The URL can be used to link to this page

Home My WebLink AboutApplications, WC and Licenses �.-- � .F}�t�c - ��t''"�k�, ;� �' TOWN OF YARMOUTH BOARD OF HE,,�.T��, n� .� /� - L� � � APPLICATION FOR LICENSE/P�I�IYII�'�2008 `�: �'� O� •, �'i ; � �� .!�� $, ?��1� * Please complete form and attach all necessary doc.iiimetrt�by December 31, 2007. Failure to do so will result in the return of your application packet. ___� - NAME OF ESTABLISHMENT: � �� - ckk �•'�' TEL. # SUS�3� '��Q� LOCATION ADDRESS: � l�� (�'1�,� �-�� I ca�� c� MAILING ADDRESS: � � Z- OWNER NAM�: ��. TAX D IN r SN - �� CORPORATION NAME (IF APPLICABLE): ��(� �v��erc��ri ' � MANAGER'S NAME: TEL. # MAILING ADDRESS_ . POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s)and attach a r.a}�y of the ce�i�t;c�n-te x�is fa�: - - -- 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 attacli copies of employee eertifications to this form. T�te Health Department will not use past vears' reeords. �'o� must provide ne�� copies and maintain a file at your place of business. l. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Saiutaiy Code for Food Service Establislunents, 105 CMR 590.000. Please afitach copies of certificationto this applieation. The Health Department will not use p�st 3�ears'records. You must provide new copies and maintain a file at your establishment. 1, 2. _PERS9N 1N��AR�E: _ . - _ _ ------ _ __ _ _ ___ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the prernises at all tunes. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. � � 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'v1IT# LICENSE REQL'IRED FEE PER'�1IT�* LICENSE REQUIRED FEE PER'�IIT= � B&B S50 �O�"�� CABIN S50 _MOTEL SSG T�T 55p _CA:�IP S50 _S�'b'IyIv1INGPOOLS75ea. �LODGE SSQ _TREiILER PARK S100 _�VHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQL?IRED FEE P£R'bfIT� LICENSE REQL'IRED FEE PERViIT= 0-100 SEATS S75 �CONTINENTAL S30 , -Oa" NON-PROFIT S2� >100 SEATS 5150 _CONL'�ION VIC S50 _��HOLESALE S75 RETAIL SERVICE: --RESID.KITCHEN S75 LICENSE REQUIItED FEE PERMIT� LICENSE REQL�IRED FEE PERVIIT= LICENSE REQti IRED FEE PERVIIT� _<50 sq.ft. �45 _>3�.000 sq.ft. S200 _�'ENDING-FOOD S'0 Q5,000 sq.ft. 575 _FROZEN DESSERT S3� _TOBACCO S50 NA.ME CHAVGE: sio AMOUNT DUE _ $ �O •00 *****PLEASE TLR\OVER A\D C0�IPLETE OTHER SIDE OF FOR�1'�•"�** _ _ a� � ;... 7+�'. ___ ��: �.� 1oi��`��.�..�.� '"'�. ' ° ' ,''� ADMINISTRATI4N � �'� Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth 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 limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient accupants must have and be able to demonstrate that they mainta.in a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more tha.n 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, sha11 generally be considered Transient. * NOTE: En�losed Motel Census must be completed and returned with t�is application. 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 Degartment to schedule the inspection five(S�days pnor 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 c�uarterly 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 Departmerrt by filing the required Temporary Food Service Application form?2 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut 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 Boazd ofHeatth. OUTDOOR COOKING: O��door cooki�g;�ra��;or display a€any food prt�duct by a re,tai�or food�rvice�stabl�sh�nt is prehibited: _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIQNS TO ANY FOOD ESTABLIS��VIEENT', MOTEL OR POOL (i.e., PAINTING, NEW EQIJIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH pRIOR TO COMMENCEME�tT. RE�tOVATIO:VS MAY REQUIRE A SITE PLAN. DATE: �tI�Q�,C�Z SIGNATURE: `'�t(� ��; —�. FRINT'NAME&TITLE: �F,�-2i�t:��. ��.�;�,�.. ��;�� io�o o- �w t , � � � � The Commonwealth of Massachusetts Department of Industrial Accidents �N�M�s 600 Washington Sfree� ��Floor Boston,Mass. 02111 Workers'Compeasation I�snranee Affidavit:Bailding/Plambi�g/Electrical Contractors �_.��__ p�P�tINT l�bl� �, _,�' � �E'G��}��k�� V��..��CLla� !v'e.ts-�'� address: ,�� 1��,' U. S�CP�� ciri l��yN�,t�.J��b� state 11 ,1� zia' �Ct3� nhone# �`��" 3 l�� '�-��!`.� work site location full address: �� N�C�S�� jt�pdel �am a homeowner perfomring all work myself. Project Type: ❑ ❑ I am a sole proprietor and have no one working in any capacity. ❑Buildit►g Addition ❑ I am an employer providing workers'compensation far my employees wo�cing on this job. com nmr address- city °!t°a°#� co. # . . .. . ,,,., ,,.� __ ❑ I am a sole praprietor,geeersl coatraetor,or homeowaer(circle orre)and have hired the contractots listed below who have the following workers'cflmpensation polices: ad ess• citv u6aae#• -- # ; : ,, iesa�auce co. � � � � . u1Re�e#- _ im cu. _ _ # �MI�'��o�t��` : , of cris�ioai pmNics of a�e�p b S1,SeY-00 aadl�r FaLare�o�ecare eevera�e a�*e9�al aader ScedOa gA of MGL 152 e�a Ind b tte h� ane years'lmptbegment as we8 as dvY pemNies in the fere�of a STOr WORK ORDER and a Snc ot 5109.85 a day�t me- 1 nederataad t6at a copy of t�is�atemeat may 6e forwarded bo the O�ce of InveNigaHans of the MA for eevenge veri�eatbe. I do hereby cer�fy uwder eGe pates axd penelties ofPe*jwry tAat NYe i»for�xadon prov�ded arbaNe is Iru�and correc� Signaturc � ' i Date 1l�a�1 c"1 ---- Print name �'�-��-�-�— \ l'Ev.l� Phone# �C3�'j- j (G �- �LU official ux only do not write in this area to 6e completed bY dty er Eewn of6cia! eity or town• permiNlice�e# OB�� chtck if immedfale reapeme is teqnQed �'s O�ce �HaN!Depatbatat co�act person: pho�#; ��Q t*�riecd s�r-�3� �� ` THE COMMONW�ALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #08-002 FEE: $SOAO THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to RKC'r EnteroTis"" an'�" �"""�Rp'� �> R''Pal�a�t at 168 Route 6A Yannouth�ort, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2008 unless sooner suspended or revoked for violadon of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to secrions twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Twentv-sixth day of November A.D. 2008. BOARD OF HEALTH: .`9�Z SR,LiP�, J�..IV.� C�t�Ctt NUMBER OF UNITS: 1 S`Floor—2 bedrooms �� J��'��,'� V�� r`G�� 2°a Floor—2 bedrooms .�jf�t�.Q��.��Glilt�ft� �:CP1�t� n, J2 ruce G.Murphy, , .5.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #08-022 FEE: $30.00 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: RKG Enterprises, 168 Route 6A, Yarmouthport, MA Whose place of business is: A a e Bed&Breal�ast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: .`�eeert SPI�Pi, J�..N., C,R�ai�crstan — C''�aviceea �. 3'Cee�iPce�c `tJice C'f�aci�cnaacn ��a�eXt 3.J��acun,�C'� � ,� 1`Tove�nber 26,2007_ "°"" Bruce G:Murphy,MP ,R. .,CHO �� Director of Health _ � ' f��r14FG ' ��O`:AR� TOWN OF YARMOUTH BOARD OF HEALTH �� ? o �: ;1 APPLICATION FOR LICENSE/PERMIT- 2007 � `�� =� �"' ' �� r�� , ,��, ,, _ * Please complete form and attach all necessary documents by Decemb r 31, 2006. Failure to do so will result in the return of your application pac t. �vIAR � � �Q�7 - , ,. _.. _ NAME OF ESTABLIS��VIENT: {� C�-� � �, r�j�e�l -i I� �'��i��i;f TEL. - �r , �� C� LOCATIONADDRESS:__�(��P^('��,,) , T � �� ;41 MAILING ADDRESS: �� -vv��.- _ . OWNER NAME: i�!�,l.v rZ��t); t�c:�- G= + I.�j!4-Z� /� TAX ID (FEIN or S SNl� :;� CORPORATION NAME(IF APPLICABLE): _/'�,.,��C°- �,�„ 7�� p/�(S ti.� MANAGER'S NAME: �'_�L� ��'��- /U�cl,c� To�J TEL. # s � � MAILING ADDRESS: s�-i��.. 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 c9�y of the certification to this form. L /�-? � �'�-' � 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitatian(CPR). Please list these employees below and attach copies of employee certifica.tions to this form. The Health Department witl not use past years' records. You must provide new copies and mxintain a tile at your place of business. 1. a'�.,' C`� rL� � 2 3. q.. FOOD PROTECTI4N 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 Faod Service Establisl�ments, 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 PERSON IN�HARGE: ___ __ _- --- --- --- ---_ - -- Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation. 1. I�,✓-��='rl-I �-��(,l �� % ��Z- 2._ ��-�� - ,�„)�L,(,7 7'�Al,) 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-chokmg procedures below and attach copies of employee certifications to this form. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � 1. ,/�,�j / � 2. 3. 