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HomeMy WebLinkAboutApp-License-Certifications t►‘% \ of > ‘12%1O1 cH HOARD OF HE ♦I.TH DEC 15 2.021 u'PI It I lO\ FOR I.I(I \SE/PF RMI'T 2022 * t'ic isc O'mplete form and attach all necessary, documents by L •em'.! - l allure to do so ss ill result in the return of your application 'sae et I S l \141 itil1\if \ I \ 1\tl __L1\ Ii.) HALLET'S ST9I�E°- t.t_?t. ,` I I t i\ 1 I)I)E I ♦s 139 MAIN STREET 1_I I 508-362-3362 ♦t'411 1\t, 1 I)I)K l S s. YARMOUHTPORT MA I Al \iI 1I)i)t(f 5S Hallet02675n,yahoo.com ( )Vs \>>\t f CHARLES CLARK )f pi #t: \ f it )\ \ \\11 tl} APPI k \Rt I I ♦1 \\ \t tI K S \ \t{I \I \II IN( \I)I)ttt rOnt 1 LIONS: the poiil supersisor must he certified as a Pool Operator.as required Its State lass. Please list the designated Pool t)peratorts) and attach .1 ,,f the t.crtitication to this form Pool operators must list a minimum of trso emptorccs currently ‘ertiticd in standard first Aid and C'ummunits Cardiopulmonary m'nary Resuscitation IC PR).). having one certified employee on premises at all times. Please list the employee% heloss and attach copies of their certification. to this tOrn1 The Health Department ss ill nut use past years' records. You must pro.ide nest copies and maintain a file at your place of business. 4 t t tx)L) PRI Ji 1'C 'l'{t )\ MANAGE RS ( E:KTtI lt' I t()\` All food %err ice establishments arc required to have at Icast one full-time employee %sho i< certified as a I e►.rci Protection Manager. as defined in the State Sanitary Code for 1 ood Ser.ice Establishments. U)5 ( \li 590.()00, Please attach copies of ccrtiti..iticxt to this application. The Health Department sill not use past scars'records. uo must provide nest copies and maintain a file at sour establishment. CHARLES CLARK RSt i\ IS ( HAK(it I ,ich fixed establishment must hasc at least one Person In Charge (PIC) on site during hours of operation. 11 f t R(il \ ( 1-R I it l( l l lt)\S• All food very,ice establishments arc required to has at {cast one lull-time employ et%sho has Allergen certification. .is defined in the State Sanitary t ode for I tiod Sere ice I stahlishments, It){ CMR ic)t) O4f i(iN +)(aj. Please attach copies of certification to this application The Health Department sill not use past years' records. l ou must pros ide nes copitimmtirm a file at your establishment. IliI111ItIIClR 11-I( :1IIO\S \II food sers ice establishments ysith 25 seats or more must hare at least one cmploree trained in the Iiemtiich \lancuser on the premises at all times. Please list your employees trained in ant i-chol►ing procedures hefoss and attach copies olemplilyee certifications to this form The Heath Department swill not use past s ears' records. ti ou must provide nets copies and maintain a file at your place of business. 1(t sI \t tt \\ sl \ i1\te I() 1 \{ -- — - —�_ -- - -- -------.-- . OFFICE UST O\I.l i ifi/e,l\t. e! ±kl ie I P I I Liao 1 11t i '.ti1 kl i,i (lti t1 III I'I tt\tl I I I+ 1 \.1 Ri 4,11 fait{ }i t t"i 14\111 K" < \lit\ S<s %14 I Situ +•^ Vat' 104 ` *1\1'01\4, i'Iw ll!.-a lttt>+,i a<` Ni NH 11w, t1,mkt Pi4, a1itka t ►1iil►s1SKIt 1 . . ".sf RI t,'N"ill I1 I I I Pt 00111 1 gt 1 '.Si RI','4 Ikl 1► t t i' 1^} it' t ii I'\s.I RI<)I ikl 14 III Pi RSII i 0, I yts rl"� �� k7".l '.I \I,1Y S \t1\ i'ktlt It S,1►i, •I \to K'eit / ° i 1\ \It Shli ' I#+rt I \l I SAt) _RI •tl1 Rili Ill N Sao RI I sit st 11 It i ;e f ,tit fii t,i1 IRI 11 III 1'I-Ft'41i# _ it I \"F RI i)i 1141 11 III t'i KS-It t - I It t \s} kl i)t Ikt t) III Pt WWI +4 = it 54;i '' ,ptq K 1 \ili\,, • 11't ell S'a i 1,1 SS1 k i. .},►eu 14111+1r i r► SI I" \ra11 t It 1.1(.1 Ki" ,AMOUNT DI°F ' s $ 225.00L . ••'••ri 11st i t KS OS 1 k %iti t t»tI'I I I I (I I Ill 14 sin' OF F tiUSt ADMINISTRATION I 'nder Chapter 152.Section 25('.Subsection O.the I ow n of Yarmouth is no% required to hold issuance or renes%al of ans license or permit to operate a business if.a person or compan does not hate a (certificate of %orker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MIST BE COMPLETED AND SIGNED.OR ( FR I . OF ISM'RAM F. .\I I a('HI 1) X OR NORKFR'S( ONIP. AFFIDAVIT SI(i\I-1):1\I):\1 1 •1(•III I) X I otcn oI 1 anllouth taxes and liens must be paid prior to renosal or issuance of your permits. 