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Home My WebLink AboutApplications, WC and Licenses . r. . , ,� . . . � TOWN OF YARMOUTH BOARD OF HEALTH [�C�(� d�p � � APPLICATION FOR LICENSE/PE ' � A P ,� . R2 . 2009 �• *Please complete form and attach all necess * � �� s � 24Q8 Failure to do so will result in the r � f y ca.rion p c . EPT. NAME OF FSTABLISHMENT: �q�-�.,o�}t, ,yoY �-1, �t�3,k �► Asso c . TEL. # So$ •3c�-� 3.0 3 LOCATIONADDRESS: /�o Dl d w+a,'� S-f. S. �/G.. .,.ov a-�, , r, A 2>�66 L/ MAILIi�'G ADDRESS: �,�. 13vx 8 'f t 5 � �a.-.•. o v-t��. OWNER NAME: ?'a w., o� yd�-� o�+�. TAX ID lFEIN or SSNI: CORFORATION NAME (IF APPLICABLE}: MANAGER'S NAME: Roo►^� e-�. ' �oe � TEL. # So Q,-3 G 7-•�3 C 3 MAILING ADDRESS: �,..� ' POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated ' Pool Operator(s) and attach a copy of the certification to this form, 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies afemployee � certificatians to this form. The Health Department will not use past years' records. You must provide new i copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments axe required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chaxge (PIC) on site during hours of operation. 1. � �oon� v �e+-•'n .i 2. �t�C �'¢ r-..e. �/ 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 a11 tunes. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' reeords. You must provide new eopies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LUDGIt�IG: LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B �55 CABIN $55 MOTEL �55 INN �5� CAMP $55 SV�IMMING POOL �80ea. LODGE S55 TRAII.,ER PARK �105 WHIRLPOOL $80ea. FOOD SERVICE: LIGENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# _0-100 SEATS S85 _CONTINENTAL $35 �NON-PROFIT $30 1��-�=��3 >100 SEATS �160 COMIvION VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# _<�0sq.i�. �50 _>25,000sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. �80 ,�FROZEN DESSERT $4Q _TOBACCO ��5 �iA�7E CHANGE: �io AMOUNT DUE = S ""***PLEASE TURN OVER Ai�D CO'VIPLETE O'THER SIDE OF FORM'��***' a„ r ? ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Cert�cate of Worker's Compensation Insurance. THE ATTACHED STATE WOItKER'S COMPENSATION�-�NSURANCE AFFIDAVIT MUST BE COMPLETED A�TD SIGNED,OR CERT. OF INSURANCE ATTACHED OR ; WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �'� Town of Yannouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK II APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISffiV�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days pnor to opemng.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate coum by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. - FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by f�ling the required Temporary Food Service Application form 72 hours prior to the catered everrt. These forms can be obta.ined 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T"HE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: '�)/6 �05 SIGNAT --T PRINT NAME&TITLE: SoS��l, �►�t�.-e-,� . �r-e S.'�t�.--� ioi2iros _ � , . '� , , � � � I �'he Commonwealth of Massachusetts Depart�nent of Industrial Accidents > l�Cl�r�s� 600 Washington Street, 7`h Floor Boston,Mass. 02111 Workers'Compe�►sation I�saragce Affidavrt:Baitdiog/i'lambi�gtLkcttical Co�tractors �� P�a�e PRINT leeibl► � name• yQY'•-�o v-1-1. �o✓�/'� '�ca Se L�a 11 AS S o c i t� -�'i a� address• /', O . �e�7lf Ab'Sr) �i�•�Ya.-,.�o��-�-, srate- 1"�A ziQ•O?6 6 � ohone# S�g '3 9'�� 1 �d� � wrork site location(full addresst: I�b O 1 d �a T., s-}. s= YA�`�c,v�'l� � ❑ I am a homeowner performing all wark myself. Project Type: ❑New Constructi�QRemodel , ❑ I am a sole proprietor and have no one working in any capacity. Q Building Addition � , ❑ I am an employer�oviding workers'compensation fos my�ployees wodcing�this job. , �� compaev�une: f -- � address: citv- ��• ias ca # ' .;,. . •:. -,. ' .... � .�;.: . ."�.; .r ,x:..:. .. .:; �r.',, -.... .�'o_;.'. - >t.F#: ..�, .,.:`..� ..i',..:.,,,, a f< ";3 d`.r��.93..z�'.2�'£t'F�,.�G b:.,:.>. ❑ I am a sole praprieEor,ge�eral coitracter,or Iw�eaww�(circ%one)and have hired the c��ractass listed below wha have the following workers'compensation polices: so��v gamme: . addresa:. i : i dtv nhate i�. . ies ce. # _ �. - �-�:; . ��;: <..�� ..�:` �Y�ue: , a_d�ess: c�iv: pioie#- , , _ � _ � k _.., . .. . . . .. . .�S ,g..,...� a �q,r`"'^r .�,:: �tr"5.;�s 3�"s�i.,,�o,`.� _ � Fa�re b secm ewera�e as reqaired u�v Sectl��2SA�f MGL 152 eu lad b IYe isp�dtl�a sf ari�al pnallia�f a��p te S1riN�0 a�dhr f oae ynn'Isptbesmmt a�we9 as civi pe�aNia�tre for�•ta STOt WORK ORDEB aed a 8ne stt1A0.M a day��e. 1�td t6at a ! npg�t t6is�tatrme�t mg 6e finvardal 1�t6e Omoe�f IaMdtl�tl�a ot tke DIA tot c�erate vn'�ea�. ; � L ro lrentby ce seder t6e pa�ns swd penddea of perjrmy dYet dYe i�for�raGton prov�ded aboae is bae Rwd cnn�ct ` . ` Date � /6 e�� Ptint name ��S e,�� 'Z—' �`t r� v Plwne# .S o�3 3�'`�''�l /0� �fficial ex onty do nat wiite ie t�s area ta be compkted bY cih'ar�wrt��al . eity or te�: pere�ice�e g �Departmeet � ❑c�eelc if imme�Ee reapsme is reqaired �� 's�ee �� ..�a s�p.mP�m�' P�ox!l; �' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #49-173 FEE: 525.00 In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter 11 l,Section�of the General Laws,a permit is hereby granted to: Yarmouth Youth Baseball Assaciation, 140 Old Main Street, South Yarmouth, MA Whose place of business is: Yarmouth Youth Baseball Snack Bar Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: ��¢tt Sf�Rf�. �..N. C'�lutur�tur�t f�,u��`,p. .��a�y.ea, r11 ice �'hcr.vttrttcrtt SEATING: O w• e. s�►.� rr�; e�� a��l 21,Zaa9 Bruce C�M hy,MP .,CHO Direct�r of Health I I � : I I i , � � s .�0 v�n Vrl+`D� � �J 'Y.k� TOWN OF YARMOUTH BO O ��' a � � �� b [� D A�,. � APPLICATION FOR LICEN ��_r � .+,�N � 3 2008 �. � - * Please complete form a.nd attach all neces�documents by Decemb r��(��7H D Failure to do so will result�n the return of your apphcation pac . EPT. NAME OF ESTABLISHMENT: r� af� �o v�'L� �jGSe.�/� USSUC TEL. # "'"""-- LUCATION ADDRESS: o�.,� ; ,�. �►•� MAILING ADDRESS: oX O� � a rt�v�o u OWNgR NAM�: _ T X ID(FEIN or SSNl• CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ,�oG � t�h�- — f'¢5� �n TEL. # ,�;'p�?Lr( ,�31�?j MAILING ADDRESS: r6- ��.,� _ _ _ r �5.�-� o i/�C>. O 2co S POOL CERTIFICATIQNS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s}and attach a copy of the certification to this forna. 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 eerttfic�tions to this form. T�te Health Depertment will not use past yea�rs' reco�ds. �'o� ��s� provide new copies and maintain a file at your place of business. L 2. 3. 4, FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one 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 applieation. 3'he�Ieal�h Departmen�t witl nat�se p�st years're��rds. You must provide new copies and maintain a file at your establishment. 1. 2. -P��f�1�T_LN��R�; —_._. _ _ --- — — —_ _ ---_�— -- - —_ _ - ------ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. SC�z T c�,. � v 2. 3v/�'e 1.,.�a�..V.� . HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of�mploy�e certificarions to this form. The Health Department will not use past years' records. You must pravide aew copies and maintain a file at your place of 6usiness. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'VIIT# LICENSE REQL1IRED FEE PER'�riI7# LICENSE REQLTIRED FEE PER�IIT� _BBcB S50 _CABiN S50 _MOTEL S50 _INN �5�- _ _CA:'�IP _ . S50 _SWL'�IING POOLS75ea. _ .___ _LUDGE �SQ _1'RRILERPARK S100 VVI-IIRLPOOL S75ea. FOOD SERVICE: LICEI+IS£R£QUIItED FEE PERMIT� LICENS£R£QLTII�D F££ �£R1��IT� LICENSE REQUIR£D FEE PERb11T= _0-100 SEATS �75 _CONTINENTAL S30 �NON-PROFIT S25 0 �IS2{ >100 SEATS S150 _C0:4L'�ION VIC. S50 WHOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII� LICENSE REQUIRED FEE PERWT= LICENSE REQL'IRED FEE PER'�IIT� _<50 sq.ft. �45 >25.000 sq.ft. S200 VENDIIVG-FOOD S20 I _<25,000 sq.ft. �75 _FROZEN DESSERI' S35 TOBACCO S50 ' NA11ZE CHANGE: sio AMOUNT DUE _ $ a5•oo I *****PLEASE TL'R\OVER��D CO�iPLETE OTHER SIDE OF FOR�Z***** ;.. . ., _ _ . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Ce�tificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURA►NCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, QR �ERT. 