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Home My WebLink AboutApplications, WC and Licenses , �. - ,,:T�,r�.. DNE CavneE S+ . �;J`^_��^ TOWN OF YARMOUTH BOARD OF HE.4�;TH � ��j�' , _1 r� _ � APPLICATION FOR LICENSE/PElilki�'I'-200 �� `` '- � " ' ` .. -= k Y ' ? � � � � �� - � - * Plea,se com lete form and attach all neces � =' �'-�` Fail p �Y doct�meirt"s by December 31 20�1- ure to do so will result m the return of your applica.tion packet. �EAL�r� C�c��_F NAME OF ESTABLISHMENT: [�N� �1��`7�� .��5-�' �'�tio TEL. # �O�- 3(c,,�L—�'S�/ LOCATION ADDRESS: �° (1�,�--1�n-.�3Z . �T. �//�-r'Z�C.rcyc/T7t �D�Z> ��'f MAILING ADDRESS: � r�' �� OWN�R NAM�: ��ti3 Co .�7�7� TAX IN r N : ' CORPORATION NAME (I APPLICABLE): � � MANAGER'S NAME: 142 Si� TEL. # MAILING ADDRESS: �_— POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ; 1. �/ �` 2. Poal 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. T�te �ealth Dep�rtjnent will not use past yea�s' reeords. 4'ot� t�ust provide new copies and maintain a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food seivice establishments are required to have at least one fiill-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 attach copies Qf certificationto this applieation. T�e Hexlth Department wiN not use past years'recards. You must provide new copies and maintain a file at your establishment. 1. - 2. _P��4I�T.�N��AR� •_ _ _ _ _ _ _- -_ ____ _ _ __ _- - --- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained•in,the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employe�certifications to this form. The Health Department will not use past years' records. You must provide new copies �nd maintain a file at your place of business. ' 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PER'vIIT# LICENSE REQLTIRED FEE PER'VIIT# LICENSE REQL'IRED FEE PER�IIT� _B&B S50 _CABIN S50 MOTEL SSO �INN �50" _CAi14P S�0 _SV4'I:�L�IING POOL S75ea. I LODGE �SO �OR��,n9 _TRAILERPARK S100 _R'HIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIIt£D FEE PERMIT� LICENSE REQUIRED FEE P£It1�11T� LICENSE REQti IRED FEE PERVIIT= / 0-100 SEATS S75 �I„3f _CON7INENTAL S30 _NON-PROFIT S25 _>100 SEATS S150 �CO,'4L�rION VIC. SSO �08�0� � _V41-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIItED FEE PERMIT� LICENSE REQUIRED FEE PERy1IT= LICE:v'SE REQtiIltED FEE PER'4IIT� _<50 sq.ft. �45 >25,000 sq.2t. 5200 VENDING-FOOD S20 _<25,000 sq.8. 575 _FROZEN DESSERT S35 _TOBACCO S50 NAME CHA�IGE: sio . AMOUl�T DUE = S /'75.00 *****PLEASE TL'R\OVER?i.�D C0�IPLETE OTHER SIDE OF FOR�i**x** � ' AD�STRATION 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 ATTACHEI? STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR , • CERT. OF 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be ' limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. ', Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 genera.11y 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)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. * NOTE: Enclosed Motel Census must be completed and returned with this appiication. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�da.ys pnor to aperung. 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 c�uarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ciosing. FOOD SERVICE CATERING POLICY: ' Anyone who caters wit�in the Town of Yarmouth must notify the Yarmouth Health Deparlmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departm�nt. ; 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 Pennit utrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: _ -Outctoar co�king,PTepazatior��r-disp�ay of any f�ad produet-by a fetai�sr€ead-servic�es�Eablis�igprohibited. NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETCJRN THE COMPLETED APPLICATION(S}AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS�ifVIVIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMME�ICEMENT. REVOVATIONS MAY REQUIRE A SITE PLAN. , DATE: I� �j SIGNATURE: ..�� PRP�TT NAME&TITLE: Ivl `'I 7` r.J� P io;u n� , ` ' t � The Commonweahh of Massach4setts ', Departmerit of Indastrial Acculents ' �� ' 600 Washington S'treet, 7`""Floor , Boston,Mass. 02111 Worlcers'Compe�s�tio�Iaserance A�davit:Boildiog/Pla�bieg/Electrical Coatrntors ..... 4.� .. . .... � . .. . . � . . ��. LaIOP. ' � j address• ci V � sfate• z� . _._ _ � r ^� ��` work site locati�(fnll address)- ❑ I am a homeowner performing all work myseif. Project Type: ❑New Caa�struction ORemodel �am a sole proprieWr and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensatian for my e,mployees wo�icing on this job. ' oomp�av mrme• addnss: ' city: nllase#- ' ce. � '�� • �-.� e ,ti .. ,�.:> a. „it z,t-x_ .,r -t��..aa, �n�.�4 �,�, s,.ru ��. Q I am a sole propriexor,ge�ral co'tractor,or�omeowser(czrde o�re)and have hired the contr�tors listed below who have the following workeas'compen4ation polices: coeouv�e- address• citv uroee#- ' i�smatoe # .. , �,.,, , ,, , _.. . ,. .. � � t� _ > .. . �.,, � . . � �-�� r: ,�,. , . �Qf�{t�lll" .. �: �': � . . � . . � . � � . p�.� . . � �ffi � . # . . . .. � . .. �. ;�� . .. ��'- . '. . y ;. � �. i ` '�.,.; .'.:., : .,..: Faila�e M secee�as req�ed»der See�M 2SA�f MGL 152 eu lead b tlre��f cHwial pnaNia�f a II�e tp b SI,S�M aadlor' eae ynn'I�tWe�t aa we�as dvi pwNies h the for�of a STO!WORK ORDER aed a Ane a[5180.6b a da�a�imt�e. 1 asdaahad trat a cepy ot fiis stalm�eet eay be firwardal/o f�e Omee�Imrc�saa of t6e DIA far cwerage vrri8atls�. I do 14enby cer�ify wider NYe pa an lti�c of perjr�ry tliet tAie i�fornietlo�provided abov,��s trxe Rxd cor� �8�� Date ��f/!�� P�II� Phone# /' '1 / effichi aae�nly do not write ia rea to be mmpkted by cily or bawn afficial cihy or tewn• perm�iee�ae# �Bai1d10E�P�*�� ❑check tf imme�ale n�peme is reQained �� ❑Sdeetmen s Offiee �lkaltk De�ard�eat ceatact persoa: P6une#; �' c�d��►) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-009 FEE: $SO.Ofl LODGING HOUSE LICENSE 'Fhis is to Certify that a Lodging House License is hereby granted to 6A&Centre Street Inc. at One Centre Street Inn, 1 Center Street Yarmouthport MA in said Town of Yarmouth and at that place only and expires Decem�er thirty-first,.2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred forty, ofthe General Laws,and is subject to the provisions ofsections twenty-two to tlurty-one inclusive of said chapter. In Testimony Whereo�the undersigned have hereto a�'ixed their official signatures,this Twenty-fourt� day of January A.D. 2008. BOARD OF HEALTH: `.��¢�ett S�� .,.Ar.� C�(�[tluxtt ('�3�c�e� ,��i'.�Pei�c `U[CQ Cl�cvunrturi xEs'rtttcTTONs: Per Board of Appeals decision#2091, �3.��Y4XUtt� �� 07112/$4,4 bedrooms-all on 2nd floor. No bedrooms on 1 st floor_ � � �'.,t`'�....�. ��C(�CD Hot tub—Not for guests/Owner use only. ruce .Murp y, .,CH Director of Heaith ' __ . _ _ . TUWN OF YARMOUTH BOARD OF�ALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-131 FEE: $75.00 In accordance with regu1ahons promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: 6A&Centre Street Inc., i Center Street, Yarmouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2008 BOARD OF HEALTH: .`��.Ctt Sf�t7(�xl�� .IV., (��Yit�ft SEATING: 10 � � � .7L.�� [Ce�[plL xEs�crloxs: IVleals to serve guests only. J��-�� Septic desigued for 4 rental rooms; 1984. Qtut � �..N- �'ueP�t.I. ��ee r January 24.2008 ce G.Murphy, , S.,CHO Direct r of H lth THE COMMONV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUI�IBER: #08-081 FEE: $50.00 This is to Certify that 6A& Centre Street Inc. dlb/a One Centre Street Inn 1 Center Street, Yarmouthport, MA IS AEEREBY GRANTED A C011�IlVION VICTUALLER'S LICENSE In said Town of Yarmouth and at that piace only and expires December thirty-first 2008 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common vietuallers. This lieense is issued in conformity with the authority granted to the licensing authorities by Generai Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: `.��E�e��e��t�t_.S�Kcta��,�J��p.,.�IV� ., ('�t�a�r�vY�rlLtXtt SEATING: lO �..fsu�uro .7�...�.�ieul�R��G� V�IICCe��.�Q�VYi1L�CtL xEsr[ucrlorrs: Meals to serve guests only_ ��lY�S.��L, �;C� Septic designed for 4 rental rooms,1984. � Q./tft i�.,.ly. �'"`�'.'�"..�-��1�6 January 24.2008 ., Bruce G.Murphy,MP ,R. .,CHO ,_ Director of Health t ' A °f r R�o TOWN OF YARMOUTH BOARD OF H �� o_. =-;y APPLICATION FOR LICENSE/P *, �� ' ��b �JAN 0 $ 2007 �; . ,,;r � '� ��1� ,� .�,.: : •.. ..... �.�� : � � * Please complete form and attach all necessary';docu�►� y December_�2 2406. Failure to do so will result in the return af your application packet. } NAME OF ESTABLIS��VVIENT: Q �L. # 36 a - �15`�/ LOCATION ADDRESS:��o��o� t y Pnrt�' MAII,ING ADDRESS: OWNER NAME: i- T �J . � CORPORATION NAME (IF PLICAB ):('p,� �}-�'�e,� ,Gl o� �'��! i MANAGER'S NAME: �2 �n / �� TEL. #��•S'/ MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation{CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Heaith Department will not use past years' records. You must prnvide new copies and m�intain 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 Cade 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 establishmen� 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. /1 � 2. HEIMLICH CERT'IFICATI NS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-cholcmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new capies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# , .