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Home My WebLink AboutApplications, WC and Licenses r -�� -�g.� � � � J�< � � `, � �,r , ,-, � TOWN OF YARMOUTH BOARD OF�EA�7'� _ , APPLICATION FOR LICENS� � � �� -��'�� a: ,,.,o ;� � : ' r�� s k� Q 4 ��0& * Please complete form and attach all necess�do�"ut�ts y Dece r l S 2008 Failure to do so will result in the retut'Y1 of your application pac =- �-.��__��-�`��. NAME OF ESTABLISHMENT: /�r� C,�� o�G � � � � TEL. #��f�-j'�� LOCATIONADDRESS: �!l L Sv�f�i S��r i7.ivr - G'fs.s �{r,�r°�' MAILING ADDRESS: .�� e'-� OWNER NAME: � � /`7�SC �G i:-o ��.. TAX ID (FEIN or SSN)• � �� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ...._.. ...__..w.�,.,._.._ TEL. # MAILING ADDRESS: ._..__..._.__.�,._....._ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operatar,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 cur7 ently cei-tified in basic water safety, standard First Aid and Community Cardiopulmona.iy Resuscitation(CPR). Please list these emplayees below and attach copies of employee certifications to this form. The Health Department �vill not use past years' records. You must provide new capies and maintain a file at your place of business. l. � 2. � 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-tune employee who is certified as a Food Protection Manager, as defined in the State Sanitaiy Code for Food Seivice Establishments, 105 CMR 590.000. Please attach capies 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 establislunent must have at least one Person In Charge (PIC) ou site dui-ing hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all tunes. Please list your employees trained in anti-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 �le at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIrG: LICENSE REQUIRED FEE PER.NIIT# LICENSE REQUiRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � B&B S55 �D -LY�S _CABIN �55 _MOTEL S55 —rn� S» _C:t�NI�r �55 _S�'IMMI1�iG FOOL S80ea. _LODGE S55 _TRAILERPARK �105 _WHIRLpOOL S80ea. FOOD SERVICE: LICENSE REQLIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S85 �CONTINENTAL S35 0��a' NON-PROFIT S30 _>100 SEATS 5160 �COMMON VIC. �60 _WHOLESALE S8Q RETAIL SERVICE: —RESID.KITCFIEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —<�0 sq.�. ��0 _>25,000 sq.ft. �225 _VENDING-FOOD S25 T<25,000 sq.ft. S80 _FROZEN DESSERT $40 _TOBACCO �55 ��E c�avcE: sio AMOITNT DUE _ $ gG,Op *`*`**PLEASE TL-R�OVER AND COMPLETE OTHER SIDE OF FORi�1 ,�,.»*:� } � ADMINISTRATION Under Chapter 152, 5ection 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 prio 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 use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool rnust 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 met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED RENEWAL AI'PLICATION(S) AND REQUIlZED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. Z 6 � SIGNATURE: �t, � /� ��'�/C�-r,�s=� DATE: I y � � PRINT NAME&TITLE:��v�h %/�'�� h P r io,�zi!os ,� ' . � The Commonwealth of Massachuselxs Departnient of Industrial Accidents �NN�� 600 Washington Street, 7`"'Floor ' Boston,Mass. 021I1 v Worlcers'Compeasation Iaswance Affidavih Bnilding/Pinmbing/Etectrical Contractors t p ��-''��1 �/- I G;S C��'I'� aadress: �Z-Z �C� � �itQ i-� ��' ' citv 1 7 �� /'�/�L'� state• �r� zip � �� ohone# ��a ��Y�' v�J wo site location full address: ' I am a homeowner perfornung all work myseif. Project Type: ❑New Construction�Remodel I am a sole proprietor and have no one working in anY ca�cih'• ❑Building Addition ❑ I am an employer providing workers'compensation for my employees worlcing on this job. comuanv a�me: _ address. ciri- �e# Ins co. � .. - ;. : .. .; _ . >.:.,,. ,. . . , ;,r Pi'�rietor,geaeral cogtractor,or homeowner(circle o�re)and have hired the contractors listed belowiwho ` .<: ❑ I am a sole have the following workers'compensation polices: comwuav o�..n�- address• citv o4Oae# jasm'aace co. � comnaav mme• addreaa: ci�Y• o�oae# I�snraace�, _ # ��ifli�l�`�e�lti� =� : ; : :, Failm�c In aecm+c as ... . .: ; , �,_ ...: , i �.. '; ,..., e°�'vaE� re9aired aadv Seetloa 2SA ef MGL 1S2 an kad b tYe ispe�a of crf�al pe�altln et a 8ne q�Ce S1,SA9.00 aadl�r �Ya�'�ptbonment as�as dvY peaaitka in the form of a STOP WORK ORDER aed a 8ne et Sl@O.N a day agaiast me. I aadetalaad�at a copy a[fhis�atemeat may be furwardM�n the O�ce ot laves�qona of t�e DIA tor covenge veri&atioe. L do yertby ce ' xnder tbe tns andpe�slties ury tHat tlYe informatlo�provided abovr tc trrre mrd co Signatut+e V /2 � Y � Date -�-- Print name `'1 i ��,�C,�("r rr� � �ne# � / '� �7r�.,� o�cia!use only do not�vrite I�this area to be compkMed by dly or Eewa s�cial city or tewn: pern�iNGcense# �Bnidin8 DeP��nt ❑check if m�mediate rapame is reqoired . 0��8 Board �Sdeetmen's Office �� rnatact P�caoa D�ar�eat �,�� phoae#; �Other THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMUUTH PERMIT NUMBER: #09-005 FEE: S55.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is herebv grauted to Ruth T Masciarotte d/b/a An hora�e B & B at__ 1 ��nth Shnr l�riv , Snnth Yarmrnrth 1��A in said Town of Yarmouth And at that place only and expires December thirn�-first,2009 unless sooner suspended or recoked for��iolation of the laws of the Conunon«�ealth respecting the licensing of innholders. This license is issued in conformiri��ith the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections nventy-hvo to thirt�'-tt�-o, inclusive, and of said chapter and sections twenty-five to tw•enty- se�•en,inclusive,of Chapter 272. In Testimony Whereof,the undersigaied have vereunto affixed their official signah�res,tUis Se��ente�nth dav of December A.D. 2008. ' BOARD OF HEALTH: .`�E�¢IL S�, J�,.IV,, C�t[�It ��33�E�i�e�c�„t 2J�lce C'Pccr.ix�tiatt NumUer of Bedroom:3 ;C�� Clrut �'xeeitBaurn, J`d..lV. Ei�e�Z J'- .��u�.e.o Bruce G.Murphy, , .S.,CHO Director of Health _ _ _ _ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-082 FEE: 535.00 In accordance«�ith regulations promulgated tmder authoritv of Chapter 94, Section 30�A and Chapter 11 l, Section S of the General Laws,a permit is hereby granted to: Ruth T. Masciarotte 122 South Shore Drive Bass River MA Whose place of business is: Anchora�e B & B Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BOARD OF HEALTH: ,�Ee�.eit S�, J�.,IV., (!Rt�� f�a�ea .�. 