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Home My WebLink AboutApplications, WC, and Licenses Prior to 2010 •: i � °' � TOWN OF YARMOUTH BOARD OF HEALTH ��M I�s DD � APPLICATION FOR LICENSE/PERMTl'- 2009��j�� fEB � 4 ZOO9 .,.. v * Please complete form and attach all necessary doc�nepts by� e H DEPT. Failwe to do so will resuk in the retum of you�appl,t'aatron pac NAME OF ESTABLISHMENT:S� � �Q,ycv 1�� (y1 a.� TEL. # 5 a8—3G �-Gs3y LOCATION ADDRESS: � S'Z �a uT G 2 S e � n+ «,�� MAILING ADDRESS: P. o , 8�ec Iv 6 }��r � 'Pu r�t O 2Cu—� OWNER NAME: P�ta Rs�Fa u P C�'A Gc.�� TAX ID (FEIN or S Nl• CORFORATION NAME (IF APPLICABLE): "'('►�� (�q.,,,��g� M qro, LT D MANAGER'SNAME: 1'N,qR,std �4. �, ('yqTLI.E'�I TEL. #Sog..» 9�� -✓ MAILING ADDRESS: P• o , g ps( S 3-� y i „� j � � �. M� aZ��,� 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. l. 2. Pool operators must list a minnnum of two employees cunently certified in basic water safety, standard First Aid and Community Caz•diopulmonary Resuscitation(CPR). Please list these employees 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. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who is certified as a Food Protection Manaeer, 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 estabiishment. 1. �a.�.« �o ks a,�Q�� z. �1 t.., L�k �w ,�.� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operarion. 1. l�33 :.cc,a �e tc.s L t.r U 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all tunes. Please list your employees trained in anti-chokwg 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 �le at your place of business. 1. T6,�� '11�� .„ s �g. 2. Vinc��rl� .IZEy �s 3. N'1.h1liA.J � E �s � i �� 4. �. LL� � (t. rzUC� d.►.Tb 5 s'f14c�. 1 ��V��O y RESTAURANT SEATING: TOTAL # � ( �b�- b J6 P V�tc� vMq,<R.lrO(as � ��cco� 5�ob�s a t.�� a i a�a�b.c �..� � ��,�, ] �a.m�,-,o..� 9 OFFICE USE ONLY LODGIti G: LICENSE REQUIRED FEE PERMI'1'# LICENSE REQTJIltED FEE PERMII# LICENSE REQU[RED FEE PERM11'# _B&B SSi _CABIN $55 _MOTEL S55 _INN S55 _CAMP S55 _SWIMI�4INGPOOL S80ea. _LODGE S55 _IRAII.ERPARK 5105 _WHIRLpOOL SSOea. � FOOD SERVICE: LICENSE REQi7IRED FEE PERMIS# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k 0.100 SEATS S8> _CONTINENTAL S35 NON-PROFIT $30 �>]00 SEATS SI60 ��._—� �COMMON VIC. S60 �D "`I—QrtS _WHOLESALE S80 RE'IAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# _<SOsq.$. S50 _>25,OOOsq.ft. 5225 _VENDING-FOOD S25 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO gjj ��e cxnvcE: sio AMOiJNT DUE _ $ ZZO.Op "`*'*PLEASE TURY OVER A:VD CO,'1�LETE OTHER SIDE OF FORM**•** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pernrit to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporazy 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 siac(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 ins ected by the Health Department prior to openuig. Contact the Health Department to schedule the inspection five(5�days pnor to opening. PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL R'ATER TESTING: The water must be tested for pseudomonas,total colifonn and standard plate count by a State certified lab, 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 CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered evern. These forms can be obtained at the Health Departmem. FROZEN DESSERTS: Frozen desserts must be tested on a montlily basis by a State certified lab. Test results must be sent 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 Boazd of Heakh. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmem is prohibited. NOTICE:Perxnits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETCTRN THE COMI'LETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS , OT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND R D BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE UI TE PLAN. DATE: f �� y" u� SIGNATURE: PRINT NAME&TITLE: VUh(ZS�' !.� I� � rA2�� A A� ��— ia�suos ._ . .. � The Commonwealth ofMassachusdRr Department of Industria[Accidents NAfe�N� 600 Washington Stree� 7t�Floor Boston,Mass. 011ll � Woricers'Compeosatioe Iasaraace ARdsvih Baildiug/Plembieg/Ekctrical Coalraetars Aoalieut�Ef�11• � � �PMue iHT le�1e. . . name: L N K I�AN C+41[.4 ( �IQ►c� �-� address� Q$�Z � �0 Z v c� �6l.CiiA ! PIL/l�a(�S� � shate �'rt zip B�b �' ohone# �Qi �lq' �y..�i(/ work site location{fv(�addreasl; � � ❑ I mm a homeowcer perfammg a0 w�k mysetf. Project Type: ❑New Construc4on QR�odei ❑ I arn a sole�propri�or and have no one woc�king in�y capacity, � . . . ❑Birilding Addition ;B I am an employer providing wo�3cers'compeacation f�my�ployces working on this job. �m�.o.��• T�v .1�Ra �s rr 'M q .� _ .amx,.: 4 SZ 'Q�s E 7 9 �a�rr N 1�¢rvv�,�, (-��4 n 2.0 t�c ctn: d�oes#� co� �,C, 8 qS 7i �,.�,aro. �AQT'Fo�(t0 �e OS L�,�� ,�� S �: �_._ , � �.,��„��,�.� � I am a sole prapridnr,g�q�a1 coatractor,or homeown�(cirde oneJ�d have hired the contiactocs��istad beio�•who Lave ' H�e following workets'compen.salion polices: � c�mmav��v.r � . . . . addreafl . � . . . . � eitv: ' . � � � . . . . � nia.s N- co. . � � � . . . . . . �,.. � ,. r.,.,. _� ...... . . ., _ . . .... _ _ , _ . . . . w•4 .t,:�. aYoouv e�me- .. W�'W' �� o�oae# - . ��areev � _ _ - . �� - — _. ._. __.. . xi�s FaiueOaeeme � .. ._ r . -.� ,. . - �... ,� ., _ ._ , . ,;y w,�,�( � °�R�aK9�d��dv3MM�2SAN'MGL132mindbtYeh�pdtlw�fai�alpeW�a�[a8oe bt1.3N.MaW/�r. . �7�+�+'�P�eame�t weB o dH pe�aNb ta the fire e(a 37'Or WORK ORDER ud�Bee dS1N.N a Aay agaimt me. 1 ndes�W t6�t a eepyNtWNa6eaM - [xw�rdrdblOcOmeeeflweWg�WmetNeDlAterovKagevvi9ntlN. � . �. 110 bdcby c w eh pains enlgenaltlrs oIPM�'!'thet Me tnfonndion provlded eborx!s dve aed cerrect . . S�g�wtwe 1�2� 6 �I r�� lZaa.�.�, � en�Ma s�� -aSs- qs3'✓ o�chl ox oWy ae oot mi4 Y t6is ua b be meplMed py.dly er 6owe a�ccht . � dy or tewe: � ��A QBoYdiaB�P�a� ❑chMc ifmme�&�eme e reqoired � . � .. ��ka�Im6 Beard . . u�"�e'a"mes's O�oe ce�tact penaa: ��# ❑Ne+NY Dq�a�eat . c�as y.mm� ❑O� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #09-151 FEE: $160.00 In accordsnce wi[h regulations promulgated uuder authority of Chapter 94,Section 305A and Chap[er I 11,Section 5 of[he General Laws,a permit is hereby gran[ed to: The Pancake Man, LTD, 952 Route 28, South Yazmouth MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BOaRD oF HEALTII: ,�feleec S� J`Z..N., C'.11aieuna�t SEATING: 165 e�qry�p �,��,�� p�� J`�a6ext :3. `.�acwc, e�exk £a'ePyn,�,�f�:J2.N. February 10.2009 mce G.Murp , ,R.S.,CHO D'uector of Hea THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-095 FEE: 60.00 This is to Certify that The Pancake Maa LTD d/b/a The Pancake Man 952 Route 28, South Yarmouth, MA IS HEREBY GRAN"1'ED A COMI�ION VICTUALLER'S LICENSE In said Town of Yarmouth aad at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3nELe_le-�r't-S� I�I, `JZ..N., C'�!�atixntan SEA"fING: IGS �p ,�, ,��lr. v(� �(X/��(jj�, J`Zadert:3. `.�8�rauuc, C'jexl� CGuc C�xeen6aunr., 52..Ar. February 10.2009 ce G. urphy, . .,CHO Director of Health °� """� TOWN OF YARMOUTH BOARD OF HEALT� �. S% � " �� ' APPLICAITON FOR LICENSE/PERMIT-`�OQ$�� FE B 0 4 2��S f �_s , g � : * P l e a s e c o m p l e t e f o r m a n d a tt a c h a l l necessary dqcum�t��m be 3 F N�y H DEs- i . Failure to do so will result in the retum a€�our application packet. NAME OF ESTABLISHMENT: I h� �A N C F1 K.E rn1�� TEL. #S�U '3�'1�-��Y LOCATION ADDRESS:r' � IZ-r� � � � a MAILING ADDRESS: � 6 �- 6 u � 4 g �-� � �� s ( o � L �! OWNER NAM�:T e .J c,� k,Y� R N, �-T � IN r N � CORPORATION NAME (IF APPLICABLE : MANAGER'S NAME:� �.5 {�a-l.l- (�. �,r�� TEL. # 5�� -� 1-b637i MAILING ADDRESS:�� ' '� o u �t� �n i c � �-� (Lt!� QZ6 y� 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. L 2, Pool operators must list a minimum of two employees currently cenified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Heaith Department will not use past vears' records. You must provide new� copies and maintain a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: 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 Establistunents, 105 CMR 590.000. Please attach copies ofcertificationto this application. The Heaith Departmentwill not use p�st ye�rs' records. You must provide new copies and maintain a file at your establishment. 1. �C t�Ec�A �T"v��;s �3urz �! 2.�icl-hfl-�Z-�D �AN�rTT�� PERSQN IN��AR�'iE- - _- - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �G T3 6 cc.R �r3o tcs r3 u�c.y 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 maiutain a file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # I $L OFFICE USE OhLY LODGING: LICENSE REQUIRED FEE PER'�9T¢ LICENSE REQUIRED FEE PERYD7� LICEK�SE REQIIIRED FEE PERbIIT= _S&B 550 _CABIN S50 _MOTEL S50 _1NN S50 _CA.11P S50 _S��7VI.\4ING POOL S75ea. _LODGE 550 � _TRAILERPARK 5100 RT-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUR2ED FEE PER\•II7 a LICEtiSE REQti1RED FEE PER�fIi? _0.100 SEA'IS S75 _CONTINENTAL S30 NON-PROFII' S25 �>100SEATS s�so �o8�iS0 / co;4cuoxvic. sso �a -6 9 _«xoLFsac.E s7s RE'IAIL SERVICE: —RESID.KITCHEN S7� LICENSE REQUIRED FEE PER1411T= LICENSE REQL7RED FEE PER�III'= LICENSE REQL7RED FEE PER�IIi= _<50 sq.R. S45 >35.000 sq.8. 