4. RESTAURANT SEATING: TOTAL# �(U OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIR�D FEE PERMIT# J B&B �50 �O I� _CABIN $50 _M01"EL $50 _iNN $50 _CAMP $50 _SWIlVIlvIINGP�L$75ea. _LODGE $50 _TRAILERPt1RK $100 WFIIRI,pOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PF.,RMIT# LICENSE REQUIRED FEE PERMti'# LICENSE REQilIRED FEE PERMIT# _0-100 SEATS $75 �COI�fTINENTAL $30 {�O��o Y NON-PROFIT $25 _>100 SEATS $I50 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: —RESID.KITCI�:N $75 LICENSE REQUIRED FEE PERMIT# LICEN3E REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.8. $200 _ _VENDING-FOOD $20 _QS,OOOsq.ft. $75 _.FROZENDESSERT $35 _TOBACGO $50 NAME CHANGE: $10 AMOUNT DUE _ $ ;30-O CS `*'••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••""* ��Q —..,.�... ,: ..�. ADMINISTRATION k Under Chapter 152, Section 25C, Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Toum 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 limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short terrn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a grincipal 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 af a guest u�it as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, 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 Dega.rtment prior ta opening. Contact the Health Department to schedule the inspection five(5�days prior to opening. PO4L 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 therea.fter. - 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 obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been rnet. QUT5IDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: - 4uYcioor r.�okingr�repar�ionror disn�nf an�food�r-etiuct-b� � � blislu�ent-is-pnahibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN TI-�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED T�AND APPROVED BY'TI�BOARD OF HEALTH PRIOR TO COMN�NCEMENT. REN4VATIONS MAY REQUIRE A SITE PLAN. � DATE: � �<�- � ^ G � SIGNATURE: C�� . G" ,. PRINT NAME&TITLE: �%��/� ��'2��' f� l�'Z ��(��. 10/17/06 - ' . � � The Com�nonwealth o Massachus � f ens . Deparhnent of Industrial Accidents ' M�fi.'I/irr�lM�i 600 R'ashington Stree� ?`�'Floor Boston,Mas� 02111 wa��com��a i�� n�r�,� ,_t. , .:,u .�.,, ,� �c � v�r:sailai�/rlam . . ., -�v�'' ��c� .�-:�':�er -s x .,,:` , s'�„=r , .�._. , ..., , 3,y� }::� i fi��O ��i --� v`� _ „��,�s �€��y , . � , e ,• ,�'; name: !�'l� 1�"►' � t�' `�ifJ t� ��{' i`c iC.f �-�� S: l�0� d/�1,$�i tv � � �� G�4 � �iri � .l„',?��f,1.�7�{ �(�l� siste• I�/�� 'p ��P�� phnae# � %/I 2 �C�'> work site location(fnll addcessl• I mn a Iwm�wner perfonming all w�k myself. Project Type: ❑New Ca�uc�aa�(]Remodel I am a sole 'etor and have no ane w ' in an ca ❑Buil ' Addition ; < � v ;. . ,�.��k��' ,,:� :. , ❑ I am an employer providing workers'compensati�for my e�nployees worlcing�tl»s job. _ ___ __ ��: _ _ __ �r : � #k� ❑ I am a sole p�aprietor,geaeral co'tracter,or homeo�va�(circle o�)and have himd tbe co�ctors listed below who have the following workers'compensation polic�s: �.._..,.._ � �: �� N �v�er �#• �• �S# — -- _ ___ � , # , FaBm�e 6�secm+e ev�e at reqair+ed aider 3alioa ZSA et MGL 152 c�a lead t�fYe hrp�af aiiwioal pe�aNip ef a�e tp b SI,SM.M aid/�r �Ya�'�Prbsnseat as we8 as dv/pe'akks ia tie fora ota 31'O!'WOItK QRQER atd a gae e[S18s.YA a day agaivat ne. I eedestaud t6at a apy ef fiit eta6e�mt euq be for�vaMcd 10 the O�ce of ltv�of the D1A fa avenge veNlieatlee. I do henby cer�ify xnder NYe paPws m�Aptns�lties ofP�3�Y��e ixfonwalio�prov�ded aboWe fs�rue rwd oorrecx Signature_ ��?•-(7i,s��,�1� Date Z �'a-7 _p � Print natne ,��Q-!'1�� .E�_��V /./��7 Z--- Phone#�.�{`` �L�L ��'� efficial ase oely de aot wrlte�this area t�6e oo�plefed bp eilY er p�va efficial city er te�vn: ��# QBaid�g Deparfie�ent ❑c�eck if Imme�ale ne�ene is reqaved ��'��8�� O.Sdectsen's o�oe �pera�n: p4eae#, �Olh�er �t ��I'"-,�,..��;�.�Li�� 4 •' ` THE COlYIlVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-011 FEE: $50.00 TffiS IS TO CERTII'Y TAAT AN INNHOLDER'S LICENSE is hereby granted to RKt;r F,n ernri e /h/a A�ane Be� &Br akfact at 168 Route 6A Yarmouthport, MA in said Town of Yarmouth And at that place only and e�ires December thirty-first,2007 unless sooner susperided or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto a�ed their official si�atures,this Fourth daq of Anril A.D. 2007. BOARD OF HEALTH: L� ff� �S. (�o�iiri,l�/Ll�., . NIIMBER OF UNTfS: 1�F1OOr-2 beCl�'OOIriS die�i��, R./V. Uice�r�i.�ir�ss 2na Floor—2 bedrooms Q�6� B�y, �� /�a�hi�l�a/�c.$�Jux� �4�� ; , R.N. Bruce G_Murphy, S_,CHO Dir�tor of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-164 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: RKG Enterprises, 168 Route 6 Yarmouthport, MA Whose place of business is: A�ape Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmo�th Permit expires: December 31, 2007 BOARD oF HEALTH: !� urs$, ytc�,os��/�1..`11,� . o��ls�i, �./V., ?/ice L�r�;�vc,�rz Ro6�t� B��, L'l� ��isc�a/�a�1� . Anri14.2007 �C�.�� ru G. Murphy, .5..,CHO Director of Health # ��8 ' ` 2 f r+ '�i � � �'�T l,J`� �} �.` i�! ��r-_...._j..� - o. R TOWN OF YARMOUTH BOARD OF Ii�t�`I:T �; ' _ �� APPLICATION FOR LICENSE/PE�M�'I"=2006 % Y;. �� -.,% � -� _ JUN 1 5 2006 �� * Please complete form and attach a11 nec a,ry�d�cu ii�ts by Dece b r 5 �/ew Failure to do so will result in the r' ` � of�'�application p . �� D��'�. !s/•�'N4Z NAME OF ESTABLIS�-IlVIENT: �C��(� '�-Q��r-�,�,�4�`� TEL. # ��-3 C�.�-�� LOCATION ADDRESS: �l.s�S '(Zc�,�� a� �y�i,r vv�e��pflr�, Y�/� MATT"ING ADDRESS: SCYv� OWNERNAME:��;� r�. �l�.i�,u.3�sv� TAX ID(FEIN or SSNI,�_��,,�..,, CORPORATION NAME(1F APPLICABLE): �.kCs ��,�,�� ti„� . MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON 1N CHARGE; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIlbE�TCH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and at�ae�i copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT_.�F A T— r�- rrnT e r u _ — - -- �� —� OFFICE USE ONLY LODGING: LI�NSE REQLJIRED FEE PERMIT# LICENSE REQilIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 #06-O(,3 _CABIN $50 �MOTEL $50 _TNN $50 _CAMP $50 _SWIlvIlvIINGPOOL$75ea. _LODGE $50 _TRAII.ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQtJIRED FEE PERMIT# LICENSE REQIJIItED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# _0-100SEATS $'75 r CONTINENTAL $30 �06�-Lgsp NON-PROFIT $25 _>100 3EATS $150 _COMMON VIC. $50 WHOLESAI,E $75 RETAIL SERVICE: LICENSE REQLJIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUI[tED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOQsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ ""'�""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM"**"" !�C��D � > . � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACI�ED STATE WORKER'S CUMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S CON1P. 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:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQLTIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVIENTS 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 EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post . . __—_ �';nncnmer AdvtsOtles. 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 results must be sent to the Health 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 of Health. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. DATE: �c�� SIGNAT'URE: �� PRINT NAME&TITLE: ��-��L�-<-�� '�� `-`»`�� 09/28/OS : p . ,p� �\ The Cammonwealth of Massachusetts Department of Industrial Accidents > NAf�ttfir�slli� 600 Washington Street, 7`"'Floor ' Boston,Mass. 02111 + Workera'Compensation IasaraHce Affidavit:Bnilding/Plambing/Electrical Coatractors i�fos7�{ie�tc P�eare PRINT keiLlv �: ��,b�� ,_ Y�.�;� address: 1�C� Rp ti`�,�, �'H citv LQ.�(�i)'t'l�.�cY?S� state- NV't zin• phone# ��('��—(�-a-6 rk site location full address: I am a homeowner performing all work myself. Project Type: ❑New C�struction�Remodel I am a sole proprietor and have no one working in any ca�city. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees worlcing on this job. COIDMSP 1�1!• . . � . iddPESS' . . . � . � � C1tY" D�161t#' CO. # . . ... . :..:- �;; i : .,. . , _. .�. .,. .... ;:, . ...�..� , ,5::. .� . . . ,�. .,,aa�;�;.,.� ': ❑ I am a sole praprietor,geeeral coatractor,or�omeowner(czrdt owej and have hired tbe contractots listed below who have the following workers'compensation polices: �moanv name• address• citv �#. issa�a�cce co. �# aommav eame• address• chv' ol�o�e#- i�su�ee ea „p,olicy# ��Y�tlrretl��rre�r�a FaihQe�o secm+e ceverage a�reqdnd�ader Sectlsa 25A sf MGL 1S2 aa Ind b fke itip�kio'of cdsioal pnaNka sf a Sae�b i1,SM.