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Home My WebLink About2022 App-License-Certifications The Commonwealth of Massachusetts Fee isgs Town of Yarmouth $260.00 Food Establishment License Number: BOHF-22-0556 Issue Date: 08/31/2022 Mailing Address: Location Address: OLIVER'S & PLANCK'S, INC 960 ROUTE 6A OLIVER'S & PLANCK'S TAVERN YARMOUTH. MA 02675 960 ROUTE 6A YARMOUTH PORT. MA 02675 IS HEREBY GRANTED A 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 217—Restaurant& Tavern, 21 —Outside Deck Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Lo,k(51 f (4,""? Bruce G. Murphy,MP , R.S. O/James G. Gardiner Health Director/Assistant Health Director TOWN OF YARMOUTH BOARD OF HEALTH VilAPPLICATION 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 NAMEC)LtUet PNO YLAIJK'6 to and TAX ID: LOCATION ADDRESS:6 ,AI PM f'Cr(, (ZOCrJ '-I1?I:, , ).t- P:XT TEL.#: 31 -36 Or.i 0642, MAILING ADDRESS: E-MAIL ADDRESS:h/P1,Jf)EY&'!JC0e)I1J ICtCA -.COIr" (. L ;7?Ci',g-t:J OWNER NAME: k 'cS-7hi r'netwo PPTYhCfC C 0{22_140 t' CORPORATION NAME(IF APPLICABLE): 01_ii)Pf'S PNii 0LPNKAS I JC j_, -L C1 MANAGER'S NAME: %JCLS2(a.D+.) C r)e)HO TELI.#: �l MAILING ADDRESS: cltS) (Ptae(A i. PA-i T-' D r;JP, tt-IP,Ntv os, C,P; (-)o? 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 of business. 1. 2. 3. 4. M -y [Hill r (b1 FOOD PROTECTION MANAGERS-CERTIFICATIONS: --i -" t1-l All food service establishments are required to have at least one full-time employee who is certified as a Food v �', Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. n o i- 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. \NJR► C)1 COP) 14p 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. `rlI c'rc -I CP'J1 LLACO 2. kbtri epbe tin 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. WPS1..11,_ C&D13 C001,40 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. ICPs`AQTY4 Y\/ 1.L()mS 2. 3.- �CIrrh& rcAtJ2. 4. i RESTAURANT SEATING: TOTAL# CQ.3 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$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 t>100 SEATS $200 JCOMMON VIC. $60 WHOLESALE SK LE $80 RETAIL SERVICE: 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 _ $ .26 C' cAO 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 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 wwwyarmouth.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 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 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 COMMENCE NT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: t,1/1 QO01R,SIGNATURE: Y` iNica WCctwC) PRINT NAME&TITLE: VVR M D E k Sllr`� C O E Z HC) koiaC Rev.10/15/19 le r Ctoe ; rAAI"4 al . +d ', 4,4 s : <... Vile. s `► = J t +,q� , s ` , +v'.f t •i4�pw• s n t iuVu s = t 4y_ w s n gote ,iu ..,..s fj Aeli � � .i> .-; .. ,. .., C ERTI FIM,_. 3CAT E OF . .4, tN. ALLERGEN AWARENESS TRAINING � ..}� s34r !„. J F Saw�C'.D Name of Recipient: WANDERSON COELHO i •07 Certificate Number: 5535253 J .Li 'iv 114 .�- �, Ay) 15 2022 +;; • .. Date of Completion: 3/18/2022 tNC ,:; r � 1 3/18/2027 ; HEALTH DEPT. Y Date of Expiration: f Cv 41► C' ❑ ❑ r Issued By: - /l� , C„ The above-named person is hereby issued thiscertificate � � .444 for completing an allergen awareness training program roll" NATIONAL _ ' "} RESTAURANT � �recognized by the Massachusetts Department of Public Health ASSOCIATION in accordance with 105 CMR 590.009(G)(3)(a�. Massachusetts Restaurant Association 800.765.2122 ,� t� N� w 333 Turnpike Road,Suite 102 wwrestaurant.org tsc4.; SI Southborough,MA 01772 71�is r,'rtificate will be valid for five(5)years from date of completion. �� 508-303 9905 r �j�= jam www.uiarestaurantassoc.org /CV _ , 0, U - .M e S.yv l , '� + 6> V i ..c..1 fy/.-i Si v l t v � j>I } ' r 4 �t�:nnr t • L?t •J AUG 1 5 2022 HEAl.TH DEPT. ServSafe National Restaurant Association TM c, Se ry a e CERTIFICATION WANDERSON COELHO for successfully complying the standards set forth for the ServSafe5 Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 10788 . 'BER EXAM FORM NUMBER 8/9/2022 8/9/2027 DATE OF EX "NATIO DATE OF EXPIRATION Local laws apply.Che ith your local reau cy for recertification requirements. ANSI hs:: J1 ACCREDITED PROGRAM et1 �7 1 American National Standards I1ute �� and Dm Conference for Food Protection , 1 She . n #0655 -tce Prewient,National Rest' ciation Solutions Or In acon+rrcc wnh ?006 Resalclat ADM N(k+8231 •...•_ .. • road!ravdaRm INRAFFI.A/I • SreSche ktpa ore trademarks of the 1'NIAEF Naeoral Restaurant Associofon3nd the arc daxgn of the t�bnwri ResavontAsexe.thoo cooed 6e reproduced or ohe ed ""`..a:11 e 1711 Conrad us wok gxsaore of 233 S Wacker Drive,Suite 3600.Clomp A.60606-6383 or ServSoieereWurori erg. NOTICE NOTICE TO TO EMPLOYEES •'"►if_ EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS cam; LAFAYETTE CITY CENTER,2 AVENUE DE LAFAYETTE,BOSTON,MASSACHUSETTS 02111 617-727-4900 - http://www.state.ma.us/dia AU& 13 As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) ,1124? have provided for payment to our injured employees under the above-mentioned chapter by insuring with: HEALT H DEPT MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222,Braintree,MA 02185-0000 ADDRESS OF INSURANCE COMPANY 014005035572122 08/01/22-01/01/23 POLICY NUMBER EFFECTIVE DATES RogersGray 434 Route 134,South Dennis, MA 02660 0 NAME OF INSURANCE AGENT ADDRESS PHONE# Oliver's&Planck's Tavern 6 Bray Farm Road,Yarmouthport,MA 02675-0000 EMPLOYER ADDRESS 08/02/2022 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 Workers' 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 services 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 TO BE POSTED BY EMPLOYER i .. 5, ,S`a,. tic t, ,�c, �' .tar... �``� ktr'S.4 American Red Cross Training Services Certificate of Completion Martha Kane has successfully completed requirements for Adult and Pediatric First Aid/CPR/AED Date Completed: 3/23/2022 AUG 2DZZ Validity Period: 2 - Years Conducted by: American Red Cross HEALTH DEFT pco RSC To verify certificate,scan code or visit redcross.org/digitalcertificate and enter ID. �� `�" Learn and be inspired at LifesavingAwards.org 0038KFi8 ro Lifeline Training Resources AdulUChild/Infant CPR & First Aid & AED . ..atos liai tl o indhodual Ms succoisfully I as I4S I S Tairwnp c*%lc ium COWS.*** to 2015 FCC%COR and AfrtAq da+rwt • ' KATHERINE WILLIAMS KATHERINE WILLIAMS Adult/Child/Infant CPR & First Aid & AED I t 265473-1659037200 inst 4d,cr. • Jun Groono 07n8R022 t .. : ,I`e'07/2U2024 PEEL and FOLD