5200 �'ENDING-FOOD SZO _<25,000 sq.R. 575 _fROZEN DESSERT S3i TOBACCO S50 �iA!1�CHAYGE: S IO AMOUNT DUE _ $ e�oo .o0 •"+"'pLEASE TL'RY OFER A\D C0�1PLE'IE OTHER SIDE OF FOR)i•""** . , . _ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 Certifiicate of Worker's Compensation Insurance. THE A1"PACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEI7" Town of Yarmouth ta�ces 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 OCCiJPANCY: 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 ofresidence 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. * 1vOTE: Enclosed Motel Census must be completed and returned w;th this appucation. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heaith Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will resuit 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 haue prior approval from the Board ofHealth. OUTDOOR COOKING: Oatdoor�oeking,pfepaFatien�-oF display efany fc�-product by�rgtail er food service establishment-is prohibited�-- NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETIJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHI�fENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMME�ICEME�IT. REVOVATIONS MAY RE UT A SITE PLAN. � DATE: l Z-2 �- � � SIGNATURE: PRI:VT:�IAh1E&TITLE: �l R�--� l-r�L� _ I�. F�� I'u�4 ti F�Cx-f/L� io?o n� � The Coinmonweahh ofMrrssachusetts Dcpartment ofledusTrialAccideats �N� 600 Washingtan Street, 7tb Floor Bostoe,Mass. 02111 R'orke�a'Compesudoe Imm�aace ASdavk:B�ildiog/PIam63�g/Eketrical Co�tractors Amtleut�wtintl�r: Pltate PRiI�PI'k�61�e i /� name_ , �" c• �a,..1 c,aa 1�,�s 4 ' 4 n rJ ' ( i O �s: �1 Sa EZ d n� � $ citv ✓o'�.l,T't{ I42.MDiA,�+t� state• l ��C zin�OZ(�,(��' phmen ��'v -3�1 �'IS�Y. wotk site locati�lfoll addtessl: . �'Q � � ❑ I�a homeowoer performing all wocic myself. Projext Type: ❑New Camstructim ORemodel ❑ I am a sole prop�ie[or aad Lave no one working iv any capacity. ❑B�rildiog Addition �I am�employer�xoviding workees'compeasation for my employeu working�flus job. �.+-c /�� wmusvumr. � �l,- ��A N CiA /�C—.� 1 I � w�J7 t�T1 , .aa�- � S� R n�.., ct-s �-43 �-Sb�..�,� `� � rn b� � �.- ti s - S p —�{ j3Y li..n�ee�.. �h r ��1-�Trb��.n �Q & w �c N L � � 3 v _ . . ... . _ .4.,s�.� a��..,:; ❑ I am a sok proprietor,ge�qgl eo�traeMr,or�omeowaer(crrde awtj aed have hixed ihe conhactois 6sDed below wln Lave the following wakas'compensation polices: �mua une: . . . � . ad�een•� � - . dtr• . � � �p� � . inea�ceeo. � . . �g aseoor�e: addem• �' olw�elF � . _ . ._ ... ---- --- - ------ -- ------ --- --- --_ -_. .__: — ... - .. _ _._ .-- ----- - i�eta�ee p .,.. : ..,.�� .. :.: .. . ..: �;_. � :.: , .< .;,, , . .� �:. _ . .�. FaiveB�xeve reqe6di�dQ3a�2SAafMGLl32tu1wdi�He�ndai�iYpeaMnd�6e�bSl.SN.MuNx'•; �ne�efn'(�prWy�nf wdo pe�altleei�Ne[�Na31'O)WOBKORD6Rud�0eeafSlN.N�dryfpMt�e. ladeNaMtlWa eapy KNb b 1Ye Omee af l�Wsr N�e DIA hr avenge verNnWe. ��a„M�Jr � e P�na7tles ojpeyxry Mat Me infonuaetoe providal abave b ave mid cernct Sigoamm 2 e,�i 0 IJ i �re ( 2� 2 (— b'� rr;oc� ti'l�l 0.�15 ��-�-- � . a, Phone u S� `a - 3 r7 � —el J 3�/ o�louwly aooetwtNeY[hhare�fo6eaaPkfed69cMYorbwea�eW � .. . eiy or tawu: pe�NOomx R I�Rein�E p�� ❑chedc ifimmedi�6c'e�peme ie`eqeitd ��6 BrM ❑SdMmen's O�ee eoebe[penou' pray�q; �Q �� lmie�ii Sryt mml TfIE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-098 FEE: $50.00 This is to Certify that The Pancake Man LTD d/b/a The Pancake Man 952 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Comxnonwealth respecting the licensing of common victuallers. Tlris license is issued in conformity with the authority granted to the licensmg authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .�EeBeaa SP�a$, `J2..lV., CPcawtmart SEATPrG: 165 ��.�LQX�P.O .�. ��C�%�[QX �lC¢�Ql�[f1bl�It J`2aBext s. `.,3�tauvt, C'�ex�i Q�uc C�'xeen�aiun., St..N. £.c�eP,�n `�•.9fa�e° February 7.2008 Bruce G.Murphy,MPA,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #08-158 FEE: $150.00 In accordance with re�arions promulgated under authority of Chapter 94,Section 305A and Chspter 111,Section 5 of[he enetal Laws,a pemtit is heteby granted to: The Pancake Man, LTD, 952 Route 28, South Yarmouth, MA Whose place of business is: The Pancake Man Type of business: Food Service To opera�e a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTII: ,q�f2¢_�e��n��S� lfqa�R�, `JZ.JV., 'C,�a"vunan. SEAI'ING: 1G$ � l.11lVfLK4 JL..`rCC�t�4JL �LCC �QlX/riQfL ✓`208ext 3. `.�3Kamn, C'dexf� Qrcrc!�'nee�rBarura, J2.✓V- Fa"e&Jn J'• .�fCuJea , Febniary 7.2008 B ce G.Mm hy, .5.,CHO D'uector of Health . , ' ,�,�� 2 0 �"o TOWN OF YARMOUTH BOARD OF HEAI.. r•^`�' � ��`�'s APPLICATION FOR LICENSE/PERMI�2� � ;; D E C 1 2 2006 �y,�. * _.-. � �� ti � �, Please compiete form and attach all necessary doeu�tents;ab j+�ece bb#B EPT. Failure to do so will result in the return of you1+application pac et. NAME OF ESTABLISHMENT:T}�c �i� Nc,p�sr �V►��J TEL. #Sc�q -3� � —�jS X� LOCATION ADDRESS: q J� R o t.�.'C'Fs 2 � 3,.r� y-a 2� a�w '('4F M A e ZG G�/ MAII.,ING ADDRESS: '' �' �, �� '- ,, .� OWNER NAME:�� (�a .,c,a i<� Mh U�.r r �, T�X ID (FEIN or �S � CORPORATION NAME(IF APPLICABLE): �• MANAGER'S NAME: INI AQ.S Ik (k�L �R'R L 1's TEL. # ""b4�-� • � �/ MAILING ADDRES S: �,v , •'f7 e+ t�l �a n n � s �6 2� Y1�tq cS2.��-1� POOL CERTIFICATIONS: The pooi supervisor must be certified as a Poo!Operator,as required by State Iaw. Please list the designated Pooi Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees curremly certified in basic water safery, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees be(ow and attach copies ofemployee certifications to this form. T6e Healt6 Department wiR not use past years' records. You must provide new copies and maiotain a file at your place of business. 1. Z_ 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one fuli-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 certiScation to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a t"de at your establishmenG 1. _ I�� . �� a S-cU�� s I�� rc� a a.�i c�ka r�a L�a��fire�J PERSON IN CHARGS: - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �l:�G C��r �TL� 1<S L✓i,�,�.� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich 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 fde at your place of business. l, Q..13 �3GGGA S �v� Vt.a.< 2_ Q 1 Llkf#�� lAv�1'rj�� 3. 4. RESTAURANT SEATING: TOTAL# � � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMI7'# LICENSE REQUIItED FEE PF.RMIT# LICENSE REQIJIItED FEE PERMI'I'ti _BBcB $50 _CABIN $50 _MOTEL S50 _INN $50 _CAMP $50 _SWA�fbIlPIGPOOL$75ea. . _._LODGE $50 _1RAII,ERPARK $100 WHII2I,POOL S75ea FOOD SERV[CE: LICENSE REQUIItF,D FEE pgRTq1•g yICgNgg gEQiJII2ED FEE pERI�qT# LICENSE REQUIl2ID FEE PERMIT# _0-100 SEATS $75 _CON1'AIENTqL $30 NON-PROFIT $25 1 »oosEnTs a�so �0� 1co�oxv[c. �so ��bbY _wiio�s.�.E s�s RETAIL SERVICE: —RESID.KITCIIE;N $75 LICENSE REQUIRF,D FEE PF,RMIT q LICENSE REQUIItED FEE PERMI1'# I,ICENSE REQiJIltED FEE PERhIIT# _60sq.ft. E45 _>25,OOOsq.B. $20D _VEPID]I•]G-FOOD $20 _QS,OOOsq.ft. S7S _FROZENDESSERT S35 TOBACCO E50 NAME CNANGE: S70 AMOUNT DUE = S�Z oo,o p """PLEASE TURN OVER AND COMpLETE OTHER SIDE OF FORM•••"• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth 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 ta�ces 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 ofthe limitations ofMotel 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 ofresidence elsewhere. Transient occupancy shall generatly 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 ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certiSed lab, prior to opening, and quarterly thereafter. _ POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Eling the required Temporary Food Service Appiication form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be sent 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 ofHealth. OUTDOOR COOKING: pntdoof ceolang�gfega�ation,c�disgla3�efany food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RET[JRN TF1E COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY POOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND PROVED BY Tf�BOARD OF HEALTH PRIOR TO COMD�NCEMENT. RENOVATIONS MAY Q A SITE PLAN. DATE: �1- $ ��- SIGNATURE: PRIN'I'NAME&TITLE: `I��l AG�!-�"�L�. P. Fa�i e� �o,,,�� The CommomveaJth of Massachusetts Deport►nent of Industrial Accidenls �M� 600 R'ashiwgton Stree� �"'F[oor Boston,Mass. 02I11 _ Wor�vs'Com�satioe I�seaeee Affid�vk:B� ' b�g/Ek�efrkal CoNractors �-� , � � , , , u:. �, , -�„.�. �� - . � _, +� � ��_ , - " '` , `�-� � , r �: I h �- n� � �A ,�t rnA,� �; � , - �. qsa (I� e �..,� ab� �, �, .-m ��a ctMov.T�k �� ,I� � rin� 0�.66� �a 5 og-3�t8-�S� an,rt stte toca4�rruu aaaressl• ❑ I am a homeowna perfoxmiog alt wodc myaelf. Project Type: ❑New Caosrrucxim ORemadel I am a sole and have m we w in aa ❑Buil ' Addition I am an employer providing w«iceis'compea4atim f�my employees wodcing on thia job. s�xarrasaae: __ �A Mt� _ _ - _ __ _ �i�• . � N: ��..�..,. �'IaRr�ar�.� .�NS. C_ e� � �,,��st , o� wE� �.s � i 3:i ❑ I am a sok pmpiietor,ge�al aotrxter,or 4ameewxr(drde owe)�d have hired the contractas listad below wlw have ihe followiog wadcas'wmpensation Pulicesr �� dtve e6we#: � L�noe eo. M sd�a�; �ry�ry: nYare S: . _ _ ._-- -- --- -.