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Home My WebLink AboutApplicatons, WC and Licenses Prior to 2010C w 1P , TOWN OF YARMOUTH BOARD OF HEALTH \N U U APPLICATION FOR LICENSE w ,R 2p,' DEC 1 7 2008 * Please complete form and attach all necessa doc I S ec b r Failure to do so will result in the return of your application pa c ® �� NAME OF ESTABLISHMENT: �6 MI VIO 1 S V12—Z,,— P TEL. # 5W -,MV— UA LOCATION ADDRESS: 2-37— i " P4,A Ozwy MAILING ADDRESS:hoz s(oid j", MA 41`7-` ) OWNER NAME: A3 �J TAX ID FEIN or SSN : 6Y 3 CORPORATION NAME (IF APPLICABLE):LzA vt� MANAGER'S NAME: YW M jY ItV MAILING ADDRESS: POOL CERTIFICATIONS: t�1� The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 3. S P� 073r&'gPS FOOD PROTECTION MANAGERS - CERTIFICATI, All food service establishments are required to have a: Protection Manager, as defined in the State Sanitary G -575-6-1n-0 Please attach copies of certification to this application. I You must provide new copies and maintain a file at d 7 ///1 04'?o GS �7'C0c, d as a Food 4R 590.000. irs' records. PERSON IN CHARGE: 0003!o s = / 2 5 Each food establislunent must have at least one Person / [tion. 3 3 7, 1._ swy- L J p �Z i 7, a� ? 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 tunes. Please list your employees trained in anti -choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # LODGING: LICENSE REQUIRED FEE PERMIT # B&B S55 NP: S55 LODGE S55 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # 10-100 SEATS S85 >100 SEATS S160 RETAIL SERVICE: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT # _CABIN $55 —CAM $55 TRAILER PARK $105 LICENSE REQUIRED FEE PERMIT # _CONTINENTAL S35 _COMMON VIC. $60 LICENSE REQUIRED FEE PERMIT # _MOTEL S55 SWIMMING POOL S80ea. _WHIRLPOOL S80ea. LICENSE REQUIRED FEE PERMIT # NON-PROFIT $30 _WHOLESALE 580 —RESID. KITCHEN S80 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $50 >25,000 sq.ft. 5225 VENDING -FOOD $25 <25,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO $55 NAME CHANGE: $10 AMOUNT DUE = $ 85.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** : " , ADNIINISI'RA'ITON Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NYOTELS 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 of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which haue been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening. PLEASE NOTE: People are NOT allowed to srt m the pool azea umil the pool has been inspected and opened. POOL WATER TEST'ING: 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 CI.OSING: Every outdoor in ground swimming pool mustbe drained or covered within-seven(7)days of closing. FOOD SERVICE CATERING 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. These 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 resuhs must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut unUl 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 ofHeakh. OUTDOOR COOHING: Outdoor coQking,preparation,or display ofany food product by a retail or food service establishmerrt is prohi6ited. NOTTCE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQLTIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I�i� 3�� D SIGNATURE:� _ � PRINT NAME&TITLE: �✓�l �YB�, oLlHe/z- i�zt�os �„'� The Commonwealth ofMassachusetts ' ;� � Department of Industrial Accidents �` : �9�.",Ps: ��'� Offce oflnvestigations '� i,,,i;;k � 600 Washington Street i" Boston, MA 02II1 ``�" www.mass.gov/dia Workers' Compensation Insurance Aftdavit: General Businesses A�plicant Information Please Print Le iblv Business/Organization Name:_ �6 tvll Vt�'S �+2Zv Address: 32�`� E�(�� City/State/Zip: �y✓I I �+N M O l�1 Phone#: _ ��'��--``�fZ� Are you an employer?Check the appropriate box: Business Type (required): L "�I am a employer with�employees(full and/ 5. ❑Retail or part-rime).* 6. �RestauranUBarBating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � pffice ancUor Sales(incl.real estate,auto,etc.) ; employees working for me in any capacity. [No workers' comp.insurance required] 8� �Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑;Entertainment theu right of exemprion per c. 152, §1(4),and we have 10.Q Manufacturing no employees. [No workers' comp. inswance required]* 11.❑Health Caze 4.❑ We aze a non-profit organizarion,stafFed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[�'Other ��'� Dr�r.vr •Any applicant thaf checks boz#I must also fill out the section below showing their workers'comprnsation policy inCotmaU . '•If Ihe coryo2te officers have exemp[ed[hemselves,but the corpora[ion has o[ha employees,a workers'compensation policy is required and such an organirntion should check box#L . � � - I am an employer that is provid/�ing warkers'campensation insurance for my employees. Below is the policy information. Inswance Company Name: Y 'E�0'�-�SS �Vfo1L11`kNt.ta . Insurer'sAddress to�- Il�e�(1(i�. .� City/State/Zip: ��,� D;7��f3% Policy#or Self-ins.Lic.# ��,� 7�3�o/�3 Expuarion Date: �12(6 y Attach a copy of the workers' compensation policy declaration page(showing the policy number and espirallon date). ; Failure to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine up to$1,500.00 and/or one-year unprisonment,as well as civil penalHes in the form of a STOP WORK ORDER and a fine of up ro$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verificarion. I do hereby cem under the pains and penalties of perjury that the information provided aGove is true and correct �naNre: � �� (�L.. Date• �7/��/'� Phone#: � . - d T-�-' �l�L� � Official use only. Do not write in thls areq to be wmple{ed by city or town afftciaL City or Town: Permit/License# Issuing Authority(circle one): � � 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5:Selectmen's Office 6. O[her Con[act Person: Phone#: www.mass.gov/dia � � 11/24/2008 13:19 FAX 15087974030 The Feinsold Companies �002/009 ACORD �E�T��E .Q� �F��LET� [��E OATEIMM/OD/YYI :. �:� 22 2��6 ,:i rnooucen ��THIS CERTIFICATE IS�ISSUED AS��A MATTER OF INFORMATION F21ri OZCI & FElR O1C� ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9 4 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR IIISllTdRC2 AJERCy� II1C . ALTER THE COVERAGE AFFORDED BV THE POUCIES BELOW. 22 EZRI Street COMPANIESAFFORDINGCOVERAGE Worcester, MA O1E08 coMrnNrPeerless Insurance Co. DEL A INSONED COMPAyV A. M. Pizza, InAc . g 384 Edgell ROaLL COMPANV Framingham, MA 01701 � � COMPANV D CAY�RA�ES . . . . . . .. . . . . THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE�POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER �OCUMENT WITH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUED OR NAV PERTAIN, THE INSURANCE APFORDED BY THE POLIQES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEflMS, EXCWSION$AND CONDITIONS OF£UCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSUPANCE � . POLICY NUMBEX POl1CY EFFECTIVE POLICY EXNPAiION � � pMITS �TA � OATE IMMIDD/YVI D/TE IMM/DDhYI � GENER.9;:IABIl1TY GENERALAGGREGATE S COMMERCIALGENERALLIABILITV . PRODUCTS-COMP/OPAGG 8 CLAIMS MADE O OCCUR PERSONAL 6 ADV INJUHY �' 8 � OWNER'S&CONTRACTOR'S PROT EACH OCCURFENCE 5 �' ! I FIRE DAMAGE IAny one tirel 5 MED EXP IAnv ona personl S AUTOMOBILE LIABILITV COMBINED SINGLE LIMIT 5 ANV AUTO � ALL OWNEO AUTO$ BODILY INJURV g SCHEDULED aUT05 IPer personl MIRED AUTOS BODILV iNJURV g NON-0WNED AUTOS . IPer acci0entl PHOPEFTV OAMAGE S GARAGE LIABIl1TY AUTO ONLV�EA ACCIDENT 8 ANY AUTO OTHER THAN AUTO ONLV ' I EACH ACCI�ENT � 8 � AGGREGATE S EXCE55 LIABILITY EACH OCCURRENCE 5 URICAELLAFORM AGGREGATE 9 OTNER THAN UMBRELLA fORM � 9 WOflKERS COMPENSATION AND X WC STATU- OTH T RV LIMIT EH A emv�oreas•uns�urr WC8423693 WC r'>/12/�8 rJ/12/�9 ELEACHACCIDENT 8 rj00 �QD THF PFOPRIETOR/ INCL EL DISE.GSE-POLICY LIMR ! S O O O O O ' PARTNERS/E%ENTNE OFFlCEFS ARE EXCL EL DISEASE-EA EMPIOYEE 5 S O O O O O I OTHEP DESCRIPTIONOFOPENATIONSlLOCATIONSNEHICLES/SPECIALITEMS re : 23 White � s Path CERTEFICKTE HO£QER �}��g , . . CANCELEATIL4H . . . . , F' SHOULD ANY OF THE ABOVE DESCRIBED POl1CIE5 BE CANCFLIED BEFOHE THE Town �L Yarmouth E%%flATION DATE TNEHEOF. TXE ISSIIING COMVHNY WILL ENDEAVOH TO M/!IL Board Of Health �Q DAYS WHITTEN NOTICE TO THE CEXTIFICATE XOLDER NAMED TO TNE IEFT. Yarmouth� MI� BUT FAILUflE TO MAIL SUCX NOTICE SHALL IMPOSE NO OBLIGATION OR UABIIITY � OF ANY KIND UVON THE OMPANY, ITS AGENTS OP REPflESENTATIVES. AUTHOHIZED flEPXESENTqTIVE � � � AC�1RD25-St1f9S) `QR£qRpC{3RPt7RhTtUk9�88 `� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-126 FEE: 75.00 In accordance with re�tions promulgated under au[hority of Chap[er 94,Section 305A and Chep[er 111,SecUon 5 of the eneral Laws,a permit is hereby granted to: A.M. Pizza, Inc., 23T Wlute's Path, South Yarmouth, MA Whose place ofbusiness is: Domino's Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BOARD OF HEALTH: .