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 APPR�PRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pwposes 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 m�tel and hotel us�. Transient accupants must have and be able to demonstrate tha.t they maintain a principal plaa,ce ofresidence elsewhene. 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)mQnth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy tha.t is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amendecl, shall generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with tbis app�iccation. POOLS POOL OPENII�TG:All swimming,wading and whirlpools which have been closed for the season must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�S days pnor to apetung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by-�S�a�e certi�ed lab, prior to opening, and quarterly thegeafter. _ _ POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the Health Department. FROZEN DESSERTS: 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 urnil 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. � 4UTDOOR COOKING: __ {��doer-eoQ�prepa�a�ie�or displa�o€�y€ood gFoduct by-�re�ail e��oed s�rvic�es�ablis�;s�ohibited. — f NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN t THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. 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 HEALT�i PRIOR TO COMMENCEME:VT. RE:�iOVATIONS MAY RE UIRE A T PLAN. DATE: � SIGNATURE: PRINT NAME&TITLE: ��- St�'�M�- ��tl��P�— ia;o�n � 'Y � The Comnronwealth of tl�ossactir�.set�s Departwrent of Indrts�nial Accidents �i�ib�i 6� w�a�,•,:�x� �Fr� Bo�,Mas� 42111 ____-- w��cc� • i.��w�� a co.a� nemC- ��G r r-� e9�f'1� y�✓�"� O U S t bo�1� T✓S S�G, address: � D. 13 a�+ �3�I J citv S� �Q r,r..a v�'�. smte: M A� zin� O a b 6'l n�ne# vwork site locati�ffoll addnessk ❑ I ffin a�noownea per�o�ng all wak myself. Projed Type: ❑New C�aron�Remoded I am a sole and have no�e w in an Addition ❑ I am an employer ptoviding waicers'caanpe�tion far my�npioyees working on this job. - .�) � ►/� ) ,.�- S ; . �. . p I an,a sole p�uprie�,aeaaal�trxbsr,or 1�.�...�er(�!e u,.�ana have}�roa 8re�cW�s lisGea be�►who have the following workers'compe�ion Polices: � �� k .. .. . . . . . . . . .. . . il . . . � .. . .... . .. . . .... . ... . .. . . . . :.. . . I I �R. . . . . �III I � . . . . �� lil . ffi FaY�+e a see.n e..era�e a.nq�ed oaer seaia sSA.tAIGI.LSi eu lea a nm h�W..tai�id pe�Me.ra�.e�a�1,sM►M a�dhr i e�e pran'6�pria�at as we/as eM pe�alqa�tre��t a S'POr WORK ORDBA atl a�e�f S1N M=�y�ae. 1 adasaid ti�K a ' aqry�f Hb t�t iq 6e firwmdai M Ne Oml�e�[ImstlptMr��f tlrc D1A�ir�D v�erf�, /�io be�+ebp �ler die�ra�wJpew�ofDa�tllu�t tbt iwfor�esdoA p�vlded oboae la�nre.sa oan+� Si � � �� /pg i name So sc, ��, E. T,•e,.� v �i Phone# �ffieiai ne yly d��wt write!�t�area H be oypl�d by eity ar lrwe� eil7 or trwa: parsiN�oede!k �� i ❑cheer if i��e nspede is req�ind ��B�aed i �'s O�oe �t pvso': �� t��-�) ♦ } TOWN OF YARMOUT�I BOARD O�HEALTH PERNIIT 1'O OPERATE A F�OD ESTABLISHMENT PERMIT NUMBER: #08-154 FEE: $25.00 In accordance with re�ations promulgated under authoriry of Chapter 94;Section 305A and Chapter 111,Section S of the eneral Laws,a germit is hereby grauted to: Yarmouth Youth Baseball Associarion, 134 Old Main Street, South Yarmouth,MA V4�hose place of business is: Yarmouth Youth Baseball Snack Bar Type of business: Food Service To operate a food establishment in: Towu of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: .�¢e¢tl S�, �J2.,.A�., C'R.ucixrttaa C"r��_a�uY_�.e'`a .3�.�'�ee�i#.e��c�`,t,7�ice C'(�awrnzan SEAT'ING: O - �/��•�� -W++L . t�lnri(�'�ceer�,./2..N. 7anuary 28.2008 ruce G.Muiphy, ,x.S.,CHO Director af Health � �'�I i � I i � I ; '` ' _�.�;., .. G3GC> G � Vf� D '2°`;_�f o TOWN OF YARMOUTH BOA ^� � '` APR 2 5 2007 o�_ . "'�� APPLICATION FOR LICENS E G�"' ' ``• �•.. ..••'�� * Please complete form and attach all necessary dacuments by�e.ce HEALTH DEPT. Failure to do so will result in the return of your application packet. � ,___ NAME OF ESTABLISFIlVIENT: �a�r„,.-}�, /o„-� 1, ,13o S�.b,�►l , TEL. # S 0 8 -3 6�-.�36� LOCATION ADDRESS: I 3 '� OC d Yh a�� S� �. Ya��, o�+ ►. MAII,ING ADDRESS: P, a . 3 v� $'� i � OWNER NAME:To,��+ e -F �a r •�.o u+� TEL3�T�T (FEIN or SSl�� CORP�RATION NAME(IE'APPLICABLE): -�.. MANAGER'S NAME: �'o e —T,�t�..� y TEL. # S"o B--3 s� -13 6� MAII.,ING ADDRESS:__P. tS B o�t � �i► 1 S, r-... v-�- � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certificat�on to this form. l. 2. Pool operators must list a minimum of two employees curr ertified in basic water safety,standard First Aid and Community Cazdiopulmonary Resuscitatian{CPR list these employees below and attach copies of employee certifications to this form. T6e Health De ent witl not use past years' records. You must provide new copies and m�intain a file at your of business. 1. z: 3. 4. �...�� FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of eertification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a fde at your est�blishmen� 1. I�e 1(, 'S sw �u v v,'� 2. --- __ _ _ _.-P�R�Il<T CI��E: __ ____ ---- _ -- -- ------ Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation. 1. M e. 11 i'S Sw Gce�. v r r� 2. �i�e. '-7'_".'c �.,� �l �� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholang 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�t your place of business. 'i l. 2. 3. 4. RESTAtT1tANT SEATING: TOTAL# � OFFICE IISE ONLY '� LODGING: I� LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# I B&B �50 `� CABIN S50 MOTEL $50 ' _ _ i INN $50 CAMP $50 SWIlvIlvQAiG POOL$75ea. ' _LODGE $50 _TRAII,ERPAItK $100 _VVHIIZLpppL $75ea. I FOOD SERVICE: LICENSE REQUIItED FEE PERMTf# LICENSE REQUIRF,D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0.100 SEATS $75 _COIVTINENTAL $30 �NON-PROFIT �25 1S�-1S��1 Z3 >100 SEATS �150 COMMON VIC. $50 WHOLESALE S75 RETAIL SERVICE: —RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T<50 sq.R. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT �35 TOBACGO a50 NAME CHANGE: $10 AMOUNT DUE _ $ �� - � •••••PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•••"• � -��-- t� r � .- . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hald issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificafie of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED f OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO� � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limita.tions of Motei or Hote1 use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transiezrt 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 six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. . PO�LS POOL OPENING:All swimming,wading and whirlpools which have been closeci for the season must be ins ected by the Health Department prior to openuig. Contact the Health Department to schedule the inspection 8ve(5�days pnar to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count _ by a State certified lab, prior to opening3 and quart+erly thereafter. _ __ POOL CLOSING:Every outdoor in ground switnming pool Fnust be drained or covered within seven(7}days of closing. FOOD SERVICE CATERING POLICY: Anyone who ca.ters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These farms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seaxing with waiter/waitress service),must have prior approval from the Board of Health. UUTDOOR COUKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pra6ibitecl. NOTICE:Permits run a.nnually from January 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RETURN THE COMPLETED APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. i ALL RENOVATIONS TO ANY �OOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TQ AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENO�ATIONS MAY REQUIRE A SITE PLAN. DATE: '��/��o�1 SIGNA �-'"" � PRINT NAME&TITLE: �a ��i ��Q.