�._ OFFICE USE ONLY LODCING: LI� CElySE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMTf# �B&B �50 CABIN $50 _MOTEL $50 $50 CAMP $50 SWIlVIlbIING POOL$75ea. LODGE $SQ �D7�0d� _TRAILERPAI2K $100 V1��RLPOOL $75ea. FOOD SERVICE: I LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMtf# LICENSE REQUIItED FEE PERMIT# � V 0-100 SEATS $75 (J 7-+�� _COrfTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 �COMMON VIC. $50 �67�t(o _WHOLESALE S75 � RETAQ.SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE pERM1T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMiT# : ,<50 sq.ft. $45 _>25,000 sq.8. $200 VENDING-FOOD $20 ' _QS,OOOsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $50 i NAME CHANGE: $10 AMOUNT DUE _ $ /'�$,dQ `' •'"•'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••""• � i i € 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 Certifica.te of Worker's Compensation Insurance. THE ATTACHED STATE WORiiER'S COMPENSATION INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: f YE5 NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use, Transient occupancy shall l� limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transieirt occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest u�it as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha.11 generally be considered Transient. POOLS POOL OPENING:All sv�dmming,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 ta schedule the inspection five(5�days pnar to opening. POOL WATER TESTING: The water must be tested for pseudomonas,tatal coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by 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 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 ha.ve been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seaxing with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN TI�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. AT"i, RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TQ AND APPROVED BY 7'HE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � � � 7 SIGNATURE:� PRINT NAME&TITLE: � � ioii�io6 � �'he Com�ronwealth of Massachusetts Depairiree�t of Indust+rial Accidenls N�ei�iii�IM� 61i8 R'ashington S'tre� 7"�'Floor Bo�,Mass. 02111 ', — -- --- Work�s'Com tios Lama�ee Affid�vi�B�ii ' ' leetrkal Co�tnet+ers ,�.. , , r . � . _�, __ ._ _ � � .�, name• V � �'G � . address• � `�- s�r !� ,��,r,�d�� : , a��/,_��_,.�# �a�G�� 9�j j work site locati�rrnu addresst- ❑ I am a homeowner performing all wocic myself. Projed Type: ❑New C�slrucria��Rernodel am a sole 'etor and have no a�e w in an ❑Buil ' Addition ❑ I am an employer providing workers'compensati�f�my employees worlcing on this job. : �• • #�� ' y� nl�a��: ❑ I am a sole proprietor,g�eral co�tnctor,or�omeew�er(e�di ow�e)a�l have hired the coatractors listed betow who have the fallowing workers'compensatian polices: �� !!� N �:�� , , , �` s. �, �1►: F�pm�e r xc,�e�..�ea�e as r�y.i�a..aer sedM.24A�Mc�.1Sz eu leaa a u�e i�p..Nl...ccr6.�w pealtla.c.�.e�p a s1,sN�N aar.r �e years'ImprM�teat as wd as dN pe�n ia the bor�ota STOt WORIC OBDER a�d a Sxe e[t1A9.M a day spioat�e. I aednsmd tLat a c�p;y�f tl�ffatc�t my 6e fon►arded 1s tYe dmee otlav��tl�DIA t�r ava�ase vu'i�eatlw I do l�d�eby ee�ijy xndcr dYe pei�s wed ' o tlY�t tlie iwfor�wadou provi�ed obov�e la true ax�d oorr+eex 3ign�re I�te d � P�� Phone# �C7 ��3 — �9 •ffieL!ose e�ly aa eot.vrife ia tF3s arra to ne c�plaed Ur dly.rin.a.mcial c�+�te�v�: �oe�se# f 1Bd�D�rtneat QLioe�Bear� ❑eYeelc if�1e rapene b ra�med �Sdccts�'s O�ce �� ce�ad persoo: p�e*; �Ot6� cTM��-�'s� . THE CONiMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH : PERMIT NUMBER: #07-Q09 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Mary SingJeton at One Centre Sireet Inn. 1 Center Street,Yatmouthport,MA in said Town of Yarmouth �d at that place only and expires December thirty-first,2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundr�i forty, of the General I.aws,and is subject to the provisions of sections twenty-two to thirly-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Fourth day of A�,ril A.D. 2007. BOARD OF HEALTH: B �. JN.�., ' ��"�"t� .�., v�e�� s'1'�uc�oNs: Per Board af Appeals decision#2091, /�o��.B�tuukt, � 07l12/84,4 bedrooms-all on 2nd floor. No bedrooms on 1 st floor. p�iic�i/�a�e/uito� ' ff�sssst��, Q./V. . Hot tub—Not for guestslOwner use only. ruce .Murphy, ., HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT ' PERMIT NUMBER: #07-150 FEE: $75.00 ' In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I i l,Section 5 of the General Laws,a permit is hereby granted to: Mary Singleton, 1 Center Street, Yarmouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31 2007 BOARD OF HEALTH: Q �rtpt��t�/. ,/��., efs�ast SEATING: IO c��'�E•IL cifKiy, ��v.`�"v�e�� RESTRieTIONs: Meals to serve guests only. Rod�el�t� BnouNs, G�le�tl(a ' Septic designed for 4 rental rooms, 1984. naf/tse�a/�a�� i4ftst C�'�tee�r�rt, R.N. Apri14.2007 HO � ruce G. Murphy,MP , Director of Health f THE CQMMQNWEALTH OF MASSACHi�SETTS TOWN OF YARMOUTH PERMIT NLTMBER: #07-096 FEE: $SO:OQ This is to Certify that Marv Singleton d/b/a One Centre Street Inn 1 Center Street, Yannouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE 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 confornuty with the authority granted to the licensu�g authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B .7t. /yl._`n., L��uvs� SEATING: lO ��s�, ��v.'�, ��e�-� xEs'r1ue7'TONs: Meals to serve guests only. /lo�e�� ,B�twt, � Septic designed for 4 rentat raoms, 1984. . p�/�� 4.t.t� R.N. A�ri14.2007 ruce G.Murphy,MP , . .,CHO Director of Health , � : _ ,��-� _ , � �,- _ Q � � � �°`,d R o TOWN OF YARMOUTH BOARD F�A�,T� S 3 "`�` APPLICATION FOR LICENS��A�i'�3T�=2�6 ``"�r�°° .IAN 1 7 2006 � Y ° �� * �4 ' "°� �,,'�-�' � 1'�i� Please complete form and attach all necessar�documents by December 3},��5�'}-{ ��,�_ Failure to do so will result in the return of your application packet. NAME OF ESTABLISHIVIENT:�tii� C�'�!T'R.� .�i �1" �%i4�1 T'EL. # �o�-36d-5��5� LOCATIONADDRESS: 19,�1� C�7,r�'R 5 r'- �/A-r2Ho�T,b� lbR-; bi�3 c3�-� �.S' a MAII,ING ADDRESS: '�,� ' OWNER NAME: � � O�- T ID r , CORPORATION NAME(IF APPLIC E): MANAGER'S NAME: l�lAfZ�/ S�'iv�C,��n✓ TEL. #� �6d-5'S`S% MAILINGADDRESS: �x.� C�N;�"'� Sr= �1AA�havrN ��.� /�� oa�°>s� '+ POOL CERTIFICATIONS: I The pool supervisor must 6e certified as a Pool Operator,as required by State law. Please list th�designated j __ _�oa}pp�tor�srar�d-attac�-a copy afthe eer�ificatio�tothis form� _ -_ _. ; 1. ._ 2 ' Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and i 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 �file at your place of business. 1. _ . 2 ; 3. 4 FOOD PROTECTION MANAGERS - CERTIFICATIONS: A11 food service establishments are required to have at least one full-time employee who is certified as a Faod � 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 fde at your establishment. � 1. ,�/ 2 __ PERSON_IN CHARGE: _ _ _ _ _ -- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � 1. 2 , ' HEIli�;�CH CERTIFICATIONS: All food service establishments with 25 seats or more must have at lea.st 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�ae�i copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# 10 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B �50 _CABIN $50 _MOTEL $50 _INN �50 _CAMP $50 _SWIl��IING POE)L$?Sea. _.. I LODGE $50 _TRAIL,ER PARIf $50 _WHIRLpppL $75ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# �0-100 SEATS $75 CON'ITNENTAL $30 NON-PROFIT' $25 >100 SEATS �150 I COMMON VIC. $50 _WHOLESALE $7S RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTf# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 ; _Q5,000 sq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ /�g'�QQ ? "•"•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••"" — � � „ ,-. 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 nat have a Certificate of Worker's j Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � NOTICE: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, 2005. � SEASONAL ESTABLISF�VVIEENTS ARE TO CONTACT TI-�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COl��IlV�NCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. i � 1 ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspecteri r by the Health Department 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 outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the Health Department. FROZEN DESSERTS: FrQ�en c�esse�t��us�-be�este�o�t-a iner�thl�basi��y-a-�tate ee�ifiec�lab. -T-�s�r€sults�xius�b�-s�nt��I�e,�1�h _ ; Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: i Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. i i OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: � /�' G. SIGNATURE: PR1NT NAME&TITLE: �� _ ,�l�J�"!4 �I 09/28/05 - � i � . ��s� �� yA�fLN�c�q1� �EA��t}►�DcPT'. � �� ___—� The Com►nonwealth of Massachrisetxs �`� _= � � � � . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � PERMIT NUMBER_ #06-011 FEE: $50.00 L0�3GING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Mary Sing,leton�d Judv M�iirohy at One Centre Street Inn, 1 Center Street Yarmouthnort,MA in said Town of Yarmouth and at that place only and expires December thnty-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confomuty with the authority granted to the licensing authorities under section tweniy-three,of chapter one hundred forly, of the General Laws,and is subject to the provisions of sections twerity-two to thirty-one inclusive of said chapter. - In Testimony Whereof,the undersigned ha�e hereto affixed their official signahu-es,this Tenth day of February A.D. 2006. BOARD OF HEALTH: B �. �iYuP�,/(��., ' d��,yi��lu�li, JV., ?l�ce G�lu�rx��s RES'rRicTloNs: Per Board of Appeals decision#2Q91, /lt�ieJ� ,�, ,B�puKt, t� 07/12l84,4 bedrooms-all on 2nd floor. No bedrooms on 1 st floor. n�1J��enixott l4�tss(��nlasr�t, R./{r Hot tub—Not for guests/Owner use only. j� Bruce G.Murphy, ,RS., HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT ' PERNIIT NUMBER: #06-150 FEE: $75.00 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: _ Mary Singleton and Jud Murphy, 1 Center Street, Yarmouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2006 BOARD OF HEAI.TH: �Q / ��. �o�snt,'/�/��/,, e�thyu.�y SEATING: iQ c��QN�KfiL� �� !llt:6(ifzGf1lhl!'it �s'r1uCTioNs: 1VIea1s to serve guests only. /ltt�l�` '�. B�sy, (� Septic designed for 4 rental rooms, 1984. n��/y�� f4�us(�Reest.�a�rt�t, R.1Y February 10.2006 � Bruce G. Murp y,MP S.,CHO ! Director of Health ! � f ,, _;�,,, . � ' � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #06-150 FEE: $50.00 This is to Certify that Marv Singleton and Judv Murphv cUb/a One Centre Street Inn j 1 Center Street, Yarmouthport,MA IS HEREBY GRANTED A . CONIMON 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 violat�on of the laws of the Common�vealth respeeting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: B �?S. ,/b�`�5., G�lr�vr�x��s sEaTnvG: 1 o d��Slsc�, �?/rce G�lr�i�r�rc xEs'rtuc'I'�oNs: Meals to serve guests only. /lo�e/1t�B� ef�e/!�a Septic designed for 4 rental rooms, 1984. ��/�c�� I.ui!�' , Q.A! �ut February 10.2006 ruce G.Murphy,MP , S_,CHO Director of Health � � ' ��b766 awE C�r�.ST. iNa Cz) '�f s R'�i� TOWN OF YARMOUTH BOA s LTH 2 o�. 