�E¢P¢K Slfll� �..N.� P.hairrmcuc sennrrc: o C,hpK[ee ,`!f, 7Cellilie�x,l 9J,,tce ClEaiaunarc aEs7xlc[7oxs: See Reverse Side. J�p�PXI S. $K�Wh, (Z�Yh Q�',I•f,I,�t,�',,K¢¢It��I{i,L,L'N'nty.�..lv. """'Y"�• """Y`"' Januarv 9,2009 ruce G.Murphy,l� ,R.S.,CHO Director of Health 'RESTRICTIONS: 1. No&yers. 2. No dishwashet machine. 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Separate water meter,for this unit 23T required. 8. All pizza ingredients are to be obtained as precooked. 9. Maanmum daily water usa�e not to eaccead 175 gpd;A montlily log is to be maintained with a yeazty repoR subautted to the Health Department by Decembet I of every yeaz. c►Aa 90 1-n x Ot =YAl TOWN OF YARMOUTH BOARD OF HEALTH . s APPLICATION FOR LICENSE/PERMIT - 2008 _ DEC 2 0 2007 * Please complete form and attach all necessary. docurmer><t �y Decembe 3 LAQAFH DEPT. Failure to do so will result in the return'of your application packet--'. NAME OF ESTABLISHMENT: orn nb, Y12_Z_ TEL. # S�$-3-fi-Lo LOCATION ADDRESS: 2-3-r N MAILING ADDRESS:_ p �ciycll 2�M�} lS112l OWNER NAME: 1:1664 T1ske w TAX ID (FEIN or SSN)• bt/ 9'/-7"0 V' 3 CORPORATION NAME (IF APPLICABLE): A -(, IVIC . MANAGER'S NAME: M 140 61,44,1 o)/ TEL. # S02--39 F- G-97 MAILING ADDRESS: Z [_ WW'e s 9�, \AeMOVO-L POOL CERTIFICATIONS: , The pool supervisor must be cev Pied as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to -this -form. - 1. 2. Pool operators must list a minimum of two employees currently certified in 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 He p place of business. will not use past years' records. You must provide new copies and maintain a file y I. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1 .PERSON IN CHARGE: - Each food establishment must have at least one Per: I. mf�lzh (�a , I"I HEIMLICH CERTIFICATIONS: N� All food service establishments with 25 s kor m Maneuver on the premises at all times. Please list attach copies of employee certifications to this form You must provide new copies and maintain a fil( 1. 3. RESTAURANT SEATING: TOTAL #_ 2. peration. 7 h'/ o 00 /8/Oo0 � (jar✓- �� DOD 1 in the Heimlich dures below and years' records. *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORJZ***** OFFI( LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT,' LICENSE REQUIRED FEE PERMIT B&B S50 CABIN S50 MOTEL S50 _INN S50 CAMP S50 SWIMMING POOL S75ea. _LODGE S50 _TRAILER PARK S100 WHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT � LICENSE REQUIRED FEE PERMIT / 0-100 SEATS 575 jh��,q _CONTINENTAL S30 NON-PROFIT S25 _>100 SEATS S150 COMMON VIC. S50 WHOLESALE S75 RETAIL SERVICE: —RESID. KITCHEN S75 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT= LICENSE REQUIRED FEE PERVIIT _<50 sq.ft. 545 _>25,000 sq.ft. S200 VENDING - FOOD S20 _<25,000 sq.ft. S75 _FROZEN DESSERT S35 TOBACCO S50 NAME CHANGE: S10 AMOUNT DUE= $ 75.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORJZ***** 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 CertiEcate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V 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: �S J No MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shali be limited to the temporary and short term occupancy, ordinarily and customarily associated with mote(and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transiern 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 sha11 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. * NOTE: En��osea Motel Census must be completed and returned witn tt�s app�icat�on. POOLS POOL OPENING: All swimrrvng,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(�days prior to opening. POOL WATER T'ES1'ING: 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 Tow�of Yazrnouth must notify the Ya�mouth Health Department by filingthe required Temporary Food Service Application 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 certiSed lab. Test resu(ts must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit urrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waitedwaitress service),must have prior approval from tke Board ofHealth. OUTDOOR COOKING: Outdoor eooking,prepaFation,or display of any food pradtiet by a retail or foed se,�vice establishment is-prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMEVCEME�IT. RE�IOVATIOVS MAY REQUIRE A SITE PLAN. DATE:� � SIG�IATURE: �/� �� PRINT:VAME&TITLE: H in��/ ��w ��/ 1p :n n- �• ll%19/2007 11:34 IFA% fax�felnBoldco.com � Yvonne Baker �003/005 ...ACORD ��R��F I��T� '.�� Ll��lLl�� E��R�S�FF� : .: DATEIMMIDDIVY� ��. �.1 19 2007 vaooucEa � THIS CERTIFICATE IS ISSUED AS A MATTEfl OF INFORMATION ONLV AND CONFERS NO RIGHTS UPON THE CEPTIFICATE F2iRCJ01C'1 & F2IRJOZCl HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Insurance Agency, IriC . AL7ER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 22 Elm St.Y'EOt. � COMPANIES AFFORDING COVERAGE Worcester, MA 01608 comPa�vEastGuard Insurance Co. YCB A — INSUHED �Y A. M. Pizza, Inc . B 384 Edgell Road i COMPANY Framingham, MA 01701 � ---- COMPANV D �OUEHAttE&� ` � I '; ; ��.; :; :; li . THIS IS TO�CEFTIFV THAT THE POLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUE�TO THE INSVRED NAMED ABOVE FOR THE POLICV PERIOD � INDICATED, NOTWITHSTANDING ANV REQUIFEMENT, TERM OR CONDITION OF ANY CONTRACT Ofl OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAV PEFTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREW 15�SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OP SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. __ _ LO POLICY NUMBEF POLICY EFFECTIVE POLICY EXVIqATION �IMITS �Tq TYPEOFINSUFPNCE ,, � DPTE�MMIDD/YY) I 04TE/MMIDDlYYI GENERALAGGREGATE ��, 5 GENEPAL LIABILITY- COMMERqALGENEFALLINBIUTY � � PROOUCTS-COMP/OPAGG �� 0 CLAIMS MAOE �OCNR PERSONFL&ADV INJURV � 3 OWNER'S A CONTFACTOR'S PROT i II EACH OCCURRENCE 0_ . � I FIPE DAMAGE IAny one flre� ' S __ �— MED E%P IAny one persanl I 5 IrAUTOMOBILE LIABIUTY . . . I COMBWE�SINGLE LIMIT � 5 I ANYAOTO � I �--"—..—... ALLOWNE�AUTOS I �'. BODILYINJUPV 5 i IPe�Person) SCHEDULEOAUTOS �' 'I �i --- HIRED AUTOS II �,i �� BOOILV INJURY �i y _ � � �I�Per acci0entl � NON-OWNEOAUTOS I '�. ,r— I I I �iPqOGERTV DAMNGF 4 AUTO ONLV�EA ACCIOENT �S GAflAGELIABILITY ' -- �� I I �OTHEF THAN AUTO ONLY: ��ANY AUTO I � i EACH ACCIDENT 5 AGGREGATE S i EXCESS LIABILITY EACH OCCURflENCE � 5 �Ir_� �IUMBRELLAFORM ',, I ' AGGREGATE_ . 6 _ � 1 CT4EP THAN UMB1iELLA FOPM I � � g � � I WC STATU OTH . WORI(EHS COMPENSATION NND I X � Y iiMl 1..�ER � � � A EMVLOVENS'LIABIIITY IDOWC805358 WC 5/12/07 5/12/08 je�encHnccioeNt �s 500 000 THEPROPPIETOH/ �'�., INCL �, ELDISEASE-POLICYLIMIT� S SOO� OOO PARTNERS/EXECl1TIVE EL�ISEPSE-EAEMPLOVEE I8 5OO OOO OFFICERS AFE: i E%CL I OTHEP I � DESCHIV�IONOFOPEXATIONSILOCATIONSNEHICLES/SVECIALITEMS re : 23 White � $ PatY1 GEfl3�ICRl'E';HDi[kEA _ fYd�'��:: . . CikNCELlAT1�7N :. ��, �':: :: SHOULO ANY OF THE GBOVE DESCNIBED POLICIES BE CANCELLEO BEFONE THE Town OL Yarn1011trl EXP�IP/A�TION DATE THENEOF, TXE ISSUING COMPANY WILL ENDEAVOfl TO MAII Board �f Health �y DAYS WHITTEN NOTIGE TO TNE CEPTIFICATE HOL�ER NAMED TO THE LEFT. Yarmouth� �+ 8UT FAIWPE TO MAIL Sl1CN NOTICE SHALL IMVOSE NO OBLIGPTION OX 1IA81LfiY OF ANV KIND UVON THE OMPANY, ITS IlGENTS ON REPPESENTATIVES. AUTHORIZED HEPNESENTATIVE ,L��I� 1f �' ~—Vr`� �. '��.ARC4ttDC#NiBkl�Sh'fiLYNi987S �� RCG1fiP RS-S:�[3i96] TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHIV�NT PERMIT NIJMBER: #08-098 FEE: $75.00 In accordance with reQularions promulgated under au[hority of Chapter 94,SecNon 305A and Chapter 11 I,Secdon 5 of the�ieneral Laws,a permit is hereby ganted to: A.M. Pizza, Inc., 23T White's Fath, South Yarmouth MA Whose place of business is: Dominds Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: ,�fe�en SfEaPt, J`2..N., C�abrmart SEAiING: 0 �� rq��,j, �,�, �h�� RESTRICIIONS: See Revetse Side. ,�/�p)yt�. ;�YO(I[�L� I:CPI[R . . Qf�l � __ UFK� �.JV. tuePtJ�a�, January 16.2008 Bruce G.Mmphy,M .S.,CHO Director of Health *RESTRICTIONS: 1. No&yers. 2. No dishwasher macliine. 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Sepazate water meter,for this unit 23T required. 8. All pizza ingredients are to be obtained as precooked. 