�O andl�r one yens'imptbos�eat aa wr8 aa civY peemlHes in the[orm n{a 3T0!WORK ORDEA and a�ne of 5100.N a day agaimst me. 1 a�detstaad tmat a cepy of thi��a�eme�t may be fonvarded to the OAke ot lm atl=atlo�of t�e DIA for coverage veriAntla�. /do Henby cer(ify xader the Pns d peeal of perjrrry tliat t1Ye iwforwiatJo�provided abo►�e is hare�md cemct Signat�ue Date � Print natne � � � Phone# �'�Ca��_"�� /� o�cial nx oaly do not w�ite�t6is area to be eempkted by dty or Nwn o�cial eity or town: ' permiMice�e# �Bnlidln8 DePartment ❑chedc if Immedia6e reapeax h reqaQ+ed Q,s O��ce _-_ ----__ �HaMM Dqnrbmmt _ _ penen: _ ------ __— _ __ hoHe . �et �� P t �G��ti;"",��3�ED THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-013 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Rebecca Newt�n/RK Ente�ri e�Tnc /h/a Ag�ne Bed&�rea_kfast at 168 Route 6A, Yarmouth�ort,MA in said Town of Yarmouth And at that place only and ea�pires December thirty-fust,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to th.irly-two, inclusive, and of said chapter and sections twenry-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto aHixed their official signatures,this Nineteenth day of June A.D. 2006. BOt�RD OF HEALTH: L� y �. �� /LI.�5., ' NUMBER OF LJNTI'S: 1 S`Floor-2 bedrooms o��G��i, ./V.. �iee C�u� 2na Floor-2 bedrooms Qo�lt��. Bh�tuit, �� n�/�c�le�uxo� �l,� � , R.N. ruce G. Mucphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-186 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: Rebecca Newton/RKG Enterprises Inc., 168 Route 6A, Yarmouthport,MA Whose place of business is: A�ape Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2006 BOARD OF HEALTH: B $. �, /l�I._`75., ' . ��"��, k�.�, v�e�� R�t� ��, �►� n��t � r , R.�v. June 19_2006 ,.~�r` ��, '�;;,�4�,��E� Bruce G.Murphy,MP , .,CHO Director of Health ' �— '' ' ' � �8`�9 A�APr 8 i� •�f�R•y TOWN OF YARMOUTH BOARD OF HEAL r _ � ..o 3 -`� APPLICATION FOR LICENSE/PERMT�2� . ` �d � , � �-�` �: .!? G; � �� s �; `��i _ _�� , .,` `. .� �� * Please complete form and attach all necessar�; ,`" �ts by Decemb r 31�j�Q0�.� 2006 Fa,�lure to do so will result in the return c�f"�y,our application pac t. NAME OF EST.ABLIS�IlVIENT: , G� �� &� TEL. # �08`36�-��4G LOCATION ADDRESS: � hJ 5 i- OU�'� A�R1r10U17� 0(Z?`- � O 2 E 7 MAILING ADDRESS: � � �km� — OWNER NAME: S�M-I�1 e. /YJ�L�SSf}- O�0 U�� TAX ID{FEIN or SSN1� CORPORATION NAME(IF APPLICABLE): � �3 � � MANAGER'S NAME: Nl �U SS� O� O fJ�K� TEL. #5G&- - 2 - 2$0 G MAILING ADDRE S S: -- S 1�-ivt P — POOL CERTIFICATIONS: The pool supervisor must 6e certified as a Pool Operator,as required by S�ate law. Please list the designated Pool Operator(s) and attach a copy of the certification to this fQrm. �_ 1. Pool operators must list a minimum oftwo employee ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CP . Please list these employees below and attach copies of employee certifications to this form. The Health De ment will not use past years' records. You must provide new copies and maintain a file at your pl of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. /". 1. 2. PERSON IN CHARGE: . Each food establishment must have at least one Pers n Charge(PIC) on site during hours of operation. 1. 2_ HEIlbg,�EH CERTIFICATIONS: All food service establishments ' 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at times. Please list your employees trained in anti-chokmg procedures below and at�a��i eopies of employee�eftifications to this form. The Health Department will not use past years' records. You must provide new�opies and maintain a file at your place of business. _ �., 1. 2. 3. 4. RESTA T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERNII'T# LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMTI'# I B&B $50 D�i-'Q _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIlVIlvIING POOL$75ea. �LODGE $50 _TRAILER PARK $50 WHIIZI,POOL $75ea. FOUD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQTJIRED FEE PERMIT# _0-100 SEATS $75 � CONTINENTAL $30 �Q3 NON-PROFIT' $25 _>100 3EATS $150 �COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIIZED FEE PERMTT# LICENSE REQIIIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,00{3 sq.ft. $200 V�'NDING-FOOD $20 _QS,OO�sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMUUNT DUE _ $ $O.00 """**PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM""""" ��l�''�f�� 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 af Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. 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 desser�s rt�ust be te�te�on a monthly basis by a State certified lab. Test results must be sent to�he Health Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terrns ha�e been met. __ __ __ __._-_ ---— _ OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR GOOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. DATE: �� 3a� �� SIGNATURE: PRINT NAME&TITLE: a�� O�--tJR� , �l-ZJ�V��L- 09/28/45 • ` �� _�__=--__� The Commonwealth of Massachusetts � � __ = Departnent of Industrial Accidenls ~ - = N�K�M� \ _ -_= 60t1 Washington Stree� 7`�"Floor , Boston,Mass, 021I1 _-- J. Workera'Compessahoa Ls�uee Affidavit-B'ild�/Pl�mb�'glEleetiricxl Co�traetors �' -,��`;` � �'��h.t�� *�,��., �� l � /T1'��1 s's� ,�20 �i�'..K� � a�s: /� �1��t/ s T • 6z� ��4- citv �/�Z.'U( /�Il( 1 0�-'T shate• � zip�2� 7� o�h�,.�# �(��S'��17 0� 2� 7� work site locati�ffoll addressl: 5�� ❑ I am a homeowner perfarnring all wark myseif. Project Type: ❑New Ca�ructio��Remodel I am a sole 'etor and have no one w ' in an ca ' . ❑Buil ' Addition �r �; � . �". . , � .�.: . ,�:_. ,, ,. . ,. � �, ❑ I am an employer providing w�kers'compensatian fa�my employees working�this job. ooao�v a�t: �k: � ❑ I am a sole praprietor,geeeral cosh�actor,or homeowoer(circle oAe)and have hined tbe comracto�s listed below who have the following workers'cflmpensation polices: ci • � �a • ,.,� � n. # d��?' M ,� , ��:�... .<�: •� � �sY eame: �: �• ��. _ - __ _ - _ _- - .:_ �� _ _ _ _. �..: z. ..,�... r.._._�. -. .., ; .. � Failare�s secve orvera�e as neq�ired uder See�a ZSA�f MGL 1S2 ua lad b tMe idpaiWa�fcri�id pe�ailks�a��►b t1,SA0.M aid/or one years'imptiaonmeat m we8 as civ/pesaltla ia t6e ferm of a 3T0!WORK ORDER aed a�ae ot 5100.00 a day agai�t me. 1 aadvshtad that a npy af tiis�6mimt my be for�varded bo tse Omoe of laveq�tioffi of t6e DIA fer avrrage verUiatly. !do hekby nder ins an penwlties ofPtr�ury tliet tlYe ixjo�unatton pr»v�ded aboWe is true a�d ce� signature �atc � " �C�— f�f� P�A� �C�t�l� � o t J�@�� Pba�# 5 0�'- 3�2 - �. 5 7G' effiicial ase onFy do s�t wrke I�this ara te be compkted by dty er tewn e�ial city ar ta�rn: pernvif/tloeese!1 �� ❑cgcck if Immedia6e rapeme is teq�ed �E Boud ❑Sdeetmm s O�ee centact penon: phene#; ��t�� tT�riecd S�t-10IXi) ��i�:�.�`��Ea _ -- . __ _ _ TQWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FUOD ESTABLISHMENT PERNIIT NUMBER: #06-183 FEE: $30.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the neral Laws,a permit is hereby-granted to: John&Melissa O'Rourke, 168 Route 6 Yarmouthport, MA Whose place of business is: A�ape Bed&Breakfast Type of business: �ontinental Breakfast To operate a food establishment in:_ Town of Yarmo�th _ _ __ __ __ ------- Permit expires: December 31, 2006 BOARD OF HEALTH: L� ' ' �y, y�� /h!�,� • ��s�, �.n�., v�e�� 2�t� ,a�, �� Q�r , r�.�. June 7.2006 Bruce G.Murphy H,RS.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUlVIBER: #06-012 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to T�hn&M liS� n'Ro�rk d/h/ Agane RPd R RrPal.fact at_ 168 Route 6A, Yarmouth�ort MA in said Town of Yarmouth And at that place only and expires December thirty-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Seventh day of June A.D. 2006_ BOARD OF HEALTH: � �J �, (��y /j�J�y,� • NUMBER OF LTNTTS: 1 gt Floor-2 bedrooms dYeP�w�E� S�y� /(✓1/. UsCe t�it�afst�ft 2na Floor—2 bedrooms fl�G� ��y, (� /�ctiiiel�Jl/lc`.2��i�tto#� �r� � , � . ��it"�IED �._ _— _ _ _ -- Bruce G�. t�r�h� PH}_R,S.,CHO Director of Heal . , ..., � #�6�3� AGa,P� � .Of e R,� TOWN OF YARMOUTH BO .�E�L��`. --__�_ ... _ �...., - ' o� �.-'c APPLICATION FOR LIC��'' � 2005 � � � ., .,'? ,; , �;.� ;�;:� ` �,;,� 1 � 2005 * Please com lete form and attach all neces do�inents by December 31, 2 6 0 Failure to do so will result in the ret�.u�of your application pa�ke� : _ ' �__ .�_ � ��f d__,� NAME OF ESTABLISHMENT: � � 2�kkFA� TEL. # 0' - 3f>2-2�Gd LOCATION ADDRESS: I //Illl�lN S"�' - Rcu'�� Y�� T MAILING ADDRESS: ��'�"�� OWNER/CORPORATION NAME: �r�MI � dj��usS� O�Ovi2K� MANAGER'S NAME� S�`� TEL. # �0 F '3�� SGO MAILING ADDRESS: S�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. P. ._l�ase list the designated Paol Operator(s) and attach a copy of the certification to this form. �.�----� 1. 2. ...�---''".v_ Pool operators must list a minimum of two emplo ees ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation ). Please list these employees below and attach copies of employee certifications to this form. The H Department will not use past years' records. You must provide new copies and maintain a fil�af your place of business. i ,.'''" 