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Home My WebLink AboutApplications, WC and Licenses I � . •� TOWN OF YARMOUTH BOARD OF � N' L D T }. � � APPLICATION FOR LICENS - DEC 1 5 2008 �e �,. * Please complete form and attach a11 neces �� do �ts y Dece ��..� Failure to do so will result in the r � f yow application p . NAME OF ESTABLISHMENT: �rcw�JFN D� � �� e- ne- TEL. # - � ' � LOCATION ADDRESS: O o�` �- MAILING ADDRESS: OVVNER NAME: � � ��ti TAX ID FEIN or SN : CORRORATION NAME (IF PLIC E): �..� � vc. C • MANAGER'S NAME: �n Sv �v��ln TEL. # cI- ' MAILING ADDRESS: v�v�i S 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 farm. 1. 2. Pool operators must list a minimum of twa employees cuxrently certified in basic water safety,standaxd First Aid and Cammunity Cardiapulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All faod 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 capies of certificarion to this application. The Health Department will not use past years'records. You t provide new copies and maintain a �le at your establishment. 1. v� � v��V1 2. PERSON IN CHARGE: _ � _ __ _ -- - - Eacli food establishment must have at least onePerson In Charge (PIC) on site during hours of operation. 1. '�M�1 � ��o�vl 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all tunes. Please list your employees trained in anti-chaking procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3, 4. � � RESTAURANT SEATING: TOTAL# ! OFFICE USE ONLY ( LODGL'�tG: LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� � B&B �55 _CABIN �55 _MOTEL �55 '� INi�T $55 _Cr'�1�1P $§5 _��Vii�Rvlt�itGPOOL $80ea. , LODGE �55 �TRAILERPARK �105 _WHIIZLPOOL $8Qea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS S85 � ��I _CONTINENTAL- �35 NON-PR4FIT $30 >100 SEATS �160 _COMMON VIG. �60 _WHOLESALE �80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LIC,ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.i�. �50 __>25,000 sq.8. � �225 VENDING-FOOD �25 f <25,OOOsq.ft._'; �80 �oq 0� ; _FRG3ZEND�SSERT 540 �TOBACCO �55 .��/7�6Zc� �v��zE cxA�cE: �io " AMOUNT DUE _ $ Z�.00 *****PLEASE TUR�i OVER AND COMPLETE 03'HER SIDE OF FORiVI****' - `��..__ � --. . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S, COPVIPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKLR'S COMI'. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS T'RANSIENT OCCUPANCY; For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggre�ate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be cansidered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENIlrTG:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until thepool has been mspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total cotiform 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(?)days of closing. FOOD SERVICE CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered eve�. These forms can be obtauied at the Health Department. ; FROZEN DESSERTS: ' Frozen desserts must be tested on a moirthly 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: i Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. � OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. � ------ --- _� _ ---- __ _ -- _^-- ___ -------- _ _ __ __------ -M I NOTICEt Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ' THE COMPLETED RENEWAL AppLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLI NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MCTST BE REPORTED TO APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY E A SITE PLAN. DATE: �� ;- � � SIGNATURE: PRINT NAME&TITLE: '��n 'v o��n 12� • io,�zi!os >. � - , +1 ♦ ' • � The Commonwealth o Massachusetts f DepwrtmeRt of Industrial Accidents NNie��rw� 600 Washington Street, f"'Floor Boston,Mass. 02111 i _ Worlcers'Compeesatiog Iesoragce Affidavih Baildiag/Plambi�g/Etecttical Contraetors name: 'v c1�n V' �- � • � � � O�K 1'�`(pJ : ��1, �; � S�YL�' address- 3'�D yMa�v • �, �� ff i � 01+�.� sfate: Y"`� zi :� h —' � � Vv ! work site 1 'on ffnll addressl: ( �J(��' : ❑ I mm a homeowner perfom�ing aIl work myself. Project Type: ❑New ConsEruction�Remodel ❑ I a sole proprietor and have no one working in az�y cap�city. ❑Building Addition �J i am an employer providing w�keas'.compensaitioit for my employees worlcing on this job. -- - - _ _--_. __ -- _ _ -- - --—r coma�mv�ms: . _ _ _ iddreas: i Clty'. . .. � . � L�iUiE!#• � � Cs. � ��'�� .>.i , :r... .., ::.' n ic:i�-a: ,: :.:: a s, ...,.� : <.,.�.:. ... ..-.;-:. ,< <.1� ., , . :�.a.-dt ,rg��S.,,w !<o:�:4 ,. -�„t�k:�,3°..a'.��ed�'`r;a;+a4� ...',�> ❑ I am a sole proprietor,geaeral coitractor,or�ameowwer(arcle o�ee)and have hired tbe comractors listed below who have the following workers'compensation polices: C6QOi�Y�!' � � �[�9� � � � � � � ��' p�O�C�• I ( CO. , # I - =r, . =s;s ,.,.�.,��5':', ��!• �: E �� D�O1�!�' i — — — -- ------- — -- -- - — — -- __ _ .._ -----��__�_ __ __ .--, ..." � . ,_ ,. .. ;. ,. ;. ,. .; . ,,.. .,, „,:: .:_ -:.:+.. ,�t?` " .r ...:;� r», ;-.� -"�,..1 ,�:i � . . _ ,:�' . :. . , . . Failn�c M xc�+e as reqaired a�dv Satlaa 2SA�f MGL I52 eu lad b tl�e i�p�Wt�fairioal pnaNia�f a Bne�p b�1,3�l.M a�dfsr ene Yean' m we0 as dvi p�akin h t6e fore►K a STOt WORK ORDER a�d a Bne�t ilAO.M a day a�aimt me. 1�d t6at a �ropy�!'fiia Ma y 6e fir�varded M t�e b�ce o!"lav��t tYe D1A tor average ver�eatl�a. !ro h�neby cerd'fy� pains 4nJ pe�sl�ofPe+j+r�'tA�tt tbt tnferNteNon pravldui aboae fs dxe axd I �� Date '�` � � Print name QN�1 \V Ol�n Phonc# � '�D�'�� •fficial ase sely de net write�t6is area te be co�leted bY.dtY ar IPwa�s�c61 . � citp er to�va: P�e g �B�d�E�� ❑e�ed[if ieme�ale reapsme is reqaired ❑Sdeetmm's Offioe j ❑Hnkt 11qnr�est i t�� 4 I � � � � !` i �A . 333 S waDasn Chicago, Illinas60�04 �D�pLOYERSELIABILITYSPOLICY INFORMATION PAGE - NEW POLICY Tcs ' �f 1a Prt�vidad� �� , ; : ' �rom i#�cy��riod; d�i�y:�lumbar ; C 4 12377393 10/18/08 10/18/09 NATL FIRE INS. C0. OF HARTFORD 026256120 A�M: ' ; ;:>. ��'�"�r� �ERS & GRAY INSURANCE AGENCY INC :TEM SULLIVAN 'S VILLAGE STORE 434 ROUTE 134 . , 330 ROUTE 6A p p BOX 1601 ' yARMOUTH PORT, MA OUTH DENNIS MA 02660 , 02675 ' FEIN NUMBER: NCCI CARRIER CODE N0: 12238 ', OTHER WORK pLACES NOT SHOWN ABOVEc SEE ATTACHED SCHEDULE(S) I YOU ARE A - CORPORAT ION/S ;01 AM STANDARD T IME AT THE I 2 , POLICY PERIOD- 10/18/08 TO 10/18/09 12 INSUREDS MAILING ADDRESS . 31�1, pART ONE OF THIS POLICY APPLIF�ECHTOFTTHE STATES LIST DSHERE: �W �D �Y OCCUPATIONAL DISEASE LAW OF MA. 3B. PART TWO OF THISSTEDIIN ITEMI3A:TTHE�LIMITSSOFILIABILITYNAR�CE FOR WORK I IN EACH STATE LI 500,000 EACH ACCIDENT % BODILY INJURY BY ACCIDENT S BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE 3C. PART THREE OFCEPTSAK ,LNDY OHPLWAS AND STATESTDESIGNATED IN LISTED HERE: i ALL STATES EX ITEM 3A OF THE INFORMATION PAGE. 3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: SEE ATTACHED_SCHEDULES ; ----------------------------- ---------------- 4. THE PREMIUM ONS TRATESOLAND RATINGEPDLANS�ALLDINFORMATIMONUREQUIREDLBELOW IS ; CLASSIFICATI , � SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. p�DJUgTMENT OF PRE:MIUM SHALL BE .MADE: AT POLICY EXPIRATION EST ANNUAL CLA55IFICATION OF OPERATIONS pR�I� $1,503 SEE ATTACHED pg�i� DISCOUNT � j E}CpENSE CONSTANT 33$ FOREIGN TERRORISM PREa'IIUM 32 MINIMUM PREMIUM 5277 TOTAL ESTIMATED ANNUAL PREMIUM $1,873 � TOTAL STATE TAXES/ASSESSMENTS/SURCHARGES $92 TOTAL ESTIMATED COST $1,965 � � � DEPOSIT PREMIUM $1,873 . � i' � RGGERS dc GRAY INSUR CB AGBNCY,INC. ' � ACCOUNT NUMBER: 0000609506 DATE OF ISSUE: 10/17/08 By: POLICY ISSUING�,� nICE: NEW ENGLAND BY , COUNTERSIGNED � a'OO�S AUTHORIZED AGENT DATE WC000001 P-33398-E (ED. 6/87) � 0�_ � � �`�.`�,{'J-d �^�^' c�^�"^""B°"°� �� INSURED TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-123 FEE: 85.0(1 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a g�rmit is hereby granted to: Sullivan Village Store, Inc., 330 Route 6A, Yarmouthport, MA Whose place of business is: Yarmouth Port Village Store Type af business: Foad Serviee To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2009 BOARD OF HEALTH: .�E¢�¢fL S�I�, `J�.JV., C'/�tat�tntan C'/liaxleb �. 9CeGeiR,ex `tl ice C'(�ucbrrruuc J�`7��e�rt �.�r.eusrc, ('.�r� SEATING: 0 �u[�� 'C�xeeii6uurn, JZ..N. Ei'e�/�c.%• ,��au�ee I January 8,2009 Bruce G.Murphy, .5.,CHO Director of Health ___ _. __ _ _ _. __ __ _ __ _ ,._ _ _ _ ____,_. . .__ _ __ --_ . ______ _ f I i TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT t f I PERMIT NUMBER: #09-036 FEE: �80.00 ' In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ' 111,Section�of the General Laws,a pernut is hereby granted to: Sullivan Village Store, Inc., 334 Route 6A, Yarrnouthport, MA Whose place of business is: Yarmouth Port Villa�e Store i Type af business: Retail Food Service less than 25,OQ(} square feet To operate a food estabfishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .`1�F,e�¢IL SR�., J2..lv., C!lfp,iaenuut ' ClEc�ea .�. ��if�ex `Uice C`l�awrnuuc ' 5��ext `.�. `.�3�cw�, C� � ��, J2..IV. lanuarp 8.2009 ce G.Murphy,MP , .S.,CHO Director of Health , , . . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-025 fiEE: 555.00 This is to cercifi-that Sullivan Villa�e Store, Inc. dlb/a Yarmouth Port Villa�e Store ' 330 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A LICENSE i � For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. '' This��t is�anted' nform}tv with Article VI�f�he Sani�arv'Code of The Commonwealth of Massachusetts,and expi ece er 31�2��9 un�ss sooner suspen e or revo ed. ' I Januara 8,2009 BOARD OF HEALTH: ,`�¢e¢�L $�Q�� .,lV., (�tq,tL � C'.flic�cP�s .�.9f,:�'�i.�x, `Uice C'l�avrnu.ua Jta� 3. i(3xacwc, C�ex� ; Qnrc 'C�xeerr�,aaun, ✓2..N. '�` E�ue�ri�• ; B ce .Murp y, , . ., Director of Health � � ; I � � � ; r ��.� ' ,'.�, �` . YPa� Vtc�AG� E ; t �.J�'Y��^ TOWN OF YARMOUTH BOAI�� '� � � ,. _.. .- ,_.... _ �.... ' t�; ��' ' I � APPLICATION FOR LICENSEf,P �{ (y7 ' ; � ' _ '� � � � � �...-�:8 �"'�.�" --� �� - J'N � � ��U/ 5 r, � � � .__.�... t. ... .�; , *Please complete form and attach all necessary document y Dece� er 31, 2007. � ; Failure to do so will result in the return of your apphcation pao F�: �`: .�a..� ; NAME OF ESTABLISHMENT: Kvrw��n o•z.� �� l� � n� TEL. . �3�� "�GO i L4CAT�01'�1 ADDRESS: �30 -r,�► ,,, o MAILING ADDRESS: OWNgR NAM�: <��2,1eS tv�ti V �V ti� IN r N - — �' CORPORATIONNAM IF PL A ): vI � o�� I � �t� � • MANAGER'S NAME: -�v�� vc� TEL. #Sp�'3�=}d�� MAILING ADDRESS: C� . � �h i S 1'N 1� POOL CERTIFICATIQNS: The poot 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 tlus form. 1. 2. Pool operators must list a minimuxn 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 t�is form. T�te �ealth Dep�rtment�will not use past years' reeords. �i'ot� ��st prov}de new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. j Please attaeh copies of certifiea�ionto this appiieation. The Health Departme�t�viH not nse p�st years'rP�ords. � You st provide n w copies and maintain a fle at your establishment. 1. '�� v ci�► 2. P��1�T IN C�A.RGE: _ __ _ Each d establis t ust have at least one Person In Charge(PIC) on site during hours of operation. , 1. �^H V�i1� 2. � HEIMLICH CE TIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of em�loyee certificatiuns to tlus form. The Health Department will not use past years' records. You must provide new copies and roaintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'1+II7# LICENSE REQL?IRED FEE PER�r1IT* LICEIv'SE REQL?IRED FEE PER�III'� _B8c8 S50 _CABiN SSO _MOTEL SSO _INN �50 _CAi4IP S�0 _SVVLVLVIING POOL 575ea. _L�DGE �SO _TRAILERPARK S100 �VVHIRLPQOL S75ea. FOOD SERVICE: LIC£I*T5E R£QUIRED FEE PERMIT# LICENS£R£QLFIR£D FEE P£I�t14i1T� LIC£NSE REQUIRED FEE PERI�II7= � I 0-100 SEATS S75 �.