9, Ma�mum dady water usa�e not to exceed 175"gpd;A monthly log is to be maintained with a yeazly report submrtted to the Healih Departrnent by December 1 of every year. � ��73� / � r ;_ ^ .l � , , - �� `;^"R o TOWN OF YARMOUTH BOARD OF EAL'CH �� 2 rFB 0 3 2006 o -'° APPLICATION FOR LICENSE/PERA31'�'- i, 6 '`. r �S . . _ a r '; �� ` � H A * Please complete form and attach all necessary documen y Dee�mber H��PT� Failure to do so will result in the return of your application packet. � NAME OF ESTABLISfIMENT: �g„,,,,�;� �I��, TEL. #50�-394-�682s LOCATION ADDRESS:�T 1�' k�le.s �q � MAILING ADDRESS: 3Fi Mc� s��o OWNER NAME:�ehrv 6<ekl TAX ID(F'EIN or SSI�•C�43-4�0 483 CORPORATION NAME (IF APPLICABLE): �M '�i� 7 �, p.t�Npp�H o2�a f,(0� MANAGER'S NAME: (a�e '> I• , u ', T'EL. # 5G8-3sro-�s&� MAII,INGADDRESS: 23-r ��e, �q-�-� 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 miivmum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department wdl 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 aze required to have at least one fiill-time employee who is certified as a Food Protectio� Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1.��C�S�v TYckucl�i 2. �aui ISan ._c��Va PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. l. Lile�s,. �nkud�� 2. Vo.vidscv� �o. S��va� HEIA+�;KH 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 attaeti eopies 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. RESTAURANT SEATING: TOTAL# D OF'FICE USE ONLY LODGING: LICENSE REQUIIZED FEE PERMII'# LICENSE REQUIItED FEE PERMIT# LICINSE REQUII2ED FEE PERMIT# _BBcB $50 _CABIN $50 _MOTEL $50 _INN $50 f CAMP $50 _SWA�ASQdG POOL$75ea. __LODGE $50 _ TRAII.ER PARK $50 __Wf�IIRLpppL E75ea. FOOD SERVtCE: LICENSE REQiJIl2ED FEE PERMIT k LICENSE REQiJIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMI'I't! �0-100 SEATS $75 �06"l,SZ(� CONTINENTAL $30 __ _NON-PROFIT $25 _>100 SEATS $150 _COMMON VIC. $50 _WHOLESALE $75 RETAIL SERVICE: LICINSE REQUIItED FEE PERMIT N LICENSE REQiJIItED FEE PF.RMI1'# LICENSE REQUIItED FEE PERMCi'# _<SOsq.ft. $45 _>25,OOOsq.ft. $200 _ _VEIdDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25 NAME CHANGE: E10 AMOUNT DUE _ $��',OQ """`^PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•*^ ADMINIST'RATLON 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 COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSIJRANCE 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 NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISf�tENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTHPRIOR TO C01�1MENCEMENT. 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 Department prior to opening. POOL WAT'ER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 selis ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These fonns 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 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 waiterlwaitress service),must have prior approval from the Board ofHeakh. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmerrt is prohibited. DATE: a ��b q SIGNATURE: � PRINT NAME&TITLE: ��n� /� � d ''r�' ovizsios •02/OB/.2006 15:01 FAA 1 508 797 40J0 FEINGOLD & FEINGOLD INS. w�uuo I r . � ift F � 3 �s '. � n y � � . t[ �EtY� 16 YR�DAlEMM10D/YV) .... � � �fy � x 3 � { 6� :'-: }F �/DN�n�,y�� ;�� iY��.�a�!r��r�.��e{...�. ��:Y��.t��3t�Y `�('.�.5lSi � .r1L.i:aii 2/09/2006 �. . t xr.+.•+r.r��+„xNnv:��w..., r.b., . <,f a.- � ,.�.. . . •e TlIYS CERTIFICATL 19 ISSUE AS A MA7TER OF INFOXtMA710N ONLY AND � °°°°�CeR CONFFR6 NO RIGHTS VPON 771E CER7IFICATEHULDER.TH1S CRR7IIrICA7E Feingold & Feingold DOESNOTAMFND,EX7£NDORALTEATAECOVERAGEAFFORDF.AHY7ttE Ineurance Agency, InC . POLICIES ow. , 22 Elm Street COMPANIIESAFFORI�1�'1GCOVERAGE Worcester, MA 01608 Y�B coMP��+v A NORGVARD Insurance Co. LFfTBP COMYnNY B � �. � i =- �� LETiER WSU�eD __ xenry �, Askew ,�,�;;M' c FEB 1 7 2006 A. M. Pizza, Inc. 384 Edgell Road L6TT60.v D HEALTH DEPT. Framingham, 1�1� 01701-3812 cowrnnr E L6TTE0. „� : s i :� a �v-;:'� � � ° �; k,t,".i ��x;.o,a ..a, �:;r � r �r! �.i r.,j:::'; `..4r??'aia�'�,,ykr.E��t..s F-..?:'':i K.<'..s�."nS,cz� t�i7�? ;5�`'tb �E �=:�,.. � .. . . ... - ��TNIS 15 '�'�CERTIFY TNAT'fNE POLICIES OF INSURANCE LISTED BEIAW HAVEHEEN 15511ED TO 'fHE INSURED NAMED AeOVE FOR TNE POLIC� PL'RIOD INDICA'fED.NDTWITHSiANDiNG ANY�EQU�RE�!EM.TERM OR CONA�1'��N OF ANY CONTMCT OR 07HER DOCUML•NT MTfN RfSPEC� 7'0 WHICN TFi1S EX[I,ll510NS AND CONOITIONS OA SUCH POLILlFS.LIMI7'S SHOwN MAY H�e BFFf1 REDUCED BY�PAID'CLA MS HFAEIN IS SU&ECT TO ALL TIiE TERMS, W 10LICYNVMEEIt DniLMMIDDPM 'DATH(MM�D�D/Yn I.�MRS � TYI¢OP N'6UY.V`1[E LEN6RALAGaiEGATE t C6NRIU1.LI�DIL�TY PRODUCTSCOMGIOVAGG. S COMM F0.CIALGENeRd L W ILIiY ,:.+i�% CL�fMSMADC��VR. PENSONN.AnD�.IMV0.Y S ��HOCCVRRENCE s .;�.• pWNER'ShC0�MG1'OR'SPROT. FIR60eMnGGlAnyenl�re) f MWRXV6tDE�AUYonepeneel f �VfOMOBILt LNOILITY MMBINE�SINGLE LIMR f ^�A� BOOIL�IN/V0.T � AtLOWN2��Vf05 ({4rPenmO 5 9CHEOUTAO AIff05 . X10.4DAUT05 OOO��YiN1VRY ' (Pot�MGnO S NON-0'M1E0 AIROS G�RA06LIABII,ITY PROOERTY��MACE s GCHOCCURRENGE � HXC6661UULlTv S AOGRFAATE VM6RElL�OAM � � .,.8 � ., . � r� 'V� �� 1 1 K�i.3a� a f��a�,�l:!�{T� OfNEMTMANUMB1tSLLAFORM �r� } >aa )'"._.... � SIANTORYLIMR$ �:...t.�... N+�S ..!�j};;�� wpa�¢x5C0UnenynTlON pWC635692 5/12/OS 5/12�06 E�CHACCIDEP+P s 500� 000 nr+n oisensc•voutruMrt s 500 000 , �ypy6ltF'L1�61LKY � DISEA366ACHLMPLOYEE t 500 000 OI'�R osscxmr`or+ovoreR.nrnvv�oc�rwNsrrem<usrsesa�l.ircres re : 23 W 10E' 5 Pdt � S011C YdYRIOUt , MA �Owt�nD'S �.zzti . , ti � .,. .i . .�, J'd� .,ip..E�.e� i .�1 , xi.J�f�t�..i i�;«`u�FY� �F!n.:�ir �.' ��'. .:. .. . �;�:.. ,`„'�d_, "NI r��4�.,d } i v��' L� ..,. u 1„ � _ n:..�. .... .>..:_,,. , ...... . .. . 7 %'j� SHOUlO ANY OF 7H��BOVE DFSCIUBED DOhICIFS BE GNCELLED BL'PORE lHE i ii; EXPIRAiION pA1E T7iERFAF, THE ISSUING COMPANY wILL ENDEAVOR TOWR Of YdL'1110Utk1 ?:,';��, MAII 1 OOAY$WRITfEN NOTICE TO THE CPA1IFlCpTE HOLDBR NAM6D7'0 1HE Attn: Health Dept . '; LEFT, BUT F��UJRE TO MAIL SUCH NOTICE SH�LL IMPOSE NO OBUGn710N OA 114 6 Route Z B "�: 11ABILI7Y OF ANY qND UPON SHE COMPANY, 17S AGENTS OR RPP0.FSENT�T`/ES. SOuth YdYmouth MA ��aN�oK¢s�a�srxr,, � � �t; � �� r�y ,.: ... , Y ' i - ��Si :�...FaA«�,i. it �Y`J...ix.� �::✓ . + 1i� R'.', , 1 .;.. t. .'> �F1�..., rsl S�' �'��'; �f� �`i.£.-�'�, .� '` x�.+�t_x1� � s�k:..��e�..! .s�> .�t�.. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-154 F'EE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted ro: AM Piz�a 23T White's Path South Yazmouth, MA Whose place of business is: Dominds Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31_ 2006 BOARD oF HEALTH: B'/ �5. /19.$/.,.� • SEATING: O �Ig�'s��y� �lCB �.�ifW�G,�y REs1lucTTorls: See Reverse Side. Ro6e/[t�. B�RiO[wg e�eR�a PG�/sic�/�o1J041It0� �liuc !�'+�sdwuk, /l./N. � � ,; February 13.2006 �` Bruce G. Mtuphy, H,RS.,CHO Director of Health *RESTRICTIONS: 1. No fryers. 2. No dishwasher machine. � 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single sernce/paper items only. 7. Sepazate water meter,for tlus unit 23T required. 8. All pizza ingredients are to be obtained as precooked. 9. Ma�mwn daily water usage not to exceed 175 gpd;A montlily log is to be maintamed with a yeady report subm�tted to the Health Department by December 1 of every yeaz. � ' �,�'/33 6 r�'i o!'vR,y TOWN OF YARMOUTH BOARD OF HEAL'I'�� L �� I� M �5 � 2 0 APPLICATION FOR LICENSE/PERMTT- 2006 � �= DEC 0 7 2005 �'� * Please complete form and attach all necessary�ocum�nts�y Dece 1 005. Failure to do so will result in the return oF your app(ication p A��H DEPT. NAME OF ESTABLISHI�IENT: dMi�o`S �y� �L # f$ 3y�6�38 LOCATIONADDRESS: ?'3 f • cs .c ,t.,..e.. ozcts� MAILINGADDRE /1//a e�s..�s /��c� / ,c�c � .•� OWNER NAME: ��•"f b� TAX ID E or S 0 "33° i CORPORATION NAME (,� APPLIC�BLE�: ly ��i O �`' �js'` � �n<• MANAGER'S NAME: !�/<•3iJ ,(i••r i TEL. # d� 3 3 ° Ml�II,��'TE�D�'.S.S: 23� Whif:f dl S. Riw+ia� oLG POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Foe48perater(s}ae�at�xeh a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certi8ed in basic water safery, 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 uew copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protectio� Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. Z. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEFR�;�CH 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 attae}i eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a 61e at your place of business. l. 2. 3. 4. RESTAiJRANT SEATING: TOTAL # � OFFICE USE ONLY LODGIlVG: LICENSE REQUIItED FEF. PERMIT tt LICENSE REQUII2ED FEE PERMI'L It LICINSE REQUIltED FEE PERMIT# _B&B � $50 CABIN $50 __ _MOTF,L $50 _INN S50 CAMP � $50 _SWIIvIIvIlNG POOL$75ea. _LODGE $50 __TRAII,ER PARK $50 __WHIRLPOOL $75ea. FOOD SERV[CE: LICENSE REQUIl2ED FEE PERMIT# LICINSE REQUIItED FEE PERMIT tl LICENSE REQUIl2ED FEE PERMIT# �0-1005EATS � $75 �ob-wy CON'PINENTAL $30 NON-PROFIT $25 >100 SEATS S1S0 COMMON VIC. $50 WHOLESALE S75 RETAIL SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT'# _<50 sq.ft. $45 >25,000 sq.ft.. $200 VENDING-FOOD�$20 _._Q5,000 sq.ft. $75 _FROZEN DESSERT $35 TOBACCO $25 NAME CHAIVGE: $10 AMOUNT DUE _ $_'75.po """""PLEASE TURN OVER AND COMPLETE OTHER 5mE OF FORM""•"" ADMINISTRATION ' � Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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. 