3fi:��r 2Jice C''l�avicrnan ✓t.c�8.e�ct ,�. ✓`3au�ce:n, C�ex� ��' J2..N. December 17.?008 ruce G. Murphy,MP , .S., CHO Director of Health . �• A-NGfh�,2AGz� Jt.Y�k �`vo�o i,; �� TOWN OF YARMOUTH BOARD OF HEALTH, ,� (.ir`� ; 5 APPLICATION FOR LICENSE/PERMIT=�008 � � .::�'� `�d (n r', (r �� '� ` ' , �,;.i * Please complete form and attach all necessary documents by December l, 2Q07. Failure to do so will result in the return of your application packet. ` ` � � , , ,��u�,�n i -ru r��c a�. - _--- _ NAME OF ESTABLISHMENT: �'! GLj o r a e I�j� l3 TEL. #.S"�oY 3��--�ZLS' LOCATION ADDRESS: /Z 2 So v�-�, S�oY 7r��t �-IJu-JS ��er MAILING ADD SS� � OWN�RNAME:( v � T. /`'1��'c��ra T XID (F�INOrSSN�• �` CORPOR.ATION NAME (IF APPLICABLE): 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 Po�l�perator(s}�d a��a ec>py of�he eert�fication to ti�is form. 1. 2. Pool operators must list a minimum of two employees currently cei-tified in basic water safety, standard Fu st Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attacli copies of employee eertifications to this form. T�te �Iealth Depertsnent will not use past years' reeords. '�'o� must provide new copies and maintain a file at your place of business. l. 2, 3. 4. -�--��.�,.�..,��.�„�,...,�.,��,..� F�OD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this applieation. The Health Departrnent wiil not nse past 3�ears're�ords. You must provide mew copies and maint�in a file at your establishment. 1. 2, _P�RS9N 1N CI-�A,R('iE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 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 yow employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maiatain a file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE OnLY LqDGING: LICENSE REQUIRED FEE PER'VIIT# LICENSE REQL'IRED FEE PER'1�iIT?* LICENSE REQL'IRED FEE PERVIIT z �B&B S50 ��QQ� _CABIN SSO _MOTEL S50 �INN S50 _CA;�IP S�0 _S��4'I�IJ4ING POOL 575ea. �LODGE �50 TTR,AILERPARK S100 �l1-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT� LICENSE I�EQL7IRED F£E PER'�11T tt LICENSE REQti IRED FEE PERv11T= _0-IOO SEATS S75 �CONTINENTAL S30 C�-O�Y _h'OIv'-PROFIT S35 _>100 SEATS 5150 _CO.'4L'�ION VIC. S50 �L'HOLESALE S7> RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIItED FEE PERMIT� LICENSE REQL'IRED FEE PERI�IIT= LICENSE REQL'IRED FEE PER�iIT- _<50 sq.ft. $45 T>35,000 sq.ft. 5200 _�'ENDIivG-FOOD S20 _Q5,000 sq.ft. 575 _FROZEN DESSERT S35 TOBACCO S50 va:�c�vGE: sio AMOUl�T DUE _ $ �O . Oc� *****PLEASE TL'R\OVER?�\D CO�ZPLETE OTHER SIDE OF FOR�i*w*** r n.� 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, QR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCIJPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy 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, shall generally be considered Transient. * NOTE: En�losed Motel Census must be completed and returned w;th t�is appl��ation. rooLs P�OL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days 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 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 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 Depaitment. 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 Board ofHea�th. OUTDOOR COOKING: _ Outdoor�ookin�u,_pregaration,�r_�isplay of any food product by a retail Qr foQd serYi�e estal�lishme�t is p�rohibited. NUTICE:Permits run annually from January l to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIViViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME=VCEMEVT. RENO�ATIONS MAY REQUIRE A SITE PLAN. DATE: � Z �Z ��_ SIGNATURE: �� j, i��L'-��'�� PRINT NAME&TITLE: /�V�� T � �S C��"�� io;o o� : Y � The Commonwealth of Massachusetts Department of Indushzal Accidents > NNfe�/i�r�fl� 600 Washington Street, 7`"'Floor ° Bosto�e,Mass. 02111 Worlcers'Compeesation I�sarance AiSdavit:Bailding/PlambieglElectrical Contractors name: l.f � � �S C/G-�''J �. address: �Z � J o ti� .,S�j O r�- �I"/Y L ciri ��SS /5�,r e r sr�te: /'%� zio•!T Z(��0 7 nhone# � �'l�lr' �''�L��S wo ite location fiill address: /Z 2 So c.�T-[-7 -s�'1 O/'� n i v t I am a homeowner perFornvng all work myself. Project Type: ❑New Construction ORemodel ❑ I am a sole proprietor and have no one worlcing in any ca�city. ❑Building Addition ❑ I am an employer providing workeis'compensation for my employees wo�icing an this job. wmpa�v aame• �ddtess- city- pllOae N• CO. # .. ... . : .. ... ... .. . . . . :. . ,;,. � '� � ,. .;:. . � �,..,�.i:. .,,;, �`� ❑ I am a sole proprietor,geaerat coatractor,or homeowner(circte ose)and have lured the contractors listed below who have tt�e following workers'compensation polices: �uaav name• address• citv o6oae#• issrra'ee�. � �mmav same: +�ddrps• titv: �#- _ . _ - Allreie��utllkars�arrrrer�* ��# Failare ba xcore ooveraae as rcqaired aeda 3ectlo�2SA of MGL 152 can la�d b f6e i�s�itlsa ef criiwioal pnaNies ef a 8ne q�b S1,SeY.N asdl�r ene years'tmprhonment aa weU as c1vY pe�altks in the form af z 3TOP WORK ORDER a.d�8�te ef S10S.0�a day ataigat me. 1 aederstaHd t6at a cepy ot t�ia sfitement may be for�vu�ded to tAe O�ce of lave�atloffi of the DIA tor cevsnge veNBcalba t do benby cerlify xnder tNe pntns aad peaelties of ptr}r�ry thet NYe iefor�uattoe provPded aboue is teue mid corrYcx Signature L r/r(l�/J(`t�> Date Print name V �� -S / �-/"�✓ Phone# .S a� ".3%� ' �� 6.� officlai n�oniy do not wrNe i�tMs area to be compkted by dty or Eown a�cial city or tewn: permit/Bceffie q �ga��P�n� Ql.icee�fmg Beard ❑check if immediale re�penx i�reqnired QSdect�en's Ot'Bce �Hnkh Dc�ar�eeat eentaetperson: phone#; �� tTMviecd Sqit Z00)) THE COlVIlVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-006 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S L�CENSE is hereby granted to Ruth T. Masciarotte d/b/a Anchorage B &B at 122 S�Lth Shnre i�rive, S�nth Yarm�nth, MA in said Town of Yarnlouth And at that place only and expires December thirty-fust,2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innliolders. 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 secrions twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereo�the undersigned have hereunto affviced their official signatures,this Tivrteenth day of December A.D. 20�7. BOARD OF HEALTH: .�Ee�eft Sl�a.�, �..lV., C�ftuut C�ayi�ea 3�.��e��if�e�'c� 2J�iee C'f�acvut:aert Number of Bedroom:3 J��Q�4X�S_��II�CU�Z, �:CQXt� Q�ZIL , `J� . ruce G.Murphy, ,RS.,CHO �� Director of Health __ __ _ _ TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-074 FEE: $30.00 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Ruth T. Masciarotte, 122 Sauth Shore Drive, Bass River, MA Whose place of business is: Anchora�e B &B Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF xEAI,TH: ,�feeert SR�af�, J2..N., ('.ffai�crnart �PCa►�cee� :�.��,��x `?�ice C!Pca�i�cnur� Ji�ext.!.✓`3�uccura, C!�exl� Qru�C�ceercfaccm, J`�..lV. December 13.2007 ruce G.Murphy, S.,CHO Directar of Health i. ..�..W�I03�IO�mS iI�H.LO�.L�'IdNtO�QAIV?I�AO NZIf1.L�SY�'Id..... 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SD►��j S�jo/�- YrN '� ��y, �jAS S��v C/ sffite• / //Q zip• 6 L b�`� nhcxie#.fU�3/�Y-��l.1^ work site 1 tian fnll address: I am a home�wner performing all work myself: Project Type: ❑New Constructi��Remodel I am a sole �etor and have ao one w � in an ca ' Buil ' Addition ,�...,, , '��-. �: ,� ,.. . . , ._ . _ ❑ I am an empbyer providing wakets'compensaiti�fa�my employees working ar►this job. �s'. -— C�IY � ❑ I am a sole p�roprietor,ge�eral cowtractor,or tiomea�raer(cirde oRe)and have hirsd the comractats listed below who have the following workers'compensation polices: f9�T�' - .�..�r• - — �y. uiaxe�: # �uv m�e- a�di^�• dir• ��` ___ _ __— __ _ _ # FaMare U accve orv�era�e as rcqained nrdv 3a�oa 2SA�f MGL 1S2 caa Ind b 1te i�rp�tloa�f ctiriW paaaNks�f a�e�b t1,5M.M a�dl�r eue yan'iesptbaoment as we8 ss dvY pe�aHiea ia t6�fera�ot i STO!WORK ORDER aed a Sae d S180.YS s dap a�imt me. I mdastud tiat a apy d t1�N�fa�may 6e far�varded 10 tee Omce�lave�oas af t6e DIA far�verage ver�atlss. /do bd+tby certr;/'y x�der NYe pa�f�s aa/perwlties o prrj�ry dYet dYe iN,for�a�ion prov�ded aboae is lrue aed oor►+ec� 7p ��G`'�'"� pate / lZ p` Sigoatnc�e� • Ptint natne��h � ��t..1�C 1�/'c//�- Phone#�� 'J l'r��16.f e�iai ase aHly ds oot w�r#e�t6is atea te 6e complaed 6Y eitY er qwn e�cial dty or tewn: permiMiceme# t �� ❑t4edc if immdliale rrapeme ia req�ired Q�'�t matact peisou: P6�#� �� p�smc mo3� . : , � � THE COMMONWEALTH OF MASSACHI7SETTS TOWN OF YARMOUTH i PERMIT NUMBER: #07-001 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T Masciarotte d/b/a Anchorage B &B �. at 122 S�uth �h�r .l�riv ., S�uth=Yarmnuth MA in said Town of Yatmouth And at that place only and e�tpires December thirty-first,2007 unless sooner suspended 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 thirly-iwo, inclusive, and of said chagter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affuced their official signatures,this Twenty-eighth� day of November A.D. 2006. BOARD OF HEALTH: B �S. ,/��., ' ��r�, .�v., v� �� Number of Bedroam:3 Qo/►e/t�� Bnot�uss, �� /��/�a�1� �4 ��, R . Bruce G. Murphy, ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUlV�ER: #07-014 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ll 1,Section 5 of the General Laws,a permit is hereby granted to: Ruth T. Masciarotte, 122 South Shore Drive, Bass River, MA Whose place of business is: Anchorage B &B Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2007 BOARD OF HEALTH: L� us�`n. A�l.`n., ' � d�e�i��S'lsG:lt, ./V., ?%ce��,r�� Rvle�ct� B�iu�s�, G'l� �a�hi�I�Mc�5� �4�us f�'nee�a.,i, R./V. November 28_2006 Bruce G. urpky, ,R S.,CHO Director of Health ' '� �3�� Anr ufo a.a� �3 f 6 .��';qR.y TOWN OF YARMOUTH BOARD OF�At�a,,��b� o� -c APPLICATION FOR LICEN,�S,�,�P�1�VIPgf-2006 ; �; ,� �._ �s �..� �� 3 �', �� 6�OV 1 5 20U� * Please complete form and attach all ne�essary�io�n�i�s by December 31, 2005. Failure to do so will result in the r�turn�'your application pacl�et. NAME OF ESTABLIS�-�VVIEEN'T: h c�l�i o�^�- e T3 �I !3 TEL. # .�y�Y Y-b'z�,s' LOCATION ADDRESS: /2 2 o c� ' S o e + .v-e -- �. - 2� � c y G� MAII.ING ADDRESS: �'�� OWNER NAME: � 7: �s c�u N o TAX ID(FElN or SS ' � CORPORATION NAME (IF APPLICABLE): ---------- MANA ER'S NAME: TEL. # MAILING ADDRESS: ___.---'`'"'��-✓ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by 5tate law. Please list the designated Poa1 Ope��$to�-ts) a.�d 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: A11 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. l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIl't��CH 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 wiil 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 REQITIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMI"P# LICENSE REQUIIZED FEE PERMIT# I B&B $50 b'�U�1 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIIvIlVIING POOL$75ea. LODGE $50 _TRAILER PARK $50 _WHIIZLPOOL $75ea. FOOD SERVICE: LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $30 d(p'� NON-PROFTT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIIZED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQIJIl2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 8O.OQ """"'�PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••*"" ADIVIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth is now required to hald issuance or renewal of any license or permit to operate a business if a person or company does not have a 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 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�Il1�lENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIltE 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. r-, 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 desserts rnust 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,preparatioq or display of any food product by a retail or food service establishment is prohibited. DATE: / '� �.� SIGNATURE: � � �`Z✓r�G�c.�..�;� PRINT NAME&TITLE: 1?v�i T �G�C�a-rc�//e — G cvti �✓ 09/28/OS `�� The Commonwealth of Massachusetxs �� Department of Indust►�ial Accidenls -_- _--- M�ara,iil�s� - � 600 Washington Stree� f"`Floor �,s' Bostori,Mas� 02111 ��"�Worlcers'Com�easattoe I��aaee Affidavit-B�I biaglEkcancal Contraetors . :�.. .;,,�.v,.. 5 � ,-�� ,.,..� �. �.: � � � � �� :, � ,�.. , ,s� �. _��-� ,� „��a'�� , name: �� /�� 1 �-S G /G r o� acki�ess: � Z Z �v vT l�t Sl�i o Y'e �r�y c �tr (3GSS �� vtr shate- I`1/� ,;p. 02(,G� nhoae# .'�V�'3�j f' '�Z6s" worksite locati�(fall addressl' S��-� �Y e I am a hom�wner performing all work myself Project Type: ❑New C�structiaa��Remodel ❑ I am a sole 'etor and have no ame w ' �n any cap�ci . Buii ' Addition - � F � � ,.�. t.��_� ��.�.. .�.�, .�� . ��. _ ��,�`,. . � � � ..�" _ ❑ I am an employer providing workeis'compensatio�for my e.�ployees wo�lcing�this job. �mm�Y�: ad�ess: ehv- nl�eat Ak: # ❑ I am a sole proprietor,ge�ersl co�tracMr,or homeowa�(cude o�)amd have lrired tbe cornr�ctots listed below who have the following workets'compensation polices: 4�,m.��e: �= dtv olr�r�: ,�. ,. i, � � ,� # .:�� ti 3 _ � . �.j .�: .. . .,. � .' , , , aannuv�: �: cltv: olie�c#: �' ` n :. # , �_.�._ . ..P_ � �, ..,. ,. �� . . .. �, Faan�e�s xe�re a�e u req�ed�tder 3ee�st 2SA�f MGL 1S2 ew kad b tl�e�.r�.��..�.r.�,4 a si,s�w�r.r �y��r�c�.Ra�dw�m��.r.sror woiex oxu�x�.a a e.�.csiae.�e s a.y��. i ona�,a.a wc� cepy et tlib�atemest nay be fenvarded�o the O�ce of lave�ptlw�s Af f6e DIA hr avcrage v�ailieatlw. I�o heneby cer(�jy xrde�tAie pni�es aad penelties of p�rjrrry tNet tbe irfonxadon pro�ded obav�e is due aud oonrcx Signature ��v_I GZ_�le/✓�.