-Q _CONTINENTAL S30 _NON-PROFIT S25' >100 SEATS S150 C0:�4ION VIC. S50 Vb�iOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERViIT� LICENSE REQL'IRED FEE PER'�fIT� f � _<50 sq.ft. �45 >35,000 sq.i�. S200 �'ENDI1vG-FOOD S20 I<25,000 sq.ft. �75 �b8-(3{� _FROZEN DESSERT S35 �TOBACCO S50 6�-O/S� NAME CHANGE: �.�o � AMOUI�'T DUE = S �oo.o0 *'�*"�*PLEASE TL'R\OVER�\�D COJIPLETE OTHER SIDE QF FORJi***** I ' � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now r�uired to hold issuance or renewal ', of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's ' Compensation Insurance. THE ATTACHED STATE WORKER'S COMPEN��S1'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I 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�rmits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTEL5 AND OTHER LODGING ESTABLISHIVI�NTS ' TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocaipancy shall be �, limited to the temporary and short term occupancy, ordinazily and customarily associated with motel and hotel us�. �', Transient accupants must have and be able to demonstra.te that they maintain a principal place of residence etse�vvhere. I Transierrt 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)manth period. Use of a guest unit as a residence or I�, dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy ! Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � * NOTE: En�losect Motel Census must be completed and returned with this appliccaation. P40LS POOL OPENING:All swimming,wading and whirlpools which have been clos�for the season must be' ed by the Health DepaRment prior to opening. Contact the Health Depaitment to schedule the inspection five��ys pnor ta apen�ng. , POOL WATER TESTII�TG: The water must be tested for pseudomonas,total coliform and standard plate count by a State eertified lab;priar ta opemag; and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered wi��iin seven(7)ciays of closin�. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmeut by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtaut�i 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 urttil 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: __ — • , ' e�is�la}�o€�ty foo�p�educ�by a retai�-or food�efviee eatab�is��p�ehhibite� _ N4TICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETL7RN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATI�NS TO ANY FOOD ESTABLI F�NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN. DATE: d-� O� SIGNATURE: FRI;�TT NAME&TITLE: ��^`� � \vu� �• �o;o 07 f • ; � � � The Commonweahh of Massachusetls � Departnrent of Industrial Accidents � �iN�IM� 60t1 WashingtuA Stree� 7f"'Floor ' Boston,Mas� 02111 ; Workers'Compe�satioa Iss�r�ce Aft�vk:Btuildiag/Plambiwg/Ek�ticai Co,tractors � � �� t �: �_ � �� ` \, i name: �,,�v a v� V�rt°�'1�- ��7vt`l , �C - � �: 33 O 11�a�� S� • '�Z-�- 6 W � � �, �-- � : 11A- �-�bd-.� ��x�n ��;�r�u�sr � I am a homeowner performing all wozkk myself. Project Type: ❑New Caa�structian[�R�nodel �❑ I a sole proprietor and l�ave no ane working in any cap�ity. ❑Building Addition an e.mployer providing wa�lce�s'compeasation f�my e,mploy�s worlcing ar►tbis job. comaa�v eame- a�ddr�s- dty: ni�ae A�- ea �Y2'C� � �� e: �� . ;k Y �,- ,, .s»� ,�; -� �-„��,� , : .. � ,:... ,,� z,��,. ,. ..�, . ��,� , , ❑ I am a sole proprietor,gd�erai ce�traet+�r,or Lomeow�er(ci�rli o�e/and l�ve hu+ed ihe c�tors listed below who have the following wa�kers'compe�ation Policesr �v rane: a�ras: �' _ oi�c/e a�. # ,. .. .,. ;, . -:: -� � �- . -, �t : ,,f: . „ ,t `'a*`" r i�'f ��EI �0 S�Y: �!�" ,._ � — �-_ _.—_ —. , ,. - �. � . .. ' -. . - - r FaiMe�e fr�eem ew�era�e as ny�ed�edv 3ee�2SA�f 1116L 1�cu kw a uk�.,w�...ce�d .t.� .. �. . � - � �a s1,sM.M�a.d/rr�� e yeaa'6eprb�a we�as cM pe�altla io tre fir�eta 3TOt WORK OBDER a�d�nse�[S1A�.N a�ey ap�t�e. I adenl�d tlst a i cepy of tlib�t t�rw�dcd M tte Omoe�tl��e D!A Ar ew+en�e vqiA�. !do berrby c�r�'rw e Pd�s rew�h�ea'ofPe�rty dY�t�Iltt�itfora�r�doe pr+ovdde�i abaas is bxt med a�rr�ert s�� nm ._ tl �i-1� �0� Print name '� �^ j\IC�� Phone# '��—3 b a' ��'�� effidai ase�nly ae oat wrPoe ie thb arn a ne c�pided by dhy er�.�iai ( cily ar tewe: p�/ �� ❑ebat if im�e�ek napsaae�ral� 05dectsm's�loe �� c��!� Ph�e�E' QOt6v , � � • � � � • . . . � rkers CompensatYon and Employers Liability : rance Polic Z(,j RI C H � y , , ��.�U�.��o�.� ; 'on Page � �IIY NO.: 10545 ACCOi7Nf NUMBER:Mp12521326-001-00001 ��ch Policy Nmnber Pro�ucer Code Previous Palicy Number REIVBwAi, AGHUS�1'fS QFFI C 411293517 OS 13688148 WC 41124397 04 �C1IIg AddiCSs P_O.BOX 10147 • JACKSflNVILI,E,FL 3224?-0197 1. Name Insured ancl Mailing Add� Prodnce�r Name and Sesrvieing A� AN VIIZ.AGE STORE INC MARK SYLVIA A(�TCY :M�ST 771 MAlN 3T . �iRMOU7�II'ORT MA 02675 031$RVILLE MA 02655-1903 (5�)428-0440 Infrnmatic�n Page,with P��Y PP��sions and��ts,if anY,co�l�this P��Y• � is: coxroltn17ox I.D.No: F.E.IN.: ' Worl�laoes 2Vat Shown Abrn►e: sBB sc�nu�.$ox n�tsuitBns Axn�C�►T�oxs 2. Policy Period: Frc�: �a�si2ooT To: iatsnoos 12:01 a.m.Standard Tm�e at the Ins�ued's Mailing Address 3. � ��Compe�nsatic�n jnsuraace: Part Oae of tl�e policy applies to the W�s Campensatian Law of the states lis�ed here � ; Employers Liability Insinance: Part Two of ti�e P��3'�P'P�to work in each state listed ia ltem 3A. The limits of our <li�bility under Part Two arE: � �IY�.1�Y bY Accidea�t S 100,OOU Each Accic�ent BodilY�.t�Y bY�sease $ 500,000 Aolicy Limit ��Y�l�Y bY�� $ 100.000 Eac�F.angloyee � Otl�r States inswanr,�: Part Tbre�of the policy applies M the states,if any,listed hene: � ALL STATES EXCEPT ND,OH,WA,W V,WY AND THOSE LISTED IN 3A. � � • � i This policy includes the�e e�nda�rne�ts and sche�iales: s�1�oR1►ts�ND BNnoRs�l�s APPr�CABI,�t�sT � �4. � � :premium for this policy will be d�by our manuals of mles,classificati � ons,rates and rating plans. AlI infonnati� � aired an the following Classificatioa Schedule{s}is�bject to verificatian and chang�by audit. � � CLASSII�CAITON SCHSDUI,B � � � d EstiunateQ Standard Premiwn $ 1,OtS3.U0 If indicated belc>w,a�dlustrneats of Premium shall be made: , nimn llisc�mt $ e�e Constant $ 318.00 � A�ualty � � � nium fot'Endo�se�rients $ 28.00 C] Semi-Annually � �and Siu�harges $ SS.OU [� Qaa�srly 1 Estimated Aninual Premium $ 1,457.OU [� Mouthiy imwn Pterriium $ 222_00 ositPremiwn $ 1,457.Ud � ....e. .,,,.,.,.,,..... .. �:: i TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISAMENT PERMIT NLTMBER: #08-017 FEE: $75.00 In accordance with regu1at�ons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted ta ; Sullivan Village Store, Inc., 330 Route 6A� Yarmouthport, MA Whose place of business is: Yarmouth Port Villa�e Store Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 Bo.�oF HEAL�rx: �e�ett S�, J2.JY., C'.haexm,aut Chau�c�ea .�.�i�eAc `?Jice C'l�aixnuu� `J�aBe�ct.rt.�B�cura, G'�ex� . tl�uc�'ceerr�iaum, ft.�v. I November 30,2007 Bruce G.Mutphy, , . .,CHO Director of Health --, _ ._ THE EUNIMQNWEALTH OF MASSAEHUSETTS ,.. ._<,: : TOi�VN OF YARMflUTH BOARD OF HEALTH PERMIT NUMBER: #08-015 FEE: $50.00 This is to cerafy that Sullivan Villa�e Store, Inc. d/b/a Yarmouth Port Villa�e Store 330 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A LICENSE � , For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS m _ I AS PER THE YARMOUTH BOARD UF HEALTH TOBACCO REGULATION. s . � ThiS�er��se�ante3d in2��orm�'t�y with Article Vi�f�he Sanit�r�Code of The Commonwealth of Massachusetts,and i exp s ss sooner suspen e or revo e . +. November 30.2007 BOARD OF HEALTH: .�E�¢tt S�t�� ..lV��tRtt I C!�icraclea �. �'CeP�ifl�c, `vice C'fEcwYnuut � � ��ct�.�t�� I cu� , �..N. I � s��e � �rn Director of Health � _ � i � � R / O � Q a , V �n � '� � ^ ' r�. v e:► � , � ,� � �a ^ _ W � � _ . � ^ _ _ _ � ,_ w � �f � .� p � '�7�� o _ 1 c�,,� ° � o eC � � " � E�+ �' E"� � o �'' a� �A G/� U +-, �., . `� '� A o� � N . : _� � �.7 � �,� ' � � � _ , �:� , ,. _. Q 'o �, � v o � � o ��, �� ww � � o ;� � � � f�•� Q � �� M � Q � O H �•� c� �o v �� oaa � � � o � � �' "� C? a 3 v� � o .� � � �n �� °' ►r+ �,, N Ey p '� � � �' '-�, °° '�C�7 � �, � s," � � �~ :� °� �� > a � � o .� � a� w r� '�� , � w �' A � � � A � � ,.o .�'.� 4-� � 0 N I �+ � � 4� 4-� vi � q t/� q� .� � 4) p - i M tsi+—� c!3 � � �j� �j � `�'—' Q" 4-a � � Q ,� � O � +.� c7 � � � O � O � � o w � o � d z Q+ � E-� [—+ a � : ' � % � ,.- „�� °�Y`� a [� c� � � M ��, . �f_�'A ,� - �° �:a�so TUWN OF YARMOUTH BOARD OF ALT� �`: -s APPLICATION FOR LICENSEIPERMIT,-�oe7: N0V 2 1 2006 � ,_ :' � �� * Please complete form and attach all necessary:dc�cu�cner�t�t�'y�Decem e#-�1,Q��,Qt�.DEPT. Failure to do so will result in the retum,o��yo��application pac e . \} �v�H i E NAME OF ESTABLISF�VVIEENT: o�� !� �'�rE �L. #�36a`d`90� LOCATION ADDRESS: S� a�v. S�- • f bP} 1� aYc. ?)��e`}�` MAILING ADDRESS: OWNER NAME: �..5 �n� ' v a�� T r -- ! CORPORATION NAME(IF APPLIC E): Sv, �voo t1 i�� t f �wQ. • MANAGER'S NAME: -ev��..,�. ��,iv�� TEL. # Io�wt Q , MAII.ING ADDRESS: �— S'o�w.� POOL CERTIFICATIONS: The pool supervisor must b�certified as a Pool Operatar,as required by St�te law. Please list the designated __.__ Pool Qperator�s)aind 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 Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Heatth 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. — FOOD PROTECTION MANAGER.S -CERTIFICATIONS: All food service establishments are required to have at least one full-time emgloyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion to this application. T6e Health Department witl not use past years'recards. You must r ide new c ies and maintain a file nt your establishmen� 'e�n� �� V o�v► , l. � 2. �I P�3i�1��N C�IAR�E: —-- --- _ __- - _ . _ _ � _ -- __ _ , Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � 1. �'��v� � �v� � 2. �� 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 a11 times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. I You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. � RESTAURANT SEATING: TOTAL# i OFFICE USE ONLY ; LODGIlVG: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _B&B �50 CA$IN $50 _MOTEL �50 ' _INN $50 CAMP $50 _SWIlVIlvIII1G POOL�75ea. � _LODGE $50 _TRAII,ERpqRT{ $100 WHIIZLPOOL $75ea. FOQD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERNIIT# ! �0-100 SEATS $75 �7r0�2 _CONTINENTA.I. $30 NON-PROFIT $25 I _>100 SEATS $150 _COMMON VIC. $50 WHOLESAI,E $75 RETAll.5ERVICE: —RESID.KTTCHEN S75 LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 �QS,OOQsq.ft. $75 �� _.FROZENDESSERT S35 I TOBACCO $50 07-o�S� NAME CHANGE: $10 AMOUNT.DUE _ $ �O•OQ •'"""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM*"•*' .. � . , ADMIl�TLSTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSU1tANCE AFFIDAVIT MUS�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 APPROPRIATEL�IF PAID: • / YES �/ NO MOTELS AND OTHER LaDGING 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 customa,rily associated with motel and hotel use. Transieut occupants must have and be able to demonstrate that they maintain a principal place af 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 s�(6)month period. Use of a guest wut as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room �ccupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. P'OQLS POOL OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be ins ed by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days pnor to operung. POQL 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 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 filin�the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: _ _ _Q�door coQking,prepar io �r displa�o£a,n�food product by a retail or fo�d service�stablishment is prohibit�l_ __ _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ' TI-�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., T'AINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIViENCEMENT. RENOVATIONS MAY UIRE SITE PLAN. _.._____ DATE: /� J- � D� SIGNATURE: PRINT NAME&TITLE: c��. 