__-------- - _. . _.. _—.._---__— .--- --- �-- ------------ -- -- — . . S FaYvei�nsve n�eqd�edodeSceW�2SANMGLL4teu1ndblYe�tltlrlai�IWpwMedais�pbil,lNMWI�r eeeynn'i■pWs�ot wdndMpwltlnHtYe6r�da3TOlWORKOBDBRadamedtlM.N�dayapWt�e. ladn+dWldt■ apyNNYMaMaeW y t�rwadMblOeOmeeo[Im.stlptl�mdtleDlAhravaageveri�e�tlw ��h�esy�y,� piws a�d pe�mlrtea ejye�wry N�Me Gjaai�tos psorided abene b are enI cermc s;� nare l Z- 6 g- � PriM nanx 1�'I�RY'-5 � L�- T � I'�R-C•� P6oce k S��3 j�X _ 1 J��j�Li effiddoxaaly Mrstwrke4WbunbbenoplMrdAYdlYxwwa�rL1 dtyorfe�ra: pamitl�eg fl�eUryalwt QlJanfl�g HrN ❑ehcde iff�e8�ie teapeme h reqWM ❑Sdx�'a OIDce QNn11Y De��nl canc�t pnass: phwe/; � perisa 5�¢moJl . TOWN OF YARMOUTH BOARD OF HEALTH PERMI'f TO OPERATE A FOOD ESTABLISHMENT PERMI"I'NUMBER: #07-097 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a pennit is hereby granted to: _ The Pancake Man, LTD, 952 Route 28 South Yarmouth, MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pernvt expires: December 31 2007 BOARD oF IIEALTH: B r.c `�. ,ibl.`�5., SEATING: 165 ��$�� ek�G�y Rod�t 4. Bnouwc, � P�k M��ll A.�Cf�, R.N. March 16.2007 +'%� ruce G.Mur� H,R.S.,CHO Director of H tli THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-064 FEE: $50.00 This is to Certify that The Pancake Man_ LTD d!b/a The Pancake Ma , 952 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALI.ER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B $. Cia+xloH, /19.$., . 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ARIf1.L�iI O.L 1i.LI'IIBISAiOdS�2IIIOA SI.LI �I£jaquza�aQ o� I .irenuep uzo�g,Cirenuus unl sinwad��I.LONi ON S� QI`�d��I'I�.L�'RIdO2IddF� }I��I��SF��'Id suuuad mo�i3o aousnssi io �emauai o;ioud p�ed aq lsn�u suaR puQ sa�ce�q�nouus�3o annos Q�I�F�.L.LH QrIV Q�I�IIJIS .LIAF��33d dY�IO� S.ZI�OA� NO Q�I�H.L.LH ��NF��II1SrII 30 '.LZI�� xo `Q��is Q�a�i�za�o� �s s.snrn�ire�� 1�i�2IRSAII AIOLL�SAi�dNiO� S�ZI�}RIOAA �.LV.LS Q�H�V.L.L� �H.L a��insuI uoiissuaduio� s,�axio�3o a;��g�ua� a aney �ou saop �iueduio� lo uosiad E 3i ssautsnq e alElado o� ;�uuad �o asuaog ,fue;o l¢mauai lo a�uEnsst pioq o�pannbai�+nou si q�nouuB�{3o un�os aq�`9 vo��asqns `�SZ II�!�S `ZSi ia;dsq��apun AiOI.L V K.LSII�IILII([�' `� The Commonwealth of Massachusetts �_�` � Depart�rent of Indrsbral Accidents __ - N�II/� — 600 R'ashington Stree; 7'J'Floor ` '�, BosYon,Mass. 02111 � Wo�iu�s Compnsaho�I�sea�ee A�davk:B�fld��lPl�mbu�/Electr¢d Cwtrxtws , . , .. ,�. .. . .�. - . , - � � "5 � x . , ,�. �*,;� �r as�k��' �c` ��' ,�. _ �:i he i�P.ac�-i�� MPti , L �� add�ess: �J �- � Oi-CT� L dJ ciri��.1.�}S T�m (Z(+{.,—�l� s��: �.NI 1 \ zio: V Nnh�-L ohoa# �g�.��" �� ,S �� wark sih locati�(foll addresal: ❑ I am a homwwner perfoming all wark myself. Project Type: ❑New Caostcucdm�R�adel I�a sole 'eta�and have m one w in aa Biril ' Addiaon . . am an�ployer Froviding wakas'compe�osatim fa my employces wo�cing�tLis job. . . . .. . .�o..y,�•i h � PPa�A i�^" `'�� iVfi� �: G,��, ��n,� � c7- f� �,:�o:�,-t-�., y�-��,, a,.� ��: �� -3��- 5 s3 ' Ur�azrr- o2P p� �Ec,tJL 6 l3v �a. i h,� . ❑ I am a sok propaietor,ge�enl c�tracror,or iomeew�(ade owe)�d Lave Lirod the camuractas li.sted below who have the following wodcas'compeasation polices: ��r�e: d�m: e�q: nYa�el: M ��: adtrw• e1tv: oYrefi: F�ive 4 aane eva�ge s�eqhN odQ Satln 2SA d MfiL 1�oe led b IYe A�pdIW d e�Yd pe�Yln d a 6�t�p bS�.SKM aWr ox 7e�n'IePr�t a�we8 n cM pmMb le He�eta STOI WORIC OBDER ud�eee dS1M.N�day�rt� 1 odeshW fYN• npy�Hb yhe[vwaMMMtleOmteKl�mo[IYeDlAhre�vengesr�nlW. !ro harey c ' w� aiepi�u.etpe�.t6ea ojpey.y p4.r We afe..eatou pnodtea.bor�e 6 6wr ad anrrect �� ll-- Zz -� � Priatname l.�- `�� R.L� PhoneB 'u�.�—�� ,�y�-=— sIDehloseody d�atwdfeYlYbunb6ea�PkfedD7dry'Nfnr��rLl dlyarfawn: per�UlomeN �lB�id�D�et ❑eheek ifiemedht�eapsne h ttqa6d �Sdxmi O�c ❑HnM�Dep�dnl ne�t Penee: PM�e g; Op� tm:a sya xawl TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-044 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of[he General Laws,a permit is hereby granted to: The Pancake Man, LTD, 952 Route 28, South Yarmouth, MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2006 BOARD oF HEALTH: Be�iuc$. C�'a3�o� ��1. ' sEn'rtrtG: 165 /��Ltic.6 ILla95�y ?/ice G�fral�tixa�c �S�R.N� Q�4� R.N. D�n�s.Z�s -__ � ��G. � i,Rs.,�cxo n�o�of�� THE COD�VIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-038 FEE: $50.00 This is to Certify that The Pancake Maa LTD d/b/a The Pancake Man 952 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This Gcense is issued in conformiTy with the authority granted to the licensing authoriries by General Laws,Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto afl'ixed their official signatures. BOARD OF HEALTH: Bpe�sr�yw� �xi�c$. C�'o3d.ag M.$. ' SEATING: 165 � � p4('4l�CtI&//M�� C� v�e�.� R��/10!!!/L�� erere�i Q��i� R.N. � December 8 2�5 .—%' ruce G.Murph ,RS.,CHO Duector of Heal o�.Y�,� � S�e, �� ; ,`�o TOWN OF YARMOUTH 0 "'3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACHEES � ��o„�,"�p,b�»� Telephone (508) 39&2231,Ext 241 — Fa�c (50S) 760-3472 B O A R D O F H E A L T A �v � To: A112005 Yarmouth Board of Health License/Permit Holders { MAY 3 1 2��5 � From: Yazmouth Heaith Department ' HEALTH DEPT. Re: Taa�Identification Numbers Date: Mazch 22, 2005 The Massachusetts Department of Revenue is now requiring that the Health Depar[ment furnish to them detailed information regarding all permi4s and licenses that we issue. One of the required details is to provide a tax identification number, whether it be an establishmenYs Federal Employer ldentification Number (FEII� or, in the case of an individual's license, a Social Security Number (SSI�. This information will be used by the Health Department purely for administrative pwposes only. Would you please fill out the fields below and return this letter to: Yarmouth Health Department 1146 Route 28 South Yannouth, MA 02664 Thank you for your anticipated compliance. ff you have any questions regarding this matter, please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is (508) 398-2231, e�ct. 241. Establishmen�` ��`'`'P1�� v,A� FEIIY or SSN: � ``�� Location Address:��L 2�u,� 2 a �� r � Signature: ,,�� Print: ��`�S�G�� ` � �� Title: �"`�,W�`(�'�� . . , � �� PrintEtlon . . ��(_..�led y , ! �p.�i�se ��__ ' ��'�^q,y TOWN OF YARMOIITH BOARD OF HEALTH � '�'� ` � o y APPLICATION FOR LICENSE/PERMIT-�2,t�5 J A N 2 6 2�� r . — S rr P'a 's, * Please complete form and attach all necessary d �ts�yISlecember i,�(��TH �.m. Failure to do so will result in the retun�'8 `y�u�sppli�ation packet. — � NAME OF ESTABLISHMENT' T�t� Pr "s�-P �c� M q. TEL # �` "� `�'G��, LOCATIONADDRESS' a' S = CZ�•'� '� z�' �%: aaa �1^`'^�' '-�� MAILING ADDRESS: S�^''� OWNER/CORPORATION NAME: 1 h� P^^i:-��k M n�� r� MANAGER'S NAME �1 «�s ��p c .J D. �=a2��s-� TEL. # �� -��b-r�� T� MAILING ADDRESS: 5 '1'� L POOL CERTIFICATIONS: T6e 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 certiScation to this form. 1. 2. Pool operators must Gst a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Commumty Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of empioyee certifications to this form. T6e 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 fiill-time employee who is certified as a Food Protection Manager, as defined in the State Saaitary Code for Food Service Establishments, 105 CN1R 590.000. Please attach copies of certification to this application. The Health Department wiR not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. I�ls C�[:��A 5�-,�s b„12.,�i 2. � 1GF: n r L r�,�Crs�J — PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 2� � (1. 2. 1. PoE�c-�-P ��1�:� ��.a HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must haue at least one employe�e trained in the Heimlich Maneuver on the premises at all times. Please list yow 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. � 2 �' ,� � � c`�' 2 � 1. Ti ( Fs - �a.r �t'b ^ ^ 4. I e� 0 7� S � A� 3.Sra �eU� '� RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQU7RED FEE PERMIT# LICINSE AEQUIRED FF� PFRMII�� LICMO� Qt1�ED a o PERMI"1' B&B $50 _CABIN $50 — — $SO SW��G POOL S75ea. _� $50 _CAMP — 'I'RAII•ERPARK $50 _WfIlRI•POOL $75ea. LODGE $50 — � FOOD_ S_ ERVICE: �E PERI�qT p LICENSE REQUIItED F� PF..RMIT# LICENSE REQ[JIRED � PFRM�� LICENSE REQUIItFD _0-100 SEATS S75 _CON"CINENTAL S30 NON-PROFIT $25 . ( I COMMON VICT. S50 OS'D� _�o�sa�.� $7s J__>ioo sFr+Ts �iso �6� RETAIL_ S�E� � pgg��g IICENSE REQiIIItF.D � PE�T# LICENSE REQ171RED FEE PFRMIT N LICENSE REQLJIRFD �t5 >25,000 s9.ft. 5200 _�DINa-FOOD S20 _<50 sq.ft. _TOBACCO $ZS FROZENDESSERT S35 ' � _as,000 sq-ft. �75 AMOUNT DUE _ $ o-� NAMECHANGE� $10 .