'I'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTf MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yow pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOT'ICE: 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, 2005. SEASONAL ESTABLISF�IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfDv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TEIE BOARD OF HEALTH PRIOR TO COMNVIENCEMENT. RENOVATIONS MAY REQI7IRE 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 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 swirruning 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. CATERIlVG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State cer�ified lab. Test results��st-be sent to th�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 waitedwaitress service), must haue prior approval fromthe Board of�ealth. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product retail or food service establishment is prohibited. DA'I'E: /2�� SIGNATURE: PRINT NAME&TITLE: l�0'�% BK l� � tn 09/28/OS � =�� The Caxrnonw`alth ofMassachusetts � _ no � DeQart�neet of lndwsrrial Accidentc � - M�N� =- 600 Washiwgton Strcey f"'Floor = Boston,Maa. 0211I •.wo.icus°compasatioa I.s�,.ee n�d.vlc:s�naug/e�.mbug/Ele�cal cu■e�acmrs ., - - .� r � "u�,K, :mr�� '� �/f+F/L B h ` iita �, �..t. /'ow�i�os`S �2.tk name: addiess: /1'//� ��/Ls0^s ��6`LC� � �iac/tl�ti /� a . ,3oeo�f �OP f/L/• ZS7'/ ��ni«�e�rrnu�sr. 23 T [.r�•tas sr s. �ir,o..t Mr ei6��! ❑ I am a homoow�perFocming all wa�lc myself: Projewt Type: ❑New CaostiucLLm�R�odel I am a sole '�or and have no o�w ' . .in�� ' . B ' ' Addition . ..._. :• _�.c�, � . . . . 4 . �.; .�..� . ... . : . . I am an�ployer providing w�cas'compens��&�my em�loyees wodcing�ihis job. . ... _ - - j,l/�1I��G BL b C9-J,�. , L.� . aosorv roe• ! �L//O ,7C�S�^S �/�u- �P�iF /t/ h � pA 3ooa�f � �pf - f/LL - LS'�� u�•d �s . o. powc6S3igs ❑ I am a sole�oprcie[rn'>Se�eral c�h�acMr,or bmeow�er(ci,ele owe)�d have hiced the conhsctas listed below who have the following wa�kas'compensation polices: �a[�: �A�rw: dtw otre B: # �.R� ' ...vh.�.s �."ti... . . ._ . ... . .. .. .. . . . . . . . ��ei iPBiIl� �� . . _ . . . . . _ _ . . � _.. .. . .. . _. ...e� ctie .�t , . . .. ' � �eT� e rv�... T. x. a.. . .. . Faive fo xcve am�e a rtqdaN udQ SaYx 2SA dMCL LS2 en kW b Ue i�pMlYt da�ieid peWlid d�ie�p b t1�M.M aW�r e�e ynn'hmpt6oamt n weB n dN pe�ltln la t!e fers ef a 37'Ot WORK ORDER ud a See dt1B9.M a day aptnt me. I odashad fi.t a capyNUbfhme�tmy forwaMedbtAeOmceoflneatlpWeeK�YeDIAfrewaa�ewMntle�. I do bereby cerdfy rn Me pdna a�AP�+W�olYM�7 dYet NYe urfonwaton providal above tr nxe a�d aorrcct �� / Dea �y'J�'d� Primname �"%iii� , /1C Phoce# 7��fl�L' ��'l e�l ux enly do eat wAte d thh un b 6e eerPki^d b9 d19 er Wm a�eLl dtyortewn: �vmq/peeaseg �geYdi�pe�r�Cs� ❑c6ett if imme�! ��k'�R BeW �eme b�a'ved �tt�n'�OBce �HuM4lkp�b�t teH1i�P�� P�k; C101te tm�sq1 ioml TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT TO OPERAI'E A FOOD ESTABLISHMENT PERMIT NUMBER: #06-104 FEE: $75.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a permit is hereby ganted to: Whale of a Pizza, Inc., 23T White's Path, South Yarmouth MA Whose place ofbusiness is: Domino's P;,�� Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2006 BOARD oF HEALTH: Bt/ $. p' �1.�., ' SEATING: O �g�,�� ,� `�g, �,k aESTiucTTONs: See Reverse Side. RoGe+tt 4. B3oawc� e�e/��s A�k M� N�� A��j�, R.N. 5�,��. � � �{ c �� January 27.2006 � � _ Bruce G. Miuphy,MPH,RS.,CHO Director of Health ',/2w ou,�n-� T�. 5. t� . *RESTRICTIONS: 1. No fryers. � 2. No dishwasher machine. 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Sepazate water meter,for this unit 23T required. 8. All pizza ingredients aze to be obtained as precooked. 9. Malumum daily water usage not to excced 175 gpd;A monthly log is to be maintained with a yearly report submitted to the Health Department by December 1 of every year. ' -f_vA ��(� �7D'i � r° � R o TOWN OF YARMOUTH BOA�iD pF HEA , , f; c� i� II " � u �z2A �� - ` -,i APPLICATION FOR LIC�E�iSE�E�t1�II�'- 2 5 ' �`� f - `�' � DEC 1 3 2004 * Piease complete form and attach all n'ecessary documents by D ember 31 2004 Failwe to do so will result in the retum of your applicatio p��'tLI�H DEpT. NAME OF ESTABLISHMENT o/+��+u s iyZe- TEL # 5�a8 �y�f�6Pf LOCATIONADDRESS: Z3l lv��i<s .�� MAILING ADDRESS: �oa �•••� St• y.�no�rPL�o✓f /�'//`1 G26� OWNER/CORPORATION NAME: 6✓yA/c o�- � iz u , Z..�, MANAGER'S NAME: P�fr+' o•��s TEL. # iaP frLC zt�/ MAILING ADDRESS: �f�Do �l•s.� Sf. yn..o.,/X,00.f H/t a i6 7� POOL CERTIFICATIONS The pooi supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2 Pool operators must list a minimum of two emplo ees currenUy certified in basic water safety, standazd First Aid and Community Cazdiopuimonary Resuscitation �CPR). Please list these employees below and attach copies of empioyee 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. 1. 2 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS� All food service establishments are required to have at least one full-time employee who is certified as a Food Pmtection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this application. The Healt6 Department will aot use past years' records. You must provide new copies and maintain a fde at your establishment. 1. fl`li /�ii� 05 p. �i�r/s�,. duS�/�� 2 � ��/r�eti l. �Nh�/dl i'G D PERSON IN CI3ARGE Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ��' �1i:d'S ,.� �� 1. 2 ��✓'�Sor //b �%va- HEIMLICH CERTIFICATIONS ' All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z 3_ 4. RESTAURANT SEATING: TOTAL# O r.oncmrc: OFFICE USE ONLY LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItgD FEE PERM[T ri LICENSE REQUIItgD FEE PERMI'P N . _B&B . �50 _ _CABIN $50 _MOTEL E50 —� �., $50 _ _CAMP $50 SWIIvIIvIINGPOOL$75ea. _LODGE - $50 TRAII,ERPARK $50 — WI-IIRI,POOL $75ea. � FOOD SERVICE: LICENSE REQiJIRgD FEE PERMI1'# LICENSE REQ[)IItgD FEE pggTq•r# LICENSE REQUIIZED FEE PF,RMI'p# �0-100 SEATS $75 �I'C�S�� _CON1'AIENTAL $30 _NON-PROFTT $25 __>100 SEATS $150 COMMON VICT. S50 — WHOLESALE $75 RETAIL SERVICE- LICENSE REQUIltED FEE PERMI'C# LICENSE REQiJIRgD FEE PERMIT# LICENSE REQiJIl2ED FF.E pggTq�i�q _<50 sq.ft. $45 _>25,OW sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBqCCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 7$,00 "•""pLEASE TURIV OVER AND COMPLETE OTHER SmE 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 pernut 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 AFFIDAVTI'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 NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPART1vIENTFORINSPECTION7-10 DAYS PRIOR TO OPENI1�tG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIItE 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 Department prior to opening. POOL WATER TESTING: The water must be tested£or 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 are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtamed at the Health Department. FROZEN DES3E�'FS: 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 approval from the Boacd ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �Z –/0 �0 � SIGNATURE: /l /i0,� //�: rrr . . pRINT NAME & TITLE: ' �I 10/22/04 – —� - - ' �� The Commonwealth of Massachusetts �� _ Department of Industrial AccidenLc �[I/ii�s _ 6INl Washingtoe Street, 7'"FJoor ,�' Boston,Mass. 02111 wuric�s'c�pna.du■la,ea.«w�mvn:saua�.grnhmM■g/Elxtr�cal cu■aadors :,.. ., „� . . .r . ,. . _ ._ .., .. .. ., .�. �. ,.,. �.��. ,.. �.. . _. ..` >.. -'„ � �.v„� r. . ��"�� *, �°� � name: Oln;/�D �S /Z 2j^ ._ .. aaa�s: ��T �✓ ��<S �/z �;ri S ��r�oNl� �n: /'7/� rio: Oz<6� �# Sc� 3��6frF work Srte tocarim�rnu aaaresgr. � ❑ i�a no�.��ro�eu W�m�►t: Project Type: ❑New Co�ucaou❑tc�� I mm a sole 'dor and�ve no me w � io�y��acic,'�. Bwl ' Addition .�' �� .� ��. ..�` `, ..,, . f °'�£ � .. . .., . . _ .,_ . . . . , . � ., .�,. . ...._.._, .. . .. . ... ... .. . I am an employer providing wa�cecs'compensation for my�ployees working a�n this job. ��- �hn/t �6 w �s2�, l�,�t _ .�a.: '7yoo f�/.s.n' f�- ��,-..�.�� a ,-f /�'//+ na67-r �'vP �u zs'�� u�,,� y��, �.a� � ,�7pwc �'�{/3FP ❑ I am a sole proprietor,geoa�sl c�trxtor,or 6omeawaa(cire%awe)and Lave hired the contcac[ocs lis[ed below wla have the following workas'compensation polices: tl�� db' oia�elk a . M _.. . . . ...