�'=5,�_ �r"�5�"��^-� ion�io6 , -. CERTIFICATE OF INSURANCE '�°"'��"""°°"'"' a/o�/o� PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORAAATION ONLY K & K•Insurance Group, Inc. AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1712 Magnavox Way CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE P.O. BOx 2338 COVERAGE AFFORDED BY THE POLICIES BELOW. Fort Wayne, In 46801 COMPANIES AFFORDING COVERAGE INSURED COMPANY A GREAT AMERICAN ASSURANCE COMPANY BABE RUTH LEAGUE, INC. LETTER PO BOX 5000 COMPANY NATIONWIDE LIFE INSURANCE COMPANY 1770 BRUNSWICK PIKE LETTER B TRENTON, NJ 08638 COMPANY C LETTER COVERAGES THIS IS TO CERTIFY THAT TH� POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS,EXCWSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO. ICYEFFECTNE POLICYEXPIRATION ` LTR NPE OF INSURANCE POUCY Nun�sER q� �y�pp�yy� pq� � LIMITS(in thousands) General Liabillty Generei�4pgregate $ NONE p� �Commercial General Li�bility 12:O lAM 12:0 lAM P�OC�'�O�"��8�e S 10 0 0 ❑Claims Made�Oxur. MAC 0 5 6 617 0 7 0 3 2/01/0 7 2/O 1/0 8 Personal b Advertising Injury $ 10 0 0 ❑Owners&contractors#'rot. Each Occurrence $ 10 0 0 ❑ Fire Dam�e(Arry one fire) S 3 0 0 Medical Expeose(AnY o�Pe�) $ 5 Participant Legal Liabilitp $ 10 0 0 Automobfle Liability 12:O lAM 12:O lAM �mbined A ❑Anyauto MAC0566170703 2/O1/07 2/O1/08 Lim9it� 51000 8 All owned autos g�i�, � Scheduled autas Injury �Hired autos g�� rson $ �Non-owned autos Injury Gara Liabil' axident $ ❑ 9e �Y Property ❑ �m�e S ❑ Excess Liability E� Oxurrence �9�e _ _-- — I _ — - - - Other than Umbrella form - - $ $ Workers'Compensatiion Statutory , and $ Each Accident � Err�loyers'Liability $ Disease-Policy limft I $ Disease-Each Em I ee B AD&D . $ 10 Participant 12:O lAM 12:0 lAM Primary AAedical $ 2 5 0 AcCident SPP0002275400 2/O1/07 2/O1/08 ExcessMedical $ NONE Weekl Indemn' $ XNONE � DESCRIPTION OF OPERATIONS/LOQATIONS/VEHICLESlRESTRICTIONS/SPECIAL,ITEMS ADDITIONAL INSURED: ANY PTsRSON, ORGANIZATION, OR ENTITY ENGAGED IN SPONSORING OR PROVIDING THE PREMISES FOR BABE RUTH BASEBALL/SOFTBALL � CERTIFICATE HOLDER ! CANCELLATION � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE � YARMOUTH YOUTH CAL RIPKEN LEAGUE ISSUING COMPANY WILL ENDEAVOR TO MAIL �_ DAYS Tierney, Joe WRITTEN NOTICE TO THE CERTIFICATE HOLDEI�'NAMED TO 3 9 Breyt Fann Road, South THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE Yarmouth Port, MA �02675 NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. ! AUTHOR2ED REPR TIVE � SL39 �6�� 1-92 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1t�NT PERMIT NLTMBER: #07-173 FEE: 25.00 In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Zieneral Laws,a peimit is hereby granted to: _ Ya.rmouth Youth Baseball, 134 Old Main Street, South Yarmou MA Whose place of business is: Yarmouth Youth Baseball Snack Bar Type of busines$: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires:_ December 31. 2007 BOARD oF HEALTH: Be i�c�S, o�►,�,/l�J,$,, • ��, �t�+/,��v'�� e�,� SEATING: O R�`�'.sB��20cfw� L� crse�a�8 P�/l9C.L7�ps0� � � R.N. _ �y i.Zoo� ruce G. urphy, S.,CHO Director of Health i � i I I � � f : �: : :�--�*— `� _ : .--�'1��a.-.t�,c,�,� ��'r R.y TOWN OF YARMOUTH BOARD TH ;�� - " - � �� ='� APPLICATION FOR LICE 06�` i ��• �'� a,� t= #� � � � Nov 15 2005 j �' �� * P lea,se com lete form an d attac h a ll n s� ' '�" ments b D ��,�-?04� ° P �'Y Y �� s :� c ��F��, i Failure to do so will result in the r�n of your application�acke�:-- _.___.. ._,��R.�, NAME OF ESTABLIS�IlVIENT: �j��'Z�'1'l-�d� ��r1# �j•J��(- TEL. # '.S`��-�/�7 LOCATION ADDRESS: ' MAII,ING ADDRES S: - c�• d� ��/ �lf�n-+�+�o�_ +'Vt�� d �-7 s'' OWNER NAME: TAX ID � IN or SSN1: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: T�✓y µ'i-t�3� TEL. # .�£'3 4 Y=27 43 MAII.ING ADDRESS: tG M/�y'�f d�� /��-- w►�--- �-s.�--z�' t � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poal�perator($)and attach a copy of the certification to this form.. _ - L 2. Pool operators must list a minimum of two employees cunently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a fle at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Ma.nager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applica.tion. The Health Department will not use past years' records. You must provicie new copies and maintain a file at your establishment. 1. 2. � �EI�SQN IN_GHAR�irE� _ _ ___- . _ __�_---_ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlb�T�H CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and attae�icropies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. , RESTAURANT SEATING: TOTAL# I QFFICE USE ONLY LODGING: , LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIIZED FEE PERMIT# I B&$ �50 CABIN $50 _MOTEL $50 I, INN -.. _ �50 - - ,_ ____CAMP $50 �_ .__ __ SWIIVIlVIING POOL$75ea. � �LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL �75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMTf# � �0-100 SEATS $75 CONTINENTAL $30 �NON PROFIT' $25 �p�O� ! >100 SEATS 5150 �COMMON VIC. �50 _WHOLESALE $75 RETAIL SERVICE: , i LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# IdCENSE REQUIRED FEE PERMIT# I i _<50 sq.ft. $45 >25,000 sq.ft. �200 _VENDING-FOOD �20 , _QS,OOU sq.ft. �75 _FROZEN DESSERT S35 _TOBACCO $25 ' NAME CHANGE: $10 AMOUNT DUE = S .�S•0 0 """""FLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•••"• ,` , , �� -�-: _. � � � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or campany does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SI�NED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR�tE9PONSIBILI'�Y Tf�RETURN TI� COMPLETED APPLICATION(S)AND REQUIKED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR TT-� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season mt�st be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdaor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: -- ---. — _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test resulfs must be sent to the Heatth Department. Failure ta 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: Outdoor cooking,preparation,or display of any food product by a retail or food service establishme�t is prohibited. DATE: 1�l--I�{�'� SIGNATURE: PRINT NAME&TITLE: ��'�� A, .�1,- �t,�'c-� 09/28lOS �--�,-' a -�K . � `� ��=--__ The Commonwealth ofMassachusetls =_- - - = Dep�eent of Indxstriql Accidenls _ �fli�� -- _-�� 6/M Washiwgto�r Sd� 7"�`Floor ---, Bosto»,Mas� 02111 .,. ' workera'com�a.tio■I.ssa.e�Affi�v1�B�iidi �lEkearfcal co■aact�rs . .__ pv. - � :. __. :� *� �..Y:��.� � ,� � , <:. „ . ,. . , ,„ , . �,� .- �. �(�-�-4�✓�''°+r�Y£� �D'�T"�/t �YY'.!�/�U"�- . �s: P� o . �io'S� ��P/ s�ib� �f�Lrt� �: !� �p: n u-r�o�� 3 9 y—�YQ7 arork site 1«�tiom fnu p I am a hom�.,m�perf�ming an Wa¢�m,�lf: rm;ecr T,rpe: ❑rtcw ca�s�caon pt�noaei -�,-�y� I am a sole 'etor and have no a�e w ' in any • • • Addition U IV�i �G�-S _ .: :.: ..� . . ' p I am an�npioyer providing wo�s•compensatiQa►for my�nployee.s working on this job. �a�: — - _; ._ _ a�s: s�hr: alte�e�k: ❑ I am a sole proprietor,ge�erai e�tractor,or�eew�(cndi owe)and have hired the�tors listed below who have the following workecs'compensation polices: ��: �p� dt+�• drere�k: ' � I -�::ti;'�., �°v Y'ti;.:�.._ .xfi�Tt;,, .. ,�, r.'w� ., '�' " �'r.�#.,-,�.��tii . n*,-;.,:fi..�a,.�>`t�ek.�5'�n':...__ "� �.... ......... .......�. . ... . . .. . . .. .._., . �Y911�l: �: �= D�6i!�• ___—__ -------- — — � — — -- —_--��_ _ _ _ ,,: ..,�..._ ....� � :.: t:�b,�-w,9„ ,: .; . . . �u. s ' '`B �4�'rx.zP:a�,"'hav�N.'� '�; � .,��9±;+'��"�� -� .�.:.z , ;'Y'.�f;., ��"�: . :-.. ..�-... � Fai�re U secQ+e cevv�e a.re�aired.�er seetls�zsA.t AIGL 152 cu le�a/Ye irp.dW..tcri�ial pnaNia.t a�.e�a s1,sM.N udl.r •�e ye�s'6eprbaammt a weY as dvY pn�kin h tAe�ra�ta STOr WORK ORDER ud a Sne dS1AIi.N a day a�imt me. 1 a�dersfud tlut a �, c�py�ttY6 Aa1e�t dy 6e firwat+ded b Ne OQtce�tl�sf t6e DIA fer eev�e verlAeatly. ' /do benby ce ' Mie pa�s�rwd pend(ies of perJr�ry tbat tAie iwforiw�io�pro►dded aboNe is dare wed onmct I i signacure Date �1 f-�So�D-� � Print name ✓V Phone#� 7 �'-?��7 ?j � e�cial ax enly do not�vrite�this area to 6e compieted by eily ar bwn�1 � city or te�vn: pern�ioense# �Department i Board ❑check if imme�ale nspenx is reqand �Sdeet�e�'s O�ee i ❑llaltl�De�ar6negt � cantad perseu: �#; �Ot� i I,�i.�a smc mas) i i �I i � � � ��^�" , . TOW�T QF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERNIIT NUMBER: #06-051 FEE: $25.00 In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the C,eneral Laws,a permit is hereby granted to: Yarmouth Youth Baseball, John Simpkins Elementary School Field, South Yarmouth, MA Whose place of business is: Yarmouth Youth Baseball Snack Bar Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2006 BOARD OF HEALTH: Be�,�$. (�''o�d�ua,/�I.$. ' p/��/�v� �� SEATING: O l(`�' ' `5�. Bfi�i�/R�f��,1�(5f8�lIB dY�f6IL e�y K✓�. i4it�(�'�ess6ass�rc, R./�r December 9.2005 �u�G.M�ny, �� x, .s., o Director of Health , . � -� y ��IQ� �v7 �� '; ��°`;aR�o TOWN OF YARMOUTH BO F I�EAL � �' � Z�0" �v T F: �,� APPLICATION FOR `` �2�00 �U N 2 0 2005 ..•• * Please complete form and attach all nece �� d V� ents by D b$��(,�qq�J E PT. Failure to do so will result in the return of your application pac . ': i ( NAME OF ESTABLISHMENT:L /L - Fi9 '� S TEL. # b'' - 7 � LOCATION ADDRESS: � r D � ,C E �E�4 MAILING ADDRESS: 2 O ii'.