* ••^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 AFFIDAVII'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR � / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED' Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIliED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, MOTEL OR POOL (i.e., PAINTIIVG, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO CONINIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTi'IONAL REGULATIONS POOLS POOL OPENING:All swimming,v�,ading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, 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 CONSUMER ADVISORY• Each food establishme�t which serves or sells ready-to-eat,raw or undercooked anima!products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hows prior to the catered event. Thses forms can be obtained at the Health Department. FI20ZEN�E3SE324'S: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemtit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mnst have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display ofany food produc�t by retail or food service establishment is prohibited. DATE: I Z -�j(-a� � SIGNATURE: PRINT NAME& TITLE: w(�zs�c� � �' � � � 1<�f( �n a �r� �0/22/04 ='� The Comnionweattk of Massachusetts � _`_=� � _ - _ Departarent ojlndestrial Accidentc - — N�ardiws�rs - 600 Was6iagton Stree; 7'"Floor �- Boston,Mass. 02111 VVorlcen'Compe�satlo�I�eea�ce Affid�vit B�7di�g/Phmb��g/Electr¢al Co�trxtors n.-:.s�s. �, �..�.� :,,� �•� ;d e . �y- �., .._�, � �'�i:�;..F '�k�, ia�e:a�::b�'�2f�,hkb�� ,. . �,-� "7 M 08mt: 111d I q�Ji.AIti 1� 1/�J � 1.� addmss:q 5 L Z o u rc 2 � cirv J o�n ci, �� a�.'r'a:t� s�a-M!1 zio: �L�4,"� ohone u S�7 g- 7 i �S� �`� ��L' work site locadi�(foll addeessk � . ❑ I�a homoow�perFo�ing all waic myadf. Project Type: ❑New Cmatnctia��Rmiadel I am a sole and have no ame w in an� B�ril ' Addition I am an employer providiog wakers'compeasation far my�ployces wodcing am this job. �.,�: �: 1��-,`�.��r C.��:� .eae.: 4 5 = jl ou -r z Z`� en.: . � o•a�� IaeM � �5�-� er�e: 7 JS'3�fK` �t��a� I�� AMlx2Aa.@9 �'NS. —`� I{ l I"wG�f� I �t� Q I am a sole piopridor,8efas�eeetraeter,or Yomeewoer(cirdt awt)aed Lave haal the conuactas listed below wla Lave tLe following wakes'compeagafion polices: �tT r�e: �� dtv: �Ywe N: N ��: ad�os• dt►• o�retl: . _ _._ . _ . . _. _. .- __.. . � -.___ ._ __ Faive Y axee a�ae n ieq�M dQ S[tIW 2SA d MGL LS2 m Ind M lie I�p�lllr KatNW pm1Ye�fa Le�M t1�9RM dla s�e yan'6iprYaamst a we8 n eM pwilb�t�e br�s[a 370i WORIC ORDER aW�B�e tf1M.N a dty apinf�e. I ode�htd 1rt a apy dtlde my 6e hrwadM 1e He Omee otlive�n dMe D1A t�r�eeqe PaMntlM. !lo henbp�h IGe pdns aW6mddes of9t+i+%tMd Me ufen�edon provWel ebope 6 bre m�d corrrct s��u�e nere l� �31-�y Ptintname �V��Ncs�v:b�, �U�le P6one# ��J� � � �llf— ',�� e�cLl ase�nly de aat wrke Y thh area b 6e es�Wefa+�DY d19 rinrn e�rril dlysrtswu: perdWoeweC fl��t ❑ehetk ifim�le �BsaN ��M�*a �Sdx�n9 O�tt �NeaN6 Depr� aehel Pv*sa: ��; � 1m'sd S�g mo31 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #OS-141 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A mmd Chapter 111,Section 5 of the General I,aws,a peimit is hereby ganted to: The Pancake Man, LTD, 952 Route 28, South Yarmouth, MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut e�cpires: December 31. 2005 BoaRD oF IIEnLTH: B�i�C$. Cjm�don,i19.$. ' sEw�r[rtc: 165 p��f�i� v�e� d�e� �'�[afc,�J�� a.�4� a.�v. Febmary 3.2005 � Bruce G.M H,RS.,CHO Director of H THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-088 FEE: $50.00 7'his is to Certify that The Pancake Man_ LTD d/b/a The Pancake Man 952 Route 28, South Yarmouth, MA IS HEREBY GRAN1'ID A COMbION VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomvty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: Be�a�sis$. (�'o�do�,M.�S. ' s�� 65 p�M� v�ef� Rod�t 4.Bao� U� ��!� R.N. �9� , R.N. _ February 3,2005 B ce G. urphy, ,RS.,CHO Director of Heal 4 1 :' � �}'��13��pp� PANuiKEr'iraN . �fe q.} TOWN OF YARMOUTH BOAR,p,OF HEALT � �._ � . 32 � APPLICATION FOR LICEI�SE �I�4II'�`- 200 f � "�� E � •' �� NOV 2�4 Z003 �, * Please complete form and attach all d��ents by Dece ber 31, 2003. Failure to do so will result in th " um " your application cki�ALTH UEPT. 1�1AM�QF ESTABLISHMENT: 1-he p� �-a r-� � TEL. # 3°14'y'a 31i LOCATION ADDRESS: q 5 Z T2�;,�.� 2�� Sn� m �l� �n��„a �-r M.t�ILING ADDRESS: P.6 . (3vx i `I sf. U 7a.,.+�s l70�t , (� h O l oy� O WNER/CORPORATION NAME:Th c �n�ct+ e,� M A U, �� MA�IAGER'SNAME: ililRQsFtA �� p. �c�2�k'� TEL. # s'a3-l"di o631i MAILINGADDRESS: P.o. 3uv- �3�E 1-ly� ..��3 !pn�f� �AR 01-b`i � �OOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pc�el t%�eratorrs)9n�t�ttach a r�gy of ihe ceatif�4tion io th.is fom�. -- - - . l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. 2. 3. 4. FOOD PROTECTION MANAGERS - C�RTIFICATIONS• All food service establishments aze 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 Establislvnents, 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. � Q.(, , r� `�.�t'W �s 3�,12V 2. j�n �iAw c�.I'Gh _ -YERSON 1NZ:HARUE: _ _ _ _ _ _ - _ . _ _ __ , _ -- ---— _._ _ -- _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 't�4"-5�c -/�' r o�suY,tLCt 2. � l �t ��tJt�Uh HE1Mi i('H ('FRTIFiCATIONS• 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-chokmg procedures below and attach copies of employee certiFications to this form. The Health Department will not use past years' records. You must provide new c ie and maintain a file at your place of business. 1.��DCii..-�. LU:" 2. �� /��i� /� kl�l��fr+ri U (n�,) 3. 1 t �7 un,�� c 4. �- . RFSTAURA�IT SEATING: TOTAL# j g � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSF.REQUIRED FEB PERMIT# LICENSE REQUIRED FEE PBRMIT# B&B S50 _CABIN 550 _MUTEL $50 INN $50 _CAMP S50 _SWIMMING POOL$75ea LODGE S50 _TRAILER PARK S50 _WHIRLPOOL S75ea FOOD SERVICE: UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMtT# 0.100 SEATS S75 _CONTINENTAL 530 _NON-PROFIT S25 I >I00 SEA7'S 5150 0�� I COMMON VICT. S50 �0`{'O�{5 _WFIOLESALE $75 RETA[L SERVICE: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FGE PERMIT# LIC6NSE REQUIRED FEE PERMIT# _<SOsq.ft. $45 >25AOOsq.ft. $200 _VENDMG-FOOD S20 <25,000 sq.fl. S75 _PRO'l,EN DI:SSI;R'f S35 _TODACCO S25 NAME CHANGE: S10 AMOUNT DUE = S 200.o0 "*"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*••• t r ADMINISTRATION , Under Chapter 152, Sec6on 25C, Subsection 6,the Town of Yannouth 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 AFFIDA�'IT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED 9� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taz�es and liens must be paid pripr to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �� NO NOTICE:Pemuts run annually from January i to December 31. IT IS YOUR RE5PONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUiRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE 7'O CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 PLAN. AADITIONAL F.GIIi ATION POOLS POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,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 CONSUMFR ADVIRORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATG� iN PO I Y• Anyone who caters within the Town of Yarrnouth must notify the Yarmouth Health Department by fiting the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. Fl2D��11 C fl�rc._ _ _ _ — - - _ - - Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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. OUT ID . F�'S• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COO iN • Outdoor cooking,preparation,or display of any food produ t by a retail or food service establishment is prohibited. DATE: I l- �5' �3 SIGNATURE: PRINTNAME &TITLE: '�at��r,,�� Q. ��lC� � �,�E<,nE�/ 10/22/03 . � . � � The Commonweallh ojMassachusetts : = Departmen!ojlndustria/.-iccidents ; Omceol/arest/OsWis 600 Washrngton Street Bnston. Mass 01111 ` ��'V W'orkers' Compensation Insurance Affidavit Aoolicant informaHon: PI A. � �rt � M n�mc I N G ��NG (kIGG. l � l�'�> l�1� loc�tion� �i s� � 6�t,� �. �i � trt. l fs�t.tkl_ ��A f..fVl 6�rYt} �� phone a �0� 'S�' � 5 3�/ � I am a homecµner penorming atl µork myself. �� I m a sole proprietor r..� ha�z no one ��orkin_ in anc capacin� m an emplocer pro�idino workers' compensaeion for my employees uorkine on this job. __ _ ---- - -- __ _ - - - _ ___. !1 -- - _- _ - --- _ __ _ __ _ comnam� name. �r � Y6.St,Av.Ys �pna L� � � � 8(�(�fcSS: —1 �� (�l.l,� d. `� � citv J�,u,il,'t YQllQ.Mn xTT �V�. � pheneY '�C �'i'.3 "lG' �J 5/i p � 1I1 �1 c1 � iosurnnce co. Nt1, ,u�n (� �t�sS- �- eolicv k ��W I� � I�'�' S � I am a sole proprietor. qenerai contractor, or homeowner(circle onel and ha�e hired the contractors listed below ��ho ha�e the follu��in2 ��nrkar, ;ompensation polices: tomG2Il�namr. . . addrcsr cin�: nhone a• i�surancc ro. yeliev# eomoanv name• � addresz: �'� � phoee M• insurance co. p�Bev N t F�ilurc�o�eeure coven`e as required uoder Seenon 25A of MGL IS2 n�ind to tYe inpaitio�oteri�id pe�dtln of a Ou op ro t1�00.00��d/or � oae yan'impri�onmeM u w�dl as eivil pendNa ia the form of�STOP WORK ORDER��d a 8s of 5100.M�d�r q�ioft m� 1 udenta�d tYat■ copy of thia satemrnt m�v be(onvvdtd to the Oliice ot Invntig�8om of Me DIA tor eovera{e verilltatlo�. - /do�hrre6y ce ij}•u er e p 'ns and penallies ojpery'ury that�he injorrrmtion provided abovt is true and corrctt Signamrc (l-� S- b3 Printname R �N/+«- ( • �C� p��k � ,ai �C16''q.S�Y , aRcial use anh do not.rite in this�rea ro be completed by eiry ar towe ollleial ciry or town: YA�ODT$ _ permiNiccex M nBuildiae Departmeot � pLieeosiog Bovd p check i!immediate response ie r�quired 261 �Stlettmen'�Oflice �Health Dep�rtmeet � contac�person: phoneM:_ �SOB� 398—?231 eEt. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-060 FEE: $150.00 tn accordance with re ati�s Promnlgeted under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�al Laws,a permit is hereby granted to: _ The Pancake Maq LTD 952 Route 28 South Yarmouth, MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establislunem in: Town of Yarmouth Pemut expires: December 31. 2004 BOARD oF HEALTH: B�cros� $, �,�J,$, sEarwc: 165 n��y(��y� y� '�. � Ro6aat4. B�, � _ _ �Sl.�, R.N. __ December 17 2003 i, Bruce G.M ,MP R HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-045 FEE: 50.00 Ttvs is to CeRify that h p 952 Route 28 South Yarmou MA IS HEREBY GRANTED A COMMON VICTUALLER'S LIC'ENSE In said Town of Yarmouth and at that place only ande�c�ires December t]urty_first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the --- licensmgof coaunun victuaHer's:�'lusiiceis�isissaed in confamri ' to the licensing authorities by General Laws, Chapter 140, and amendments th�o ntygrant� In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Be�y�i.a `.11. (�'�+td,as, M.2. ' S�,�G: �65 p�.a� v� ef� Rod�t 4. B� Gle�,4 � Sl��., R.N. December 17 ,2003 Bruce G. M hY>MP >R.S., Director of Health ; `"''� TN�F#�nicA M �F Y^�+ TOWN OF YARMOUTH BOARD OF HE�.�T - �' o � � i L- ' i I; '`y �. i1 � 3 � APPLICATION FOR LICENSE/PERN�T-200 � f �nns� r .;= �� a.,� t �. 5 C * Please complete form and attach all necessary do�timents by Decem�er�31, 2002. Failure to do so will result in the return of your applicahon packe r!^",� �"� ` T)°-.�-T. NAME OF E4Tt�RL.ISHIVLF.NT• "C11- �T TEL. # 5[S$-3`��T3�- L 5 l o T3� 43 yaa,m MAILING ADDRESS• 'I a�'Z 12ouT� 24� ...,_ �� Fk2M n�i � TI • �Ne ��vwcow� t-T MANAGER'S NAME• Af!_e� A u � �u 2c,�/ TEL. # 5�3 -3`J8 -�S3Y MAILINGADDRESS• � a, l�bx S31 kyt�� uri� �b1A O1G �1`j POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opeiator(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 basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certificafions to this form. The Health Departmeat will not use past years' recorda. You must provide new copies and maintain a file at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIF'ICATIONS• All food service establishments are required to have at least one full-tune emgloyee who is certified as a Food Protection Manager, as defined in the State Sazutary 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.�L �cs��.� � :�sg uc�� z. ��2a LAa�,� PERSDN-II�T CHARGE: __ _ . __ . _ _ Eac ood esiablishment must have at least one Person In Chazge(PIC on site during hours of operation. i�E , bae a. �,u�r� L�� o.S H�,.,MLICH 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 a116mes. Please list your employees trained in anti-chokmg pmcedures below and attach wpies of employee certifications to this form. The Health Department will not use past years' records. You must provide new cop and maintain a file at your place of business. 1. PC_Cv- �c,�r,,_, 2. 4 C2 r c� �'i �-�C(Oc.c�� 3. n —� 4. I'✓IGcv Ce RESTAURANT SEATING: OTAL#� OF'FICE USE ONLY I6?IZGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# _BBr.B $50 _CABIN S50 _MOTEL $50 INN $50 � CAMP $50 _SWA9vfING POOL SSOea _LODGE $50 _TRA[LERPARK S50 _WE[[RLPOOL $25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT S25 1 >100 SEATS $150 O.�'��Ga I COMMON VICT. $50 O � _WHOLESALE $75 RETAIL SERV[CE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 <25,000 sq.ft. $75 _TOBACW S20 <50 sq.ft. S45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ 200.00 *•+'*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**` # ADMINISTRATION ' Under Chapter 152, Secrion 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 ATTACHEB� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth tases and liens must be paid p ' r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPAR'I'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, 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 CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. 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. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen�tesserts must bertested osa marrthiy tsasis b��State cernified lab: 'Fest results must be sent fo�he Healtfi 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),m st haue prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food pm ct y a r�tail or food service establishment is prohibited. DATE: � � 1� bv SIGNATURE: PR1NT NAME& TITLE: o i,t� �• �p,�Lis` 10/18/02 -. onrelMMmonr) : ACORD„ �`ERTI�`��*1a1T� ;�F L��lBILITY iN�UF��I�I�"'.E ii/zo/oz : rnooucea �� THIS CER7IFICA7E IS ISSUED AS A MAITER OF INFORMATION OLDE CAPE COD INS AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON 7HE CERTIFICATE HOLDER. THIS CEFlTIFlCAiE DOES NOT AMEND, EXTEND OH ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW. 435 MAIN STREET COMPANIES AFFORDING COVERAGE HYANNIS MA 02601 COMPANV A ONE BEACON INSURANCE GROUP INSUFED COMPANV THE PANCAKE MAN LTD AND/OR B MARSHALL FARLEY CqMPANV P O BOX 148 � HYANNISPORT MA 02647 COMPANV D caruesa�Es THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 7HE POLICV PERIOD INDICATED, NO7WITNSTANDING ANY flEQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEflEIN IS SU&IECT TO ALL THE TERMS, EXCLUSIONS AND CONDffIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. CO rypE OF INSURANCE POLICY NUMBEH �UCY EFFECl1VE POLICY EXPIfiAl10N uM� �Tp OATE(MM/DD/YY) DAIE(MMIDDIYY) OENEHAL LIRBLffY GENEfiAL AGGREGATE $ COMMERCIAL GENERAL IIABILITV I PRODUCTS�COMP/OP AGG S CUIMS MADE ❑OCCUfl i PEFSONAL&AUV INJURV 4 � OWNER'S 6 CONTRACTOR'S PFOT EACH OCCURFENCE $ FIFE DAM/GE(A�ry aw fire) $ MED EXP(My one person� $ AUTOMOBILE L111B0.RY COMBINm SINGLE LIMIT $ ANY AUTO ALL OWNEU AUTOS BODILV INJURV SCHmULE�AUTOS (��5��) S HIflED AUTOS BODILY INJURV NON-0WNED AUTOS (Par acddeM) $ PROPERTYDAMAGE $ GARA6E WIBLRY AlJTO ONLY�EA ACCIDENT $ ANV AUTO OiHER THAN AUTO ONLV: EACH ACCIDENT E AGGREGAiE 5 EXCE$$L111BILIfY �CH OCCURRENCE $ __ UMBRELLA FONM AGGREGATE $ OTHER THAN UMBRELLA f-0RM $ WOPKEXSCOMPENSATONANU QB03H242044 8��1��2 8/O1/03 X TORVLIMRS ER EMVLOYENS'LIN&LIfY � EL EACH FCCIOENT $ S O O� O O O � TME P�Pq�� INCL EL DISEASE-PoLICV LIMIT S S O O� O O O PAFttNER5lE%ECUTVE OFFlCERS ARE: EXCL EL DISEASE-EA EMPLOVEE $ S O O � O O O O7XEH DESCNP710N OF OPERATONSlLOCATONSNEXICLESBPECULL REMS Cl�i'tYHCA't'�:<Nq�� AN��i,tJ17WN �� SHOULD ANV OF iXE ABOVE�UESCN�ED POIJCIES BE CANCELLED BEFOHE iXE � TOWN OF YARMOUTH EXVIXA110N UI11E 11EAEOF, TIE ISSUING COMPANY WILL ENDEI1VOfi TO MAIL 1 O DAY$WHTEN NOTCE TO TE CF31i1FICAiE XOLUEN NIIMED TO iXE LEFf, MAIN STREET BIIT FAIWXE TO MAIL SUpI NOTICE S iAPOSE NO OBLIOATON OH IIABILiTY SOUTH YARMOUTH� M.� 02664 OF A Y KNO UPO COMP Y, ENfS OH NEPHESENfR71VE5. OR c�� J it D. Sullivan JS A i0.f`�Df� '�.'r� (E�5} �;4Cf'�E1p ; .�tRpLtfU1'XI4A1 t88B; TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #03-062 FEE: $150.00 In accordance with regulations promWgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: The Pancake Man, Ltd., 952 Route 28, South Yarmouth, MA Whose place of busmess is: The Pancake Man _ _ Type-ofbasiness: Food-Service __ _ _ _ _ : To operate a food establishment in: Town of Yarmouth - Permit expires: ,December 31. 2003 BOARD oF�Ai,Tx: (�daa4a'�. zd!l.Eea. �ibarn�a.c sEnn'rnvG: 165 �a�. �nemus�� .D.. �/lee Patrlek I�Doa.xett i�de«Ska�4, ,�71. Decemberl7 ,2002 nue G.Miuphy S.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-038 FEE: $50.00 Tlvs is to Certify that The Pancake Man. Ltd. d/b/a The Pancake Man 952 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirry-first 2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued 'm conformity with the authority ganted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo�the undersigned haue hereunto affixed their official signatares. BOARD OF HEALTH: (/,ka�dea�, xeilt4ac. (��a« sen't1rrG: t65 ,�g a�. Scenwc��9., viee �afiilek 7XCDanxotC � S , R.�t. December 17 ,2002 ruce . w'P Y, ., Director of Heakh r , - �D�,Y �i �oa-� Pan+car.E Ma-� � � ��T� TOWN OF YARMOUTH BOARD OF HEALTH � r APPLICATION FOR LICENSE/PERMIT -2002 � � n ,; : � � � * �ease complete form and attach all necessary documents by December 31, 2001. Failure to �c$:So�ij� p�[in the return of your application packet. �.. , NAME OF ESTABLISHMEN j�- 4 n�cc>v �' M1a �r�r u � na � ou G' �y LOCATION ADD F 4 ti 2 �2 � cs, S'�„�-n, `t A R� Q ,�� I G DDRE S: G.4 , s ; �LU'1 WN C ON E: h� P u �.a �� MAN GE 'S N E: S�a n �� e,t, TEL. # 5� �-� � I—�1e3,/ ivTAILINGADDRESS: Y.J . cS�x 5 �, � yo�+��y u� � pze4 "1 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 minunum of two employees currently certified in basic water safery, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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£ile at your place of business. L 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 Departmeut will not use past years' records. You must provide ne copies and maintain a file at your establishment. i. ��vG� �i��la,�R�_ 2. PERSOId�1Y CHARGE: _ _ _ Eac ood establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. ��JeLr.