�8 , ,: ..�... , . .... ... ..: . . .. . _,. . . . . . _ . . �r�e• adtar SIRf• nia�e�: B � . . . . . . � ' � ;, � . '�...� . .:. �... . .. Faiue Y feeve wvQ�e n r�q�iead udQ Saelir 2SA HMGL LS2 m Iead p He 6s�dabYal pea�llks�f a O�e�p b=1,3MM aMl�r ..�rn**'�rr�..�.�..�..a.��du■6�.r,simwomcosoeemae.�.rsia.aaay.�.�. i�awuu. npy NNb Natme�my 6e[erwardrd te Ife Omee o[1mWptlees af IYe DIA farawaa`e verMt�tln. /4o Mert6y cnlffy r r NYe pdns m�dP��oIP�H�Y tbet Me d�fenp�lon proddded abovr lf twe a�d corvrcc ��re � �Z —/O � �S6 Plintnamc // �� PLone# lOf' / L6 Z��/ emd.�a�e owy a..w...ite r fW...rx m ee�Ar ekr.r ww..mdal eHy or tewu: pcmNCee�k r'•�_.. Dep��eot ❑eA�rk Hf��le�eme h'Mo� OSdec�'�Omm �NeMA Dep�r�e� cea4el Ws^e: Phooe S; Qqgv l+id 5�t mm) TOWN OF YARMOUT`H ' BOARD OF HF.ALTH PERMiT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #OS-086 FEE: 75.00 In accordance with regulations promulgated under authonty of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a peimit is hereby gran[ed to: Whale of a Pizza, Inc., 23T White's Path, South Yannouth, MA Whose place of business is: Domi�ds Pizza Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut expires: December 31_ 2005 BOARD oF HEALTII: Be.cja.rsirc $. (�'o+�oK,M.$. ' 5�,�.,G: o n�M��u, v� e� xEs'1'xtc'rtoxs: See Reverse Side. /jp�+��. B3pr�, � e�C S�sr�i, /1./�. A.f.�� R.N. January 27,2005 Bmce G.Murphy,MPH,R.S.,CHO Director of Health *RESTRICTIONS: 1. No fryers. � 2. No dishwasher machine. 3. No clothes washer maclune. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Sepazate water meter,for this unit 23T required. 8. All pizza ingredients aze to be obtained as precooked. 9. Mawmum daily water usage not to excced 175 gpd;A montlily log is to be maintained with a yeazly report subm�cted to the Health Department by December 1 of every yeaz. �� S�c . �$�F�-��'�a TO �TN OF YARMOUTH 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � � MATTqCHEES � �'"�o„o,,,�ow"� Telephone (508) 89&2231, Ext 241 — Fax (508) 760-3472 B OARD OF HEALTI-I To: Yazmouth Boazd of Health Permit Holders � � � � � `� � D From: David D. Flaherty Jr., RS. � APR 1 4 2005 HeakhInspector � D� HEALTH DEPT. Town of Yarmouth Re: Federal Tas ID Number Date: March 22, 2005 The Massachusetts Depaztment of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(F'EIN)otherwise Irnown as your"I'ax ID Number". This is purely for administrative purposes only. So� businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please SIl out the fields below and return this letter to Yaruiouth Heafth Department I 146 Route 28 South Yarmouth, MA 02664 11�ank you for your anticipated compliance. If you have any questions regazding this matter, please do n.ot hesitate to ca11. The office haurs aze Moncay Yo Friday, 8:30 a.m to 43Q p.m The telephone number is(508) 398-2231, ea�t. 241. Establishment: �Om�n i1 f /`��Z� FEIN or SSN: Z�y' 3306 2 6 Z Location Address: 2 � W�' ` r t 5 �f� i Signature: `' �i�y �x � �' i�f� <� Z' Print: Title: � Printed on ( Recycled L .S Paper �. - .• ��01°��a�`' �ID � 2�F�R.� TOWN OF YARMOUTH BOARD OF �tEA T� ��i APPLICATION FOR LICENSF� � -�'�� ` NOV 2 5 Z003 � �• * Please complete form and attach all necessary doc�nt v December 1 I-3�@Y�TH DEPT. Failure to do so will result in the return of yo application packet. A I M N : o.•,.^ o '� ��Z`� TEL. # 3oyssv fy I.00ATION ADDRESS: 23 T Jv�, frS � S. kr�+v« Oz6yk L�I.AILINGADDRESS: �`�`O9 ��,^ S�t• Y-^•��r�p.,,i �/.a ou7-r 4WNER/CORPORATIOI�I NAME: <'' '`�` � � ��y"� �^`• MAI�IAGER'S NAME: < <� ""�' TEL. # S�� 3`z s3' MAILING ADDRESS: `�`�Dr ��'^� St. y iM,o... �n o 26 }f POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Poc! Operator(s; ar.d attach a copy of?hc certification to this farm. L 2. Pool operators must list a minimum of two employees currently 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 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 - CERTIFICATIONS: 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 Establishments, ]OS CMR 590.000. Please attach copies of ceRification to this application. The Health Department will not use past years' records. You musLt provide new copies and maintain a file at your establishmeat. � / 1. QTGs I�iivoS /�Gn�r � /<(4Ci�v 2. PERSON IN CHARGE: Each food estab/lishment must have at least one Person In Charge (PIC) on site duri/�ng hours of operation. ��G/ /�i/✓Oj v6i/+ if � /<<F�L.rO l. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY wnct�vc: LICENSE REQUIRED FEE PERMIT# LICENSE RIiQU1RED F6E PERMIT# LICENSE REQUIRED FEE PERMIT# B&B 550 CABIN $50 _MOTPL $50 tNN $50 CAMP S50 _SWIMMING POOL S75ea. LODGE $50 'PRA[LER PARK S50 WH[RLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED PEE PERMIT# LICENSE RGQUIRGD FGG PGRMIT# LICENSE REQU[RED FEE PERMIT# I 0-]00 SEATS 575 0 -0 _CONTINENTAL S30 _NON-PROFIT S25 >I00 SEATS $I50 COMMON VICT. S50 WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSG REQUIRBD FGE P6RMIT N LICBNSE REQIJIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. 5200 _V GNDING-fOOD $20 _<25,000 sq.ft. $75 _FROT.EN DHSSIiR'P SJS _T06ACC0 S25 NAME CHANGE: $10 AMOUNT DUE _ $ 1S,00 *"«••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or pernut 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. PLEASF, CHECK APPROPRIATELY IF PAID: YES `� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETUItN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISFIMENTS 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 REPORT�D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL FGU ATIONS 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 standazd 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 CON� FR ADVI�ORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATE iN PO I Y• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FR . sr .ccr,�Ts� 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 wilt result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUT ID . FFS• Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Boazd of Health. OUTDOOR COO IN • Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �//� lg— a3 � DATE: SIGNATURG: PRINT NAME& TITLE: � v��g"h �" , ��s`dt^ � ' 10/22/03 . � The Commonwealth ojMassachuselts � : Department of Industrial.-I ccidenu ; Of11t00//OPCSdyfl/IIf 600 Washington S/reet Bostort. Mass. 02111 " "��,` W'orkers' Compensation Insurance Affidavit Aoolicant information: P►esseFR[IVTTeb�"ida �jj��tklG c L � �za� '� o � � p n�me� i GnC� ��n�no J /iYLti, i��su�� Z 3 /' �✓/� frs � Ta'� cic� S TF�MJ,..I� /�I!'I 02`6�{ ohonep lDf .i��-�� I am a homeouner perfortnin,ali work myself. � I am a solz proprietor ar..'. ha�e no one«orking in am capacin� �I am an employer pro�idino workers' compensation for my employeesµarkine on this job. �vti� ;� o� � P,zLz , �.��. _ _ _ _ _ _ - - __ m n�' m • N aJdress• �� / /�� S�. / C - ��.. /�'�/✓�/JH<tiQo� ` �/9 fiZb �'� �Or( 3�2 /S 3a -- phone pt insur�nceco ""� �yF�� 5. GO . �o''C�a /�o�✓c �30G6� � I am a solt proprietor. _eneral eontractor, or homeowner(eircle anel and hace hired the contractors listed below ��ho ha�z the follu�cin_ «orkzrs :ompensation polices: comQanv name• � addrc • ��• phone#• insur�nce co poliev N a vn -adrc�•• — rie.�• phoee Ih ��.��.�,, eelin M ■ F�iiure to�ecure covenee�s requved under Secnon 25A of MGL IS2 n�Ind to tAt iepai6w of erisi�tl peultle of�O�e op to 51�00.00 a�d/or ooe rnn'imprisonment u w�d1 u eivil peaaltla io the form o(�STOP WORK ORDER�ed i Ilse of 5100.00�d�y K��mt m� [��dmu�d that a copy of tAH etatement m�y be fonv�rded m t6e ORee ot inrestiQ�uom ott6e DIA tor eoven�e vetiflatlo� l do hrrcby crrtij�•u er thr pains artd perta((ies ojptry'ury fha!tht injoimation providtd abovt is Wt and eoirteL Signaturc � //'/�/� 3 Print name ` /L� �� 5� Phone N /`� � 3�Z �li �3v aRcial use onh do noi rrite in this�rra ro be eompleted by eity or low�e olllei�l ciry or town: YA��IITQ permiNieceu M nBuildine Depanmcu� � �Licensioe Bo�rd p check if immedine rcsponse in required Z61 ❑Sdectmen'f Olifee . �ya�ttE Depa�rtmeot � contactpersan: phoneM;_ �SOH� 398�2231 eat. nOther TOWN OF YARMOUTH ' WATER DEPARTMENT 99 Buck Island Road West Yam+outh, MA 02673 Tolephone: (508) 171-7921 • Fax: (Sd8) 771•7998 Damincae Pisza Fex to: 508-362-9530 Re: Water ueage 2003 - 37,000 2002 - 38,000 2001 - 89,000 2002 - 54.000 � , TOWN OF YARMOUTH BOARD OF HEALTH PERMI'1'TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-082 FEE: 75.00 In accordance with resulations promulgated under authority of Chap[er 94,Section 305A and Chapter 111,Section 5 of the�'ieneral Laws,a permit is hereby ganted to: Whale of a Pizza, Inc., 23T White's Path South Yazmouth, MA Whose place of business is: Dominds Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut eatpires: December 31_ 2004 BoauD oF HEA[.TH: Bur�s `.b. (joedwr, M.