'vc�� n� • 10117/06 'r` ti � The Com�ronwealth of Massachusetts Depart�rent of Indrtsb�ial Accidents �1f�MMI��i 600 Wasbiitgkin SYnee� ?f"'Floor Bosto�,M� �Zlll - -- Workers'Cem I�s�a�oe A�avi�B�iil • leedrkal Co�tratUers name: address: S�y state_ zio: �# work site locadi�(fWl addressl: ❑ I am a homeownea perfaaning all wak my�elf. Pmject Type: ❑New Co�vctia�QRe�nodel I am a sole and have no a�e w in an ❑Buil ' Addition am an�npioyer p�oviding wadcers'�o�f y employ�s �cing an this job. _ _ --- _ % ` 9�-V'tl'".`- . �_ C�+"�'C��`�1 1�t�8 'E � �V� ' - ---- -- - =-- I �3a W�a�� S� • �Z.�t- b 1A- .R w�a��-�n c vt.�, IPI- S7�6'�"�b �-,�'�-10(� vv�.�� YU ' � 11 rt 3 � ❑ I am a sole proprietor,g�a�al�tracbsr,or�e�w�er{circle ow�e)amd have hinod t}�coatractors lis�sd below who have the following wot�Ce�s'com�ation polic�: ----_____ — _ - - --- , -_— � — � F�n+e M see�e+e a�era�e as nq�4�ed a�der Sal�2SA�f MGL 1St m Ind b IYe ir�itlK�[QiN�d pe�alYn�f a�e�p b i1,3M.N aa�thr i eae y�nts'isp as wdl a�eM peadfies i�rie f��ta 3T0!WORK ORDBB ud a A�e�f f1M.N a day�ae. 1 adenhrd fMt a apy�f tl� �oay 6e firwa�ded M the(1�ce�f l�ntl�tl�as,f 1Ye DIA fit a�erage v�Miatln. I�o l�er+e�y xwdee dY aaape�ad�of psqiray dYot tAs lu,foriw�prov�ed aboae la bare aNd s�s� ,� �r � r D 6 P�� ,� �1 Lv�� P��# s��- 3ba = ��.o � r .�.x�y a.�oc.�r.�.u�c��o�er a�r.��w.,.m� ; dty ar t.wn: �g � I ❑c4eelc if immed�e neapebe is rcqmed �a p� � t��'�°�'' ��+ �' � � � _ � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #07-012 FEE: 75.00 In accordance wi�ret�ulations promulgated under authority of Chapter 94,Section 305A and Chapter i l l,Section 5 of the Zieneral I.�ws,a permit is hereby granted to: _ Sullivan Village Stare, Inc., 330 Route 6A, �armouthport,MA Whose place of business is: Yarmouth Port Villa�e Store Type of business: Food Service To operate a food establishment in: Toum of Yarmouth Permit expires: De,cernber 3 l, 2007 BOARD oF HEALTH: B �5. (�'' ��,, • d�e��4�Salq R"��cs G��ru� Rod�t 4. B�ou� Gl� SEATING: 0. ��,�t � �I�uc�j''�,ews��, R.IV. November 28_2006 Bnuue G.Murphy,MP S.,CHO n Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #07-005 FEE: 75.00 '' In accordance with regu1ations grom�igated under authoriry of Chapter 94,Seclion 305A�d Chapter '', 111,Section 5 of the General Laws,a peimrt is hereby granted to: ' Sullivan V�illage Store, Inc., 334 Route 6A, Yarmouthport, MA Whose place of business is: Yarmouth Port V'illage Store ; Type of business: Retail Food Service less than 25,000 square feet ' To operate a food establishment in: Town of Yarmouth ; � Pernut e�ires: December 31, 2007 BOARD oF HEALTH: B $ /H-`n, ; a��;lulr„ �i�el��rr�� R�t� B.�«� Gl� ' � p�A�� '�s�, R.tV. November 28.2006 ruce G.Murp y, ,RS.,CHO I}irector of Health kt f a • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-005 FEE: $50.00 This is to ceraf'y rhat Sullivan Villa�e Store, Inc. d/b/a Yarmouth Part Villa�e Store _ 330.Route 6A, Yarrnouthport MA iS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PROD CTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This t is anted� �y v►�th Article VI f Sani�y Code of The Commonwealth of Massachusetts,and expu�s�ece�ber 31�1� t�m�ss sooner suspent��revokeS. November 28_2006 BOARD OF HEALTH: B �. (��/�$., • ��s� Rrv, v�e�� a�t�a�, et� �� 4 , a.�v. ., n;rector�of x�eattli� � , /�' 7 : oF�,�,aR �'1� - ��` , �2+E ; ,'._.�c TOWN OF YARMOUTH BO ,.��AI�TS'��!?�� _. � APPLICATION FOR LICENS ERM�'F-2p06 ;, ° , - ,s ;� � ��V � � 1005 � �� • * Plea,se complete form and attach a11 neces ��iocu ents by�Decem ,31,2,UQ�: ��, ;� Failure to do so will result in the retum of yow application pac�=----�- ��- - NAME OF ESTABLISF�IlVIENT: vi.vv�7� ��-�"��1� � r2.�- TEL. �' —3��O LOCATION ADDRESS: �� . �4 � Yc., MAILING ADD SS: OWNER N �-- tnti � �v�� T ID r S —� � � CORPORATION NA�APPLI E): \ � vcn�.. 1 •\�ovi: Q, v�l� • MANAGER'S NAME: �v��.�� '�JC� TEL. # — — � 1vlAa,rNG ADDxESS: �c�C. �n��> V\ � b POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required_b�5t�te law._Please list the desigr�ax�d Pool Operator(s) and attach a copy ofthe 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 Resuscitaxion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wiIl not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applica.tion. The Health Department will not use past years'�records. You m provide n w copies and maintain a fde at your est�blis6ment. 1. `Q-v��.v 1 ' �G\� 2. PF�SON IN C'H�R�'iE: ---- __ __ _ _ _ ___ _ — - -- __ __- Eac od establis nt ust have at least one Person In Charge(PIC) on site during hours of operation. 1. �.1�� 1 V G'�� 2. HEIlb�T�H CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and at�ae�i�ec�pies of employee certifications to this form. The Healt6 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 SEATING: TOTAL# OFFICE USE ONLY LODGIlVG: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 iINN $50 _CAMP _ $50 _SWIIvBvIDJG POOL$75ea. _LODGE �50 _TRAILER PARK $50 _WHIRLPOOL $75ea. . FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# I 0-100 SEATS $75 •O3O CONTIlVENTAL $30 NON-PROFIT $25 >lU0 SEATS $150 COMMON VIC. $50 WHOLESAI.E $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQIIIItED FEE PERMTf# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 _>25,000 sq.tt. , $200 _VENDING-FOOD $20 �QS,OO�sq.ft. $75 �0�� _FRQZENDESSERT $35 �TOBACCO $25 ,,�� NAME CHANGE: S10 AMOUNT DUE _ $ I�S.O� """""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"" c ADIVIINISTRATION 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 CUMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETiJRN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3 l, 2005. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENIlVG FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENGEII�NT. RENOVATIONS MAY REQUIlZE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to 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 establishmenf 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 ca.tered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: _ _ FrQz�r��s�x�s_m��t b�t�t�o�a mor�lil�l�a�is�z�� e ce�tifie�lab._Testses�lts_m�t�e s�n�t2�h�-I��h _ Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any fo d pr uct by a retail or food service establishmerrt is prohibited. � DATE: �l �°� Q� SIGNATURE: PR1NT NAME&TITL . Jc,w� �v G�� i'� • 09/28lOS � -�- � ,� . � _- --=-=� ?7ie Commomvealth of Massacl��setxs .� __ _-- - - _ Depa�rinent of Indrisnnuil Accidents -_ — NM�r�i�pNM� _ -= 6(lU Wirsbisgton Stisee� 7"�`Floor --�w Bosrto�e,Masx 0211I workaa'c� do■I.s�a.ce Affidavt�Bdt kdric�l ca■axet� �_ ' � �' �. � . c� � � n. �- � � � a�- � �— � � �.�- V�nb9- - 6 - p� � �i -�, rnu � v�.�. ❑ am a homoowner perfomning all wa�C m . Praject Type: ❑New C,anstivctia��odel I am a sole and have no a�ne w in an p�� I mm-as-�P1oY�P�'o�i�-wedceas'- � fa�n�Y�IaY�s w+o�leing�t�s joh _- _ _ _ -- _ as.u.�.� V�2.1 C,N � P.� • S3ok l01°��- _...�___ � �� : -- a.�3� �� u � L� � �. � ❑ I am a sole p�roprietor,g�ral ceatractor,or kom�wter(cn+clt o�)and have hired ihe camractacs listed belaw who have the following warlc�s'com�on Polices: s�x mrrr� .. . �Y: �,�•�� mrt� .�. �a � �c� FaYve b seem�e errera�e as req�ieei oYQ 3ee1M�ZSA�f MGL L�en lad b tl�e irpNillN�f ai�id pe�s�f a�e�b i1,SM.N aid/�r ••�r�+' �..�a�dw�w��.e��..r�smrwoxrc oRnxa�.a.e.�.rai�.a.y�.c�. i..a�a.a�� : c�py.rm� ..y e��1s He omoe.cl�tl�tl�.ctlrc nu t.rc�aa�e�w,. � � I I 10 JYatiby ruelee Nie of perjrwy tl k�t Mie hrfornr�to�p�vidad eboae fa�rxe a�d onn+ect i S'� Dete �� -�1 �� 1 I Prim name �v1� SJ 1\\ V c�1 U1 Phone# "� I� 1 � •ffichi ose esiy do.ot wtitc i�t�s arta to be aea�l�a ey dl��r er�a.�Li �,��'�y- P�� ;"��B�!D�� ❑cheet if le�ediah raps�e is nqQed �� i c�� #' � � i I I � I ! � :`� ;�., `� I �:. �r.;� � � � �. N�� i ��I�' � � . � %� +Co�mpensation and Employers Liability � � i ,�e Policy ��j ,CASUALTY COMPANY �: �. � ��age �t . � any No.: 10545 ACCOiJNT NUMBER:Mo12521324-Op�tt'. �, IL � Policy Number Producer Code Previous Policy Number REtvEwAL WC 41129397 03 13688148 WC 41129397 02 t� `�Address P.O.BOX 10197 JACKSONVILLE,FL 32247-0197 Name Insured and Mailing Address Producer Name and Servicing Address � >YILLAGE STORE INC � � MARK SYLVIA AGENCY ``� �� lOS �� ST 969-MAIN ST = �� THPORT MA 02675 OSTERVILLE MA 02655-2018 m��4 � � i Ithef, (508)428-0440 armation Page,with policy provisions and endorsements,if any, completes this policy. � � � ,� �, =ls`. � CORPORATION � � � �� .No: F.E.I.N.: „ O11cpIaC2s NOt ShOWri AbOVe: SEE SCHEDULE OF INSUREDS AND LOCATIONS �M> "; °.2'. Policy Period: From: 1oi18�2o05 'j'p: 10/i8/2006 12:01 a.m.Standard Time at the Insured's Mailing Address `�'3. . :�Vorkers Compensation Insurance: Part One of the lic a lies to th e Work r 1� e s Com t' Y P ensa ion Law of t P he states li t se P d laer�' M A �` Ernployers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our � <liabiiity under Part Two are: E' . Bodil In' b Accident $ 100,000 Each Accident Y J�'Y Y "� � �ti� Bodily Injury by Disease � 500,000 Policy Limit � � Bodily Injury by Disease $ 100,000 Each Employee VIA, ,' �:` Qther States Insurance: Part Three of the policy applies to the statec. *f any, listed here: ALL STATES EXCEPT ND,OH,WA,WV,WY AND THOSE LIST'ED IN 3A. j i i DE, � .> This policy includes these endorsements and schedules: SEE FORMS AND ENDORSEMENTS APPLICABLE LIST ��EM 4. �he premium for this poiicy will be deternuned by our manuals of rules, classifications,rates and rating plans. All information � in ��quired on the following Classification Schedule (s) is subject to verification and change by audit. , � SE�CLAS5IFICATION SCHEDULE , t �'a��stimated Standard Premium $ I�348.00 If indicated be�aw,adjustments of premium shall be made: � � Premium Discount $ �� xpense Constant $ �q..pp Q Annually �� ! �� F�emium for Endorsements $ 26.flp Q Semi-Annually �'axes and Surchar es ` }� g $ 59.00 [� Quarterly .� : '�afal Estimated Annual Premium � � .$ � 1,69'7.00� �[] � Monthly ,�� A�Ii�imum Premium $ 211.00 � � � � � �� ,_ �epositPremium � $ 1,697.00 �� u ,�. �.; �. WC-40 . : � ;��r �,t,on�� ue Date: o9n3i2oos nvsu�n cqPY Counter�igned B��Authonz�d ,°� �,� ;; , � S$7,7�?nn nn ni n m� nn n�� '.onVTivht.19R7 Nafinnal('nunril n..('.......Ane�rv..n i�,.ro,.��o . . :, ,ar;��.�,£',�`„�', � _ _ _ _ : ��_ �- �-- ,� _ __ . , �_ ' —,. _- _ :�. �,� ; - _ ` � , -` ..��,,+ �a- ''` ;�. M. ��' '�` ` Taw�v ��i�ou� BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OG-030 FEE: $75.00 In accordance with re�ations promuigated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the eral Laws,a permit is hereby granted to: Sullivan Village Store, Inc., 330 Route 6A, Yarmouthport, MA Whose place of business is: Yarmouth Port Villa�e Store _ Type of business: Food Service � _ To operate a food establishment in: Town of Yarmouth Permit expires: L?ecember 31, 2006 BOARD OF HEALTH: Be�C�rri�`h. !