1'I F \tit ('I IR K : }'I'ROPRIA I U.l• II- PAID: 1't ti x \() MOTELS AND OTHER IA)DCIN(: ESTABLISHMENTS TRANSIENT(K (•l'PAV('%: I or purposes of the limitations of Motel or!bold use. I ransicnt 4ic upanc% skill he limited to the temp►►rars and short terns o ceupalc%.ordinard and customarily associated sy ith motel and hotel use transient occupants must base and he able in demonstrate that the maintain a principal place of residence elsewhere Transient oo;cupane shall eenerall% refer(o conlinu ous.ecupa1k% of not more than Ihui 1 WI Jays.and an aggregate of not more than ninety 10111 day s %ynhul ems sit Ibt month period. I se of a guest unit as a residence or dwelling unit shall not he considered transient. (Iccupancs that is subject to the collection of K000n(kcupanc} I seise. as defined in \1(i I c. MG or X111(•\1K MG. as .upended .hall i'cnerall% he considered transient POOLS POOL OPENING: \II ssslmnuni. %%ading and whirlpools which tare been dosed for the season must he inspected In the I lealth lkparnnent prior to ►►peeing (-ontact the Ilealth Department to schedule the inspection three 1.11 doss prior to opening. I'l I Ns! Si II I.. People are \(►I allowed to sit in the pool.area until the pool has been inspected and opened I'001.N.%TER TESTING: I he%s.ucr must he tested for pscudonu►nas.total cohlonn and standard plate count h% a State ertificd lab. and submitted to the I le.dth Department three I J 1 days poor to opening. and qu.u1erls thercatter 14N11.(.1.0SI\(.: I see% outdoor in ground sw1111111111g pool must he drained or cosered within sewn 1"t sass of closing. FOOD SERVICE SE•AS(1\\L FOOD SERVICE OPENING: All towed sets Ile est.lhli.hments must he inspected In the Health IN pa: ment prior to opcain flease cowu.ict the Health I k partment to schedule the mspeetidwi three 1 1 doss prior to opening ( ATERI\(. \pyrite who eaters within the Iowa of 1•.11111o►uth must notify the 1 anni uth Health Ikpartment h% tilin• the required Temp►rar% Ford Senile \pplication form hours prior to the catered et cm I Ikse forms can he obtained at the Health l)epanment.or from the Io►yns wchsne at wwss.3arnu►rnh ma us under Ilealth Ikpanment. 1)ownbsidahle I irnls FROZEN DESSERTS: I roicn A...4m.must he tested in a state certified I.rh prow it,opening and monthly thereafter. with.supple results suhnntted to the Ilealth Ikp.rtnient I ail WV to do so %sill result in the suspension or res►kantin of sour I well I ks•ert vomit until the .dory e terms has e been met ()I TS111F ('AFt:s: I lntside tales dose..outdoor seating with waiter wattres• smite t. must hate prior approval from the Braid of Health Ol I INNIR U(N)KING: 1 hitdd►or kooknt_. preparation or display of am tool pnrluel tin a ret.al or ford see ice establishment is prohibited TOBACCO PROM'CT PERMIT('.\P \ hwhawk permit h►'Ider \ill ° has tailed Io renew his or her permit tt ithin thins 1 days ..t the plc%i,'us s ear's permit e\piration date is considered an expired license. and the tobacco license cap is reduced. \O 11('F: Permits run annually from January I to December t I 11 IS 1 OI R RESPONSIBII.IT1 11►1I I t R\ I III ( (I\II'I I 11.1) RI \I % \I \PI'I I( 1l ION S1 \\I) RI (11 !RI Di 1 l iso nil 1)1 ( I ♦Im K Ix. ,11'11 11 I RI \IA \ II()\S II) •1\\ IIMIt) I SI \I3I ISII\11 \I . \I0I1 I I►K 1'1►1►1 tie '\I\ II\( \I V. I ()1 ll'\II \1. I I( I. S11 s l Iil RI I'1►R I I I) TI) •\\I) \1'I'R(IV ) 1111 tit I (II III 11 III PRIOR I(► ( (I\I\IF\( -\11 I RI \(►\ \I I()\S \1 \1 RI " ' I 111II / Shi\ \11 RI : PR I\1 \ \\11 11111 ONWER CHARLES CLARK The Commonwealth of Massachusetts Fee Town of Yarmouth $225.00 Food Establishment License Number: BOHF-15-1310-07 Issue Date: 1/1/2022 Mailing Address: Location Address: HALLET'S STORE 139 ROUTE 6A UNIT 2 139 ROUTE 6A YARMOUTH PORT, MA 02675 YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Frozen Dessert Manufacturer; 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: Soda Fountain -5 Downstairs- 13 Upstairs-11 *Restriction: Use of upstairs limited to ten (10) events per year. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston &C4 ) ( Bruce G. Murp y, H, R.S.,CHO Health Director jr. in I. �y sty S / \ J J / ^^'7If `� - l to ���� CERTIFICATE OF Q<.; . . .t, ALLERGEN AWARENESS TRAINING . Name of Recipient: (*WLESCLARK .