�s Date ��/�.Jr l�� Priutname� �/ ,�� /. /'l G-SG�G—/'D � Phone# 3��'3 f��LG.� efficiai a�e only do eot write�t�s area to be d�pleted Dy dty er�wn�chl eity ar te�va• permif/�iceme! �t Bsard ❑e�eck if immedjale respense h requaed ❑Seixdes's O�oe QHakk De�atbewt contad pe.rson: phene#; � (��-�) THE CQMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #Ob-004 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a Anchora,�e Bed&Breal�ast at 122 ��uth �h�re l�rive, S�nth Yarmnnth, 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 Ninth day of December A.D. 2005. BOARD OF HEALTH: Qe�sscirs�l. �j�� /��. ' Number of Bedroom:3 Ro�JtL��nosast, t�C�� s�, R.N. � , R Bruce G. Murphy, ,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT, PERMIT NUMBER: #06-054 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Ruth T. Masciarotte, 122 South Shore Drive, Bass River, MA Whose place of business is: Anchorage Bed&Brea.l�ast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 200b BOARD OF HEALTH: L�esry�r,u�`h. C�'anc�s,J19.$. ' ��+��t, v�e�� R�t�. a�, �� ak� s�, R.N. �I��n��.�, R.1Y. December 9 2005 ruce G. Muiphy,MP , S.,CHO Director of Health 1"�,a""'i'"- � � ��q�� `�' l� F A M � LT T H � _ . [ o�d=- � �`"� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 " MA7TACMEE5 � M� � Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 ' �AOONAiE6 6 � C' B o t1 d0 SJ O 1' %1 E tA L 1 �;�._.._. .....a--.....e._.-�,-.�e.,..,�.__.T..-,,,,.,,, y � � . . -: .. ... 4 To: Yarmouth Board of Health Permit Holders § a � t [ From: David D. FlaherEy Jr., RS. ',�r�r � ��L�I.Lt� D�;�i� �� Health Inspector � Town of Yarmouth Re: Federal Tax ID Number Date: Mazch 22,2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federai Employer ldentification Number(FEIN}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Hea.ith Department 1146 Route 28 South Yarmouth, MA 02664 , Thank you for your anticipa.ted compliance. If you have any questions regarding this matter, please de not hesitate to call. The office hours are MQnday to �riday, �:30 �.rn. tQ �:3�i p.m. The telephone number is(508)398-2231, e�. 241. Establishment: �h c,h o>" ��-c �-,/ 6 FEIN or SSN: Location Address: l Z Z S o c,� f�►o,^�.- �i— (3 G-s S J��u�r Signature: I<VT�i � /�G-PC��i'l� Print: � v T`G, T I�G-sc/� rt� //e. Title: � �..t� �i' ��. Printed on :`�+ � � Recycled Paper �'��.� �;��; �, •o flqR ,.., ///�/`-rS"�c�SE�� z .r: �o TOWN OF YARMOUTH BOAR�?-OF HEALTH � �,� � -'` APPLICATION FOR LICENSE/I,'�R�I��2005��Sa �: .,/i � � _ �.� ••. ..... N �,. . ' � � � � �' �I � D * Please complete form and attach all necessary_doc�timents by December 31, 2004. Failure to do so will result in the return of your application packe . �j 0 V 1 9 2004 NAME OF ESTABLISHI��NT: o � r 13 TEL LOCATION ADDRESS: Z S � e ��.-e � w-ts � - MAILING ADDRESS: WNE CORPORATION NAME: �.IG�c r AGER'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 ta this form. L 2. Pool operators must list a minimum of two emplo ees currently certified in hasic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). 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 fde at your establishment. 1. 2. PERSON 1N CHAR�E: _ _ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIlVILICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# I B&B $50 OS-G�(� _CABIN $50 MOTEL $50 _INN $50 _ CAMI' $50 _SWIlvIlv1II1G POOL$75ea. _LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $'75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERNIIT# 0-100 SEATS $75 lCONTINENTAL $30 S'2�l NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQLJIIZED FEE PBRMIT# LICENSE REQ[JiRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 ____VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $SO•C� '•""*PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM"•'*• M � , ,Y _ , 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 HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONA�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 Depa.rtment 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 C�NSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FRO�EAT�SSERT�: - _--- _ _ 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.,outdot�r seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �� / a SIGNAT'URE: ��,��/��.,G `�� PRINT NAME& TITLE: �v�l, T /'''j�.Sc�r a//v 10/22/04 � �� The Comnwnwealth of Massachusetts ---_-_--� =��_ __-- -_ Department of Indsstrial Accidents � _- �cfNrw�/M�s' - -:== < 6(10 R'ashington Stree� f"'Floor _=�,s� Bost�►on,Mas� 02111 _ Workers'Com�reaanhos IHs�ee A�davit:B� leettic atneburs �� ,, . ,p �� ,�:, , . _ '3 � �,:r �� L ��;�� r,� � �„. �� 3 name: K V'�'� T �G�.� G/�G�r d� �S: /Z Z S o v f'�,� o�^c. �ri v a ��, f3a.sr R,yer �t�� M,n �;P- aZG�y �# ,s"oY 3 sp'-9'tGs' work site locati�rfnll addressl: � � I am a homeowner performing all wo�k myself: Project Type: ❑New Ca�structi��Remodel I am a sole 'etor and have no one w ' in an ca ' . ❑Buii ' Addition F a � ' " : ,.,_ �.w. ; . ❑ I am an employer�+oviding w�kers'compensatian fa�my employees worlcing on this job. ao��e• a�: �: ol�ats#k- ❑ I am a sole proprietor,ge,eral co�tractor,or homeowaer(c�rcle o�re)and have hirad the contractats listed betow who have the following workeis'compensation polices: eommt+r�ume• �S; div niu�e� # s�amsQ mme: �: i�': nka�r�• # - _ _ .�.,� .., �: ,. .. Failm�e�o secare�e a�reqeiral eeder 3ec�a 2SA�f MGL 152 aa Ind b IYe��f ai�ial peaaMks�f a�e�p b tI,SN.M asdhr oee ynra'imptbeament as we�as dv�peu�ltles in t6e br�of a 3TOt WORK ORDER ud a 8ne e[S10S.OS a day agaimt�e. 1 aadaataid dnt a apy ef tiia statemeat may be forwardM�o the OAke of lave�atlona af t6e DIA for cevsrage veriAatiea. !ro hertby caYt;jy xndee tAie patns and pene�ties ofPerj�ry dYet dYe iwforarelion prov�ded nbov�e is trxe awd oomrt s�s� � '�L'fc�►�� n _/�,.�/o�f Ptim natne Phone# a�cial aqe only do sot�er#e I�this area to be eomPided DY dh`gr fowa s�l �9��= per�ce�e# �� ❑c�cck if immediaEe respesx is req�+ed �+s p�Y ❑lfeaith De�att�eat centact P�� phese#; �Q tTMvieea Scp-ZON) THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-002 FEE: $50.00 TffiS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T M cciarotte /h/a chorage Bed&Bre�kfast at_ 122 S�uth �h�re Thive, S�nth Yarm�n h 1�RA in said Tawn of Yarmouth And at that place only and expires December thirty-first,2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. Tlus 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 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 affi�ced their official signatures,this Twentv-eigYi�_day of December A.D. 2004. BOARD OF HEALTH: L�e�s+it�. (�'o�on,/I�I.�,.� � ' /��ic��lc`��, ?lr.'ce C�iar�u.