1. /� 2. 3. / 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years' records. Yoa must provide new copies and maintain a fde at your establishment. �i/ 1. 2 _ PERSON 3R�CI�GE: -- —__ _— _ __ - ---- _— _ e_ Each food establishment must have at least one P n In Charge(PIC) on site during hours of operation. 1. 2• HEIlVILTCH CERTIFICATION : All food service establishme s with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premise t a11 times. Please list your employees trained in anti-choking procedures below and attach copies of emplo e certifications to this form. The Health Department will not use past years' records. You must provide ew copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICEN E REQUII2ED FEE P�RNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# ( t B8i $50 ��'�I� _CABIN $5� MOTEL �50 .,;. � $50 _ _CAMP $50 _SWIl�IlVIING POOL$75ea. LODGE $50 _TRAILER PARK $50 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICEl�]� UIRED FEE PERMIT# LICENSE REQUIIZED FEE PERIvIIT# 0-100 SEATS �75 �CONTINEN $30 �� NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRfiD FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 ____VENDING-FOOD $20 Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACGO ^$25 NAME CHANGE: $10 AMOUNT DU�8 O. O� ..,�,�. PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•"�`"�------- ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR � / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/ Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: _ YES_� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�Il�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS _ POOLS POOL UPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depa.rtment prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISQRY: Each food estab ishment 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 Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior t4 the catered event. Thses forms can be obtained at the Health Department. _ _ �S:_ ____ __--- _ _ _ - Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �— l'� —0 � SIGNATURE: �C� VI��''-�`��"LC.. PRINT NAME& TITLE: �� R�U►R-�� ; C'�W ti�l'` 10/22/04 . `�� T7ie Commonwealth of Massachusetts ��- -�j De artment o Indus�rial Accidents � __ P f . � - - NNfatNiN�� - == 600 R'ashington Stree� 7`�'Floor - � � 02111 ��,�` Bosto�e,Mass. � Workers'Com�reasahoa Ies�aaee Affidavit:B'ildii Iamb��/ElecbricAl Coatractors .,,. , „ �... � .. ,., � _.,�. ..,,._ _ � � �. x 9.a .. � " �� k�,�,�a ��,.�a�� _>�� "��3� , �, , � `�C-r��l �� v�(Zf�� aadn�ss• �b�. I�1� �llll � '7'- RT� � � � ��ri Y�-M o u��t- �Po�T Stete' /V 6 � Zin' �/L-"7� n1K�# s a 8- 36'�-2��0 wrork site 1 -� r„u addreSS_ S'�"`� I am a homeowner performing all work myself. Project Type: ❑New C�struction(]R�nodei I am a sole 'etor and have no ame wo � in an�ca _� • ❑Buil ' Addition ..,;.. . :a. .:. � . , .. .. : . ❑ I am an e�mployer�viding wo�eas'compensatiasi for my employ�s wadcing on this job. #: ❑ I am a sole propri�or,geeeral coitractor,or homeo�ra�(�rclt oae)and have luted ibe ccmttactoss listed below who have the following workers'compensation polices: ___...—.--- � il� . ,, � � � �� .. _ , �:. . � .,, . . : # ~ ...� e.. .. � , _., Failm�e 10 secme ar►era�e�f req�ed uder 3ectloi 2SA d MGL 152 aa Ind b IYe irpalH�a�!'ai�iW pe�aNks�f a�e�p b S1,3N.N aid/or ose yeais'im{ni�o�enc as.re8 as civ�pe�ltl�in t6e forn ata sTor wox[c oRUEx a.a a nae af sleo.oA s aay aaahst ae. I andcnana mc a apy ef thia Nateasent my be fonvarded bo the Onice of�ffi of tke DIA for esverage veriAeatl�e. I do beneby cemfy xnder tJie patns m�d pen�uies of perjary tliat the infonire�fon provPded oboae is dxe and corre�cx . gi�� ` " Date Z ^� oZ —Q S Print nazne ��«` � �l��J U/'�= Phone# �� — Z o � v efficial ase only do sot write is this am to 6e cemptetdi bY dtY er�ewa e�a3al city er te�va: P��* ��t ❑c�eck if�mc�ale respe�e is reqaimed �'s O�ee 0�Depat4eeet rnntact persan: Phe�e#+ ��* (.cviecd Sqit 2003) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-013 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to To n &MeliSca O'Rourke d/b/a A,ga�P RP� �R*'Pakfact at 168 Route 6A�Yarmouthport MA in said Town of Yarmouth And at that place only and expires December thirty-fust,2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto aff�ed their official signatures,this Fifteenth day of September A.D. 2005. BOARD OF HEALTH: Be�t�'.�u�s� �5. �ondo.�, A�1.�l. ' NUMBER OF iJNITS: 1 gt Floor—2 bedrooms P��c��,,� ��v�� 2na Floor—2 bedrooms Qa��• ��. �%� a�st�, R.n+. �4.��j��L�.,z, R.IY. Bruce G.Murphy,MPH,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-198 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: John K &Melissa O'Rourke, 168 Route 6A, Yarmouthport, MA Whose place of business is: Agape Bed&Breal�ast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2005 BOARD OF HEALTH: Besr�ntirs�S. (�'o+u�s,�61._`h. ' /�c�Mc$�u�lt, ?/rc�G�v� Rod��t� 6��, G'!� �s�, a.�. �v��, R.�v. September 15.2005 Bruce G.Murphy,MPH,R.S.,CHO Director of Health o�'�� : �� _ . o �` � Y �1 �' � � `3 ll46 ROUTE 28 �OUTH YARMOUTH MASSACHUSETTS 02664-4451 � MATTACHEES � � 7� � � h��A�OAFTE0�6�� Te1�p11OI�lE (508} 398-2231,�.xt. 24I — F� (508) 760-3472 B OARI� OF HEALTk-� To: All 2005 Yarmouth Board of Health License/Permit Holders From: Yarmouth Health Department Re: T�Identification Numbers Date: June 1, 2005 The Massachusetts Department of Revenue is now requiring that the Health Department furnish to them detailed information regarding all permits and licenses that we issue. One of the required details is to provide a tax identification number, whether it be an establishment's Federal Employer ldentification Number (FEIN) or, in the case of an individual's license, a Social Security Number (SSN). This information will be used by the Health Department purely fqr administrative purposes only. Would you please fill out the fields below and return this letter to: . Yannouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to ca11. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is(508)398-2231, ext. 241. Establishment: _�� a gR�KFI�T'� ��r SSN: (�� Location Address: /�� '"��S T- �� Signature: Print: �C� �-1� �1`�'U 1Q� Title: C�f,�J�l1 �� , A; r,. SC��C� �.�� : � Printed on Recycled �� Paper �;. ' ��66�1 qc�aPE E_YR_ �� -�� ._R.�C TOWN OF YARMOUTH BOARD OF H,EALTH � � � �� D APPLICATION FOR LICEN�F,l��R��'�.�-2�04 °�;. „!s �, ,Y, � �� * Please complete form and attach all necessary c�cuments by Dece ber`3�1�2�0�.Z004 Failure to do so will result in the return of your application p �ALTH DEPT. �ME OF ESTABLISHMENT: � �D � kFA�7' T # �S-'�d2 ZBG� LOCATION ADDRESS• 16 S� �'l�-l�V 5'� 'i� 6 - �L�tcvi�- -c��- �1�- p2.6��.' — S. � — OWNER/CORPORATION NAME: '�4�i11 � /1��L�SS O (��,�'� MANAGER'S NAME• /�'l�z G�SS s�- Q�i/�1G� TEL # S(1R��2- 2g44 MAILING ADDRESS: — S A?l'�/�. ' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P:,o1 �perat�r(s) and attach a ca�y of th;, :,ertsf cat:crz t� th:s fcrm. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. �'ERSUN IN CHARGE: ___-- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAU�tANT SEATING: TOTAL# OFFICE USE ONLY 40DGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# I B&B $50 �{'GI _CABIN SSU _MOTEL $50 _INN $50 _CAMP S50 _SWIMMING POOL$75ea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL a75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICGNSG REQUIR�D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $30 �U�I�I'��J NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. S50 WHOLESALE $75 R�TAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRGD PEG PERMIT# LICGNSE REQtJIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sy.ft. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZFN DBSSL'R'C S35 _TOBACCa �25 NAME CHANGE: $10 AMOUNT DUE _ $ 80•OO ` �"•,"�a ; � **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****" �" � `�'� I r .� _ . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � 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: ES NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION?-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 POOt.S POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. G�ATERING PO.�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. �RO�E1�1�ESSERTS: _ __ 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. OU'�OOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: d 2� � SIGNATtJRE: PRINT NAME& TITLE: �� a�vR�- m��'�''v� 10/22/03 : ' , � � ' Th e Conrmon weulth oj Mossach usetts � � Department ojlndustrial.