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HomeMy WebLinkAboutApp-License-Certifications _. TOWN OF YARMOUTH BOARD OF HEALTH luxE'' i ` ` 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: it, /till– � TAX ID: ADDRESS: I oZ $• f f/4} 0266 4 TEL.#: co? – 3 y� –/y��t LOCATION i 3 R MAILING ADDRESS: l 'l Roue 2 S. r�U4 Pk oac4 E-MAIL ADDRESS: 'Crk-Ca o tivtalie-CO11 OWNER NAME: ti Vero�(�,., t6t4 CORPORATION NAME (IF)PPLICABLE): TL aexk GA. Mc-. MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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 wirirmostam years' records. You must provide new copies and maintain a file at your place of busin ass. L-~=`'`=" 1. 2. DEC 2 8202 3. 4. 1-ItALII-1 Utl'I- 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 mustee_v\provide new copies and maintain a file at your establishment. 1. C-'1 re R U rve.. 2. PERSON IN CHARGE: Each foode _ establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. ()�( v-0 (RUfK.e._ 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 providennew copies and maintain a file at your establishment. 1. CelC-IN ro '6ucke- 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# 14- 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 $125ONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 7C _ 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 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 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 : PLAN. DATE: f2 t yat/ SIGNATURE: .p PRINT NAME& TITLE:A / L.r Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 r Food Establishment License Number: BOHF-15-1042-07 Issue Date: 1/1/2022 Mailing Address: Location Address: THE JERK CAFE INC. 1305 ROUTE 28 THE JERK CAFE SOUTH YARMOUTH. MA 02664 1319A 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, 2022 unless sooner suspended or revoked and is not transferable. Conditions *RESTRICTION: 17 seats only. Board Hillard Boskey,M.D.,Chairman Mary Craig,Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston ruce G. Murphy,MPH,R.S'CH P. /James G.Gardiner Health Director/Assistant Health Director . . . . . » � ,s. q/ |J ' 0 \ mor k� ` - , =! ƒ/ F-,,,, \Au »i{. '`p /(j tin 6 +!; -LSF .!7IIIIL Ek ; ®[y §9 . - ii . \ . . . . y. . . . . . & & i \ 2 E E ? ° C) . . . . . . rt lin , e . /> K ƒ i . \� » f / a 70 0 2 M ; ! -a ; . .. . r» P12 (ID 2•n . . / { Jx C § f \ / � . p / 2 . Z Milli 9 } - z \- ƒQ - } \ / 3 \ \ ^ /\ ~ \ ii<,`b- 0 mom § @ a a R .< el in \ k ir k e ¥ . ) ƒ, ƒ CO > \ ( _ 2 $ _ & ® 7 S C ' ( g §• x ƒ 5-- a- . a ` 0 = ( k ƒ Qal m cri J ` > m Z . > EZ x b Q \ ) c I T a / / "141' \ 9K Y ; } � 7 - { ; 2 y : 7 , C k \ \ �% R. CO ƒ r / m m 09 2 a. - if a ir \ . / 8m\ § . V 3 ( } § / §-,. • \E THE HARTFORD BUSINESS SERVICE CENTER THE '', 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 December 20, 2021 Glenroy Burke 13198 ROUTE 28 SOUTH YARMOUTH MA 02664 Account Information: Contact Us Policy Holder Details : JERK CAFE, INC Business Service Center Business Hours: Monday-Friday (7AM -7PM Central Standard Time) Phone: (866)467-8730 Fax: (888)443-6112 Email: agency.services(cthehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 It' DATE(MM/DD/YYYY) '`'�`'�`"' CERTIFICATE OF LIABILITY INSURANCE 12/20/2021 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 SUBROGATIONIS 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: MCSHEA INSURANCE AGENCY INC PHONE (508)420-9011 FAX (508)420-9010 08088402 (A/C,No): (A/C,No,Ext): 1645 FALMOUTH RD RT 28 BLDG D E.MAI ADDRESS: CENTERVILLE MA 02632 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Hartford Insurance Company of the Midwest 37478 INSURED INSURER B: JERK CAFE,INC INSURER C: 39 JOE LINCOLN RD WEST HARWICH MA 02671-1416 INSURER : 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 INSR WVD (MM(DD/YYYY1 (MM/DD/Y YYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL 8 ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO- LOC PRODUCTS-COMP/OP AGG JECT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) —A• LL OWNED S• CHEDULED BODILY INJURY(Per accident) —AUTOS —AUTOS H• IRED N• ON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE DED RETENTION$ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY Y/N E.L.EACH ACCIDENT $500,000 A PROPRIETOR/PARTNER/EXECUTIVE N/A 08 WEC CN0740 06/26/2021 06/26/2022 OFFICER/MEMBER EXCLUDED, E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION Glenroy Burke SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13198 ROUTE 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED SOUTH YARMOUTH MA 02664 IN 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