�st Number of Bedroom:3 /��G�Bh��y� e�� d�� S�, R.N. � , R Bruce G.Murphy ,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHIVIENT PERMIT NUIV�ER: #OS-018 FEE: $30.00 In accordance with reguiations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pennit is hereby granted to: Ruth T. Masciarotte 122 South Shore Drive, Bass River, MA Whose place of business is: Anchorage Bed&Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 2005 soARD oF xEAI.TH: l3erryc��ss`�. C�'o�ost,/yI.`h,.� � ' p�/�a�5�+irxa�`, �/rce Gls�-�vuis�rs Rolr�t� Bnoc.�, G� �f�Sl�, R.N. �1.��.�G�, R.1N December 28.2004 ' ce G. 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I do.hrreby cerrif}•under the poins and penalties of perjury that lht injorntation providtd abovt is tnte aad eoned Signamrc v (' `iv/C��✓i�:c.� Dau NO�f�iii/�e./ �G�� r Print name /�l � ��/ �� /a:fC / �-�"'p� Phone M .. o(Ticial use onl� do not..rite in this tres to be compieted by ciN or towa ofllcial city or town: Y�M�IIT$ _ permitAicease M n8uiidiog Departmmt pLieensioe Board � cheek if immediate response i�required 261 �Seleetmen'�ORce �HealtA Departmeot cont�ct person: phonelt;_ �SOB� 398�7231 eat. nOther ,�...��. .t :�A', THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-001 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a Anchora�,e Bed&Breakfast at 122 South Shore Drive South Yarmouth MA in said Town of Yartnouth And at that place only and expires December thirty-first,2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing authoriries 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 Whereo�the undersigned have hereunto affixed their official signatures,this Fourth day of November A.D. 2003. Boax�oF��.�: �e��D. ��, �?l.D. �u� �a�iic��P�Den.xot�. 2/�ee ��xa� ___ --- - NumberofBedroom:3 _ _ ----- - __ __. ,�o�it�. �7aa��c, l� _--- ��s ��t ruce G.Mwphy, , .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #04-003 FEE: $30.00 In accordance with regulafions promulgated under authority of Chapter 44,Section 305A and Chapter 111,Section 5 ofthe General Iaws,a permit is hereby granted to: Ruth T. Masciarotte, 122 South Shore Drive, Bass River, MA Whose place of business is: Anchorage Bed&Breakfast Type of business: Continental Breakfast _ _ __ ___— _ -- To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 soARn oF xE�.TH: �ieAccja�.xi.c D. C�a�da.t 71L,D. �avr.�cau �a��llcD�.xo�, ?lice C'�ain.,rawc �o�ait�. ��, ele�rk �� s�. ��t November 4 ,2003 � Bruce .Murphy,MP , .,CHO , Director of Health ` • An�ufio¢.qCTE .�f e R.� TOWN OF YARM � ALTH r 'L�=(�� o x �� APPLICATION F R LIC NSE/� �2M -20� - �: . .,!s ��'�'�� a� �„'�� .��;� * Please complete form and attach al necessar,�c�o ts y December 31, 2002. Failure to do so will result in h�t�i� ' ation packet. N ST IS T: r, ,-c�e i��-��3 TEL. # .1`0�' 3�S�-�Z l,.f LOCATION ADDRESS• 1 Z Z So liure `S�riwc- - (3�-SS i��v�e� A DRE • S � OWNER/CO E: v ��'��. c � ` l�1ANAGER'S NAME: TEL # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,�s required by State law. Please list the designated Poal 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 Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintaitt 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 em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. _____PERSON_ Il�I�:__ _ _ _ . Each food establishrnent must have at least one Person In Charge(PIC)on site during hours of operation. L 2. HEIMLICH CERTIFICATIONS: All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY �ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B&B $50 � �O� _CABIN $50 _MOTEL $50 _II�1N $50 _CAMP $50 _SWII�Rv1ING POOL$SOea. _,LODGE $SO ^TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $'75 �CONTINENTAL $30 03��J _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 �'AIL S RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 �TOBACCO $20 _�50 sq.8. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ SO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE O�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 ATTACHEL� OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yaimouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED 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 OPE1vING: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 haurs prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frvzen desserts mt�st bc tested on a monthly basis by a State certified lab. Test results musfbe sent to the HeaIth 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: �� Z" SIGNATURE: c-� // d%�t�✓�..�9 � PRiNT NAME & TITLE: � �h % /�w,fC��o� � 6'wdi�-✓' 10/18/02 • 4 � The Commonwealth of Massachusetts � � Department ojlndustrial,-�ccidents � o OfJlce ol/�resllpstl�is � 600 Washington Street ' �` Bnston, �fass. 02111 �~ '��y V4'orkers' Compensation Insurance Affidavit Annlicant information• PlesscPRiN1'Te�tihiir __ _ � n�m� I�✓ JL7 �/ �/G�- C/� /'rr� ^ /��C/�Q/'�-�� tj 9�� Is�cation:��- �i'(/� S!?O!'� tis� I��.S�S ��ive/' — ��G� phoneM.Sl3� '.31�Y"�Z�s— � am a homecwner pert�rming all work myself. � I am � sole proprieror=-,a, ha�e no one ��orkin� in am•capacit�� - � am a�€�p��-p�a„din�.u�orkers' compensation for my employees w�orkine on this job. m n • nam : G/!O �y ddress: LZ �dV� / //y �- � G Z-6 G p. �surance ca p�Y q � I am a sole proprietor. generai contractor, r homeowner(ci�cle oneJ and ha�•e hired the contractors listed be(ow ��ho ha�e the follu��in� ��orkzr� ,ompensation polices: �mnanv n�me: a�dress: ��h'� hons H• iasurancc co. �olic�•# s�m�anv name• address: — _ _ _ _ _ _ __ �'� ohoee+�• insurance co. ��,* t Failure to seeure coverage as required uoder Secnoo ISA of MGL!S2 n�Ind to tbe iopaidoe o(erisi�!pesaltles of a O�e op to SI¢00.00 a�d/or one yean'imprisonment as w•efl a�civil penalda io the form of a STOP WORK ORDER aad a lint of 5100.00 a day tpinst me. I a�dersta�d tLat a copy of thy statement may be forw�rded to the Otree of Invatig�dom of the DU for eoven;e veritfutfo�. I do hrreby cerrif}�under�h�pains and penol�res ojperjury that the injornration providtd abovt is ntre and eor►aY Signamre ��1 ��vllyJG-�� o p� lj��L Print name �+one N .. o(Ticial use onl� do not write in this area to be completed by eiN or town o(fitial ciry or town: Y�M��TQ _ permitAieeex M nguildiog Departmeat �Lieeasiog Boa�d �eheek if immediate response i�required 261 �Seieetmen'e ORet �Health Department contace person: phonep;_ �508� 398�2231 eat. nOther .. < .,,.: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-001 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a Anchorage Bed&Breakfast at _ 122 South Shore Drive South Yarmout _ MA in said Town of Yarmouth And at that place only and eacpires 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 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 Whereo�the undersigned have hereunto affixed their official signatures,this Eighth day of November A.D. 2002. _ BOARD OF HEALTH: (�i� i�ef�i, �i(cai�r�c �'e.tfao�ci.c?