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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-17-0628-05 Issue Date: 1/1/2022 Mailing Address: Location Address: CAPTAIN PARKER'S PUB, INC. 668 ROUTE 28 CAPTAIN PARKER'S PUB WEST YARMOUTH, MA 02673 668 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: 130 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston . Bruce G. Murphy,MPH '. , 0 Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $260.00 Food Establishment License Number: BOHF-17-0628-05 Issue Date: 1/1/2021 Mailing Address: Location Address: CAPTAIN PARKER'S PUB, INC. 668 ROUTE 28 CAPTAIN PARKER'S PUB WEST YARMOUTH. MA 02673 668 ROUTE 28 WEST YARMOUTH, MA 02673 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: 130 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 Health Director ACRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `I 11/18/2021 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 Joseph Dupuis McShea Insurance Agency, Inc (A/c.No.Ext): (508)420-9011 FAX ,No): (508)420-9010 1645 Falmouth Road, Rt 28 BLDG D AIL ADDRESS: joe@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: The Hartford Insurance Company 11000 INSURED INSURER B: NATIONAL GRANGE MUTUAL .14788 Captain Parkers Pub, Inc. INSURERC: The Hartford Insurance Company 22357 688 Route 28 INSURER D: West Yarmouth, MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000413-0 REVISION NUMBER: 1 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 1 POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD.ao_, POLICY NUMBER (MM/DD/YYY (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y Y 08SBANX5037 04/05/2021 1 04/05/2022 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ _ 5,000 PERSONAL 8 ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y M1T2388U 08/07/2021 08/07/2022 COaBINEDSINGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS HIREDNON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accident) $ A UMBRELLA LIAB X OCCUR Y Y 08SBANX5037 04/05/2021 04/05/2022 EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ _ _ _ $ C WORKERS COMPENSATION 08WECCM3443 04/01/2021 04/01/2022 X I PER I i OTH- AND EMPLOYERS'LIABILITY STATUTE I ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Liquor Liability 08SBANX5037 04/05/2021 04/05/2022 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required Liquor is included as part of the Commercial Package policy with The Hartford Limit of$1,000,010 pej, JiliniF$2,001,000 Aggregate Location address: 688 Route 28 West Yarmouth MA IZO1 e i A011 o 7 A hs1 =tm CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Building Department, Board of Health, Liquor ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 — South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE i (JFD) / ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are re ' ered marks of ACORD Printed by JFD on 11/18/2021 at 10:24AM , . ... .,-..2-74- 4,4;11--•;4%;',P-.;,-,-k,- -,4.-----;:-..•:7.- -,- ,--4-•:-. -•`;.-'--...',*J -.2.---,-..,• ..---:..-:.:-.•;•-r- -s-4WIA7'.f4;M:T;••7'7if,"-,':',-, •z*-::* *---,-*-**W.**,-!,5-tt-4,-..*:!:'4--1.'".%*,*-•-•*..,* •'**- t*,62*•-:,/ **•-*S ---,r7 -e- AI -'1,--:* - -,,***, *. ,>,-.7-.Ims---.6t2,4--r...---• ..-.„.-. ;---.,:--,..„ •,-,..4 •,,,-,:r:,--- - ',-.•:--4-...-',..,--- , W wwcap eppd s4 f gkyirain.i n g.c o rn c- -_,- NSCCPR ,.-1,* ''"E',5,-,:41-5* ii=i-''0101- st:c.:i:..,-.:s,,;-:,• . -- - - , , '- -Course EL1,7, " _- - -AdUlt Child, Infant, FBAO &AED .„...5,..1.„ otu 1 3 20-21--- t - -,_ .,-__ .t • (Choking) „.HF,ALT1-1 DEPT. Name: Roger Gardiner.,,, _,-..- ,:-, ,. -,,,-:- „ -, Is'- %,"..,- ---% "*, Security Control No. I Address: Captain Parkers Pub,,'- — -- - 9 0 9 8 0 6 Address: 668 Main Street,Route 28 1 i City, State,Zip: West Yarmouth,MA 02673 ',-.:-= _.,1 • , ,,. . i' .. ,.. •• a. ,, - ' -• • ' , .-: .,g ,.,;, -) .':" ..'f-' 54 , ' - --I-. 2 nr-.: k;i• .,.. „,„, - ,-e...,.-2. ....., .ii -2- - 4 •. _• ,, ',A-_• kla -a_,..- A.,, ,,N_,.- ..-,-;;; ,,,e:_,.re- A 1 i Course Completion Date: 12/1112021 Training Center: Cape Cod Safety Training 1 Expiration-Date: 1219112Q23 1- ,r Narri-6-:,, :Rick toild i ,• _- _--. --- •- -,‘ - umber:-•," 100918=_ I _- _- ---- i 3 i Roger GL c.79cliN:',..? .4;,'''--.i- ilti="': ''''4* '-PN_• 1 has successfully completed the NSC CPR I. ,,'"- ,... ,\T's 'elines for CPR and ECC. 4 , 1-'-'i-7-.' :,,..-;,`, _ = :,---.. .''',,T, -,..,i, .k.t.._,V, • i The National Safety Council eliminates preventable death, -ommunities,and on the road through leadership,research,education and advocacy, For more -.4 ses from NSC please visit nsc.org/fatraining - ;.. ;,'5A• i • f,,,-- •_____ _____________________ _ '-'!' ,-;** L''',.t'k.'- L':,1-1 .•P,,, -_, ,..,,, ,7' -Z_ !•-t.'-i, ;le:..-•'__‘-e- •-•;%,,,:-."- THIS DOCUMENT IS VOID IF REPRODUCED - -.. il. 1,... ,7• tr- --31:'-]'A-i. .ie--".1:, nr.5' • _-: witr.V. 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' - _ _ 1 , _ _ Security Control No, i Address: Captain Parkers Pub - ' '-‘- ''' -'- ''''r 921605 Address: 668 Main Street,Route 28 CityState Zip: '' - - West Yarmouth,MA 02673 ,. ..,.- . _-.. _•-, ,,, ..... ., - ,••.• - •,.„, '',-._- '_-_-.1. 1'1* 1 Course Completion Date: 12111/2021 Training Center: Cape Cod Safety Training 1 Expiration Date: • 12111/2023 Instructor Narne;_-, Rickottsi . ., ., Instructoi-Vurritiarr- .11)4#.918- = - - i- '.-Ls." •--V-- i i • - - i • ''''-:-t4 6-''4i.' ..-1.-:-"`--?---N. -'-''1. 0'_41 i-to• i -- - t •- '--1 Gerry Manning -'',.."':• t-'i t -,,:-..- t-,, t.1 c.-,,:;, .,-. .,---?.• 3.-,..-- ==1. Zit- ' - , •••.',_,' ,--Fe -L;4- i , has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. I ,.- _._ ....., 0 t , ..1...it- , 'I • ;*" =--IP` .,--' -e- 11--i' 51 -. • ‘ ,. , -„- ', - 1 The National Safety Council eliminates preventable deaths at work,in homes and communities,and on the road through .,„ .,_„, , ) _, -4;_` leadership, research, education and advocacy,For more life-saving courses from NSC please visit nsc.org/fatraining -. .,,'t. 1•'---: N--, 1 . 1 -..,1 4%, .'t- '- '' ' •-*- — „- , . - _, 7,,_1' k.*.• '''--a ---_ ,-'2-=‘' •:C. ' 1 ... - -• t- .1 I i 1 THIS DOCUMENT IS VOID IF REPRODUCED J . ,...... .,*., •-1'Al. 'V• „.-*,... • , ,,, •.,-...-etR,..---,-.--7..7?---,,,,,.7,-..,"-,,,,i2-,--•'-' D., ••L -_-,D, -,•• . ''''';',.'':.,'' .:,-...• ;,=:,,-J.', -^-- a,- • • ., ,a4,-.:=.L.--- -:.Z:.fafi--.i-',s4.zr....!N.-5--,:-'4,--- • 7 -,- -:,-,,. ,,-.,” .oF. .:--i. ...„--...._-_,/-6'=-,,,,,,wft,,,,i,--,:z6-1,- --.' -0- )•.- ..-, .,,„ ,,,,,, ,I,-,.. Security Control No. • , . n:,..:•' , -` Gerry Manning 921605 --F. --Y--Tt4-- :1:::,4 ,'" -----."';'`' .,4 7 •=.---.' _,-,.•., ,t?':- .1"."'''',..-- •.-7.-"?.:' 1*-1"'-a....-4,4k••e • ,•-_., -.i ,-t jilt a-,‘ y" ,itit has completed the -• --- ; , .; ,,,,F._ PV 7,1- NSC CPR Course sv 1._.._ •,-, A,. We want your feedback! Adult,Child,Infant FBAO,CPR &AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaideva(uation to ,. Completion Date; ' 12111i2021---• ".-.1 ; • .i. take a brief survey and share your opinions • • , nip 2!11!2023 J211112023, ._- Instructional Hours: • , about the NSC course you completed. , • • . ., xt c.o. 14,...v - - #1040918 Instructor Signature Instructor No, NSC-in it for life° nsc.org/tatrainIng} - ,- - --, -Keep,this card for your record%Void if reproduced. - , 50M04e12020 1015.900009130 czois National Safety Couaca 79174-0000 .. -. 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For more life-saving courses from NSC please visit nsco rg if a t r a i n i n g t ..±- ,,, ___ -:-;.+E J.q.. .4‘4W-T, it'ti- .4.:::!,;,, • ',.• .- '- . .. n_. - .J THIS DOCUMENT IS VOID IF REPRODUCED -- , , t'''' ..4-1 __- -: ._--4. *,-'4-=''': •C 4 et*--';:-.....!: Ikk Vi 1 '3_k ;56._ ' ''.7.I `2-'-1-.1.-• 1- '-1,-.- .- -...,, ":1.• 'C.:-..-.,'' 74'1 ....g.- -..1.,-.=-"•, 4,,, ._-, „ ..•:- -.:-t -,71". '`'''''` :S--: kt-,-. Is'. .,--, .n..`, --,,,- 4,..;-„,'T 1... A -.'--5 r',. Av.,. ...A.. 5- ;A: • . -- -.. - -4.-- • I ..,...T-7;,z-4-Wif':;•',$r-,i,-5•-riAti•J;kkft.t.._-_V_1-..- t.,- -.."'.., SeCUritY Control No. .*:::-,4---7,;;,,,,...7.-_,,,,..71/2v-.k1k•i.rx-1.1'-..--- lilik.... •-4-.--- k:40-Wk:k11--Z...,-44,..-t.-..,--,--- k='' 14 ,..zZW•-z-,.'--. (--i-1/2;5,t,--i.,iiit,t;'- -‘,$1,' Catherine Kasser 90 980 2 ,-...s,..‘4,,,4.... .....- 1,4-2,".id-s,,--' • - _ -; ,,,,,..&- A-, .,s,,,...,, ,, .... ......,„,..,ii. ,i ,_ .'-'.\ ri.' ..'...7•- -",-% :.`-,-k...... t'''. ,-' A ...).. v, --2) VA. 1 _..-_ -1/2 kii has completed the - -ii -1/2, ts- ?-,---=i 4.11,4 -ti: .4.4...-r 01,1fl-Illf- -• .-,..,-, i;-.1-4;'•E" '-'" .' NSC CPR Coursefj-„, ro- --. - - --- - ,,.... 0:7 r,:•-:' We want your feedback! Adult,Child,Infant FBAO,CPR&AEI) Cape Cod Safety Training Please viTraining Center:sit nsc.org/firstaidevaluation to completion Date: --12il121:....-, ,,...";•_.44a-.. take a brief survey and share your opinions '= - = .`‘.= c --. Instructional Hours: Expires:- 1/2'12/11120Z'12: ._-4.''• - about the NSC course you completed. Instructor Signature Instructor No. °40918 - - 1'l SC-in it for life. nsc.org/fetrainihg_y ',1"..:'`._ :'' !ceen this card for your records.Void if reproduced, I ,-,-_,/ 5„7:t...i,„--, ..:,,.-.,, •1 , 120*,1015 410008V0 C2016 Hatkonal Safety Council 70174 0000 „ , tilr•-•-..''-_ •'---4-i.. 1 ,-- -:: -.,”, 77_ *,-..V •'.., ----. '`',..1r-V- -On.- ,1,..'" "_.:,t ,..ra :,i .1 TOWN OF YARMOUTH BOARD OF HEALTH t•..T+' '; 0 APPLICATION FOR LICENSE/PERMIT -2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. Captain Parkers Pub, Inc. ESTABLISHMENT NAME: bb>✓ Kt.ZU (Main at. TAX ID: 01 f .274t 025-3/ LOCATION ADDRESS: West Yarmouth, MA 02673 TEL.#: sz8.77/ -ya 6 6 MAILING ADDRESS: � E-MAIL ADDRESS: gegiAy MAA'04nnrle,'l C'"(,,.ct• het OWNER NAME: Ge►<nld v/ 1444n4,1 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: •S'o$-Sly- s Toa MAILING ADDRESS: 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 Departffr years' records. You must provide new copies and maintain a file at your place of basin �=``= 1. 2. MOV 1 8 2021 3. 4. HEALTH DEPT, 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.// &jig 1. C-eKA fe) /1j4nnv 2. C/•1-tte0I"e cc - PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. Ge, 4 2. �(�( l> f`�� o`cn�NC i� 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. CA 14 e' t(/1 4- k/A.-S c--r" 2. Ceot43 ici HA V 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. G 4k-,4 to 4'}4(n (n 2. A •tk. 6I'1-et a (N{O'�- 3. Clh'f'htu"••-t 4 scgt� 4. , . rF „------ 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 CAMP SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 74 0 100 SEATS $125 _0 SEATS $200 CONTINENTAL $35 NON-PROFIT $30 /COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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 = $ .760 *****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 r 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 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 PL . DATE: )1- 18.- 09/ SIGNATURE: yy..„.„,i PRINT NAME &TITLE:C ck lc) Hi9 h h n eee s C)�^T — 14 nY�ge,�c._ O Rev. 10/15/19 �/ ""►;, TOWN OF YARMOUTH BOARD OF HEALTH t• ;►'� APPLICATION FOR LICENSE/PERMIT -2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Captain Parkers Pub, Inc. TAX ID: OL/ 02 7 H a S3/ LOCATION ADDRESS: 668 Rt.28 Main St. TEL.#: MAILING ADDRESS: West Yarmouth,MA 02673 E-MAIL ADDRESS: OWNER NAME: ( ,(4I c.� N it n n,n j CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: s ci8-34loo MAILING ADDRESS: 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 yearsrecords. You must provide new copies and maintain a file at your place of businessili NED 1. Ce it ft (C\ HA A A t 2. IijV 1 8 .2021 3. 4. HITHPT 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. C-e ft-W (c...\ 6,g el (A r g 2. C►a T -ea f et 4 cc., PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. rr c 1. CeAA ( U fI/it(A '1 ( y 2. a •e;t- a-,,. 6( vi-e4� V 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 h cc-� Ci 1. � � � � 2. HA 1 J 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 providelnew copies and maintain a file at your place of business.us 1. CCrtrf-(U I 01 n ' 2. /�'1�-eh G �C( (he� 3. (� Pr t'1�,.,r r^-t Y Ar S (k- 4. d-- le t rh c Ic f RESTAURANT SEATING: TOTAL# l 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$1 l0ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 !/COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID. KITCHEN $80 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 = $ o? 6O *****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 er- 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 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 TH BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ IRE A S '• PLA . DATE: /1- I �a ( SIGNATURE: PRINT NAME &TITLE: �x 4 13 `t ^"` /9K-eSi cSrf —Fiel � 9 ex Rev. 10/15/19