�'ondosr7/d�`?S. ' p��' �_s ��,' v_ ,�e�� SEATING: 0. ��B�� C� Sl�, R.N. � �4.t.��'��, R.N. .�:.:.,.,., . December 5_2005 Bnice G.Mu�phy, RS.,CHO Director of Health TOWN OF YARMOUTH I, BOARD OF HEALTH i PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT � i PERNIIT NUlVBER: #06-010 FEE: $75.00 � In accordance with regulations promulgated under suthority of Chapter 94,Sectian 305A and Chapter ' 111,Se�tion 5 of the General Laws,a permit is hereby granted to: ' Sullivan Village Store, Inc., 330 Route 6A, Yarmouthport, MA Whose place of business is: Yarmouth Port V'illage Store , Type of business: Retail Food Service less than 25 000 square feet � To operate a food establishment in: Town of Yarmouth � Pernut e�ires: December 31, 200b BOARD oF HEALTH: L�e,ryr�rrist$, f�orr,/�1.�5. ' A�til�� ?/�G'�,�� '!�R.�Y.� f �1+��, R.N. _ _ ---- _ __ - -_ _ ___ _ , December 5_2005 . ruce G.Murphy, S.,CHO � Director of Health � . � £ "� _ � � tis .. ..l - - �..:: .... �- L �--. . z;`��. _ . '. ..; �.... �_�,��„� - � ,F.�' . ; . .. _ � �--- -- . .. . __ : �. s' ' r '�3 , e.,,� �°d? a � ,.� x � . . � � ,' . . IM - -.�b_ y'� ,� ��- . . _;�., _. , CLIMMONWEALTH OF MASSACHUSETTS �; ` :_ . _ : _ TQWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-009 FEE: $25.00 This is to Certify that Sullivan Villa�e Store Inc dlb/a Yarmouth Port V�illa�e Store 330 Route 6 Yarmauthport MA IS HEREBY GRANTED A LICENSE For_ SALE AND DISTRIBLTTION OF TOBA CO PRODU TS - -- A�-PER TI�-YARMOUTH BOARD OF HEALT-H T-OB74C�0 RE��.ILATION. This�e�t fs�ant�in��n6forum�'t�y with qrticle Vi�f�he Sani�Code of The Commonwealth of Massachusetts,and �P � ss sooner suspen or revo , December 5.2005 BOARD OF HEALTH: �e�tsi��. �'o�d�,�.�., P��, v�� R�t�B�, Gl� � � �'l�k, R.N. �4.�� R.N. R •, Director of H�ealtli � i i i i ------- � _ __ _- --- - -- -- - _ _ - _ _ _- -- -- _ _-- , � i ( ; i i � O�'•Yq� �-�r^�' �� : . �O T � Wl� O� F Y1�. RMOUTH O - � —y �„ :-_, �, 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 �MnTrncMees /�� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-�472 ��AVORATEO�'�C'' B OARD OF HEALTH � � � '� �� lf s '1, � JUN 0 8 2005 To: A112005 YarmouthBoard of Health License/Permit Holders HEALTH D�P'T. From: Yar.mouth Health Departmem Re: Tax Identification Numbers Date: March 22, 2005 D�� y� Y- 3'he Massachusetts Department of Revenue is now requiring that the Health Department furnish to them detailed information regarding all permits and licenses tha.t we issue. One of the required details is to provide a tax identification number, whether it be an establishment's Federal Employer ldentification Number (FEIl� 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. Would you please fill out the fields below and return this letter to: _ - Yarmouth Health Department 1146 Route 28 South Yarmouth,MA 02664 Thank you for your anticipated compliance: If you have any 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�rt. 241. , . � Estabiis�ment: c�y2�1/� o��- V t 11 �o�SN: ��{ '`. � � Location Address: �.�6 �cr��+1 S'1' • �} ��'" aviv�nc)J`�-.� ovi Signatur �' i i Print: �titi S� � v D�v� Title: �12� . _ f ( �� d on � cied � aper I � � � � ��?� � �/ � F�'q � IPOQTV�l�l�1({�iST�� ° .. R�c TOWN OF YARMOUTH BOARD � APPLICATIUN FOR LI ��' �I� � �� . '�r,: �,.;.Zy' i;, .,� :'� ) ••., .. � � 6 * Plea.se complete form and attach a11 necessar�-�o s by December 3 , 2�.+� � 0 2004 Failure to do so will result in the return of your applica.bon packet. HEALTH D �- NAME OF ESTABLISHMENT: vc�MoJ vt, i �. TEL. # - LOCATION ADDRESS: � - �Z.�- bY� MAII.,ING ADDR�SS: Sc�w�'�- OWNER/CORPORATIO NAME: v� ivc��n V�� v\C • MANA ER'S NAME: �e..�nt� v� iv vi TEL. # � � MAII,IN ADDRESS: Y �c 1'tdl . ��5 0�6I�a POOL CERTIFICATIONS: The pool supervisor must be certified�s 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 certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. ' FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tirne 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 Healt6 Department will not use past years' records. , Yo�f must provide new copies and maintain a fde at your establishment. j 1. Qv�v� v � v c�� 2. PE1�S6R��iV-C��-�_ �_ - -___.___�_��-- ---_ _ _ ��__-�._ _=_._y_-----—_-- Each food establishment must have at lea.st one Person In Charge(PIC) on site during hows of operation. 1. �Q..�nv� S�' �v rn� 2. HEIlI�LICH CERTIFICATIONS: A11 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 our place of business. l. N 1� 2. 3. 4. RESTAiJRANT SEATING: TOTAL# OFFICE USE ONLY LODGIlYG: LICENSE REQUIItED FEE PERM[T# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B S50 CABIN �50 _MOTEL $50 INN $50 CAMP $50 SWIlVIIVIING POOL$'75ea. LODGE $50 _TRAII,ER PARK $50 WHII2LPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED BEE PERMTT# I,ICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 �O �O _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VTCT. $50 WHOLESAI,E $75 RETAIL SERVICE: LIGENSE REQUIlZED FEE PERNIIT# �,ICENSE REQUIRED FEE PERNII'P# LTGENSE REQUIl2ED FEE PERMIT# ' <50 sq.ft. S45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 _j,_Q5,000 sq.ft. $75 S�6� FROZEN DESSERT $35 �TOBACCO $25 6 �01�O i NAME CHANGE: $io AMOUNT DUE _ � I�S•OO '••••PLEASE TURN OVER AND COMPLETE OTHER 5mE OF FORM"•""* c , ADMIl�TISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hpld 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 ;COMPENSATI4N INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR , CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta3ces 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 RESFONSIBILITY TO RETLJRN TF�COMPLETED APPLICATION(S)AND RE�UIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPART�NT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL REN4VATIONS TO ANY FOOD ESTABLIS��b1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ( ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimmin�,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openmg. POOL WATER 1'ESTING: The water must be tested for pseudomonas,total colifarm and staridard 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 A,DVISORY: Each food estab'shment 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 reqwred Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be obtained at the Health Department. �RA�FrAT BF.,�S�RTS: _ . __ _ _ __ _ _ _-- — -- --__---- _ __ __ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failwe 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,prepazation,or display of any fao p oduct by a tail r food service establishment is prohibited. DATE: l� �� I SIGNATURE: PRINT NAME& TITLE: ��•.�• �v o�� , 10/22/04 s � . � ti _--`�`-__--_�--_--�_ The Co�nmonweaJth ofMassochuset�s =--- - D�part�rtent of Ixdus�riat Accidentc -- �f 11ilMI�� - 6A0 Washiiegtow Stree� 7�"Floor „�, Bos�o�r,Mas� 021I1 � Worl�ers'Com ' ■I�s�iee A�dav� ketr3cal Co�hae/+ars name: 'V 0.H V'1 �S 'E N(,,' . 1R, Ovt,� V l, �s: �() �a�vt �1+�,'�� 't-- �n�' �!� ��. 3b 0� - 1 -an rnu add� : S_o�w.'�. . � I am a homoowner performing all watk Projed Type: ❑New Co�iaai�Retnodel I am a sole and have na a�e w ' �in an Buil ' qddition I am an emP�3+�P��S wa�as'��fac my�loyees wo�cing a�e thffi job. . �i,yrz:�ct�: ar�- '��- _ 0 . h ,,�., �_ - p a� S � �. �:>,.� S ❑ I am a sole praprietor,g�ral c� ,or ta�v�er(�rc%oue)a�i have hined fl►e caat�cW�s listed below who have the following worke�s'compensation Pofices: �� .. �... �, .,�. � . .�_ ii c�.v: �� I i _ � ��e: �..,.. � dl�. ��. } Fai�re�see�re a�wer�e as reqiral�rder 3ectl�a 2SA�AlGL 1S2 m kad a tlm��f a�id pn�Nles�f a fe�p b=I,S�RN a�dhr �ae yinrs'�t as we8 as dN pmltla ia tie��f a STO!WQRK ORDER atl a Sre�f t1A�N a�y��e.1 ndasb�d tht a � c.py�ub �ay be E.rwarded b o�ee�f la��tlrc DIA tor�.�rra<e v�r�tatlu.. i i I�o beneby dtr dYe sud of perjrrry tAr�t t1Ys isfor��on provlded obovr is dare asd onn+�ct ' Sig�are � � ��Q �Q� � � �� .�,� �1 :� �.� -� o C Phone# b� � � effidH me o,�y as aot wrtce i�c�s arn c.be c�ple�ed 6Y e3ti.r�pr..R�i i cily or t��ra: p�fllioe�e� o�pe�nr�nt ❑cheet K�e rap��e�nq�ed �� I �� "°°- ❑otr� 4 c�:m s�c zoa+� i �:.- ��, �, � , � �* �' �,._ � �� sorkers Compensation and Employers Liability Z U RI C H ��urance Policy � ..�� `�RYLAND CASUALTY COMPANY �irmatiot� Page �; CCI Company No.' 10545 ACCOUNTNUMBER:M012521326•001-00001 , ;. �nch Policy Number Producer Code Preuious Policy Number 1tEtvEwAL Y 4 HARTFORD EAST WC 41129397 02 13688148 WC 41129397 O1 �ervicing Address P.O.BOX 10197 JACKSONVILLE,FL 32247-0197 '.= EM 1. Name Insured and Mailing Address Producer Name and Servicing Address SULLIVAN VILLAGE STORE INC MARK SYLVIA AGENCY 330 MAIN ST 969 MAIN ST YARMOUTHPORT MA 02675 OSTERVILLE MA 02655-2018 (508)428-0440 This Information Page,with policy provisions and endorsements,if any,completes this policy. Insured is: CORPORATION i Risk I.D.No: F.E.I.N.: �i Other Workplaces Not Shown Above: SEE SCHEDULE OF INSUREDS AND LOCATIONS I�� I'i'EM 2. Policy Period: From: loiisi2oo4 To: ioiisizoos 12:01 a.m.Standard Time at the Insured's Mailing Address ; � �`I'EM 3. i �1. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here MA i B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our ' liability under Part Two are: � Bodily Injury by Accident $ 100,00� Each Accident Bodily Injury by Disease $ 500,000 Policy Limit I Bodil In' b Disease $ 100,000 Each Employee E Y J�Y Y C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: ALL STATES EXCEPT ND,OH,WA,WV,WY AND THOSE LISTED IN 3A. D. This policy includes these endorsements and schedules: SEE FORMS AND ENDORSEMENTS APPLICABLE LIST ! TEM 4. I "�The premium for this policy will be determined by our manuals of rules, classifications, rates and rating plans. All information j F`required on the following Classification Schedule (s) is subject to verification and change by audit. � � ;;&EE CLASSIFICATION'SCHEDULE ; i i Total Estimated Standard Premium $ 92'7,pp If indicated below,adjustrnents of premium shall be made: �Premium Discount $ ��x nse Constant � pe � 264.0p 0 Annualiy :,Premium for Endorsements $ 23.00 � Semi-Annually �Taxes and Surcharges � 45.00 � Quarterly ="Total Estimated Annual Premium $ 1,259.00 Q �Monthly ��linimum Premium S 211,00 ' �De�wsit Premium $ 1,259.00 � ,�., k: ��,.� .. . . � . O1-A ;` 7io3 .` ue Date: o��.I4�ooa In�SUR�D COPY Countersigned By Authorized Representative � � �`00 UO 01 13 t I:d.09-02� Copyright,19R7 Nation•rl Council on ComFxxnsation Insurance '�'Vorkers Compensation and Employers Liability �nsurance Policy Z U RI C H >�1ARYLAND CASUALTY COMPANY �chedule of Insureds and Locations �Branch Policy Number Producer Code HARTFORD EAST WC 41129397 02 13688148 �... SCHEDULE OF IlVSUREDS AND LOCATIONS �� SULLIVAN VILLAGE STORE INC � 330 MA1N ST � F.E.I.N.#: YNt��(Xfti-t�RT MA, 02b75 z, � �;: � �� : �; i � I � I i � � i � I I sue Date: ov ia�cxu � ,C 99 00 0?(I:d. 10-99) I\SI;RI:I)('OP1' _ G!: 1 01= I I ,� � � TOW�T OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUR�IBER: #OS-043 FEE: $75.00 In accordance with regulah'ons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby gzanted ta Sullivan Villa�e Store, Inc., 330 Route 6A, Yarmouthport,MA Whose place of business is: Yarmouth Port V'ill e Store Type of business: Faod Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31. 2005 BoaRD oF x��,T�-�: $essfa�`7!. !