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Home My WebLink AboutApplication 1 . TOWN OF YARMOUTH BOARD OF HEALTH (i— i APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by Decem r 5 NOTE:ALLBLTS. rSESWITHLI(!L'OINK,LIC;�NSESMUSTRETL'RIV ER15°: P.a.ro to Al en 1,1,7;11 I.. ♦ :rt.—.....,1: i,...... ,.L,,. ESTABLISHMENT NAME: Tha Panrakp Man TAX ID: LOCATION ADDRESS: 952 Route 28 South Yarmouth,MA 02664 TEL.#:508-398-9532 MAILING ADDRESS: 952 Route 28 South Yarmouth,MA 02664 DDRESS: managerlgpancakeman.com i E-MAILIL 1 OWNER NAME: The Pancake Man.Ltd. CORPORATION NAME(IF APPLICABLE): The Pancake Man,LTD MANAGER'S NAME: Marchall P Farhy TEL.#: 508-398-9532 MAILING ADDRESS: P 0 Box 537 Hyannis Port,MA 02647 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operators)and attach a copy of the certification to this form. 1. Pool operators must list a minimum of two employees currently certified in etandard Pint Aid and ClAmmnnity -ri f Cardiopulmonary Resuscita t on crK - -- -'i C� ),ha vmg one cerhhed employee on premises at all times. Please list the :y [! employees below and attach copies of their certifications to this form.The Health Department will not use pasty a' years'records. You must provide new copies and maintain a file at your place of business. ' 1. - ---.. G. 3. 2. .a� U 4. ruuu mu i>✓t:t IUN MANAUtKS-CEIQ WJCA I IONS: 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 a d tarn a file at your estab• , en r 1. c L e cc.t S 001 ttv L( 2. Q rG4. �t4 n,tJl ;, PERSON IN CHARGE: establishment must Mr at east one Person In Charge(PIC)on 'te durin hours of operation. 10� rcA- ALLERGEN CERTIFICATIONS: All fond cPrvier octahlichmante aro rormi.w,i to ha.,o a+!".,et,,.,e F,11+ ,,.....i.....e,...1.,,1.,.,. A lt.,- as defined in the State Sanitary Code for Food Service Establishments, - 105 CMR 590.009(Gx3xa). Please attach '—"- copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and ma_.m� p fill at your establishment. 1. , , �.0 C [1t. 0,t4.4.7 2. HEIMLICH CER I llgCATIONS: tLl tuuUu aCt Vn:G Caapi lainnenne with 25 sears or more must nave at least one employee trained m 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 nst provide new co,pier anl maintain a file at your place of business. 1. c 2. le,C24 kr Lt-t t^'^s tsr 3. (:.).`\'\v\ l 1.10+61e,t V't& 4. S4, ,S ittb1AUKAN1 StsA1Mr: IO1'AL# A J ecikIf-ly-lcs346,-, LODGING: OFFICE USE ONLY LB&BICENSE REQUIRED FLEE PERMITS LICENSEREQUIRED 5 CABIN $55 FEE PERMITS LICENSE REQUIRED FEE PERMITS =LODGE $55 MOTEL $110 $105CAMP 5WHISRLPOOL POOLIMMING�L$1110ea =TRAII.Fdt PARK LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMITS LICENSE REWIRED FEE PERMITS 0-100 SEATS $125 CONTINENTAL $35 Q =>I 00 SEATSWHOLESALE $30 ._(_COMMON VIC. $60 �� _WHOLESALE SSO RETAIL SERVICE: —REBID.KITCHEN$80 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS A50 ..ft. $50 >25,000 R $285 VENDING-FOOD$25 —<25,4 4 4 sq.$ S150 _FROZEN DESSERT$40 TOBACCO $110 NAME(MANGE: $15 AMOUNT DUE = S 260.00 _ I PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** riLlrlilI AC,lam 1iVa, 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 ATIACHEI) 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: yFe Nn MOTELS AND O I'HRR 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 aanaron!rafar to nnntinarma neramonev of not me-we than thirty('ifll Anne and an aoore..Oatp of not more than ninety(90l 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.640 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 Npalth rlepartment prior to onenino. C.nntact the Health Department to schedule the inspection three(3)days nrlor 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 obb. at the Health Department,or from the Town's website at www.yarmouth.ma.us under Heald: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 H ealth terms Department Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the aboveOUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. nirrnruiQ r nnurntr__. 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 REQUIREDFEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT,;MO /111L OR POOL (i.e., PAINTING, NEW PAT UIPMENr RTC`) MUST RF.RRPORTF.n TO ANn APPROVFifj RY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUAD -PIAN. UA l E: 11/9/2014 SIGNATURE: PRINT NAME& 111"LE: Marshall P Fa j Manager Rev.1e/23/18