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Home My WebLink AboutApplications, WC and Licenses .. . . ti� c, ' � � TOWN OF YARMOUTH BOARD OF HE�cI,�'H � ° ��`?�r�, � APPLICATION FOR LICENSE/P��1VIIT-20 ��,-�,, 6 �..� �'�,`�.�� R b �� * Please complete form and attach all necessaryy�'�:cum�nts by Dec� � Failure to do so will result in the return of our a 1 E��• y pp ication p . NAME OF ESTABLISHMENT: � Z� TEL. 4� -�'�`\ LOCATION ADDRESS- �tf � d/' D MAILING ADDRESS: �' �� OWNER NAME: TAX ID FEIN or SSN : � - � � CORFORATION NANIE (IF PLICABLE}: � p MANAGER'S NAME: U ' TEL. MAILING ADDRESS: q .-� t� POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Poal Operator,as required by State law. Please list the designated Pool C��erato�•(s) and atta�h a co�y of the ce.-t�ficatia�� to rhis form. 1. 2. Pool operators must list a minimum of two employees cuirentl�certified in basic water safety,standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies of employee cei-tifications to this form. The Health Department �vill 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 requu•ed to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitaiy 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 Chalge (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 ui the Heunlich Maneuver on the premises at all times. Please list yaur employees trained in anti-choking procedures belaw and attach co�ies of employee certifications to this foim. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 3. 2• 4. RESTAURANT SEATING: TOTAL # Lovci�c: OFFICE USE ONLY LICENSE REQUIRED FEE PERNIIT# LICENSE REQI)IRED FEE PERMIT� LICENSE REQLTIRED FEE PERMIT# _B&B S5� CABIN �',55 — MOTEL S55 �TNN S$� #Q`(--�' � _CA_�l�IP cgs �cz�rn r T _n r c '�::::`��.�O� „3Cea. _LODGE S55 _TRAILERPARK �105 _WHIRLPOOL S80ea. FOOD SERVICE: LICENSE REQi11RED FEE PERMIT� LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S85 _CONTINEIVTAL S35 I >100 SEATS S160 NON-PROFTT S30 �� COMMON VIC. S60 ��x��,(/ _�tHOLESALE Sgp RETAIL SER��ICE: �-u�� LICENSE REQiJIRED FEE PERNIIT# LICENSE REQIIIRED FEE PERMIT# —�SID.KITCHEN S80 LICENSE REQUIRED �EE PERMIT# _<50 sq.ft. �,50 _>25,000 sq.ft. �22g _<25,000 sq.ft. 580 _�NDING-FOOD �25 _FROZENDESSERT �40 TOBACCO �j� \A��TE CHAVGE: S10 — AMOUNT DUE _ $ 2-�,o 0 *"""*PLEASE TLR�OVER AND CO.?VIPLETE OTHER SIDE OF FOR'47 x,�,�,�* � . 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 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES N� MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel 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 shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CNIR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days prior to opemng.PLEASE NOTE:People axe NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate 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 CATERING POLICY: Anyone who caters within the 1 a lon form 72 hours prior to he cat red evente Th ee forms can be ob ained at the Temporary Food Sernce App Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN 'TI-� COMPLETED RENEWAI-APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR P4O L�(�OF HEAL'TH PRIOR EQUIpMENT,ETC.),MUST BE REPORTED TO AND PROVED T'HE B TO COMMENCEMENT. RENOVATIONS MAY RE UI E A SIT AN. Y DATE: SIGNATURE: pRINT rTAME&TITLE: � � � 1o��zi!os ,--�. ACORDM CERTIFICATE OF LIABILITY INSURANCE � 10/29/2008 � PRODUCER Serial# 2890 THIS CERTIFICATE IS ISSUED AS A MATi'ER OF INFORMATION KIRKILES 8 ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COMMERCIAL INSURANCE BROKERAGE LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 273 RIVER STREET NORWEIL,MA 02061-2209 INSURERS AFFORDING COVERAGE NAIC# INSURED iNsuReR A: MA RETAIL LMERCHANTS WC GROUP INC. ANTHONYS PIER FOUR INC. iNsuReR s: 299 SALEM STREET INSURER C: SWAMPSCOTT,MA 01907 INSURER D: � INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIINITS SHOW N MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR noo'� POLICY EFFECTIVE POUCY EXPIRATION � TR NSR TYPE OF INSURANCE POLICY NUMBER M pT LIMRS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENER4L LIABILITY DAMAGE TO RENTED PREMI E E c r n S CLAIMS MADE �OCCUR MED EXP(An one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- J CT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea acadent) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNEDAU70S (Peraccident) $ PROPERTYDAMAGE $ (Per accidenQ � GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTOONLY: qGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGRECaATE S $ DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND X T RY LIMITS �TR EMPLOYERS'LIABILITY 014005031008108 1/1/08 1/1/09 ELEACHACCIDENT $ rJ0�,�0� ANY PROPRIETORIPARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED7 EL DISEASE-EA EMPLOYEE $ �JOO,OOO If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ 'rJOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS NAMED INSURED:ANTHONY'S CUMMAQUID INN, INC.,RT.6A,YARMOUTHPORT,MA 02675 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF YARMOUTH DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �� DAYS WRITTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 1146 ROUTE 28 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SOUTH YARMOUTH, MA 02664 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE � . f�"t'`''�}yy'f..