�. G�io7do�s, 'I11.�.. 2/iec Number of Bedroom:3 �o�� '��, � �atftic�e�t��cof� `�fe�c S ,��l. ruce G.Murphy, H .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-001 FEE: $30.00 In accordance with regulations promulgated under authority;ofChapter 94,Section 305A and Chapter ll 1,Section 5 of the General Laws,a permit is hereby granted to: Ruth T. Masciarotte, 122 South Shore Drive, Bass River, MA Whose place of business is: Anchora�e Bed&Breakfast - Type o��usiriess: - -�ntiri�ntal��akfast _ _- _-- -- ___ _-- To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2003 Bo�oF��,�: �a�clea s� �e�!(�ticai, ��rca� �e�c�a.x�c D. ��do�c. �D., �l/�ee ,�oGart�. �r�c, C'� �a�'iic��11e?��uxot� �fele� Slrak, ,�?2. November 8 ,2002 , ruce G.Murphy, H, .,CHO Director of Health r j � b � n/v�IQF� �1 � � F YARMOUTH BOARD OF HEALTH . - � ATION FOR LICENSE/PERMIT -2002 � ' � -: ' ' ''- i'�) ; U � ia/y/v� ��,o� G3 C=�kr+ .t � r�, 9 i * Please complete form and attach all necessary documents by December 31, 2001. Failur to ��o�vil�l�e��tt in the return of your application packet. HEALTy UEP�i. AME OF ESTABLISHMENT: v (>� TEL. #.�`d�'.�ysr'-��is' LOCATION ADDRESS: i z,� S=��,t� Sd,o,�� ,y� -3�ss 2,y'er -��y MAILING ADDRESS: .S'�-�� OWNER/CORPOR.ATION NAME: G�f� �`LvT/� 7 �''9Af� IAIZoT'7'E 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. 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 iist 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 CHARC'iE: 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# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $50 02^�7' _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIMMING POOL$SOea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 �,CONTINENTAL $30 Oa�c _NON-PROFIT $25 >100 SEATS $I50 _COMMON 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 AMOiJNT DUE _ $ E3a•00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � y i , . � � ..;.,"� . �: , ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's 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 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, 2001. SEASONAL ESTABLIS�-IlVIENTS 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 C'ONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health 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: �� '� �� SIGNATURE: l�v�`'/ /' /�'/�Gu'-�-�i7=� PRINT NAME &TITLE: � ✓ �� T � �S G/ �N v � 09/11/O1 • .. . �-\ The Commoawealth of Massachusetts � � Department ojlndustrial.-lccidents � o Olflce ol/aves�lOst/iis 600 Washington S�reet ' -` Bnston, Mass. 02111 �" '��y W'orkers' Compensatioa Insurance Affidavit ARnlicant intormation• P►essePR 'Wir n�m� �11 T/� T /�/� SCi✓� FZ vT7�. L�cation: jlZ ,.SU t�Ty SyoiZc �Jli v/= �s.� �l��s"f /i/vt•t' _ /yl/-� - C� ZC".G g �o�� ,.S o Y 3`!�'-3'��" �am a homeowner pert�rming all work myself. � I am a sole propri�ror=-� ha�e no one ��orkin� in anv capaciry � I am an employer pro�idino workers' compensation for my employees w�orkine on this job. s�mnan�• name: �13�' �luC /�GJ�/��x'C ��`l�� dclress: ��3��--- tit�•: nhone#• insurance co. policy# � 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� ��orkzr �ompensation polices: s9moanv name: address ��n" nhons�• insurancc co. oolic�•# somoanv name: address- �'� nhoee M• insurance co. �o�n,* e Failure to secure coverage as requ�red uoder Secnoo 2SA of MGL 152 ae!nd to tbe iopositioo o(erioi�al peadtla of a O�e op to 51�00.00 a�d/or one years'imprisonment as w�cll a�civil penalNes io the form ot�STOP WORK ORDER aod a Ooe of 5100.00 a day a�aiost me. t s�denta�d tfiat a topy of tAy statement may be fonva�ded to tht OfTice of Inveetig�tiom of the D[A for eoven`e verititatio�. /do hrreby certij}�under the poins and penallies ojperjury rhat tht injormation providtd abovt is trtrt and eor►�d Signaturc /��-�l�' �/'��lC-c-�.-�-t�/�-- Date ��/D/ Print name !1 V 1`� / ( �CL S G/�-/^D//� ' Phone N .. o(Ticial use onl� do not write in this�rea to be compieted by eiN or towe oAleial city or town: YA�� _ pe�mitAicense q nBuiidiog Department OLicensiog Boa�d �check if immediate response i�required 261 �Seleetmen'�OtTice �Healt�Depanmeat cont�ct person: phoneN:_ �508) 398�?231 eat. nOther THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #02-004 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a The Anchorage Bed& Breakfast at 122 South Shore Drive South Yarmouth 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 First day of March A.D. 2002. BOARD OF HEALTH: s� �e�c�'cez eqcja�ci.a?�. l��ido�c, .�lee Number of Bedroom:3 ,�o�i�t� S'�a�, (� �aauek?'jleDaurratt � �s ��t ce G.Murphy, .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-064 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: R � h T_ M � i rott , 1 So � h Shore Driv ,Ba��River, R�A Whose place of business is: The Anchora�e Bed& Breakfast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEALTH: �ca�ed�, zeP�ac, L'��ra.c ��D. c��, ��., v� �� , �e� ��D�u '�feP�s S<ra� .72. March 2 ,2002 � ruce G.Murp y, MP , . .,CHO Director of Health : �, �� . � a ANG,�{�2f}6E BED f�KF?#ST � : ' �= Z = f.�, o L� C� � OM [� � TOWN OF YARMOUT�O � H� �� APPLICATION FOR LICENSE/PERMIT -2001 DEC 1 1 Z000 * Please complete form and atta.ch all necessary documents by December 31, 2000. Fai in the return of your application packet. ---------------------------------------------------------------- -----------�------------------------------- ------------------------------- c� �- - .��d fj < . - d—, �z Z- du � i v�. -I �SS iv r - OL�� f t QWNER/CO MEx / v�-� 7 /1 G-s c��r�/� MANAGER'S NAME: TEL # ��I�ING ADDRESS: --------------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATTONS: The poal supervisar must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two emplayees 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 bnsiness. 1. 2, 3. 4. HETIVILICH CERTIFI�ATIONS: All food service esta.blishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at 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# NON-SM�KING SEATS: TOTAL# � - _ � -- - - -- ----------------------- _ _ - - OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# !a&s �so �o�_�o i _cABnv $so _INN $50 _CAMP $50 ^LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: — NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-1 OQ SEATS $75 / CONTINENTAL $30 .� �- Zg _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 ,WHOLESALE $75 RET i .RVIC : LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.8. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHA�IC�E�. $10 AMOUNT DUE _ $ 80.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** ,,�- �. r s , . , ADMINISTRATION Under Chapter 152, SectiQn 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of Fany Iicens� q�r`pexm'it 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�armouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAY5 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. A1�DITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to operung,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS• The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As sta.ted in 105 CMR.590.000(K),enforcement of Consumer advisary, Food Code 3-603.11,will be unplemented January 1,2001. Only establishnnents which sell or serve ready-to-eat, raw or undercooked animal products aze required to have consumer advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. . FRnZFN DESSERTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Departxnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFE�: Outside cafes(i.e.,outdoor sea.ting with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerit is prohibited. DATE: SIGNATURE: ��/"��'�� PR1NT NAME & TITLE: /�✓�f-� � .��-s L/�-�r�� '�w,/��/' 11/16/UO � � The Commonwealth of Massachusetts w W Department ojlndustria/.-�ccidents T ; Ofllceo/%st/ostl�is � � 600 Washington St�eet � �.` Boston,Mass. 02111 �'" "� Vb'orkers' Compensation Insurance Atfidavit Annlicant infnrmati�n- PleBscPRRQT7l�ibTi[ nlmr �/%� /Yli�_ �c�i"�=,g%-C ��'l ��/''�'�:��_j/ �_ �- �(/ }, location• �1- � S�%c�/!� -�/�er� Y�-, v �. �jt� �ll-=�_S 11✓�9t'�" " ��_ L' � � �'� phone# S�'�' i�"��--'�a' ��m a homeowner pertormin�all work myself. � I am a sole proprietor�:;� ha�e no one��orking in am•capacit-r � I am an emplo�er pro�iding workers' compensation for my employees working on this job. compan�• name• address �y• phone q• _ insur�nce co Dolicy# � I am a sole proprietor. oeneral contractor. or homeowner(circle onel and have hired the contractors listed below ��ho ha�e the follo�+in� ��orker� �ompensation polices: gQmp�v name• address• citv• Dhone#• insur�ncc co �}oli�# com�anv name� _ _ _ _ -- - -- ..a,dress -- _ _ ----_ _ s�,• nhone#• insurance co i�Y� ' Failure to secure coverage as required under Sectioo 25A of MGL 152 eaa lad to tbe imposition of crimi�al peaalda of a Oae op to 51,500.09 a�d/or one yean'imprisonment as w•ell as civil penalde�io tde form of a STOP WORK ORDER�od a lint otS100.00 a day apiost ma I s�denti�d that a eopy of thy statement may be forvvarded to the Ot6ce of Investigatiom of t6e D!A tor eovenge veritiatfo�. /do hrreby certij��under�he pnins and penalties ojperjury that Iht injor►nation providtd abovt is true and eonteL �Signature ��-�!% /' l��e��c==c-t-�`-/l�= pate /// � f Print name ��' ��`) �—�� --5 C�-/l-c Y`c) � Phone# -j �'� _�%� "�� .. oRcial use onl� do not M rite in this area to be completed by city or town oflicial city or town� Y�M�IIT� _ permit/lieense# I'IBuilding Departmeut — �Licensiog Board � check if immediate response is required 261 ❑Selectmen's Of6ee �H-alt6 Departmeet contact person: Phone It;_ �508} 398t2231 ext. nOther Irevised i;95 P)AI THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O 1-001 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d1b/a The Anchorage Bed& Breakfast at 122 South Shore Drive South Yarmouth MA in said Town of Yannouth And at that place only and expires December thirty-first,2001 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 Thirkv-first day of Januarv A.D. 200 L BOARD OF HEALTH: �d� �et�ed, C�ca�t (�,��a�rled� �e��. �/ice (�,`iaGrs�ra.� Number of Bedroom:3 ��t� ��, � I��iQel 0 �.C� � .�D. t_ ruce G.Murphy, ,R. ,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #01-028 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: Ruth T_ M G i rott ., 1 So � h Shor Driv , Rass River, R�A Whose place of business is: The Anchora.ge Bed&Breal�fast Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d� �ette�, ��iav�ias� �ianlea� Za�. ?/�ee L�a�� a6�t� �'�a. C?� ��clreal d '.C' eo�jao,ru��• ,�11Z.?�. 7anua,rv 31 ,2001 .c.�' ` Bruce G. Murphy,MPH R.S., HO Director of Health � ,, _i_4��,%`�1(�d ic ti'c�j � _� , , � TOWN OF YARMOUTH BOARD OF HEALTH � � � � � M � � " APPLICATION FOR LICENSE/PERMI,� �400 � .. �o v 2 2 19g9 .: �� . �v ,. * Please complete form and attach all necessary documents by D�ecemb�r 31?�1`�99�Faii'ure t d� �11�- w ; �� . the return of your application packet. � - � ---- • • -------------------------------------------- ---- --- l ---------------- - --- �- ��'--------------------- -- ---. --- - ---- -- - - ---- --j - --- - - ---- N F EST I N • c c.l-�e �/ r�dc s TEL # .%%d''�''z�s L AT Z � r-i v.e, - l3�-t � �r LIN D �.�--�-- OWNER/C �...��/�sGl�-f-o MAN�..� -�R�'S N�ME: —�---� , , TEL. # MAILING ADDRESS: POOL CERTT_FICATTC�NS: The pool supervisor must be certified as a Pool Operator, as required by new State taw, Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z. 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 ydur 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# NON-SMOKING SEATS: TOTAL# ------------------------------------------------------------------------------�------------------------------------__--------------------------_ OFFICE USE ONj,Y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B&B $so -3 _c�nv $so INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMNIIIVG POOL $SOea. WHIlt.LPOOL $25ea. FQOD SERVICE: LICENSE REQIJIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 �CONTINENTAL $30 2 "� >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 R�TAII. SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ ��'� """""PLEASE TURN OVER AND COMPLETE OTf�R SIDE OF FORM'"""" . : . ADMINISTRATION ' UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOLTT`H IS NOW RE�UIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR. CCIMPANY DOES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MU5T BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF Y�UR 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 COMI'LETED APPLICATIQN(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TQ OPENII�TG FOR'THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY'I�BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIl��IMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE C�UNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlvA�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �TERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQtTIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT 'THE HEALTH DEPARTMENT. FROZEN�ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN TI-� SUSPENSI�N OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTII,T�-�ABOVE TERMS HAVE BEEAT ME'£. _ - _ _ __ _ _ __ _._ ---- ___ _-- --- __ OUTSIDE CAFES: OUTSIDE CAFES(i.e., OIJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. QUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: SIGNATURE: ��I��G'-�e�- �� PR1NT NAME& TITLE: �� / �cZ.S c/G- �"a� �Dc�ricr�� 11/12/99 , . � The Commonwealth of MassQchusetts � � Department ojlndustrial.