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Home My WebLink About2022 Licensing The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-17-3961-05 Issue Date: 1/1/2022 Mailing Address: Location Address: LA PLAYA INC. 416 ROUTE 28 EL MARIACHI WEST YARMOUTH, MA 02673 416 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: 117 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston P3-4- Bruce G. Mu hy, H, R.S., CHO H alth Director • TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2022 MAK t 'LU Z *Please complete form and attach all necessary documents by December 18 2/ 1. Failure to do so will result in the return ofyour application pac et. HEALTH DEPT. ESTABLISHMENT NAME: VI MQI1Gd11 MT)(l;)n 11t� t.'r(j14 TAX ID: LOCATION ADDRESS: Li Pe BJ i' VJ• *rr) k IYIA a2.b� TEL.#:SM6- -3l l o MAILING ADDRESS: H b * JR (P- 7 Or NlA Q'b13 E-MAIL ADDRESS: to 0 il( r(a ' t OWNER NAME: Plak,i(A0.7. CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: a nd TEL.#: sd%-z 4 j2% MAILING ADDRESS: eIv11h0Vpnco(pit cgtil I.Cj1rvl POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool noerator(s)and attach a copy of the certification to this form. 1. y 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. 1. kyliciq k1KTa 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 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 provii�dde\\new copies and maintain a file at your establishment. 1. tlUer(.Cll FlOte5 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. Dam d (oPe . 2. 3. 91 4. RESTAURANT SEATING: TOTAL# S 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 $l l0ea. FOOD SERVICE: LICENSE RE IQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 1 >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;00 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $1101 NAME CHANGE: $15 AMOUNT DUE = $ "G 0 " 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 p 'd 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.yannouth.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 m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: 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]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: 3-/1��2 SIGNATURE: PRINT NAME&TITLE: I)avt Logi Ou)OCti Rev.10/15/19 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents tt taL ' Office of Investigations C}= 1OVIU . h 5 ;�1 r 0 1 Congress Street, Suite 100 rl N i- 1 B 2022 1 �j, Boston,MA 02114-2017 `"•:i.- www.mass.gov/dia H EALTH DEPT. Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: CI MGVIQCI1 i `1M '� e qc ii4 Address: 1'1 b ,41*• ) City/State/Zip:A).y0lv1`noo t1 O )-3 Phone #: SOF< ` 4 - �i9-(4) e you an employer?Check the appropriate box: Business Type(required): 1. I am a employer with I 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] 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 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 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.i Insurance Company Name: W eS�,Q�Q I1�v R WC� Cojvt�m Insurer's Address: )SO(o � (W CtSCni C40r Sir, City/State/Zip: S pzyksuvz V!1 99°fib I Policy#or Self-ins. Lic.# \IV w (, 3S 4'ZS to 9 Expiration Date: " I S- 7-2- 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 certify,u • the pains and penalties of perjury that the information provided above is true and correct. / 3 Signature: Date: (%- 1'Z Phone#: 5 `ZS 2. - V 1 -tO 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 33/18/2822 88 : 36 From : 5093633917 Anderson Lampe, P3 Web£ax Page : 1/i Ad J MID CERTIFICATE OF LIABILITY INSURANCE DATE 1/23/2021 ITHIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOER NOT AFFIRMATIVELY oR NEOATIVEIYAMEND,EXTEND OR ALTER THE COVERAGE AFFORDED ISY THE POUCi a BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORUANT; If the certificate holder Is an ADDITIONAL INSURED,the polloy(Ies)must have ADDITIONAL.INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condtlons 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 endorstayont(s). PRODUCER .11u_ Debbie Klsponls Brow Bro &Brown of Masseohusetb,LLC 7rr , (791)455-0804 1W 980 Washington Sine .;';:_.. dldeponlsOrodmanins.corn Suke 325 NSUREISAPPOBOI NG cDsERAoe T NAIC e Dedham MA 02020 ElULR to Thin City Fire Insurance Company 29459 NSURSo INaI S• Wesco Insurance Company 25011 LaPlaya dba El Mariachi 8 Nogales Inc INS C: 150E N Washington Street INSURER D: _INSURER E:; Spokane WA 99201 IMF. I COVERAGES CERTIFICATE NUMBER: CL21112388826 R!1/iSION NUMBER; TNIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ADoVE