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Home My WebLink AboutApplications, WC, and Licenses Prior to 2010 .� . 3. � �.�, l�l��'1 � [�� i ' ' � ► TOWN OF YARMOUTH BOARD OF HEALT � � APPLICATION FOR LICE��T�TT�?=�t �� NO V ;? � L�1U8 ..,, �.: * Please complete form and atta.ch all necessary documents by De Y4��• Failure to do so will result in the return of your applicahon pac et. NAME OF ESTABLISHMENT: �.C� TEL. # �- 7(�7O•/,�l� ; LOCATION ADDRESS: � v�- - MAILING ADDRESS: OWNER NAME: � � t TAX ID FEIN or SSN : ' CORFORATION NAME (IF PLICABLE : ` �. MANAGER'S NAME: `I TEL. # �"JQ•��.Gb�f�' MAILING ADDRESS: - j POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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 cun ently certified in basic water safety, standard First Aid and ; Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies of employee ; certificatians to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fle 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-tune employee who is certified as a Food Protection Mana�er, 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. �.��o � �i�.. 2. ��, �c�r�� PERSON IN CHARGE: � � Each food establishment must have at least one Persan In Charge (PIC) on site during hours of operation l. (� 2._I/l� ��T1�tS !'`tJCJ �17�� ( HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlicli ; Maneuver on the premises at all tunes. Please list your employees trained in anti-choking procedures belaw and i attach copies of employee certifications to this form. The Health Department will nat use past years' records. ; You must provide new copies and maintain a �le at your place af business. i 1. � �� _ 2. �l�J ��_� ; 3. 4. i �-- j RESTAURANT SEATING: TOTAL#-�� OFFICE USE ONLY t LODGPiG: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� _B&B S55 _CABIN �55 _MOTEL �55 _TNN S55 CAMP �55 SWIl��IING POOL �80ea. LODGE S55 TRAILERPARK �105 WHIRLPOOL �80ea. FOOD SERVICE: ---- ___ _ _ - -- ---- _--- --_ � _ _- _- - - ---- -- _ —_. __ �� LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE RI;QUIRED FEE PERMIT# , _0-100 SEATS �8� _CONTINENTAL S35 NON-PROFIT �30 L>100 SEATS �160 �� /COMMON VIG. �60 ;��j _WHOLESALE $80 � — ' RETAIL SER�'ICE: —RESID.KITCHEN S80 i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i _<50 sq.t�. ��0 _>25,000 sq.ft. S22S VENDING-FOOD �25 _<25,000 sq.ft. S80 _FROZEN DESSERT �44 TOBACCO �55 �a�zE cxAVGE: sio AMOUNT DUE _ $ 220. oo � *****PLEASE TUR�OVER AND CO.'VIPLETE OTHER SIDE UF FORiVI***** �� "� � � ¢ - � '�?��`e� :,�'sm.�"��.� � i i ; ' w► � «� � � t � ADMINISTRATION Under Cha.pter 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'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIG D AND ATTACHED ' Town of Yarmouth taxes and liens must be paid prior r`enewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES . NO ' MOTELS AND OTHER LODGING ESTABLISffiV�NTS ' TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be ' limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transiem occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an ; � aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or , dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ' � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. ; POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, prior to opening, and quarterly thereafter. { POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yannouth Health Departme�xt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: ! Frozen desserts must be tested on a rnonthly 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 Board ofHealth. ' OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN � TF�COlVIPLETED RENEWAL APP�,ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED OF HE '�i PRIOR '� TO COMMENCEMENT. RENOVATIONS MAY QUIRE E PL II DATE: r � � SIGNATURE: � PRINT NAME&TITLE: i 10/21!OS f r i _ ` � � /" __ _ »r . , � �\ The Com�nonwealth of Mr�ssachusetxs Department of IndustriaC Accidents NI�eiNA�r�sflf� 600 Waslungton Street, ��'Floor Boston,Mass. 02111 � Workers'Compensation I�snranee,d►�davit;geild�ag/�lambiag/Electtical Contractors , namei. � ci �,� : a�s: �3 V, h 1� �� - �; , `�� - /S7� .., work site locatirn,rfiill addressY. ` � I�'S Ft�'�V�.-- � I am a homeowner performing all work myself. Project Type: ❑New Canstruction�Remodel i ❑ I am a sole.proprietor and have no one working in any capacity. ❑Building Addition �an employer providing wo;keis'compensati�f�my e,n►ployces wo�lcing on this job. oom a�me• I �� i � address: ( i .C�. . � . S�� " �Q�/`i�•\ � .. � � � . � . i . .. C�: i IBf C9.�"'"�' � � � .. ._ . N .��.. �`�J�D (!U � . . .:�. ., . , . . : . .. _ .. .. i . . .:�: ..,;. .., � � .� ._ .._t.,:;.:. . ;��,.�� ,�..;:: r <. .-�u ."rt.�r:�'.�:t°,�'�af�tya-,aa!�w,..<i ❑ I am a sole proprietor,gegerai coatnctor,or�omeowner(carde ont)and have trired We cornractars listed below who have � the following warkers'compensation polices: � comn�av i�amr• � f address: ( cit9• pkaue#. � - � iwsmytnee co. # i � �,,;;:: ... .�.�_�,��' R.•: aommev�ame- addras: clt�: ��. � i � . N I , : ., . . ...� .,., : '� .--:, -�:�. ..': � -:;. �,t. +:., � Y�: .,::' �^.�>z-•;`xh �f,-, <f � .. � �..-..... . . . .. �r"-:' , . .�. . . , . ..,.. �4 : _. :. . ..,rt„�.4. ..,..�.. . Faitme ts sccme cevvase n requU�ed odQ 3eclioa 2f�A�t MGL 1S2 e�le�d t�tYe i�paifba�f u6�ia1 pnaNia�f a 84e tip b t1,SM.0Y uN�r �e yean' t as a pea� fora e WORK ORDER aed a 6ne d i19�As a da � Y aaaiast se. 1 aadna0ud that a cepg�f lmieat fonvarde O� a fipfMaa e DlA for e�verage ver�afiw. /do by ce ' NYe a of pe►jrry thet tlie tnjor�elio�prov�ded aboae is lrue mid on � Si Date / /�V`fi��"(J � Pri�tt Phone#��_�[_a ��• ` S� o�ciai ase only da aot�vrite la t�is ar+ei to 6e oompleted bY�Y�'��°e�1 � dty er to�: Per�eese� QBaidioS DePartment I ❑chec![if fm�me�a�e re.�penx is reqoired - �� QSdeetmea s�ee centad peraou: ��, ��, ��d� c�d�-�3) ' . ��es��, �'!1i.�� i,"�� a �ir�: � ��...:�� °�a d`'�� .r� � � . , � v .g � o v .� c _° n+ o0 � z � � ` � N v� � � � N � � �,, �j u � �'" '+�' � N � � � '�'i p„ � i � � a v � � ,� � � � � � o ~ U Q c � �- � � a�, � 3 � � � � � � '�'r � ,� �, '� c►.� W $j w y i t!� � � g •�; � z � � � �, � ,.r a � � .,., ... � � �..+ O � �,�, � .� �� 0 0 � � i� O �o �r ; � "[ O Z G.4 �y � -� ❑ «� L'� � I �y.�+ �V C.� ia •� �, a, � ..., .5 „ Cn � � � '� � � � I � o � .� � g � �.� � i � � ° � � � .� � o � � � � w � w � c�, Z � '' o � `'b� ?� i ; � O � t� �, o � ; `�' � � � � a � ¢ � � � � � � � � .� � ; •,,. � � -� H � � � � z � p � � � � i � � � � � � � � w � � � V � tn C .,D ¢ !� ' y � .r � � � � � � � -� � � g .� � � ¢ � v � � � o � � o � � � �z f � � � •� � � � a � � � � �+ x � o, � O � 3 0, m � � � .;; c� �"',�" y � '' ^.. `" � v� .«+ � +. 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Q W ,-� � :y v �o w � � g � � a �' � � � � � � ; U � � w z � � � , � .� � � � � F � �,� � r � � � v � � ai Cfl t� � y � �b I � � V � � .� z i �--� � � N � � � � ��+ � � � � 5 � _; � � � w I a.'�'s�'' .r � w -° � � � i a � � � � -� a � 1 � � -� � Q =.: � t N m �� `� � '" � � ; �► � � t�# � � .� �' q �.� ! `� � � � � �� a � i v, t} � � s,,,� �, o � � ;� •� � :, ; .� � � � � � � � ,� m � � �� a' � :�,� I � 4-- �' � � C7 .� ' 3 � � ; � ..� '�,� � i �, ..� � `� � `� � 9� � � -° � �� ° .� �' w � � �- � �.r' l �"' � � r� ^� � V � � � � ~ �9� �� 7 �� V � " v �j � �j �: I 3 � � �. � R � �.� �� Zw inw � - � �4 . . . � �o�.��c�� 2c�v - ,� ---� THE COMMONWEALTH OF MASSACHUSETTS ' ALCOHOLIC BEVERA�ES CONTROL COMMISSION ,- Application for Alcoholic Beverage License for Retail Sale � City/Town: Y�JTH 0 New License � ❑ New Officer/Director ', ❑ Transfer of License ❑ Other i ❑ Transfer of Stock cs�av) ; 1. Name to appear on the license: ��SIDE TAVERIV LLC � Business Name(d/bJa),if different: '1"hg ME'ditel�'anean GZ'llle I Manager of Record: JOSC'ph A. Jamiel, JZ'. FID of Licensee: � i Address of Premises: Street: � StdtiOn AVP_Ilue, _____ _, .�.��,,,�.,y. ,., Zip Code: Q2664 ' Phone Number of Premises: ou u , ; ( ) Unknown at this time 2. Type of license: (check only one) j ❑ Club ❑ Package store ' ❑ Veterans club I ❑ General on premise �] Restaurant ❑ Other � ❑ Innholder ❑ Tavern ts��ry) � 3. License Category: �] All Alcoholic � ❑ Wine and Malt k ❑ Malt only ❑ Wine only ; ❑ Wine and Malt with Cordials Permit � 4. I.icense Class: E � Annual ❑ Seasonal 5. Person(attorney,if applicable)who can be contacted concerning this application: ; Name: peter L. �eeman Es ire - Li Drurrrnond & Freeman � Address: 86 Willow 5treet, Ya�uthport, MA 02675 � • i Phone number. ( 508 ) 362-4700 . � � i i 6. Give a full and complete descriptian of the premises to be licensed,including location of all entrances and exits: � 5,000 s.f. , all on first floor with a front door in center, foyer/waiting area and hostess stand in center; kitchen at rear; take out area on left; bar and lounge area to right; dining areas to right and left. Lounge seating: �o seats at tables and 1.a. ' � bar staol.�; di.ri5r;g �reac: 8o seats. F]nergency exit at back right. See floor plan ; 6a. attached. Seating capacity: � 3,Z • � Occupancy number: )SO 7. Applicant is an: ❑ Association ❑ Corporation ❑ Individual � ❑ Partnership ❑ Non-profit corporation X Limited Liability � C�nY�'� .�'� � r� � -�*�.. ; �'��.�� `��i`�`�„i�a.� FORM 985 A.M.SULKIN CO.,BOSTOf�MA C . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-045 FEE: S 160.00 In accordance�cith regulations promulgated mider authorit�of Chapter 94,Section 305A and Chapter - ' 111,Section�of the General La«�s,a perniit is hereby granted to: ' Southside Tavern LLC, 23V White's Path, SouthYarmouth, MA Whose place of business is: Ardeo Type of business: Food Service ; To operate a food establishment irt: Town of Yarmouth Pernut expires: December 31. 2009 BOARD OF HEALTH: ��e�t SPta�, J2.JV., C'f�aixnuut i � C'l�cr�r�ee .�. 9�i�'CiR��i `Uiee C'Rr,crvrnurn � J`�Z�e�ct �.J`3�carun, c�exP� i Unn C�cee.rc�cuc�n, J2..N. � �. i � December 4,2008 � Bruce G�Murphy,MP , .,CHO r Director of Health i __.. __---- - ---------____ ---- -----_ __ _ .--- . _ ___ _ _ - -- I i i � � I THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH � PERMIT NUMBER: #09-030 FEE: S60.Q0 This is to Certify that Southside Tavern LLC d/b/a Ardeo 23 V White's Path, South Yarmouth, MA IS HEREBY GRANTED A � COMMON VICTUALLER'S LICENSE � In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless � sooner suspended or revoked for vialation af the laws of the Commonwealth respecting the ' licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities b�General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their afficial signatures. BOARD OF HEALTH: .��e�ett Sf�uc�, ✓�..N., C'l�acbr�tuut C'�i�C�c�ea �. 9f��i�ten `lliee C'fEcr�taut 5��.�e�ct 3. �f3�rauu�, C'�ex� Qruz ��cee�cG��ccun, Jt..il r. 9'. December 4 2008 ��; .�. _.� � �� -�--�� Bruce G.Murphy,MP , .S.,CHO ��:� .� .,� Director of Health _ __ _ ! � _ • �J��Yak� TOWN OFYARMOUTH BOARD OF HEALTH �,�f� ��v� � '. �J ��-� APPLICA1TQN FOR LICENSE/PERMIT-200 .k`� " y' � � � �0 O l r '? - * Please complete form and attach all necessary docum��ts by'�ecember�1, 20Q7. - � ' Failure to da so will result in the return of your application packet. , NAME OF ESTABLISHMENT: �NL��A TEL. # •.� �� LOCATION ADDRESS: i , ' a� '; MAILING ADDRESS: c�4�M.� ' OWN�R NAM�: T IN r N - CORPORATION NAME (IF APPLICABLE): ( ; MANAGER'S NAME: �o -rN, TEL. # • • Lo� , MAILING ADDRESS: � � _ _ __ . 3 POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - --�ee1- a rop��f t�e ce�tific�tion 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 eertifications to this form. The �ealth Dep�rtfnent will not use past years' reeords. 'Yot� �t�s��rovide new copies and maintain a file at your place of business. l. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS_ � All food service establishments are required to have at least one full-time employee who is certified as a Food . Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attaeh copies of certifieationto this applieation. �he He�lth Departme�rt�iH not nse past ye�rs'records. ' You must pravide new co ies and aintain a file at your establishment. � 1�. � � 2. �� { f � P�R�QN 1N��.�:�E: _ _- - - - _ `. _ _ -- - - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ; l. �o �tm i�. 2.��- 5 ! � HEIMLICH CERTIFICATIONS: ; All faod 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 copie� of employ�e certifications to this form. The l�ealth Department will not use past years' records. ! You must provide new copies and maintain a file at your place of business. ` �. ��-��-� 2. R�b Q�o ; 3. _ 4. � RESTAURANT SEATING: TOTAL# I b� � OFFICE USE ONLY � LQDGING: ( ; LICENSE REQUIRED FEE PER�+IIT# LICENSE REQL?IRED FEE PER'4IIT* L10EI�'SE REQL7RED FEE ' PER'�IIT� � TB&B S50 _CABIN S50 _MOTEL S50 _INN �50 =CAll4P S�0 _SV4'I_'bL1rIING POOL S75ea. �LODGE �SQ TTRAILERPARK S100 !`L'HIRLPOOL S75ea. � FOOD SERVICE: LICENS£REQUIItED FEE PERMIT� LIC£NSE REQLTIItED FE£ P£R1�11T� LIG£NSE REQL IR£D FEE PERVIIT= ! _0-100 SEATS S75 _CONTINENTAL S30 _NON-PROFIT S2� j �>100 SEATS 5150 a�-�O I CO:�fON VIC S50 ��;�� _W-�OLESALE S75 ' RETAIL SERVICE: —RESID.KITCHEN S75 ' i LICENSE REQUIRED FEE PERMi?� LICENSE REQUIRED FEE PERbIIT= LICENSE REQL'IRED FEE PER�fIT� � _<50 sq.ft. $45 >25,000 sq.n. 5200 _VENDII`'G-FOOD S20 j _<25,000 sq.n. 575 _FROZEN DESSERT S35 TOBACCO S50 NA1�IE CHANGE: s�o AMOU�TT DUE _ $ aoo.oo n � �a.�-�:r **'«*PLEASE TL'R.ti OVER�\�C0�IPLETE OTHER SIDE OF FOR�Z**w*��`��,�� I I I ; _ { x,.� .� ,�; , �[! :R ADMINISTRATION f � ; 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 � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, QR , � • CERT. OF INSURANCE ATTACHED � OR � , , , 4;� . ; • � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior renewal or issuance of your pernuts. PLEASE CHECK APPRQPRIATELY IF PAID: : YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiTPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with mot�l and h0tel us�. I Transient occupants must have and be able to demonstrate that they maintain a principal place of resid�nce elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) da.ys, and an aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CN1R 64G, as amended, shall generally be considered Transient. ! * NOTE: Enclosed Motel Census must be completed and returned with this appiication. � POOL3 POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected ' by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days gnor to apening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count : by-a S�ate 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 � � CAI�RING POLICY: � Anyone who caters within the Tovm of Yarmouth must notify the Yannouth Health Departme�by filing the required � Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtasn�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 Frozem Dessert Perrnit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. i � OUTDOOR COOKING: Q�doar s�4king,�re�aratio�or di�lay_of any food product by a retail or food service establishment is prohibited. l i NOT'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ! , THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. i i ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEEN'T, MO POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APP Y BO HEALTH PRIOR TO COMMENCEMENT. RE�VOVATIONS A PLA. DATE: �,l�I��O� _ SIGNAT �, PRINT NAME&TI Q '� � ' i�?u o� � � . , � The Cominonwealth o Massachusetts , f Depart�nent of I�dustriwl Accidersts �N�Ni� 600 Washingt�►n Stree� f"'Floor Boston,Mass. 02111 Workera'Compeasatioe Iosaraaee A�d�vi�Bu7din�/Plimbi�g/EkclrfeA!Contraetors ' ,I ` Z"�ar�e�il�1'Y'I�lr � name• address- i citv state• ziR' �hrne# i work site locati�ffull address): i ❑ I am a homeowner performing all work myseif. Project Type: ❑New Ca�structio�QRemodel ' �❑ I sole proprietor and have no one working in any capacity. ❑Building Addition ; an employer providing wcrrkers'compensatio�f�my employees worlcing oY►this job. _ _ --__ _ - — 4 l r — - �C, --- _-- ------ - _ ; m vlme: 1 � ��` _ i � ,�� s . . � . . . . � � . . . � S� � �-wl a D �� #: r . � ��.�i C c� �"D3 �' l� � � - �, � � , F ,,_ . ,.. = . ' .. , ..0 .i . �. ..�,.-.G��'*`�r'�:Sre%'.:. ❑ I am a soie praprietor,ge�eral coitractor,or Lomeo�vter(cirde oaej and have Irired�e co�racta�s�listed below who have the following workers'compensation polices: �4fto�v�ume- address: � � cits: ��• i _ # � _ „ . . �,�� .. �y�e: �: � �• , ��• � _ _ _ - - —_ ---------- -- ------ —_ _ _�__ __ . - - --- w. # ` � FaYn^e b�ec�+e ewsra�e n req�ired a�dv Sectla�2SA�MGL 1S2 cu lad b Ike i�iti�a�tai�ial peaaNb�f a�e�p b S1,SM.M aid/�r � ene Yan'isprb��at as we8 as ciM pmiUes in the fira�eta STOt WORK ORDER a�d a Ase�tilAO.N a day atair�t ee. 1 o�dayqrd t6at a npy�t ub�ta1�t�ay Ue[erwarded ts tse 1�e�ptMm of t�e nlA ter e.veragever�Cau.e. 4 !do Gd�eby rd'jy xn . ,e� dkot tlie iwforiaaBo�prodded aboNe is aa�e med oomrt ' �8� Date 1�` /� `0 ( � Ptint natne I \ � Phone#�� C.�L � vV T� e�cial ase oaly de not wdte�this area to 6e compkted bp e1tY er iawa offic61 eity or tewn: permk/�oeose# Rsa�at�»Dep�ros►ent V ❑e�eck N�mdliale reapeme is reqaQ+ed ❑�� I eck �Sdee�s O�ce ` �� D�at c�� p��' ��°`"��1 '��m .::�#�+� � � � ACORD, CERTIFICATE OF LIABILITY iNSURANCE °"�`'"�°'"""' � ARDE4-1� OH il 06 f PROO�� THIS CfRTiFICATE!S ISSUW AS A MATTER OF MIFORMA71pN Tham►as F. xesfe Ina. Agcy. Inc OiVLY Mlfl CONFERS WO WGHTS UPON THE CERTIFICATE i 51 Wes t Centzal Street HOLDER.THlS CERTIFICATf DOES NOT IIMEND,EXTEND OR P. O. Box IC ALT£R THE COYERAG£AFFOttDED SY THE POUCIE3 BELOW. , Fsanklin !SA 02038 Phoae: 5fl8-528-3310 Fax:5a8-528-3887 INSURERSAFFOROtNGCOYERAGF NA1C�t n�su�Eo � u�sua�n: Firs t Cardinal South Side Tavarn LLC iwsuru�e: Trua�bull Iaa. Co. DHA A2't�lO INSt1RER C: DBA Ardeo Gri12e at 1Cings iAay 23V �hites Pith '►NSURERD: South Yarmouth DtA Oa664 INSURER E COVERAGES i TNE POLICIE$OF INSURANCE USTED BEIOW HAyE BEEN ISSUED TO 7ME INSURED NAA�D ABOVE FOR 7HE POLICY PERIOD 1NO�qTED,NOTWII'tlSTANDING ANY REQUIREMENT,TERM OR CON017"ION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICtI THIS CERTIFICATE kV1Y BE ISSUEO QR MAY PERTA�1,THE INSURANCE APFOR�D BV 7HE POUC�S DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERM3,F�(CLUSlONS ANO CON01T1�15 OF SUGH POUCIES.AGGitEGATf LtANTS SH04VN MAV HAVE BEEN REDUCEp BY PAID CLAlMS. LTR N$R TMPE OF INSUpANCE POLICY NUMBER DATE MkVODlYY DATE UMNTS GENERAL 1IA81liTY EACM OCCt�RE�E S CAMMERCIAL GENERAI 1U181LITY PREAMSES Ee oowrct�a s---- ': _ CUUMS MADE �OCCUR I�D EXP(MY�P�) f PERSONAL 3 J1DV 1NJURY f GENENALAC�GREGATE f •C�N'l AGGREGATE LIMIT APPLIES PER PROa/CTS-CONP/OP AC,Ca f POIICY ��a LOC If AUTOMOBILE 11A88.ITY ANY M1T0 �a��UMIT = ( i All OWNEO AUTOS �OILY INJURY : ! SCHEIXILED AUTOS (�P�I f HIRED AUTOS � BOOtLV INJURY s � NON-OWNEO AUTOS (��) ;��OAMAGE f � GANAGE ItABILITY AUTO ONLY-EA ACCIOENT S i ANY�WTO I EAACC S on��ltuw AUTO ONLY: �G = EXCESSft)MBRELLA LIABILITY EACH OCCURRENCE S � OCGUR �CLAMIS MADE AGGRfGATE ; - � 5 oEoucne� s � RETENTION S s YNORKERS COMPfJdSAT10N AND X TORY CIMITS ER � EMPWYERS'W1BN.ITY A ANVPROPRIETOR/PARTNERlEXEC(J�IVE 014005030285106 Ol/Ol/07 Ol/O1/08 E.