�� /.� � �'Y!o OWNF,R/CORPORATION NAME: , t1�/�D�A�,� �!7!'1,.� -�i�3 FrClt: ; MANAGER'S NAME: �/�'�/ /Y!Gt s'GD TEL. #.1'Gd" 3 q�-d2 793 ', MAII,ING ADDRESS: A f' ' 4 � POOL CERTIFICATIONS: ! The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certificaxions 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. � i FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies o�certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. . �ERSUAT IN CHAR�CE: -— _ __ __-__ --- - ___ __ _ — _ _ _ Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation. l. 2. HEIlVILTCH 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 tra.ined 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. RESTAURt�NT SEATING: TOTAL# i OFFICE USE ONLY LODGING: ; LICENSE REQUIItED FEE P�RMIT# LICENSE REQUII2ED FEE PERMTT# LICENSE REQUII2ED FEE PERMI'P# BBtB $50 CABIN $50 „_MOTEL $50 � INN $50 _CAMP $50 _SWIlVIlVIQIG POOL$75ea. I LODGE $50 TRAII,ER PARK $50 WHIRLPOOL $75ea. FOUD SERVICE: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMTP# CONTINENTAL S30 NON-PROFIT $25 O • O aioo s�Ts s�s L �� >100 SEATS $150 COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIlZID FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERNIIT# _<50 sq.ft S45 >25,000 sq.ft. 5200 �VENDING-FOOD $20 �Q5,000 sq.ft. $75 FROZEN DESSERT $35 ^TOBACCO $25 NAME CHANGE: �10 AMOUNT DITE = S 2 S•Oa '*"**PLEASE TURN OVER A1�iD COMPLETE OTHER SIDE OF FOItM""••• ` ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensaxion Insurance. THE ATTACHED STATE- WORKER'S COMPENSATION 1NSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1� Town of Yazrnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES i� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN 'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-iE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENIlVG FOR TI� SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IMEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POQL OPENING:All swim�ning,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISURY: 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 who 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. j FROZEN�ESSERTSr _ _ _ _ _ __---- - 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. 4UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOi�NNG• Outdoar cooking,preparation,or display of any food product by a retail or faod service establishment is prohibited. DATE: a a o� SIGNATURE: � PRINT NAME& TITLE: /��G1�E��U �1�'l.�s e a 10/22/04 � __—-__—� The Commonwealth of Massachusetts ---- --= Departw�ent oflndrtstrial Accidenls ' = N�wlfiiw��li�` _ 600 Washington Stree� 7"�`Floor _ ---�� Bost�n,Mas� 02111 'wo��c� • ■i.se.�wma�.�� u ca.� �: ��-/Zv� o u�f L i i T�� .0��G/�l t � �: �3ox �'�i ��► �,�t3�2 rn or�� : �t?- a��1 �#�'a� 3��- 9/0 7 � ��t '� �,u�g: �� I am a homeow�perfom�ing all wadc my�elf. Proj�ct Type: ❑New Ca�ucbia��Rmnockl ('t �.Q,QjS I am a sole and have no a�e w in an Addition p 1 u n p I am an employer proviaing wa�s°co�ion fa�r my employces wo�king ou rhis job. a�e• - - -- �� - , , , ettv: . d�e� ,,, ,' ❑ I am a sole proprietor,gseral co�tract�er,or hemeaw�er(c�rele a�t)a�have hiied the c�tractas listed below who have the followin8 w'orke�s'�mp�ian Polices: ��,��' �,_ '�'a-- �...r.� S�'a �� .,., �� .�... dtvs' oi�rel►e .— _ Fail�re t�sec�e a�era�e as req�ed oder SafM�2SA�tMGL L�m M�d 1�1te i�IMa�[e►i�iul paiaNies�f a ie ap M sI,SM.N a�dhr �e yeus��wea as cn��.�e�..ra sror woa�c onn�a..a a�.[xi�a a.y��e. i oa�ua mc a apy�tlde�ta1�t my be r.rwmdM r He O�eee dImM�Mi�s�f�e D1A hra�e v�riAaw�a. r�w�e�,eey � ,�,�r d�a�.,�� ojpe►j�ry tAr�t�11s urjonw�doe provtdad oboae is�e�d oem�ct �8� � � — P�� T � us c� p��#(',�� c� a.��3 .ffidal ase.aly as..c.eribe ia riis ura a e��by al�er w.a.�e�l �� QO�� p��r�k��ny�a ��o� �� o�t�: p��e; C1arQ p�.sca sep.zar„ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-190 FEE: $25.00 In$ccordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: Yarmouth Little League, John Simpkins Elemen School Field, South Yarmout MA Whose place of business is: Yarmouth Little Lea�ue Sna.ck Bar Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 3 l, 2005 BOARD oF HEALTH: B�r�c `,�1. �j'u3�,orr�/y`.�5. ' p��, v�e��.� � SEA��: o a�t� B� e� ; �s�, R�v ; �I.ui y'�tdr�s«r„ R./V. i June 20.2005 Bruce G.Murptiy;�;�.5.,CHO Director of Health � _ _ � � 1- �- IS !1 `IC� [7 � � � � �t5� � ?°`�R '�'�� 2i�04 TOWN OF YARMOUTH BOARD - ' ° ° } � �� ^ APPLICATION FOR LICENS�Ef� =� 04 !rr�� 4 °; ^ y HEA��EPT. �.. ..', ; X * Please complete form and attach all necess��d' , �+e s by Decem e , Failure to do so will result in the rett�l of�our application packet. L�T�ME OF ESTABLISH ENT• +a�- �o� TEI, # 3�Y zZ-g3 jVjAiT.iNC't A1�1�RF�S: • v �Q� ��i y��n� �t,r_ OWNER/CORPORATION NAME• '�/�t.�� o��t �-r�[ .��n� MANAGER'S NAME• A.��ro,�,/ �n�s u� TEL # 1V�ILTNG ADDRESS: �� o b�o� �'�� }//�� POOL CERTIFICAT ON�: The pool supervisor mnst be certified as a Pool Operator,as required by State law. Please �ist the designated Pool Operator(s}and attach a copy of the certification to this form._ � - 1• 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation{CPR). Please list these empbyees below and attach copies of employee certifications to this form. The Health Department will not use past yesrs' records. You must provide new copies and maintain a fite at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmen� L 2. __ i n�'c��. - ---- --- _ _ _��- -------=----- - �_ .__ --- ___ _ _ _ ___ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 2S 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 Heaith Department will not use past years' records. You must provide new eopies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY I LODGING: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _B&B $50 _CABtN _ $Si3 _ _,,vtt7TEL S50 - ; _;INN S50 _CAMP $50 _SWIMMING POOL S75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea. �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S75 _CONTINENTAL $30 LNON-PROFtT $25 0�/6 I i >100 SEATS �150 _COMMON VICT. a50 _WHOLESALE $�S RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMlT# LICENSE REQUIItED FEE PERMIT# <50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 �<25,000 sq.ft. S75 _FROZEN DGSSC;RT $35 _TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ ZS•00 *****PLEASE TURN OVER AND COMPLETE UTHERSIDE OF FORM****" n � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATI4N INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED Sl_$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewai or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES • NO j�,/ � � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR R,ESPQNSIBII�ITY TO RE'T�URN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003. SEASONAL ESTABLISF[�viENTS 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., PAINTING, NEW EQU�PMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS ti_ _ _______ _. _ _ _._ -- -_ _ �_�_ POOL OPE1�iING:All swimming,wading and whirlpools which have been closed for the season must be inspacted by the Health Department prior to opening. POOL WATER TESTING: 1'he water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CAT�RNG PQLICY: 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. _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 af your Frozen Dessert Permit until the above terms have been met. � QUTSIDE �'�AFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�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: �''(Z-� � SIGNATURE: PRINT NAME& TITLE: }�.�/rn+J ryws� -� +' L'o.�.�w-J mP.��-t. 10/22/03 ,. . _ �,, � The Commoawealth ojMassachusetts � � Departmenl oJlndr�strial.-lccidents � ; ol�lcs ol��rasayis � ; 600 Washington Street ', ,,�` Boston.Mass. 02111 �� w'orkers' Compensation lnsurance Atfidavit A,Rniicant information: P'IeasePRINT'�eriiri�r aamr� �iv77� �✓ fYL v J'c� location. • � �� !n� a �s f�—z��3 ��' 1 am a homecw�ner pertormin�all w�ork myself. � � f am a sole propriztor�r.,�. ha�e no one ��orking in am•capaciri• �� - � I am an employer pro�i�ins w�orkers' compensation for my empioyees working on this jab. . comnanv namr address ��t�"' nhone i!• iosurance co. policy# � I am a sole proprietor. generai eontractor, or homeowner(circle oneJ and hace hired the contractors listed below «ho ha�e ' the follu�cin_ ��orker��ompensation polices: '� �om a�hv namE• I address• II citv• nhone M• I i insuran�c co. �olicr•!