�S. ' SEATING: O �Ma��u, v:� e� t�snucnoxs: see Reverse side. Rado�it 4. B�to�we, L�lmn�i e�fslak Sha&. R./Y. Jacmary 23.2004 ` Bruce G. Mu�phy ,RS.,CHO Director of Aealth *RESTRICTIONS: 1. No fryers. 2. No dishwashea machine. 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-pizza oven only. 6. Single sernce/paper items only. 7. Separate water meter,for this unit 23T required. 8. All pizza ingredients are to be obtained as precooked. 9. Maximum daily water usage not to exceed 175 gpd;A monthly log is to be maintained with a yearly report submitted to the Health Department by December 1 of every year. ` - r �OM(NOS ' � TOWN OF YARMOUTH BOARD OF HEALTH ""~° APPLICATION FOR LICENSE/PERMIT -2002 � t � �� . � -�� :Please complete form and attach all c ecember 31, 2001. Failure t� $o so�iH`�esult in t.��.e return of your application packet. ,�-oa�a-93 ,°9.r "d : NAME OF ESTABLISHMENT: •^ �� Y'-�- TEL. # S�Y _�y� t!P` LOCATIONADDRESS: 23 % ti'�' `s �� ,��^�^� aYtty MAILING ADDRESS: ��Foo f%c.�' sf. .cii..o� r�pn a /�?1 �z }i OWNER/CORPORATION NAME: l✓�i4�t ° ` `' '+"' r `^c . MANA 'S NAM : Gt•�^'•"' Lc� T L. # Sor �'!z Ss't� MAILINGADDRESS: �f*�� i"Jti.� Sr. �.,,.,.� p.�s H dz-`�r POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cunently 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 51e at your place of business. L 2. 3. 4. �OD PROTECTION MANAGERS - CERTIFICATIONS: 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 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. 3 � t. G�''c,��us L«.c �j`lr-� ,•7 � 2. PERSON IN CHARf3E:" ' - — - - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 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 procedwes 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. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _BR,B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP S50 _SW[MMING POOL$SOea _LODGE $50 TRAILER PARK $50 WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 � Oa-DOIo _CONTINENTAL S30 _NON-PROFIT $25 _>I00 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 1t _TOBACCO $20 _<25,000 sq.ft. $75 TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE = 5,,,� *`*"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* ADMINISTRATION y . Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewa�l 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 yow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES '� NO NOTICE: Pemuts run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT"I'HE 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. ADDITION i REGULATIONS POOLS POOL OPEPiING:All swimming,wading and whirlpoois 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 standazd plate count by a State certified lab, prior to opening, and quarterly thereafrer. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE ('nNSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CAT RING POLICY• Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health DeparUnent 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. - --- - — _ __ FRO EN 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 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),mus haue prior approval from the Boazd of Health. OUTDOOR COOHING• Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: r� � �� SIGNATURE: /G°''� /' /f� �d{ /ISi Ln, • PR1NT NAME & TITLE: � 09/11/O1 _ /_ A � �\ The Commonwea/!h ojMassachusetLs • 3 : Deparlment ojlndtcstria/.-�ccidents ; O/1/COOI/CYCSd��d/Ii 600 Washington Sl�eet Bosron.Mass. 01111 'a" '"� '` W'orkers' Compensation Insurance Affidavit ��lilt d` H ,Llar `nL . �v,.,.... � `S . sW, . namc. /� location: �3 /� ��'� �tS /� r� S f�/MO�..r� /�/t Uz6G� So� 3tis�- �� t� enon a � I am a homeowner pzn�rtning all work myself. � I am a sole propriztor :c� ha�e no one �corkin_ in am capacin� [�I am an emplo}er pro�idine workers' compensation for m�emplo}'ees workine on thisjob. camnam� name• j��lL cL •� ✓�z� , /�.��. address: ��J ��"� Sf' �„„��.r� ��G iy/� ozG l�� 08 3�Z �s3� tih�: nhone p• insurance co. ��'S`G�N C�FS�L��7 �5" policv N vY �Old��/�� I am a sole proprietor. qeneral contractor, or homeowner(cirde onel and hace hired[he contractors listed belou �.ho ha�e thz follu��ing ��nrAer> ;ompensation polices: companv name• address• cin�: ohone k: insur�ncc co oolicr# tomoanv name• iddress: _. .. . . _ . _ _._. . . ._ . .. . — -- - .__ . _.. - - — .. . . t�y: phooe N• insuranee eo. eoRev M t � F�ilure ro secure covenge a requtred uader Secnoo 25A o(MGL IS2 n�Ind to Ne inpaidw of cri�i�l pndtle ot�O�e op to 51,500.00 ud/or oee ye�n'imprisonmem a�well u eiril pea�ltla io�Ae(orm ot�SiOP WORK ORDER aed�Ilee of 5100.00�day q�intt me. 1 eWenh�d tl�t■ topy of thia sntement m�y be forw�rded to the 011itt of Invntig�tiom of Ihe DlA tor toven�e veri6atlo�. l do-hrreby cenij}• der the pains and prnalties ojperiury fhat the injonnolion provided abovt fs but and cor►eet Signature r/�/L/i � /�, ,� � � �l2 �i's'3� Print name �- / � Phone M �, .• olTicial use onh� do not•rite in this arn ro be compkted by eiN or tmvn ollleial city or town: Y�M�IIT$ _ permil/liceeu M n Buildiog Dep�rtmeot �Liceasiog Bo�rd �check if immrdiate responee i�required 261 ❑Seiectmen'e ORce �Hea1tA Dep�rtmmt - �o��cP«so�: pno��a:_ <508) 398�2231 eat_ nOther R%I�h 12, 2�,p2 Domino's P�zza Water Usage (Gallons Per Day figured on 360 days per _year open): 1998: 47,00� gail4ns :3:;. _.:;.::. 1999: 47,000 gallons i�v.o E.�.ci. 2000: 54,Oflfl galians i5�7 �.u.d. 2flfl i: 89,fl00 ga3lans 247.2 �.�.d. Up ta 1999, water usage was n�t ta exaeed 1�5 g.p.d. ";:�,Ft t�a9, cvater usa�e ivas n�t to exc;e:,�' I75 g.p.:. � ,� TOR'N OF YARMOUTH BOARD OF HEALTI3 PERMIT TO OPERATE A FOOD ESTABLIS�IME1Vt�1VT PERMIT NUMBER: #02-006 FEE: $75.00 In accordance with��alionsprom ulgated under authoriry of Chapter 94,Section 305A and Chapter 11 I,Section 3 of the Creneral Isws,a permit is hereby ganted to: Whale nf a Piz�a inc_ 23T VJhite's Path_ Snuth Yarmnuth_ MA Whose place of business is: Domino's Pizza Type of business: Food Service To operate a food establishment in:_ _T4wn of Yarmouth Permit expires: December 31.2002 BOARD oF AEALTH: eka�ea r?�. xallGfes. � sen,�wc: o - 1�. l�n�c 7I(C.D., 4/rae RESTRIC71oNs Te.wv: See Reverse Side. '�. 6soaeva, e(ez(e �Q�l1C��O7Mm�' Januarv 24 ,2002 ' Bruce G.Murphy, , .,CHO Director of Health #RESTRICTIONS: 1. No fiyers. 2. No dishwasher machine. 3. No clothes washer machine. 4. No seats-take out only. 5. No stove-Qizza oven only. 6. Single serv�ce/paper items only. 7. Separate water meter,for this unit 23T required. g, p]I�iz�a ingedients are to be obtained aspre cooked. 9.Maxwwn daily water usage not to exceed 175 gpd' A monthly log is to be maintained with a yearly report submitted to the Health Departrnent by December 1 of every year• 10. Engineer must evaluate septic system and the septic system flow usages and submit findings to the Health Departmentby January 31,2002. 3 �Ee R.s,c TOWN OF YARMOUTH BOARD OF I� �, , `._-, � `� `; ,_,� �C�= APPLICATION FOR LICENSE/F�I�NII�S 03 ,�y�dfi .:`' � � C ' ` * Please complete form and attach all necsssai}�b�w�fents b�D cember 31, 2002.` Failure to do so will result in the r�m of your applicatio �&�@�.TH D�P�• NAME_OF EST .I H RNT: ^'"^u S ,yu- L # 6Y 3�i5�� ` S : 23 !�✓ iYss ti ' MAILING ADDRESS: • �c/mo.+t , f9R OL�. , � C TI N —�� t d � �ti� � �t . MANAGER'S NAME: G�'��^'�� S cs-� � TEL # SoF �' �� MAILINGADDRESS: 23 T G� � �s R , ��.-�>�r o C� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opeiator(s3 andsttach a copy ofthe certificahon to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safery, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deparhnent 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 - CERTIFICATION • All food service establishments aze required to have at least one full-6me emgloyee 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 applicadon. The Heslth Department will not use past years' records. You m st provide new copies and maintain a file at your establishment. 1. U°�lsn iti s LG�G- 2. �� x PERSQN IN CHABCtE_ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 �L/1.