�.E��io� i 500000 OFFICEWMEMBEREXCLUOED? E.L.DISEASE-E/tE1NPLOYE S rJO�OOO ��^��OMf E.l.OISEASE-POIICY UMIT s 50000 0 �°rr�a , � B Liquor Liability VQ000451? 06/14/07 06/14/08 Liability $1,000,000 OES�RIPTION pF ppERA7�N$/�OCATION3/VEMCIES/EXCLUSIONS ADDED 8Y ENDORSEMEM/SPECIAL PROWSiONS � Restaurants at 23V Whites Path South Yarmouth and 81 Rings Circuit � Yarmouthport ( PAX 508-394-3049 ��'d��.�� ',`"" .�; , "'� 1 CERTIFICATE HQIDER CANCELLATION Y�Q_1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANGEILED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING IN3URER 1NILL ENOEAVCR TO#W L pqyg yyp�N NOTICE TO TME CERTIFICAtE HOlOER NAAIED TO TFIE LEFi,BUT FNLURE TO p0 gp SNpL� Towts of Yarmouth Md�A Street IMPOSE NO OBL OR IITY OF ANY KIND UPON TMElN3URER.ITS AGENTS OR Yaxawuth MA 02664 RE?RESENT es. AUTHORIZ REP EN A Thoma f I s. c .Inc ACORD 25{2�Oiro8) � �ACORO CORPORqT10N 1988 TOTAL P.01 f � . - �-� � , .• _ � i TOWN OF YARMOUTH " E�OARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-040 FEE: $150.00 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 1 t 1,Section 5 of the General Laws,a permit is hereby�granted to: Southside Tavern LLC, 23V White's Path, SouthYarmouth;MA Whose place of business is: Ardeo Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2048 BOARD OF HEALTH: .�Ee�ert Sfl�aRt, J2..1Y., �'$acvtert�arrt C'f�ayceeo 3�.9£��'@iR�c `Uice C'/facvYntacn �s.�i�u+v�,n,� � November 28.2007 B ce .Murphy, H, S.,CHO : Director of Health i � _ __ _ -- _ _ _ � ; i THE COMMONWEALTH OF MASSACHUSETTS � � TOWN OF YARMOUTH ! f PERMIT NUMBER: #08-033 FEE: $50.00 I i This is to Certify that Southside Tavern LLC d/b/a Ardeo � 23 V White's Path, South Yarmouth, MA M IS HEREBY GRANTED A CONIlVION VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereuuto affixed their official signatures. , BOARD OF HEALTH: .�EE�E�'t S�i�i, :I��.N., � � �'�ear�c�e� .� ��e�iP,�i�c �Jice C"�aycrnacn � fi��e�ct .tt. J3�u�curt, C''� �arun, J`�. . November 28.2007 �,�, � �:,r� ruce G.Murphy, , . .,CHO _: �� `�' h �"�irector of Health � I � , � M s��.-� 4 -, - C�r�f+s : ' - o�laR � G3C� C�' C � M � DD 3� ,�: �o TOWN OF YARMOUTH BOARD;,�}E�EALTH ` ,:-� �.:_ ;;� APPLICATION FOR LICENSE/P�;l�ilT-20� �" N 0 V 2 0 2006 E;y.�,�- * Please complete form and attach all necessary�cuments by December 1�;{�fpQ�TH ��I'T• ', Failure to do so will result in the return of your application packet. � NAME OF ESTABLIS��VIVIEENT: TF.T,. # /S'�-� � LOCATION ADDRESS: G�} ` ; MAILING ADDRESS: � ` OWNER NAME: � � T IN r - 4 CORPORATION NAME (IF PLI ABLE : � �_ i � MANAGER'S NAME: � � r` TEL. #�a`D��7�3,3 � MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated i , Pool Operator(s)and attach a co�y of the sertific�tion to this fQrm. - -- — ---- -- --- -- ; 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 ; certifica.tions 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. , l. 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 ` Protectian 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 Healt6 Department will not use past years'records. You must provide new copies and maintain a fde at your establishmen� ' ; l. � � � 2. i P�RSON II1�-EHARF�:------ -_ _.___ _ __ _ . _ _ __�� _ � Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation. � 1.� Y` � � �- � �� S i � HEIMLICH CERT'IFICATIONS: ; All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich f 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. i You must provide ne copies and maintain a fde at your place of business. � 1. I��'�M 2. 3. 4. � RESTAURANT SEATING: TOTAL# � � � OFFICE USE ONLY � LODGIIVG: C LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _BFcB $50 _CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIlVIMII�TGPOOL$'75ea. LODGfi $50 _TRAII,ERPARK $100 WHIRLPOOL $75ea. � FOOD SERVICE: LICENSE REQUIRED FEE PF,RMIT# LICENSE REQUIRED FEE PERMff# LICENSE REQtJIRED FEE PERMI'T# ; 0-100 SEATS $75 _COrfTIlVENT,AI, $30 NON-PROFIT $25 � 1 >ioos�Ts $iso �07-obg / coa+�orrvlc. $so �07-�06 wxo�sar.� $�s � RETAII.SERVICE: —RESID.KITCHEN $75 � LICENSE REQUIl2ED FEE PERMfT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIItED FEE PERMTT# � 1 T<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 E _45,�0 sq.ft. $75 _FROZENDESSERT $35 TOBACGO $50 � NAME CHANGE: �10 AMOUNT DUE = S �OU•00 •:"•"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ..... �� .� � �� :� �.�'..r�`.� ,��4m-�� .� --- – _ _ � �_ � , , ADMIlVISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yaxmouth 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 Inswance. THE ATTACHED STATE WORKER'S CUMPENSATION INSURANCE AFFIDAVIT MUS'�BE COMPLETED AND SIGNED, 4R CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO ' f E MUTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall l� � limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. ; Transient occupants must ha.ve and be able to demonstrate that they maintain a principal place ofresidence elsewhere. ': Transient occupancy shall generally refer to continuous accupancy of not more than thirty (30) days, and an ; aggregate of not more than ninety(90)days within any su�{6)month period. Use of a guest unit as a residence or � dwelling unit sha11 not be considered transient. Occupancy that is subjecct to the collection of Room Occupancy � Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � � POOLS " POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected I by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to openulg. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by_a State certified lab, prior to a�ening, and quarterly thereafter. ; POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days af ' closing. FOOD SERVICE CATERING POLICY: i 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 obtauied at the 'i 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 Pernut until the � above terms have been rnet. OUTSIDE CAFES: I Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. ' ; OUTDOOR COOKING: O��door cooki�g,p�'epazation,or.ttis�lay of any fooc��rQduct b�a r�tail�fnod seruice-establishment is pr-�hibited. � ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN �I TI�C4MPLETED APPLIGATION(S).AND REQUIRED FEE(S)BY DECEMBER 31, 2006. i I ALL RENOVATIONS TO ANY �OOD ESTABLIS�IlViENT, M4TEL OR POOL (i.e., PAINTING, NEW �' EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; DATE: SIGNATURE: PRINT NAME 8t TITLE: � ioii�ro6 • � � ��d�/- _ a ! ___ _ � � The Comnwnwealth of Massachuset�s Drpartrnent of Indeis�rial AccidenLc > M�Nrw� 6(IU R'ashuzgton Stree� 7'�`Floor � Bos�o�,Mass. �2�11 I -- wurl��a'com�.saho.i�se�ee.a►ffii�vit:s�iidi.�JPl.mbi�kcd�cal cuitnetu�s I �.�,�,�.�.,�.� _.�. _w,�,,� . .�:.w,�,...�,.m..� ��„r.��.�..___.. - �x- - � � name• � � t i S11y state• zin• p�vtte# v�rorlc site loc:atian ffnll addressl• � p I am a homoo.,mer,�erfoaning all wo�k m,�seeif. Pro;ect Tppe: p xevr ca�aa�pR�anodel i I a sole ' and have na o�w ' in an ' . Buil ' Addition j I am an ariployer pcoviding wa�s'compensation fac my employees worlcing ai this job. ? - __ _s< - � [._�'i__ . _ ' � - - -- -- - -, . _ _ _ -. , L,�L_—� ! V VW V �: '��! ' � , � � p��D�O `�i ; ❑ I am a sole pmprietor,g�a�al co�tract�r,or kom�(cirde o,fe)and have hu+ed the comr�ctois listsd below wlw have the following workc�s'�on Polices: ' ; � ' I i _ j � � ' ( � ; i I �1t�C , ��+�.� �.r.��.., � � • I __- - — I — - --- - - - - — _ _- i I I FaYve U seee+e erreera�e as req�4a1 atider Seelba 2SA�f MGL 132 m Iaid b tlm i�p�itba�[�id peaYlfes�f a�e t�b�S1,3M,N aail�r � e�e yens'Ispr6N�mt as we�as paalf . ra�sta 31�0!WORK OBDER aad a Aae Kt1N.M t day a�aieK�e. I ndershid ti�t a � apy�thi��t u ai Omee I �f tlrc DIA fir c�v�a�age va�atlw I !�o lY by cerdfj� Pe�w nfPerjrr�'tl F�t d�e 3�efornt�loe prov�ded nboae!a dwe awd csmrt s� � �n ��• �'�� Print name � - Phone# l � � � .�ffidal ase an�q d�..c.rrke Y t�s ara m ne oa�pl�d by dly er�rwn.�ial ! �� Dep�rlt�mt � ❑e4eck if�be reapenae b ttq�ired ��pffiO� � p�nq�t E cea�t Per'aeo: P�e�k; � ; c,�a s�r.mo's� 4 I I I � � � ,� �-+ e� a�� $ ��,.�,s%� �r� `�is ��;.M i � � ENDORSEMENT Date Prepared: 5/24/2006 FEIN: Name of GrouA: MA Retail Merchants WG Group Inc. Name of Member: • Ardeo �outh Side Tavern, LLC Address: 23V Whites Path ' South Yarmouth, MA 02664 Policy Number: 014005030285106 ' Policy Period: 1/01/2006 - 1/01/2007 ; Effective Date: 5/22/2006 Carrier #: 34355 INTENT OF ENDORSEMENT (INDICATE ONLY ONE ACTION PER ENDORSEMENT) . i ( X ) ADDITION OF ENTITY/LOCATION($) � INSTRUCTIONS: ' � For changes; indicate -below-the name or �._ Indicate below the new name or address ' address prior to endorsement. Each item ; after change or the �ame and address of an ' on the left must correspond with an item � addition or deletion. For deletions give � on the right. � disposition. I f � Ardeo j � South Side Tavern, LLC • � 23P Whites Path � South Yarmouth, MA 02664 � Federal• ID $: 043495590 � Limited Liability Co � � Ent/Loc 7D �:0(30000�J001 I I � Ardeo � � South Side Tavern, LLC � Kings Way , � 81 Kings Circuit � Yarmouthport, MA 02675 ( I ; I . a0000 I Federal ID..#:, 000000000 � Federal ID #: 043495590 f � Limited Liability Co : , .:, � - , . � : .. ,. . .. ,. . ., . _ , , � _ . Agent: 548 - Thomas F Keefe Insurance Agency, Inc. I Requestor: JCLENDANIE - � , �,� STATE INSURED FILS AGENT ��"•.�:,"• �'.