•� �,u �cs3�q�- �1 2. HEIMLICH CERTIFICATION : 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. Y must provide ne�Y copies and maintain a file at your place of business. / 1. � Gl � C 2. 3. 6 l�Kc:�. � I�tI�YH�e` � G. RESTAURANT SEATIN : TOTAL# F ��_ t OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INA7 $50 _CAMP $50 _SWIMMING POOL$SOea. _LODGE $50 _'I'RAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICF� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONT[NENTAL S30 _NON-PROFIT $25 I >100 SEATS $150 OZ�O�/� I COMMON VICT. $50 �QZ�OZ$ _W[-IOLESALE $75 FTAI cFRVI . .; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. S75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ 200•00 �. ***•*PLEASE T[JRN OVER AND COMPLETE OTHER SIDE OF FORM**'*• a ��^�"... � . "'^"e�..-� _ , . ,. ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY TF PAID: YES � NO NOTICE:Pernuts run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILI'TY TO RET'URN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISFIIvIENT5 ARE TO CONTACT TEIE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 PLAN. ADDITIONAi REGULATIONS POOLS POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 ('ONS MER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or underwoked animal products are required to post Consumer Advisories. ('ATERiNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Depaztment. _ -- ----_ --------_ __ _-- _ __. _ FROZEN DESSF.RTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 appmval from the Board of Health. OUTDOOR COOKING: '� Outdoor cooking,preparation,or display of any food rodt�c by a retail or food service establishment is prohibited. DATE: l Z' IR—U � SIGNATURE: � PRINT NAME & TITLE: �R(�u 4 L � ��G-�—��/ ►"lA �� ,� 09/11/Ol .. . �- � The Commnnwea/th ojMossachusetts = Department ojlndustria/.�ccidexts ; 0II/ce o!/sr�stlOsWis - 600 Washington Slreet ' Bosron. Mass. 02111 " R'orkers' Compensation Insurance Affidavit Aonlicant information: pl�sepR[NTT�siidv n�mc Lstcatiorc . ��t` ehon X � I am a homeowner penorming all work m}self. � I am a sole proprieror �r.� ha�e no one norkin_ in am capacin� �1 am an employer pro��ding workers' compensacion for my employees uorkinc on this job. ssmnanv �ame• T�1 ° 1�(1 f1C;G� L'i� M 1J11 L� ,�} ��'7— address: �I S Z K@�� jG �� sit�': OI.I '1�1- �� A�MbwS�f �.� 7119b�i ehoneN• J��6i- S�i �'��lS"�� i�sur�nce co. ��N�N �P�� oolicv p �Ci �I� � o� � v� � I am a sole proprietor. _enerai contractor, or homeowner(circle onU and hace hired the contractors listed beloµ ��ho ha�e the follo�+in_ ��orker; ,ompensation polices: snmoanv name: � address• �7LY;- ohone M• insurancc ro ooli y N comoanv name: address [iLv' ehoee N• � insuranee co. neliev N t Failure to�ecure covengt as required under Secnoo ISA of MGL 152 n�Ind lo Me iepo�idoe oterisi�l peWtln of�O�e op to 51,500.00 ud/or one ytan'imprisonment i�w�ell ia tirii pendHn io t6e torm of i SI'OP WORK ORDER�ad a Oee ofS100.00 a dq qtiwt ma I��dershW that■ eopy ot thb�ntement may be torw��rded to the ORee ot Inve�tig�tiom otthe DIA for emera�e veri6utfa. I do-hrreby� erti n r t r pains and penaltier ajperjury thm�he injormation providtd obove is nue end correct Signamrc �Z—�1�0 � � �.r� Print namc LS �� C�'ti-�` �� one M ��- �'1�''�J �Y ., oRcial use anh do not wriee in�his area ro bt completed by tity or tmva ollleial ciry or mwn: Y�M�DT$ _ ptrmiNieeex M nBuilding Dep�rtmmt �Lieemio;Bovd � check if immediate response i�required 261 �Selectmen'e ORce �Hedth Departmeet � ron�act ptrson: pAoneM;_ CSOS} 398�7231 eat. nOtAer TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #02-045 FEE: $150.00 In accordance with regularions promulgated�mder authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pecmit is hereby granted to: The Pancake Man_ i.td_ 952 Rnute 2R South Yarmouth_ MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2002 BOARD OF HEALTH: eiFanCea�, xe(likac. �(,laGuxsac SEATING: 165 �.1� ��f D. � 9K.D., �(/�ee 1�o�9t17• �2aWrt. � �aariek�ou�rott :� Skak.,�ryl. February 21 ,2002 ruce G.Murphy, .5.,CHO Director of Health THE COMMONWEALTH OF MAS5ACHUSETTS TOWN OF YARMOUTII PERMIT NUMBER: #02-028 FEE: $50.00 This is to Certify that ` The Pancake Man Ltd. d/b/a The Pancake Man 952 Route 2R SoLth Yarmonth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto�xed their official signatures. BOARD OF HEALTH: �ifanlea�. xef�ec. ��,lis�wra.c senTwc: 1Gs �D. Cjmrda.� yil.D.. `Giee ,�o8ett'3. b'iotavc, eletk �afitck'I1lc�Dr�r.xotL' �f S ��l. Februarv 21 ,2002 G.M hy, H, .,CHO D'uector of Health . . �.,r. ,.,..�_ . ;�.: �,�, „�,..�..._ _ ,�s. A P�vcc�Kc MfJrJ . �� `c.::�-`',k35 G'3CKC� L� � MG� � TOWN OF Yr1RMOUTH BOARD �� ,� �q N 1 0 2001 APPLICATION FOR LICENS T��I�OI�� A HEALTH DE 7. • Please complete form and attach all necessary documents by December 31, 2000. Failure to o so v�n the retum of yow appiication packet. ----------------------------------------------------------------------- ----------------------------------------------------- I�AME OF ESTABLISHMENT: T Q DA�JGA�� M A�..) TEL. # �,4 B-`Li�1/ LOCATION ADDRESS: �: -r z8 IYIAII.INGADDRESS: Y�„x� I�It'� 4k�ia+�+��s �,rQ' a26�1`1-Dl�u N • Z"Vu_ ,� e,� .,. MANAGER'S NAME:YVI r�a, , a�i e� TEL. # MAILING ADDRESS: �o,� � ;_-��i�i nn�s �a �t� +t '-�-vJ 5� -----------------------------------------------------------_.—__--------------------------------------------------------- POOL CER'TIFICATIONS: The pool supervisor must be certitied as s Pool Operator, as reyuired by new State law. Please list the designated Pool Operator(s)and attach a copy of the cerhfication to tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Carciiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tivs form. The Health Deparlment will not use past yeara' records. You must provide new copies and maintain a file at your place of businesa. 1. 2. , 3. 4. HEIMLICH CERTIFICATIONS: All food service establislunents 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-chokiug procedures below and attach copies of employee certifications to this form. The Health Dep artment will not use past years' records. You must provide new copies and maintain a fde at your place of busineas. 1. �ars�n �� C , �, ' 2. 3. 4. RESTAURANT SEATING: TOTAL#� NON-SMOKING SEATS: TOTAL# l� � _...._.___.��.�.---�,..._�----- =-_— ------------ ------- _ QFFICE USE ONLY - - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMINGPOOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 / >100 SEATS $150 l '(v7� _NON-PROFTT $25 _ 1 COMMON VICT. $50 �0 I -0&3 WHOLESALE $75 BETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _45,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NeLME CFLANGE: $10 AMOUNT DUE _ $ 200.o0 *•*•'PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM••*'* _.__ . - : � �: - -: . , ADMINISTRATION Ut�der;Chapt�r 152, �ection 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of�y'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 Yannouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_S� NO NOTICE:Pemuts run annua(ly from January 1 to December 31. IT IS YOUR RESPONSIBILI'TY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHIv1ENTS ARE TO CONTACT TE�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENRQG FOR THE SEASON. 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 PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depanment,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,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 NF'W 4TATF CANiTARY CODE FOR FOOD ESTABLISHMENTS• The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establishments must have at least one person-in-charge who is a certified food protection manager. �s provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory, Food Code 3-603.1 l,will be implemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked a�imal products aze required to have consumer advisories. CATEIZiNG POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requited Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ' FR07.F,N DESSERTS: Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health DepaRment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. O T E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waiiress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food p uct by a retail or food service establishment is prohibited. �� DATE: 1� - L`�'b b SIGNATURE: PRINT NAME & TITLE: �� Q Y(�� i �AN P��; / 11/16/00 � . NOTICE NOTICE TO - TO EMPLOYEES EMPLOYEES � . The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston Massachusetts 021ll 617-727-4900 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: Eastern Casualty Insurance Company (Name of Insurance Company) 325 Donald J. Lynch Blvd., Marlborough, MA 01752 (Address of Insurance Company) WC94161802 08-01-2000 TO 08-01-2001 (Polic�•Number) (Effective Dates) Olde Cape Cod Insurance Agency,Inc. 435 Main Street,Hyannis,MA 02601 (508) 771-3300 (Name of Insurance Agent,Address,Phone) The Pancake Man LTD DBA The Pancake Man 952 Main Street, Yarmouth,MA 02675 (Employer,Address) Employer's Worker's Compensation O�cer(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 Inquiry must be given to the injured employee. The employee must select his or her own physician.The reasonable cost of the services provided by the treating physician will be paid by insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, empioyees are hereby notified that the insurer has arranged for such attention at the (Name of Hospital) (Address) TO BE POSTED BY EMPLOYER . WC 7506e(Ed. I-89) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #01-134 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of the General Laws,a permit is hereby granted ro: Th Pan ak Man i td 95 Ron R 40 � h Yarmo rth T��A Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2001 BOARD OF HEALTH: $d� �etl¢Q, �liai�uuaa SEATING: 16$ e��, �jl, z�y ��, /f/��ra.