-�ccidents � o Olflceol/�s1l�sdiis 600 Washington Street ' ` Bnston. Mass. 02111 �~ '��y' W'orkers' Compensation Insurance Affidavit ARoiicant intormation: PlesscPR � namr L�cation� �` �hone� � i am a homecwner pert�rming all work myself. � ( am a sole proprieror �-� h��e no one �.orkin� in anv capacit�� I am an emplo�er pro��dino w�orkers' compensation for my employees w•orkine on this job. , comoan�• name: ��"� � ��uSs �' Q�UVeK� Ag�' �I11� �� /`"vl�+��ar address: !D � �i�'�� K! � pta' s�!': 7 �►�LW (!�r �� nhone il• �V O '�.7G a�2$�'l/ ' iosurance co. lUlAl.��-t� � ��N1//1 oli y# 1/�� ` � � I am a sole proprietor. generai contractor, or homeowner(circle oneJ and ha��e hired the contractors listed below ��ho ha�e the foUo��in: ��orkzr� �ompensation polices: comoanv name• address cin•• Rhone#• insurancc co, policv# comoanv name• address• _ _ _ _ _ __ ii2Y: boe �• insurance co. Fo�n,� t Failure to secure coverage as requlred under Secnoo 25A of MGL 1S2 n�iad to t6e iopo�idoa of erisi�al peadtles ota 6�e op to Sl¢00.00 a�d/o� one yean'imprisonment a�w�ell a�civii penaidee io the torm of a STOP WORK ORDER asd a lise of 5100.00 a dar a�aiost ma t a�denta�d tbat a copy of thy statement mav be fonvarded to the Of(ice of lnve�tigation�of t6e DIA for eovenge veritiado�. I do hrreby cen' •under the ains and penalties of perjury tha�the injormation provid�d abovt is ttue aad eorr�d Signature � � p ( " 2�� d� Print name `�� V VI`,N� PhoneM �Do � �� " 2�� .- o(iicial use only do not write in this area to be completed by eiry or town oAfcial ciry or town: Y�M�IIT� _ permit/licen�e p nBuildieg Departmmt �Licensiog Board �check if immediate response is required � Selectmen'�Ofiiee contacc person: phone M:_ �508� 398�223��`:�w h��,,,��meat .. < a,,: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-013 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to John&Meiisca n'Ro �rk / AganP Red Rr Rreakfast at__ 168 Route 6A,Yarmout�ort, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2004 unless sooner suspended or revoked for violation of tiie laws of the Commonwealth respec:ting the licensing of innholders. T1us license is issued in confornuty with the authority grar►ted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-iwo to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their o�icial signatures,this Twenty-third day of April A.D. 2004. BOARD OF HEALTH: Besc�ts�z�1, �, /GI.�, ' NLTMBER OF UNI'TS: l st FloOr-2 bediooms /��NSC��lC.[�e?IKO�� viCe�Mlflti 2"d Floor—2 bedrooms Ra��. B3ar�wr., �eh� dU�e� �'e�t, Q./�. �� , R.N Bruce G.M hy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHMENT PERMIT NUMBER: #03-193 FEE: 30.00 In accordance with regu ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Seetion 5 of the Genl eral Laws,a permit is hereby granted to: John K. &Melissa O'Rourke, 168 Route 6A, Yarmouthport, MA Whose place of business is: Agape Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2004 BOARD oF HEALTH: L;�as yu�es�c `.�. C�''o�,ok, /1�$. ' p�a'a��, v:�.e�:�� R�t�. a�„�, et� � 5�., R.N. � R�V. �C��s�� Anril 23.2004 Bruce G. Murphy P , .S.,CHO Director of Heal , �Z'I�(��J?� ��0�'✓ AGAPE �� - 2oF��e,yo TOWN OF YARMOUTH BOARD OF HEAI:'1`I�� o 3 " =�� APPLICATION FOR LICE ERMIT-2003 ' Q � C� C � 1�/J [� � 0.� y � �'•.. ..�'��? ��.: e * Please complete form and attach all necessary �cum;�nts by December 1, Z�. 3 1 2003 Failure to do so will result in the return o�our application packet NEALTH NAME OF,�STABLISHMENT• DB� �'�P� B�b � �2�I�KFh-�r TEL # �d�-�52-28� LOCATION ADDRESS /6� vyl A--iN �T /�TE �++�-- �9�1�+1T� P�� I�'�� d� �5 MAILING ADDRESS• — �� — OWNER/CORPORATION NAME• ��ti � �Yl�Z1 ss¢ �2c��I�.C� — �,�Al`TAGER'S NAME• �A�yl F TEL. # .5"4 -36 2�2 MAILING ADDRESS• �'�"'�� POOL CERTIFICATIONS• The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and_attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - C�:RTIFICATIONS: 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 Esta.blishments, 105 CMR 590.000. Please attach copies of certification to this application. Tbe Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2• PFRSON IN CHARGE• Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. RF.STAi RANT SE{�TING: TOTAL# OFFIC�USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 B&B �5� 0.3��3 _CABIN $50 _MOTEL $50 INri $50 _CAMP $50 _SWIARvIING POOL$SOea. LODGE $50 TRAILER PARK $50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 I CONTINENTAL 30 % s�F�'(� NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 �TAIL S 4 VR ICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TOBACCO $20 _<25,000 sq.ft. $75 ____TOBACCO $20 _<50�.�. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 �iAME CKANGE: $10 OLTNT.I�UF� __ $ g0•OO �� _� ��.� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE O�'FORM***** . . L � ADMINISTRATION Under Chapter 15�, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '; of any licen�e'or permit to operate a business if a person ar company does not have a Certificate of Worker's ` ' Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEL� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town 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 annua.11y from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO R�TLJRN THE COMPLETEiD APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS _ _ _ _ _ _ _ _.________ POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yartnouth 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. �ROZEN DESSERTS: Frozen desserfs 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. OUTDOOR COOKIN • Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE:V�a 7 J �� SIGNATURE: � PR1NT NAME& TITLE: �G/fdlJ C,Q'��IC� ��,v,��f� 10/18/02 t r 2 � � The Commonwealth ojMassachusetts � � Department ojlndustrial.-lccidents � o Of11C001/OYCsI/p�d1lt � 600 Washington Street � ,= Boston. Mass. 02!11 �'" °"�y W'orkers' Compensation (nsurance Affidavit �Rnlicant infnrmafinn� �C83C T�Tl�I��it n�m�_ �l�'W/� U �'Z�l�� IJf�VV��n-e'� YV�� !�'�j�,l�� `jfY a ��!�- '" �� Incation• I 6 � �.�'l/1/ S% /�=�� O /'�- / N��rY �'i�� /'�� 20 �S �-�r� phone q 5�J��J�f �- Z�50Q J„I am a homecµner perturmin,ail work myseff. ( am sole proprieror �-� ha�e no one ��orkin� in anv capaciri� � I am an empio�er pro�idin�workers' compensation for my employees w�orking on this job. comP�n�• name• �ddress� s��•• nhone M• iosur�nce co policy# � I am a sole proprietor. 4enerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follo��in� ��orker� ;ompensation polices: comp�v name• ddress• �n•- phone H• insur�ncc co Folic}'# -- som�nv name• _ _ . ___ .__ . addr ss• Sjly• nboee A�• insurance co R�� a Failure to seeure covera;e as required uoder Secnoo 25A o(MGL 152 na lad to tbe iopaioon o(trivi�al pesaltles of a d�e ap to S1�00.00 a�d/or one vean'imprisonment a�w•e0 a�civil penddte in the form o(a STOP WORK ORDER asd a tiee of SI00.00 a day apiost ma t a■denn.d e�a�a copy of thb statement may be fonvarded to the OtTice of Inve�tig�tiom of t6e D1A tor eoven=e veritiqdo�. /do hrreby cerrif}'under rh5 porns end penaltfes ojperjury tba�t/rt injormation provided abovt is tn�e and corrtcL Signature � o'�� 7 � � ('�,' �a8- 362- 2�OQ Print name ��ll� � - v�0 �� Phone M .. o(Ticial use onl� do not writt in this trea to be completed by ciry or towe ottleial citv or tow.n. YARMO�TQ _ permitAieeau tt nBuilding Departmeat ' � — �Lieeasiog Board �� "� '�-�� Sdectmen'sOfTiee �cheek if immediate response i�required �y.-,y, � �Health Department cont�ct person: phone M;_ �508� 398-2231 ext. Other .. . � _,.. �1 i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NLTMBER: #03-013 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to 3ohn&Melissa O'Rourke dJb/a A�ave Bed&Breakfast at 168 Route 6AA Yannouth�ort�MA in said Town of Yarmouth And at that place only and expires December thirty-first,2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing auWorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inctusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereo�the undersigned have hereunto affixed their offcial signatures,this T'h►rd day of February A.D. 2003_ BOARD OF HEALTH: ��s�. �efli�(cac. (�xaec ��D. (�,mcd°'t, �l D.. 2/�ce ,�a�t�, b'aoav�c, L� �a�:ick'J1�c?�ar.uatr � Se�k. ,Z?72. � ruce G. hy, R.S.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-150 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 ofthe General Laws,a permit is hereby granted to: John K. & Melissa O'Rourke, 168 Route 6A, Yarmouthport, MA Whose place of business is: A�ape Bed&Breal�ast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2003 BOARD OF HEALTH: �canf.ed's�. �ellilv� ��ui.c �e•� D. G��mzdo.�. �?l.D.. �/�ce ,�od�� i'�rotwt, L� �a�cic��c�rJuxott � s ��t February 3.2003 ruce G. urph R.S.,CHO �� . ��=� Director of Hea � _ -; AGAPE B+8 + .