'y APPLICATION FOR LI� ' 2005 G� [� C� G 0 M C DD � . .;/� �F �': � JU 22005 ••.. .. � � ��X * Please complete form and attach all necessary�il+a+�nents by Decem er 31,�0�4" Failure to do so will result in the reti�rn ofyour application pa k�t{EALTH DEPT. NAME OF ESTABLISHIVIENT: �� -2✓�, ,(�.,Q� TEL. # �1 � LOCATICIN ADDRESS: � �N' r MAILING ADDRESS: �a'�''3 r� OWNERICORPORATION NAME: O e., -� r1 3S'�a MANAGER'S NAME� �(a,r G�. VYl/.Z��, TEL # ��-�e MAILING ADDRESS: c� �nm�p POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State I�w. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in hasic water safety, standard First Aid and Communi Cardio ulmon Resuscitatton PR PI C . ease li t these m 1 ty p ary (y ) s e p oyees below and attach copies of employee certifications to this form. The Healt6 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 of certification to this applicaxion. The Heatt6 Department will not use past years' records. Yoa must provide new copies and maintain a fde at your es lishment. 1. l �I. �:' ' 1l�1��'C �'P�i "Ty Q'E ��2 P �� _._ .-_-.T��SG�VZI�---,.`-�._._:_ .._._.___"..___.�:- ___.-._._-__'_-_-. ..._.. .......... .. ._______ ._.-"_ . _.....-___ . __ .... __...__.____� ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. � � S� z. HEIlVILICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2, 3- 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PBRMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 EABIN $50 MOTFT• _ $50 _ ' _IIVN $50 _ _CAMP $50 _SWIIvIlVIING POOL$75ea. I I LODGE $50 O�6'—O I Z- _TRpII,ER PARK $50 WHIlZLPOOL $75ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# f �0-100 SEATS �75 �os r4r _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 �COMMON VICT. $50 �O S�i(� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE pERMtf# LICENSE REQIJIl2ED FEE PERMIT# , _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 � �<25,Q00 sq.ft. $75 _FROZEN DESSERT $35 �Tt�BACCO $25 ' NAME CHANGE: $10 AMOUNT DUE _ $ �75, OO " '••""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM"*"•" _ ��--- ^ � . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yazmouth ta�ces and liens rnust be paid prior to renewal or issuance af your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES V NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN � TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISHMENTS ARE TO CONTACT THEI�ALTHDEPARTN�NTFORINSPECTION7-10 DAYS PRIOR TO OPENING F(?R THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CO1��IlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department 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 outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVIS�RY: 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 ' reqwred Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. - FRflZEN D�SSERTS: _ _ _ - - _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdo�r 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 establishment is prohibited. DATE: 1 � `'1 O� SIGNATURE: PRINT NAME& TITLE: � r��f'��(;��> � 1I C�l,'J1(�!�-.✓' l.V11� K-�iPi�� 10/22/04 � � � � � , � T� -=_—� The Commonweahh of Massachusetls ��--_v =-- _ Depart�ne�et of Indushial Acculents _= N�'1/frlNi� - - _- < 600 R'�tshiiegto�e Stree� 7t"`Floor _ --�, Boston,Mass. 02111 � Work�s'Com�aahos I�saraaee Affidavi�B�ii ' bi�/Eleetrical Co�tnctors � . .:-, �, K �. , . � ��. :A , _.� , a. ., .�, . . _ ,.., > �. � , � . � . .�; �_ (`��, I�j,Qs��- �s: i ct,r n�1..�� oY . �'�S Sag 3 �- ��1�1 work site locati� fnu address: ►'�Q `(�� ✓1 S�-�� O��v.Q SS I am a homoownea perfoaning all wadc myself. Ptoject Type: ❑New Ga�tio��Remodel _ I am a sole 'etor and have no ane w in an Buil ' Addition ❑ I am an e�mP�Y�P��S warkecs'compensation fas my employees working o�this job. c�nrv inne• __ �.� � � � � clts- ni►e�a�k; ❑ I am a sole ptoprietor,ge�ral coitractor,or�omeew�er(circJt oae)and have ltired tbe cornractors listed below who have the following worlcers'compensation polices: m�+r�: �s« dir• uiore�: �E �4�: �: �f*; ��Et ----- -- -- - ---- _—`_ -- --- - _ I FaYm^e M secue ervera�e at reqtU+ed udv See�2SA�tMGL 152 cu lad b tlie i�lp�qa�f ai�lial pmllks K a�e�p b S1,SKM a�r �,' e�e�nn'ie�prbn�nt as weY as dd pmNfa ia t6e fer�Ka STOt WORIC ORDBR a�d a Sae dt16S.N a day atai�t re. 1 odershod t6at a apy�t tl�M�fateae�t�ny 6e forwa�dcd p�tYe OIBoe�f I�va�af 1Ye DIA far avera�e v�riAatlN. I ro yer+eby cer�ify xnder Nis s on�pen�of perJr�ry t1Yet tbe ihfonw�loe provTded aboae ia trxe d Signature Date � Print name��-�� \V��S� Phone# :Jv� � `4'� `l � efficW nse esly d�aot write i tYa arn te 6e asaPkted bY dh'�r lrwn�ffiClai dty or te�rn: p�q �� ❑e4eck if imme�ate respsne is raqeed ��t ceatact petaoH: pge�e#; Qp� c,�ssmc zom� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-012 FEE: $50.00 ' LODGING HOUSE LICENSE ' This is to Certify that a Lodging House License is hereby granted to__One Centre Street Lnn_Inc. at _ One Centre Strcet Inn. 1 Center Street Yarmouthport,MA in said Town of Yarmouth and at that place only and e�ires December thirty-first,2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority grant� to the licensing authorities under section twenty-thrce,of chapter one hundred forty, of the Generat Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto aff�ed their official signatures,this Fifteenth day of July A.D. 2005. BOARD OF HEALTH: n�J��sc�G�k�i�r�� ; REs1'�uc'r�olvs: Per Board of Appeals decision#2091, Q o�t t�[�iRou,wy, � ! Q7/12l84,4 bedrooms-all on 2nd floor. No bedrooms on 1 st floor. d�¢Lest e��u-�, /�,/{� f4�ut(�'�tee�rad�[int, /l./Y. Hot tub—Not far guests/Owner use only. Bruce _Murp y,MPH,RS., H ' Director of Health I TOWN OF YARMQUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-191 FEE: $75.00 ' In accordance with regulations promulgated under authority of Chapter 94,Section 3QSA and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: One Centre Street Inn, Inc., 1 Center Street, Yarmouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth '�, Permit e�ires: December 31_20Q5 BOARD OF HEALTH: Be�a�ss,t`�. ��,/��, e��-�y SEATIlVG: 1 O p�/�7C��, v�e�.�.� xESTiuc1'totvs: Meals to serve guests only. /lo�iel�� B�yS.e�e�1�t Septic designed for 4 rental rooms, 1984. d�e� e'�y IQJY. I �4��, R.N. i l July 1 S.2�5 �, Bruce G.Murphy,MPH,RS.,CHO Director of Health a � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-113 FEE: $54.00 This is to Certify that One Centre Street Inn, Inc d/b/a One Centre Street Inn 1 Center Street, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aff�ed their afficial signatures. ' BOARD OF HEALTH: B 's�. ��`'o��3�d�� ,n M' .$n.,' G��u-� SEATING: 10 nLti��1//C�e�JI1Wiy� (/�17B(iflGK�p1G�l �s�cTTolvs: Meals to serve guests only. Ro�e/t��Bnot�wt, � Septic designed for 4 rental rooms, 1984. o�eLeit�'��i, /�./V. I f4�tit C�'�teer�r�, R.N. � I � July 15,2005 � ; Bruce G.Murphy,MPH,R.S.,CHO i Director of Health i .- �� (o�a" � t?5°�''i ��°`:�`R�s TOWN OF YARMUUTH BOARD O �` - ,�� - � ,� J ; - _:� ;�, �. � ,� ,; \_ � ��, ; o: _,,� APPLICATION FOR LICENS � , ��-N 5 f 0 C T 0 3 ' �" ��, 2005 ' * Please complete form and attach a11 nece t y Decem er 31, 2004. Failure to do so will result in the r fy��plication pac eHEALTN DEPT. NAME OF ESTABLISHIVIENT: TEL. # � G � LOCATION ADDRESS: Q � 1VtAILllvG ADDxEss: N o�2 � OWNER/CORPORATION NAME: /' v v l�LI MANA ER'S NAME: �u<' TEL. # ' MAILING ADDRESS: POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two 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 certifieations to this form. The Health Department witl 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 atta.ch copies of certification to this application. The Health Department will not use past years' records. Yoa must provide new copies and maintain a fde at your establishment. 1. 2, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2, HEIlI�ILICH 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 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. 2, . 3. 4. RESTAURANT SEATINC: TOTAL# OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PBRMIT# LICENSE REQUIRED FEE PERMIT fl LICENSE REQUIRED FEE PERMIT# _BBcB $50 _CABIN $50 MOTEL $50 _INN $50 _ _CAMP $50 _SWIlVIlVIII�TG POOL$75ea. j LODGE $50 �a 5-0�S _TRpII,gR PARK $50 WHIRI,POOL $75ea. . FOQD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT'# LICENSE REQUIRED FEE PERNIIT# I 0-100 SEATS $75 #'O S'ZOO _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 / COMMON VICT. $50 �� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.8. $200 VENDING-FOOD $20 _Q5,000 sq.ft. �75 �FROZENI�ESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �7�QO � '"•••PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM""••' 1 r ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �^ Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: / YES !/ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TI�C4MPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�HEALTH DEPART'MENT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEAS4N. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIV�NCEMENT_ RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS PUOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to operung. 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 vcrithin seven(�)days of closing. FOOD SERVICE CONSUMER ADVIS�RY: Each food establishment 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 Town of Yarmouth must notify the Yarmouth Health Department by filing the reqtured Temporary Food Service Application form 72 hours pnor ta the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so 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 ha�e prior approval from the Board of Health OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. DATE:lo�3�G,�_ SIGNATURE: PRINT NAME& TITLE: �d , I � 10/22/04 `�� The Commonwealth of Massachusetxs � -�--� Depart�reent of Industrial Accidentr -- _ N�I N��i - -= 600 Washi�gton Stree� 7t�'Floor -_-�, ` Boston,Mas� U2111 wurkers'com�satioi Iasar�,oe n�H�vir:sa7 • bi�/Ekri�rical coeaaecors ��, . w.:. „ .. ,,F_ �. � , , , ,� , ., � .._ ,. . t ,_ : ,. �.- �. , . name: t �D I'� �� 1 �� , �'�R•u a�� Q � �n: �L� rip_��,�S�# �o dn ' 3�� - �r g.