°'.1,� �>•"�� _ � ENDOR EM S ENT Date Pre ared: 5/24/2006 FEIN: � Name of Grou : MA Retail Merchants WC Group Inc. � Name of Member: • Ardeo '. South Side Tavern, LLC Address: 23V Whites Path . South Yarmouth, MA. 02664 Policy Number; 014005030285106 Policy Period: 1/01/2006 - 1/01/2007 Effective Date: 5/22/2006 Carrier #: 34355 INTENT OF ENDORSEMENT (INDICATE ONLY ONE ACTION PER ENDORSEMENT) ' . � � ( X ) ADDITION 4F ENTITY/LOGATION(S) j I INSTRUCTIONS: � For changes, indicate below the name or � Indicate below the new name or address address prior to endorsement. Each item � after change or the name and address of an on the left must correspond with an item ; addition or deletion. For deletions give on the right. { disposition. I � � Ardeo � � South Side Tavern, LLC � 23P Whites Path � South Yarmouth, MA 02bb4 � Federal� ID �6 043495590 � Limited Liability Co � �nt/Loc TD �:QOOOOOp001 I - i � Ardeo � South Side Tavern, LLC ( � Kings Way � ; � 81 Kings Circuit j � Yarmouthport, MA 02675 - I � , ( , 00000 � Federal ID.�:, 000000000 � Federal ID �: 043495590 � Limited Liability Co : i , , . � , _ � . ,. . _ � _ �„�� f--.M, x.' !" ° ►�-- �i� gen : 548 - Thomas F Keefe Insurance Agency, Inc. � Requsstor: JCLENDANIE `"��``"'`� ``� '`3 `'`"�'�'"'�`'� STATS INSURED FILE AGII�1T � i - i � � TOWN OF YARMOUTH BOARD OF HEALTH ` PERMiT TO QPERATE A FOOD ESTABLISHMENT � PERNIIT NUMBER: #07-008 EEE: $150.00 ' In accordance with regulahons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby-granted to: � Southside Tavern LLC, 23 V White's Path, SouthYarmouth,MA � i � Whose place of business is: Ardeo Type of business: Food Service � To operate a food establishment in: Town of Yarmouth f � Permit expires: December 31, 2007 BOARD OF HEALTH: Be _`?�. ,/1�`�1., � ��r�, �'�`z, v�e�� a�t� a�, et� � p��1�� 4�� , R.N. November 27,2�6 ' Bruce G.Murphy, S.,CHO � Director of Health ' i � f � C THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH i , , E PERMIT NUMBER: #07-006 FEE: $50.00 i This is to Certify that Southside Tavern LLC dJbla Ardeo � 23 V White's Path, South Yarmouth, MA IS HEREBI'GRANTED A � CO1��IlVION VICTUALLER'S LICENSE I In said Town of Yarmouth and at tha.t place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. , In Testimony Whereof, the undersigned have hereunto af�xed their official signatures. � BOARD OF HEALTH: ,Q ' ' �S. , /��5., G��i�r�rross : ��s`t�, ��r.'�, v� e�� i Ro�t�. ,8�, G'l�k r /�c�isc�/Ylc�l�no� � �� , R.�v. � �� --�---,. ��y .., . � ��: rroV��2�.Zoo� ruce G.Murphy,MP , .,CHO Direetor of Health .•: � � , i - , --.___.,�.��._.-�-�__ 2.��'e R.� TOWN OF YARMOUTH BOARD � A . , �' . �. � ''� APPLICATION FOR LICENS 6 � � � ��l;j NOV 3 p 2005 ��; !x � . ;:�>� rt� �� ,� " � ••.. .. � �; �--- * Please complete form and attach all necessa�{doc ents by ecember 31,�2QQ,S Failure to do so will result in the return of your application packet. �---=--= „ �--�- - - NAME OF ESTABLIS�-IlVIENT: �L-v TEL. #�0 a �Z(�0 I SZlU LOCATION ADDRESS: c�!3 V LJ+fi �5 �'- y ►�K.� ��, MAII,ING ADDRESS: ��1+uf- OWNER NAME: aS 1� ` e Q.__ T ID r •� - ' CORPORATION NAME( APPLICABLE): �oc.1►-�•�;c��(2/v�, L<,C__. ', MANAGER'S NAME: �o �tri�.i�— TEL. # �� 39'-� [7b�f�' ' MAILING ADDRESS: �.� V �J i-h-f-e� ,� �- y�AY�-u�l . �NYt.�..- I � � A� POOL CERTIF�CATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ; Poal 4perator(s)and attach a copy of the certification to this form. � 1. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place af business. l. 2. 3. �— 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food ` Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ;' Please attach copies of certification to this application. The Health Department wilt not use past years' records. ' You must provide new copies and maintain a fde at your establishment. ' 1. �� i�r� 2. PERSQN IN�HARGE: _ _ _ ------ -_______ ._ __ ___ _ _ i; Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. //� I 1. L/. I HEIlb�I�H 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 � at�a�i cc�pies 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. C . � 1. /��ti'f/�,.� ,SE��T-4�� 2. 3. 4. � RESTALTRANT SEATING: TOTAL# ; I OFFICE USE ONLY � LODGING: ' LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTT# _B&B $50 CABIN $50 MOTEL $50 iINN �50 _CAMP $50 _SWIlvIlvIING POOL$75ea. ' LODGE $50 TRAII,ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# �0-100 SEATS $75 CONTINEN'PAL $30 NON-PROFIT $25 �>100 SEATS $150 �a�e��,� I �COMMON VIC. $50 0 �OaY �WHOLESALE $75 ' RETAIL SERViCE: LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIIZED FEE PERMI"P# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 � _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOITNT DUE _ $ ZOO .QQ G ' f fY R R R RpLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM""""" i ��'''�'�`s/iiy'`��i�r�Y' j i � f � � � _ � I 0 6 ' � t ADNiINISTRATION � . ; Under Cha ter 152 Section 25C Subsection 6 the Town of Yarmouth is now re uired to hold issuance or renewal I'; p , , , q 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 k CERT. OF INSURANCE ATTACHED OR i WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED - � f Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � NOTTCE:Pernuts run ann�t�ly from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN TF� COMPLETED APPLICATION(S)AND REQIJIKED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS��VIENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7- � 10 DAYS PRIOR TO OPENING FOR THE SEASON. � � i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO ' COlI�IlV�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ' ADDITIONAL REGULATIONS POOLS f � -1'b6L�P�I�fIN�:All swimming,wading and whirlpools which have been closed for the season must be inspected i by the Health Departrnent prior to opemng. 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 autdoor 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 required Tempora.ry Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. � FROZEN DESSERTS: � - roze e se us e es e o a montl�y�asis�y a Stafe certi�iec�lab. `rest resu�fs mus�fiie sen�fo tfie Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the , above terms have been met. I OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must ha rior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food u a ail or fo d ervice establishment is prohibited. � DATE: � �� 'O� SIGNATURE: PR1NT NAME&TITLE: , � j�. ,�QJO ; � E � 09128J05 � i i � , - r - _=-��_= The Commonwealth of Massachuset�s - — Depart�neRt of Ind�strial AccideMs � _ '_ �f Ifr� - = < 60B WashiRgtow Stnee� 7"�'Floor _-�, Bostoii,Mas� OZlll � Worl�ers'Com�aaho,I�s�a�oe Affidaviitr B�i! ketricat Co�traeters �, .r ._ o, . �, � �_ � _� - � �� , . . .. � . � . „ � �• x � . . • �: � � ��`�Sic�-2_�I L L.0 addcess_ �3 � � l�l d'� �(�l "� I �-riy c5`�y�hA.. �h• �c• , Z1p. �°� 1 oLoae# J�'l� ��U �� arork site locatioa(fnll addc+essl• ❑ I am a homoowner perfom�ing ai[wark my�elf. Praject Type: ❑New Ca�uclion�Reznodel I am a sole 'etor a�i have no one w in an Addit�on . i [��am an e�ployer pmviding w 'co�tian fac my e.�loyees working on this job. i p �o- i�(� - . _-- _ ; ��: � ll W tr�� `�-� �'^� � �� ?��`Z7 �; �� i�..c.r►n -..�'v�� C� ��- � . .�----� . 11'� e��c-5 S oc . DJ� t9o5' 3 a-f� I p5� , o - ; ❑ I am a sole proprietor,geseral coatract+ar,or komeo�r�(cirde oire)ancl have hiied ihe co�ctors listed belaw who have the following worlce,rs'compensation polices: � ; ckv n6are�lt; ' f � � i , �:. C �w: I �: �.�= — _ __--- -- - -- . ____ _ _._�_ �,_ _ __—_ _ __ _ - --- --_---- - ---- ---_ _--- _ --i Fa�ve 1�seces crYera�e as 2SA�tMGL LS2 na le�b iYe i�itl�t�f cttd�d pe�fNks�f a�ose�b 31,SN�N aadl�r i e'e yeaes' as h tie fir�of a STO!WORIC OBDER aM a me df1N.N s day��e. I nde�sbad t�at a apy d tlds Ne �f l�re�tlwsa of/�DIA Gr av�a�e v�iatl�a. ' I ro henby �eetfy Nie Rwd of pe�rry tlY�t dYs�fonN�lon proro�ded aboae ia tnre e+rd c+�n+ecx Signatme p� /��cJ Q• �_ Print name � i Plwne# .�� /�9 D ��tJ" efficiai�e only de eot�vrke i thb am to be c�plaed b9 dly er brw�s�eLl � �Y��= per�oease# (�� j ❑eYeck Kismedia�e�apsau b rc�dordl �� *mt i � ��- P� ' Oo�' I �., c.� x -�*_,N. I �,� ��'�, .,��''� .,� ��,z � .�a � i _" 't TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TQ OPERATE A FOOD ESTABLISHMENT PERNIIT NIJMBER: #06-039 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Southside Tavern LLC, 23 V White's Path, South�armouth, MA Whose place of business is: Ardeo Type of business: Food Service To operate a food establishment in: Town of Yarmouth ' Permit expires: December 31, 2006 BOARD OF HEALTH: Besry�rsrs�. �'on�s,Jl�l.�. ' ' A�k il�l��tt`, v�l��.,��t Ro6�t� ��eo�uaa, G'le�tk �s� R� , December 6 2005 ' Bruce G.Murphy, ,RS.,CHO Director of Health _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH i PERNIIT NUMBER: #06-034 FEE: $50.00 ' � This is to Certify that Southside Tavern LLC d1b/a Ardeo � 23 V White's Path, South Yarmouth, MA � IS HEREBY GRANI'ED A � COMMON VICTUALLER'S LICENSE ,' In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless � sooner suspended or revoked for violation of the laws of the Commonwealth respecting the � licensing of common victuallers. This license is issued in confornuty with the authonty granted to ; the licensing authorities by General Laws, Chapter 140, and amendments thereta ' � In Testimony Whereof, the undersigned have hereunto a.ff�ed their official signatures. ; BOARD OF HEALTH: ,. �r�/`I� ('�y� /j�J'.�y. G��u� � �, v� e�� Rel,�t�. ,8�, G'l�k � ��sl�k, R� . . � � , �rt �� r� � �R� D��-6_Zoos �� „� .e� ._.