�a'J' J ACORD 25(2001/08) OO ACORD CORPORATION 1988 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-004 FEE: �55.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv's Cummaquid Inn, Inc. d/b/a Anthonv's Cummaquid Inn at 2 Route 6A, Yarmouthport, MA in said Town of y'amiouth And at that place only and expires December thirt�•-first,2009 unless sooner suspended or revoked for violatian of the laws of the Conuiionwealth respecting the licensing of innholders. This license is issued in confornvry with the authority granted to the licensing authorities by General Laws,Chapter 140,and aniendments thereto and is subject ta sections nvenn�-n��o to thirtrn�-n��o, inclusive, and of said chapter and sections twenty-five to hventl�- se�•en,inclusive,of Chapter 272. In Testimony Whereof,the undersigned hace hereunto affixed their of�icial signattires,this Eleventh day of December A.D. 2008. BOARD OF HEALTH: .�E¢�efL S�, �..N., C�cClXfttatt RESTRICTION: Swimming pool not for guests- �a�X�¢d `.�. .�`�e�(�1�1lG.� �(C6 �ltr(nfltlCft Family use anly. J�O�� 3.��Otll�L, �.�¢x� Q�ftK ��Y�P�2t1�Q4lIlt� �..lV. t'"`"''J'��• Bruce G. Murphy, ,R.S.,CHO Director of Health _ _ _ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-064 FEE: 5160.00 In accordance�c•ith regulations promulgated iuider authorit�%of Chapter 94,Section 305A and Chapter 11 l,Section�of the General La«s,a permit is hereby graiited to: Anthony's Cummaquid Inn, Inc., 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .`1�ett SPta�, `J�.✓Y., C'�ta,vuntart SEaTnvG: 400 C��lXX.�i3 .�. S�� 6C¢ C�ItRfL J?o.�ent 3. J3acccuun, C'�e�cf� Q�cra C�'Xeert�a�ecrn, J2..iV. �ue�cJ.� J• !'facr�e� December 1 l.2008 � Bruce G. Murphy, , R.S., CHO Director of Healt THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NtTMBER: #09-046 FEE: 560.00 This is to Certify that Anthonv's Cummaq�id Inn, Inc d/b/a Anthony's Cummaauid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE � In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualiers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��'en SR�c�, J`Z..lv., C.'f�a.vrtttatt sEarnvc:400 �� C,� ��tce �'f�av[tturrt ;CQJI�t Qft.K ��L¢BfZ�lUlitt� �..lY. �'"``^'J''..�' �� December I1,2008 Bruce G.Murphy ,R.S.,CHO Director of Healt • ' , A-�oN y s J4�Y�k f TOWN OF YARMOUTH$OARD OF HEALTH �------- o �� = ��`�� ;y ��r-�O(b� r� D APPLICATION FOR LICENSE/PER11��I'-2'Q��j �, c��'? ,/ � � `'r..c.,�� d � � ti , E„_l. * Please complete form and attach all necessar��t�oE`�n , y�I� ber 37, 2�0 . Failure to do so will result in the return,of yi�a�i�ip ication pa k��AL H DEF'i�. NAME OF ESTABLISHMENT: /J D �Q/J7A7 lC/G'G /� TEL. ��i{—�� LOCATION ADDRESS: a� G r o O MAILING ADDRESS: � J'Ga77� � Q' 4WN�R NAM�: TAX D E1N r SN - CORPORATION NAME (IF LICABLE): /y�a ! /J MANAGER'S NAME: D eiQ I~ TEL. Q �o ' D� MAILING ADDRESS: 4lII J' - d�' D POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required b3�State law. Please list the designated Poo1 IIperato�js)and attach a copy of the certification to this forrn. -- -- - - 1. 2, Pool operators must list a minimum of two employees cunently certified in basic water sa£ety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these enlployees below and attach copies of employee eertifications to this form. T#e I�ealth Department will not use past yea�s' reeo�ds. �'ou t��st 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 Saiutary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. 'i'he Health Departrnent will not use pa�t�e�rs'records. You must provide new copies and maintain a file at your estabtishment. 1. 2. PERS9N 1N�HAIZC'iE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTffICATIONS: 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-chokuig procedures below and attach copies of employe�certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'v11T* LICENSE REQL'IRED FEE PER'�IIT� LICENSE REQL'IRED FEE PERVIIT= �B&B S50 CABIIv' S50 _MOTEL S50 I INN S50 _CA:�IP S�0 _SV4'Ii�LVIINGPOOLS75ea. _LODGE S50 �TRAILERPARK S100 _RZ-IIRLPOOL S75ea. FOOD SERVICE: LIC£2+1SE REQUIRED FEE PERMIT� LICENSE REQLTIRED FEE PEI�:�-tIT# LICENSE REQL'IRED FEE PERvi1T= _0-100 SEATS S75 _CONTINENTAL S30 IvON-PROFIT S2� I >100 SEATS S150 / CO;�L'4ION VIC. S50 V4'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PER�IIT� LICENSE REQL�IRED FEE PERVIIT= LICE:�'SE REQtiIRED FEE PER�fIT= _<SO sq.ft. ' Sd� _>25,000 sq.ft. 5200 _VEI`DING-FOOD S20 _<25,000 sq.R. S75 _FROZEN DESSERT S35 TOBACCO S50 NAl�CHA�IGE: sio AMOUNT DUE _ $ ��. c�c� '�****PLEASE TL'R.\OVER a\D C0�IPLETE OTHER SIDE OF FOR�Z***** � r' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRL4TELY 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 customa.rily associated with motel and hotel us�. Transient accupants 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 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. * NOTE: Enclosed Motel Census must be completed and returned with tlus appiication. 