�`j wo,�_site locati�,crnll a�ressl: ❑ I am a homeownea performing all wo�lc myself. Project Type: ❑New Caa�structioa��Remodel I am a sole 'etor and I�ve�a�e w in an Buil ' Additian ❑ I am an e.mployer providing wark�s'compensation fa�r my e.mploy�s wa�cing on this job. � � � � �; � c�� . �� ,�i �e � �1� ,�� ..�.�� 9�.�/ ❑ I am a sole proprietor,geaeral co�trxter,or komee�er(�di oae)and have hined the co�actors listed below who have the following workers'comp�ation Polices: ��: � c�v: uiw��: � �Q m�e: �� _�_�= Fs�re�s aecoe a�era�e as reqired udQ See�a ZSA�MGL 1�eu Ind b tl�e hrpaitl�a�f Qi�id peafl6a�f a��b S1,3N.N a�d/�r e�e yan'6epriwa�t as we8 as ciN pe�Nks in t6e fera��f a 3'POt WORK ORDER a�d a Sae dt1AaN a day�re. 1 odashad that a apy�f tYi�st�t�mimt my be firwardcd 1s Ne OAlce�f lm�of tYe DIA for cwrrs�e verHieatly. !do l�ertby ceKJfy�rnder Nie rta/ f pe►jray tlYat tlYe iejonaadon provide�ebowr is dare a�d c»rnrt Signarture Date l0/.Y �� p�� -r Pbo,�� e�� 3G� 9�lsj offidal ase snly de a�t write i�tris arca b be cNpiefed bp oly er lwvs s�l ' c�y or tewac pe�/liome/ f lB�Depu'lment ❑e6eek if immediale respe�e b rrqah+ed �deetsn s�oe �HaMk Depr�t contact P�tsen: ph�e#; ❑p�gn' (TM��-�) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-015 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Mary Singleton and Judy Mur�hy at One Centre Street 1 Center Street Ya�mouthnort MA in said Town of Yamiouth and at that place only and e�ires December thirty-first,2005 unless sooner suspend� or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issu�in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred forty, of the General Laws,and is subject to the provisions of sections twenty-two to thirly-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto aff'ixed their official signattues,this Fourth day of October A.D. 2005. BOARD OF HEALTH: Berr�-�tsit�. (��,/N.�S. . ��r�� v�e�.�� RESTTucl�orts: Per Board of Appeals decision#2091, llo�ht� B�iwy e�h� 07/12/84,4 bedrooms-a11 on 2nd floor. No bedrooms on 1 st floor. d�e�est eS'��t, Q./V ' 14�tst(�?�eeir�i�st�, R./� Hot tub—Not for guests/Owner use only. Bruce G.Murphy,MPH,RS.,CHO Director af Health ' i TOWN OF YARMOUTH I BOARD OF HEALTH ' � PERMIT TO OPERATE A FOOD ESTABLIS�NT PERMIT NUMBER: #OS-200 FEE: $75.00 ' In accordance with re�1ations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the(ieneral Laws,a permit is hereby granted to: M Singleton and Jud Murph , 1 �enter Street, �annouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemiit e�ires: December 31 2�5 BOARD OF HEALTH: Be�t��rti�s�. ��,/y�. e�tw.�itatt SEATING: lO ��M�� v�e�� s�eTTONs: Meals to serve guests only. Rode�� B G� Septic designed for 4 rental rooms, 1984. a+�e�eit e�,�, ��, R./Y. o��4 Zoos Bruce G.Murphy,MPH,RS.,CHO Director of Health I _ _ _ , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' PERMIT NUMBER: #OS-119 FEE: $50.00 This is to Certify that Marv Sin�,leton and Judv Mur��d/b/a One Centre Street Inn 1 Center Street, Yarmouthpart, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended ar revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo�v oF��,�: pw��!� ��'ti1.�., e�� SEATING: lO �p��` ��,�-�,�y �s'1'�ucTTONs: Meals to serve guests only. /�ode?��}.1Q (ifPJiR Septic designed for 4 rental rooms, 1984. d�el�y eS'�ty, R,/{� �4.,�l�'��, R./V. October 4,2005 Bruce G.Murphy,MPH,RS.,CHO Director of Health ,I � r � • 1 � 3 �� Y��, �� -. _,. � �' W N � �' Y � I� LT T H ' � " `� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 ;i �MATTACMEES� Telephone (508) 398-223I, Ext. 241 — Fax (508) 760-3472 �,.� N�ONOONAT[0�4�9 i � B O A R I) O F H E A L T H C� � � i=� �l 1v� � � � �r j � � 2��J5 � To: All 2005 Yarmouth Board of Health License/Perrnit Holders HEALTN GEPT. From: Yarmouth Health Department i � Re: T�Identification Numbers I Date: July, 2005 The Massachusetts Department of Revenue is now requiring that the Health Department furnish to them detailed information regarding all permits and licenses that we issue. One of the required details is to provide a tax identification number, whether it be an establishment's Federal Employer ldentification Number (FEII� or, in the case of an individual's license, a Social Security Number (SSN}. This information will be used by the Health Department purely_ for ' administrative purposes only. i Would you please fill out the fields below and return this letter to: ' ; � Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 � Thank ou for our a.ntici ated com liance. If ou have an y Y P P Y y questions regarding this matter, please do not hesitate to ca11. The office hours are Monday to Friday, 8:30 a.m, to 4:30 p.m. The telephone number is(508) 398-2231, e�. 241. Establishment::�Q��,�J,��e� �„ FEIN or SSN:�� '"', `� i Location Address: �i��/� s� /�,��d�� 2�' � Signature: �� Print: /� � � � p Title: ; � � ^� �� Priiited on �'`r Recycled x �. � Paper �x� I `• J � f-Yq � Q 1JE�ST�FT � ,� "�. TOWN OF YARMOUTH BOARD OF HE�,I` � �a _� ;2 f� � i� I-' ��'7 i� � APPLICATION FOR LICENSE/PE 2004 ' '` ' •,',��' RM��. 2 2 2003 JE�, * Please complete form and attach all necessa��r�e�t��''December 1, 2003. Failure to do so will result in the return y�ur',�pptication packet{ HEALTH D�F��iY. T # � �� AT N DRES • �` � m MAILING ADDRESS• �,,rv�.s� MANAGER'S NAME• �� ;� (lV�G�� TEL # � MAILING ADDRESS: b GZ,�_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated 'i Pool Operator(s)-�.nd attac`�. c�py of the certificat�on �o th�s foz�m. 1. Pool opera.tors must list a minimum of two e oyee ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitat` PR). Please list these employees below and attach copies of ' employee certifications to this form. ealth artment will not use past years' records. You must provide new copies and maint ' ile at your place business. l. 2. 3. 4. �40D PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who is certified as a Food : Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. C c:��r �-� ��.s�� 2. --��sioN rr��x�--- --_ ------ - _ ------ _---- —--- __ _ __ _ _ . ---_, Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. ��1;� � J r , ��-- 2. I�� Gl S�� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. �STAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN �50 _MOTEL $SO _INN $50 _CAMP S50 _SWIMMING POOL$75ea. I LODGE $50 _TRAILER PARK �50 _WHIRLPOOL a75ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 _CONTINENTAL �30 NON-PROFIT $25 >100 SEATS $150 I COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# L(CGNSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VGNDING-FOOD S20 _<25,000 sq.ft. �75 _FROZEN DESSf;R'i' $35 _TOE3ACC0 S25 NAME CIiANGE: $to AMOUNT DUE _ $ C"15•00 ***"*PLEASE TURN OVER AND CUMPLETE OTHER SIDE OF FORM***** � � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR . CERT. OF 1NSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPRQPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ' THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. ' SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT 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 TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RFGULATION 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 CONSUNLR ADVISORY• Each food establishment which serves ar sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATE iN POI�I�Y• 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. _ F n . rr n�cc�u�rc._ ._ ; _ ___ __. _ �_ _---_ __ _ --- ' 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��S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Boazd of Health. OUTDOOR COO IN =• ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE: � y� 3�l G� " SIGNATURE: CC�,1. PRINT NAME& TITLE: CC� r �Cti � 1�C�S� `�r�� ' �j � 10/22/03 � ., � � The Commonwealth of Mussachusetts � � � � � � � � � � Department ojlndustrial.-iccidents � y 011lceo)leves�lOslliis MAR p 2 2004 a � ; 600 Washington Street HEALTH DEpT. ' ` Boston,Mass. 02111 �~ ��y' Vh'orkers' Compensation (nsurance Affidavit ARnlicant intormation: pleesepRiN't'Te�,'Wir 1 � nam�: �� I�Q l'�. �(�O �Y`� �l/1 i� - f s � ' , �, � Y1�1� � SU� �'�` �i� I am a homecµ�er pertorming all work myself. ) I am a sole proprieror �r.,a. ha�e no one ��orkin� in am•capacin� � I am an employer pro�idins w�orkers' compensation for my empio��ees w•orkine onshis job. _ _ - _ __ _-- - -- _. _ _ - -- _ ; somaam• name• address• tiri•: ,�}hone q• iesur:►nce co. oiicy# � i am a sole proprieror. generai contractor, or homeowner fcircle oneJ and ha�•e hired the contractors listed below �tiho ha�e the follu��in_ ��orker�� .ompensation polices: comnanv n�mr address• cin•: nhone M• insur�ncc co. oolic�# comoanv name• _-------_-- ---- _ --- - _- -- __- ------- -- -- _ _ -- _ ------� iddress• , - �.: — _ __ — -- - --- __ _--___ ehoee 1!• ' insurance co. �* ' t Failure to secure covera;t as required under Seenos ISA of MGL 152 ta�iad to tee iepailioe of erisi�fl pesdtla of a 6�e op to Sl¢00.00 a�d/or , one years'imprisonment as w•eU a�civil penalde�io the form o[a STOP WORK ORDER aed a Aae of SI00.00�dar a�ain�t ma I a�dersta�d tsat a ! eopy ot th'n statemen[mav be forw-�rded to the 011iee of Inveatig�tioro of tAe DIA tor eoven=e veriBatio�. /do hrreby cer►if}•under rhe peins and prrtalties ojperjury that tl�t injorniation provrdtd obove is tnte aied eontct , ��_.,� `�. .� rl V �,;�;�=,. �°�' .� _ b �'f�d' �� .. oRcial use onlp do not+.rite in this area to be compieted by eiry or town oAleial ciry or town: Y�M��T� _ pennit/lieeax M nBuildiog Department �Liceasioe Boa�d �cheek if immediate respoese i�required 261 �Stlectmen'e OtTitt �Healt6 Departmeet - contace person: phone R;_ �508� 398�2231 ezt. nOther — — i � .. ._� <a„. � i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMUUTH PERMIT NUMBER: #04-OQS FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby gr�ted to Carla J.Masse at One Centre Sh�eet Inn. 1 Center Street.Yarmouthport,MA in said Town of Yarmouth and at that place only and ercpires December thirty-first,2004 unless sooner suspended or revok�for violation of the Iaws of the Commanweslth retating to the Iicensing of Lodging Houses. This license is issued in eonfornuty with the auttcority �tefl to the ficensing authorities uIIder section twenty-three,of ehapter ane hundred forly, of the General Laws,and is subject to the grovisians of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatw-es,this Fourth day of Februa,� A.D. 2004. - BOARD OF HEALTH: Be�aaii��. y'o3c�t��ty,/I��. ' �u�`�ic��c$�, ?!u� G��ar�i� xEs'rtucTToxs: Per Board of Appeals decision#2091, /to��B�u�rt, � 07/12/84,4 bedrooms-all on 2nd floor. No bedrooms on 1 st floor. a��t S�a�, Q./� Hot tub—Not for guests/dwner use anly. I Director of H�eattti � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-119 FEE: 75.00 In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: Cazla J. Masse, 1 Center Street, Yarmouthport, MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Petmit expires: December 31.2d04 BOARD OF HEALTH: B�e�s�t`��jts�t �. �o�t,/��., els�'.veyta�t SEATING: 1 O /�f�isC1��, v�e�� RE3TRICTIONS: Meals to serve guests only. Ro�pe�u��. B � Septic designed for 4 rental rooms, 1984. d�e�e�t e�lioli�. February 4,2004 nice G. Murphy,MP , . .,CHO Director of Health � j � ' � � THE COMMONWEALTH OF MASSACHUSETTS � TOWN UF YARMOUTH PERMIT NUMBER: #04-081 FEE: 50.00 This is to Certify that Carla J. Masse d/b/a One Centre Street Inn 1 Center Street, Yarmouthport, MA IS HEREBY GRANTED A COIVIMON VICTUALLER'S LICENSE 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 common victuallers. 