��i(� � ��+ �TOWN OF YARMOUTH BOARD OF HE�LTA r� i; � �� ,V L,;. � 3 �� " APPLICATION FOR LICENSE/PERMIT -2002 , �� * Please complete form and attach all necessary documents by December 31, 2001. Fail r will r��ult n the return of your application packet. ��"��k �'m'� ` '� NAME OF ESTABLISHMENT: G�1� � D �i R�A-KF�T TEL. # .505�36 a- z 8oG LOCATION ADDRESS: /6 $ M A-!N �]' 2T� G�¢ ��'(�i12vv'T%�PPR7' !Y1/9- O 26 7S MAILING ADDRESS: S� � OWNER/CORPORATION NAME: �n�d-N � �'1�C-rSS9- 0�12at�,2P� D F3 A� MANAGER'S NAME: S6rY/F� TEL. # MAILING ADDRESS: 3�'1 F� POOL CERTIFICATIONS: The pool supervisor mast be certified as a Pool Operator,as required by State law. Please list the designated Poa�-8perat�rfsj and a�tael3�-eapy-o€�� ..`;�� l�is�e�.-- 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. - 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. FE�SON IN CHARGE: _ _ _ _ _- - - _ _ __—,__— �__�.,_-=-�v. Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# __ .__ ,�._ J� �� OFFICE USE ONLY LODGING: LICENSE REQUII�;ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# l B&B .-°'��J . $5f1 .�a'OIA _GABIN $50 _MOTEL $50 '`'� I'1�iN� $50 _CAMP $50 _SWIMMING POOL$SOea. _LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: µ - LICENSE REQUIRED FEE PERMIT# LICENSE REQUI D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 1 CONTINEN $30 #a�-�33 NON-PROFIT $25 �� — >100 SEATS $I50 �"-�01GIMON VICT. $50 WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT_�35__ NAME CHANGE: $10 � � AMOUNT E _ $ ��•00 5�,��`;��!�-�� *****PLEASE TURP1 OVER AND COMPLET E OF FO�f*�-**_____.._.--- . t • ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: -- �E� 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�-IMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swi.mming 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. C�ITERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. __ _ _FROZEN DESSERTS:----- _ _ 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. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: � �� d/ SIGNATURE: ' `�ca� Q�o��l c�-� ��.v�v� PRINT NAME &TITLE: 09/ll/O1 �� ` �� r � � The Commonwealth ojMassachusetts � � Department of Industrial.-�ccidents � a Ofllce oll�s�lpst/iis 600 Washington Street ' �` Boston.Mass. 02111 �,y �� L'orkers' Compensation Insurance Affidavit ARniicant information: plesseYRi�'I'T�-�• namr �D(� `� l4'l �LL( �lS� Q��/ e/1� L�cation: f 6 9 /1��/� � �T�L �f� �tt� y�lj��'�-�r� i"QI�N /�,'� �a�U �,� phone# 5rJ t�' �`a-Z�SQ C'/ � I am a homeowner pert�rming all work myself. � f am a sole proprieror =-� ha�e no one «orking in am�capacit�� I am an empio�er.pr4�_�dins w�orkers',compensation for my em�io��ees workine on this iob. s4mnan�• name: �T��"i') � 1�lZ� � I��ZP7/F�.��C7� 1� �0�9N '& ��L.C�S/� pl�Z/i� ��"?- -- �ddress: �6 S � �/V � /� � � �" � tit�•: l rl�lndV�d' ��'ll� � 1�' �2� 7 / phone M• 508 - 36 a- zgo� ��s��e�a. S�-ct�2s P�P�-�r� c�U�ry Ao,;sy# ��0 16 33 �' 7 � ! am a sole proprietor. :enerai contractor. or homeowner(circle onel and ha�•e hired the contractors listed below �tiho ha�e the follu��in= ��orker �ompensation polices: comoanv name: address: ��"� nhone e1• insurancc co. polic�•# comoanv name: _ _ _ _— address: _ _ __ __ _- �'� nhoee M• insurance co. �� ' Failure to secure coverage as requ�red under Secnoo 25A of MGL 1S2 ess lad to tbe iopaitioe oterivi�l peedtles of a Ooe op to 51,500.00 a�d/o� one yean'imprisonment a�w�ell a�civil penalde�io the lorm of a STOP WORK ORDER aed a fine of S100.00 a day ataiost ma [a■denn.d e�a�a copy of thn statement may be fonvarded to the OlTiee of Inve�tigation�of tbe DIA for eoven`e veriQaeio�. I do hrreby cenif}•under rh� ains and ptnalties ojpery'ury that!ht info►nration providtd above is trrt[and eoned Signamre � /�/�� ol��tJ G�(�.oUK.K-� � P�int name Phone Il �Q$�3��` 2$�d .. ofTicial use onl� do not write in this�rea to be completed by citv or town o(lttial city or town: Y�M�IIT� _ �r �� p n8uilding Departmeot � �"`"•-y' +�� LicensingBoard �check if immediate response i�required 261 �Seiectmen'�ORice ---,�----- �Heaith Departmeet contact person: phone q:_ �508� 398�2231 ezt. nOther , , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-010 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to _ John&Melissa O'Rourke d/b/a A�ape Bed&Breakfast at 168 Main StreetlRoute 6A. Yarmouth�ort,MA in said Town of Yarmouth And at that place only and expires December thirty-first,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Tenth day of May A.D. 2002. BOARD OF HEALTH: s�f, xe� fa.nuc D. CFanalai. ,�iee ,�oP�rt� �aw�, C� �a�r�ek�� s�, � ruce G. Murphy,MP .S HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-133 FEE: $30.00 In accardance 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: iohn K_ &Melis�a O'RoLrke, l68 Main Stree /Ro � 6A, YarmoLt� or,MA Whose place of business is: A�ne Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2002 BOARD OF HE�,Z H: elcanfed?f. ��il:ez, elraur.,ra.� �e�c�u�ri��. �iaralo.i, �D.. 2/Ece �arac�' t� S�noua�, �ar� �a�r�ck 11leDe�a� �� s�, �� Mav 10 ,2002 �+ ��,� "��'�F' ' �`�� ruce G.Murphy,MPH .5., O D'uector of Health -� ��'�` ;TM""�`�,��.NRI03 30��S B:�LLO t'[.L�'IdJ�1i0�QI�I�'8�A0 I�RIfl.L�S1P'�'Id••••• --r� $ _ �na s�r�ora� ot$ u ��nt ooz$ ��bs 000`sz< S£$ .LZI�SS�Q N�Z02I3 SL$ '$'bs 000`SZ> oz$ o��goi s�$ ��bs os> #i�x�a a�3 a�na�t asK��l� # i�xaa a�3 Q�na�x asNa�lz :� i s�� a�s�zo� os$ �s�ln Nov�oa S Z$ .LI302Id-l�iOI�I 0 S I$ S.L�'�S 00 i< � 0£$ 'I�.LI�I�I�II.Ll�tO��T SL$ S.L��S OOt-0 #ZIY�I2i�d ��3 Q�2IIf1a�2I�SN��I'I # .LIT�I2I�d ��3 Q�2IIf1��2I�SN��I'I �� Q 3 '�SZ$ 'IOOd'I2IIHAA ��aOS$ 'IOOd JI�tIY1tNIIAc1S OS$ 'I�.LOI�I OS$ ?I2Idd�I�'IIH�IZT OS$ �JQO'I OS$ cII/�I��i OS$ NNI OS$ l�ti�'� ��'�Z� OS$ g�BS � # .LIY1i2i�d ��3 Q�IICl��2t�SI�I�aI'I #ZII�Ri�d ��3 Q�2iI11��2i�SI�I��I'I �S�'J(T�� u 3 •-------------------------------------------------- ------------------------------------------------------------------------------------------ #�ioi �sidas ��ov�s-uor� #�soi ��rus��s i�n�is� �� z � •ssauisnq 3o aa�jd rno�f�e ai�g u�B;uiem pu� saida� h►au ap�noad �snw no� •spaoaa.� �saBa�;s�d asn �ov ��r,ti►�uaw�.r�daQ y;reag aqZ �uuo�scc��o�suoi��gi�a� aa�Coiduza�o satdo�u��E pue nnoiaq sampa�o.�d �u�o��-i�u�ui paure.z�saa�oidu�a.�no��sij as�aid �sauit�j� �� sasnua.zd at�� uo iannau�y� u�i�.uiaH aq� ui paure�� aa�olduza auo is�al �B an�u �snu� a.zotu �o s��as SZ u�inn s;uauz�s�Iq��sa a�in.tas poo3 II�' I 'b '£ 'Z 'I •ssaaisnq�o aaeid.�no�;g aj�� aiw�u��m puB satdoa n�au ap�no.�d ;smm �o� •sp.ioaa.� �s.iea�;s�d asn�ou��uaw�.i�daQ q��ag aqs, �uuo�sn��o�suoi��t,�,�aa�olduta �o satdo� u�� pug nnoiaq saa�oiduia asau��sij as�aid '(2Id�) uot��i�snsa� �.reuouijndotp.re� �S�tunuxuio� pu� pTy�s.n3 p.r�pue�s `��a�s sa�Enn�is�q ut pagT�a� �I�ua.un� saa�oidwa onn�3o umcu[utcu B �s�i �sncu sio��elado iood .Z .i �uuo�s�� o�uoi��gt�.ra�aq�30�doo B q�B�B pu� (s)so��adp jood pa�.�u�isap aq� �sti as�aid •�Bi a��;s ,�au ,fq pa.cmba.� s� �.to��.�adp jood � sB pay��aa aq ;snw .�osi�+.iadns jood aqs . N I =� Q I�II # � � �2I �'��j ��?�w ��-� �� N .L ��'-q S ��3`�'2�CI�JI�II'I . L 9 Z f� �Ytt -�-?J_ ��'✓1M �` � �1� J I,LV 'I .____�o�z-�9� # �� ! ��J �c�-�lJ � i a � u ----------------------------------------------------------------�------ --------------------------------------------------------------- ��ax��d uoi��tidd�ino�f�o u.cn�ai aq� �n�.it��.os op o�ain�C�3�666 i `i£-�aquza�aQ�q s�uacun�op��ssa�au ii�c�a�� pus uuo3 a�.aldu�o� as�aid * i � M AY 1 2 2000 �,�,`�ppOZ-.LINRi�d/�SI��I'I?I03 I�IOI.L��I'Idd�' ,.-, s _ HEALTH DEPT. HZ��'�3O ��'�g HZnO�i�'A 30 AiAAO.L . �� . , " ��a��.-�� !t . �� 66/ZI/I i ��vv�� '�� N}�o� �� u�a � ��xni�u�ls o o �� ,�Q 'Q�,LISIHO?Id SI,LN�Y�ff�SI"Ifl�.LS��IA2I�S QQ03 ZIO '�Il�v'Z�2I V Ag.L�11Q02Id Q003�I�30!i�''IdSIQ 2I0 `I�IOIZ�2I�d�2Id`JNI?I00�lIOOCLLf10 O 'H,L'IH�-I 30 Q2I`dOg�I,L Y�IO2i3'I�AO�idd� 2IORId�A�'H.L�I�Y `��IA2I�S SS�2I,LI�'MRI�LIVM H.LIt1c,JI�II.L��S 2I00(ZLflO `'a'i)5�3�'��S.Lf10 Z - - _ _ _ '.I.�T l�i��g �AHH SNRI�i,�AO�K�L'II.LNf 1.LIT�I2i�d.L2I�S S�Q Nr'�ZZ02I32II10�301�IOIZ��OA�2I2I0 I�IOIS1�L�dS11S �-I.L I�IT.L'If15�2I'I'IIAA OS OQ O.L�2I(1'II�3 '.LI�i�T.L2I�d�Q H.I.�H�H�L OZ S.I�I�S�g.LStlY�i S.L'If1S�2I isai ��z a��ixa��z�is ��g s�s�g��.r�o��uo aaisai �g isnv�ssx�ss�a u�zox.� z �ZI�I�I.L2I�'d�Q H�.'IH�-i �-LL .L� Q�I�iI�.LgO �g Nd� SY�RI03 �S�H,L '.I.I�I�� Q�2I�Z�v'� � O.L 2IORId S2If10H ZL NRI03 I�IOI,L��I'IddF� ��IA2I�S Q003 �2IH�IOdY�i�.L Q�3IC1��2I �H,L IJI�II'II3 �g ,LI�I�I.L�'d�Q H.L'I�'�-I H Lf lOi�1RIH�i�L��.LOI�I,LSf1T�I H.Lfl0Y1RI�'A d0 NMO.L�.L[�IIH.LIM S2I3.LH�OHM�1�I01�i�t�' �� d �.L ��IA?I�S Q003 -��uso�� 3o s��a(c)�n�s �ilnn Q�ano�xo a�xa�g isnv�zooa�uan�nums �xnox�ru xoo�.no�xana ��uso��ooa �x�i��tasx�na ar� `�ru�aao oi xo�a `8�'I Q��.L?I��,L�'ZS �'1�g,LI�If10� �Z`d'Td Q2I�QN�'.LS QI�IH Y�i2I0�'IO�'I�'.LO,L `S�'I�tOY1IOQf1�Sd �03 aais�x�.