� v'��. ��. �, �ry� e1� �Col'QH[CSL �. �OK. ��(„ [/. Mazch 8 .2001 ruce G. Murphy,MP , ., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #01-083 FEE: $50.00 This is to Certify that The Pancake Man. Ltd. d/b/a The Pancake Man 952 Ronte 2R South Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2001 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. Tlvs license is issued in conformity wrth the authority�anted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigied have hereunto affixed their official signatures. BOARD OF HEALTH: �//[d�f�K,�.� /��etl�eya-,ee�,/�� 1'aa SEATING: 165 ��_vBw--.cJ� fT. /��CG�G, V[LG� �iQC11yK{iy �O�L � �, �R �eai a�' fCozdox. 'f1�D. March 8 ,2001 ' ruce G. Murphy, M� , R� , CHO Director of Health �fF�,ci�c�� N(a�� G3 � C� f� � V� (� D " "E s TOWN OF YARMOUTH BOARD OF HEALTH �o�� p N 1 3 2000 APPLICATION FOR LICENSE/PERMIT- 2000 �C • c�' �ti� HEALTH DEPT. * Please compiete form and attach all necessary documents by December 31, 1999. Failure to do so w� resu the return of your application packet. ------------------------------------ ------------------------------------- ------------------------------- F E I ' �e � hx.i>I�e M.4a . L`f' T> # �ct�v-�3L LQCATIONADD�SS� c15Z CYs 2S ' yacmbu�t�s, a � LIN owrr�ivco�o�T��nME: Q_ 7�.` �s a # ��3'� , MAII.,INGADDRESS' �' b , ay. 1`-i � yc�n��s �� , 02b 1 —_-----------_.._________W_--------___�____�___----------------_��-------------�_____��__. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the designated PooY Operator(s) and attach a�opy of the certificarion to tlns furm: 1. 2. Pool operators must list a minimum of two employ�s currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitadon (CPR). Please list these employees below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain $Cle at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maaeuver 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. 'Mm.�s�.��,� �-�n z. 3. � 4. RES�'AURANT SEATING:- T1�TA�,1�-��- -I�I(lI�I-SMOKI2�IG�EA�'�: �11�'�-tkZ�L-___ - ---- --_ ------_______--__-------------------------------�---~----------------------------_--_—_-____�. OFFICE U,,E� i0� LICEN3E REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _IlVN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 MOTEL $50 _SWIl�IINGPOOL $SOea. _WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT # _0-100 SEATS $75 _CONTINENTAL $30 I >100 SEATS $150 YZK- 152 NON-PROFIT $25 i COMMON VICT. $50 YZ{L-8fo WHOLESALE $75 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME AN E: $10 � AMOUNT DUE _ $ ZC� - '••••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM^^••• �-'�`L, ADMINISTRATION � r � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQUIltED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A • PERSON OR COMI'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTI' MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � 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 NOTICE: PERNIITS RLTN ANNUALLY FROM JANLJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTY DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIlVG FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY 1T�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWINIIvIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY THEREAF'I'ER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWINIIvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY TF�YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TEIESE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf-IE HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN TI-� SUSPENSIONORREVOCATION OF YOURFROZENDESSERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEI�MET._ _ __ _ __ _ _ _ __ _ ._ _ _ _ _ _ �JT IDE FF : Oi7TSIDE CAF'ES (i.e., OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM Tf�BOARD OF HEALTH. OIJTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. DATE: �2(Z` ( �5 SIGNATURE: PRINT NAME& TITLE: �ta f�� I� �Q( �L(.1 �I-��;,�_ 11/12/99 � � ', The Commonwea!!h ojMassachusettt s � Deparlmenf ojlndustrial.-Iccidents � a 0/1Ic0 o/%vesl/Ostll�s 600 Washingron Slreer Boston, Mass. 01111 ` �� ' w'orkers' Compensation insurance AHidavit �pnlicant informallon: PI n=e� n�mr lacation: cit� phone a � I am a homeouner pzn�rming all work myseif. � I am a solz proprietor a: � ha�e no one norkin� in am capacin� � I am an_employer pr9�idino workers' compensation-for myPmployees workin¢on this jab. ' y�� > comPanv name• �Vl`� �U,v�cu.�3- 1��A �sldress: Q `� �- (Z�G Z 9 titv: s �! LlC'!Yl o u1d pheneu. 5 06 -3`i S -�1�3Z �sur�nceco EA,CTsea� l AS .Sz.�TV nnlieyk �� `r l �o� ��J�L 7' � I am a sole proprietoc generai contractor. or homeowner Icircle onU and hace hired the contractors listed below ��ho ha�e thz follu�cin_ «orkzrs ;ompensation polices: companv name: � ad d ress• ciR�: phone p• insurance co po�i��p eomoanv name: addresr �'� phoee M• insurance co. noRev M Failure to seeurt covenLe�s required under Secnoe SSA of MGL ISS n�Ind to tht iopnidw W eridW pndtlea of��e ap to f1,500.00��d/or ooe yean' imprisoement u w�ell��tirii peeddn io tht form of a STOP WORK ORDER ud a Oae of 5100.00�dar q�in�t m6 I��denta�d Nat a eopy ot IAn sutemen� �y be fonv�rded to t6e 011fee of Invnti`�tiom of IEt DIA for eoven�e veritinWa /do�hrreby c i un er rh pains and partaf�res ojpery'ury tha�the injormatian provided abovt Is true and contct Signamrc � ZI �� Cl � Print name n�'�V` l � oneM ..3y� ��5� )/ .. olfioial use onl.� do not w rite in this�m ro be completed by eiry or tmvo oflleiil city or town: Y�M�DT$ _ � permiNieeeu M nBuildine Departmcot �Liteesioe Bo�rd �check if immediate response ie requir�d 261 �Seleetmen'e Otfiee (508) 398-2231 eat. DHe�lth Depanmeet contact person: phone N:_ __ _ nOther , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: Y2K-152 FEE: $150.Q0 In accordance with regulations promulgated under authoriry of Chapter 94, Section 305A and Chapter I 1 I, Section 5 of the General Laws,a permit is hereby granted to: The Pancake Man i td 95? Rn � R 4nnthi Y�rmn ��th 1��q Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:��/. ,}gt�ggs, C'�a(�r,,,tazq � SEATING: 165 �(�oa/re�c 7�/u�llivan.��/r�g.�/ , �/�e C�(�� Kaberf y0 .pl�rown, l,[erk a6rie�lea Ja�no�a�y/-g.�oopee k�L do h[in January 28 .2000 ruce G. Murphy, MPH, R.S C Director of Health ..,,_-___ _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-86 FEE: $50.00 This is to Certify that The Pancake Man- Ltd d/b/a The Pancake Man 952 Ro rt R 4outh Yarmonth MA IS I-IEREBY GRANTED A COMMON VICT[TALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirry-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornuty wrth the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��r`�sNaa+g� C'�a(d�r�nqa�n � / /J/ SEAT[NG: 165 oa/rt C�. �/a�lCivan�/K�g.///., Vic� l,hairman obert e�g 9�rowpn, C,[e,r/k a6rieCle.�a�nU�Zy-✓doopse • �lQ �'o,�/ �� ]anuary 28 ,2000 � ruce G. Murphy, MPH, . O Director of Health . • , � F�c�r,dCC�lce.. vna;� 1 ° TOWN OF YARMOUT b��'�P�� H APPLICATION FOR L CE�T��/P�E��- 1 9 ' * Please complete form and attach all necessary docume t �Ie��6�zf�T 1 98. Failure to do so will result in the retum of your application packet. ------------------ ------------------------------------------------- ---------------------------------------------i-------- TABLI h � i= � L. 3�' � �1J 33 A I D c Z $ � � -rt� Q � t�- a � �I T N vi c a �J c�- - � �T R' N 5 w le ' # 1-0 �3� MATi IN D F 4 • P o �v h x S 3�1 y� r� a � P rz� 1 M(k p 2G�✓1 --------------------_—___------------------ - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. _ Pool operators must list a minimum oftwo employees currernly certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to t}us form. The Health Department will not use"past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. HEIlVILICH 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 �t'de at your place of business. . 1. i �� l: 2. 