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 ha.ve hereunto aff�ed their official signatures. - BOARD OF HEALTH: Bn �1. �'�+tc�,�1�� 1.�., G��ra�,rari SEATING: 1 O /�G��3AKQ�� vK:�C.��/llGlt xEs�cTToxs: Meals to serve guests onty. Ro�� B�tou�, � Septic desig�ned for 4 rental rooms, 1984. d�e�t eS'�, /l./�. Februaty 4.2004 Bruce G. Murphy, H .S.,CHO Director of Health � �, ' , c.b�'3�� "'-� � [�� ; of;'`R.� TOWN OF YARMOUTH BOARD OF HEAL�� JAN 0 2 2003 � o o= � APPLICATION FOR LICENSE/PERMi�.�2� 3 a:. ' < < s A �_ a.. �� `�� ' LTN DEPT. * Please compiete form and attach all necessary doc � �� t�ce ber 3 Failure to do so will result in the return of you '•` pli�ion packet. ;. M T LISH E L # 6� � C DDRE : � � ! OWNER/COR.PORATION NAME• � S , iVLA1�IAGER'S NAME• TEL.# �lD _ 1VLAiLING AI�DRESS• POOL CERTIFICATIONS: _ Tbe pool supervisor must be certified as a Pool Operator,as required by St�te law. Please list the designated ' Pool Operator(s) and attach a copy of the ification to this form_ ' 1. 2• Pool operators must list a minimum of two employees c tly certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Ple list these employees below and attach copies of employee certifications to this form. The Health Department 'll 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 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.,�_��:—� 1 I v �«.�--- 2• ' i �3€'s�S`3i hfi�I�1�I��i�P�'_ _ ____ � __ _ ----- __ ___ — _ - - -- - - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2• NFIMLICH 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-chokmg procedures below and �,; attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. : 3. 4. RF.STAURA1�tT SEATING: TOTAL# OFFICE USE ONLY ' LODGING: ' • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# B&B $50 _CABIN $50 �MOTEL S50 INN S50 _CAMP S50 SWIMMING POOL$75ea. �LODGE $50 �OU$ _TRA[LER PARK $50 (//y✓HIRLPOOL $75ea. �--� ]C�J �'QOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LO-]00 SEATS S75 �a _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 / COMMON V[CT. $50 ��-0811 _WHULESALE $75 RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft. $45 i>25,000 sq.ft. $200 _VENDING-FOOD $20 <25,000 sq.ft. $75 _FROZEN DESSERT �35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 2�� ' _�s o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' �� 7�• �� , . .__. ..._�_... . . � _ y � � ADMINISTRATION ': +>� _1:, ..,. i . '-��`Urider�hapter I'S2; Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ! AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_;� NO NOTICE:Permits run annually from January l to December 31. IT IS YOUR RESPONSIBILITY TO RET[1RN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT 1'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEI�TING: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: T'he water must be tested for pseudomonas,total coliform and standard plate count ' by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. ' FOOD SERVICE CONSUMER ADVIS4RY: 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 Temporary Food Service AppIication form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ----��Q�C�I �2ESSE8TS: .-- _ --- — --—-- Frozen desserts must be tested on a monthly basis by a State certi�ieci�lab.�I'est results must be sen o��ie rie�- -- ' 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),�have prior approval from the Board of Health. OUTDOOR COOKING; Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: �y�3� l 0 a— SIGNATURE: ' � PRINT NAME &TITLE: ( 1MGtS S� Q�P� � JL � 10/18/02 ..� � � _-i � /� . �\ Th e Conrmon wealth of MassQch usetts � � Department ojlndustrial,-lccidents � ; Of11CQ 0//ODCS�0�1111/t ` 600 Washington Street ', •� B�ston.�fass. 02111 �'" ��y W'orkers' Compensation Insurance Atfidavit Annlicant information• Please i1�47'Te�."i.Tir nam� � �Vl, � 1 � \�� r lucati�n• � ��i l.�V��.�/ ��Y.J.J��.�' � I �1 ►'� . , Por ►�YY�I a2�(.p�s # �08` 3(�a �S 1 I am a hom cwner pert�rmin;al work myseff. � I am a sole proprieror �r.� h��e no one ��orkin� in am•capacin• -f� I artT an empto�-er pro�r�ine wbrf:ers'-compensation for my emplo�ees u�orkirtg oRthis job: = - . comoan�• nams• ' address• ' �itv: nhone#• insurance co. �olicy# � I am a soie proprieror. generai contractor, or homeoµ�ner(circle oneJ and hace hired the conaactors listed below ��ho ha�e the follu��ing «orkers ,ompensation polices: comqanv name• address• cisy: nhone#• insur�ncc co. Folicy# company namr addresr c�y: ehone M• insurance co. pORey{f a Failure to secure covenge as required uoder Secnoo 25A o(MCL 1S2 ea�lad to tbe iopaitioa ot erivi�i pesdtla of a d�e op to S1,500.00 a�d/o� oae ynn'imprisonment s�w•ell a�civil penaldea io the torm of a STOP WORK ORDER aed a liee otS100.00 a day a�tinst ma I r�denta�d t6st a eopy of thH statement may be fonvarded to tAe ORce of Inveuie�tiom of t6t DIA for eoven�e veritiqtfo�. /do hrreby certif}�under rhe poins and prnalti�s ojperjury that tht injornration provided above is trrie aad conect Signaturc ate 1�� Qc� Print name �� s�/� Phone M �� 3 � � � l � I .- o(Ticial usc onh do not Mrite in this are�ro be completed by eiry or town oAlcial ciry or town: Y�M�IIT$ _ pertnitAicense N n8uildiog Departmeot �Licen�iog Board �eheck if immediate response i�required 261 �Seleetmen'�OlTice �Heait6 DeQartmeot contact person: - p��p;_ (508} 398�?231 e.xt. nOther .. ._� < �.,: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #03-008 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Cazla J.Masse : at One Centre Street Inn, 1 Centre Street Yarmouthport.MA ' in said Town of Yazmoath and at that place oniy and e�ires December thirty-first,2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred forty, of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimany Whereo�the undersigned have hereto affixed their official signatures,this Twenty-fourth day of January A.D. 2003. BOARD OF HEALTH: �ra�cd�. i��c. �ra�vtMca�c -- --- - -- _ _- - - - -- ----_ —��D.--C%�.�dG.�_-.-�1�- ' xEs'1'R[c'r�oxs: Per Boazd of Appeals decisioa#2091, ,,_� �.,S%roaaa, � „ 07/12/84,4 bedrooms-.all on 2nd floor. No bedrooms on 1 st floor. �a�tit��c�o�uKot� ' s`�ele�.SiFak, ,�.�1: ruce G.M y, .S.,CHO ' : : ; Director of Health , : _ __.. _— -- --_ . TORtN OF YARIVIOUTH _ . ��. ._ : . ,:.. . . � � �� BOA��OF��4L�`� �� " � ��'�. F��`� ,_,� �;, f� i PERMIT TO OPERA'TE A FOOD E5TABLISHMENT � - ' ' ,. s;: : ; PERNIIT NLJMBER: #03-138 '` - F'�E: $75.OQ # In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapt�r , _ _ 111,Section 5 offfie General Laws,apermit is hereby granted to: - , ;-.., �� ; _ Cazla J. Masse, l.�exrtre Street, Yarmouthport,MA . ;� < � Whose place of business is: One Centre Street Inn : . , � �`, ' . , , ' .,, ype o usmess: oo rvice To operate a food esta.blishment in: Town of':Yarmouth Permit expires: December 31.2003 BOARD OF HEALTH: ��`�, i�o(�i1�e�, ��a�c s�n�rn•iG: 10 . ��c��ic�c D. C�s7al°u, �JlG.D.. 21ice `�a�uc.rra�c xEs'rlucTiotvs: Meals to serve guests only. ,� jt, b'aoas�c, �� Septic designed for 4 rental rooms,1984. �a.�riek�aro�w�t ��P,�c.�i�rQl�C, �� , January 24.2UO3 ruce G. hy, .S.,CHO j Director of Health a THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-084 FEE: $50.00 - This is to Certify that Carla J. Masse d�bla One Centre Street Inn 1 Centre Street Yazmouth rt MA IS HEREBY GRAN'TED A COMMON YICTUALLER'S LICENSE In sazd Town of Yarmouth and at that place only and e ires December thirty-first 2003 unless sooner s ded or revoked for violation of the laws o the Commonwealth respecting the licensing�nvnon victualler's. This license is issued in conformity with the authority granted to the licensuig authorities by General Laws,Chapter 140,and amendments thereto. In Testimony Whereo�the undersigned havE hereunto a.ffixed their official signatures. --- -- --- - --�E}�RD-OF-I�A�TH:--�ianle�rI� xal�i. 1�� ____ _ -- — . �: sEa�rrrrG: �o �e�c�D. yardau. �9fG.9., ?/tee�— _ . �o�rt�. �, �� RESTRICTIONS: MeaLs to serve guests only. ` ��tiC'designed for 4 rental rooms,1984. � �<. , z,._. �a�tie��e��,. , . �f�.�i�c. �� Januarx24.2003 tl1Ce . y, •� . ` : : _ Director of Health ; �. •,� � .r . ,.� : . : . , ; , .,� F - :; ;. : , � �� _ _ � ; �r+�ss�NRIO.�I 30�mS 2I�H,LO�,L�'IdI�NO�QNV 8�A0 NNfls�5�3'Id�r►+rsr . $ _ ►�Q.L�OW�' OI$ •� � S£S.L2I3SS�a 1�I�Z0� OOZ$ �t'�000`SZ<. 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" •uuo� s�o�suo��e�r�r�a�aa�oidu�a�o satdo�q�� , pue nnojaq sampa�o�d�rz�o��-que ui paure�saa�ojduia.mo��sij aseajd •sauzi�j��.�sastuza�d a�uo zannauey� ' q�i�.uiaH ay�ut pau�.z�aa�foidiva auo �seai �� an�q�snuz a.�ouz ao s�eas Sz q�inn s�uauzqstjq�sa a�in.zas poo� ji� �,_. � •y � . ' -: �..��.' " �' !I�� •� . .�� •uor��ado�o smou�ut.mp a�is uo(�I�aSatiu�uI uos.�aa auo�.seai��an��snux�uau.a�siiq��sa poo t o� � 'Z �, 7 'i � •uoq�tj siqa o�uo�e�gr�a�3o satdoo�I��Id , '000'06S�NI� SOI `S1uau�sgq�sg aoiruar� poo3 ao� apo��s a��s a�ut paugap se `.za��y�uor�aa�ozd poo3� s� par��ao st oqnn aa�oiduxa aun}-i� auo�s�aj �� an�� o�pa�mbaa aa� s�uaun�siiq�sa a��as poo3 tId �. '{, .£ � •Z 't �� ,` •ssa �o sai o��pu�nnojaq a a as sa��zouz�ndotpie��tunwLuo� pere P?�;�3 P�P�`�a3��+�t�Q�pa�a��uaun�saa�ojdiva�onn�3o umuzraiuz��sti�snuz s.�o��ado iood -. __.,...._.,Z •j .` •uuo3 sng o�uor��gr�ao a��o�do��q��e pue(s)�o��adp iood ' pa�su�isap a��sti aseaid � . � .