�� ruce G.Murphy, H, •, � Director of Health � �. Y f,�$Jc • ��.YA�� TOWN OF YARll�IOUTH � _ � ° �H -_^ i`j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 " MATTACMEES� � ' '� ��afl,�„�,�o,bfl�' Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 B O A R D O F H E A L T H To: Yarmouth Boazd of Health Permit Holders � � � �� , ,�� _�. 7��5 �, From: David D. Fla�be�rty Jr., RS. ;� , HealthInspector ✓�� HEALTH C�PT. � Town of Yarmouth � Re: Federal Ta�i ID Number Date: March 22,2005 ; The Massachusetts Department 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 establishmerrt's Federal Employer ldentification Number(FEIN}otherwise known as your"Tax 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 fill out the fields below and return this letter to Yarmouth Health Departmern � 1146 Route 28 � ' South Yamiouth, MA 02664 Thank you for your anticipated compliance. If you l�ave any questions regarding this matter, plea.se do not hesitate to cail. The oi�'ice�iours aze Monday to Frida.y, 8:30 a.m to 4:30 p.m`�'he telephone number is(508)398-2231,ext. 241. ' Establishment: __��,V�� FEIN or SSN: ��—'�� Location Address:� ��,�5 �rl �• ' `"'"� • 3� `� s��e: � � � p � �t: � � � Title: l�� j I � �:� �� 1 �� i�� Printed on Recycied � – f � � Paper � � , �� ,a�� F yq A�DEa �2�"r_R'y0 TOWN OF YARMOUTH��O TH G3 (� C� I� f] M (� DD o..,, "�'.`3 APPLICATION FOR I� ,� '�k os �` , :� '� 4` `� ", � N O V 2 6 2004 •.. .. � � �� * Please complete form and attach all neces�ry ocuments by Decem r 31 2004. Failure to do so will result in the return ofyour application pac eti�ALTH DEPT. NAME OF ESTABLISHMENT: TEL. # 5'0$• � � LOCATICIN ADDRESS: t�-i , Vh� . 7t,p• 1S"�O MAILING ADDRESS: OWNER/CORPORATION NAME: S` 1..�-.C� MANA ER'S NAME: t�iM'�+ ► TEI,. # • D•/S� MAILING ADDRESS: P• • X 3 . c'.�'1VbIS y'►2u . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Qperator(s)and attach a copy of the certificat�on to this form. 1. 2, Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - 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 o£certificaxion to this application. The Health Department will not use past years'records. ; You must provide new copies an maintain a fde at your establishment. j , . � 1. 2. � � i _--P£��6hfi�N CHAR�E: __-- - _ --- --- --__ __. __ ___ �_ Each food establishment must ha at least one Person In Charge(PIC) on site during hours of operatio . ' � . 1. � 2. Gt�V ' HEIMLTCH CERTIFICATIONS: ' • - A11 food service establishments with 25 seats or more must ha.ve at least one employe�e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and ' attach copies of employee certifications to this form. The Health Department will not use past years' records. : You must provide new copies and maintain a fde at your place oF business. l. �IU'tf7�' �� 2. 3. 4 � r RESTAURt�NT SEATING: TOTAL# ; i � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B S50 CABIN � $50 � �� MOTEL � - - S50 �-� INN $50 _CAME' $50 _SWIlVIlKIlJG POOL$75ea. LODGE $50 _TRAII,ER PARK $50 WHIIZLPOOL $'75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQiTIRED FEE PERNIIT# ! 0-100 SEATS ��5 _CONTINENTAL $30 NON PROFIT $25 I �>100 SEATS $150 0 �OI �COMMON VICT. $50 QS�O� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE pERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEB pERMIT# _<50 sq.ft. $45 _>25,000 sq.8. $200 �VENDIN(3-FOOD $20 _<Z5,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $25 NAME CHANGE: $io AMOUNT DUE = S 200•OO "'�•"PLEASE TURN OVER AND COMPLETE OTHER SIDE O ■••*• �� s*a,�� :a.�.s:,�. �� " �::t,� ��''�,� �s a� i `r ' �'� �[ 1� I ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ' Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK ! APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. ; , SEASONALESTABLISHMENTSARETOCONTACTTI-�HEALTHDEPART'MENTFORINSPECTION7-10 � DAYS PRIOR TO OPENING FOR THE SEASON. � f ALL REN4VATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i � i ADDITIONAL REGULATIONS POOLS POUL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. i POOL WATER 1'ESTING: 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 clasing. FOOD SERVICE CUNSUMER ADVIS�RY: ' Each food estab 'shmem which serves or sells ready-to-eat,raw or undercooked animal products are required to post ! Consumer Advisories. CATERING POLICY• � Anyone w o caters within the Tovm of Yarmouth must notify the Yarmouth Health Department by filing the � required Temporary Food Service Application form 72 hours pnor ta the caxered event. Thses forms can be � obtained at the Health Department. _ _�Ei�T-��SS�I�3'S: --- -- Frozen esserts 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 Board ofHealth. �UTDOOR COOHING: Outdoor cooking,preparation,or display of any food odu r � food service establishment is pro6ibited. ! DATE: • (�! •d SIGNATURE: �� PRINT NAME&TITLE: � t� � � ; � � 10/22/04 I � > : , �� The Com�nonwealtb of Massachusetts �� Depart�nent of Indus�ruil Accidents - _- �� _-- < 6118 WashiRgttin S'tnee� f"'Floor -,,,. Bosto�e,Mas� OZlll � workers'com�aahue Issura�ee affialavic:s.ila�m�l�dx w. ,��-: „�..._ .� �, �•:.,.., _., .,�,..,....., _,�,.m..,�.�. _ Costractors 4; .. .w �, ,w.. f.�w..�. ...��_�. �_�.._.�_�n... �_. � name' I f �[C.RS: �� ( . C31V 31atC . . . . ZlD' i7�109C� . � � QVQlIC S1LC IOCBh��I 3�I'CSSL' . . . . � ❑ I am a homeowner perfoaning all waa�C myself. Ptoje.ct Type: ❑New Canstcuctia��Remodel I am a sole and have no a�ne w in an BuiI ' Additian ❑ I am an employer�xoviding wadc+eas'compensatiost fa�my empk�y�s wa�icing o�n this job. ` �` i.1.,C� t�'1�� .�. . _ � t�1l�� t , 2�a 6� • , • : . . . aS�a `� 11(1�/t�.�i.vt, . (�1 � Q -" � ❑ I am a sole p�aprietor,ge�ersl co�tracMr,or�eewter(cirde owe)and have hired tbe co�r�ctors listed below who have , tbe following wvrkeis'compensation polices: ( �� i i � � ! f � � � � , s�: ��t- � �Y� ; �: dtvc ��- i i Fa�m+e r sec�e caMera�e as req�h+ed�rder 3atl�a Z4A�tMGL 1S2 cu Iad b IYe i�iH�a�f a�id peafNin�f a�e�p b S1,3M.M aidhr I� o�e y�s'bePthaaeat pea ia tie��f a STO�'WORK QRDER a�d a A�e�[S1�.N a day�t�e. 1 ndasdod t6at a apy� 1s Ne �f lm�tlpwm ot tlro D1A far av�a�e v�eriAatlw. I do k c ofPerjrr+�'dF�t tlYe i�fonww�toa pradded aboae la Inre rt�d c+�n+�ct �8�n llate 1''G-J '�� ; 1 p Q Q /' ' Print na� Plane# �DO ' Z�CJ• /Z�( i i effieia!ase o�ly as eot write i�c�s uea to be asplefed b9 dtg ei'a,.n.�cid ; �y or taw�: pve�o�e/ ('�� ! ❑e4ed�if�!e nspseae is ieqeed � � �a �Pv'sese p�e#, �� . �,,�"�,� �^ e x + ', '.�y ,; i �''.�.��'"'��d"_i iIC��k�aar.�rri� � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMEIITT PERMIT NUMBER: #OS-013 FEE: $150.40 In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is hereby granted to: Southside Tavern LLC, 23V White's Path, SouthYarmouth,MA Whose place of business is: Ardeo ' Type of business: � Food Service To operate a food establishment in: Town of Yarmouth ' Permit expires: December 31 2005 BOARD OF HEALTH: Bs�i-.�r,u��. go�uP,or�,/l�`.?S. ' P�M�s�� v�e�� s'�R�.N.� � R.N. ' December 28 2004 ` � ` Bruce G.Murphy, ,RS.,CHO ; Director of Health ` � � � i _ f i THE COMMONWEALTH OF MASSACHUSETTS ! TQWN OF YARMOUTH � , PERMIT NUMBER: #OS-011 FEE: $50.00 � � This is to Certify that Southside Tavern LLC d/b!a Ardeo : 23V White's Path, South Yarmouth,MA IS HEREBY GRANi'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless a sooner sus ended or revoked for violation of the laws of the Commauwealth respecting the ' licensing o�eommon victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. � In Testimo�Whereo� the undersigned have hereunto a�xed their official signatures. BOARD OF HEALTH: Q�� . (��,�, /j�I.�. G��iar�irasz � ��r�� v� e�� i Ro�Ge�t�. l3� G� : � s1�, R.ti. ' �4� �j �, R.N. � I , Dee�28.2004 .,.... .,. . ,�. 4 °'�'` "� '`�` °-�, �, r� � ruoe G.Murphy,MP �: ��CT�O � ' } �:�.�� Director of Health ; P _.----�,,,� ��. ` 4 ��,q �IRO iB � .= R� TOWN OF YARMOUTH BOARD OF HEALTH � � � � � �� !-°� 2 . -•.o �: _';,s APPLICATION FOR LICENSE/PERMIT-2004 NOV 2 6 2003 * Please complete form and attach all necessary documents by Decem r��0�� DEPT. Failure to do so will result in the return of your application pac . !.�'CaO D S �d. �� •� ` vYVI�P.t- 2fc 0 T N A ` t_..I,.C_ A ER' AM c7 ` MAILING ADDRFSS• �A1Vl� POOL CERTIFTC'a'rintv�• The pool supervisor must be cert�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a capy of the certification to this fozm. 1• 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. �'OOD PROTECTION MA�1A iFRS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defin�d in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health bepartment will not use past years' records. ; You must provide new copies and aintain a file at your establishment. �d l� e� � � l. 2. I ; -- -— --- ----- — ___ _ - I . __ _ E:_ _ _ ____ ___ ____ ___--_ _ .__ __ Each food establishment must have t least one Person In Charge(PIC}on site during hours of operatio ; � ,��1.� � �� 2. � HFIIVLLICH CERTLFICATIONS: � � � � All food service establishments with 25 seats or rnore 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 eopies and maintain a file at your ptace of business. 1. 2. 3. 4. i IZRSTAURANT SEATING: TOTAL# f i i LODGING: 4FFICE USE ONLY i LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CAB1N �50 _,MOTEL S50 � _II�1N �50 _CAMP $50 SWIMMMG POOL�75ea. _LODGE $50 _TRAILER PARK S50 _WHIRLPOOL $75ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _0-100 SEATS a75 _CONTINENTAL �30 _NON-PROFIT S25 ( �,i >100 SEATS �150 ��•0 3� I COMMON VICT. $50 O � �.QZ.