3. � 4. RESTAURANT SEATING: TOTAL# 1 q � NON-SMOKING SEATS: TOTAL# i�� _-------------_--_—_---------------------------------------------------------------- -- - - - --___ _ ._ _ UFFICE �T�E ONLY LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII.ER PARK $50 MOTEL $50 _SWIlVIMING POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT # 0-100 SEATS $75 CONTINENTAL $30 I >100 SEATS $150 99��L NON-PROFTT $25 1 COMMON VICT. $50 � -7O _WHOLESALE $75 RETAII.SE�VICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ �-�- """""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM""""" ADMINISTRATION UNDER CFIAPTER 152, SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOUTH IS NOW REQUIltED 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 � , 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 NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBII.TTY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�vvfEEIVTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISF�VVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMNffNG, WADING AND WHIIZLPOOLS WHICH HAVE BEEN CLOSED FOR TF�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENf,AND THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEI�iING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY 'I'f� YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS _ - _ TiAVE B�EN ME�. _ . OUTSIDE CAFES: OUTSIDE CAF'ES(i.e.,OiJT'DOOR SEATING WITH WAIT'ER/WAITRESS SERVICE), �HAVE PRIOR APPROVAL FROM Tf�BOARD OF HEALTH. . OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY�QF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. �\ � � ��\ �' � � DATE:�� ' �`'G� � SIGNATURE: � PRINTNAME& TITLE: \�1\u(SY�G.V� \� Q�� Y`G�� • a � The Commonweaf[h ojrNassachusetls W Department ojlndustria/.-lccidents ; 61flce ol/srestlDsWis 600 Washington Street Bosfon, Mass. 01111 ��'` Wbrkers' Compensation Insurance Affidavit Anolicant information: P►eauPRilQ'1'4bSd'a � nam�: � �1 YG�1 CG��U. 1��..)i �-�� loc�tion: �5�' �`n' Z D . ci[�- �• �ILlfYV1U1A �C. \� I� ehon # �'7Pi� �J �Jv � I am a homeowner pertortning all work m}self. � I am a sole proprieror _-d ha�z no one uorkine in an} capacih� '�] I am an employer pro�iding workers' compensation for mp employees workine on this job. comPan�� name: 1 1\P � .. .�6 h(XY 1C t � i I P�J � �—�`Y> . __. . . . . . . .. _ . _. _— _. aJAress: I 5� ��: 2J iih.: �J61.1'S�.+ `%A�mouc�.a MI, ehonek: Sug- 3�C�- � � 3L [psurance ca. L�5� 2 uJ CA 5`�0�-ti�n S�S `o � policv# �A �- "l� '� � �e � �b�' � I am a sole proprietor. �eneral contractor, or homeowner(circ/e onel and have hired the contractors listed below �cho have thz follo«in_ «orkzr ,ompensation polices: comppnv name: address: cirv: phone H: insurancc co poliev k eamRany namr. � � - . _. .__. . . _.. . _ . . . .. __ . .. .. _ ..---- _ . ._. _. addresr. � .. . .... . ... .. . - � c�: phoee N• insuranee co. ooliev N Failure to xeurt covengt as required under Setrioo ZSA o(MGL IS2 nt Idd to the iepaitloe oferisiW pndtln of�O�e ap lo f1�00.00 a�d/or ooe ye�n'imprisonment af w�ell at eivil penalHa io the form of�STOP tYORK ORDER ted a liee of f100.00�d�y qdert m� 1 a�denh�d th�t• eopy of thb shtement may be for.vardcd to the ORce of InveniQaliom o(the DIA fo►emen�e veriReatlo�. /do�hrr ( enijy ur�'er rhe pains an�(�enal�iet ojpe�ury that�ht injormation providtd abovt is nue and rorreet � A �Y1AN, �� SignaNrc OT��r� � Dau ��'" I l—5 y ,n,, T Printname 1�'tA (S�a, �� . �0.�� al�u oneM �"�- 39B -`��3�— . oRcial use only do not.ritt in this�ra ro Ue completed by eity or rown oHltial cily or town: Y�MODTQ _ permiNieeax N nBuildiog Depirtment ❑Lieensiog Bo�rd �check if immediale response ie required 261 �Stleetmen'�011fee (508} 398-2231 eat. �Hea1tA Departmeet contac�person: pAone N:_ __ _ nOther UmneE iA5 Plnl • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: 99-112 F'EE: $150.00 In accordance with regulalious promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a pecmit is heteby ganted to: The P�ncake Man i.td 952 Rnnte 28 Snuth Yarmouth MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31 1999 BOARD OF HEALTH:��P/. ,�otta�pe, C'�(��,/a�,.� / /J SEAI7NG: IGS � - oa.a C�. �nullurany/K7a.///.� Vice l,�irman o�erf�nO,roavgn� l�[e,r/k a6rie�Ja�/o1ld�y-gJdoopee . � ic� ,O� Cou9�lin February 8 , 19 99 Bruce G.Murphy,MP R ,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-70 FEE: $50.00 This is to Certify that The Panc�ke Man,Ltd d/b/a The Pancake Man 952 Route 28 Sa �th Yarmo �th MA IS HEREBY GRANCED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and eacpires December thirty-first 1999 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��Yl. �ett�wg, C�/�;+�q/�nn / /� SEA7'ING: 165 �(�oan��7Knl(svan�K.1//.� Vice l.�irman Ko�e�t�Jg . /�rowan� CG/�/k . . . a6,�ieUa@�a.�o/e�y-.Mnnpoe ' �L o in eF bniaty.g, ]9 99 ruce G.Muiphy,MP RS HO Director of Health �� "'?:'� �-`��_ � �CVI��' �"1U _ ,,' f", � ` G�3 [� C� (� � �u [�'; lo TOWN OF YARMOU'I'H BOA�tD OF HEALTH APPLICATION FOR LICENSE / PERMIT - 1998 JAN 1 3 1998 ��ga�3 , �-{t.A�?H Di PT. '�Please Complete form and attach all necessary documents by December 31, 1997. FaTuie to oc� so will resuk in the return of your application packet. --------------------------------------- - - ----- - - -------------------------------------- - ------------ NAME OF ESTABLISFTMEN � i l�- an�°-� ��-- � u � TET # �S 3- �S 3 u ADDRESS: 45a t'�az-n= a v So...t�+ �/arM c�� N�A � Hc� �AILINGADDRESS P o, 3�x 1�{ 4 }l�a,r� � j�rt� (.dA c�Zb�ll 9__�R/CORPORATION NAMF• T6,- Pan� k.c- M�J �� MANAGER'SNtLiviF:i�p,GZs�+au.- '�. �o �1e.� TET # �7I-o��'� I�AILING ADDRE4S• t3 ok 5.'�� FS�.��,�, , �J� �i� ,�q o Lt�� ------------------------------------------------------------------------------------------------------------------ POOL CERTIFiCATIONS: Pool Operators must list a minunum of two employees currently certified in basic water safety, standazd firsk sid and Community Cardiopulmonary Resuscitation(CPR).Piease list these employees below and attach copies of employee certificafions 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. l. 2. 3. 4. 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 cartifications to this form. The Health Department will not use past years records. You must provide new copiea and maintain a file at yaur place of busiaess. 1. 2. 3. 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL # ----------------------------------------------------------------------------------------------------------------- OFFICE USE ONLY LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQLTIRED FEE PERMIT# _B&B $SO _CABIN $50 _INN a50 �CAMP $50 _LODGE $50 _TRAILER PARK $50 T MOTEL $50 _ SWIM POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LIC. REQUJRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# _0-100 SEATS $75 _CONTINENTAL $30 _j,._>100 SEATS 15 ��7 _NON-PROFIT $25 _,(_COM. VICT. 0 �H_� 7? _WHOLESALE S75 $ETAIL ��:A�'i�E� LIC. REQUIRED FEE PERMIT# LIC. REQLJIRED FEE PERMIT # _<50 sq. ft. S45 _TOBACCO $20 _<25,000 sq. ft. $75 _FROZ. DESSERT $35 __>25,000 sq. ft. $20Q - - - - _ __ _ l�� SeparaEe payment is needed for AMOUNT DUE _ 'J� liquor or entertainment licenses ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSLJRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. P,L'BASE CHECK APPROPRIATELY IF PAID: YE5 ✓ NIO NOTICE: PERNIITS RUN ANN(JALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL fiSTABLISHIvIENTS ARE TO CONTACT TI� HEALTH DEPARTMEN'I'FOR INSPECTION 7-10 DAXS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTA$LISFIlv1ENT,MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TQ AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. t�nDITIONAi REGULATIONS POOLS POOL OPENII�tG: ALL SWIMMING, WADING AND WHIRLPOOL5 WHICH HAVE BEEN CLOSED FQR'tHE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMA�IING POOL MUST BE _ DRAINED OR_CQVERED WITHIN SEVEN(1)I�AYS OF CLflSIrICx --_ FOOD SERVICE SATERiNG POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING'I'HE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. 'I'I�SE FORMS CAN BE OBTAINED AT TI�HEALTH DEPARTMENT. FROZFN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI� HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATIdN OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET. � � � �� OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI-IE BOARD OF HEALTH. OUTDOOR COOKING: - OUTDOOR COOKING, PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�vvIENT IS PROHIBITED. DATE: l 2� 3 -�i 7 SIGNATURE: PRINT NAME 8c TITLE:��°�Ci C�I�. � I' . �A. ��`� ��,o c�c/' 10/97 page 2 of 2 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-124 FEE: $150.00 In accordance with regulations promulgated under aufliority of Chapter 94, Secrion 395A and Chapter 111,Section 5 of Ute General Laws,a pe[mit is hereby ganted to: The Pancake Man T,td_ 952 Rrn�te 2R Sonth Yarmnnth MA Whose place of business is: The Pancake Man Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31_ 1998 BOARD OF HEALTH:�d �/. �ettae, C'�atr„�a2 SEATING: 165 �[�oan ��7s/u��a�,/,�7/��/ , vue c��,�,� Ka�ert a,a}. 9�row/n� l,[e/r/h a6rie[le �a�r/o�/a�rj-.htooPae '� fC�@� oIOU��[42 � January 27 ; 19 98 (_.i�_ � ��--� Bruce G. Murphy,MPH, R S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-77 FEE: $50.00 This is to Certify that The Pancake Man_ Ltd. d/b/a The Pancake Man 952 Route 28, Snnth Yannonth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 1998 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��/. .`��oittpave, C'�/,�a.,�n/a�n/� / /� SEATING: ]()$ �(�aa/n ��7Ju/�lCivan� K/.//l.� 1/�+:w l��Tzirmun Kober�QJD . O>rowan� �Le/r'h a�rie[laQ�na�i/o1/a�i�/-.//htooPe:t ic�aeKj/oCauQh(i �" � . 18a��z� , �y 9s l ;� ��r% y t�cc- �.1,_� Bcuce . ucphy,MPH,R.S., CHO Director of Health