HomeMy WebLinkAboutApp, WC License & Certifications i h e Pav,ca'(.c )-14 1
•,, 'TOWN OF YARMOUTH BOARi) OF HEALTH
APPLICATION FOR LICENSE/PERMIT - 2021
. •.
* Please complete form and attach all necessary documents byccc
December Ih, 20211.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: TFt "['AX ID:
LOCATION ADDRESS: q lgc.,ut.Te; TEL.#:� g -3q
eMAV N Q ADDRESS: M..ALA crot ® pa+tc. kl Now c V'
ni,t�E�I A►(I.ADDRESS: �jj �o_c1 6 9- ka& r a 14 oa,- '^ D c`_y)
OWNER NAME:
CORPORATION NAMI (iF APPLICABLE):11 12�a,,>cgr, �( 4, L;f
MANAGER'S NAME: pra41{-/4 t L 1 A �•n5� TEL.#:SO 6-ago -i$7
MAILING ADDRESS: ►'•a 9215,c X3'7 [49 aA4t $ 176 r-1- 1M.A C3a-(.)er?
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 ofHtittess-.-- -- --
1. �.
3 4. MAR 31 2021
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments arc required to have at least one bill-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. ,P G, pa* C,4(3/A/v '-S 2. v CG Lc 573d/<5 66,
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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 tile at your establishment.
I. 1 % r t i S1`6.)Ic40-& —
HEiMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the 1-Icimlich
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.
I. D6g6,La,J./'� 0,0 $4'N/ 'S C�j
--� r� 4_�»q
3. Z., '114 V"A ",d _4. 54 )O Z
RESTAURANT SEATING: TOTAL # r!g
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED) FE+ PERMIT RM'II ii LICENSE RI?QtttRI 1) II I. PERMIT 11 i IC1'NSI�. REQI II RED ITE PERMIT-11-
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
AFF'IDAVI'T MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACI IED
Oil
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 I lotcl 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.E. c. 64G or 1530 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
I lealth Department prior to opening. Contact the I Icalth 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 he drained or covered within seven (7)clays of closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the I lealth Department prior to opening. Please contact the I lealth
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 he tested by a State certified lag prior to opening and monthly thereafter,with sample results submitted to
the I lealth 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 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 lood 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 l to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN
mut. orm ADI 1-rr1--) Di-NI MX/AI ATM)! 10AT►nnlrc1 ANit) RR(ltllt?I:fl Ft:t i Zi RV flifiIVIRFR I R 'mn
The Commonwealth of Massachusetts Fee
Town of Yarmouth $260.00
Food Establishment License
Number: BOHF-15-1034-06 Issue Date: 1/1/2021
Mailing Address: Location Address:
THE PANCAKE MAN, LTD. 952 ROUTE 28
THE PANCAKE MAN SOUTH YARMOUTH, MA 02664
952 ROUTE 28
SOUTH YARMOUTH, MA 02664
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: 165
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., HO/Mallory R. Langler, R.S.
Health Director/Assistant Health Director
The Commonwealth of Massachusetts
tt Department of Industrial Accidents
� 1_ y Office of Investigations
1 Congress Street, Suite 100
•
_mr
_;' Boston, MA 02114-2017
'=' z www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 111\ 1) A li C_A r, V V L
Address: "- S O -. )1 Ae.,Mb g‘.n-A O 9- b %,
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Business Type(required):
1.❑T I am a employer with = employees (full and/ 5. ❑ Retail
or part-time).* 6. [/Restaurant/Bar/Eating Establishment
2.I1 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]*
4.111We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ 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'i Qmpensation insurance for my employees. Below is the policy information.
Insurance Company Name: / rV j ► j, ; �; L r ri„(
Insurer's Address: 5 LI I 1-"I2 0 Ad r 3 a)? D
City/State/Zip: C.-)URL.--.1 .{b VJ , rV l 0 I D .9
Policy# or Self-ins. Lic. # V KiC 1 0 b4. d 1 k I I h Expiration Date: , /L)')
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, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: --/
Phone#: D � - C( Cl ti rl
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
1
- 'f RF IN r0T riil'iTIC fla tip,, IIT { }h,gi tP11 R4- r---
`= DATE(MM/DOtYYYY)
1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I
IBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHQRILeu
rIMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be enaorseo. IT OUDKVW4 I MANI w iwrurcii,bUUICb:i.. I
Na..-.fownrIc',I'd r.,-.'/tonne of the irr.,cf./lain roollcipg.may reouire an endorsement. A statement on this certificate does not confer rights to the
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PRODUCER CONTACT Martha Findlay
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HYANNIS MA 02601 IINSURER A: AIM MUTUAL INS CO 1 33758 l
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PANCAKE MAN LTD INSURER C: 1
I P C)BOX 148 1
INSURER E: I
tiYANNIJYt)P(1 mr, Ucv+I )Inwncn r.
COVERAGES CERTIFICATE NUMBER: 626972 REVISION NUMBER:
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I
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TYPE OF INSURANCE nrc'r wIm POLICY NUMBER ((MM/Do'v vv I LIMRs
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PREMISES(Ea occurrence] i S
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I IDESCRIPTION OF OPERATIONS below I _ •__• _
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I Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay
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IThis certificate of insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the I
ISearch tool at www.mass.govflwd/workers-compensation/iinvestigations/. I
t`FRTIFI:ATF HOLDER CANCELLATION
I
IISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I
n,r ;cvo.a47rnAr nA-rc •tucpertic NOTICE WIII FIE DELIVERED IN
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Town Of Yarmouth
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(')1985-2014 ACORD CORPORATION. All rights reserved.
ITHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES j
DM 11W TI41Q f"CDTICM`ATC AC 1►IQIIDAure r1ACC WAT r1 UICTITI ITC A f`Aa1TOAPT DCTWCCII TLC IQQIIIU/`_ 'MCI IDCD/C1 AIITNl1D17CR
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pRODuC� 508-771-3300 ( CT Martha J Findlay
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Olde Cape Cod insurance PNONe 508-771-3300 FAX 508-775-3821
Martha Findlay WC,Ra,EnI I FIX,Nom%
1300 Winter Street I Wee.martnarroccia.com
IHvannie_.MA 02501 I" - t
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HYannlsport.MA 02847 INSURER C:USURER 0; 111
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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.
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