�'��`�.s � na�tii�a J�c��, �/ic��lra�3rx� SEATING: 0. ��B� � � �� R R.N. 7anuary 12.2005 ruce G. S.,CHO Director of H�eal�th� _ TOWN OF YARMOUTH i BOARD OF HEALTH ; PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT � PERMIT NUMBER: #OS-Q20 FEE: 75.00 In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter � 111,Section 5 of the General Laws,a permit is hereby granted to: ' _ Sullivan Village Store, Inc., 330 Route 6A, Yarmouthport,MA ! Whose place of business is: Yarmouth Port Viltage Store Type of business: Retail Food Service less than 25,400 square fcet . To operate a food establishment in: Town of Yarmauth ' Pernut expires: December 31, 2005 BOARD oF HEAL.TH: Bes�o�ira$. (�'a+�or�,�J,$, l�Gfnsc�A�lc��, ?/�G�� Rode�r�E`� B� Ll�k i �5�,. R.N. ��j��y R�V. ; , ; _ January 12,2005 G.Murp ,MPH .,CHO I Director of Health ; f I e � k • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-016 FEE: $25.00 This is to certiiy that Sullivan Villa.�e Store, Inc. d/b/a Yazmouth Port V'illa�e Store _ 330 Route 6A, Yarmauthport MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIB ITION OF TOBA O PROD S AS PER TI-�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. �u�s�te e�b�er�31�1��ss�so�onArticl��ed oi Srev�oke�.Code of The Commonwealth of Massachusetts,and J�,�ia.Zoos so�oF�.�: Be�.,��. lfoado.��1.�., . P�M��, v�G�l�� Rode�`4.B�o�„ Gl� ��, R.N. �� R.N. e ruce .M Director of Hea1t}i � � � ; � � � ,' _ - �� . �. 41'`a,(p � � � 'yPor1.T Vt uRC�E� f_�,q �J�V P :,yx z° ,r "o TOWN OF YARMOUTH BOARD OF �,' '�� f� C� f� � M I� DD 3 "'�� APPLICATION FOR LICENSE/P , 2$04 °�; .;s � �. �� NOV 2 6 2003 � � _e� � ��• * Please complete form and attach all necessaty documents by Deeem r��Q�3H DEPT. Failure to do so will result in the return of ynur application pack 0� G`JL. ,(� D q 4 � r . R' N - Nt .� ;�� S �-6 C POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as reqaired by State law. Please list the designated Pool O�erator(s)and attach a�Qpy of the.�ertification to th�s form. 1. 2. Pool opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintaia a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTII'ICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.400. Please attach copies of certification to this application. The Health Department will not use past years' records. You t provide new opies and maintain a file at your establishment. 1. '�� 2. ___��OI'�� -- -- - — --- - - - - _- - _ _ ._ , _---- ------ -_ _— _ _ Each f establis n ust have at least one Person In Charge(PIC)on site during hours of operation. 1 +�v�ti�; � \�� 2 HEIMLICH CERTIFICATIONS: All fvod service establishments with 25 seats or rnore rnust have at least one employee trained in the Heimlich Maneuver on the premi.ses at all times. Please list your employees trained in anti-chok�ng procedures below and attach copies of employee certifications to this fotm. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RE$TAURANT SEATING: TOTAL#� QFFICE USE ONLY i..UDGING: L�ENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERM[T# LICENSE REQUiRED FEE PERMIT# _,3&B $50 _CABiN S56 �MOTEL S50 _INN $50 ,CAMP S50 _SWIMMING POOL�73ea. _LODGE $50 _TRAILER PARK $SO �WHIRLPOOL $73ea FOOD SERYICE: LICENSE REQUIRED ERMIT# LICGNSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# I �0-1(�SEATS a75 �_� _,CONTINENTAL S30 _NON-PROFIT $25 II', >100 SEATS 5150 _COMMON VICT. S50 _WHOLESALE $75 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25.000 sq.ft. 5200 �VENDING-FOOD S20 �<25,000 sq.ft. S75 ��(� �FROZEN DESSER'C S35 �TOBACCO �25 ` 0`I�01�' � IYAME CHANGE: �io AMOUNT DUE _ $ 1'7S.oo � **""•PGEASE TURN OVER AND COMPLETE OTHER SIf�E OF FORM***"* ' � � � �� 1 ;; ¢ 4 fi � ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certifica.te of Worker's Cornpensation 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 t 'renewal or issuance of your permits. PLEASE CHECK AFPROPRIATELY IF PAID: YES NO NOTI�E:�ermits run annually�`rom 3anuary l to December 31. IT IS YOUR RESPONSIBILI'TY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2403. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTIlVG, 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 POQL 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 TE5TING: The water must be tested for pseudomonas,total colifarm 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 COIY,�UMER ADVISORY: Eaeh food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. S'ATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtainned at the Health Department. _ _ _ __ _ _ _- _--- --- _ ---- — -- Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF'�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. Qj��DOOR COOKING: Outdoor cooking,preparadon,or display of any f pr uct by a retail or f d service establishment is prohibited. DATE: �� SIGNATURE: '��, PRINT NAME&TTTLE: ; '�i. 10/22/03 I II . - . . � I The Conrmonwealth ojMossachusetts I � � Department ojlndttstrial.-lccidents � ; BfylCd O/lOI�QS�Of�I/f + 600 Washington Street ', ,,= Boston.Mass 02111 " "� V4'orkers' Compensation lnsurance Atfidavit m '�- �.' , � n: � �- � Y11A1`l7J ` vZ'�_ � # �j ' � I am a omecw�ner pertormin,all work yself. � I am a ole proprietor �:-� ha�e no one norkine in am•capacit}� (�` I am an employer pro��dins w�orkers' compensation for rny employees w•orking on this job. l� -`''} - ( _ _ comnan�• name: C �1(L�L Vl i� d ess: 0 W`�.� C�ti ��'� av w��ov L. p o • � a v ' �v.� � # � � a � I am a sole proprieror. _eneral contr etor, homeow•ner(circ/e oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ ��orkzr_� �ompensation polices: t9�nanv`n�me: I address• ' �: phone M: - il insurance co. Rolicy!! ', �moany name: ' � address- �I ciri: ehoee M• � iesurance co. entiev ff II a I Failure to secun covera�e as required uoder Seenoo 2SA of MGL IS2 n�lad to tbe iopaitioa o(uisi�l pe�dtla of a d�e op to 51,500.00 a�d/ot ' oae rean'im risonment as well s�eivil penalda io the torm of a STOP WORK ORDER aed a liae otS100.00 a dar K�io�t me. i a�dersla�d tsat a , eopy ot thi�s ement may be fonvarded to tbe ORice of Invatie�pom of tbe DIA[or eovera�e verifiptio�. �!� /do hrreby cfe if}•under r e pain an�d enalti�s ojpery'u th6t tht injornwtion providtd obort is trat d eo ex I �., ''�� ! Z Signaturc '!�-�� ' �� / Print name � �� one N ` "� \" �v .. ofTicial use only do not Mrite in this area ro be compieted by eitv or towa otlltial ! city or town: YARMO�TQ _ permitAicense N nBuildio�Department '' OLieeasiog Board Q cheek if immediste response i�required 261 QSdeetmen'�Ofiice ' �tieaittr Departmeot • contact person: pbone N;_ t508� 398�2231 e�[t. nOther ,.. .� :<�,,, TOWN OF YARMOUTH I BOARD UF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHN�NT. I PERMIT NUMBER: #04-044 FEE: 75.00 I''� In accordence with ri.�gulatt'�s promulgated under suthority of Chapter 94,Sectian 305A and Chapter 111,S�tion 5 of the Ceneral Laws,a permit is hereby granted to: � Sullivau Village Store, 330 Route 6A, Yarmouthport, MA , Whose pla.ce of business is: Yazrnouth Port Villa�e Store �' Type of business: Food Service 'I To opera.te a food establishment in: Town of Yarmouth I Permit expires: December 31. 2004 BOARD oF HEALTH: B�iu`n. ��1.$. ' �.t��s� v�e�� _ __—��:�.--- _ __ ---��' ; December 2.2003 ruCe G. urphy, , S., H ��I DireEtor of Health I TOWN OF YARMOUTH BUARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIV�NT PERNIIT NUMBER: #44-015 � FEE: 75.00 In accordance with re�ons prmnulgated under authority of Chapter 94,Secfion 305A and Chapter I, I 11,Section 5 of the al Laws,a permit is hereby gr�ted ta Sullivan Village Store, 330 Route 6A, Yarmouthport,MA I Whose lace of business is: Yazmouth Po V'ill e Store � P rt � Type of business: Retail Food Service less than 25,000 square feet I ------ - i To operate a food establishmem in: Town of Yarmouth � Permit expires: December 3 l, 2004 Bo�oF xE�.T'x: ��?J�os��J�xa� '' R�d�.�t`�. B�, � � R.N. December 2_2003 ntce G. utphy, , .,CHO I Director of Heal . , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-012 FEE: $25.00 1�is is to cerrify that Sullivan Villa�e Store, Inc. d/b/a Yazmouth Port V lla�e Store 330 Route 6A., Yarmouthport, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PR�DUCTS AS PER THE YARMOUTH B�ARD OF HEALTH TOBACCO REGULATION. This t is wnth Article VI f Sam Code of.The Commonwealth of Massachusetts,and expu��l�l��sooner suspen�rev� �t�2.aoo3 Bo�un oF�.Tx: B��h. �do.�,M.�., . p��s� v�e�� __ __ R�lw�t�it. B�,, �__ _- _ _- -------___ _ ---_____ ____ �f.� R.N. � 1?irector of Health � . .�� I� � ; i { � � I t � � .. , �f6 24 �'�?5��-- ,� f YqR-� �� e .�o TOWN OF YARMOUTH BOARD OF H��I (,�, (E� I� �I M IE I� o� ��4 APPLICATION FOR LICENSE/P ,R1k�IIT�-2�,0� Y ,, ,..� � � �, J A N 0 2 2 0 0 3 � � �� * Please complete form and attach all neeess�ocuments��Sy Decembe 3 � Failure to do so will result in the return��your application pack ��Re�H DEPT. � — - a' � S' 6.�nn `� E �t• ' E• �Q,�nv� VO�v� ��5��g MAILING ADDRESS: �v.v�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opera.tor(s)and attach a copy of tl�e ce�tifrcation to�ihis £orrri�- ___ ._ _ l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. �(?OD 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. Y ust provide new copies and maintain a file at your establishment. 1. v4v�v � - N` �V a�W 2. PERS��i-IT�TZ:�FIAI��E:--- _ --_ _ - - _ __ Ea ood establis ent must have at least one Perso�-In Charge(PIC)on site during hours of operation. 1. �.�^ • �..1 ��V C��01 2. All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must,provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEG PERMiT# I,ICENSE REQUIRED FEE PERMIT# _B&B - S50 - - =CABIN S50 � _MOTEL $50 _INN $50 _CAMP $SO _SWIMMING POOL$75oa. _LODGE $50 _TRA[LER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 10-]00 SEATS $75 '�`D�J'I S _CONTINENTAL $30 NON-PROFIT �25 ' - ! >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: � � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICGNSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 �<25,040 sq.R. $75 O3'�� _FROZEN DESSERT S33 �TUBACCO $25 �a ^O�j N�#ME CHANGE: s�o AMOUNT DUE _ $_�r�T ***''*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"**" '�� . _ �... �-�.--:� �....__.,__.._ ' ' � " �;;k` '- , � � � < �=: � � � ' ADMINISTRATION ¢ , . �; ��t. � ection 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 CO PENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT TGNED AND ATTACHED '-, � .� Town of Yarmouth taxes and liens must be paid prio 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 Y4UR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31,2002. SEASONAL ESTABLISHMENTS ARE TO C(�NTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL. RFGULATIONS POOLS POOL OPEI�IING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior ta openmg. 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 �N4iJ R DVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CAT�RNG 'OLICY: 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 obtamed at the Health Department. FRO .FN i�ESSERTS: - - --- - -- -lie iesie�on a monthr�asis by a�tate ceriifiea lab. �est 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 abave terms have been met. OUTSIDE CAF + : Outside cafes(i.e.,outdoor seating with waiter/waitress service),uil�s�have prior approval from the Board of Health. Oi TTDOOR COOKING: Outdoor cooking,prepara.tion,or display of any o product by a retail or food service establishment is prohibited. DATE: � � �� SIGNATU : RINT NAME&TITL : z.�.,, � � V��^ V� 10/18/02 Y '�-R�. t` ; � ` _ The Commoawealth of Massachrisetts � � Department ojlndustrial.-lccidents � ; olJlceoll�ra.stl�stJi�s . 