# comp�y name• addre��: eitY: eboee It: i i insurance co. �* � i Faiiure to secure covera;e as required uader Seeeoa 2SA of MGL IS2 n�iad to tbe i�paitio�oteri�i�al pt�dtla o(a O�e.p to S1.S00.00 a�d/or one yean'imprisonment��w•ell u eirii penaitlea io the form oi a STOP WORIC ORD£R asd a A�e otS106.00 t dar a�aiost mes I��dsrsta�d tbat a copy of thy statement m�y be for+v�rded to tAe 011iee ot IavesN�auom otthe DU tor eoven;e veriflqdo�. I do hrreby cerriJ'� nder rhe pains end prnalria ojpery'ury that tl�e injormation provid�d above is tr�e aed eorra� Signaturc ,. ->—f�� I Print namef�.,�-✓ ��r� ph�e� �'a8� 3��-z��3 � i .- olTicial use onh do not Mrite in this area to be completed by,ei[y or towa oAkial I city or town: Y�M�� _ per�sitAicenx N nBuildin�Department ' �Liceosiog Board ' �check if immediatt response is rcquired 261 �Sdeetmen'�Oflice i __ptl�alt6 Depacsment • � contact person: �oM w;_ (5�� 398--?.Z31 eat. nOtAer .�. ..0 � .< ��4; - � � n TOWN OF YARMOUTH BUARD OF HEALTH PERMIT TO OPERATE A FQOD ESTABLISHMENT PERMIT NUMBER: #�Q4-159 FFE: $25.Q0 In accordance with n��ons promulgatad under authority of Chapter 94,Se�tion 305A and Chapter 111,Section 5 of the al Laws,a permrt is hereby grffited to: Yaimouth�outh Basebal2 Assoc., 7ohn Simpkins Elememary Schoot Fie1d, South Yarmouth, MA VVE�hhose place of business is: Yarmouth�outh Baseball Association Snack Bar 'Fype of business: Food Service To operate a food establishmern in: Tovm of Ya�mouth Pernut expires: Decemher 31. 2004 BOARD oF HEAI.TH: B�rya�a�w$. �,.�$�,.f _ ' �/�c�e�r�v��,�'`Utt�s G'k�i�riu.�s S�A.T'ING: 0 R�9��.BR9ftNiy cise7�s �� Q� �c�'taw�da.ww�, RJY. 1Vlarch 5.2004 Bruce G. ucphy, H, .,CHO Director of Heal ; ; ; ; � ; � � I � k I � �� _ - T ��3,q � �'-=q TOWN OF YARMOUT O �' �� G� A� o�o d�R�y APPLICATION FOR LI 3�� +0 � � � � ,,. ,? JA N 0 9 2003 �,,. * Please complete form and attach a11 necessary documents by Dece �l��Q,02. Failure to do so will result in the return of your application h DEPT; r A I o S �I?tr EL �Q o ' Ss' o ' s # � a8 39 - 7�� A- O �l POOL.CFRTIFICATIONS: The pool supervi�or must be certified as a Pool Operator,as required by State law. Please list the designated _- ��th�+c�rtification#u this form. -- _ _ 1. 2. Poal operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees belaw 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. FOOD PROTECTION MANAGERS -C�RTIFICATIONS: All food service establishments aze required to ha.ve at Ieast one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a f�le at your estabtishment. l. 2. _ _. _ _-____ . --____ ,�. �— --_- __ .-- __- __- ---=_---_ __ _ Each food establishment must have at least one Person Iri Charge(PIC)on site during hours of operation. 1. 2. �IMLICH 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-cholcing 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. I, RESTAURANT SEATING: TOTAL# i i i OFFICE USE ONLY I LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 I� I _ _ __ _ _ :_ , -_ __ � _INN �50 ' _CAMP $50 _SWIlvIIvIING POQL$SOea. _LODGE $SO _TRAILER PARK $SO WHIRLPOOL` �25ea. FQOD SERVICE• I LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F'EE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 I NON-PROFIT $25 O !��a' >100 SEATS $150 _CO1�Il�10N VICT. �50 _WHOLESALE' $75 � �TAIL 5 RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,_TOBACCO $20 _<25,000 sq.ft. $75 �TOBACCO a20 <50 sq.8. $45 ,_>25,000 sq.ft. �200 _FROZEN DESSERT$35 NAME C NGE: $io AMOUNT DUE _ $ ZS.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�*** .....�..�.-.�,---�-'....---� � : : ,wt S` __ ; t `` ADMINISTRATION ,_ ;. , ., . � nd��.�p��r'"1��on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal o = icerise or permit to opera.te a business if a person or company does not have a Certificate'of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEL� 2 � / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1�'' Tovtm of Yarmouth ta��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES •� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FbR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS . __�_��_ _ __ __ _. _ _ POOL OPENiNG:All swirnming,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 establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Deparkment. FROZEN DESSERTS: _Fra�er�desserts�rttst be t�ste�o�a�t�-basis�-��te�er�ified lab.-�es�-res�s tnus�be�er�t tcr�e-He�t3r- 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$oard of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DAT'E: � d-3 SIGNATURE: �� PRINT NAME & TITLE: G! '�� G(� 10/18/02 -�� __ � ' " ., � The Conrmonwealth ojMassachusetts � � Department ojlndtcstriaJ,-lccidents � 0 01'Jlcsolleres!l�stlyis � 600 Wushington Street '. ,,= Bnston.�lass. OZlll ~ �� W'orkers' Compensation Insurance Aftidavit A,Rnlicant information: p'lessepR '�a � n�m�• `/ H?�I�JOLt�� vv///� ��/4[�_ �d��1�T/Q�J Ltz�ation• �/ ��li� �/m�,�1�.5 `��L�� it� �` 7f'�i��1./�� ehone� � t am a homecw�ner pertormin,all w�ork myself. � ( am a sole proprietor�r.,'. ha�e no one��orking in am•capaciri� �/� �, yd�u��r-� _ —$� , . _ . 'ets' conrpctrsation for rnv employees�s•orkine on tfrirjub. — ---. _ _ _ comoan�• name• address. citv: ehone+�• iesurance co. ��y p � i am a sole proprietor. generai contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e thz follo�.in_ ��orker��ompensation polices: �omoanv n�me• address• cttt" hon !1• insurance co. Aolicy# comoanv nAme: ------- -- -- �-- --— — — ___ _ _ iddress: _ -- -- - ------ siLY: nboee M• insurance co. �r� • Failure to secure coveraee as required under Secnoo 25A of MGL 1S2 ta�iead to t�e iepaidoa oterisidl pe�dtles ota d�e ap to 51,500.00 a�d/or oae years'imprisoement as w•ell a�eivil pendde�io the form of a STOY WORK ORDER a�d a Ase dS106A0 a day qaiast ma I a�dersta�d t5�t a copy of thy statement may be fonvarded to the Ot'Iiee of tovatig�don�of t6t DIA tor eovera=e veritiqdo�. I do hrreby ce ' •under rh�perns and penalti�s ojperjyry that tht infornration providtd abovt ts trut and correct ' � Signature G� f L�� Print name ��1�� Y�((i/S� PhoneJll��)--��,�" OS� /� � . otTici�!use only do not..�ite in this area to be compieted by eiry or towa offkial YARMOIITq � ciry or town: . _ pertsitAicen�e M nBuilding Department ; �Lieeasiog Board Q cheek if immediate response is required 261 �Sdeetmenb Oliiee �� Hea1tA Departmmt contacc person: phone p;_ �508) 398�2231 eat. nOther ,.. .��. � .c J1�: � . �- , „ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMEl�T PERIVIIT NUMBER: #03-142 FEE: $25.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 t 1,Section 5 ofthe General Laws,a permit is hereby gtanted to: Yarniouth Youth Baseball Assoc., John Simpkins EIementary School Field, Sauth Yarmouth, MA Whose place of business is: Yarn�outh Youth Baseball Association Snack Baz Type of business: Food Service To opera.te a food establishment in: Town of Yarmouth Pemut eacpires: December 31. 2003 BOARD oF HEAL,1�: (�4anl�a?f i�dl�(ai, eifa�.xa�c �e�Ja�w D. �%esalo.� 79�D.. ?Iie;e sEnTnvG: o ,�a�att jl. �ioaac, � T�Q�tfCl� �zcvOtiYlAO�' !�'�S�taR. �� January, 27,2�(13 � ruce G.Murphy, S.,CHO Director of Health , � I i i � I f C ( � � I� I I I, " ` ' '�YAR .Y� TOWN OF YARMOUTH$OARD OF H =y� `�= �� C✓J [� [p� APPLICATION FOR LICENSE/P I ' ;} P ��y ��R 2 5 2Q02 * Please complete form and attach all n�cessaty documents by Dece 3 ,200 . Fai�t��re°to do.so�f��ult n the return of your application packet. � -- �----� N�ME OF��T Bt T�HMFuTM I��I'I?OL�"1�/�/ RAS�^�LL��},SS' -------��__�w___� LSL�ATION ADDRF.SS• ' � �ILING ADD��S• , , � : l -d 7 -�--- ________________________�_________.��____�_._______________________._�.� PO�RTIFICATIONS• The pool sup�ervisor must be certiSe�i as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operatorts)and attach a copy of the certification to tlus form. 1. � �� 2 � Pool operators imust list a�minimum of two employees cune�tly certified_in basic water sa.fety, standazd First Aid and Communiky Cardiopulmonary Resuscitation(CPR). Pl�ease list these employees below and attach copies of employee cert�fications to this form. T6e Health Department will not nse past yeara' records. You must provide new copiea and maintain a file at your place of buaine�s. L 2 3• 4. �IML.ICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on t�e premises at all times. Please list your employees trained in anti.choking procedures below and attach copies o�employee certifications to this form. The Healt6 Department will not u�e past year$' records. You must pravide new copies and maintaiu a file at your ptace af business. 