HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee
ic.' Town of Yarmouth $185.00
Food Establishment License
Number: BOHF-14-0302-07 Issue Date: 1/1/2021
Mailing Address: Location Address:
RYAN FAMILY AMUSEMENTS INC. 1067 ROUTE 28
RYAN FAMILY AMUSEMENTS SOUTH YARMOUTH. MA 02664
116 WATERHOUSE ROAD
BOURNE, MA 02532
IS HEREBY GRANTED A 2021 LICENSE
TO OPERATE:
Food Service; Common Victualler
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Conditions
SEATING: 20
Board Hillard Boskey,M.D., Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
1111
* .
Bruce G. Murphy, MPH, '.S., CH•'/M ory R. Langler, R.S.
Health Director/Assistant Health Director
F: """ TOWN OF YARMOUTH BOARD OF HEALTH
OF Y .
f 461\ APPLICATION FOR LICENSE/PERMIT - 2021
* Please complete form and attach all necessary documents by December 18, 2020.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: 121itii jralI` 7 iii-i""f F4'""'' s TAX ID:
LOCATION ADDRESS: /0429 Xi- 1S' TEL.#: So I-761-15'4,4'
MAILING ADDRESS:km-xi F4��i,11td/r j#' f I.& e-✓gkkitr gd. 73 ag,),LA. !ofd
E-MAIL ADDRESS: rem 4 loe ai Cdw /VAC/— _
OWNER NAME: Pr-ret !i/a aFvi—
CORPORATION NAME (IF APPLICABLE):/ ' -Y ltd R/ 1). 2-14e-'
MANAGER'S NAME: ? 4 G°/a,s/ t,- TEL.#: S-a---3.,‘-79 ra
MAILING ADDRESS: lt1. 4/i rKe 0e 4,t % .0640-4 ,40- a2-5-302-
i
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. DEC 2 2 2020
1. 2. -'•tTI.
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. Pear at(1 2
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. (t1 Cpolt4(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
provide new copies and maintain a file at your establishment.
1. Vtite CRt I 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. Pt14( ('extlbt i1 2.
3. 4.
RESTAURANT SEATING: TOTAL # Z'.
OFFICE USE ONLY
LODGING: •
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
.". .� .n,_, —r1.11 Y cc k.1!VT CI ,r l I/1
The Commonwealth of Massachusetts
Department of Industrial Accidents
II t
Office of Investigations
1 Congress Street, Suite 100
moi•i�
• --�•— Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly_
Business/Organization Name:_/l/�-A' f44 "$
Address: `/t' 4/A-774/01-- JE ;21)
City/State/Zip: /3y_"/2 vim /0#- 02 Phone #: ,S t7S4—6'—`141,
Are you an employer? Check the appropriate box: Business Type (required):
1.Z I am a employer with [ 00 'remployees (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. 17 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.❑ Health Care
4.7 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.17 Other
`Any applicant that checks box 41 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.
Insurance Company Name: 4 4., 6-v,/t0 j- v.Q lfrei Co '7
Insurer's Address: Oa.(/. (/� C� 3 l P / /( c 4/t lkej - a7re /0d Z g d
City/State/Zip:
Policy # or Self-ins. Lic. # IQ yhiC-10l 702 c(y Expiration Date: ` l5/4e
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 5250.00 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 certif, under the pain d pen ies of perjury that the information provided above is ue and correct.
Sig-nature: � yDate:
5
Phone #: bit iv f'`5 �'y
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 #:
0.e to
.,,yy���iii Al t„a� � •n(� •�,i�;= �r,., _;h n 1P �Y�' ii yy,./...C.f Li pit
iC,.` •��C ���..i ,j�.�`ri►� t',l.ilm....} iw, : t i yAN.:, 7 -n ; A.i( Wt/ 7 '
''' � C../J C`�� j ` C' �, G\.fib. 12,
• f
14 :
e.71,1
.,c)-
� � aaaEi � iiiiill
,645f.
ma F4 Nz
p:ii ea '
Cilit) xs
to A
'1' ..:4y
.2
4..;CI.
, wA i 1'.
z n- -
E•,7 o
,, n z
Fes, S17-74.
�� o �. ,�'ttiliril
efJ a, C)`''')oa 'a' CD p S 5
Q a eQ p' L__IP: _�
y 711 ' rrJ' Q ra _
lc+,• b a *4 e `t3 Z ‘I'?"5'n
i>.
,_F�? �: pZ,
/may
cn cn m « •�=,
r-iii Mil
n . 4 .
)4 rs, NJ cn
KZAWN Z1
-o r
AV5 w m tailL___..i> 'v.