600:Wa,s�iington Street ' � Boston.Mass. 02111 �� . . � � �'�/ V�y\� . . . . . . . � � .. .. . .. .. W'orkers' Compensation Insurance Atfidavit ARniicant information: __ _ PlesscpR�'T'T�r.'i.i�r n m•� �f2.�IV�SD� � v�\ e '�d�.� 33� W\r�:.�. : � e, `�.�- �1f�- � , �w�o�J �2,� a 3 -�- �� 1 am a o ecwner pertormin,all w�ork myself. � ( am a so e proprizror�-,�, ha�e no one��orkin: in am•capaciry � �:_.,.,.. :a:,,,, ,�„cl�efs• �ion for�au:em v�s woFl�i�a on thi�� -� _ _ an--c�! - �----u ts�e-�s . �.' _ }ab:__ m . n . �v �1 G. \ Q. � . �,� �kC. , d res : ��\?� ciri•: hone#• �0 a��o� — � IV� insurance co. ��-� �-� policy# W� ��1 � 1�� I am a sole proprietor,. _eneral contractor, or homeoµ•nec(circ/e one/ and ha�•e hired the conrractors listed below ��ho ha�e the_folio��in�'��orkzr� .ompensation polices: companv n�me• address•. citv: ehone Il• : insurance co. polic�# comoanY_�am_r. - -_ — _ - _——— -------__- tddress• ___._ --.� --- � �i1Y: . eboee ii• insurance co. eoRev�f , • Faiiure to secure coverage as requircd under Secnoo 25A of MGL IS2 a�ind to the iopait�oteriei�i pe�dtla of a d�e op to 51�00.00 a�d/o� oae ynn`impr ment asw•dl a�eivil penaitle�io the[or�n of a STOP WORK ORDER asd a tiat otS100.0��dsr Ktiott sa [a�dersta�d t5at a eopy of thi�sta nt may be fonvarded to tht ORiee of investi�adom of t6t DIA(or eoven�t verititatio�. _ /do hrreby ce �under th pains vnd � '�s ojperjury thal llet injornmtion providtd abovt is trtte and eorrtd Signaturc ��- 1 3 V / �� Print name �.�n l�lA one M �3 '��` .. olTici�! use only do not nrite in this area to be completed by city or tow�n oAieial ciry or rown: Y�M��TR _ permitAiteau k n Buildine Departmeot �Lieeasioe Boa�d �cheek if immediste response is required 261 QSelectmen's OfTice �HeaitE Department conncc person: pbone M;_ (508) 398�?231 ezt. nOther ... .� <a,,: TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NLTMBER: #03-048 FEE: $75.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 ofthe Laws,a permrt is hereby granted to: Sullivan Village Store, 330 Route 6A,Yarmouthport,MA Whose place of business is: Yarmouthport Villa�e Store Type of business: Retail Food Service less than 25.000 sq..uare feet To opera.te a food establishment in: Town of Yarmouth ____. Permit expires: December 31. 2003 soAtt�oF HEALTH: �a�rlia� Z�, �a�ca� - --- _ -- -_ ---- ---- _ — __ __. .. tec . _ , Z' �. �soaoMc. � , �a�tc�7�e�ar�rat� , _ s?�e�Skak. ��l. . , ar danuary 24.2003 ruce G.M hy, .,CHO ! Director of Health ' _ I , .. . -. ;... . , . ' r � . . , ,I _ « .--- _ _ _ _ THE COMMONWEAIr�H t�F-11�ASSAC��JS�TTS , TOWN OF YARMOUTH -� � .y��;�� : BOARD OF HEALTH ,_ PERMIT NLTMBER: #03-034 F��$25.00 'r�;s is to cercifythat Sulllivan Village Store.Inc. d1bJa Yarmouthport'Vi�lag��,��re 330 Route 6A. Yarmouthport.MA s IS HERE$Y GRANTED A LICENSE , �:;�; � For S�I.E AND DIS�RIBLJTI�N O�TOBI�CCO�RO�I�CTS =.., � :-. ,�:� � „ °`=� � � � : �: <, _ � ,=ry: , : � AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGTJLA'TION. This, t is rm�ty with Article VI f e Sani Code of The Commonwealth of Mass�ehusetts,and : � elcp�es�ece�ber�l�L 1�)�unt�ss sooner suspen��or revo�. Januar�24.2003 BOARD OF HEALTH: �ra�ll�d s��. i�e�llZ�Oz, .,��a�c b'ucfetaru,c 9. �la�o��ou. 'IK 9.. 2/lcc ' ,�e�ett�. �rarac, � , �a�rf�ek'�Dor�xet� � � S�. .�1. I � .MurP Y�MP -� Director of Health � � . TOWN OF YARMOUTH BOARD OF HEALTH FERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-135 FEE: $75.00 � In accordance with re$ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is hereby granted to: Sullivan Village Store, 330 Route 6A, Yarmouthport, MA Whose place of business is: Yarmouthport Village Store Type of business: Food Sex�vice To operate a food establishment in: Town of Yarmouth Permit_expires• December 31. 2003 Bo.�RD oF��L.TH:�Fa�rlea s� x�,�k� — ----- – --_ • ------- -- - – — -- �'e�r1�c D. C�ialowc. ?K.D.. 2/�ec ,��t�, b�roaar; (,Jl,e�rk sEa�rn•rG: o. �a�ek�J1ldD�wwtt ;; '��e�c S�aiE. ��Z. January 24.2003 t�ce G.Murph ,MPH, S HO ;. : ' _ ' _ = Director of Healttf ` ` .� . , ., .� � � .�� - _ � � - -i , . . . , , ! . , , ; , _ . , . A . . - ,._ _ . . . : ;. x . .. , . � � . � � � E f � .. . . . .. �:. ;.. � . . . . . . � ._�.. . . � I � ,f. i i . . . . . . .. � i � I I � � I i - -� �c� � TOWN OF YARMOUTH BOARD OF HEALTH � C`' � -� ` �1 �' � . APPLICATION FOR LICENSE/PERMIT- � C Z � 2001 �'2 7 /�' oz� * Please complete form and attach all necessary documents by December 31,2000. Fail the return of your application packet. ------------------------------------------ - ��- - --2� ��-e- —�--_------------------ �a--- --� . � �,� �,�e_ • � � .� ; ,2�e. ' �vtw ;vo��n c- �+ � ti�� ------------------•-------------------------.�.._.__-__�._�.� POOL,CERTIFI .ATiONS• ~ --___ � The pool aupervisor must be certified as a Pool Operator, as rec�uired by new State lnw. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2 Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Healt6 Department w�ll not use past years' records. Yoa must provide new copies and maintain a flle at your place of buaine9a. 1. 2 3. �. �IM�I�H C�RTIFI�A'�IDNS• , All food service establishtrients with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premis�'s at all times. Please list your emp loyees trained in anti-choking procedures below and attach copies of employ�e certificadons to this form. The Healt6 Department wiU not use past yexrs' records. You must provide nyvv copies aad maintatw a fiie at your plxee of buaines►s. 1• 2. 3. � 4. RESTAURANT SEATING: TOTAL# NON•SMOKING SEATS: TOTAL# _-____-----____ ---------------------------- _ �-�--- ----- ---------a-_----_.____________________,._.._.___._.________._.� OFFICE US�ONL•Y LODG�� LICENSE RFCIUIRED FEE PERMIT# LICENSE REQLTIRED FEE FERNIIT# _B&B $50 _�ABIN $50 —.� $50 lCAMP $50 — LODGE $50 �TRAILER PARK S50 ____MOTEL $50 SWIMMING PO4L $SOea. --- — FOOD SERVIe �� WHIRLPOOL $25ea. ,.___._. NOTE: Per t6e new lOS CMR 59Q.000 State S�nitary Code for Food Eatablishments,the effective date for food protection m�tnager certification ia Octobcr 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0•lOQ SEATS $75- _CONTINENTAI,, $30 � _>10 _ ATS $150 � _NON-PROFIT $2� COMMON $50 � — .,_ OLESALE $75 BET I .RVI .F.��, . � LICENSE REQUIRED \ PERMIT# LICENSE REQUIRED FEE PERMIT# ' � ..,`.<54sq.ft. $45 ` � �,T4BACC0 $20 �6a.-Oc�i� � �<25,OOQ sq.ft. $75 —66d �FROZEN DESSERT �35 . -- >25,000 sq.ft. $200 ' N�MF f'NAN(:F• $10 � � � AMOUNT DUE = $ - -" **"�*PLEASE TURN OV�R ANp COMpLETE OTHER SIDE OF FORM**"** ,\ -� .. �� -t � ADMINISTRATION � �� ...,�;,• . . � . . {; ..'. � � � � ��t:«.� �rn! #n�` -?'� � ' Llnder 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 Insutance. THE ATTACHED STATE WOR,KER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED , f Town of Yarmouth ta�ces and liens must be p ' prior to renewal or issuance�f your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUF�.ItESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DEG�MBER 31,2000. SEASONAL ESTABLISHMENTS ARE T4 CONTACT THE HEALTH DEPARTMENT FOR IlVSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL �t PfJOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE B�JARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION�i�;I�,F.� TA IONS POOLS - — POOL OPENIlVG:All swimming,wading and whirlpools which have been closed for the season h�uwt be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard platc-�couFai by a State certified lab,grior taopening;�quarEerly�ereafter.- __ __ ---,-- - - -- _ - - POOL CLOSINC: Every outdoor in ground swimming pool must be drained or covered within sel•en(7)days of � closing. FOOD SERVICE NEW STATFa�,�NiT RY COD ,�QR FO,QD F,�TARi.iSHMF,N C� T6e effectwe date for food protection mansger certificallon is October 1, 2001. As stated in 105 CP�� 590.003(A�2), food establishments must have at least one person-in-charge who is a certified food�rotectai�n manager. Ttus provision is effective one yeaz from the.date of promulgation of 105 CMR 590.000. The effective date for can$umer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consutner advisory,Food Code 3-603.11,will be imp lemented January 1;2001. Only establishn�ents which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer adviso*'¢es. CATI' • Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Depar��ent by filing the required Temporary Fovd Service Application form 72 hows prior to the catered event. T�ses forms can be obtained at the Health Department. F�S�N 1�E��T� Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be �.��nt to the Health Department. Fail�re to do so will result in the suspension or revocation of your Frozen Desser``Permit until the • above terms have been met. 0�,1TSjDF,,CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the`Zoard of�ealth. OUTDO��Q.Q =: _ Outdoor cvoking,preparation,or display of any f uct by a retail or food service establishment is prohibited. DATE: O � SIGNATURE: PRINT NAME&TITL 11/16/00 i _. . , .� � ,,x. , . ., » _ __ . _ _ � _ _ �.:_ _ _ _.___s _ - ------ � � t m�� The Commonwealth of Massachitsetts _ � Depa�tme�t ojlndtutriol.-�ccidents - ; �1!lce�l�ir�st/ostJliiis � � 600 Wvshington Street , �,= Boston,Mass OZI11 � " Workers' Compensation tasurance Affjdavit I A��licant information: PlessePRIRTTe�h'i�tc � �.�\ .,,a.�, �;\l ��e `��c. � .� S� e� � �OwVL.W�O� �V2.""� ohone M��v�-�O"C�� Q 1 am a homeow•ner pertarmin�atf worlc m}�seif. � i am a sole proprietor�r.,� hatie no one�t�orkin� in any capacin �1 am an employer proti idins worl:ers' compensation for my�employees working on this job. a V3,:W�.,� � � R�`�c �✓1R,�... ' r c • � C7��vl �� • � 10.C� �rz,�- $-36�--c�- Z?� , anc l `/ � � I am a sole proprietor. _tneral contrac ,ot homeowner(circle onel and fia�•e hired tht contractors listed belov►� «ho ha.e thz follo�cin` ��orkzr_� .ompensation polices: ;.emaanv n�me• �ddress• _ � �y• " nl�one 11• insur�nce co ,policv# =omRanv namr - 't_ �� -- ,_ �,. n6oee th - insnraqce�u �fie�►f! failure to secun coren�e u nqsind uader Seedoa 2SA ot MCL tS2 n�ita��s t�t iap�lie�of ai�i�eaUtld�i A�e�P to Si.S00A0 aad/or oae ynrs'ia�prisonmeat a�wz11 a�eivil penaltits ie the form of a STOP WORK ORDER a�d a!ht of tt0�.A0�dty Kare�t sc t��sta�d tfat a copy of tatemeet m�y be for.varded to tbe Otfice of tavestiptioa�of tse DU tor eoverqe veriAndN. /do�hrr errij�uade lhe poins � aitia ojpery'vry that ths injorn�atloe provided abort Is bnt awd conrct Signature Print name •�� VG�� O��R...�. one�E.Z�Sd .�_ r� O - oRci�t use ool.- do not w rite in this arrs to be compieted by citv�town oAkiai citv or to�.o. Y�� _ • permitAitease p , nBuildiag Departmeo� �Lieeasiae Board (]chtek if immediate resQoase ie required 261 QSeleetmea'a Ofiiee �Heatth Oepartmeat contact penon: pbo�p;_ �508� 398-�2231 ext. nOther lrt�nea;��P1A1 � _ 1 ' �1!?7/OZ 9�D4 AM From� MARK SYLVIA AGEN�Y p• 2 cf 2 � G� (� Car� nt�rr� ►� ; ` ACO�RD., CERTiFICATE tJF LIABiLITY INSU A °;?rz'�°�oo; : rnooucen 508 428-0A40 THI$ CERTIFI T TE QF INFOR1IIAtION ! AAARK SYLVifl AGENrY ONLY AND C E eERT9FICATE � i70R MAI�'STREET MOLdER. THIS CERTiFICATB OtsES Ht}T AMEND, EXTENQ OR ALTER TNE GOYERAGE AFFt)RQED BY THE POL.ICiES BELOW, OSTERVI�LE, MA Q265`•'r � iNSURER�AFFQRDING COVERAdE � � I iNsu�o �� w q. * uWsuReA n.. FARM1A FAM��LY CASUF�L7Y INBURA.N:E GQMPH.IVY ' ��,•��:� � INSVREP& � �i DSA YARMOUTMPOFiT �� STnRF 33Q MAtN STREET F�TF 6A ihsuHrx c YARMOUTHPORT.MA 026�5 �NsureEa o I iNSUR�R E - � �, cavE�nces ' THE FOLICIE5 OF�N5URANGE LiSTED BFL0�1U HAVE BEEN�5SUED TO THE INSUREC NAMEQ ABOVE FOR THE POLIGY PERIOU INCiICP.TEO.N�7.NITHS7ANOING ' AN'P REQUlREM£MT, TERM OR GONDIT'ION 0=RM7 GONTRAGT pR OTHER DOCUMENT WITH RESPEG7 TO WHIGH'iH15 CERTIFiCA7E MAr BE ISSiiE� OR MAv pERTAIN,THE lNSURANCE RF�OROED BY TFfE POLICIES OES�RIBED HEREIN IS SUBJECT TO ALL TNE TERM$,EXClU510NS Ak0�C(3N41T ONS UF SL7i.H � �I. PGLICiES AGGREGATE L�MIT3 BHpWN MAY HAVE BEEN REDUCED BY PAI�ClAIMS. � �N� TYPi OF INiYRANGE POL�C(NUYtE1l � POL{CY CTIYE POUCY EI[PlRA ii 4MITE . BENERAL LIABILIT! E�4CH OCCURRENGE , COMMER:I3._i=AFR:,! .IAB�t!TY F17E UAM0.G°fany me f�a, _ C.LA:iM£MAJE 4G�� MEC EK��,Aiy cne cersa�i� 5 � PCRSONAL 6 AJV IN„IlRY : � � � • GENERA�AGut7EGATc S � 6EN L�lGRE3ATE LIMI�APPL E3 PCR PPODUCTS�COMP�'UP 4GG 5 P6LCY PRO- La` 4uTf]MOBiL!Li481L1TY CENARItiE(7 SINCIE LIGI' .