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HomeMy WebLinkAbout2022 App-License-Certificatoin The Commonwealth of Massachusetts Fee /..' Town of Yarmouth $185.00 Food Establishment License Number: BOHF-18-1307-04 Issue Date: 1/1/2022 Mailing Address: Location Address: DAYBOARD, INC. 168 ROUTE 6A THE INN AT YARMOUTH PORT YARMOUTH PORT. MA 02675 168 ROUTE 6A YARMOUTHPORT, MA 02675 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: 10 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston / /,/ ) ,r7... .� ), Bruce G. Murphy, ., HO/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-18-1307-04 Issue Date: 1/1/2022 Mailing Address: Location Address: DAYBOARD, INC. 168 ROUTE 6A THE BLUSHING OYSTER B & B YARMOUTH PORT. MA 02675 168 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 10 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, .S., O/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth so.00 Lodging License Number: BOHL-18-1305-04 Issue Date: 1/1/2022 Mailing Address: Location Address: DAYBOARD, INC. 168 ROUTE 6A THE INN AT YARMOUTH PORT YARMOUTH PORT. MA 02675 168 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Bed and Breakfast This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions NUMBER OF UNITS: First Floor- 1 Bedroom; Second Floor- 4 Bedrooms Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston uce G. Murphy, MPH, R. , CH /James G. Gardiner Health Director/Assistant Health Director .....� -- TOWN OF YARMOUTH BOARD OF HEALTH DEC 13 2021 E� ►' °' APPLICATION FOR LICENSE/PERMIT -2022 HEALTH DEPT * Please complete form and attach all necessary documents by D Lr.nber 18, 2021-. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME:-7/74e "AJAU 14 T r i voi---h Po/`TAX ID: ` a - 305 3705 LOCATION ADDRESS://PS---/go L'7F10- 7rirEL.#: BO - 7,74 /-7 5/(,7, MAILING ADDRESS: c$ 4`K:sz 5 Q b IV E-MAIL ADDRESS:fr/q, 5O i G,i k ) OWNER NAME: /,A/.'eiiJ r s do Doe,'' CORPORATION NAME (IF APPLICABLE):,D, y6 �/ //I `G- MANAGER'S NAME cI f 2/p eA) 4L.t TEL.#: to/ 7/0 33/W MAILING ADDRESS:/y,k,4-5,,A, lv,�¢ raf 4 tA� �rh tz-T 44,4 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 place of business. 1. _ 2. 3. 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. I. ? � /lf- '-/' l - '/G ! �' -A!_ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. Ae. f' 4), /t{ rSO N .b cz-L-/ 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 a file at your establishment. / 1. arm r' �1; ' K5o 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# 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 $1 l0ea. FOOD SERVICE: L NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I7-100 SEATS $125 COMMON $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 CHANGE: $15 AMOUNT DUE = $ I l/ *****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 COMPL TED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid p •or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES V 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: I oZfq SIGNATURE. Ckzkge"e-- k4..s--Qyl D PRINT NAME & TITLE: ICON Rev. 10/15/19 The Commonwealth of Massachusetts . {= --- Department of Industrial Accidents • ' _it: _ 1_ ."4" Office of Investigations `r' ; ' 1 Congress Street, Suite 100 DEC ;g 201 ='�_!— Boston, MA 02114-2017 �``. ""`, www.mass gov/dia H TH DEPT, Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 7")c-t,c, i 2 ,,--6-(, /4,;-C,: Address: / (�' .� �v 7`- -� ,� ' City/State/Zip: Cl,>-i���� �,y?� �1 «?` Phone #: 1��-- �f`f %. Are you an employer?Check the appropriate box: Business Type(required): 1.A I am a employer with _; employees(full and/ 5. 0 Retail 2.❑ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 1--1 �^ ,:�� employees working for me in any capacity.. '—� Office and/or Saks����.1. real estate,auto, etc.) [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, 11•❑ Health Care with no employees. [No workers' comp. insurance req.] I2.EI Other Sep-,'- ;e F"4; c �-c, -Aj A.' *Any applicant that checks box ill 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#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: /'L), )//"—. f z i/ i ./1; /r'/2 ���/1 , Insurer's Address: , :. 1',/,1i' , fi City/State/Zip: .�y -'C /-,1C.f. 0725 ,4v/4 ( ,- Policy#or Self-ins. Lic. # \rV/T /,�` e', ci-- ' 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$1.500.00 and/or one-year imprisonment,Ilf well s 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 cert fy,under the pains and penalties of perjury that the information provided above is true and correct. Signatur. /iU�� i-�, I/ �� ���� . Date: ho #• r>S'-- / -- J r - 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#: www.mass.gov/dia as ServSa' fe National Restaurant Association ServSafe® CERTIFICATION KATHLEEN LARSON DAY for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection(CFP). 