��<s �� 2. /��I f °� HFI LICH CERTIFi('ATTnN4• 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 tunes. Please list your employees trained in anri-chokmg procedures below and attach copies of employee certificarions 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. KESTAURANT SEATINr: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _1NN S50 _CAMP $50 _SWIMMING POOL$SOea _LODGE $50 _TRAILER PARK a50 _WHIRLPOOL S25ea FOOD SERVICE• / LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 �3�01� _CONTINENTAL $30 _NON-PROFIT $25 _>100 SEATS $I50 _COMMON VICT. $50 _WHOLESALE $75 RFTA�i .RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAMECHANGE: $]0 AMOUNTDUE _ $ ")5,p0 •*'*•PLEASE TIJRN OVER AND COMPLETE OTHER SIDE OF FORM*"•*• ADMINISTRATION . Under Chapter 152, SecUon 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 ar 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 taaces and liens must be paid prior 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 RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMEN"I'S 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.), Mi1ST 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 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 are required to post Consumer Advisories. CATEffiNG POLICY: Anyone who caters within the Town of Yannouth 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. k'ROZEN DESSERTS: Frozen�esserts musf$e tested on a monthlybasis by a State certified lab. Test resuIts 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),mu t have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product b a retail or food service establishment is prohibited. DATE: !/� ///�L SIGNATURE: � PRINT NAME & TITLE: '�C �F �GS� �y ` 10/18/02 . . � The Commonwea/th ojMassachusetts , : Depar�ment ojlndustria/.-lccidenrs ; Omceal/ares�lysdiis 600 Washington Street Bosron.Mass. 01111 " "� '` R'orkers' Compensa[ion Insurance Affidavit nm •�. DOfn/nJ �s /LZG. 1 . Z 3 � �✓6i, flS F cth � F/�sso�.. f� /' /� �Z"S� ehon p l�d! 3�7f��fJ � I am a homecµner penurming all work m}self. � I am a solz propriecor �r.,', ha�e no one norkin_ in am capacin� (�I am an emplo?:€r vo�i�in2 workers' compensation for my employees workine on this job. eamnan�� name: /A � h�i��o� �� %�z��; �� . adAress: .� "' �00 /"/tiin� S�. �/>YIJu�.�!'+PAL� �- �� /� /) : y��ou��/�w� /�,'� oa� �.f „. So� 3�2 �'�3� e� /' /�0 33�f�5`S insuranceco. u�� f. LO . nolicvk �C � I am a sole proprietor. general contracmr, or homeowner(eircle onel and hace hired the contractors listed below �iho ha�e thr follu��in_ ��arkar; ;ompensuion polices: tomv�na,ne: � . ad d ress: tin�: ohone M: insuranc�co. oelicv N m ny�e• address: .. . . _..�.... -- � - ilN: Q6oee M• insuranee to. eefler N t F�iiure to sceurt coverqe�s required under Seenon 25A of MGL 153 u�Ind lo the i�paitlo�o(eriW W pe�dtle of�O�e ap�o SI¢00.00��d/or ane ynn' imprisonment u w�ell aa tivil pendNa io tht form of�SiOP WORK ORDER�ed a 6at of SI00.00�dar apimt m� (��denn�d�h�t.a� eopy of thy sntement m br fonvvded ro Ihe ORct of Inve�tlg�tlom of the DIA[or eovera{e verillutlo�. � l do�hrreby cenij nder the pains and parte(�ies ojperjury thm!ht injormation provided abovt is nue and cunteL Signature //��/��L Print na /�/ �j�� Phone M ��7 � �b Z �%S J� .. oRci�l use only do not�rite in this arn ro bt eompkhd by eity or tmva o111eia1 ciry or towe: y�M�DTQ _ permitA{eeeu M nBuildine Dep�rtmmt . pLicemioe Bovd � thrck i!imm�dialt response i�required 261 �Seiectmen'�Offlet �HedtE Department � roniatt person: pAoneM;_ �508} 39H�2231 eat. nOther , � � �� 0 G? GG [� � dG� � MAR 1 1 20U3 HEALTH DEPT. Ta Town of Yarmouth Health Dept Frorrc Greg Fox C� file Dame 3/9/2003 Rg Water Usage Report Attn: David D. Flaherty,Jr. Heatth Inspec[or David, please accept my apologies for just now responding to your request dated 12/6/02. I just now received your letter. They have changed the mail distribution system at Station Ave. If you could send all cortespondence to my office address:4400 Main St.,Yarmouthport, MA 02675 , it would be greaty appreciated. Water Usage: Nov. 1/01 0567000 Total usage 11/1 to 1/31/02 is Dec.1/07 0569850 8410 gallonsl92 days=91 gallons/day Jan.1/02 0571950 Feb.1/02 0575410 Feb.16/02 0000000 meter changed Mar.1/02 0002410 Apr.1/02 0005230 May.1/02 0008350 June.1/02 0012080 Total Usage from 2H6 through 10/31 July.1l02 0015830 is 29,682 gallons/287 days= 103 galions/day Aug.1l02 0019975 Sept.1l02 0023346 Oct.1/02 �26570 Nov.1/02 0029682 1 , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #03-014 FEE: $75.00 In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter ll 1,Section 5 of the General Laws,a permit is hereby granted to: Whale of a Pizza, Inc., 23T White's Path, South Yarmouth, MA Whose place of business is: Domino's Pizza Type ofbusiness: Food Service To operate a food establishinent in: Town of Yarmouth Pernut expires: December 31. 2003 BOARD OF HEALTH: ekanlea'�f, zePlikaa. �a.a SEATMG: O �� . S�CK�Q.IK1K D. �aSd.OK, �.D., Y�CGC � RESTRICTIONS IF ANY: See Reverse Side. �o�t�`�, b��, �r� �a�ue�'lKlDasrwatC �e�e.c Skak, ,�.12. November 20 ,2002 ' ruce G.Murph ,R.S.,CHO D'vector of Hea *RESTRICTIONS: ' . 1. No fryers. 2. No dishwasher machine. 3. No clothes washer machine. 4. No seats -take out only. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Separate water meter, for this unit 23T requ'ved. 8. All pizza ingedienu aze to be obtained as precooked. 9. Masimum daily water usage not to exceed 175 gpd;A monthly log is to be maintained with a yearly report submitted to the Health Department by December 1 of every year. 10. Engineer must evaluate septic system and the septic system flow usages and submit findings to the Health Departrnent by January 31,2003. . �.Y�l�l�,�..,-"�� .. , . . ,_ `: ' TowN oF YA�oi7iCg BOA�oF��L� �'I Go3 z :�;;;" �� r r� D " APPLICATION FOR LICENSEfPERMIT- 2000 � �,1�,� � L�c t: Q 3 1999 * Please complete form and attach all necessary documents by December 31, 1999. Failur tot�l�ono�ld�in the retum of your application packet. --------------------------------------------- --- - -=---------------------------------- -- -------------------- NAME OF ESTABLISFIMENT ��' "'�~5 �Z Z" TEL # 3y`�" ��Y L A I 23 � Ni�� a `1 O� r MAILIN�} ADDRESS: �f�f°.� p/ti.^ St • �si..+o.. 7 /.�o. f /'/ ozt�Yt N Lv/+,��t ab <. pts.: , j„r. MANAGER'S NAME '�lh °� TEL. # 3G� 9sjv MAILING ADDRESS: -----------------------------------------------------------------------------------------------------------------------• POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd F'ust 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 fde 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 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 �file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# — -------------------------------------------------------------___-----------------------------------------_ OFFICE USE ONLY LODGING: LICENSE REQUIItED FE$ PERMIT# LICENSE REQUIRED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIR�IINGPOOL $SOea. _WHIltLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # I 0-100 SEATS $75 Y2K-5Z CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII.. SERVICE: LICENSE REQUIRED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ ��) �' •••'•PLEASE TURPI OVER AND COMPLETE OTHER SIDE OF FORM^'"`• �/ - -..� ADMINIS'I'�L4T�ON .` � ' UNDER CHAPTER 1'S2, 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 PEitSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSIIRANEE. TH� 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. PLEA3E CHECK�PROPRIATELY IF PAID: YES NO NOTICE: PERMITS RiTN ANNUALLY FROM JANLJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII.TI'Y TO RETURN TF� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIIVG FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE kEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. Ai�DITIONAi RF_GLT►ATIONS POOLS POOL OPEIVING: ALL SWIMI��NG, WADING AND WHIRI,POOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TI�WATER TESTED FOR - PSEUDOMONAS, TOTA�.COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPETTING, AND QUARTERLY T'I�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING POOL MUST BE DRAINEb OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE �ATERING POLICY ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOLITH MUST NO'ITF'Y TI-IE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI-IE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. 'I'EST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN Tf IE SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT LJNTII.TI-IE ABOVE TERMS HAVE BEEN MET. 9UTSIDE CAFES: OUTSIDE CAF'ES (i.e., OtITDOOR SEATING WITH WAITER/WAITRESS SERVICE), M(IST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. 