�NY.lJTO . � IEaacqtlen:i E �IA�'A'NEDAU"US tlOUILYIN.I�RY 3 SC•�E7ULE7+.UTC5 fPi�perpou� . HIRE:�V'OS� B6DILV INJURY � NON.O'd�NE�a11TCS (Pe•acL:tlenq 5 i . 1 PROPER7YpAM'.n:;C y j �PA�i(,(j7p�11 I . QARAO!1IA01Ll'fY � 4t1TOOtil��EH AI::":t+FN' S r. . :NYAJTO . p'Tr1CR7H4N Fa�+C.: S AJ�O DY.Y aou s EIICESS LIABiUTY raCN CGCUkRFr�:^ > I Q;,CUP CLfIMSM�DE A3GREGaTE � D�U'��CTIBLE � � R='EV51'JR S 'a�'.,5 A l- _ n . A YiIDRKERSCOMPEd3AYlONNND 7GQY IIMITS ea �pr�b��i��un TO BE ISSUED 10-18-61 70-18-02 . E.4 EkCHACCiOEaT 5 'I(�{},(�{�Q t�D 5EaSE�E�E�uP�O+EE S �4[?QDO cLO15EASE-PCItGI'L�IAf s � 50C.GOC GYXlR ' DiSCRIPTfON OF OPERATIOMilLOCAliONSNEH!CIESIEI[CWSIONS A�OEO YY ENDORCGNGNTIiPiC1AL AROV�IOMS STQRE ' ( +i i GERTIfICATEHOLDER aeariow��Nsu�ea;imsuRePc�ene�- CANCELLATIQN BHOUI�AMY OF THE ABOYE DESCRINEO P4LICIE5 BE.CANCELLE[}BEFQI4�TNE FXPIqAT!OH roUVN oF Yfi�nnou rH OATE THEREOF,TXE 4$$UIN6 INSURER WILI EHOEAVOR TO MAIL____DAYS WPITTFN I LICENS!NG AND P�RMITS IiOTCE T6 THE CERTK�CaTE NO�OER NAYIEO TO iHE IEFT,BU4 FAILUNE 70 00 SO SMALL �Z� RTE ZB IMPOS!N4 08LIGATI�QN 4R LIABILIT7 OF ANY KIND UPON TM&INSURER.175 AG@NT5 QR 50UTH Yf#RMOUTH MP, 0266� A£PRES NTATWES. aUTNQ REPqESE TWE ACORD 25•8(T147� C�ACaRD CORPORATION 7988 ; TO�VN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIVIENT PERMIT NUMBER: #02-060 FEE: $'75.00 In accordance with regulatiansprom under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General�,a permit is he�reby granted to: � SLllivan Village Store,330 Main Sfi�eet/Rnute 6A, Yarmouth�,MA Whose place of business is: Yarmouth rt Vil �e Store Type of business: Retail Food Service less t6an 25.0(�sauare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31,2002 BOARD oF HEALTH: ekwdea s� zd�lt�a. �adr«�oa�c �,a�cja�c D. C�'mrda�c. 71��.. �/lee �o6ert� �ro�c, el,erk �� e+laic S�uE. ��l. June 27 .2002 ruce G.Murp y, .5.,CHO THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-046 FEE: $20.00 This is to Certify that Sulllivan Village Store d/b/a Yarmouth rt Vi e Store 330 Mai.n Street/Route 6A.Yarmouthnort,MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTTON OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted'm conformity with Article VI of the Sanitary Code of T7ie Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revok�l. June 27 ,2002 BOARD OF HEALTH: �a�led� Zd�rez. �a�urara�c �i�v��. G�mrdoa. '1��.. ?/fce ,�o�jl ��taawr, �la� �a�rte�7A�oc«ra�A.' ka� .?t. Director of Healtli � _ :�. � -� �= � � y�a��a,�T ��s�� r: . �:�. / TOWN OF YARMOUTH BOARD j � �4��,�' TH �p (�—�p'�+ � � '��.'y l�9 L5 � V Lr': 'v/ APP L IC A T I O N F O R L I C E N S '2 0 0 1 DEC � 5 ZOOO ' ,P�. . * Please complete form and attach all necessary documen � `� � ber 31, 2000. Fai ur��i�o��ll�sul'in the return of your application packet. ` ------------------------------------------------- ----------------�- -------- -----------------------s„4� ,3 6 a^�---- 0 .T d � ' f ��6 . r POOT.CER'TIFICATIONS: The poal supervisor must be certified as a Paol Operator, as rec�uired by new State law. Please list the designated Pool Opera.tor(s)and attach a copy of the certification to tlus form. 1. 2. Pool opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commuruty Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. The Health Department will not use past year9' records. You must provide new copies and maintain a fde at your place of bu$iness. L 2. 3. 4. HEIMLICH CERTIFI�ATIONS: 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. L 2. 3. 4. RESTAURANT SEATTNG: TOTAL# NON-SM4KING SEATS: TOTAL# _.:_-- - ---- ----- - ------ ------ ----- - -- - --------------- - _—__— _ _ _ _ _ _ -- --- _ _ -- — _ _ _ --- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# B&B $50 CABIN $50 INN $SO CAMP $50 LODGE $50 TRAILER PARK $SO MOTEL $50 SWIMMING POOL $SOea. VVHIRLPOOL $25ea. ��RY�CE: � '� NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for � food protection manager certification is October 1,ZOtll. � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j . � 0-100 SEATS $75 CONTINENTAI., $30 � >100 SEATS $150 NON-PROFIT $25 - ,COMMON VICT. $50 _WHOLESALE $75 ! I3�TAIL,S �RVICE• � i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# E ; � _<50 sq.ft. $45 / TOBACCO $20 �Q/-OZ?, i ; � �'15;Q00 sq.ft. $75 �"o I- 02(� FROZEN DESSERT $35 ��>25,000 sq.ft. $200 'F � N�ME CHANGE: $10 , � AMOUNT DUE _ $ 9S 00 � ; '�****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***''* � i f R � ,� - -,�.�. ,��,.:, �.� ------�— _______. _ _ �- $ � ! _ �� "�"` �_` ' ADMINISTRATION � �`�` ". . � • � Under�l�a,pter 152, Sectic�n 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any licens� �r L4_i .'t �o operate a business if a person or company does not have a Certificate of Worker's Ca��s �a�'i�µ-�su�i� THE ATTACHED STATE VVORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED � / W�RKER'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 i/ NO , I NOTICE:Pernuts 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�ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS � � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)da.ys of closing. FOOD SERVICE NFw S'�ATE S�NITARY 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. T�us provision is effective one year from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As sta.ted in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be unplemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories. � � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the � required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. FROZF.N DESS •RTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTS �� I Outside c es(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. DATE: �d �3 SIGNATURE: �((��'r-� PRINT NAME&TITLE: S�,B�Z,�- ,�L L�/k'� %�<�/o� 11/16/00 _:, � � � �� J �. --� � � � The Commonwealth ojMassachusetts � W Department ojlndustrial rlccidents � a �IflceoJl�asd�s�lliis � � 600 Washington Street , �,.-` Bnston,Mass. 0211I " W'orkers' Compensation lnsurance Affidavit n. .: �� )'r- OV' Q 'on: � D �� Y`�t4��D��lT\ � � ��7 !/a �� phone# �C� .3�o�c3�� I am a homeowner pertorming all work myself. � I am a sole proprieror�� ha�e no one��orkin� in am•capaciry _ (�I am an employer pro�idino workers' comp:ensation for my employees working on this job. com��n.k name• _��^ T� 330 Mairr Street (Route 6A) dr ss ; , �Dts 3b ��17 insu ance c . l J � � � C� �� "� � I am a sole proprietor. oeneral contractor,or homeowner(circle one) and ha�•e hired the contractors listed below• ��ho ha�e the follu��in��orker� �ompensation polices: n adress• - citw phone#• i�sur�ncc co �olicy# _ i4iRt3.29.}'^'m�' -- address• — ciri• Fhone#• insuran�co R�Y� Failure ro secure coverage as required unde�Secdoo 25A of MGL 152 ta�lad to t6e i�poridon otuisi�al pe�altla of a B�e op to Sl*500.00 a�d/or I� oae yean'imprisonment u weU as civil penaide�io the form of a STOP WORK ORDER asd a fioe otS100.06 a day apiest sa I a�dersu�d t6st a i copy of thi�statement mav be forwarded to the Ottiee of lavestigation�of tht DU for eovera=t veriAutio�. � /do•hrreby e ijj�unde��he pains and penalties ojperjury tha�the injormotion providtd abovt is tnte and o Signaturc � � , Print name �+�rtl��,�k'�� Phone�t � � �� '�� I ., o(Ticial use onh• do not M rite in this'rea to be completed by eiry or town otiicial II� city or town• Y�� _ permit/lieease p nBuilding Department �Licensing Boud I 0 check if immediate response i�requi�ed 261 ❑Sdectmen'�Ofliee �Hcalt6 Departmeat contact person: phone#;_ �508} 398�2231 ezt. nOther Irevned 3;95 PJA1 `` THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #O 1-023 FEE: $20.00 This is to Certify that Yarmouthnort Vill�e Store Inc 330 Main Street/Route 6A Yarmouthnort.NLA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBIJTION OF TOBACCO PRODUGTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 3 l.2001 unless sooner suspended or revoked. ' February 13 ,2001 BOARD OF HEALTH: �� Ctled, �t�Z6t�� elra�r�d r�. i�e1!�I�CZ. ?/l�;e L�r�a�c i��e�r��. �to�o�, �� 71�i�1 d'L'a��yr�c , � , , Director of H ae lth � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #Ol-026 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: Yarmouth=�rt Vilia,�e Store Inc_, 330 Main Street/R_oLte 6A_ YarmoLth=or�MA Whose place of business is: Yarmouthnort Village Store Inc. Type of business: Retail Food Service less than 25.000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d� �e�, ��u��ra.c ��'anlea�. �a�. ?/use L�a�vu,ra.� �'o�e�rt� i'nouac, L� ��u'kaee � �.L� e.�' D. . 7'1l.D. Februarv 13 .2001 Bruce G.Murphy, H, . .,CHO Director of Health ,��,,- � �._. .,�'�, 4` t .- � � � � - TOWN OF YARMOUTH BUARD O��EALTH ,� � � APPLICATION FOR LICEN� -� I'�,';��000�� D 9 ?�'�`� ti � �+ ° � �� HE LTH DEPT. *�Please complete form and attach all necessary documents by De�-c�mber 31, 1999. Fail esu in the return of your application packet. -----------�E-------------------------�?�rYL�---:il �- --- -,�-- - � ��.._ ------�- - -----#---�al�-�-___. • 11 L T D ►� � � - 7 �L �'T" P ✓ t/ � ,�s� MANAGER,S NAME: � c�� L,f��YZ � TEL # 3 6�-�3�A�r7 1�AI�.1NG ADDRESS: � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designatEd Poal �Pe�a�tcn�s)and �ach a copy vf the c�rtifi��ti6fr�o thr�'fo�m." -__ - _ -_ - __ 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certiflcations to this form. lfie Health Department will not use p�st years' records. You must provide new copies and maintain �fde at your place of business. i. z. 3, 4. HE1M.I,ICH CERTIFICATI 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 a.11 times. Please list your employees trained in anti-choking procedures below and attach copies af employee certifications to this farm. T6e 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. _ - -RESTAIJitANT SEATINCs:--�'QT�,-#�--- ----��N'-S�QI�I��'S:_'�OTA��— __�_ _ _ _ _. _ ------____�_��----------------------------------- -----------�--- ------------------------------_____--- ------__---_ OFFICE U,,�E LY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CANIl' $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SVVIlVIlVIING POOL $SOea. I WI-�tL,POOL $25ea. II FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $�5 CONTTNENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 i RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sc�.ft. $45 C/I'OBACCO $20 K.'Zg ' _<25,000 sq.ft. $75 -33 FRO?EN DESSERT $35 ' >25,000 sq.ft. $200 _ NAME CHANGE: $10 � i AMO�TNT DUE = $ �S � � •"'""PLEASE TURN OVER AND COMPLI�TE OTHER SIDE OF FORM"""" i � � . _ �_.�---�._.