•.7 i��= 4. Certificate Number: 3310109 � )i, u. Gr `' 'n i: Date of Completion: 3118=19 C"" - Date of Expiration: 3/18/2023 C'S ..,:2, n el- Issued Ey: Yc, The above-named person is hereby issued this certificate \— fI' for completing an allergen awareness training program del---hillig, RESTAURANATIONAL NT recognized by the Massachusetts Department of Public Health ASSOCIATION aSt_7k((( in accordance with 105 CMR 590009(G)(3)(a). Massachusetts Restaurant Association 800.7652122 , -4.7.,•JV 333 Turnpike Road,Suite 102 www.estaurant.org C.C+i n This certificate .f°r.�'e(cate will be valid 5 rom date ..completion. Southborough,MA 01772 n' .� �yearsf of comp 508-303-9905 'e) www.marestaurantassoc.org (='t ., qi ..6-- ,,clef G� ..C1c6'C\7.Cle�'6—\7.C1c7Clc7:G�7.Cl G\7.Cle�,. ,tlit u 1t u 7 u - ^ , . '� u ." n, '- v T' ' u 'a'+ ''. u r� A� r h r rc. + ''...,-Au,-.."' � r�. 15 r � r �+ a��c s t > t > t 7 ' 70 ' "4.1") • ServSafe CERTIFICATION ' ark Hare: ' 3 ,�4 Expires 3119120 , ' coo 11111111111111, 2 1 S'+morn!Rer.:as.rcant Assucr,.tcnr. raucatarm 1"csuretaUar iNIR E1 t At nghts ritscarme Sep/Safe 1.. ServSate a rag uwac tracasm rk'the NFAEf,4:104 urtzktr Its am as ay Nabratal Restaurant Assorant*ors Salt crs: U.C The k qc. r rime la Stsfe ti a +,:ir,r•ric cf"amsationatl Rams.aurart As:ioot trrr Local laws apply. Check with your lot regu atory agency for certification -�7�.�7� 0 requirements. 0, ..11.r•p • i a � a i-�j� • ]�7� 4 • ce. . ifs. ■ . i .. .,,,a/ r, +al..r srlw,,fffir..:,,a.. ".+.1•$i The Commonwealth of Massachusetts Department of Industrial Accidents . 4 Office of Investigations 1 Congress Street,Suite 100 It Boston,MA 02114-2017 = ° 4 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: HALLETS STORE D Il A CHARLES CLARK Address: 139 MAIN STREET City/State/Zip: YARMOUTHPORT MA.02675 Phone#:__ 508 362-3362 Are you an employer?Check the appropriate box: Business Type(required): I 1.❑ I am a employer with employees(fi'11 and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(ine),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. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 4.0 We are a non-profit organization,staffed by volunteers, MO Hea'`h Carc 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 "If te corporate onicers nave exempted themselves,but the corporation has other employees,a workers'compensation policy if equited and such an 'rganirarion should chxs box wt. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: LOVEQUIST-MURRAY INS AGY INC Insurer's Address. 296 MAIN ST City/State/Zip: WESR DENNIS MA.02670-0038 Policy#or Self-ins.Lic.# SBP 1065339 Expiration Date: 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 S 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 S250.00 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 verificatio, . .50 I do hereby certify,under, Bury that the information providedJ above is true and correct. Signature: .,—/7-' r Date: /2////./ Phone#: 508-362-3362 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#: u u-v.Ma SS.so•;/dia CERTIFICATE OF LIABILITY INSURANCE r A�O DATE(MM/DD/YYYY)I 12/13/2021 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 Catherine Murray CIC NAME: The Oceanside Insurance Group PHONE (508)398-2282 FAX (508)760-2211 (A/C,No,Ext): (A/C,No): E-MAIL catherine@oceansideinsurance.com ADDRESS: PO Box 38 INSURER(S)AFFORDING COVERAGE NAIC# West Dennis MA 02670 INSURER A: Cambridge 19771 INSURED INSURER B CHARLES CLARK INSURER C: 139 MAIN ST INSURER D INSURER E: YARMOUTHPORT MA 02675-1713 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21121308749 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 ADDL-SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREM S SO(EaENTED r n occcurce) $ 50,000 MED EXP(Any one person) $ 5,000 A SBP1065339 12/13/2021 12/13/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 1,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: CYBR $ 100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. 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 Attn: Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S.Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD