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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee is Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-1832-07 Issue Date: 1/1/2022 Mailing Address: Location Address: SLACKS OUTBACK INC. 161 ROUTE 6A JACK'S OUTBACK II YARMOUTH PORT, MA 02675 161 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 54 Board Hillard Boskey,M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston ' Bruce G. Murphy, M' , R.S., CHO Health Director of TOWN OF YARMOUTH BOARD OF HEALTH Eer)1APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 0.Gic; (:X)i•1061-e-tc. 1L TAX ID: ,?- LOCATION ADDRESS: 11.,2 1 120 0 4,c, 6 v4 vy,tri-A.0)441poTEL.#: 50g3u? '&6')(i 0 MAILING ADDRESS: 110 I -DJ{'c 620 L, E0f1Mv,411,o°4,' 11&t&. 0: 75- E-MAIL ADDRESS: (JtOn0. L G(.1, o 01-4-hatic D', 4.-0YvN OWNER NAME: " ) 0 ark -F,0, t-I-rk CORPORATION NAME (IF APPLICABLE): 6 i ( S v 0 4-b a frL • MANAGER'S NAME: p(1 Gl j ar ek14-a TEL.#: �O$? (lb 1 -e5-"-- MAILING e5-"--MAILING ADDRESS: 1(2I (_0ol-t,(2p \i,Arv1.° (61-, 0/L(_ 6 -0-74-- POOL -074--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 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 establiishment./� 1. 0 Y E(li�Gt,1-{Zl 2. 141 x1'0✓t tt i k - PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation, 1. .� t/'v1Gt bLl( &k 2. f x Pond` , , 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 andmaintain a file at your establishment. `�� 1. Y JO 1/1 -0Ct i'Gi,1/ 2. P7l`L x P6►'i d€` 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. .wAC1a 2. _0 c(AA` ;�tnG i 3. LAA 1,5 4. d l/Oo 6 )�i 14 TNT["T A T TT A ATT C",1--' A TTA Tr". T/1T A T 11 NOTICE _- _ NOTICE ,. * TO w _v ' - TO EMPLOYEES , 'moi EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street,Boston, Massachusetts 02111 617-727-4900-http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: Arbella Protection Insurance Company NAME OF INSURANCE COMPANY _ 1100 Crown Colony Drive, Quincy, MA 02169 ADDRESS OF INSURANCE COMPANY #4220059223 12/04/21-12/04/22 POLICY NUMBER EFFECTIVE DATES RogersGray 434 Route 134, South Dennis, MA 02660 NAME OF INSURANCE AGENT ADDRESS Slack's Outback Inc DBA Jacks Outback II 161 Main St—Route 6A, Bldg 2, Yarmouthport,MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act.A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury.In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the Name of Hospital Address rTl1 11T 11l1CTIT TN 1117 T111 /1/1-111- 11X711771 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 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. 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 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 COMM NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA-N. DATE: -3 ti �'� SIGNATURE: r Rair,-rp'" " PRINT NAME&TITLE:l)0►1k.-Bia.9—A. 0 LOP\cC 2 Rev.10/15/19 M Fit: M. •�o g i E ft 1 2 i -Ea De z d - w o Z X1 1 o Qv° '� N o _ 1 3 ® Y O 0 Z 1Q C X eN'— .. -2 '- w ch e c H 1641111 IuuIou N0 - - il 6.- � V 1. 1. 41) V —< '2 1 0) a O Nz a N \ 0 ® < - a zZo � LIJ 5 .QT o � �.... 2)f Z z iii. _. R L Q 8' z = a Si 0 Cle g / II Q C H T Liii o O cO O � �N d m U M vsiw • 8 o _ o' W c " 1111 ¢ O1. 1 0 ,,,-„.,-3 tO j5 z w^ ac misnl. ao. ve ti E,.. N ©: _o L a)--0 1 o < 4. 0 U � 1 > p N -c 0 O Y2Q t0 '` W O Co ,. 0 ii 0 c 0 •_ ° Xfi 11 a � Z } ‘....§... a) 4.) sc, ~ D O � +Mco U N CD L. 0N ^, N .. 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Adnit•8PR/Pediatric-8PR/Adult CPR&AED Holder's 03/31/2004 03/2006 signature Issue Date Recommended Renewal Date moo American Heart Association rimming with this and will altar Its appearance. 70-2981 70-2961 5-02 American Heart ,0 AMA Association. Region New England Affiliate Fighting Heart Disease and Stroke Community Heartsaver CPR Training Centel id-Cape Instructors -Raining Melissa McKenna Site ;Kings Way/YED This card certifies that the above individual has successfully },, completed the national cognitive and skills evaluations in Instructor Robyn Rt`erosby, oordinator) accordance with the cuhicuium of the AHA for the Heartsaver CPR Program. Adnk-BPR/Pediatric•ePR/Adult CPR&AED 03/31/2004 03/2006 sign re Issue Date Recommended Renewal Date 02000 American Heart Association. TMttpetig with this said as dam as appearance. 70-2961