't:.,
c c b
C W Cf”Po
i
711,
o O G
` C+.b p p V Er ‘1"WJQ
i4)7 A t'
e.
FjVE.
r5 a a
b pp
M♦. M VAN 4`:
1 co Wim ?
.,1.°
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 I-lealth 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 he 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_iuspected-by the l legal-th-Depo tment-prior-to opening:Ptea e tontaet ttie 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 l-lealth 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
Tut; ormiTD1 FTFTI R FNMA/A T APP! ICATTnN(SI ANn R POI llR RD FFF(S'I RY DFCF.MRER I R. 2020.
Worker's Compensation and Employer's Liability Policy
"�/Berkshire Hathaway AmGUARD Insurance Company - A StockCo.
�!%, Y Policy Number RYWC017284
Insurance
rance Renewal of RYWC995289
GU
,• �- Companies NCCI No. [21873]
Policy Information Page
[1]Named Insured and MailingAddress Agency
Ryan Family Amusements Inc MACKINAW UNDERWRITERS INC.
DBA/TA Ten Pin Eatery 10 NEW ENGLAND BUS CTR
116 Waterhouse Road SUITE 110
Bourne, MA 02532-3867 Andover, MA 01810
Agency Code: MATPAA10
Federal Employer's ID 04-3541210 Insured is Corporation
Risk ID Number 917565287
Additional Names of Insured
(N2) 769 Iyannough, Inc.
(N3) Ten Pin Eatery
Locations on Policy - See Extension of Information Page - Schedule of Locations
Policy Period
From December 31, 2019 to December 31, 2020, 12:01 AM, standard time at the insured's mailing
address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts, Rhode Island
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident -each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 33,654
Total Surcharges/Assessments $ $1,133.00
Total Estimated Cost $ $34,787.00
I NTERNAL USE xx Page - 1 - Information Page
MGA : RYWC017284 WC 000001A
Date : 11/26/2019
MANOTE
Issuing Office: P.O. Box A-H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com
A Worker's Compensation and Emolover's Liability Policy
AmGUARD Insurance Company - A StockCo.
-/ Berkshire Hathaway Policy Number RYWC017284
a* GUARD Insunce
Compranies RenewalNCCI No.0 218739
Policy Information Page
Extension of Information Page
Schedule of Locations
(L2) 200 Main Street , Buzzards Bay, MA 02532 (12/31/2019 -12/31/2020)
(L3) 441 Main Street , Hyannis, MA 02601 (12/31/2019 - 12/31/2020)
(L4) 1067 Rte 28 , South Yarmouth, MA 02664 (12/31/2019 - 12/31/2020)
(L5) 115 New State Hwy , Raynham, MA 02767 (12/31/2019 -12/31/2020)
(L6) 1170 Main Street , Millis, MA 02054 (12/31/2019 - 12/31/2020)
(L8) 23 Town Hall Sq. , Falmouth, MA 02540 (12/31/2019 -12/31/2020)
(L9) 19 Circuit Ave , Oak Bluffs, MA 02557 (12/31/2019 - 12/31/2020)
(L10) 268 Thames St , Newport, RI 02840 (12/31/2019 - 12/31/2020)
(L11) 769 Iyannough Rd , Hyannis, MA 02601-5027 (12/31/2019 - 12/31/2020)
(L12) Cape Cod Inflatable Park, 512 Route 28 , Yarmouth, MA 02664 (12/31/2019 - 12/31/2020)
(L13) Cape Codder Resort, 1225 Iyannough Road , Hyannis, MA 02601 (12/31/2019 - 12/31/2020)
(L14) 136 Water St , Plymouth, MA 02360-8727 (12/31/2019 - 12/31/2020)
(L15) 769 Iyannough Rd Cape Cod Mall, Hyannis, MA 02601-5027 (12/31/2019 - 12/31/2020)
INTERNAL USE XX Page - 2 - Information Page
MGA : RY 84 WC 000001A
Date : 11/26/20126/201 9
MANOTE
Issuing Office: P.O. Box A-H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com
XFINITY Connect Forgot this one Printout hltps://connectxfinity.com/appsuite/v=7.8.2-15.20161130.042044/p:
Yarmouth <rfayarmouth@comcast.net>
12/7/2016 10:27 AM
Forgot this one
To rfaaccounting@comcast.net
e max, — ..
Ps — __
ac�,n t.
i10• 1;.10
i',, fit .,.r��N+
:
., ,4 , �
Yr
▪ r:r t�. µms ,k'aypv
1 .