�nn�r,a� `,r.r��,�a�a�.��.r.�g a�,��asru�g isnv�Kos��s� 2IOd Q�SO'I�1�I�'3g�A�'H H�IHM S'IOOd'RIII�AA QI�I�'jJI�IIQH.t1c1 `JI�III�TLI�MS 'I'IH ��JNIN�dO 'IOOd S'IOOd N .LI 'N�''Id�.LIS�' �2IIfld��L1I SI�IOI,L�AON�2I ',Ll�i�i��I�t��t0� O,L 2IORId H.L'I��-i d0 Q2I�'08�L 1�g Q�A02Idd�Cll�t�O.L Q3L2tOd"32I�g,LS[1T�`�'�.L�`.LI�I�idifla� 1yc1�NN `JNI.LISI�d `'a'i) 'IOOd 2I0 'I�,LOY�I `.LN�-ISI'I�,LS� Q003 �I�IV O.L SI�IOIZ�'AOI�I�2I 'I'IH �uos��s �,xo��aao oi�o�a s��Q OI-L I�IOLL��dSI�II 2I03.LI�i�LL2IVd�Q H.L'IH��I�H,L.L��'.Ll�iO�O.L�SZl�t�iSI'I�.LS�'I�'I�IOS��S �866I `i£2I��Q 1�g �S)��3 Q�2IIfla�2i Ql�i�' �S)NOI.LH�I'Idd�' Q�,L�'IdY1t0� �I,L I�IHIl.L�2I O.L �.LI'IIgISI�IOdS�2I ZiROA SI .LI 'i£ ?i�SY�t��Q O.L I 1�?I�'f�l.l�t�f I�IO2L3 A'P�I�'flNl�I�' N112i S.LIL�I2I�d ��I,LOI�i OI�I � S� �QI�d�lI'I�.L�'RId02Idd�'�I��-i� �5��'Id 'S.LII�I2I�d�IC10A 34��I�I�f15SI 2I0'I�dM�[�I�2I O.L 2IORId Ql�'d �g,LS11L1i SN�"I Ql�t�' S�.L HLf10Y�i2IH� 30 Nt1AO.L S��l� Q�I��',L,L�QN�' Q�1�IJIS .LIA�QI33� 'dY�IOa S�?I�I2iOtSc1 � Q�-I��.LZ�+'��N�'2tf�Sl�tI 30 '.L2I�� '2I0 `Q�I��IS QI�Id Q�.I.�ZdI�1i0� �g ZSIlb1i .r.in��3� ��u�ns�u uo��su�ar�o� s�x�on� �.I,�zs Q�H��ii� �gi ��nsru NOIi�sN��o� s�2I�011A 30 �.L�'�I�.L2I�� F� �A.�H .LON S�OQ 1�l�i�dY�TO� 2I0 I�IOS2I�d � � ssarusng� �.r.vx�ao oi ii�xaa�o asN��lz� 30 �m��xo a��nssl a�ox oz , Q�2IIlla�2i MON SI H.Lf10L�t2I�A 30 Nt1AO.L�-I.L `91�IOIZ��SSI1S `�SZ NOI.L��S `ZS t 2�LdHH�2T3QNf1 � � t l�i0I1.�'2I,LSII�IIbtIQ�' � , , ' � ` � The Commonwealth ojMQssachusetts ' � �� i Departmenl ojlndustrial.�ccidents o Of11Ce01/eveS�l�f�lilt � 600 Washington Slreet ' �` Bnston, Mass. 02111 qt4 S�,�. w'orkers' Compensation insurance Atfidavit Anolicant intormation: p►ess�pRil�'rTe�,-wir namr location� �� phone� � f am a homeowner pert�rmin,ail work myself. � I am a sole proprieror �r.,: ha�e no one ��orkin� in anv capacit�• � I am an emplo}er pro��din� w�orkers' compensation for my employ s working-o�this job. o m a n • n m �� 1i� 'f�- �j�-r�7/�� c�C)� � �-�`�/�� ddress: �v � /`�� cirv: �� f�J� �� Q�� nhone t�• insurance co. z U��''bt ��'�'�1 p.41�SY# �z � � ��7��'—�Z �f � I am a sole proprietor. :enerai contractor. or homeowner(circle onel and ha�•e hired the contractors listed below �tiho ha�e the follu�+in_ �+orker� �ompensation polices: s4m�anv n�me: address• cin�: nhone#1• insur�ncc co. �oticg# comoanv name• _ ad d ress: �'� �ee M• insurance co. __ ��n,� t Failure to secure coverage as requ�red uader Secnoo 25A of MGL IS2 ca�!ad to t6e ioposidoa o(erioi�al pesdtles of a O�e op to 51,500.00 a�dlor one yean'imprisonment a�w�ell a�civil penalda io the fo�m of a STOP WORK ORDER aed a lioe otS100.00 a day apinst me. I a�dersta�d t�at a copy of thy statement may be forw�rded to the OI'lice of Inve�tig�tiom of tbe DIA f�eoven;e veritieatio�. I do hrreby cerrijj•under the pains and prnalties ojpery'ury that th injormatinn providtd above is lrut and eorreet Si nature � . 8 �' � ate .`t-�'�C'`CS Print namc �\1P.`�.s�ri ��'�. �� Phone 1� �(n��.,- !��C'))l3 ., olTicial use onl� da not..�ite in this area to be completed by eih or toan oQitial city or town: Y�MO� _ per�itAicenu p nBuiiding Departmeot ;�=,�� Licensiog Board � check if immediate response i�required �� ` 261 �Sdectmen'�Ottice �HealtA Department contact person: .�...�.��--�p��-p!"'�"'E�B� 398�2231 ezt. nOther .. _ ,,,. . • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: Y2K-14 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to John& Melissa O'Rourke d/b/a A�a,Ae Bed&Breakfast at 168 Main Street, Yarmouth�ort, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confornut_y with theauthority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenry-five to twenty-seven, inclusive,of Chapter 272. In Testimony Whereof the undersigned have hereunto affixed their official signatures,this Sixteenth day of Mav A.D. 2000. . BOl�RD OF HEALTH: �� elfe�, C�iairmam Ko�erE,}. �iown� Cr�er� ab�ie6le�a�iol��ir�-JdooPea ichael O oCou�hlin ��'�..� Bruce G. Murphy,MP ,R . HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-185 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,5�tion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: T�hn K & Melitsa n'Rourke, 168 Main Street, Yarm�uth or , MA Whose place of business is: A,gane Bed & Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �at��, C�t�.�� ,�o�e,E� r�,aw�, c�,� abrielle�ahof�hc�-✓�tooPed ichael 0 oCou��lirc Mav 16 ,2000 ° � � � ��i'- '' �� Bruce G. Murphy,MPH,R .,C Director of Health � � � � , _. ,A- � - ipe �d ��r�a kk��- � �,� �� -`> � ;� �- � :, � Q � � c� od � � V�_�N OF YARMOUTH B4ARD OF HEALTH ��►� � 1 �9�PI�ICATION FOR LICENSE/PERMIT- 199 ►��O JAN 1 1 1999 H E �i't-i I�c E'�i. y� �I;?T * Please com �tr►�l�acfi all necessary documents by December 31, 1998. Fail �'ilt ' the return of your application packet. ----------------------------------------------------------------------------------------------------------------------------------------- N STAB I N : ' - � re, �4- L # O ATI N D S: S - MA,�LING ADDRESS: S�e�ne (OWNER/CORPORATION NAME: ��1� t � 1 i sq C'a ' (�r�u�ke MANAGER'S NAME: �m e TEL. # ��ro F 1V�.�ING ADDRESS: .SC�mF ----------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS: ��G �c�c;l The pool supervisor must be certifi d as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. -- -- —_ —. __ _1� �_- __ _ _ ___ _ _ _ l. 2. Pool operators must list a minimum of two em�ployees currently certified in basic water safety, standard First Aid and Community Ca.rdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your ptace of business. �. � � � 2. , 3. 4. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide ew.copies and maintain a file at your place of business. 1. � �i 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---------------------------------------------------------------------------------------------------------------------------------------- _ OFFICE-U��61�L� �ODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 1 B&B ,6$so —( _c�nv $so INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 MOTEL $50 SVVIlVIMING POOL $SOea. WHIRI.POOL $25ea. FOOD SERVICE: LICENSE REQU]RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 � CONTINENTAL $30 �-1� _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 WHOLESALE $75 RETAIL SE�tVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE• $10 AMOUNT DUE _ $ � � "'"""'"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•"" E + ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSiJANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINES5 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 2 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MU5T BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECI{jAPPROPRIATELY IF PAID: YES �� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQITIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING: ALL SV'VIMNIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR TI-� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND THE WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVV�IlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERII�TG POI�ICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FR�EN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABQVE'TERMS HAVE BEEN MET. -_ _ - -- _ - -_ ___ _ _ OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING� OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISf�VVIENT IS PROHIBITED. DATE: �- 1�� SIGNATURE: ` �A�,,, � � I�a�� PRINT NAME& TITLE: �1�e\��sa C'�� 1�n«<�P- �Ln��c�.n� � a -+ , � � The Conimonwealth ojMassachusetts w W Department ojlndustrial,-iccidents � ; Of/Ice o1/�s�lost/iis � 600 Washington Street ' = Boston, Mass. 02111 �'" '��y W'orkers' Compensation Insurance Affidavit A,Rnlicant information: pleasaPRINTT�d.'W�r n�m�: (1[� 1.>E�C?x � !>CH.QF.�QS} — ��Cl r `��\CSSQ �J, AC> >C P L�cation: I�[a� `�` 1Cttc1 5`�t'e'e} - , �- a��s � 3��- �� t am a homeowne pert�rming all work myself. I am a sole proprieror�� ha�e no one �tiorkin� in am•capacin� � I am an emplo�er proti idin� workers' compensation for my employees w�orking on this job. - --- ---- - — — _ - — _ _ _ companp name• 't�1 np ��ed� � QY�.ce�`�ra�}- address: I�og �C��CI � �- tit�•: ��r-�`cl�c f�h�n�-�- , � 6��75 ohone#• �3�o� -�.� U � insurance c . lic # I am a sole proprietor. general contractor, or omeow circle onel and ha��e hired the contractors listed below �`ho ha�e the follu«in� ��orker �ompensation polices: companv name: �c��l� � �R r��,r�� - r:i�(�r�-�;c �tl�e �� 1�.