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 Depa.rtment to schedule the inspection five(�days prior to ogsning. 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 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 obtasned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor�oQking,�r�g�r��Qn�or dis�lay of any food product by a ret_ail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[1RN THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO PROVED BOARD OF HEALTH PRIOR TO COMMENCEME�iT. REvOVATIONS MAY QU RE A SIT P . . DATE: SIGNAT'URE: PRINT NAME&TITLE: 4� �/r �' �� Y`"� �'� � , io;o n� ACORD CERTIFICATE OF LIABILITY 1NSURANCE D 11/02/2007� PRODUCER Serial# 2429 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KIRKILES&ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COMMERCIAL INSURANCE BROKERAGE LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 273 RIVER STREET NORWELL,MA 02061-2209 INSURERS AFFORDING COVERAGE NAIC# INSURED iNsurteR A: MA RETAIL LMERCHANTS WC GROUP INC. ANTHONYS PIER FOUR INC. iNsuReR s: 299 SALEM STREET INSURER C: SWAMPSCOTT, MA 01907 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. InISR ADD'L POUCY EFFECTIVE POLICY EXPIRATION T N R '�PE OF INSURANCE POLICY NUMBER DAT D A E M D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMGE TO REo TED ce $ CLAIMS MADE � OCCUR MED EXP An one erson $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY ECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acadent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Perperson) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERN DAMAGE $ (Per acddent) GARAGE IJABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: qGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ a DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND X TOCY IMIT �ER EMPLOYERS�uaeiurv 014005031008107 1/1/07 1/1/08 ANY PROPRIETORlPARTNER/IXECUTIVE EL EACH ACCIDENT $ rJ'OO,OOO A OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPlOYEE $ 'rJOO,OOO If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ �JOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS NAMED INSURED:ANTHONY'S CUMMAQUtD IN1V,INC., RT.6A,YARMOUTHPORT,MA 02675 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �0 DAYS WRITTEN TOWN OF YARMOUTH NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL BUILDING DEPARTMENT 'I�4F)ROUTE ZH IMPOSE NO OBLIGATION OR LIABIIIIY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SOUTH YARMOUTH,MA 02664 REPRESENTATIVES. AUTHORIZED REPRESENTATNE ��7�u:t�'.'`."r ACORD 25(2001/08) OO ACORD CORPORATION 1988 "�� y�•�l Hivinurvr'S r1tK 4 7815989321 P.11 ACORDTM C��TIFICATE 4F LIABILITY �IVSUI�A,NCE °�'� � � PRODUCER �,�� ES 8 ASS�CIATES Serial� 2429 THIS CER7IFIGA7E IS ISSUED AS A MATTER OF INFOWNqTiON ONLY AND CONFERS NO RIGNTS UPON TNE CERTiFICATE COMMEliC1AL 1N3URANCE BROKERqGE LL� HOLD�R. THIS CEI�TIFIGATE D0�3 NOT qMEND, EX��ND OR �S RIVER STItEET �TER THE C�VERAGE AFFORDED BY THE POUCJES BELOW. NORWELL,MA 02061-�209 ir�suae� W9URER$pFFORDlNf�C�]yERAGE �� • � nvsu�n: MA RETAII.LMERCHANTS WC GROUP INC. ANTHONYS PIER FOUR INC. z98 SALEM STREET ��' SWAMP3C01T.MA 01907 ' p+suaea c: - n+suR�re o: . ; COVERAGES WSURER E: 7NE POLICIES OF INSURANCE LISTEp gEtfiW HqyE BEEN ISSUEp Tp�{E IRSURED �'REQUIRgWg►��M OR COND171oN OF ANY CONTRAM OR�OTHER DOCUM��WI�RE.�SpECT T�p��TM��F�,�q��qr�B�UED ORG MAY PERTAIN,T}IE INSURANCE AFFORDEO BY 77�ppUCES OESCRI�Ep y�� SUB.IECT TO ALL THE TERM$, p(CWSIONS AND C�NDRIQNS OF SUCN pOUC1ES,AGGREGATE UMITS sHOWN INAy HpyE g�EN REDUCED 8Y PAID ClJWY1$, 7YVE OF INSURAWe� POtJLw NUMBEp N �ENERAL LIABlU11r � COMA�RCULL GEN6RAL W18�riy EACN oCCURR6VC� s CuiMs AeppE �OCCIm a MED D� e�p 8 PBt60WLdMVINJURY s GETPL AGGR�'(E�APPLIEB PER: ��A��TE S POL1Cy P �C � PRD��1{`�, B-CpNppP AOG S AuioeA081tE uABILtTY ANYAl1T0 �CO►i1B�GLE�Ihvi � ALL OWNED AUTos BCHEDULEO AUTOS �L�Y I�t�L�NRy i HIREp AU7'05 NONI,IWNIEDAUTOS B�ILYIWURY = p'ere� a�naac��qeuaTr : ��°ePe�i� a ANY AUTO o ^�'O ONLY-EA ACCtDEN[T S 07t�R'iFiAN F�+aCC 8 • �� AlliO ONLY: � � OCGtJR �CWMS MADE ��RR�'ICE a AOQREGAT� _ DEDUCT18lE � RETENt1oN s . ��EN8A7��►1 AND S �1.OY�ps'UqBI1dTy X ANYPROPRI�pR/pqI�N�C�� 014005031008107 1/1lp7 1/1/08 A OFFIC�D�CLUDED7 EL EACN ACCIDETII7 i SOO OOO If�p,�g�� SPECUIL PR01/�810N9 bqqiy EL OISEABE-pq FJ�(,p� a ��Q OTMER EL OISEASE-POIICY UAIR � �OOO �ACRIPTON OF�BRATIONSILOCq ACDED BY ENDOI� dAMED INSURED:ANTHONY'S CUMMqQU10 INN, INC.,R7.8q,yqRM�U7'PHppRT,MA OZ675 ��RTIFICATE HOLDEFi CANCELU►TION BHou�o ANY aF rrie nBovE DESGR�o POLiGBS BE c�wcRLLED BEFORE 7HE o�iRAnON TOWN pF YARMOUTH �TE 171EREOF,T►{��$gUING INBUR�R WI�� pEqypR Tp Mq�� p �Ys��N BUILDING DEpARTMENT NOTiGH iD THE CERT�FICATE HOLDER Mp,MED TO Tl�{�,eur Fn,u�ro 0o so sNnu_ ��46 ROUTE 2$ . IMpp3E NO 08LICiAT10N OR LA8ILITY OF ANY pND UPON 7}1@�NSUNEq,lTS AGFmB OR SOUTH YARMOUTN,MA 02664 REPRE$ENTp7ryEg, avn�n rtEvr�xranvE 30FZD 26(2001/08) �� ACORp I�I�pORq7�ON 1988 THE COMl�ZONWEALTH OF MASSACHUSETTS TOWI�T OF YARMOUTH PERMIT NUMBER: #08-005 FEE: $50.00 : THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthon�s Cummapuid Inn, Inc. dlb/a Anthonv's Cummaquid Inn at 2 Route 6A, Yarmouthport, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders_ This license is issued iu conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to secrions twenty-iwo 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 Eleventh day of December A.D. 2007. BOARD OF HEALTH: .