�.._��... r , f „ � . , ADMINISTRATION = � IIt CHAPT�R 15 ,SECTION 25C, SUBSECTION 6, 'THE TQWN OF YARMOUTH IS NOW REQUII�ETJ► O,�,D�S µ }C OR RENEWAL OF ANY LICENS� C1R PERNIIT TO OPERATE A BUSINESS IF A P ��``8� � ' D4E5 NOT HAVE A CERTIFICATE OF WORKER'S COMPEATSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURAATCE AFF`Y:DAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ; �' _ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED_�/ TOWN OF YARMOUTH TAXES AND LIEN5 MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK APP RIATELY 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, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH D�FARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENTNG FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR PUOL (i.e., PAINTING, NEW EQUIPN�NT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEM�NT. RENOVATIONS Mt�.Y REQUIltE A SITE PLAN. ADDITIONAL REGUL TIONS POOLS POOL OPENING: ALL SVVIlVIlVIlNG, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND THE WATER TESTED FOR _ PSEUDQMONAS,TOTAL�'��'�,IRM AND STANDARD PLATE CQUNT B.Y A STA'T'F f'FRTIF�I.AB, PRIOR TO OFENII�tG, AND QUARTERLY THEREAFTER. � POOL CLUSING: EVERY OUTi)OOR iN GROUND SVV]INIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NOTIFY TI�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED 'TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR T� TI-� CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI-� HEALTH DEPAR.TMENT. FRO�N�ESSERTS: FROZEN DESSERTS MUST BE TESTED 4N A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST � RESULTS MUST BE SENT TO TI-�HEALTH DEPART1v1ENT. FAILURE TO DO SO WII.,L RESULT IN THE SUSPENSIDN ORREVOCATION OF YOURFROZENDE5SERT PERMIT UNTII,THE ABOVE TERMS HAVE — �. ` -- -- - --- -- --- --- - _ _ _`_________�__.�- -- -- - QLTTS�LCAFES. � � OiJTSIDE CAFES(i.e., �UTDOOR SEATING WITH VVAITER/WAITRESS SERVICE), �.'�HAVE PRIOR i APPROVAL FROM TI�BOARD OF HEALTH. , G �UTDOQR COOKING: OUTDOOR COOKING,PREPARATION, OR DI5PLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLIS�IlvIENT IS•PRUHIBITED. DATE: /� SIGNA'TURE: PRINT NAME& TITLE: �es�.�� 11/12/99 J �� !� � The Conrmonwealth of MassQchusetts � �' � � Department ojlndustrial.-lccidents " ; 011IC00/%S�l�sd11/t ' + 600 Washington Street ' ,,•` Boston, Mass. 02111 ' ~ �� W'orkers' Compensation Insurance Atfidavit �-,�— n m•: J ✓ L�cati�_ 3 V �1 '�-I� ��" �� 1��1V 1 T7 1'� � I .� �- (�a b��✓ �hone q )/�O �6.� 'c�� ( am a homeow�ner pert�rmin,all w�ork myself. � I am a sole proprieror�:-,a, ha�e no one ��orkins in am•capaciry __ � I am an em lo�er ro�i��n� w�ori.ers com ensation fgr_mv emni ��ees_��Q�. ' � — r__ :P �P__�_-_�-�:-_�_-�— -� -- - --� r�s-3°b-=,- µ - ___--- --- _ m n • n T d i! V � / �✓� �jt.L, address: �� M �9- � 1'l) S'f' T �JQ/�'" . SD� _ i u ra n c //1 G! � '. �,v t' I �!� �� I am a soie proprietor. generai contractor, or homeowner(ci�cle oneJ and ha�•e hired the contractors listed below �tiho ha�e the follo��in_ �.orl:zr_� �ompensation polices: s9mdanv name• address• [tn'• nhone A!• insur�ncc co. ooli v!! comnanv name: iddress�_ tiri: oh�ee M• insurance co. ��r� Failure to sccure coveraee as required uoder Secaon 2SA of MGL 1S2 w iad to t6e i�paitio�oterisi�al pe�dtla o[a tf�e op to 51,500.00 a�d/or oae years'imprisonment a�w•ell a�civil penaltlei io t6e form of a STOP WORK ORDER a�d a Aae otS100.00 a day apis�t ma i��dersla�d t�at a ' copy of thh statement mav be fonvarded to tfie OI'(iee of Invati�adon�of t6e DtA tor eovera=e verifiado�. ' 1 do hrreby cerri j•unde he pains and penaUi�s of perjury thet�he injornration provedrd abovt rs true and cone 'I Signature �1� �ot �� i, Print name ��(Z.i� �" `l�'! _ /�� Phone l! 5�� 3 6 a �Lh� � I .. ofTicial use only do not write in this area to be completed by eitq or towa otlftial ; ciry or town: YA��IIT� _ permitAieense a nBuildiog Departmeot pLieeasiog Board �check if immediate respoese i�required 261 �Stiectmen'�Otiice pHealtb Depanment f __ r coniict� erson: _- � � � . � �� ,�-=-�5 � ,_398s2231 eat. P �Pfiionc _ __ _ nOthef--- -- - --_ i ... ��,�: � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-33 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 i,Section 5 of the General Laws,a permit is hereby granted to: Yarm�Lth o Vill ge St�re Inc_,3�0 Main Street, Yarm�Lth=or, MA Whose place of business is: Yarmouthnort Villa�e Store Inc. Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:��/. ,�ett�, C'�t.,�� oan G. �uG�ivan, /'C.//., �dce ��irm,a �o�ert,}. �rown, �ler� � abrie[��ako(.��-.J�toope! 'i/ici�a�d DoCo �lin � December 27 , 19�Q ruce G.Murphy,MP .S. HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-25 FEE: $20.00 This is to Certify that YarmouthDort Villa�e Stnre Tnc_ . _ 330 Main Street Yarmou l�rg�,MA IS HEREBY GRANTED A LICENSE For _ SALE AND DIS iRi TTi(�N OF TOBA (�PR c�T�i 1("T4 � _ � AS PER THE Y�RMO 7TH BO R OF HE i TH TOBA .�n RF.C'Ti1T,ATT(1N, This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and � expires Dec�mber 31.2000 unless s�ner suspended or revoked. December 27 , 19 9� BOARD OF HEALTH: Gd � .tel�, C�airman �oare� �u[[ivaa., K.�/•, Vics C,�irman ' Ko�art,.t. /�i+vwn, C.lark �a6,�1�sa��,�y��P6� �l0' o � D�tor of H�ealtt�i - y��v��a�. � � �x TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT ��,�,��'�� L� C� C� C � M (�S DD . . . ..-.. � afp � '9 �#,- , � C' � e r� * Please complete form and attach all necessary documents by D�c�hbe��1 z 1��. �Fail e t o�o so v$vill��$lt ' , , ; , the return of your application packet. HEALTH DEPT, ---------------------�---------- ----- - -------�ll T --o------ -- --------- ------- -----------------#---�---------� A I D S� � � T- Ud6`7 v� � � R� # 3�a - ► s --- - --- ------ ------- POOL CERTIFICATIONS: The pool supervisor must be cert�ed as a Pool Operator, as re�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. l. . 2. : Pool operators must list a minimum of twoemployees currently certified in basic water safety, standard First A.id and Commuruty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICA I'� ONS: 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. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# _ _ _ _-_ _ —_ - _ _ i - -- _— - LODGING: �I i LICENSE REQUIRED FEE PERMIT'# LICENSE REQUIltED FEE PERNIIT# B&B $50 CABIN $SO _INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 � — — i MOTEL $50 _SVi�IlVIlVIIlVG PDOL $SOea. j � WHIRLPOOL $25ea. FOQD SERVICE: — LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# _0-100 SEATS $75 CONTINENTAL $30 _>100 SEATS $150 N(�N-PROFIT $25 _ -- � _CONIMON VICT. $50 WHOLESALE $75 RETAIL SE�VICF. LICENSE REQUIRED FEE �ERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 � TOBACCO $20 �'� �<25,000 sq.ft. $75 •ZZ FROZENDESSERT $25 _>25,000 sq.ft. $200 �TAME CSA�1� $10 AMOUNT DUE _ $G�jr' *"•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•" �' _." � ..__.. � _ ._. _�_., ADMINISTRATION F VNDER CHt�PTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOLJTH IS NOW REQLTIl�ED TO HOLD ISSUANC� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PER�SflN QR CQMP�ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE: "THE ATTACHED STA'�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARNiOUTH TAXES ANl IEN5 MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK ROPRIATELY IF PAID: YES NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURlv TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�NTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE 5EASON. ALL RENUVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMIV�ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. AT�DITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR 'THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTIV�NT,AND TI�WATER TESTED FOR PSEiJDOMONUS,TO`�AL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENTNG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVV:LMMIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE C'ATEI�rrvr POI,IL CY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII,ING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. �O�FN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERNIIT UNTIL TI�AB�VE 1'ERMS__ ._ --- HAVE BEEN MET. OLTTS�E CA_F�S: OLJTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITERlWAITRESS SERVICE),MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. I OLTTT�OOR GOOKI�IG: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLIS��VVIEENT IS PROHIBTTED. r DATE: cl,\ �_SIGNATURE: I J�i PRINT NAME& TITLE: ��►„��n�Y-� "� ��.�A\IQ� '1 f D.e�..C�✓� ' ' '''"�' � The Comnroawealth of MassQchusetts � W Department ojlndustrial,-lccidents r � = _ o Ol/Icsol/erssU�►snNis � 600 Washington S�reet •''` Boston, Mass 02111 �% M v• W'orkers' Compensation Insurance Affidavit m�� ✓ ��;�": �`�(� Yl/1� 1 ri l � �it� \I I'�IU V 1 D U�t 1 1'D� / � ► 1T Do1b7� phone a ..S�O 3�p� �C77� � I am a homeow�ner pertorming all w�ork myseif. � I am a sole proprietor�-;� hace no one��orking in am•capacin� �I am an employer pro�idin�workers' compensation for my empioyees working on this job. _ - -- __. _ comoan�• name� �..�1v»iJ7-�-P�►� 1!, ��,` ��f�, _ _ __ address: 7�� 1M .�� nl � �itv: �/ f��m �1� T`F-��t/�' 1�l f7 nhone tt .S-o �r 3 6 a�r�l� in ranc o. lil /I'l � # b3 � I am a sole proprietor. general contracto .or homeowner(circle onel and ha�•e hired the contractors listed below� �cho ha�e the follu��in� �corker' ,ompensation polices: comnanv name• address: � S�tY� �hone R iosurance co. polic••# cotnoanv name• j � tiri: llI14�E� iesurance co. ��y� k Failure to secure coverage as�equired under Secdoo 25A of MGL 1S2 e��lad to tYe ioporiCioa of erisi�a)pe�dtlp of a A�e op to SI,S00.00 a�d/or oae yean'impriwnment a�w�ell aa civil penaltia io tbe torm of�STOP WORK ORDER aad a liee of 5100.00 a day apiott se. [e�dersta�d t�at t e copy of thy statement may be for.varded to the OtTice of Inveuie�tion�of t6e DU tor eoven=e veritieado�. /do hrreby cer�if}�unde�the pains and penalties ojperjary thot the rnjornmtioa providtd obovt is trtre and eo et , Signaturc � Print name _ ��Pr1'�1 pi(L�4- �-�(��} � /�� Phone il __.�U�l 35,� — �� .. otTicial use onl�• do not w rite in this ara to be completed by ciN or town of}ieial city or town: Y�M�DT� _ permit/lieenu k nBuildiog Department pLiceesiog Board 0 ehtek if immediate respoose is required OStlectmtn'e ORiee 261 �Hnith Departmeot contact person: phone p;_ �508} 398-�2231 egt. nOtAer (recisM i,v5 P1A1 _ _ ___ _ _. _ " s TOWN OF YARMOUTH , BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-22 FEE: 575.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Seetion 5 of the General Laws,a permit is hereby granted to: Y rmo � h=ort Villa�e 4 nrP Tnr,� ��n Main CtrPPt� Yatmo� h��, ll�s � Whose place of business is: Ya.rmouth ort V'1 e Store Inc Type of business: Retail Food Service less than 25,00�,0 .�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31,1999 BOARD OF HEALTH:�d�/. �at��, �'��»,an �oaa� Jullivah,��(•, Vice C,�irmaa /�o�ert�}. /�rowit� (�fer� a�vie��al�of��ooPe� /�/ic�e6 ooCo �fsii � Januarv 19 . 19 99 ruce G.Murphy,MPH,R .,C Director of Health THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH � BOARD OF HEALTH � I PERMIT NIJMBER: 99-19 FEE: $20.00 This is to Cerafy that Yarmouth�ort V'�lla�e Store Inc. 330 Main Street, Yarmouth�,MA IS HEREBY GRANTED A LICENSE i For SALE AND DI5TRIBLJTION OF TOBACCO PRODUCTS ' ' AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. ; I � This permit is granted in conformity with Article VI of tl�Sanitary Code ofThe Commonwealth of Massachusetts,and 1 eacpues December 31. 1999 unless sooner s�uspended or revoked. ! Janusty 19 , 19 9� BOARD OF HEALTH: Gc�///. ..tof�ee� ��ai-rmun i . � �in G. �u6[ivan,K.//-� Vice C.�ia�man Kobo�t.}.6,rouin� l,fsrh �adried[e�a�Zo[ek�ooPee �' �0 oG lin DilCCLOf Of�1�1 � �