FOR THE POLICY PERIQO INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NalCH THE CERTIFICATE MAY Be ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS. EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. l Tii. TYPE OF INNIWINCE rOupat WEto NW POLICY RUNNERamanJ:kmLWrrs K.COMMiwiciAL DAL LIASILITY EACH OCCURRENCE s 1,000 000 DAMAGE r'REmise3( e ea rrentel gams-mace 1,000,000 x Liquor Liability met)E (my one Ranson) 4 6,000 A OSSBMAD4757 08/18/2021 06/18/2022 PERSONAL 6ADYINJLRY t 1,000,000 SEM_AGGREGATE UM!APPLIES PEP GENERAL ACOREgaTE f 2,000,000 I POuCY I I JCCT E Loc PRODUCf5-oomprowADO $ 2.000,6°° OTHER _ AUTOMOEIL LWBILnY n:e AABietIS1NGLELIMIT _ aCN ANY AUTO EDGILY INJURY(Par parson) $ \ � OWNED �._._ SCHEDULED AUTOS ONLY AUTOS �BOOII.Y INJURY(Pm ecCldaN) I � H ON-OME NJTOS 0M Y NJTOS ONLVD (Per t f T $ LIMMILLA UAS OCL'LP EACH OCCURRENCE S WfctiTSUAa CLAIMSMAC6 AGGREGATE I 4 CEO I L RFENTION$ q� WORKERS COMPENSATION 1 I I ER AND EMPLOYERS'LIASN ITY ANY PROPRIETCK7/PARTNEFLEQJT yE �Y!N 500,000 B OFRCE]TmB.eERDca ER,F; I ' t NIA VONC35426E4 OBH512021 09/15/2022 E.L EACH ACCIDENT s pie".°ryin* E.L D5EA3E-EAEM'LOYEE $ 500,000 II yett,,4ac lt!yndw - DESCRIPTION OF OPERATIONS SOON` _ E L DISEASE-POLICY LIMIT $ 500," a rescoa'nON OF OPERATIONS/LOCATIONS 1 VOIICLOS(Mow soi,Adesattl Remake Sch mkie,meg be Ilataded Ir more apses Is reWlred) -- F.u MAR t 2022 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE ONCEISIIO POLICIES II CANCELLED IBPORu THE EXPIRATION DATE THEREOF,NOTICE WILL SG DGL1VI:Rib IN Town of West Yarmouth AOOORDANCU me e POLICY PROVISIONS. AUTIIDRIXFD REPRESENTATIVE . Wtst Yarmouth IAA ,� •.-- - J m 1988-2015ACORD CORPORATION. All rights reserved. ACORD 25(2018/03) The ACORD name and Togo we registered marks of ACORD TOIL-TIiil1 1Fd Tr:CZ iIZOZ-0C- Co G GJ i.a N a N NO w eo n 19 Certificate of C om Pietion American David Lopez , Red Cross has completed the requirements for Adult First Aid/CPI:AED NI . 'ai • E conducted by " - . American Red Cross �„•„ Date Completed: 12/20/2021 • 44:16:111 Valid Period: 2 Years j .,. 0 Certificate ID: OOQDENI Scan cod or visit: https://www.redcross.org/take-a-classicircode?cerf lumber*) OCIDEN1 0 1- 1,133.0YED hi/A i- 1 f3 2022 HEALTH DEPT. T #_ PA A w f .0; i . _ .ti -Neal �:.a. .:i...rr►+ ,may-2.. .... +A.a":,". iii r, "�" �"�' DJ., r` . 4 4 iii . a III ' ....,, I z n .. .- ..,,, i 0 ..,. a , , ..„-, 4 it L., •offi 72 '`i► • ini 4fal 3 t VW X VIM iIP 1 !'" tn • ., -�-, , 441M I ++ +R % i tr' r . t ervafe atone Res±aurant Association ServScife® CERTIFICATION ANGEL RIVERA for successfully completing the standards set forth for the ServSafee Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 20614181 5520 3 CERTIFICATE NUMBER EXAM FORM NUMBER z G cxt`l 5/21/2021 5/21/2026 p DATE OF EXAMINATION DATE OF EXPIRATION r.3 Local laws apply.Check with your local regulatory agency for recertification requirements. ANSI =_ ACCREDITED PROGRAM American National Standards Institute and the Cootereerce for Food Protection #0655 Shermai'Brown Executive Vice President,Notional Restaurant Association Solutions OMB p M accordance with Marine tabour CaavpAicn 2006,themtution ADM N 068-2013(Rsgulhton 3.2.Sbulord A3. - EXitit* Restaurant rd R' rory Assecie�on Bducotio Foundation RAEt)Al oglesoglesreserved.SueSals.and the mrks SereSofe logo are tader of the NRAEf.National Restaurant Association®and the arc design ore of the Nut JR$1 Re keeoro Aesocia8oa. This document comet be reproduced or altered. 17110E111 v.1711- Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,1L 60606-6383 or ServSafeeresiourant.arg. r -- TOWN OF YARMOUTH Board of C = Health 1 146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Telephone(508) 398-2231, ext. 1241 Health ;' Fax(508) 760-3472 Division April 8, 2022 El Mariachi Restaurant David Lopez 416 Route 28 West Yarmouth, MA 02673 Re: El Mariachi,416 Route 28,West Yarmouth Board of Health Hearing—Monday, May 2, 2022 at 6:30p.m. Mr. Lopez: Based on violations from the Food Establishment Inspections of December 13, 2021, February 14, 2022, March 15, 2022, and March 18, 2022 you are required to attend a Board of Health hearing on Monday May 2, 2022 at the Yarmouth Town Hall. Please plan to have the owner manger and Sery Safe personnel at the meeting to discuss the cleaning schedule . If you should have any questions or comments regarding the above matter, I can be reached at the Health Department at (508) 398-2231 ext. 1241. Sincerely, Bruce Murphy Health Director Cc: Board of Health