�E¢e¢It SR� J�..N.� C�L�t ItESTRICTION: Swimming pool not for guests- �� `.�.��[.�[�JiG., �iC¢ ��Lp.It Family use only. .�i�'(l��41[��.��lAWtt, �.�Jl� rli(.uft� � . ruce G.Murph , .5.,CHO Director of H TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-066 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Anthony's Cumxnaquid Inn, Inc , 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD oF HEALTH: .�fe�e�rt S�, �..N-, «� SEA�vG: 400 ��'� '�"��'� ��(�� J�O�i� �.��tl�tWZ� �:C.�12 . Cl�ut C�ce.e,t.�auc�n, J�..IV. December 11.2007 ruce G.Murphy, H, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOU i'H . PERMIT NUNiBER: #08-051 FEE: $50.00 This is to Certify that Anthonv's Cummac�uid Inn, Inc. d!b/a Anthony's Cumma�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers_ This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: �'Eeeeri Sfia�, J2..N., C"f�ai�rcrn� SEATING:4O0 ��F�d .�. .`��i�P�� 1C8 t�ftA.fL J?,o.8errt.�'f�.J`3�uw�r�, C'�cP� , J2..IV. December 11.2007 Bruce G.Murp , ,R_S.,CHO Director of Hea th � - f.Ya � �y ��c�� D .o.�=R o TOWN OF YARMOUTH BOARD OF HEALTH F��s APPLICATION FOR LICENSE/PERMIT-200 ,� D�C 2 � 2006 � * Please complete form and attach a11 necessary;docuir�ents by Decem eht�A � ��T� Failure to do so will result in the return of yo�r'application pac et. NAIV� OF ESTABLIS�-IlVIENT: �. � � � ' � TEL. #1Cl�D�c�i�a�.-��'"d� LOCATION ADDRESS: ' - �' o�!' D �' MAII..ING ADDRESS: .� �c'vT �j` �J OWNER NAME: T ID IN r ' � CORPORATION NAME (IF PLICABL : '� 9� MANAGER'S NAME: 'I'EL. #,�'� ' _ _ MAILING ADDRESS� �1' - 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 m�intain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary 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£�AR�: ---- —__ _ s_ _ _ ___ . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlVILICH CERT'IFICATION5: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE U5E ONLY LODGING: LICF,NSE REQiJIRED FEE PERMIT# LICENSE REQIJII2ED FEE PERMIT# LICfiNSE REQiTIRED FEE PERMIT# _B&B �50 _CABIN $50 MOTEL $50 / INN $50 �v7�O�S _CAMP $50 _SWIl�II�AIGPOOL$75ea. _LODGE $50 _TRAILERPARK $100 WHIl2LPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMtI# LICFNSE REQtIIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 �>100 SEATS $150 � (� / COMMON VIC. $50 Q –Q'f`r _WHOLESALE $75 RETAIL SERVICE: —RESID.KITCHEN $75 LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.8. $200 VENDING-FOOD $20 _45,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE _ $ c�SO-OO '•'••PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM'•*"" ! � ADMINIS'TRATION 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 VtForker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGN�D, OR CERT. !JF 1NSURANCE ATTACHED !� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES__,� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel 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 Qccupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha.11 generally be considered Transient. POOLS POOL OPENING:All swimming,wadin�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(5�days pnor 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�pening, and quarterly therea.fter. POOL CLOSING: Every outdoor in ground swirnming pool xnust be drained or covered within seven(7) days af closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requir�i Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Qutdoor_�ooking,preparation, or display of any food product by a r��l or��l s�rvir.��stablishrr��nt is prol�ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN THE C4MPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO PRO BY THE BOARD OF HEALTH PRIOR TO COMI��NCEME . RENOVATIONS MAY A LAN. DATE: � � � d � SIGNATURE: PRINT NAIViE&TITLE: l� 'U'�� Z , �ox � .� � 10/17/06 . DEC-26-2006 14=12 ANTHONY'S PIER 4 7815989321 P.01 � � /�i��/�' �'vrni+'Ii��2.c�� • • 140 Norther�n Ave . Boston, MA 02210 Phone: (617) 482-b262 Fax� (617) 426-2324 �� A� ' � � �� ' i�� F,r m• r� � � Fax: � � � � Pa es: including Cover Sheet) � r Phone: Date: DEC 2 6 zQQ� �:_ _ CC: Confidentiality Notice: This page and any accompanying do�uments are confidential and protected by law. If you are not tlie recipient stated abo�e, please destroy any pages you may receive and contact the se�der at the phone number listed above. Your cooperation is greatly ap�reciated. Comments: ' ' , DEC-26-2006 14�12 ANTHONY'S PIER 4 7615989321 P.02 ' -- ---� + � � •• •• •��• � � �� v� ��»u4LPv�� Viar fYa VJJ JJVLJ r. 4 � A CORt7 n�*�� „ �,,,�,,�„ . . ... . 1Q131lZD06 PRODUCEit uQEri81# 18� TNle CPJtYtF'ICA1�E i8 ISSI�b A$ � N�►TT�q QF r�ORNA'noN ELFNA KIRKILES di ASS061ATE$ OI�LY ANb CdNFERB NO RIOHT9 tJAON TN� CFR7IF�A'T'E 279 RI1/ER$r��r r+o�,o��, n��s c��Ficdr� �s NaT•AMENo ��r�,a o� AL7LR.TFIE COYERA�E AFFORD�O BY THE POL�'4ES �LLQVU. Ha��, �nn oxae�,izas crmep,aw�es AFFortorK�cavew►ae �H:�e1-s�9�aoo F,q�C 781-s6e�a86 c°'''P"""r MA RETAII MERCHANTS WC GtZOUP INC. a iNsuqE[t � co�rrwr AN7HONW3 P'IER FDUR ING. B 26B SAI.EM STREET 3W�1MP8CpTT,MA p1907 CONPANY i C . . .. . . .. CbuPaNr - , � . . . � . . . TNI818"('0 CEqiiFr THA7 THH ROUCIES OF INSURANC�LLSTEO BELQIN HqYE�E1�t ISS{�p'Tp'fHE INSUREO MAMED IIBQYE FOR 7N E Pd1IGY p�Wpp ' IND1Cj1iEp,NONN'f}{BTANOINO J►NfY R�QUIRE]AEN7,7EqM pR CONOinoN pF nwy C�MrrAacT oR OTMER oocuneEnrrwlrH REePECT T�WM�f�n��s CER1'�FIGA1$iNAY SE f5Sl7EQ OR MAY PERTAtN,TNE WSURAI�/�FFOaDEo B r THE PpLIC�ES OE6CR�8ED HEREIN IS SUB.IECT TO ALL 7HE T�R�IS, E7CGLUBIONS ANU CONDf170N6 OF SUCM POLlC1ES,L��zS 61t01NN Mllr HqyE�EM REDUCEb BY PAr�Cuu�uaS. i�rn � • 7YPE Gf IMSIR�NC� PouCv NUkIBER � wucr��ecnv� aoucv��uno�+ • �►ip IlMwddlYYJ DiIT�IMY�dpJ71'} Uwts ��1 �'�A�� QEMENALAGGRC�C'sATE t G�fEkCINI f�1�RAL l.►�g�ll7�( Pp001lC►S-COi�4pP Afip f C��M� �OCCUR o�RSDW�L�Aw nu�uRr 5 owHER'8 a Ct9NTRACTpq�$PROT ' � ��C�� s , ._._ . . FIAEDAMN�G4�Yoerltr�� t �D FXP (Arb ai4 P��o^) S 1W1dMOa�I.E L�AglUT1� � ANY AUTt'S ' ' G�y61NE0 SR�6LE L1hlfT � - ALt OWNEDAUT�S � � rIw Ry I St�lEOtllEb At1TpS �� NIREDAUT,0.9 • NOiN�OWNE6 AU'iDS (v�fio�efQw1U� L . ~•. _. ... PROP6ZTY OANAGE j c�uuoE uwa�urr AUTO ONLY•FJI/�CC pENT i ANY AUTiO p7t{EftTHAN�O ONLY� -'_ EqGN ACGD�NT Q MiOR�tiATE s E1(CEBJ 11ABILli'� .. � FJ�Cr�DCGJRRENCE i UMBREL(q FDRIyI ' 1LRGREdA7l� 4 o'RiEaTNAN UMe��LIAFOfUs i NORif&Ite COYPI�W1noN ANO . X arw� q �*�Ave�s�r��m r _, a��J'�� e/1/08 ?�tl07 ei,�wcYr�ccmENr a 6DO,OOU � �� ' �k�� . �I.o�S�ee-roi�cr�qA�' s 500,000 w��c�x�,R,a� ��A� �� EL DlaFitSE-FA @NFtOYEE i 8�, D on��a • �C r�w aF o n � �OR INFORh�IATfQNAL PURPOSES QNl.Y � ` ' s�u�o aNrav rr�6 wgare �ueo �oua� ee u►u��, �n�e ' ERMRATIdV �ATE THBR�iOF. 7?IE!�lANO TOMlANY 1M�L EI�pAVOR m pWl ' �'OR fNFORMA'�I�NAL PURPOSES OIVLY — �va ww�► Wone�iv�t�ece��c�.,��EReV.,rEo�o,�ue �; .. ?�T Fw1�unETo wNl_9ucH No1l(�ENAI.L MPpae Mo oet.fMnoN we�u►eRa7r Q ANY 10N� UPON l�!! COMPAM', 17S AO�TB QR R�71�LkTA"IIVea. 6 r ATYE TOTAL P.02 �°1�� °��' � � :� � �` �� . ° � --• �''�„ 1146 IZ��TTE 2� SOL'TF� YARMOLJTH MASSACHliSETTS 02669-44:�1 � � ."' t\y_..�,MATTAGHEES Teleplione (5Q81 398-2231,Ext. 241 — Fax (508) 760-34'72 . . `�L a��ACORAitD�6y9� 'U g Q �4, IZD OF HEALTH . March 27, 2007 Anthony Athanas/Anthony's Cummaquid Inn, Inc. dlbla Anthony's Cummaquid Inn 299 Salem Street Swampscott, MA 019�7 Re_ 2007 License/Pernut Application Anthony's Cummaquid Inn, 2 Route 6A, Yarmouthport, MA Dear Mr. Athanas, Thank you for submitting the year 2007 application for your establishment's pernuts issued through the Health Department. Please note that for the food service and common victualler pernuts,a copy of the Fgod Pra#erctio� Mx�ager's certification, as well as copies of Heimliei Man�ver� c'e�fi�tti�ons aze required to be submitted with the application. 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. 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 note that the Health Department cannot use past year's records, as we are unable to verify if those staf�members are still under your employment. As soon as our office receives the above noted certification copies,we will be able to issue the food service and common victualler pernuts to you. If you have any questions on the above, please feel free to contact our office at (508)398-2231, extension 241. Thank you for your antieipated cooperation. Sincerel , � Mary Alice Florio Principal Department Assistant /maf cc: file �� Pzinted on Recycled Paper THE C�A�IlVIONWEALTH QF MASSACHUSETTS TOWN OF YARMQUTH PERMIT NUMBER: #47-008 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv's Cummaciuid Inn, Inc. d/b/a Anthonv's Cummaquid Inn at 2 Route 6A, Yarmouthport, MA in said Town of Yarmouth And at that place only and e�ires 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 confornuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to se.ctions iwenty-two to thirly-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�ced their official signatures,this Twenty-seventh day of March A.D. 2007. BOARD OF HEALTH: B �S. �it /LI.�., ' RESTRICTION: Swimming pool not for guests- c��S�ic�t, �./V. �u�e��a�ih�stc�st Family use only. Rv�� B�u,�ss, �� a��lux� , . Bruce G. Murp , H,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT . PERMIT NUIV�ER: #07-115 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�'ieneral Laws,a pemut is hereby granted to: Anthon 's Cummaquid Inn, Inc., 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31, 2007 BOARD OF HEALTH: ,Qr�j u[�s/t�,, �joq�� /rts,�/IiI.n.