1. ' 2 3. , q,. RESTAURAh�I'SaEATING: TOTAL# N�N-S�1�I4KING SEATS: T�TAL# _.__.__�_.�______.._�_w�M_______________________��___________ __—__ !. _ OFFI�E i��„ONI,Y - -- ----- — - , - �--__ —-- -----— - -- -- - j LICENSE RE�UIRED ' FEE PERMTf# �,ICENSE REQUIRED FEE PERMIT# _B&B ,' S50 � CA►BIN $SO _� $50 � �CAMP $50 �LODGE $50 `TRAILER PARK $SO � _MOTEL $SQ _SWIMMING POOL $SOea. FOOD SERV WHIRLPOOL $25ea. . 1�TOTE:Fer e new 105,CMR 590.000 State Sanitary Coide for Food Eatatblishmen�,the effective date for fuod protecttqn manager certiffc�tion is October 1,20t11. LICENSE RE�UIRED FEE PERMIT# �,ICENSE REQUIRED FEE PERMIT# �0.100 SEATS $75 CONTINENTAL $30 .,_._ T3 S 4 50 �NON-PROFIT S�5, �'�L=��- ' >1�3EA — �COMMOI�VICT. �50 �WHOLESALE $75 ,�I �L..��YIS�E�. ' � LICENSE RE(�UIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# 'I ; <50 sq.ft. ' S45 _TOBACCO $20 —QS>U�sq',ft• $�S �FROZEN DESSERT �35 i >25,000 sq.ft. $200 � � � , �E CHANGE• $1Q i , i , ; , AMOUNT DUE _ � ZS,cap ; �'' **"**PLEA3E TURN OVER AND COMPLETE OTHER SIDE OF FOItM •««.� ��- k� � � � i ADMINISTRATION � � � � � �" ' � �`�� . ', � � � Under Chapter 1152, Seetlrori 25�,Subsection f�the Town of Y�rmouth is now required to hold issuance or renewal of any license ar permit �o opera"te a business if a person or company does not have a Certificate of Worker's Compensation tnsw�ance. THE ATTA�IED STATE WORKER'S COMPENSATION INSITRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF�NSURANCE ATTACHED ; � I WORKER'S COMP. AFFIDAVIT SIGrNED AND ATTA � � � , CHED � Tovm of Yarmo�th taxes and liens must be paid prior to renevrral or�issuance of your permits. PLEASE CHECK APPROPRIA'T£LY IF PAID: ./ ! YES V NO NOTICE:Perm�ts nui annually&om January 1 to December 3�, IT IS YOUR RESPONSIBILITY TO RETURN TH��(?�I�ETED APP-1�,ICATION(S)ANB REQUIRED F��(S)�Y DECEiV€BE�31,200f�. _ SEASONAL ES ABLISH,I��TTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPEC'ITON?-10 DAYS PRIOR O OPENING FOR THE SEASON. �� . ALL RENOV�4TIONS 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 T'O COMMEN�EMENT. RENOVATIONS MAY REQUIRE A SITE FLAN. ; I Al?DITIO_��RF.0 Ln•ATIONS ', I , POOLS POOL OPErTIl�TG:All swimming,wading and whirlpools whi'ch have been closed for the season must be inspected by the Health D�partment,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,pnpr to opening,and quarterly thereafter. , , .-��:�:I�S�UG��v�outdear in ga�t�nd�vviinmirrg poai m�be drained or ca�vere,�i�iti�seven E�daYs of _ ., I �� . .__ : �s�g: , ,, ' ' FOOD SERV�CE . The effective �ate for food protecNon mana er certification is October 1 2Q01. As g , stated m 105 CMR 590.003(Ax2), �food establishments must have at least one person-in-chazge who is a certified food protection manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000. The el�ective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be im lemented January 1;2001. Only establis]aments which sell or serve ready-to-eat,raw or undercooked animal pmducts ar�required to have consumer advisaries. . Anyone who within the Town of Yarmouth must notify the Yarmouth Hea1th Departrnent by filing the required Tem rary Food Service Application form 72 hours prior to the catered event Thses forms can be obta,ined at the , ealth Department. , Frozen desserts _ - — -- __ ____ --- -- -__ —_____�____ _ -- --- _��1�Y3i�: • --- _ : must tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. F�ilure to do so will result in the suspension or;revocation of your Frozen Dessert Permit until the above terms ha�e been met. � • i � I � ; dutside cafes(i. .,outdoor,seating with waiter/waitress service�,�have prior approval from the Board of Health. � OUTDOQ� Outdoor cookin ,Preparation,rn'display of any food product b�a retail or food service establishment is prohibit�. � �� DATE: � � �c� SIGNATURE: G'� PR1NT NAME&TITLE: f�/��G�'��l ,/,��'C.IJ i iii6ioo ; ��P��T/�/�/�� I ' �� , • , � - 4 q Y S �` The Con:monwealth of�Iossachusetls Z � Department ojlndustrial.-�ccidents o �fllC001/017�5��'ldllJ� ; 600 Washingtoa Street , ,,� Boston.Mass 02I11 � Workers' Compensation InsuranceAftjdavit Annlicant information• PI se i1'a7"Tc�.'i.ter nam��lQ VI/I01,/77-� �4 G/T f-� � N°S��/�}C_C. ,�SSO C�'j��/D/�}` Lc�catio�:� d 7 ' (/• �d� � T'� eit� � ' F ��vL ;/'_1�_�„�� on �.�e�� 9 y-a79� �(am a homeou•ner performin�all worfc mys�lf. ✓i„ �/�LU�1l T�S � i am a sole proprieror_r.� ha�e no one�.�orkin� in am•capacin l�— � I am an emplo}•er pro�idinQ workers' compensation for my emploLees working oa this job. �omoam name• , �tl d ress: ciri•• nhone 1!• , insurance co. �olicv t� [] I am a solz prop�ietor. generai contractor.or homeow•ner(circle onel and ha�•e hired the contractors listed helow� ��ho ha�e the follu�cin��orker:" ;ompensation polices: ' companv name• ', ad d ress• I . � city: � �hone�!: iesur�nce ca �elie�!! tomRany name• —— � �. S�'y: eioee N: insnranee ro. peliev M Failure to xenre coven=e u required uader Seetios 2SA of MCL 1�n�lad to t�e i�p�lie�ettri�l pmltle��a 8ie y�to S1,S80.00 a�dJor o�e vean'imprisoemtut as weH u trni peualtia ip the form�a STOY WORK ORDER a�d a Mt�f S10f�.00 a d�y Kais�t s� I�sd tlut a eopy of thi�statement m�v be faw�a�ded to tUe Oilke ot lavestital�otttie DU fi�covera=e�eri�atie�. 1 do�tirreby c� ' •under the poias urd enattfa�o�pery'nry tbm tht i�jon�iow p�ovided abowr b t�e and con+ect Signature 3 / �'� b� T Print name��-i��),�,� vl.S Pfione Nt�b�� ( I � ?7� - oRciai use onl.� do not w rite ia tAia area to 6e comQleud by antY�tawa aAkial city or tov►a: Y�DUT$ _ • peraitAieeax M n8uildiag Departmeat �Lice�sio�Boan! Q check if immediate response ia required 261 OSeleetmea'�ORiee (5�8� 398�?231 �t. �Healte Depanmeat contact penop: pf�c 11:_ npt6er �,r��a��v»� TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISAMENT PERMIT NLTMBER: #01-192 FEE: $75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 3 of the General Laws,a permit is hereby granted to: Y�rmo�th Yu �h BasPball Asc.^�, Tohn Simnkins F.lemen�rv�chcx�l Field, So� h Y rm�� h_MA Whose place of business is: Yarmouth Youth Baseball Association Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31�2001 BOARD OF HEALTH: �anlea� x�. �avr.,�ca� �c1a.xac D. C%aadau, 711.D.. `l/�ee SEATING: O �� • (�'�'� �a�atek�cDez.,�cot� `� .Si4a�, hl. March 29 ,2002 ruce G.Murphy, H, Director of Health � , i ; � : :� :�'� �-(� .t '" ',� AR.yo�� O�SGI/R�.�. TOWN OF YARMOUTH BOARD OF HEALT [� ��' C�'�C�� APPLICATION FOR LICENSE/PERMI �� p�qR 2 5 2Q02 * Please complete form and attach all necessary documents by December 31, Ol. Fai ure t do so will result m the return of your application packet. � �l��'+�"�� :°��,� NAME OF ESTABLIS�LMENT: TEL. # i.n(':ATT(�N�DDRESS' MAILING ADDRESS• MANAGER'S NAME: U� �vS� TEL. #��' 3�i�Z%7�� iIAiLING ADDRESS• /9 /YI.A� �A�� C,�. Y.Q/L �i.�. o zG'�f POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Paol Operator(s�and atta.ch a copy of the certification to this form. _ 1. 2. Pool operators must list a minunum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the Sta.te Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2• ._ PERS�N�I�r�A�U'�- -- __ _ _-- -—_ _-----�__- -- -_ __ ----__ - -� —, __-- - - , Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �'J1l11»� /1?U.S�•c� 2. �•�1 ryi vS'� ' HEIMLICH CERTIFICATIONS: ', All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '' Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and ', attach copies of employee certifications to this form. The Health Department will not use past years' records. , You must provide new copies and maintain a file at�your place of business. ', 1. 2. i 3. 