�] _WHOLESALE a75 � GICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SO sq.ft. $45 >25,000 sq.ft. $200 iVENDING-FOOD S20 <25,000 sq.ft. �75 _FRn7F,N DL'SSfRT S35 _TOBACCO $25 NAME CI-LANGE; $10 o,,��I�(�1�. DUE _ $ - - ?..00.�O �� v�;��T **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"" _ . �_ � _ i - �' � � ADMINISTRATION '� Under Chapter 152,Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal j 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 A1'TACHED STATE WORKER'S COMPENSATI4N INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens mus#be paid pri to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO ' NOTICE:Permits tuti annually from January l to December 31. IT IS Y4UR RESPONSIBILITY TO RETLTRN ' THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. ' i SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPA.RTMENT FOR 1NSPECTION 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 i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; i � i � � � I f i II ADDITIONAL REGULATIONS POOLS 4 POOL OPEl�TING:All swimming,wading and vvhirlpools which have been closed for the seasan 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 CON,�UMER ADVI�ORY: � Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post ! Consumer Advisories. 4 .�TE NG P ,�ICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary �qod Service Application form ?2 hours prior to the catered event. Thses forms can be obtained at the Healih Department. 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. ' OUTSID�' CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTD�S'OOKING: Outdoor cooking,preparation,or display of any food r reta r food service establistunent is prohibited. ' DATE: ��`�� SIGNATU ; ,(� � PRINT NAME&TITLE: �� h' � 10/22/03 i 1 _ - . � • •� � The Conrmonwealth ojMossachusetts � � Department ojlndustrial.-lccidents " ; OIfIC�0//e/�IDS��dI/f + 600 Washington S�reet '. ,,� B�ston,Mass. OZlll ~ �� 11�'orkers' Compensation (nsurance Affidavit Anolicant intormation: plessepRil�7"Ti•�.'wa ' nam�� 11'JEII'V�c'71� �i�� L—� ��-� � 3 w s � � � � � � � � � �'� . � �o !s � I am a homecw�ne pertormin,all w�ork myself. � I am a sole proprieror�r.,a, ha�e no one��orking in am�capacitr ' am an empioyer pro�iding w�orkers' compensation.for my employees working on this job. ; - , _ G a n • n `� �� 3 � � ddress. ' � �. � /1P� �� iesurance ca �`�' • f`� ` � A.Q!!SY# ��VIZ 7�5 L��I 9� I D�/.�J ; � I am a sole proprieror. :enerai contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below �tho ha�e � the follu�.in� ��orker� ,ompensation polices: � ; i tomnanv namr t �dress• � f citt�• hon4 li• � insur�ncc co. Rolic••!! ; f comQanv name• addresr. ; i citv: phQns_+�. ' insurance co. �,� � � i Faiiure to secure coveraee as required uoder Seenoo 25A of MGL lS2 n�kad to the iopo�it�o(eri�i�al pt�altla of a 6�e op to 51�00.00 a�d/or i oee yean'imprisonment a�w•ell a�eivii peeaitie�io the form o!a STOP WORK ORDBR asd a Aae ofSI00.00 t day apin�t me. I r�dersta�d t5at a copy of thy sate mav be f e e Ifice of invatiguioro of t6e DU for eoven e veritipdo�. � i � /do hrre cerrif}• r e d rna ' o perjury that tht injornmtion provrded above is tnte aad cor►tct � Signature �/ ��J "v� I /�7ty�� i Print name one 1l vLJ�� . k � k I .. o(ticial use onh do not M�ite in this area ro be completed by ciN or town oflleial ; ciry or town: Y�M�IIT� _ permit/licea�e N nBuilding Department j �.�.- " "� OLiceasiog Board �cheek it immediate response i�required ��u�+�� OSdectmen'�Oliice ( 261 " �y��Departmeat • � contace person: �_��Rti �n�..331 eat. nOther ... .� � a�.: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated industries of Massachusetts Mutual Insurance Company ' Burlington, Massachusetts NCCI NO 26158 ' (800)876-2765 ' POUCY NO. �Z 8003719012003 ' PRIOR NO. WMZ gpp371gp12pp2 ITEM 1. The Insured Celebrities,Liquors,Inc.dba Christines RestauraM(see schedule) Mailing Address: P O Box 313 West Dennis MA 02670 ' (No. Street Town or City County State Zip Code ❑ Individual ❑ Partnership � Corpora6on ❑ Other FEIN Other workplaces not shown above: 2. The policy period is from��2�3 to �� 12:01 a.m.standard Ume at the insured's mailing address. 3. A Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; , MA ' B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. ' The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 po�icy limit "' Bodily Injury by Disease $ 5 0 0,0 0 0 each employee I � { G. Other States Insurance: See Endorsement WC 20 03 06 A f � D. This policy includes these endorsements and schedules: SEE SCHEDULE � � •i i , I , 4. The premium for this policy will be determined by our Manuals of Rules,ClassificaGons,Rates and RaUng plans. � All infortna6on required below is subject to verification and change by audit. � i Classifications Premium Basis Rates , Code Estimated Per S700 Estimated � No. Total Annual of Mnual I Remuneration Remuneration Premium i INTRA 083583 ', SEE EXT NSION OF INFOR TION PAGE Minimum premium$ 219.00 Total Estimated Annuat Premium $ 16,352.00 ' As indicated,interim adjustments of premium shall be made: Deposit Premium $ 4,297.00 � ❑ Annually ❑ Semi Annually ❑ Quarterfy � Monthly � MA Assessment Chg. $18.57,6.88 x 4.5000°/a $836.00 This poCcy,including all endorsements,is hereby countersigned by 02/11/2003 ; Authorized Signature Date � GOV GOV KIND PLACING CLAIM NAME SAFETY t STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Thomas F Keefe Insurance i MA 9079 8 804 0500 Agency Inc � WC 00 00 01 A(11-88) P O Box K�� Includes copyrighted material of the Natiaial Council on CompensaGon Insurance. �� ,C� �r��3"�""`.k`��038 r3:�; . � , . . used with its pertnission. �1�+ �a u t��''v"b� ct:w,�s�s..c�" I � I Title: Schedule of Locations Remarks: Celebrities Liquors dba Christines Restaurant 581 West Main Street West Dennis, MA 02670 South Side Tavern LLC dba Ardeo 23P2 Whites Path South Yarmouth, MA 02664 ; � : Y ... f G � I � I f ' • I This endarsement is atteched to the policy indicated below and is etfective on the date stated herein,at 12:01 A.M.,standard time at Me address o(the insured as describad in the informadon page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WMZ 8003719012003 0500 04/O1/2004 04/O1/2003 001 Issued to Additional Premium Retum Premium Celebrities,Li uors,Inc.dba Christines Restaurant(see schedule) ; ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY ; 4 I � � � �� >; � �,t ,��' ��'Sa�� Countersigned ! horized Representative i i TOWN OF YARMOUTH BOARD OF HEALTH PERNII'r TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-037 FEE: 150.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a pemut is hereby granted to: Southside Tavem LLC, 23V White's Path, SouthYarmouth, MA Whose place of business is: Ardeo Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD OF HEALTH: B��a�xs�$. ��M.�. ' P��f�s� v:�G'f�� Rad�,t�. B� � �� Sl�k, R.N. � � � l November 28.2003 ��- - , ruce G.Murphy, S.,CHO Director of Health : i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ; PERMIT NUMBER: #04-027 FEE: 50.00 This is to Certify that Southside Tavern LLC dJb/a Ardeo ; 23V White's Path, South Yarmouth, MA IS HEREBY GRANTED A , CONIMON VICTUALLERLIS LICE1rTSE ;. In said Town of Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the ' licensing of comrnon victualler's. This license is issued in confornuty with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: L�e�rs� �. �jr'r�P�t�s, M.�S. G��ai�sus�s p�� v� e�� Rc�t�. l3�, G�'� ( � � � , R./V. � G � �',� r�'� " ' � � ��,�� r�^--�, , r� �� '"�� _=�� /, November 28.2003 ' ' ' � `"'�� .s,��_ Bnice G. Mitrphy, .,CHO , __.___ Director af Health ' a x� � n Qp� ��'-Y'�R TOWN OF YARMOUTH BOARD OF T 2 •'- �o . �,' , i� ,-, r,� n � ,w��`��, � -'�� APPLICATION FOR LICENSE/P � :` 0 IJ s �=� `� � � J O.z y Y � ,Q �y:.:�� O •., ...•' � P sarY Y D � �'��2��.��;� * Please com lete form and attach a11 neces d n ec Failure to do so will result in the ret�� ` .i lication ' , ,;��=,> � P P��..To-� ��ti�;_w T "' # byD a3 w�s-� �s a 3 3 � o��o TI t_LC � ,�+` # 3q -a85] D ��n I,� o POOL CERTIFICATIONS: ^ , ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated _�'�LQ�ra�or�s�ansi attA��h a conX 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 empioyees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must , provide aew copies and maintain a file at your place of business. 1. 2. ; 3. � 4. � � i ; FOOD PROTECTION MANAGERS -C�RTIFICATIONS: ' All food service esta.blishments are required to have at least one full-time em�loyee 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. � � � �� 2. n�ucn�r r�r r'�ueu�F•_ __--__ ' _ _ -z-��.-��.�,,. _ . -- ____ _ . ____— - - _--_ . __-. __ _ ._ k Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1, �� V� � 2. � HEIMLICH CERTIFICATI NS: : All food service esta.blishments with 25 seats or more must have at least one employee trained in the Heimlich ; Maneuver on the premises at a11 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 maiatain a file at your place of business. 1.�`t'G v�(1 ��aCJ�..�(Z-0� 2._�7�.v1��- J�� 3. 4. ' i RESTAURAI�TT SEATING: TOTAL#� � OFFICE USE ONLY ` LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j I _B&B $50 _CABIN $50 _MOT'EL $50 _INN $50 _CAMP $50 _SWIlI�IMING POOL$SOea. _LODGE $50 ^TRAII.,ER PARK �50 _WHIRLPOOL �25ea. ; _ - -��s�u�c�. _ -- —- -- -- ---- - --- - _ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItE�F�Y P�RIGII�# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 � ,�>100 SEATS �I50 `�� ( COMMON VICT. S50 �0?j'O� _�OLESALE $75 R�'TALi.S RVI • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE 'PERMIT# _TOBACCO $20 _<25,000 sq:�t. $75 �TOBACCO $20 _<50 sq.ft. `�45 \ _>25,000'sq.ft:- a200 _FROZEN DESSERT$35 rT.