`h,,, • SEATING: 400 c�ry�c7KG�L� KJI y vlC6(�K�Ihlyl�fL Rol�`�. ��ia�cusL, G� � ��/�a�S� �I�ua�'neessG�u.,i, R.N. � March 27_2007 Bruce G. Murphy ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-074 �E: $�p.pQ This is to Certify that Anthony's Cummaauid Inn, Inc dlb/a Anthonv's Cummac�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affxed their official signatures. BOARD OF HEALTH: B ��' `�`. f�oA�� oss, /dl.n$., ' SEATING:4OO �e�l�¢it e�HG�L� IZJr.� �I[l�(i�lG�ft Rodent�s.Bnou�rs, G� A�ti1��tt �l �_ , R.N. March 27_2007 Bruce G.Murph ,MPH,R.S.,CHO Director of Health • cl��a� � A�v�oNYs ��`;'�R o TOW N OF YARMOUTH BOt�T�D OF HEALT� �v p V 2 � ?D 0 5 ° � �v � - � APPLICATION FOR LIC S�lP'ER1V�I��2006 �ou ' � �� ,,.. � �� 0 z. y . F . �'� * Please complete form and attach a11 n essary documents by December 3 l, 2005. �� F a i l u r e t o d o so wi l l resu l t in t he re turn o f your app lication pac ket. N�� 1 $ Z�� NAME OF ESTABLIS�-IlVIENT: I"1 � , L��IJl7o� d!! TEL. � ��a '�7�0� LOCATION ADDRESS: - i d MAII,ING ADDRES S: � OWNER NAME: G'JZ TAX ID EIN or S : CORPORATION NAME ( APPLICAB E • ' ` (� ` � � MANAGER'S NAME: L. # .l ' � MAILING ADDRESS: Q 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 oftwo 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 ProtectiQn Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: -_ _ _ __ __ _- - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operatian. l. 2. HEIlb#E,�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 a11 times. Please list your employees trained in anti-chokmg procedures below and at�ae�i eopies 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 REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 — �INN $50 O � � _CAMP $50 _SWII��IIvIII1G POOL$75ea. �LODGE $50 TRAII�ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQIJIItED FEE PERMIT# �0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 I >100 SEATS $150 #OG�O� �COMMON VIC. $50 �O��o _WHOLESALE $75 RETAIL SERVICE: LICENSE REQIJIItED FEE PERMI'P# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _Vh�NDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �-5��O� `•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" �` � ADNIINISTRATION 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 COMI'. 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:Pernuts run annually from January 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�Il�lENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�ilNG 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 CONIlV�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 paol must be drained or covered within seven(7)days of elosing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certi�ied lab: Test res�tlts must be sem t6 the Heaith - 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 waiterlwaitress 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. DA�: NOV 2 2 2005 SIGNATURE: PRINT NAME&TITLE: C( ' �� I 'r�-'C L} � 09/28/OS ��D 1Norkers' �or,�nen�tion and Emoloye�'s Liabilitv Policv AmGUaRD Insurance Company- A Stock Company SUE�ANCE po��cy N�m�e�aHwcesz�6z �j�� ] Renewal of ANWC�33816 �� r NCCI No. [21873] Policy Information Page Endor�sement _ . ._._._._ __. _,._._.__�...____._ — __ __. ________.____.. _ .._ � [i] Named Insuced and Mailing Address Agency i ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Standish Road Swampscott, MA 019Q7 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's iD Insured Is Corporation Risk ID Number 000062137 ; Locations �ther Than Above � (Li) 153 Humphrey Street , Swampscott, MA 01907 ' (L2) 95 Oxford Street, Lynn, MA 01901 � (l3) RT 6A , Yarmouth Port, MA 02675 � (L4) 200 Terminal 13 Logan Airport, Bosten, MA 02108 # (L5) 140 Northern Avenue , Boston, NIA 02110 _ .�._ __.....___�.__._.�.__.�._.�_ .____ ._,_ __.....r......_.--_._ _�..__., _._.___.,.__ [2] Policy Period From August 01, 2005 to August 01, 2006, 12:01 AM, standard time at the insured's mailing address. , i En+dorsement Endorsement #1, ef�ective on the date shown betow, 12:01 AM, standard time, changes the listed items. All other terms and conditions of the poilcy remain unchanged. WC890415 - Rates - Eff. 06/01/20Q5 , ___.______._____ ....�_.�___...___.�._�_____.__ _____.__w.. _._....�_ .__.----- ._.._.. _...._.._.. ._ __�. _ [3] Coverage A. Workers' Cbmpensation Insurance - Psrt One of this policy applies to the Workers' Compensatian C.aw of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to worlc in each of the states listed � in item [3]A. The limits of our liability under Part Two are: � Bodily Injury by Accident - each accident $500,000 Bodity Injury by Disease - each employee $500,000 Bodity Injury by Disease - policy fimit $500,OU0 i C. Other States InsuranCe - Part Three of this poNCy appties to all states, except any state listed in � item [3]A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming. � D. This policy includes these endorsements and schedules: See Extension of Information Paqe - 5chedule of Forms � �._, _�_.. _ _.__��_._�-.e_. �__.__ _._._____._..,_._.,..._._ _._ ._._._._ _._.�_�� __._.�_._.._�.._�__..