4. � � � RESTAURANT SEATING: TOTAL# i OFFICE USE ONLY � LODGING• � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _BBcB $SO _CABIN $50 _MOTEL $5� ` _INN $50 _CAMP $50 _SWIMMING POOL$SOea. � LODGE $50 TRAILER PARK $50 WHIRLPOOL $25ea. �OOD SERVICE- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _0-100 SEATS $75 _CONTINENTAL S30 I NON-PROFIT $25 : OZ�/02 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 �ETAIL SERVICE• � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! _TOBACCO S20 _<25,000 sq.ft. $75 _TOBACCO $20 � _<50 sq.ft. S45 �>25,000 sq.ft. $200 FROZEN DESSERT$35 i - i NAME CHANGE: $io AMOUNT DUE _ $ 25•OO f *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i � � � • � ADMINISTRATION Under Cha.pter 152, Section 25C, Su`bsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license ar permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � / YES V 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, 2001. SEASONAL ESTABLIS�-Il�IENTS ARE TO CONTACT'TI-�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POQLS _ _ _ _. POOL OPEl�1ING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CnNSiJMER ADVISORY: Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATFRiNG POi.ICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. -- --__ _ - - -- - ----_. __ -------- -- _ ---____ _ FRn7.F,N DFSSERTS: 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 of Health. ( k OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE; � �� 6 � SIGNATURE: PR1NT NAME&TITLE: �'�i(,� Cd �PR�S�/7`�-Tl v� ��Ti3 G� 09/11/O1 J ' � � Th e Common wealth oj Massach usetts � � Department ojlndustrial.-�ccidents T a OfJlce ollares�lOsdiis 600 Washington Street ', ,•` Bosron,lKass 02111 " v� W'orkers' Compensatianlnsurance Affidavit Aoolicant information• p►eas�pR -�• �m�� yl�� r/Yt 1� Ll"TTI� �t9 GfT�I �/�St P�t�L.� ,�-SsG'�/f�T/d XJ I�cati�:� 7 • � • /> ��( � �� -�� o u -� M s � S� 3 -� 9.3 I am a homeownerpzri�rtnin;all w�ork myseif. �u �/�LUN7, � I am a sole proprieror �r.� ha�e no one norkin: in am•capaciry �S � I am an empioyer pro��ing w�orkers' compensation for my employees working on this job. comnan�• name• �ddress` citv: nhone M• iesurance co. A�y# Q I am a sole proprietor. general contractor, or homeowner(ci�cle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ ��orker� :ompensation polices: sQmoanv name: address• citv: ohone t!• insurancc co. ooli v!! t�meanv name• address• � �'� nboee A�• II � insurance co. ��er�y '� a Failure to secure covera;e as required underSecdoo 2SA of MGL 1S2 ca�ind to tre iopo�itioa otuisi�al ptaaitld of a O�e op to 51,500.00 a�d/o� � one vean'imprisonment a�w�ell a�eivil penalde�io tAe form of�STOP WORK ORDER tod a lise otSl00A9 a dar a=aiatt me. I a�derfta�d tbat a � copy of tha statement may be fonvsrded to the 011ice of Inveatig�qom of t6e DU tor eoven;e veritiqtio�. /do hrreby ce ' •undei the poins an nal�ies ojperjury that tht injornrartrion provided obove is trrte and correet ; � Signaturt ,� a�� v� � ( Print name . �ji(��'rti/�.�J��i�� Phone lll��39�-a�� I � .. otTiciat use onh do not w rite in this area to be completed by tiN o�towa ofllcial � city or town: YARMO�Tf� _ permitAieeau N nBuilding Departmcot �' i �Lieeasin6 Board f Q check if immedi�te response i�required 261 �Seleetmen'�Olfiee ; (]HesltA Qepartment � contact person: phone N:_ r5�� 31 eat. nOther f ,�,.� _ • .'., TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #02-102 FEE: $75.00 In accordance with regulationspromulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: �'�rmoL h Yotth Ba�ehall Acc.�, � o n �imnkins Flementasv�chool Field, SoL h Yarmo rth_MA Whose place of business is: Yarmouth Youth Baseball A�sociation Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31,2002 BOAxn oF HEAI,TH: �an�'� i��. ��a�+cc �u�D. C%�. 7�?�., �l/�ee SEATIlVG: O i��7• �• � �asrle��I1Y�Dorrxot� � s� .� ��b a9 ,Zooa ruce G.Murphy,MP .,CHO Director of Health i � I ' i I � i I � �{ k � �r � `��`� TOWN OF YARMOUTH BOARD OF HEALTH � � � � U � � � , � APPLICATION FOR LICENSE/P'ERMIT- � t�`v APR 1 9 2000 � � * �.� :`'� t �,. "x t ,� HEALTN DEPT. , Please com lete form and attach a11 neces documents b �e t�r,� �9��ilu o so wi resu t m P �Y Y . ,� , �� :, .:� ��.. the return of your application packet. ��' �,`�� ----------------------------------------- ---��-------.�;`�✓� !J9 F�.� �J c�i...,,-------------------�-��-Z-7 c3----_. A • �. ,� �•Nt•► S>- ...,► S�r-�.:t_.� �AII.ING ADDR�SS: �9 �7'IL��v� c�. �. �. ir�1n.. ,vt.� v-�-��'" O��C RPORATION NAM�: 1X�`I��I�"R'�`1,4.?i�••.: ""�G L'V`1 /11t�/-s�`'�y lr.l...� MAILIl�G ADDRESS: POOL CERTIFICATIONS: The pool sapervisor must be certified as a Pool 4perator, as rec�uired by new State law. Please list the I �de�ignated Pool Operator(s)-and attsch a copy of�ie Ga�ti�teatic�rr#�-tl�ns-�orm: - ji 1. 2. � � Pool operators must list a mitiimum of two employees currently cert�ed in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR}. Please list these employees below and attach copies of I employee certifications to this form. The Health Dep�rtment will not u�pxst years' records. You must provide i new copies and maintain a file at your place of business. L 2. 3. 4. I�IMLICH CERTIFI�ATIONS: I'i All food service establishmems 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 Healt6 Department will not use past years' records. I You must provide new copies and maintain a t"de at your place of business. 1. 2. 3. 4. , RESTA��I�IT SEATI�IC"T T�'r�T_� - rrt�rr c_��nrtn�r��Tc:-�'A�'-A�# _ _ -_ _ _-_---__--_-- _ _ �------________-------------------------------------------------------------------- ----------------------------_.._---_,.------------� I OFFICE U��E_ONLY �, LODGING• 'i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $50 CABIN $50 I INN $50 CAMP $50 ' LODGE $50 TRAII,ER PARK $50 MOTEL $50 SVVIl��IlVIIIVG POOL $SOea. WI�tLPO(7L $25ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 — ____CONTINENTAL $30 >100 SEATS $150 NON-FROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 � >25,000 sq.ft. $200 �TAME CHANGE: $10 AMOUNT DTJE = $ �� '•"""PLEASE TURN OVSR AND COMPLETE OTHER SIDE OF FORM••"" � - �� .�f� ADMINI�TRATION ��'� ER CHAPTER 152,SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUdRED ! Q7��.D;ISSIJ:�1�TC,E OR RENEWAL OF ANY LICENSE C1R PERNIIT TO OPERATE A BUSINESS IF A�` PERS�v OR �C'Ol�'ANY D(3ES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT , MUST BE COMPLETED AND SIGNED, OR ,-r CERT. OF INSURANCE ATTACHED� � � � WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUAI�CE OF �YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO �' ' NOTICE: PERMITS RUN ANNL7ALLY FRtJM JANUARY 1 TO DECEMBER 31'. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 3 l, 1998; SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT'THE HE.ALTH DEFARTMk,'NT FOR INSPECTION 7-10 DAYS PRIOR T4 OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COIVIlV�NCEM��NT. RENOVATIONS Mt�Y REQUIRE A SITE PLAN. ADDITIONAI REGULATIONS POOLS POOL OPENING: ALL SVVIlVIlVIlNG, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR TI�SEASON MUSTBE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SW�NIMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN('7)DAYS OF CLOSING. FOOD SERVICE CATERING POLIC�: ANYONE WHO CA'FERS VVITHIN THE TOWN OF YARMOUTH MUST NO'TIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI-� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH � DEPARTMENT. F�tOZ;��I�E+ S�RTS: FROZEN DESSERTS MUST BE TESTED UN A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT.'FAILURE TO DO SO WII.,L RESULT IN THE �USP�[SION ORREVOCATION OF YQURFROZEN DESSERT PERMIT UNTII,THE ABOVE TERMS HA.VE _--- - ---- - BEEN MET. - _ _ _ . _ - O T�SID_�CAFES: OUTSIDE CAFES(i.e.,OU1�tJOR SEATING WITH V�AITER/WAITRESS SERVICE),MIJST HAVE FRI01Z APPROVAL FROM TI�BOARD OF HEALTH. I OUTDOOR CO,QKING: OUTDO�R COOKING,PREPARATION, OR I7ISPLAY OF ANY FOOD PRODUCT BY A RETAtL OR FOOD SERVICE ESTABLIS�Qv�NT IS PROHIBITED. ;^ � �, R ; l�ATE. ��'±�� , SIGNATURE: j FR�N'T I�AIuIE& TITLE: ��rt-..J �, t✓t � � c..�, 11/12/99 . APR-06-00 THU 09: 18 AM FAX N0. �_ __ _ P. 02/02 . � , _ ._.. _ .. .- -- ---- �- . �'' �, �� CERTIFICATE OF INSURANCE ��92 � � 3!3o%oG • Pfi U Eb�p—' — -- ^ _� � 1: Fr K I i�o u r�.n t e �i 7C�p p p� r n C � TH�S CERTIFlCATE IS ISSUED AS A MqTTER OF INFORMA7'ION oNLY AWO CONPERS NO RIGHTS UPON THE ,CERTIFICAT6 J 71 2 !>tu�navox �aTay NOLDER. THIS CERTIFICAT� DOES NOT AMEND, EXT�ND OR P. O. B a X 2 3 3 a ALTEq THE COVERAGE AFFORDED BY THE POLICI�S BELOW. �'ort Wayne . Iti b6801 �Ns� � COMPANIES A�FORDlNC,� COVERAGE P��SE 1;Ui k� �,FAGUE ZNC. COMPANY ATTG I1�SURA�:Cr CUKPA�iX �� aX SoOf� ' �SEE zci�348) ��R ..�,—. 177(! TiRUNSWICR AVEN[TE COMPANY T FkENxON , NJ Q8638 LET7ER B COMPANY C � LETTER COVERAtiES - .,� THIs 13 70 cLFifIFY TtIpT TH�POLICtES oF iNSui•11AANCE USTED BELOW HA1/�BEEN ISsuED 7o THE INsVRLD NAMED ABOVE Fo(i THE POLIGY pEAIOD IN• DICqT'EQ NOYWITHS'tUWWDiNQ ANY A�pU1REMENT,TEqM OA CONDITION OFqNY CaNTFiACT OR OTF�1Ep DOGUMEIVT W�TH RESP�CT'Ip ydH�CH Ti 116 CEqTIFICATE MAY 8E 133UtD OR MAY PEHTAIN,TH8 INSURANCE AFf�ORDEO BY THE POLICIEB DESCHIBED HEREIN IS SUBJECT Tp qLL TNE TERMS,EXGLUSIONS ANO CONDI• TIONS oF SUCN POLICIES. I.IM17s SHOwN MAY HqVE DEEN REDUCED BY pAlp CLqIMS. CO NPE�F INSUqANCE POLlCY NUMBER P�L��ECTIVE POLICY EXPIRATION ~� � bATE(MM/DD/YYj DATE(MMIb0/Y}� UMITS(in thous8ttds) Cionoral Liabili[y �� A (�erd" I A00te te a �� Commom.