> � � '��. �Z-Z")E-�# �55 �^! ''Vi�"�`�", ' i c `�n"'�" �y�1` �fl 7� �s"v10 - �S dT� , � •SS Q� � " ')LA �-,1 ��'°� o`,�,'2� ' � � � . , �S `�- # .L `i' - -�, -aJ vi —�e� =,LI�I I �Y� •�ax��d uoi��eoijdd�mo�3o um�a.�a�� ui�jnsaa Iitnn os op o�amj�3 �j OOZ `i£�aQuza�aQ�Cq sauaum�op tiressa�au j��8 pu�uuo�a�aiduzo�aseald * �� :-�� zooz-iu�x�a��su��iz�o,�uoii��i�aa� � �°-�� A o�� --� H,L'Id�I 30 Q�I�OS H,LRONRI�X 301�IAAO.L �„ F ; 4 � �;�':� e�� . ,�, _..._._ .. . . 1 ADMINISTRAT�N 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 Certificare of Worker's Compensation Insurance. THE AT'�'ACHED STATE WORKER'S COMPENSATIOl�' INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED S�8 . WORICER'S (;ONIP. AFFIDAVTT SI��D AND ATTACHE ,. , Town of Yarmouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSTBILTTY T'4 RETURN _ THE COMPLETED APPLICATION(S)AND REQ�JIRED FEE(S)BY DECEMBER 31,2001. SEASONAL ESTABLISHIvIENTS AR.E TO�ONTACT�HEAL'TH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ' , `:,, ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTIN�'i, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTF�PRIOR T4 COMMENCEMEIVT. RENOVATIUNS MAY REQUIRE A SITE PLAN. - _ __ _ en�li�'iil�ifi.�t:iT��AT-�ON� - --- _ , POOLS POOL OPEI�IING: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: T'he 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 CATERIN(s pOLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the req,uzred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Departrnent. FROti�N D�SSFR'1_'S: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit unril the above terms have been met. OUTSIDF CAF�S• , Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus,t have prior approval from the Board of Health. ' OUTDOOR CQOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � ��-1� E�� DATE: SIGNAT'URE: PRINT NAME&TITLE: �'r�� Y�aS��-- � P ,�.�s �� 09/11/O1 � � , ,��..... ,. K � . _ The Commonwealth of Massachr�setts � � W Department ojlndustrial,-1 ccidents � a Olflce ol/�es�l�stJ�is � 600 Washington Street ' ,,•� Boston,Mass. 02111 �'" '�� Workers' Compensation Insurance Affidavit Aoolicant informaHon: pieascPRilQT7e�'}�T�c . � n m•: � ' 'on: y , rr,��1,�- P o � � � 3(p� a-q^17 � I am a omeowner pertorming all work myself. � I am a sole proprieror�^,� ha�e no one��orkine in am•capaciry � � I am an empioyer pro�iding workers' compensation for my employees working on this job. comoan�• name: addresr ' cit}•: phone N• ' insurance ca Aolicy# � I am a sole proprietor. general contractor, or homeowner(circle onel and have hired the contractors listed below «ho ha�e the follo«in� ��orker� �ompensation polices: companv name• address• city: phone#!• insurance ca � � policy# � i � I tom a�ny namr f addrcss• � I � � i c�y: Ahoee#• � i insurance co. �q�y ff � Failure to secure coverage as required under Sectioo 25A of MGL 152 ea�lud to t6e iopoeidon o(erioi�al pe�dtla of a 6�e op to S1,S00.00 a�d/or � one years'imprisonment as well as civil penaldes io the form of a STOP WORK ORDER and a fioe of S100.00 a day K�iost ma I a�dersta�d t6at a eopy of thy statement may be forwarded to the Ofiiee of ImestigaGonrof tAt DU tor eorenge veriliat�o�. /do hrreby certij}•under th ains and penal�ies ojperjury that tht injornwtion providtd abovt is due d eorrt � �d'� � I ' Signature � � _ � Print name l_.�,r l� �1 ' Y lQ�_��✓ Phone�� l�� t�� .- o(Ticial use onh� do not w rite in this arca to be completed by city or town oRicial � i city or town: Y�M�IITR _ permit/liceose# nBuildiog Departmeot � QLicensiog Board i �check if immediate rcsponse is required 261 �Selectmea'�ORee ! QHealth Departmeat contact person: phone q;_ �508} 398-�2231 egt. nOther E (re.�ised 3;95 P1A1 � i � � �� -�� 4a�CE�u�Sr,�'r�lnrN ��FY�� TOWN OF YARM T � ,, o O U H ll46 ROUTE 28 SOUTH YA.RMOUTH MASSACHUSETTS 02664-4451 � � MATTACMEES � � ,�+r,,,op�it,,b�� Telephone(>08) 3)8-2"�31, Ext. 241 — Fax(708) 398-2365 � 2 �ia � � pn 2 � L V V LS BOARD OF HEALTH .�(�p 12 2002 HEAlTH DEPT. May 28, 2002 �� ` � � �`� � � Dear Permit A licant, �� PP �p Your application with the Yarmouth Health Department cannot be processed at �b this time due to the following reason(s): ➢ The application lacks a signature and/or date. ➢ The application needs a Workman's Compensation Policy Number or�davit. ➢ The application lacks Copies of Certification: ■ ServSafe, ChokeSaver, CPO, CPR, First Aid, Water Safety � /, ➢ Additional permits are required as well as ad " fEes. �rn,o7l/ V l�', `" SQ,D-d ➢ Restrictions to your pernut require Engineering or Water Usage Reports ➢ Restrictions to your pernut require Reports that detail safety issues regarding your Swimming Pool or Spa. ➢ Other: �� C�(� � ��l��tl� If you have any questions plea.se do not hesitate to call me at(508)398-2231 e�. 241. Sincerely, David D. Flaherty Jr. � Health Inspector Town of Yarmouth Health Department � � � �� Printed on Recycled L Paper 1 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-084 FEE: $50.00 This is to Certify that Carla Masse/One Centre Street Inn.Inc. d/b/a One Centre Street Inn 1 C:entre Street_ Yarmouthnort MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authonty granted to the licensing authorities by General La.ws, Chapter 140, and amen�ments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �?�. Z� Lkavuxa�c ' sEn'tvvG: 10 � D. C�ozda�c. 711.D., `r/�ee �a�.,ra.� ' 1zES17uC1'[orrS �F n1vY: Meals to serve guessts only. ,� � �roaoMc, elP� Septic designed for 4 rental rooms, 1984. �a�tiek�� f .$i�. May 7 ,2002 ce G.Murphy,MPH, S., O Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NLJMBER: #02-130 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: (".arla Masse/One Centre Street inn,Inc_, 1 C'entre �treet Yarmouthnort,MA Whose place of business is: One Centre Street Inn Type of business: Food Service . To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2002 Bo�oF�.�.�: �� z�, �� s�TnvG: 1 o D. C�o�rdowc, 7'Jl.D., 2/iee L�a�c �S'rx�c�rtorls g',�r1Y: Meals to serve guests only. � � �rot�c, ele� Sepric designed for 4 rental rooms, 1984. �a�ek�ozuroti,` �fe�c.�i�ia.k. ,�.'� May 7 ,2002 Bruce G.Murphy,MPH, S.,C Director of Health 1 . THE COMMONWEALTH OF MASSACAUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-007 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby ganted to Carla MasseJOne Centre Street n_Inc. at One Centre Street Inn. 1 Centre Street Yarmouthport.M�l in said Town of Yazmouth and at that place only and e�cpires December thitty-first,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority ganted to the licensing authorities under section twenty-three,of chapter one hundred forty, of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Seventh day of May A.D. 2002. BOARD OF HEALTH: �s�, i��Z �D. G��mral�. .�lee �SZ'tuc'r[o1�1s rF,4tvY: Per Board of Appeals decision#2091, ,�o�e�rt� �aoao�c, �r� 07/12/84,4 bedrooms-all on 2nd floor. No b�rooms on lst floor. �i�ilek�e�rirrot� s�C�i1c .5�, i�� Bruce G.Murphy, H, .,CHO Director of Health � �. _ .:� ""�� e-� , �-,-�•,, d NE CEN712-E cS77z-E.LT(il1A/ 4 ` <� f 5 ��" o TOWN OF YARMOt�i � �F�-I�RLTH� � � � � � � � � � APPLICATION FOR LICENSE/PERMIT-2001 QE C O 7 �OOO ; � * Please com lete form and attach all neces H E LT+-i NT . $ p sary documents by December 31, 2000. Fail i the return of your application packet. � ---------------------------------------------------- ----------------- ------------------------------------------------------------------- ' N ME OF E T R ISH FNT• C�r�Q �vn-�-rd, �jI-��t- �n I� T , ' T,�s# SD� °3b�. �lql� � - � D i N � I ; , � � �... "------------------ ---------------------------------------------------------------------------------------------------------------------- � The pool supervisor m be certified as a Pool Oper�tor, as rec�uired by new State law. Please list the � designated Pool Operator(s) attach a copy of the certification to this form. ; 1. 2. , � Pool operators must list a minimum of two e layees currently certified in basic water safety, standard First Aid i and Community Cardiopulmonary Resuscitatio CPR). Please tist these employees below and attach copies of � employee eerti�cations to this form. The Health partment will not use past years' records. You must provide new copies�nd maintain a file at your plae f business. l. � 3• 4. HF i.ICH CERTIFI�ATION� All food service establishments 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' reeords. You must prnvide new copies and maintain a file at your ptace of business. d�w n�r �s `�'��-�r:L NuYs�z.. � I. ' 2. 3. 4. � � RESTAU1tANT SEATING: TOTAL# �'" NON-SM�KING SEATS: TOTAL# _..�.��_-..-------_.._..______.,..�___..__.._______------------------�,�______�_ �_.�___.�,,,� __ . _- - _ -- -------s--^--e _ _-- --- ---------------- OFFiCE USE ONLY - LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 I —.� $50 _CAMP $50 / LODGE $50 � i- p TRAILER PARK $50 _MOTEL $50 +SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVI� � NOTE:Fer the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $75 0 I-61 _CONTINENTAL $30 _>100 SEATS $150 �NON-PROFIT $25 �COMMON VICT. $50 �0(-D I ��OLESALE $75 �T ii.4F.RVi F• � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _,<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 TFROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CHANGF,� $10 AMOUNT DUE _ $ /75.00 '�****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , I i �� _ ,_,. -_....f._. .....,._... . _._ ... . . . � a � �� . � . . . .. � � . . . � ADMINISTRATION ; � L�nde�,Chapter 152, Sect�on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal o€a.ny lir,�nse o�p�rmit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT' SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES J NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLIS�-Il�1E'NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS .....`. POOL OPENIl�TG:All swimming,wading and wfi��,00ls which have been closed for the season must be inspected by the Health Department,and the water tested for pseutie�ionas,total coliform and standard plate count by a State cerhfied lab,prior to opemng,and quarterly thereafter. `�. `�w... POOL CLOSING: Every outdoor in ground swimming pool must��ie drained or covered within seven(7)da.ys of closing. , FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR. Sg0.