: 1/1/2022 Mailing Address: Location Address: KOUNADIS ENTERPRISES 335 ROUTE 28 THE YARMOUTH HOUSE WEST YARMOUTH. MA 02673 335 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: 264 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge 11116 Health Eric Weston / Bruce G. Murphy, MPH, R.S., C '0/f.mes G. Gardiner Health Director/Assistant Health Director 5 , 3,..4' "".") _ • ir L_`i F`a >; hM, :(7 :111911 1 00) • S D v 3 _.,, w , c G...) el 0 m `O 7. a ` N h e' a 0 A M > M T n X r m ..... al, .. 3. r. W mil m 8 z I) mon II< , a v. . , s 0 F MIMI aft 1 R a Irn a i M 0 11111% 3D Li _ Z M g c ("z? D 0 ar s N „ 2 9 I T W 0 3 ^ T 7Q r D Z C o Z ,� 5 Nov 242 c. ° s Q c m HEA-114°EPT. w U. Q I o .�D Qe ® [ / -- . y,«: z }( (® g ©? & < » _\ ! ( \ F, \� .. _ . . :y. z £t , }/, , , Mr / {} 3- G (� \ .00 a 3- 3 q %[) \ (/ ( ® )t7 / CA ( ƒ\ \ _\2 �® • \ ;@ � }\` ^ \ ai ( (( / \ M _� 8 ' \ Mk t 10 Q8- \ f / (/ $ z .: & a - % § _ . a, 0 \ � \ ! o \\ C3 �� 07 7 d ƒ / w rs) in � ( y$ fm o ƒ 7 n C K/: 0 % 3 % § m r Q � . ) -^ CO A c ^ ƒ \ ƒ 8 \. � m ® \ P113 (11:11 & 7® ƒ § � \ \co 2 \ Z ƒ Eimill19 �Z �® a' II 0 > \ \ R _w a2 CL \ 0 (' Ialmil MEM CD , 2 0 mimim w r) 0 : $ ) f ƒ ` V R.- §' E 2 C W { 3 $ Fr } m4 0 73 E §' ƒ \ \ ) { r-14 ƒ olimm i ! { o m E tl k ] m k ® CM @ Z M 30 � 7 ® o - cb cb -n w 0 S is Po F` RI x a)c ® 2 Z 9) / \ > �\ I \ 0 m / r= Z g o. \ ii o o. - -. 3ƒJ \ §� \co gED . NOVhd) ] § ( 2 .--- a. HEAL H DEPT ' 44. '4@ )) ServSafe t<ationaf Restaurant Assooat on ServSafe AIIergensTM Certificate of Completion Awarded to GARY SPRAGUE Provided by the National Restaurant Association Certificate Number 4165637 Date 11/20/2019 ANSIExpiration Date 11/20/2022 ACCREDITED rtss / ASTM ts / Certificate hsua ,[. Sherman Brown CIL Executive Vice President,National Restaurant Association Solutions NOV 19 2021 HEALTH DEPT. BASIC LIFE SUPPOR BLSAmerican Provider Heart ss ciation, Angie;zambelis has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Issue Date Renew By 6/5/2020 06/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 eCard Code Training Center City, State 205503338082 Pembroke, MA Training Center Phone QR Code Number o}� o -,.o f (781)826-2011 To view or verify authenticity,students and employers should scan this QF code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3001 R3/20 HEARTSAVER 1000R Heartsaver° American First Aid CPR AED Heart Association. Jarrod Brand has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver First Aid CPR AED Program. Optional modules completed: Issue Date Renew By 12/10/2020 12/2022 Training Center Name Instructor Name Emergency Medical Teaching Svcs Chris Read Instructor ID Training Center ID 02112303145 MA00640 Training Center City, State eCard Code 206007614325 Pembroke, MA Training Center Phone QR Code Number (781) 826-2011 To view or verify authenticity,students and employers should scan this OR code with their mobile device or go to www.heart.org/cpr/mycards. ©2020 American Heart Association.All rights reserved. 15-3002 R3/20 N4� 9 X021 H��TH pEpT AC DATE(MMIDD/YYYY ��- CERTIFICATE OF LIABILITY INSURANCE 10/2o/2oi1 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 NAME: STANDISH INSURANCE GROUP INC. PHONE 774.28374425— ; Fax 774.283.4243 303 COURT STREET UNIT 1B rL°.E-a�_--- i WC,No): ____ ADDRESS: ANDYR@STANDISHINSURANCE.COM PLYMOUTH,MA. 02360 INSURERS)AFFORDING COVERAGE NAIC a INSURER AIM MUTUAL INSURED INSURER B:CAP SPECIALITY KOUNADIS ENTERPRISES INSURER C: _ THE YARMOUTH HOUSE INSURER D: 335 MAIN ST INSURER E: I WEST YARMOUTH MA 02673 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. (ADDL SUBRi I POLICY EFF POLICY EXP ILTR — TYPE OF INSURANCE INSO WvD; POLICY NUMBER I(MMIDDIYYYY)hMMIDD/YYYY)I LIMITS X COMMERCIAL GENERAL LIABIUTY CS1800192502 4/01/2021 4/01/20221 EACH OCCURRENCE I$ 1,000,000 B I DAMAGE TO RENTED ( I CLAIMS-MADE OCCUR j I 1 PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) S _ 5,000 I PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I$ 2,000,000 1 POLICY, 1 PRO ! i LOC I PRODUCTS-COMP/OP AGG f S Z000,000 I JECT i OTHER: I I I$ ~ AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT I$ (Ea accident) ANY AUTO j BODILY INJURY(Per person) '$ I OWNED 7 i SCHEDULED BODILY INJURY(Per accident) S _I AUTOS ONLY I _ `AUTOS i - ---- 1 HIRED 7 !NON-OWNED I I PROPERTY DAMAGE 1$ _j AUTOS ONLY I_,.;AUTOS ONLY I I$ I(Per accident) T I ' 1 UMBRELLA UABOCCUR ' j EACH OCCURRENCE 1 S j EXCESS UAB I CLAIMS-MADE I 1 I AGGREGATE $ I 1 DED !RETENTIONS i I $ WORKERS COMPENSATIONWCC5005022314 • .STATUTE I I ETH __ AND EMPLOYERS'LIABILITY Y/N ,', 6/08/2021 6/08/2022 I .ANY PROPRIETOR/PARTNER/EXECUTIVEi I E.L.EACH ACCIDENT I$ _ 500,000 A OFFICER/MEMBER EXCLUDED? ,N/A (Mandatory In NH) 'E.L.DISEASEE-EA EMPLOYEE S 500.0Q0 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below ' ' E.L.DISEASE-POLICY LIMIT($ 3 LIQUOR LIABILITY 1 'CS1800192502 4/01/2021 4/01/2022 j PER OCCURRENCE 0,000,000 I GENERAL AGGREGATE$2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) LSL U LE.'-' = ' OUTSIDE DINING IS ALLOWED UNDER THE GL&LL NOV 19 2021 HEALTH DEPT• CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 ROUTE 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. 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