�s�Generat�iabiliiy S 5 p��5 O 1��S 0 U 3 3/�9/0 0 2/O 1/0 Z Produccs-Comp/o�s//y�orc�ate $ U ❑Claims Mtde �]OccuG P'ersonal&Adverlisi n n I n i u !Q 0 0 �O N n�er's&con lr�c tors Prot. Each Occurrencc 1 0 0 �— Fire Dama c Any orte fire� S 3 00 hledical Expensc fA�y onc person 5 - FerticfpaM L al Liabih'. ty^ S 10 0 0 nutomabiie Llabihty 12;O 1 A M 12 : 01 AM �+b�ed �* �Anyauto SST�'375U145003 3/29/00 2/O1/O1 Sirqrc umit $ 1 D 0 0 t❑�All c�ampd aums �i� u Schedulcd autos Injury sr arsnn $ 1v�Hirod autos e�h —.—_ 'hJNon-owned autos " ipjury�� $ a G�erege Liabiiity _ ��Y 9e a � �xco�s LIabllity " E� 000urronoe I1�qrogate ❑Other than umbrella form s $ ' —�— .-_--, Workers' Compensation _ Sta._wtury and � Each Accidorn Eniployers' U�fility S ,_�D�gessc-Poli l.lmit .� � S Dise&se-EatO__ ___h_Ern��cye� A SPX37S0],45t03 3/29/00 x�p�%p^. '��&D � �' PArticipant Prima Medic�l S � AcCident �xccss Medic�l $ iriiori ren'hfioris�'�r�o � tH��in�r "�i�' � �ow r ��c"r7C�j �ek) N�demnity a X AnDITIOtd.11L ZI+tSUR�D: ANX PERSON, O�GA14I?.AT10N, OR F.rITZ7'Y F.KGAGFn xN S1�ONSORI�i OR PltOVTDIIt�G THF PTtf:MISGS �'aR 13ABT3 Rt1�A BASEBAL�,/SO�'$�iALL OY�R.�,�'IQ;�S, BU� SoI,LLY AS R�:SP�C�S TH� OPERI�TIONS pF T�E NAt4�A YPISUREA. , CE�tI'lF1CATE H01,DER , , � CqNCELLATfON ' �^ SHOUID ANY OF THE ABOV� DESCRIBED POI,ICIES 8E YA�.'1�10I11FT YOITTH BAB� Riixl� LL�AG'pL� �NCELLE� gEFORE 7HE EXPIRATION OATE TH�fi�F, THE ' AT i N: 'f O NY MLi S C U �6SUINCi COMPANY WILL �NDEAVOR 1d MAII, pqY3 19 tdANY O,AKS CI RCI,F; ERFT, BUT FAILUR 7p pAqIL SUCHAN�fICE S�Ll I�MPO E NO YAfi MO U 1.'[i, MA 0 2 6 7 5 OBLI(3ATION OR UAR��y pF qNY KIND UPON THE COMPANY, ITS A4ENTS OR pEPREBENTATIVES. ��y� -�. , SL 39 i-92 TOWN OF YARMOUTH '� BOARD OF HEALTH + PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-181 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: YarmoL h YoLth Ba�eball A��oc , Tohn 4im,nkins F.lementar;�Sch��l Field_ S�� h Y rmo � h_ MA Whose place of business is: Yarrnouth Youth Baseball Association Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �s�, C'�t..�n SEATING: 0 Ko�ert� �rocun, (..ler� abrieile�a�o[�� J�oo s ��I� 0�o �1,� � � A nn '124 ,z000 4-�- ~ ruce G. Murphy,MPH,R.S H Director of Health :� �� , ,.7-Q� �VIu�SC� /��,-� J�-5 ��,� TOWN OF YARMUUTH BUARD OF HEALTH APPLICATION FOR LICEN5E /PERMIT - 1998 � C� � �(! N1 � � APR 2 7 1998 * Please Complete form and attach all necessary documents by December 31, 1997. ailure to do so will.result in the return of your application packet. . HEALTH DEPT. N-------------------------------------- -�r-�,�---- -----�---- -- -:`- ----- ---------------�3�-�---- -- �� , crn-� ING D �' -r'Ko� �'St � r 3 �/-6 MAiT iNC AT�D�SS• ------------------------------------------------------------------------------------------------------------------ PO�L CERTIFICATIONS: Pool Operators must list a minunum of two employees currently certified in basic water safety, standard first aid and Community Cardiopulmonary Resuscitation(CPR).Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintain a Cle at your place of business. 1. z• 3. 4• HELMiJICH CE TIR FICATIONS: 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 yaur pla'ce of business. 1. 2• 3. 4• RESAURANT SEATING: TOTAL#,_,Q_ NON SMOKING SEATS: TOTAL# � O FICE U ES ONLY I,ODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# s&s $so c�srrr $so nv�v $so �c� �so LODGE $SO TRAILER PARK $50 , MOTEL " $50 SWIM POOL $SOea. '� _WHIRLPOOL $25ea. �00„� ,�ERVI�: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# 0-100 5EATS $75 CONTTNENTAL $30 >100 SEATS $150 �ON-PROFIT $25 Q�- t� COM. VICT. $50 WHOLESALE �75 I � I � BETAii� � ��E�Y�E: LIC. REQUIRED FEE PERNIIT# LIC. REQUIRED FEE PERMIT# <50 sq. ft. $45 TOBACCO $20 <25,000 sq. ft. $75 FROZ. DESSERT $35 , ; >25,000 sq. ft. $204 ; , AMOUNT DUE _ /��. i I ,��, ,�;. i ___ - -- - -- _�-- ��- _ _ _ —, � �..��s y - ADMINISTRATION ` ;�L;f1��I�; r,_,, TER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS i , NOV�R�t� RED TO HOLD ISSUANCE OR RENEW.AL OF ANY LICENSE OR PERMIT � TO OFERA E A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A , �� IFIC E OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED �- �=.�'�.��RKER S COMPENSATION INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MU5T BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMtTS. PLEASE CHECK APPROPRIATELY IF PAID: YES N10 � � NOTICE: PERNIITS RUN ANNUALL�FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL ESTABLIS�iIV�NTS ARE TO CONTACT THE HEALTH DEPARTMEN'I'F�R INSPECTION 7-10 DAYS PRIOR TO OPENiNG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL 4R POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REP4RTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlvIENCEMENT. RENOVATIONS 1VIAY REQUIRE A SITE PLAN. AnniTIONAL REGt1T�ATIONS POOLS � POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED F�R THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO OPENING. POOL CLOSING: EVERY OUTDOOR IN GROUND SWI11RUING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE �,TE�NG POI,ICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING�'HE REQUIRED TEMPOItARY FOOD SERVICE APPLICATION FORM 72 HOUR3 PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPA,R.TMENT. FROz�N D�SSE�: FROZEN DESSERTS MUST BE TESTED 4N A MONTHLY BASTS BY A STATE CERTIFIED LAB. TEST RE5tTLTS MUST BE,SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO 50 WILL RESLJLT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. �C1T��jDE GA�'ES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �,'�HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. QUTDQOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS��VVIENT IS PROHIBITED. DATE: �I''c��'�S� SIGNATURE: �� .� PRINT NAME &TITLE: ��i'1 10/97 page 2 of 2 .._. _ �___._ _-- --- � `�' , � The Commonwealth ojMassachusetts � W Department ojlndustrial,-�ccidents � ; Ofllceo/%res�l�sdiis I � 600 Washington Street . . � y�y � . B�S�O//�Mass.. 02111 � �� W'orkers' Compensation Insurance Affidavit A,Rnlicant information: pteas m. .� � na �: Lc�c_ati�n; // /,!�/�'� �� ` 7�.,(lA'h,.0 v;�/� �it� . nhone# 3� '7� 9 J �3 l (a'( am a homeowner pertorming all work myself. - � (..- � G� N 1,.� � I am a sole proprietor�r,� ha�e no one�rorkin� in am•capaciry � I am an employer pro�idino workers'.compensation for m��employees working on this job. somoan�• name• �ddress: . citv• ehone H• iQsur�nce co. AoliFy# ,I � f am a sole proprietor. ;eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below� ��ho ha�e I the follu��in� �+orker� ,ompensation polices: I sompanv name: address• � c�y: �hone t�• � insurance co. Rolic�•# comRany namr address• sitv: nhoee M• insuranct co. poti� Failure to secure coverage as�equired unde�Secdoo 2SA of MGI,lS2 a�lad to t6e i�paitioa oterisi�al pe�dtla ota 8�e ap to 51,500.00 a�d/or one yean'imprisonment a�w�ell as eivil penaitia io the torm of a STOP WORK ORDER aad a li.e of 5100.00 a dar a�ainst ma I r�denta�d t6at a copy of thia statement may be forwarded to the Ot'�fee of Investigatloo�of tbe DIA tor eovenge veriBalio�. ' /do•hr�eby cerr' �ri rh�pains and penolties ojperjury thw!he injornmtion providtd abovt is bue and corrtet Signaturc � � �—Z1,� (j � � Print name Q NTa,tJ Y11. m V S G� Phone N 3 '�! y'r / 0 � � .• olTicial use onh� do not w rite in this area to De tompleted by citv or bwa otlkial city or town: Y�M��T� _ permitAfeeeu p nBuildiog Departmeot OLiceasiog Board �check if immediate response is required 261 �Seleetmen's Offiee (508) 398�2231 eat. �Healtb Departmeot i contact person: phone q;_ __ _ nOther � Irn�ised i;ot PJA1 I f � : .�; , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-179 FEE: Waived In accordance with regulations promulgated under authority of Chapter 94,Section 395A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Y rmouth outh i.i le I. a � ., Old Main Street�,SoLth Yarm�uth Whose place of business is: Yarmouth Youth Little Lea ,�ue Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31,, 1998 BOARD OF HEALTH:��/. �ett��, C'��,�.� �oan C�. �a[livan, K.//., �ice l,�irman Ka�ert�}. �rorun, (..[er� abrie[le�a�o[�ht�-✓vooPe9 ichaeG�oCou �Lirc � Apn127 , 19 98 ruce G. Murphy,MPH,R.S. � HO .� Director of Health i � I � � i � I �