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. T6e ef�'ective date for consumer advisory is January 1,2001. As stated in 105 CMR.590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consurner advisories. CATERING POI.ICY: 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 farms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te 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 of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � J DATE: Iz- �/� -G5v SIGNATURE: PRiNT NAME&TITLE: =�`�rr�� n�Q(� , (��,c��1,�j� 11/16/00 . ' � _ -. , � _ The Commonwealth of MassQchusetts 4 W Department ojlndustrial,-�ccidents � o O�Ilceo/%ves�►ost/iis � 600 Washington Street .� Bnston,Mass. 02111 / y �'" �• Workers' Compensation Insurance Affidavit ARt�licant information: Please�Il4TTe��?� ��mc: location: �� Ahone� � l am a homeowner performing all work myself. /�I am a sole proprietor�� ha`e no one��orking in anv capacity � I am an empJoyer pro�idino workers� comPensation for my employees_workingon this job. __ I _ _ � �,�mpant name• ' address ��•• ehone#• _ insur�nce co Aolicy# � I am a sole proprietor. ;eneral contractor,or homeowner(circle onel and hace hired the contractors listed below who ha�e the follo��in��'orker_' �ompensation polices: g�nnanv name• -- address citv• phone#• insur�ncc co policy# compan,y name• - address• -– i sjiy- Ahoee i{• incurgfl�O CO ��,,�Y� Failure to secure coverage as�equired under Sectioo 25A of MGL 152 na lad to tbe imposidoa of erisi�al ptsaltia of a li�e op to 51,500.00 a�d/or one yean'imprisonment a�w�ell aa civil penalda io the form of a STOP WORK ORDER aed a fioe of SI00.00 a day apiost ma I a�denta�d that a copy of thy statement may be forwarded to the OfTiee of Imestigation�of tbe DIA for eovengt veritiulio�. /do hrreby cerrijy�under�he poins and pena/ties ojperjury thot tht injorn�ation provided abovt is tnte and conect Signaturc ��B (�.� �d�—. e.['�O Date • _L� `� `° � Print name ��n ��/��d Phone�t. ��' �� '�� ., olTicial use only do not w rite in this area to be completed by city or town ofllcial ciry or town: YA��DT� _ permiNieense tt nBuildiog Departmeut pLicensiog Board �check if immediate response is required 261 QSelectmen's Ofiiee OHralt6 Departmeat contact person: phone q;_ �508} 398=2231 egt. nOther i trec�sed;;95 P1A1 � C TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-019 FEE: $75.00 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: Karen A_ I nn llo, 1 '. .nt_rP Stre � Yarmo � hz�rt,MA Whose place of business is: One Centre Street Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires:_December 31.2001 BOARD OF HEALTH: �'�. �et'�`ed, ��rtQ.wtt SEATWG: 10 ��'��C�1L'�d rl'. /�C�IG(�l�l. (/f�CC ��iRvlillQlQ�l RESTRICTTONS IF ANY: Meals to serve guests only. �aavr.� � �i7,Of��, �;u�u� Septic designed for 4 rental rooms, 1984. %�iCliQ� d �.� � . , .�. Januarv 26 ,2001 ruce G.Murphy, .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #01-006 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Karen A.I ello at One Centre Street Inn 1 Centre Street.Yarmouth�ort.MA in said Town of Yarmouth and at that place only and expires December thirty-fust,2001 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred forty, of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Twentv-sixth day of Januarv A.D. 2001. BOARD OF HEALTH: Ed�G. �etted, �re�in�xet�,c el�a�r�ed s�. �e1�. �/ice ,(�,�ravrsxct� �S'['tucTiotvs �as1St: Per Board of Appeals decision#2091, �o�j�, t�totu�, �� 07/12/84,4 bedrooms-all on 2nd floor. No bedrooms on lst floor. %��iC�iQ� d �.� se.t ' D. . �11.�. ruce G.Murph , ,R.S.,CHO Director of Health I i I � 1 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NIJMBER: #01-014 FEE: $50.00 This is to Certify that Karen A Iannello d/b/a One Centre Street Inn 1 C'entre 4treet Yarmouth�t, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2001 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authonty granted to the licensing authorities by General Laws,Chapter 140,and amendments thereta In Testimony Whereof,the undersigned have hereunto a�xed their official signatures. BOARD OF HEALTH: F,d'J1� �e�ea. ��a� s��rn•iG: �o ��s� i�'e�!lik�i. ?/ice �ravuxa�c t�s'r'wc�otvs �arrY: Meals to serve guests only. ,�o��t�. �. �� Sepric designed for 4 rental rooms, 1984. �� d . . Januarv 26 ,2001 � ce G.Murphy,MP .,CHO ; Director of Health 1 � f f r ( ! i � � � � � ��1Q,��'�- ��ee�)nv�1 t TOWN OF YARMOUTH B��D��F HEALTH � ; A � � � � � � � � � APPLICATION FOR LTC�� F.�RMIT-2000 *'�� ✓ `` �«� ��s�� D E C 0 3 1999 � * Please complete form and attach a11 necessary documerit��y December 3�, 1999. Fail re to do so will result n � the return ofyour application packet. t�IEALTf•� DEPT. � �i� --F ESTA�LIS��NT (�h¢. �D�fY'�� "!2z'�f'--�;�n-------------TFL # 3(�. —$�l 16 � L(?GATIQN ADDRESS� 1 rrl-r .�� u�Ym � �t- �i�-� r,Z��S—� L e � 9wNER/colt1'oRATIC�N N�MF: r /� . �ann.�{ a MANAGER'S NAME: _Srrfrrn TEI, # �U,Z —�d�{(p l�[AILINGADDRESS� ,Sam� � �� ] The pool supervisor n be certified as a Pool Operator, as rec�uired by new State law, Please list the designated Pflol Operator(s) �t�ch a eopy of th��ertifieatic�a t�t�s form. 1. 2. Pool operators must list a minimum of two emplo s currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CP Please list these employees below and attach copies of employe.e certifications to this form. The Heatth Depardnen ' not use paat years' records. You must provide new copies and maintain �fde at your place of business. L 2- 3. 4. HFIlI�ILICH FRTIFI ATIONS: �W Y�r �S ��.l��"�(�.e� �U Y��-� All food service establishments with 5 seats or more must have at least one employee tra�ned m the Heimlich Maneuver on the premises at a11 times. Please list your employe+es trained in anti-choking procedures below and attach copies af employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RE�TAURANT SEATIlVC: '�0'�'AI,#� . _NOAT-�1�IDI�F�T-G-�£�14�'�:�-��'�#----- _ _-- - --- ------_______---_-----------------------------------------------------------�------ --------------------------------__.._-----------______. OFFICE U5E QNLY L01�GING: LICENSE REQUIRED FEE PERhIIT# LTCENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 �LODGE $50 C• � TRAII,ER PARK $50 MOTEL $50 SWIlVIlVIIIVG POOL $SOea. Wf-IIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 Y2K-�,2. �CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 2 -Z.. _WHOLESALE $75 RETAII. SERVICE• LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 >25,000 sq.ft. $200 �YAME CHANGE: $10 AMOUNT DUE = $_ ��r '""""PLEA5E TURN OVER AND COMPLETE OTI�R SIDE OF FORM""""" --._. __ _ U�" _�_r. _.._�w. _ . ._.. ..____., ADMINISTRATION I�NDER CHAPT�R'152; SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQU�RED � T'O HOLD ISSUANC�OR RENEWAL OF ANY LICENSE OR PERMIT TQ OPERATE A BUSINESS IF A P�RSON ,OR COMPA�NY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION I1�33SUR�4i�CE�� '�"�� ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED .� VVORKER'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 PROPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNLJALLY FR4M JANUARY. 1 TO DECEMB�R 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTIVI�'NT FOR INSPECTION 7-10 DAYS PRIOR TO OPEl�]ING FOR'THE SEASON. ALL RENO�TATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTINC, NEW EQUII'MENT,ETC.),MUST BE ttEPORTFD TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEM�NT. RENOVATIONS ME�.Y REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVV][1VIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLUSED FOR THE SEASON MUST BE INSPECTED BY TI-�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. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIIlVG POOL MUST BE DR.AINED OR CQVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICI': ANYONE WHO CATERS WTI`HIN'TF�TOWN OF YARMOUTH MUST NOTIFY TI�YAFtMOUTH HEALTH DEPARTMENT BY FILING THE REQUIItED 'TEMPURARY FOOD SER�ICE APPLICATION FORM 72 HOURS PRIOR T4 'TI� CATERED EVENT. THESE FORNiS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FRQZEN�ESSERTS: � FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN THE SUSpENSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTIL T�-�ABOVE TERMS HAVE _ - _ __ _--- __ - - _----- _ __-- -- --- -- --_------ OUTSIDE CAFES: OUTSIDE CAFES(i.e., OUTD�R SEATING WITH V�AITER/WAITRESS SERVICE), MIJ5T HAVE PRIOR A,PPROVAL FROM TI-�BOARD OF HEALTH. OUTDOOR COOKtNG: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISf�1ENT IS PROHIBITEA DATE: `! `� ��% SIGNATURE: , �^ PRINT NAME& TITLE: �1'��LI"1 /�" - �Gf►rl R.�{�� 11/12/99 ��n�r � , The Commonwealth ojMassuc/rusetts � - � � Department ojlndustrial.-�ccideats � ; Ofllceol/eres�lOsdiis I 600 Washington S�reet ' ` Bnston.Mass. 02111 . �% " �• W'orkers' Compensation lnsurance Affidavit A,Rnlicant information: plesse il'�TT�.'i� namr� �I�Q�J'1 =/.t YIIIX/1 �� lucation: �n�G L.(Ll 1.�� rlP��" �tt� "I a.rl'1�,D wL�� Or ! �,� ��0�.� phone� �J' �Z —�� C� � 7 am a homeow�ner pertormin,all w�ork myself. �( am a sole proprieror ��,', ha�e no one��orkin_ in am•capaciry I am an em loyer ro�idino workers' com ensa�n-for my�err� loxees-vrorkirt�on this � ` "- - - ❑ P p � F . P .� .. T�� comnan�• name: dl"l� l'�1r1,�Y� -...T�I F''Q'1�� J1j� �ddress. � ��)'L � siri•• "1 Q�mfS l��0'� rE�1�� 1►I TT b Z�� ehone p• �.�G �'�� 6 insurance co. R�y q � I am a sole proprietor. generai contractor. or homeowner(ci�cle oneJ and ha�•e hired the contractors listed belo� �tiho ha�e the follu��in� ��orker� .ompensation polices: �omnanv n�mr. address• ,�� • �� iosurance ca �`- policy# >, .� '��, sQmnanv namr `�.. — --- __ __-- -- �� ......___. `A R address• � - �.,- �ri'� nhoee#• insuraese co. �y* t Failure to secure covera;e as required under Secaoo 25A o MGLLIS2 ca�ind to t0e iepaitioa oteri�i�l pe�dtla of a O�e op to Sl¢00.00 i�d/or one yean'imprisonment��w•ell u eivil pendda io the fo�m of�STOP WORK ORDER aed a Aae otS100.00 a dar apiost ma i a�dersn�d t5�t a copy of thy statement may be fonv�rded to the ORiee of Inve�tig�dom otthe DIA tor eoven;e verifiado�. I do hrreby certif}•under th�parns and penal�ies of perjury rhm tht injorn�ation provided obovt is true and coriect Signature �� 7 � Print name �Q�11 � �rl�,l� Phonell ��'�"/� �v7�� .