4UTDOOR COOKING• OUTDOOR COOKING,PREPARATION, OR DISPLAY OF AIyX,�00D PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS�IMENT IS PROHIBTTED. �f DATE: �� f �y� SIGNATURE: � PRINT NAME& TITLE: -� /��j 4� / �f f i0/l�� - � 11/12/99 � _ �� The Commonwralth of Massachusetts ' s = Deparlmenf ojfndustrial.-Iccidents ; Omceol/sresao�G�i•s 600 Washington Street Bosron. Mass. 01111 ` '��'` W'orkers' Compensation Insurance Affidavit namc �Dr»�,i u `S i2Lti location� �3 � w�' ` ftS ��/ cm J. �/v+�v� �� phone d 3!'1 c�' �li�� I am a homeoµner pert�rmin, all µork myself. � I am a solz proprieror�r.,'. ha�e no one ��orkin_ in am capaein� [v]�I am an emplocer pro�iding µorkers' compensation for my emplo}ees workine on this job. comnanv name: '" ��' /G.. � � � / �ZL�: � ��` �ddress: 7 �UiJ /�s4'.n S� - citv: ld�'O.n ��o✓ � / /� �Z6 ��r yhonep• ��L �SJ-7 insuranceco. / ' fG�'a" � �""� oolieyp W-OZFtfLj / - O/ � I am � sole proprietor. aeneral contractor. or homeoµner(cire/e onU and hace hired the contractors listed beloµ �iho ha�e the follu��in_ «orkzrs compensa[ion polices: companv name• � - address• �jsv• nhone q• insur�ncc co policr# — tompanv namr _.. addre • ujy phoee M• — IIISU�3IIte co ��n'M — f F�ilure to seeure covengt u required uoder Secnoo 25A o(MGL 152 w lad lo tYe ieporidw of trisiul pedtln o(a O�e op to 51�00.00��d/or onc ye�n' imprisonmrnt u w�dl u civil penaltln io tht form of�STOP WORK ORDER�ed a Oee of SIOD.00�d�r K�i�t ma 1��denh�d tl�t■ eopy of IAH statemrnt may be(onvvded to the Oflice of InvnNg�6om of tse DIA for emen�e veri(futlo�. �' 1 do�hrreby certij}•u �e pains and penol�ies ojperjury�hat th[injormation provided abovt is trtre and cnrrert Signaturc -�� a� /y '/ ' ��7 7llG; �B/v Pl�one M )�L �.�J O Print name ' / ., olTicial ust onh do not wri�e in this�ra ro bt tomplettd by eity or tmvn o0ltiil city or mwn: Y�M�DTQ _ - permiNieense M nBuildiag Dep�rtmm� � �Liunsiog Bovd � check if immrdia�e response ie required 261 ❑Sdectmen'e ORce pHealth Departmeat contact person: phoneN;_ �508� 398�7231 eEt. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-52 FEE: $75.00 In acwrdance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Sec[ion 5 of[he General Laws,a pertnit is hereby granted to: Whale nf a Pi��a,jnc 23T Un';rP�� Path_ Cn�rth Yarmnnth_ MA Whose place of business is: Domino's Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d ��/.+�ettp�g, C'�a(�t�,Q»qa.� q / /�/ SEATING: 0 �[�oan G.�7�ul[ivan�/K�a.//J.� Vica C.hairma RESIRICTIONS IF ANY: $ee ReV¢rse Sid¢. ///K777o�arE gJa .��7ro/uign, C.L/er/k �a�r/iallge Jakno[a�y-�.htoaPea tchaal do h December 17 , 1929 Bruce G.Murphy,MPH, .,C Director of Health ' - .' �Yrli/10'S �1't"�C1 ,_._. ,.. _. ;--.,..,,� , TOWN OF YARMOUTH BOARD OF HEALTH . �' � �' � � b � � w APPLICATION FOR LICENS�/PERMIT- 1999 DEC 1 0 1998 x Please complete form and attach all necessary documents by December 31, 1998. Fail C�R�ult the return of your application packet. -------------------------------------------------�- -------------- -� ----------------------------------------------------------- N TABLI N !/o�"'�^� 'S .az # �y'f-�6��' ATI N D 23 ' � 5 � M TLIN ADD F � w•^ ,s�r,.o.r�oQ. f'J o2 ) RAT N N L o s. ,�z� � �„� . ER' N /o,+, �t r// L. # 2 53� MATT ING ADDRESS� yOJ Hfi.�� • B/MJH ��/1 Q ---------------------------------------------------------------------------------------------------------------------- - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tivs form. 1. 2. Pool operators must list a minimum of two employees currernly certified in basic water safety, standard First Aid and Community Cazdio�ulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certificahons to tlus 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. HEIMLICA 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-cholcmg 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 Tde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# O NON-SMOKING SEATS: TOTAL# ___-------------------__________---------------------------------------------------------------------------- QFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # _B&B $50 _CABIN $50 _INN $50 _CANII' $50 LODGE $50 _TRAILER PARK $50 MOTEL $50 _SWIlvIMING POOL $SOea. _WHIRL,POOL $25ea. FOOD SERVICE: LICENSE REQLJIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# �0-100 SEATS $75 ��3 _CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 WHOLESALE $75 RETAIi SERVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIltED 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 _ $ �5"- "*"""PLEASE TURPi OVER AND COMPLETE OTHER SIDE OF FORM••^^" � ADMINISTRATION ` LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TF�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 MU5T 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: PERMITS RUN ANNUALLY FROM JANiJARY I TO DECEMBER 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFIMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMIvIING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENf,AND Tf�WATER TESTED FOR PSEUDOMON[IS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMA�IING 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 TI� YARMOUTH HEALTH DEPARTMENT BY FILING TI-� REQiJIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE 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 THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN T'I�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS - _ __ HAVE BEEN MET. _ OUTSIDE CAFES: OiJTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. O TTD OR COOKING� OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBTTED. DATE: ,2 / � -�y SIGNATURE: /� � PR1NT NAME& TITLE: �/'`�/ �'� ��S�d�h� . _ � , " The Commonwealth ofMassachusetu = Department ojlndustria/,4ccidents _ o OlAceal/erssal�stlais 600 Washington Sbee1 Bnston, Mass. OZIll Wbrkers' Compensation Insurance Affidavit n m�: �m�n J `3 i2LU- location: �-; I/ �.r/iT! fL S �f/ ��, S. f��a�o�-l� f'�� DZ�6� pno�e a � I am a homeowner pzrtorming all work myself. � I am a solz proprie�or acd hace no one ��orkine in any capacin ((y�l am an employer pro�idin� workers' compensat on for my emplocees working on this job. comnanr name: �/�i�1L v 6 a �v�- y;�� . aJdres : Y`Td0 �Ciin s�• {ih': ��/»Ow��OL r / i� �Z6 / � phons tl. f�lo 2 �� J� �f�Gil� �S�6�f� G,�.I- vYG l'I��"65�0'�D . insur�nce co. yulicy p � I am a sole proprieror. general contractor, or homeowner(circle onel and hace hired the contractors listed below «ho ha�e the follu�sin= uorker compensation polices: comoanv name: ad d ress: ��n�� phone�• insurance co po��.p � � � s4mnanv namr. � address: . __ _ _ �' phoee�• insunntt to. eoRev M Failure to eecurt coveragt as required uoder Seedoo 25A ot MGL 152 ea�lud lo the i�pa�itloo o(eris1W peultla ot�O�e ap to f1,500.00 a�d/or one ynn'imprisonmmt u w�d1 a�eivil penaltla io the form of�STOP WORK ORDER nd�Ilae of f100.00 a d�y a�Nmt ma 1 a�denh�d H�t t eopy of�hH stitement m�y be tor.nrded to the ORee of►nva8galiam otthe DIA for emen�t veri6utlw. /do�hrreby ceriijy un e pains and penal�ies ajperjury�hat�he rnjormation provided abovt is nut and corrceL Signaturc �Z' � '�1 r' ate Print name __ �"_/ �� J6 2 — �'s'10 Phone N .. oRci�l use onk do not�ritt in this area to Se tompleted by eiry or row�n otflti�l ciry or mwn• YA��DT� rmiVliceaee k n � - P� Buildiog Departmeat pLiccosing Bo�rd p eheck if immediau response ie required 261 �Sdettmen'�Oflite conroct person: (508 3 QHealtb Departmeet . p6one p;_ __� 98��31 eat. nOther ae.nee;,as PIAI TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-43 F'EE: $75.00 In accordauce with regulations promulgated under authority of Chap[er 94,Section 305A and Chapter 111, Sec[ion�of the General Laws,a permit is hereby ganted to: Whale of a Pi��a T�, 23T White's Path South Yarmouth MA Whose place of business is: Domino'c P'»a Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 1999 BOARD OF HEALTH: �� ett�/��, C�a[�;�,/n�naa /� , /�/ SEAT[NG: � �/Joa/n �c7�/u�llivan�/K�p.///.� VKe l�hairman RESIRICTIONS IF,'�NY: $ee ReVe7SC$IdO. � /Co6ert 0J0 .nG�rowpn� l�Le/r/h a6r/iel[e Ja�nxoG��i/y-�J�oop¢d icha Odoughlin� December 17 , 19 98 4' — ce G. Murphy,MP ,R. ., CHO D'uector of Health *RESTRICTIONS: I. No froers. 2. No dishwasher machine. 3. No clothes washer machine. 4. No seats-take out onlv. 5. No stove-pizza oven only. 6. Single service/paper items only. 7. Separate water meter,for this unit 23T required. S. All pizza ingredients aze to be obtained as precooked. 9. Mavmum daily water usage not to exceed 175 gpd;A monthly log is to be maintained with a yearly report subm�tted to the Health Department by December I of every year. 10. Engineer must evaluate septic system and the septic system flow usages and submit fmdings to the Health Department by January 31, 1999.