\c-r�k ��k�'� ci�y: Ahone t�• insurancc co. Aolicy# com a�ny name: - - - - -- -- - ------- —_. zddress: -- - c�,i y: Ahoee k• iesurance co. �}osy M ' Faiture to secure coverage as�equired under Secnoo 2SA of MGL 1S2 ne lad to the iopaidoa o(erisinl peaaltla of a A�e op to SI,S00.00 a�d/or one ycan'imprisonment ae well a�civil penalNes io the(orm of�STOP WORK ORDER aad a fiee of 5100.00 a day apiost ma I s�dersta�d that a copy of thy statement may be torrvarded to the OfTice of Inve�tig�tioo�of t6e DU for covenet veriAatia. I do hrreby certij}�under�he puins and penallies ojperjury that!ht injormation piovrded abovt is true and eorreet Signaturc �a`�4 � ' I�rrr A��Y�n Date �- �G-9� Print name �p��ca ��n� ,��'� Phone# ��0�`�+�Q� .- otTicial use onl� do not..rite in this area to be completed by citr or town ofllcial ciry or town: Y�M�� _ permitAicense k n8uildiog Departmeot �Liceasiog Board 0 check if immediate response is requi�ed 261 �Selectmen's ORiee (508� 398�2231 ezt. �Hea1tA Departmeet contact person: phone M;_ _ nOther ��e,�see;,es vi�� . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-11 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to _ John & Melissa O'Rourke d/b/a Agape Bed & Breakfast at 168 Main Street Yarmouth�ort, MA in said Town of Yarmouth And at that place only and expires December thirty-first 19 99 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with theauthority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to tliirty-two, inclusive, and of said chapter and sections twenty-five to twenty-seven, inclusive,of Chapter 272. In Testimony Whereof;the undersigned have hereunto a�xed their official signatures,this Tenth day of__ Februarv A.D. 19 99 . BOl�RD OF HEALTH: �d� �eltee, C`iairman. �oan � �ullivaic, K.I"/., Vice (,hairmare Ko�erE� �rowre� (�lsrh abrielfe�ahof�hc�-.htoo�Oee , ' �el � ou �lir� ruce G.Murphy,MPH, .5., O Director of Health TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-139 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section�of the General Laws,a permit is hereby granted to: John & Melissa O'Rourke, 168 Main Street, Yarmouthnort, MA Whose place of business is: Agane Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 1999 BOARD OF HEALTH:��% �et��, C'��.�aa.� . �oarc� �u[f�van�K.//.� Vice l�hairman Kobert J. �rowrc� (�lerh � abri�l[e�a�of��ic�-.htoope� 'i/ichael oCou �lisa Febru 10 19 99 L�-� ' "`�`'" � — ruce G. Murphy,MPH,R ., O Director of Health .• _ ,- .. �� , � . ,�� `` �`a' � � �, , � , � � �y,,- � � ---.______ TOWN OF YARMOUTH BOARD OF HEA �' (� C� C� (� � t`r' I� J APPLICATION FOR LICENSE /PERMIT - 1998 �f�� 2 0 1998 * Please Complete form and attach all necessary documents by December 31, 1997. Failure to do ' ' ' ''`"aT so will result in the return of your application packet. N---------F--------------------------------------------------�-------- --�--�----------#�----,36�,- �ga� S: � d IN�I,�.ING A.DDRE S S �.rn�e OWNER/COR.�PORATION NAME•�,jc� '� �le'��Q C�`4�a�+h� MANA('t�R'�NAME• �cc�� TEL # MAILING ADD�SS• ��m� ---------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, s#a.n�a.rd first ai�and�ommunity Cardiopulmona�y Resuscitation(�PiZ).Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years records. You must provide new copies and maintain a file at your place of business. 1. �1G C3o� _ 2. 3. 4. HEIMLICH CE�TIFICATIONS: 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 wilt not use past years records. You must provide new copies and maintain a file at your place of business. 1. 1�� `S�sc�,�� 2. 3. 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL# -------------------- - �— i� ri�:.� JS� i��i.�' j�ODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# ..,r-�, ` B&B $SO ;� _� CABIN $50 INN �50 �CAMP $SO LODGE $SO TRAILER PARK $50 MOTEL $50 SWIM POOL $SOea. WHIRLPOOL $25ea. �QQD SERVICE: �.IC. REQUIRED FEE PERNIIT# LIC. REQLTIRED FEE PERNIIT# 0-100 SEATS $75 �CONTTNENTAL 30 j �g�dq3 >100 SEATS $150 �i�i�-�R�irr�� COM. VICT. $50 WHOLESALE $75 $F.�Ii� � ; LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT # <50 sq. ft. $45 TOBACCO $20 <25,000 sq. ft. $75 _FROZ. DESSERT $35 >25,000 sq. ft. $200 AMOUNT DUE _ ��'```� � r^. �'r�,�; L,�� , .., .. .. . . ._._...._.., ADMINISTRATION LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT . TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSUR�NCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCF AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR T� RENEWAL OR ISSUANCE OF YOUR PERMTTS. LEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE: PERMITS RLTN ANNUALLY FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPON5IBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)�Y DECEMBER 31, 1997 SEAS�NAL ESTABLIS�-INIENTS ARE TO C�NT�iCT THE I-i�A�.1�'H DEPART�1lrI'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 COM1vIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONA�RE�UL�T_I_ S POOLS POOL OPENiNG: ALL SWYMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE 1JKAlN�1) l�I�L��!�l��l �"N1Tt�1�1 j��iV(%�i�f-�`�'� �'��i,�iivl�. _ _ FOOD SERVICE �'ATFRING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MU5T 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 DEPAR.TMENT. F�O,�EN D�S��TS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASI5 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. OLJTSIDE CA�ES: OUTSIDE CAFES {i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. QIITDOQR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIVIENT IS PRUHIBITED. DATE: �- ��- `�.fS SI(_'�NATURE: '1 � C�� ` 1�r�r�. PRINT NAME &TITLE: �1�\�«�, �'1�e��ck�� _ �c�J� C� � (S - C�t.,�n�'C" J ` 10/97 page 2 of 2 �— , ...., . a> . ,�°�=o '��a I��Zi86£ (SOS� :#auoyd :uos�ad»e�uo� iaaw�sdad Q��saHp a�yp c,wwi�a�as� I9Z pannba�n asuodsa�a�sipawwi�i��ay� ❑ p�soe Saisuaa�lD �aaut3��dad 8a�p�mg p asuaa�N�a�ad �IIO��a :u.Mo��o,U�� si�Wo u�►o��o�i7n,Cq pa»�dwo�aq o�san s�y1 ui a��..�ou op ��uo asn �u�yo =• 0 0$y�_� p ouoqd � aw¢u 1w�d h' _L1_ ote ! »n�euB�s ��o�pua aiut sr anoqc p�p�eold uot�mu�oJvi�yt m yi tinl�ad Jo sar��nuad pun suiad�yl fapun.ffrua��fqafa y op/ •�opayua�a8siaeoa�oJ nQ aq�)o caonaS��sa�u��o a��p ay�03 pap�ekuo�aq esw�uawa�sis Wy��o,Cdw s�sg�p�q�ap�a j �am�to�s's�fsp s pp•ppls)o aa�{s pos�(3Q2I0�iOM dO.LS�)o w�o��y�oi ca��suad�un cs��a.�cs�uawuos��dw�,s�sa�auo �o/p��pp'pp�lS o1 dn aap s�o sap�saad��mu�Jo ooqwodm�aq�o�Ph!on ZSl '1JNi 1�VSZ�ouaas�opon panoba�ss ags�a�o>»n�at o1 a�n��s� � :aweu nue wo �#. �� •o� a�ue�nsui :q .. � .s a�p e :a u nue w :sa�i�od uoi�esuadwo� _.�y�a�� ui��o��o� ay� a�ey oyt, �o�aq paisi� s�o��e.uuo�ayi pa�iq a�ey pue lauo a�� au.,�oawoy � •�o�ae��uoa �e�auaD ��o�audo�d a�os e wr � ❑ # !I ' �aaue�nsu� •M :n3� :ssa�ppe : weu . ue wo •qof s�yi uo au��o.M saa.�o�dwa.�w�o� uouesuadwo� ,s�ay�o.M ou�Fi+ad�a:�o�duta ue we � ❑ .111JEdEJ.1UE UI �ui��o.�� auo ou a��y �::� �o�audo�d a�os c we � ❑ �,��as.�w�lo.r ��ouiulio ad 1au.,,oawoy � we � ��- S # �- , } _ :uoi � a.. ,wL u � ��eP11d a�ue�nsu� uo��esuadwoJ �s�ay�o,M �� ~�b, I I T ZO 'ssayy 'uo�sug ; � 1aal�s uol8u�ysnM 009 ' siips�Qs�ita//o��!!l0 ° : � sJuapr��f•�at�lsnpul Jo 1uau��lndaQ � z s�lasn y�Dssnyy!'o yl�naMuou�u�o,� a y,� � ' - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-193 FEE: $30.00 In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: 7ohn &Melissa O'R�Lrke, 168 Main Street, YarmoLth�,MA Whose place of business is: A,g,ane Bed&Breakfast _ Type of business: Continental Breakfast _ To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 1998 BOARD OF HEALTH:�d�f. �et��, C��.�n �oan� �ullivan�� Vica (��irman l�berE�}. p.�rown� l..[erh a�ris6le�a�ol�hc�-.J�tooPee ic�e6 oCou lin Julv 21 , 19 98 ruce G.Murphy,MPH,RS., H Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-15 FEE: $50.00 THIS IS TO CERTII�'Y THAT AN INNHOLDER'S LICENSE is hereby granted to 7ohn&Melissa O'Rourke d/b/a Asane Bed&Breakfast at 168 Main Street Yarmouth�ort_ MA in said Town of Yarmouth And at that place only and expires December thirty-fast, 19�$unless sooner suspended ar revoked for violation of the laws of the Commonweatth respecting the licensing of innholders. This license is issued in conformity with theauthority granted to the licensing suthorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-twq inclusive, and of said chapter and sections twenty-five to twenty-seven, inclusive,of Chapter 272. , In Testimony Whereof,the undersigned have hereunto affixed their official signaiures,this Twentv-first day of J�y A.D. 19�. B�ARD�F HE�II.TH: �d///. ..tel�� C.�iairman �oan G. �u[livan.,K.//., V�ce l,�irman �obert� 9�rown, l,�rk a�rie[la�akofdkc�-..J�ooPee ic�e[0' u�hlin ruce G. Murphy,MPH,R .,C Director of Health