- olTicial use onl� do not..rite in this area to De completed by eiq or town oAieiil ciry or town: y�M�DT$ _ permiNicen�e a nBuilding Department �Lieeasiog Board �eheek if immediatt response is required 261 �Selectmen'�ORce �Hea1tA Depanmeat contace person: p�o��p�_ (508� 398�?231 eat. nOther ... ._� .c Ji�: , � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-3 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Karen A.Iannello d/b/a One Centre Street Inn at 1 Centre Street.Yarmouthport.MA in said Town of Yarmouth and at that place only and expires December thirty-first, 19�9 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundted and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Sixteenth day of December A.D. 19 99 . Bo�,Rn oF�ai.�: �'d�1'/. .�gt��, c��„„�,� �oan� �u6[ivan, �I'J., Vice (..�irman RESTRICTIONs �F nNY: Per Board of Appeals decision#2091, /�o�ert.�`. �rorun, C�[eer�i 07/12/84,4 bedrooms-all on 2nd floor. No bedrooms on lst floor. a��iel�e�a�ol��iy-.�ooPe� ///ic�l �oCou h[in � ruce G.Murphy, MPH,R. ,C Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: Y2K-42 FEE: $75.00 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: Karen A Tannello, 1 Centre 4treet Yarm�Lthno�r�MA Whose place of business is: One Centre Street Lnn Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. .�g�, C'�irman SEATING: 10 �oan.G. �u6divaiz, �//., Vica l,ji,airma 1tESTiuc'r[otvs t��vx: Meals to serve guests onty. �od B�E,��. �rown, C�e�� Septic designed for 4 rental rooms, 1984. a��ie��e sa�o��y-�ooPe , /� ic u�h[in . December 16 , 19 99 Bruce G.Murphy,MPH .S. O Director of Health ___ t , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-27 FEE: $50.00 This is to Certify that Karen A. Iannello d/b/a One Centre Street Inn 1 (:entre Street, Yarm�uth=ort, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth 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 vicivaller's. This license is issued in conformity vv�th the authonty granted to the licensing authorities by General Laws, Chapter 140,and amenclments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �'c��% `�elta�, C'�at�,nan SEATTNG: 10 oa�� ulliva�c, K.//., Vice C,�irman RESTRICTIONS IF ANY: Meals to serve guests only. o�ert J�. 9�rown, (_.lerh Septic designed for 4 rental rooms, 1984. a��ia[[e�a�o[��y-✓�tooPea ' �` � - o i� December 16 , 19� $ruce G.Murphy,MPH .S. O Director of Health ! .� `''" � � ;�'°� 2�PV1 � ; � �.', r1 '►Y'-e�-ce�}- 7 n r� � � TOWN OF YARMOUTH BOARD OF$�A�'�� . � (� [� Ca [ Q `UJ [� [I� � �: APPLICATION FOR LICENSE/P'ERMIT- 1999 `` �t� 0 1 1998 3 � � � * Please complete form and attach a11 necessary documents by December 31, 1998. Failur t��£c�yil�y��t in ' the return of your application packet. ; ------------------------------------ ------------------- ---------- ------- --------------------------------- -- --------�-- � TAB � - ---- :� �,�1 r'� E -- � �--3[�� 39 io { A I N D S� 1 M R bZ� -' M m�. OWNER/CORPORATION N iviF• r�v� Pc• ..�n 11rL o ? MANAGER'S NAME• �xtrv��. � TEL # 5am,� � �G ADDRESS: �x1'm� POOL �ERTIFICATIONS� " - ---------------------------------------------------------------------- The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. 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 tlus form. The Health Departmedt will not use past years' records. You must provide new copies and maintain a file at your place af business. L � �c 2. 3• 4. HEIMLICH CERTIFICATTONS• All food service establishments 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 witl not use past years' records. You must provide new copies and maintain a file at your place of 6usiness. l. IJ 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# - - — -------------------------- ------------- -------------------- . __ _ _ _ _ _ _-- __ QFFI�E LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 _,INN $50 CAMP $50 �LODGE $50 �-lo _TRAII,ER PARK $50 MOTEL $50 _SV�VIlVIlVIlNG POOL $SOea. WHIRI.POOL $25ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# �0-100 SEATS $75 � CONTINENTAL $30 _>100 SEATS $150 NdN-PROFIT $25 t COMMON VICT. $50 gg-18 WHOLESALE $75 RETA SERVI E• LICENSE REQUIRED FEE 1'ERMIT# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 TOBACCO $20 �<25,�00 sq.ft. $75 FROZEN DESSERT $25 >25,000 sq.ft. $200 �TAME CHANGE: $10 AMOUNT DUE _ $ ��'� ' *""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•"" �..--_ _� ::�,.,,_ '' r :� � ADMINISTRATION ' ;UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOUTH IS NOW REQUIRED' TO HOLD.IS��I�11�TGE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A ; PERSON OR COMPANY DOES 1'�TOT HAVE A CERTIFICATE OF WORKER'5 COMPEN5ATION INSURANCE. THE ATTACHED STA�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �o �� CERT. OF INSURAN�ATTACHED WORI�ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMIT'S. PLEASE CHECK A�PROPRIATELY IF PAID: YES �� NO NOTICE: PERMITS RUN ANN[JALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-� 5EASON. ALL RENOVATIONS TO ANY FOOD ESTABLISf�VIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS ' POOL OPENIlVG: ALL SV'iTIlVIlVIING, WADING AND WHIRI.POOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY THE HEALTH DEPARTIVIENT,AND THE WAT'ER TESTED FOR P5EUDOMONUS, TOTAL COLIFORM AND STANDARD,PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMIVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. ' FOUD SERVICE CATERII�TG POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOLJTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI-� HEALTH DEPARTMENT. FR07;,EN DESSERTS: FROZEN DESSERTS MU5T BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI-�ABOVE TERMS - _ - - -- - -- - --- . - _ _ _ ---__-- _--- - HAVE BEEN MET. _ _ . OUTSIDE CAFES: OiJTSIDE CAFES(i.e., OLITDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR ' APPROVAL FROM'I'HE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT$Y A RETAII,OR FOOD ; SERVICE ESTABLIS��VViEENT IS PROHIBITED. ` > DATE: �L `s . �� SIGNATURE: i PRINT NAME& TITLE: °�Gf,Y�1 � �cn r�i io � � �� _. ..�*'�� ' ' � . � The Commonwealth of Mossachusetts � W Department ojlndustria/.accidents � � a 01fICe0l/aves�lostliis ' � 600 Washington Street � ��,=` Boston, Mass. 02111 W'orkers' Compensation Insurance Affidavit Aoolicant information: pleas�pRlNTTedGid�r namr: ��Q i?l.Yl �—laYli�l O I�C') --- 'on: Q t�K; C1 � �'— f� ' -1 11�l �, a►�Irb�� c�r�" Iv� �4 d z�o'�� .�Z -$q 1 d , � I am a homeowner pertorming all work my�self. - �I am a sole proprietor�^� ha�e no one ��orkine in am•capaciry � I am an employer pro�iding workers' compensation for my emptoyees working on this job. _ _ _ __ -_ . _ _ _ _ __ _ __ _ _ _ _ ___ __ ... . b t�-� C��r�-t�� -r�fi �n n _ _ comoan�� name• address: � � � ; .. rno �" Oz�`�-�� • �`� �,Z --�a( /C� insurance co. policy# � I am a sole proprieror. :eneral contractor, or homeowner(circle one/ and ha��e hired the contractors listed below ��ho ha�e the follo��it�� corker� �ompensation polices: comoanv n�me• '� .�� ddress: •'`�- {S �. . ,-\. - � � . � ��. �it�': ''�-, �hone#• •..s , # in r�nce a n n ��`� nhoee 8, insurance co. oolie;M � Failure to secure coverage as required under Sectioo 25A of MGL 152 eaa Ipd to tbe i�po�idoa of eriol�al pe�altles of a O�e op to 51�00.00 a�d/or ' ooe yean'imprisonment a�w�ell as civil penaltiea io the form of a STOP WORK ORDER and a fiee of 5100.00 a day apiest sa [a�dersta�d teat a copy of thh statement may be fonvarded to the OfTiee of Inveatigation�of t6e DU for eoven=e veritie�lio�. /do hrreby cer7ij�under�he puins and penalties ojperjury thw l6t injornwtion providtd above is Mie and eorrtet Signaturc � /�L`-S ` �� Print name _`1\Ql�Y1 � , �l�l�-��U Phone N l R�"�� —�� ., otTicial use onl� do not w rite in this area to be completed by city or lown oflltf�l city or town: y�M�IIT4 _ permitAicea�e M nBuildiog Departmeot pLicensiog Board �check if immediate response is required 261 �Seleetmen's Otlfte �Health Department contact person: phone q;_ �508� 398--2.231 egt. nOtAer (re.��sed 3;9t P1A1 '� i � THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERNIIT NUMBER: 99-18 FEE: $50 00 This is to Certify that Karen A Iannello d/b/a One Centre Street Inn 1 ('entre Street, Yarmouthnor �MA IS HEREBY GRANTED A � COMMON VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless �" sooner suspended or revoked for violation of the laws of the Commonwealth respecting the � licensing of common victualler's. This license is issued in conformity with the authority granted • to the licensing authorities by General Laws, Chapter 140, and amendments thereto. ` In Testimony Whereof,the undersigned have hereunto affixed their official signatures. � /�j /�/ $�t�D �F��..�I: d///. �e�ee, C..hairman � SEATING: 10 �oan G. �ullwan�K.//., Vice l,�irman ` RESTRICTIONS IF ANY: Meals to serve guests only. Kob�rt.}. �rown� l.[erh Septic designed for 4 rental rooms, 1984. a�rie[le�a�ol��-.l�toopea • �e�0' �� . December 16 , 19 98 ruce G. Murphy,MPH,R.S.,C O Director of Health i ; f f r I i i i i I � I � i ( ( I THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: 99-6 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify Wat a Lodging House License is hereby granted to Karen A.Iannello d/b/a One Centre Street Inn at 1 Centre Street,Yannouthvort.MA in said Town of Yarmouth and at that place only and expires December thirty-first, 19 99 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto a�xed their official signatures,this Sixteenth day of December A.D. 19 98 . Bo�xv oF�ai.Tx: L'd�Y/. ��r�, e��.�,� �oarc � �u[livan,K.!/., Vice C.�irman 1tEs'rx�c'riorrs �'a�t: Per Board of Appeals decision#2091, �o�e�t� �rowa, ��r�i 07/12/84,4 bedrooms-all on 2nd floor. No bedrooms op lst floor. a��ee6[e�a�iof��-✓�tooPee ic�eL ooCou��lirC ruce G.Murphy,MPH,RS., HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-29 FEE: $75.00 In accordance with re�ations promulgated under anthority of Chapter 94,Section 305A and Chapter 111,Section of the General Laws,a pernnit is hereby granted ta Karen A_ Tannell�, 1 . .n r StrePt, Yarmoi�t�rt„MA Whose place of business is: One Centre Street Lnr� Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 1999 BOARD OF HEALTH:�d�/. �ol��, C'��.��. SEATING: 10 ' �oan G. �nu6livan�K�a.//.� �ice (..hairman xEs'r�uc'rlolvs g'.A1vY: Meals to serve guests only. �o�ert� i,rown� C�ler�Z Septic designed for 4 rental rooms, 1984. � a��is6fa�a�o[��-�tooPea , /�/ichael � hlin December 16 , 19 98 ' ruce G.Murphy,MPH,RS. CH ' Director.of Health � i