-lccidents " T a Offlce ol/�estlostliis 600 Washington Street ' ` Bnston. Mass. OZlll . �'" ��~ W'orkers' Compensation insurance Affidavit ARniicant information: P►esseYRil�'i'T.�.'hia n�m� GfZO J�'✓ l,J/`P.W' � Lucation� � Z Z > o v]�"Lj .f�a re �r/V-2.. - , �I� -�� -- a Se � 3f P= �zG.s� I am a homeowner perturming all w�ork m}self. � f am a sole proprieror �-� ha�e no one ��orkin� in am•capacin� � I am an employer pro��din� workers' compensation for my empioyees working on this job. comoam• name• �ddress: ��'� nhone�1• i�sur:►nce co. Qoli�,y!! � I am a sole proprietor. :enerai contractor, or homeowner(circle oneJ and ha��e hired the contractors listed below ��ho ha�e the follo�.in� �+orker� �ompensation polices: sompanv name: address• cin•• nhone#!• insur�ncc co. Qolicv# companv name: _ _ _ - -_ __ zd d ress: . _ - _ — - _ �: ohoee 1!• insurance co. �y�f t Failure to stcure coverage as required under Secdou ZSA of MGL 1S2 ta�lead to tbt iopoeidoa o(erisi�al peadtles of a d�e ap to f1.500.00 a�d/or one yean'imprisonment a�w�cfl a�eivil penaldee io the form of a STOP WORK ORDER aed a Ifae otS100.00 a day apin�t ma t a■dersa.d m�e a copy of th'n statement may be fonvarded to the OfTice of Inve�tiguiom otthe DIA tor eovenge veritiutio�. /do hrreby certij}•under rhe pains and pertal�ies ojperjury tkat�ht rnjormation provided abovt is trne and conect Signature ✓/��' /�lG�! l�iGc.tid��,� Date Print name �✓�h T ��-S C/ �-�"a/� Phone�!��/ �lr�' �LG� .- o(Ticial use onl� do not r►�iet in this are�to be completed by cih or town ollieial city or town: Y�M�IITQ _ permitAieense p t'1Building Departmeot �Licensiag Board �check if immediate response is required 261 �Selectmen'�ORice �Healt6 Departmeat contact person: pAone p;_ �508� 398�2231 egt. nOther .. .,,, . THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: Y2K-3 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a The Anchorage Bed& Breakfast at 122 South Shore Drive South Yarmouth 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 conformity 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, inc(usive, 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 Thirtieth day of November A.D. 19 99 . Bo�oF��,�: �'d?�l. �Bt��, c��,,,,�K �oan� �ullivan, K.I'/., Vice l�hairman NumberofBedroom:3 �odert� p�iown, l.ler� abrie[le�a�of��iy-�ooPe� • ��O' ��,� . Bruce G. Murphy,MPH,R. .,C Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-8 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: R � h T_ M � .i rott , l So� h 4h�r . l�riv , Ba��River� 11�A Whose place of business is: The Anchorage Bed&Breakfast Type of business: Continental Brea�k�ast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2000 BOARD OF HEALTH:�'d� �gtt�, C'��r„��. �oan� �u[livan, �//., Vice l..�irma Kobert� �rown, �lerk a�rie[le�a�o%�c��ldooPe� ��10�0�� November 30 , 1929 Bruce G.Murphy,MPH, R.S., CHO Director of Health ....%�o�a�o��s��so�i�z�oa�tv x�no rtuni�sv�za�..�. �",,�$ _ �nQ,�uno�� ot$ u ooz� �u�bs 000`sz< SZ$ Z2I�SS�Q N�Z02I3 SL$ '$'bs 000`SZ> OZ$ O��gOZT Sb$ '$'� OS> # ,LIY�2I�d ��3 Q�2IIf1��I�SI�I��I'I # .LIY1RI�d ��3 Q�2II(1��I�SN��I'I � s SL$ �'I�'S�'IOHAA OS$ 'ZaIA NOY�TL�iO� SZ$ .LI302Id-I�IQI�t OSI$ SZF��S OOI< �—�� 0£$ 'I�.L1�I�NI,LNO�� SL$ S.L�'�S OOi-0 #,LIY�RI�d ��3 Q�IICla�2i�SN��I'I # ZIIr1I2I�d ��3 Q�IIfld�i�SN��I'I �� -�aSZ$ 'IOOd'Ti�IIi�t1 '�aOS$ 'IOOd jJi�[II�B�IIAAS OS$ 'I�,LOY�I OS$ ?I2I�d 2I�'II�'2I.L OS$ �tJQO'I OS$ dY1i�'� OS$ I�II�II OS$ I�tIfl�� OS$ g�88 � # .LIL�RI�d ��3 Q�2IIf1(��?I�SN��I'I # .LIY�T2I�d ��3 Q�2IIf1��2I�Sl�I��I'I ��S�I _ - 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insur�nce co policy# � I am a sole proprietor. qeneral contractor. or homeowner(circle onel and ha��e hired the contractors listed below �,ho ha�e the follu��in� ��orker�� ompensation polices: companv name• „a�ress �n;• phone#• - insur�ncc co �olicy# m n n address• _ __ . _ - _ _ _ . __ _ �, Rhone#• insurance co A�X.�1 — Failure to secure coverage as�equired under Secrioo 25A of MGL IS2 eae lud to t6e iopaidoo o(crisi�al peedtla of a O�e op to 51�00.00 a�d/or one years'imprisonment as w•cll as eivil penalde�io the form of a STOP WORK ORDER aod a Aoe of 5100.00 a d�y apio�t ma I a�dersta�d that a copy of thy statement mav be fo�vvarded to the ORee of Inve�tigation�of t6e DIA(or eovenge veriBatio�. I do hrreby cer�ij��under�6e pains and penalties ojperjury thal tht injormation provided abovt is hue and coi►ect Signature___c-=��/, ��G�//GG cr��a�%�c..— psu / / 3U j�'P� Print name l � U T�� A-S C/��d�y� Phone� ., oRcial use onl� do not Mrite in this area to be completed by ciN or town oflleial city or town: y�M�IITQ _ permiNiceese q nBuildiog Department — pLieeesing Board �check if immediate respoese i�required 261 pSeleetmen'�Otiiee �Hea1tA Departmeot contact person: phone p;_ �508} 398---?231 egt. nOther (re��istd 7�Q5 PJAI � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-1 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Ruth T. Masciarotte d/b/a The Anchora,ge Bed&Breakfast at 122 South Shore Drive_ South Yarmouth,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 thirty-two, inclusive, and of said chapter and sections twenty-frve to twenty-seven, inclusive,of Chapter 272. In Testimony Whereof;the undersigned have hereunto affixed their official signatures,this Tenth day of December A.D. 19 98 . B�E1RD�F HEf�I.TH: �d� Jelted� (��irman �oan � �ullivarc� Ko.//.� Vice C��irman Number of Bedroom:3 Ko�ert�}. �rowrc� �fer`i a�rielfe�ahofehc�-.�too�nea � �e ou� �L Bruce G. Murphy,MPH,R .,CH Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIVV�NT PERMIT NUMBER: 99-5 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: RLth T Masciarotte, 122 S�u h Sh�re Drive� S�uth YarmoLth, MA Whose place of business is: The Anchorage Bed&Breakfast Type of business: Continental Breal�ast To operate a food establishment in: Town of Yamiouth Permit expires: December 31, 1999 BOARD OF HEALTH:��/. �elt��, C�t�.�,� ' �oan � �ul�iva�� K.//.� �ica C��irman Ko�ert� O,rown� l�fer� a�rielle�ahof��i�-.�tooped ///ichae oCo �lirC � December 10 , 19 98 Bruce G.Murphy,MPH,RS. CH Director of Health