�MF.('gAN�E• $10 AMOUNT DUE _ — $ 200•d0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF F��•** � �, � ��K�.,,,.��,�-,R$. _ 0�.�i +s��:e�.� I i 5� I � t { f � , ADMINISTRATION � I Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � � � CERT. OF INSURANCE ATTACHEL� � OR 4 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED k , � ; Town of Yarmouth ta.��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK C APPROPRIATELY IF PAID: 1 � � YES V NO � G NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTI�NT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIl�iG FOR THE SEASON. � I 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. � � i _ 4 i � ! Al)DITIONAL 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 �� CONSUIV�ER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post � Consumer Advisories. i CATERING POLICYs � 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 pnor to the catered event. Thses forms can be � obtained at the Health Department. FRn7.FN D�,SSF�RTS:, - - Frozen desserts must be teste�on a monthly basis by a State certified Ia�. Tesf results must�e 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: Outsicte cafes(i.e.,outdoor sea�ing with waiter/waitress service),a�ust have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any ood pr y re ' or food rvice esta.blishment is prohibited. � i � 4 � DATE: � SIGNATU PR1NT NAl��&TITLE: o (�'W1 � � 10/18/02 � � � . �,., . . i _,..�.,,.. -,_ s�.,..�°� ,Y . _-` � � — -- _� _ � The Conrmonweulth of Mossaclrusetts � � Depa��ment ojlndustrial,-iccidents ', � o Ofllceoll�s�loslliis � 600 Washington Stree[ ' � Bnston,Mass. 02111 i �'" ��y`' �L'orkers' Compensation Insurance Atfidavit ARnlicant information: plessepRiNTTed,-i�iir '! n m• �� --rJ �^ � a �� o'Z3�/ � � , . 5- �---V�l..� � . ��.�� I am a homecµner pert�rming all work myself. � I am a sole proprieror ��,a, ha�e no one«orkine in am•capaciry am an em ioyer ro� dino workers' com ensation for mv em loyees workine on this �ob. _-- P____ _ P _ —=__ : P _.� p .. J __ an • n c �C��f 2YI �� dress: V �1�, � . r� a 1 i u n c f . ! � V� �. W � � CK�� I am a sole proprietor. general contractor, or homeowner(circle one) and ha�•e hired the contracton listed below ��ho ha�e ; the follu��in_ ��orker�� ompensation polices: ; f C9fI1DaI1V Ilaffl!' i address• i � �'tt�" ehone k• insurancc co, oolic}# �mD,�,nv name• � --- ---- -- -- - __, --____ address: _ ' �'� nhoee 1{• insurance co. �,* t Faiiure to secure coverage as required er Secnon 2SA of MGL 1S2 n�Ind to tre iopaidoa ot uiei�al ptaaitle�o(a 6�e ap to 51,500.00 a�d/or � one vean'imprisonment w•ell i� ril p a io the form of a STOP WORK ORDER aed a Ifae otS100.0A a day apin�t sa I r�dersta�d t�at a copy of thy em t be ar to t ce of Investi�atiom of Me DU[or eoven�t veri8atio�. /do hrr by ce '}• er nd p ojptry'ary that!ht i�rjorn�ativn providtd above ts due an eo ' Signature � / / �� , Print name �.1 � �` ! � � one N 'J `d�1�3-1J 7��1J� � .- otTicial use onl� do not M�ite in this area to be completed by city or fown oflieial I city or tow•n: YARMOIIT$ _ pennitAicease M nBuildiog Departmmt ; �"`"�'� '� �;"�`�,�`�"' "'� �Lieeasio6 Board cheek if immediate res nse is re uired �'�''�' '�� y �°°�� q 261 ❑Seiectmen'e Offlce � �S�Q� �oQ �� OHea1tA Depanment contact person: phone N•_ __,,., _ -- • nOther ; � ( .. .�. :<a,,: I I . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-080 FEE: $150.00 , In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 111,Section 5 ofthe General Laws,a permit is hereby granted to: 'I Southside Tavern LLC,23V White's Path, SouthYarmouth,MA Whose place of business is: Ardeo � Type of business: Food Service '; To operate a food establishment in: Town of Yarmouth : _ Permit e�ires: December 31.2003 BOARD OF HEALTH: �a�a s� xelli�ez. �a�iraxa�c ' __ _ • • D, y�. 7'll.�.. �/ru ' _ �o�ar� �, �k ' �aaitek I?l�D� : � S� .7Z. : December 19 ,2002 ruce G.M hy, . .,CHO Director of Health ' i ; ; � —___.__.____ � � � _ � THE COMMONWEALTH OF MASSACHUSETTS TOVVN OF YARMOUTH ., ;. . . . PERMIT NUi1�IBER: #03-054 FEE: $50.00 � This is to Certify that Southside Tavern LLC d!b/a Ardeo ; � � 23V White's Patb, South Yarmouth,MA j , � IS HEREBY GRANTED A � � COMMON VICTUALLER'S LICENSE , � In said Town of Yamiouth and at that place only and e ires_Dece,�nber thirty-first 2003 unless _ soo er ed far-viohtiou- - espeeting the - f i licensing o cominon victualler's. This license is issued in conforxtuty with the authority granted to the licensing authorities by General Laws, Chapter 140,and ameendments thereto. ' In Testimony Whereo�the undersigned have hereunto a�xed their official signatures. . � BOARD OF HEALTH: ��anled�. �e��, ��ia;�a� � �'a�,rr�c�. C'�do�c, '!�?�. . �Iiee ��a.�c ; � � �?a�rt� �. L� � � , �a.�uek�c�er�tt 'si� S . �72. i � � December 19 ,2002 ��,, �, �� • ,� � � ��''-�a. �.a�m.,� , , Director of Health , . � -�.-- .� _ .,A:,` ; A-RDEb � ��"� � � �'" � WN OF YARMOUTH BOARD OF HEALTH ,.,� '�' ` PLICATION FOR LICENSE/PERMIT-2002 � , . .. § � * Please complete form and attach all necessary documents by December 31, 2001. Failure to do so will result in the return o��ur�pplic��ac�,lt AME OF ESTABLISHMENT: TE . # ZI� T S• i S MAILING ADDRESS: �d� ��c� � . ��Pr�lt2/5 u . 2'O WN I E: � 'L ' N T . # S ,� MAILING ADDRESS: P D. JC �3(�'� (.J� 7�P/►'�✓l!� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated PoQI Qperator(s)and attach a copy fr€fi�e e��tifrcatis�e t�is 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 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. FO�D F�:fl�'i'��I�€1��C��'�"��+��' ' 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 apphcation. T ,�ith De�artmeat vYi�not use,past years' records. � Yee'�' �tE�IT �`a: ��= ��:��• _ �"` I 1. �� 2. � � � `4 . . _ PLil\�7VlV 11V l..il�VL'.__. -."_._.. .._.- __.- _.__._ ._.__.____'____ .___._..__ _-__._._ _ _ .. __ _.. . . -i Each food establi ent mu have at le ne Person In Charge (PIC) on site during hours of operation. � ` ` E�1 � � 2, "T'T�., ¢ . ,..� _ .�,:�.- 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 atta.ch copies of employee certifications to this form. The�-Iealth Department will not use past years' records. Ydu must provide new copie and maintain a file at your place of business. 1. \� �a� � �:,!��- 3. 4. RESTAURANT SEATING: TOTAL#1� OFFICE USE ONLY �.ODGING• ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# r B&B $50 _CABIN $50 _MOTEL $50 � _INN $50 _CAMP $50 _SWIMMING POOL$SOea. i f _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea 4 �OD SERVICE: � I,ICE'�REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _0-100 S'"�TS $75 _CONTINENTAL �30 NON-PROFIT $25 � �>100 SEATS''�.;,p, .$150 � �COMMON VICT. $50 �Od'QQ� _WHOLESALE $75 RETAIL SERVICE: '' �, LICENSE REQUIRED FEE ;,PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _TOBACCO $20 ��;�, _<25,000 sq.ft. S75 _TOBACCO $20 ' _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOITNT DUE _ $ 20O.OQ � � �h � �fi�i: *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM* ;��;••�•�d�;� '�. �,,;;� _�...� -- - _ - r � �� • t -� T � I ; ADMINISTRATION � - � � f Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal r 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 � � ' �JWORKER'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 -- f NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN ; THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2001. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT'I'HE HEALTH DEPART'MENT FOR INSPECTION 7-10 �4 DAYS PRIOR TO OPENING FOR THE SEASON. � I ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. _ _ � _ � _ , I i � ADDITIONAL REGULATIONS t POOLS _ � _ __ . _ _ _ ; POOL OPEI�TING:All svvimming,wading and whirlpools which have been closed for-1�e season��st be�pected 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 Sta.te certified lab,prior to opening, and quazterly thereafter. f 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. ("ATERING POLiCY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _�—_ _-- -_ Frozen desserts 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 Permrt until the I above terms have been met. � OUTSIDE CAFES• I I, Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. i OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food p ct b a •food rvice establishment is prohibited. , � I V ( ,I/ ��w A 3� DAT'E: Ia•�`O'V I SIGNATURE: �� . � �l',,�INT NAME&TITLE: � � . + � � �� _�: � � ,,��__ � � � � � 09/11/O1 n�� ' w. , ` � t The Commonwealth of Massuchusetts i- ' � = Department ojlndustrial.-lccidents R y � :� Ofllce oll�s�l�s�lais .� > ��a , � 600 Washington S�reet ' ,•`�l�/d/� o�� Boston.Mass. 02111 Q1y �♦ �L'orkers' ompensation Insurance Affidavit n m• � �O a � : tJG�,J�S �� f am a homeo ner pert�rmin,all w�ork myself. � I am a sole proprieror�r.,�, ha�e no one«orkine in am•capacin� _ _�_._ _,....,- am an empio�er proti i�ins µorkers' compensation or mv e plo��ees w•ork_in�Qn_this jol� _ ---_ _ _ - - - - -- - r--�. _ — - - m n � n r. ��n'�9�CXJ � � f/l,� � �ddress: V �►el I � �' ��,l..t q• �D� /�.�-/�./ i I in uranc � i � I am a soie proprietor. :enerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below «ho ha�e � the follo��in: ��orkzr �ompensation polices: ; f comoanv n�me• � , .