, y
�, �.�73` 3+�r .�frxl T(
.§
4 � a
.� om
-...,..-.,•,...._4.,,Ire f
i r
a ;4t a i
�r r r
a i -...''''' ''.&',':',. :::
.�, „a
e t
•
f E a� -,-•••:,•;,;1•••4:t.,... 9'9t;T' S r a k
.:-.1':'
, t ib „r t � f .4 a t 7-.+1^ • 1 6',.' a , '
k - w. t:� r uv' -'..;
1' t 1 1 . i jdtr + y '� Y 1
�w
'1}F ,F{ry 1 + �y 1 t f �et
�� ♦ � M9 .7" �,•�rf•��n tiE } �. i.a •1 LN��'�{ *Y E'�
i t
t
ill4d�;'T ti.' I _ .
't''.(;-;.,.''';'-,.2- ;-
4 - - ;'.'.1f,:: ,
P'
• tr 1 J l r 1 Yt:.�
t � _
1 �:
1.▪ ''.,:''''.:1'''''.."':-.:'
_,t q ' L 1.. 1
• v
�OFOOO J NATIONAL REGISTRY OF
ti4 ��� FOOD SAFETY PROFESSIONALS®
card
' O
y rteiuri CERTIFIES
±" PETER CAMPBELL
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
°� FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT: 11..;°P 4,00‘,.......
AP
LAWRENCE J. LYNCH,CAE
ANSI ,t
i ,
ISSUE DATE:JUNE 17, 2019
ACCREDITED PROGRAM EXPIRATION DATE:JUNE 17,2024
Amman Standards Imututa
°°dlneD°"r°'°n<°'"Food"°�"w' CERTIFICATE No:21596545
>arst,
TEST FORM:EXE81
6751 Forum Drive,Suite 220,Orlando,FL 32821
P(800)446-0257 F(407)352-3603 www.NRFSP.con1 This certificate is not valid for more
than five years from date of issue.
National Registry of Food Safety Professionals'
`�°FEcnn'r'��� National Registry ofFood Safety Profession
Notification of Test Results CERTIFIED FOOD SAFETY MANAGE.
ti
# o
ID#: xxx-xx-
Scaled Test Score: 90 IP
�tr,„.I;yp,ntsa PETER CAMPBELL
Candidate Status: Pass
Test Date: June 17, 2019
6:31 Forum Drive
Suits 220
Orlando,Fl.32821 --
Toll Free(800)446-0257 Certificate No:21596545
Phone(407)352.3830 Issue Date:June,17,2019
Fa:(+D7)3szaens Expiration Date:June 17,2024
www,NRPSP.cuuI
Congratulations!Attached is your certificate and wallet card.Please notify PETER CAMPBELL
the National Registry of name or address changes at the address below.
1067 ROUTE 28
S YARMOUTH, MA 02664
Preventing Contamination and Cross Contamination(Mastered)
Ensuring Personal Hygiene and Employee Health(Competent)
Actively Managing Controls in a Food Establishment(Competent)
Monitoring the Flow of Foods(Mastered)
Ensuring Product Time and Temperature(Mastered)
Conducting Cleaning and Sanitizing(Mastered) •
Managing:Physical Facility Design&Maintenance:Preventing&Controlling Pests(Competent)
National Registry of Food Safety Professionals® i 6751 Forum Drive Ste 220 i Orlando,FL 32821 i Phone:407 352.3830 I Fax 407 352.3603
N
D
U
04
I
Q
0
N
M
N
N
c
Q
= enu_
ct
E
o
0 C
IMO L m
a
Cite row -1-
M
0 I • Z
(' W
mime
M in
� (DQ.
Fa Pe ) t.
aL o ?> OV
N 7.e .
oo a
C 4 O oc..y
a
E O E - s a
8 a p U O N ea
Ec- €s
Q r-+
XE
E
1 = = 0 a
c o — € I
0
c N
r 4- rrk` Q L F C u 44 cn
ci 0 M� ( , C3 tr LUCCO
a) c ?+ ad
t O N
Vey' (� L ^^t �' ! chi o
VV In- U >1 v' V 0
ITS
`'= u N N4.• o
• _ ah g 73. it
N � x
g 1 �, N i U L
IZt CA v t .. c _g 06
IaS
n
a o
ti v x
L > '� v a o
Cue .0 o
v ~
L ;.)
s r
Tialle
L 48 E-
O M 6 lCare CI _
U U
r N c3 N H v w
T . ui>�l 0
e a
-- "O I " m
ci
c X05 �� o
N � _ �
= in
it,G U
a
a)
r
a)
U
o
O ai
N -U
O L
N
N N
N a
L