853758 10555 TIFICAT . UMBER EXAM FORM NUMBER 12/11/2017 12/11/2022 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply. Check with your local regulatory" ency for recertification requirements. 2 ACCREDITED PROGRAM Sherman Brown American National Stanmrda!metne SVP, National Restaurant Association Solutions N r_ ` and the Conference for Food Proteco]n Fri _0 13.R'T�r�r� #0655 In accordance with Ma.time labour Convention 2006,Resolution ADM N 068-2013(Regulation 3.2,Standard A3.2). •�• •oi. ©201 5 Notional ':::uuralt Association Educational Foundation tNRAEFI.All rids reserved,SeevSofea and the 5ervS4 logo are trademarks of the NRA[F Nati..,•,' •want Association)and the arc design are trademarks of the National Restovrant Association t cannot be reprcduoed or altered. "', s•`•a 1 v.1401 Contact us with questions at 175 W Jadaon Blvd Ste 1500,Chicago,IL.60604 or ServSafeerestourant.org. r ir , r r r .1 rir , r r , k A l A � 1 T_ A �� i! rp , 1 1, k" 1 b. `v v 1 Y, v 1 Y. $ `v too rA Yr t r of iM wf OW wf fk wf f`r wf #, wf fM wf / \ J \ -I \ J N. J N... J J \ ' ' - :4G)) 1.‘;‘)1,- "' • , �} CERTIFICATE OF - y. � ., -.. ,c1/4 , 4-t��1 ALLERGEN AWARENESS TRAINING-6C.",,,2/ -� l4S I., Name of Recipient: KATHLEEN LARSON DAY 4,1 )41114 � ) Certificate Number: 3191804 k• A a" � Date of Completion: 12/15/2017 '� r �� Date of Expiration: 12/15/2022 �� rt � , 2 ) , F. -111," C"i 11 fts.'S r, Issued By: T.;;Crwa:1 -. The above-named person is hereby issued this certificate MHO NATIONA ' " for completing an allergen awareness training �� , g gRESTAURANT a � �� recognized by the Massachusetts Department of Public Health DOSIalinaM `moo"- ASSOCIATION„ A • in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 ;, ; 1 3" 333 Turnpike Road,Suite 102 www.restaurant.org yfC Southborough MA '% H" This certificate will be valid for five(5)years from date ofcompletion. 508 303,-990501772 c-r�i VI r ��� www.marestaurantassoc.org 4�h�„'f,;r, --i via +„-.. .- .Va==e ;,ice ,- , AL J 4 10 i , K . if Viy: Guts ACORC CERTIFICATE OF LIABILITY INSURANCE S DATE(MMIDDr'YYY) ‘,----- 12/06/2021 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 Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (NC,No,Ext): (NC,No): 973 lyannough Road E-MAIL treeves@doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Norfolk and Dedham Mutual Fire Ins Co 23965 INSURED INSURER B Dayboard,Inc,DBA:The Inn at Yarmouth Port INSURER C: 168 Route 6A INSURER D: INSURER E: Yarmouthport MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2112692411 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 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A R1801801A 01/12/2022 01/12/2023 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY PRQ LOC PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER: Innkeepers Liability $ 3,000 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) $ X UMBRELLALIAB — OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE BINDER 01/12/2022 01/12/2023 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N N/A WE183697A 01/12/2022 01/12/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1 000 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , , DESCRIPTION OF OPERATIONS I LOCATIONS I 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 endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended thecoverage 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 `'1r,�.�4--�` T-- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY----INFORMATION PAGE INSURER: POLICY NO: WE183697A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NpCI Company No: 21059 Acount No: DEC 1 3 2021 FLIN: 82-3053705 HEALTH DEPT. ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: DAYBOARD, INC. DOWLING & ONEIL INSURANCE 168 ROUTE 6A AGCY YARMOUTH PORT, MA 02675 PO BOX 1990 HYANNIS, MA 02601 AGENT NO.: 20762 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 01/12/2022 To: 01/12/2023 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 1 ,000,000 each accident Bodily Injury by Disease: $ 1,000,000 policy limit Bodily Injury by Disease: $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 226 Annual Premium: $ 888 Audit Period: p,NNUp,I, Additional I Return Premium: Comments : Issued At: Date: 12/03/2021 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance PRODUCER COPY