� address• cin•• ohone+�• � insur�ncc co. ooli y# � zomoanv name• k - ______ --- _ --_---- __� ---- -- I addrcss• i �'� nhoee M• insurance co. ��n,{� ; a ' Failure to secu vera as r ired under cnoo 2SA of MGL 1S2 n�ind to tAe iopaitioe o(erioi�i pe�altles o(a O�e op to 51,500.00 a�d/or ooe ynn'i rison e t w• i areivii pendd �io t -torm of�STOP WORK ORDER aad a liae of 5100.00 a dar qaiest me. I a■dena�d m.c a eopy of thy tateme be arded to ice of[nve�tiguiom of the DIA for eoven�e veri8eario�. I do hrreb cerr' r h s and pen l�ia ojperjury t6at t/re i�rjormotion provrded abovt is urre and correct ' Signature � 1 r��o�6i � � e �(Q 22 I Print name one 1l �J(JU'�� -�J� j .. o(Ticial use only do not M rite in this�rea to be completed by ciry o�towa oflleial � city or town: Y�� _ permitAieease a nBuildiog Depanmem ' pLieeasiog Board f �cheek if immediate response i�requ�red !_ — 26� �Sdettmen �y0�� '�p�rcrivax i contact person: - `--- phonc t�:_ �508} 398--2231 e pr�: � � _ _ T��. � 1 1 TOWN OF YARMOUTH BOARB OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISI�MENT PERMIT NUMBER: #02-003 FEE: �150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General I.,aws,a permit is hereby granted to: SoLthside Tavern .i.C, 2�V WhitP'c Path_ S�LthYarmnLth,MA Whose place of business is: Ardeo Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: Deeember 31, 2002 BOARD OF HEALTH: (�anlea?f. �olf�c'r(r�i, eiFa�iuxa�c �e�c�auru�c D. C�.mcda�c, !JL D.. ?/iee ,�o�oat� ��. L� � �e7.xotL' Januarv 24 ,2002 Bruce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-003 FEE: $50.00 This is to Certify that Southside Tavern LLC d/b/a Ardeo 23V White's Path, Sou h Yarmo rth, MA IS HEREBY GRANTED A ' COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authority granted to the licensing authorities by General Laws, ehapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto�xed their official signatures. BOARD OF HEALTH: ��,a�rled� �e��, �utvuxa�e �e.,c� D. C►.mcdou. 711.D. . `�/u:e C�xa�c ' �o�it� �arou�c, �� ; �a�rick 7,1�e?> Januarv 24 ,2002 - ruce G.Murphy, R.S.,CH4 ' Director of Hea} � �;,�;�. ., ._ .� ....;� __-___-.__ � � i � . G�3 C� Cc:��f�.►i �'. _r��, � TOWN OF YARMOUTH BOARD OF HEA��, \00 � � ``� � A P P L I C A T I O N F O R L I C E N S E/P E R M�.fi'-�0 0 0�� J A N 1 0 2 0 0 0 '` '`t; :.� � f,: * Please complete form and attach all necessary documents by iy�c��i�x`�1`;��999. Failu the return of your application packet. �-°° NAME OF ESTABLISHIVIE�..tT: �Th� �'Ie�, -}-e��a?eG•, ---�j��y�--------------------�L-# 39 8--363.G------ , L T �6 'fG i � ve J- a��,,�� l-� ✓1-e - d G�/ C 2 3 � �.•.-�i,.%• MAILING ADDR�SS: �-� �w � x 3 1�,� w - e�� 1� ,^, �-. � �- s'� o �'G�� OWNER/CORPORATION NAME� S a�1'�� S 1 6tP '-TG v�/N L LG MANAG�.�.$NAME: 'S bSc�1• � ��_m,i'e/,z �'� ��- TEL. # 39 8� 36 �6 ' MAII,ING ADDRESS: �• � `�3�X � �3 . �� 7J�.•�i 5� r�,-t�� a Z 6 7 0 POOLCERTIFICATIONS:--------------------------------------------------------------______--_------------------------------------• i The pooi supervisor mast be certified as a Pool Operator, as ret�uired by new St�te law. Please list the ; designated Pool Operator(s) and attach a copy of the certification to tlus form. ' 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community 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 capies and maint�in a file at your place of business. 1. 2. 3. 4. �ICH S'ERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 4 Maneuver on the premises at all times. Please list your employees trained in anti-chok�ng procedures below and attach copies of employee certifications to this�arm. 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# NON-SMOKING SEATS: TOTAL# ______________-----------------------------------------------------______.___•�___..____________------------------------------- ----------� OFFICE USE(1�L LODGING: E LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � B&B $50 CABIN $50 INN $50 CAMP $50 � — � � LODGE $50 TRAILER PARK $50 � MOTEL $50 SVVIl��IlVIIIVG POOL $SOea. WHIRLP(�OL $ZSea. FOOD SERVICE: � ��.� ��....,� LICENSE REQUIRED FEE PERMIT# LICENSE REQU�RED FEE PERMIT# 0-100 SEATS $'75 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 N�ME CHA�tGE: $10 � AMOUNT DUE = $ �D�. � . *"`""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""': � � � �� , �r��va�i v�� __ --_ _ _ � � � � ADMINISTRATION -- �JNDER CHAPTER 1��, S�CTION 25C, SUBSECTTON 6, TI�TOWN OF YAR�VIOUTH IS NOW REQUIRED �'O.HOLD ISSU�1vC� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINE55 IF A ��?A3�4�� CE'��ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION 1NSURANCE. 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 t-� TOWN OF YARIVIOUTH TAXES AND LIENS MUST BE PAID PRIC?R TO RENEWAL OR ISSUA1�iCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES v� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILIT'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLTSHIV�ENTS ARE TO CONTACT T'HE HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR T4 OPENAVG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMIVIENCEIV�NT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGLTI,ATtnNS POOLS POOL OPENING` ALL SWIMM][NG, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE 1NSPECTED BY THE HEALTH DEPARTMENT,AND'THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE GERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. P�L CLOSIlVG: EVERY OUTD�OI�IN GROUND SVI�IlVIMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. F40D SERVICE �ATERING POLI Y: ANYOI�IE WHO CATERS VVITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI�YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM ?2 HOURS PRIOR TO TI-� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPAR.TMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI-� SUSPENSIOl�T OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTII,TT-�ABOVE TERMS HAVE BEEN MET. I QUTSIDE CAFES: ( OUTSIDE CAFES(i.e., OUTD04R SEATING WITH WAITER/WAITRESS SERVICE), MLT5T HAVE PRIOR APPROVAL FROM TI-�BOARD OF HEALTH. i�jJTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR F D P UCT BY A RETAIL OR FOOD SERVICE ESTABLISHHIVIENT IS PRUHIB D. _ � DATE: ��i��w� ��,�D a J SIGNAT �b�k1,Ir��c ,�� L C. C . PRINT NAME& TITL . "- D c � �i'h 'e� ;� . �'I4� a �-- � 1 U12/99 ,,� .. _ _. �. ,_. � _�.��_.._,-- �.y.... �__ , �\ � The Commonwealth ojMassaehusetts ` � Department ojlndustrial,-fecidents � � " Olf/ca ol/svestlpstfiis > 0 : 600 Washington S1ree! ` Bnston. Mass. 02111 . � �.y � V4'o�kers' Compensation Insurance Affidavit ARolicant informa ' nam�� c9•J�s t�',Jn '"�W v�i•, ��l' . 7 [r'.S I�t S�/ f c.r v�Ql f Cl^� f�6 S�4�r\ '�"1 �'7 V'e � Loc�ti�n: S 5� J l�ic,;-, S4 • ! •o• �0 3� 3 � C �a� �.•,��L{ •�� D�C 6 Sr � r �it� w�5'� �er,� ;�i /�/� • da�7 d phone� 3'F� -36 3 6 � ( am a homeow�ner pertorm�n,all w�ork myseif. ' � I am a sole proprizeor �::,�, ha�e no one ��orkin_ in am•capacih� (�ram an emplo�er pro��dino ��orkers' compensation for my employees w•orkine on this job. sQmnan�� nams• `av��,st'f� r'�vr�h LLC - T�a �+'ied� ��.a-r�a��. ��' �1� �3 v ��.+e�, natk/ address: Sa � f�� ./� �P ' 1/-�' �l l l�� d�'•,Q ,/� sih•: S. Li a�r,b .,�� .^7 /�{ . �� 6 e/ nhone M 398 ` �6 �G , i �surance co. �G �fih �G �a 1�S policy� wC' 9'.5�' a � 0 4 �j � � �, � I am a solz proprietor. oenerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed beloµ ��ho ha�e thz follu�ti in� ��orker' ;�mpensation polices: � s4m�anv name: �dress: � ` sis��• � nhons l!• i insurancc co: ��.� � s�mnanv name: 4 id.dr.sss: � sity: nhoee t� • i � a �Failure to secure covera�e�s requi�ed uo 2SA of MGL 152 r nd to oposidoe olerisi�al peaaltle�of a Q�e up to 51,500.00 a�d/or f one yean'imprisonment a w•ell a�civil Ida io t ST ORK ER and a Qee of SI00.00 a dar K�iost ma I a�denta�d tbat a � copy of ' men nv d the Otfi nvaNgi 'o t tbe tor coven�t veriQado�. � !do hrreb e ' er� n perj 1ht jorniation provided abovt i.s tnie arrd eorrect i ; � Sign �4��G,w � '� � � o o�s i Print name ��J� /� � ��'{ 1 �- . � Phone N '3 �8 � 3 6 36 � . � .- olTicial use onl.� do noc..�ite in this area to be compieted by eih or torrn otReial f city or rown: YA��IITQ _ permitAicenu N nBuiidiog Deptrtment �Lieea�ict Board Q cheek if immediate rcsponse is required 261 �Sdectmen'�Otiice pHealt6 Departm�pt comact person: (508� 398�2231 e� r + ;_ � phone M•- -- — (��_ , ��,Y�m �� f ... .� :. „�, . TOWN OF YARMOUTH J• BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-148 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 1, Section 5 of the General Laws,a permit is hereby granted to: S� � hsid . Tav rn_ T.i.�, SOf� Station AvenLe, So � hY rmo � h, MA Whose place of business is: The Mediterranean Grille Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�'��f. �et��, C'��r,�,� �oan� �ul[ivan� K.i'/.� Vice l��irman �o�ert.�". 4�rown, C,,lerh a�rie[Ce�a�Zol��ir�-J�tooPee �� Januarv 28 ,2000 Bruce G.Murphy, MPH, .S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-83 FEE: $50.00 This is to Certify that Southside Tavern. LLC d/b/a The Mediterranean Grille _ 506 S a ion Av n ��, 4oLth Yarmo �th, l��A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornuty wrth the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto�xed their official signatures. BOARD OF HEALTH: �'d Y�J. ��tt�, C'��„�,� ' nDD [�q� q � /� ; oan.G. �ullivan, K.//., Vice C..�irmart obert� �rouin� (�ler� a�rielLe�a�o(,�1�y-.�tooPes ' l�!"'�''�".,�, -+, r^ �-v ► � •, .,. hae6 � o �[in ' January 28 ,2000 .�� ,, :;„� ��`�,,,,�„�� ruce G. Murphy,MP , R. ,CHO ' Director of Health � ; , �