� [4] Premium The Premium Basis and,therefore, the premium wiii be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. Aii required information is subject to verification and change by ; audit. (Continued on another page) ; .�..., �-...,.�..,.� Tota! Estimated Poficy Premlum � lit,7i4 Total Surcharges/Asse�ments $ 4,OS8 � Total Estimated Cost � i15,772 .....wvn x:r�anr;rmwcw.Mpel�w . . . . .. vremx,..«e++a+h VTFRNAL USE xx Page - 1 - Endorsement GA :ANWC652762 WC890600 ate : 11J17J2005 16 South River Street•P.Q. Box A-H •Wiikes-Barre, PA 18703-042Q.www.e��arri_�nm „ f �� orkers' �omQensatic� na�d_Enr�love�� Liabflitv Policv AmGUARD Tnsurance Company -A Stock Company iNSURAN�E Poticy M�mt�r awwc6s2�ez � (�(�� 1 1 [� Renewal of ANWC533$16 �.�✓�� l�J f NCCI No. [21873] Policy Ynformation Page Endorgement Extension of Information Page Schedule of Endorsements WC OOOOOOA - STANDARD POLICY WC OOOOOlA - INFORMATION RAGE WC 000112 - PENDING LAW CHANGES TO TRIA ACT 2002 WC 000403 - EXPERIENCE RATING MODIFICATION �ACTOR W� OOQ406A - PREMTUM DISCOUNT ENDORSEMENT WC 000420 -TERRORI5M RI5K INSURANCE ACT ENDORSEMENT WC 200301 - MA LIMITS OF I.IABILTfY ENDORSEMENT WC 200302 - MA ASSESSMENT CNARGE WC 2003036 - MA NOTICE TO POLICYMOLDER END�RSEMENT WC 200401 - MA PENDING PREMIUM CHANGE ENDORSEMENT WC 200405 - MA PREMIUM DUE DATE ENDORSEMEN7 WC 200601 - MA CANCELLATION ENDORSEMENT WC 990002 - PARTICIPATING ENDORSEMENT NTERNA� USE xx Page - 2- Endorsement iGA :ANWC652762 WC$90600 �ate : li/17j2005 1Ei SA��th RivAr Ctroct�O /1 Q.... w u _uan__- ^----- ... ..._..._ -^-- THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-QO1 FEE: $50.00 THIS IS Ta CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv AthanaslAnthonv's CummacLuid Inn, Inc. d/b/a Anthony's Cummaquid Inn at 2 Route 6A, Yarrnouthport, MA in said Town of Yannouth And at that place only and e�ires December thirly-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. Tlus 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 thiity-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 Second day of December A.D. 2006. BOARD OF HEALTH: Be�ts�t�. 4'o�ost,/I��. ' RESTRICTION: Swimming pool not for guests- p��c��lu�w�� /�ice��r�t Family use only. R�lt��. B�u,wt, �:L�lufa � �� Sl�, R.N. �l�� , R.N Bruce G. Murphy RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #46-020 FEE: $150.00 In accordance with regulahons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Anthony Athanas/Anthony's Cummaquid Inn, Inc., 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2006 BOARD oF HE�,�: Ln�e�,�_ • r',r�in's$. ('r�u�,/I�I._`?S. ' SEATING: 400 /��ifC1�/Y(C�S�LNI(�t, v�e��.� - �s�R.N.� �4.t.z��.,�, R.N. D�t�2.Zoos ruce G.Murphy, , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-016 FEE: $SO.QO This is to Certify that Anthony Athanas/Anthony's Cummaquid Inn Inc d/b/a Anthony's Cummaquid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo�xn oF��..Tx: a�,��h. g�,n�' �s.�f �� • SEATING:4� P��ClJ�j (llC6��ftG�lNl�fL Rod��. B�eocust, G� � s�k, R.N. t4.�� , R./V. December 2.2005 . _ _ Bruce G.Murphy RS.,CHO Director of Health �� Y`q,� �.5��'. �� .: :�o 'I�' IOT F Y A R O U T I-� � � � ''� ]146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACHEES � Telephone (508) 398-2231,Ext. 241 — Fa.x (508) 760-3472 � ��A�ORAIE�6�4� �� B o L'1 dl L o i' dl T. � L T rl ' '��'` �' '�- �� M � � To: Yarmouth Boazd ofHealth Permit Holders A;� 1 1 2005 From: David D. Flaherty Jr., R.S. ;�D� HEALTM DEPT. Heahh Inspector � Town of Yarmouth Re: Federal Tax ID Number �aie: tvlareh 22, 2t�05 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regazding all permits and licenses that we issue. One of the details tbat they require we send to them is every establishment's Federa.l Employer ldentification Number(FEIN)otherwise known as your"Tax ID Number". This is purely for administrative purposes oniy. 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 Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to ca11. The office hours are Monday to Friday, 830 a.m. to 4:30 p.m. The telephone number is(508) 398-2231,ext. 241. � � � ��.. '- , .-- Location Address: ��u/ `�-' .la � c��l.�� 0i�'� �/%'��.$' • a��,�'� � i Signature: . Print: ��- /�� Title: ��' � �� Printed on � � Recycled Pager � . c�3��° a�� AN� Ys �'� � ; �,, ; . �°f:aR 0 (;��'��-� TOWN OF YARMOUTH BOARD O HEA '� :��, " r -iC o_. . _ y � 4�`,� f � APPLICATION FOR LICENS 1P.�RMIT- 00 , �"l`�� ' � . �EC 2 1 2004 � � .;�' .. � w✓... * Please complete form and attach a11 necessaxy;d�icuments by c � Failure to do so will result in the re'turn'of your applicah ��T' ; NAME OF ESTABLISHIVIENT: v ' � TEL. # �• � LOCATION ADDRESS: - ' � /' �t " v i¢ CJ �',� MAILING ADDRESS: ' � It� enT>` d'! ' "7 OWNER/CORPORATION NAME: �' s � � � MANAGER'S NAME: D a� TEL. # !J . ' 6,;� MAILING ADDRESS: a - �'� p - 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 capy of the certification to this form. 1. 2, Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS� All food service establishments are required to have at least one full-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 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 employe� e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3- 4. RESTAUR�NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE P�RMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 I INN $50 �Q��Q�p _CAMP $50 _SWIlvIlvIII�iG POOL$75ea. _LODGE $50 _TRAII,ER PARK $50 WHIItI,POOL $75ea. FOOD SERVICL: LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIlZED FEE PERMIT# _0-100 SEATS $75 _CONTTNENTAL $30 NON-PROFIT $25 I >100 SEATS $I50 0 .. I COMMON VICT. $50 �Obc� WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIlZED FEE PERMIT# LICENSE REQ[JIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOITNT DUE _ $ oZ�j0•OQ "•'•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R R�R 1 • A ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION IN5URANCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, 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 DEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, 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 standaxd 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 clasing. FOOD SERVICE CONSUMER ADVIS�RY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. �'ROZEi�i 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.,outdo�r seating with waiter/waitress service),must have prior approval from the Board of Health. OUTD04R COQKING: Outdoor cooking,preparation,or display of any food product by a retail or faod service establishment is prohibited. NOV � 4 Zpp� DATE: SIGNATURE: PR1NT NAME& TITLE: V l_ S C. 10/22/04 � �� Workers' Comnensation and Emplover's Liabilitv Policv y AmGUARD Insurance Company - A Stock Company IN�V�f�1��E Policy Number ANWC533816 � �("'�j/"'1 � � Renewai of ANWC432336 f`C ti.,l NCCI No. [21873] Policy Information Page Endorsement [1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Standish Road Swampscott, MA 01907 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's ID Insured is Corporation Risk ID Num6er 000062137 Locations Other Tha n Above (L1) 153 Humphrey Street, Swampscott, MA 01907 (L2) 95 Oxford Street, Lynn, MA 01901 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Terminal 13, Logan Airport, Boston, MA 02108 (L5) 140 Northern Avenue, Boston, MA 02110 [2] Policy Period From August O1, 2004 to August 01, 2005, 12:01 AM, standard time at the insured's mailing address. Endorsement Endorsement #1, effective on the date shown below, 12:01 AM, standard time, changes the listed items. All other terms and conditions of the policy remain unchanged. WC890406 - EXPERIENCE MODIFICATION - Eff. 08/01/2004 [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this poticy applies to all states, except any state listed in item [3]A. and the states of North Dakota,,Ohio, Washington, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Endorsements [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 125,026 Total Surcharges/Assessments $ 4,570 Total Estimated Cost $ 129,596 TERNAL USE RP Page - 1 - Endorsement �A :ANWC533816 �te : 09/24/2004 WC890600 16 South River Street •P.O. Box A-H .Wilkes-Barre, PA 18703-0020 •www.guard.com , DEC-23-2004 14�13 ANTHONY'S PIER 4 7815989321 P.01 . � ► � . ' . . , � ' . .i� � 1 � / � � . . . 299�Selem Street � Swampscott„ MA Q1907 ' Phone: (781) 595-5377 Fax� (78Ij 598=9321 �� (� Q �' �,' �, � 1��.. �r�� n-��vn , . �� t. . � � L.� n .. � .� . ��x; Q �� pa es; includin Cover Sheet phone: �f il� Date: �E� 2 � � � � Confidentiaiity Notice: This page aud any accompanying documents are confidentxal ' and pratected by law. if you are not the recipient stated above, please destroy anY Fages � you may raceive and contact the sender a.t the phone aumlier listed above. .Your . cooperation is greatly �ppreciated. ' �..�-- �- - - � .� a.. .,; Comment�: � � � � u�� 4� �2004 i . r � • �-��/�� .��T.. . . / ., . . � � r }�-� �� l /! � � ' /� � � . � ^ � � IS � �. � l a - � D , � � 1� �� , . �� - �r ��. . � � � .-. . rr�= � - � �� DEC-23-2004 14s13 ANTHONY'S PIER 4 7815989321 P.04 CUARD� �,, _�30�e , 4Y��A�� A� �111I� irr.■�a ��bil-6r�d'�� N S U RAN�� Am6UARD Insurance Company � �O � , , Poltcy Numb��ANWC428533 P ` R,en�swaf of NEW NCCI No. [Zt873� Poli,cy InT�orn�ation Page - Final Audit (T�Pe: Actuatl Physicai) �4] P�'emium (�nt.) Ma�achusvtts Ciassification Code Premlpen Basis: �te Tota1�stirttated � �mated �1� Annuai Annual Remuneration Ptv��tnium � Remunerattan Efrettive: 05/14/2003-�8/Ol/2003 CLERICAL QFFICE EMPLOYEES NOC RESTAURANT NOC 810 13 9 •ig 247 9079 612 6B4 .19 13 g Rate Deviation Increas�d LimNs Emp li�b �037 5 - 8 ExpghgnCe Modiflcmdon 9607 1.009� 13Q Schedule Modi�cation 9896 g . g2 All Rlsk Adjustment Program 988? 5.009�6 -643 • 0 77 .QOQ p Minlmum Premlum �47 Tct Es[Prem 05/14/2Q03-08/01/2003 207 Premium DlscounC Tot Est Standard Premium for Massachusetts � •��`�' 1 12 006 P ic T 15 � Total Est 5tandard Premium for Massachusetts �Z,006 Expsnse Ccnstant MA 0900 53 Minimum Premium Mq $q,� 7otai Estimated Annual Premium 12,059 MA State Assessment 4.500°�6 578 Tota1 Estfmated Cost for ANWC428533 12,fi37 Total Estfmated Cost Prior to Endorsement 15,508 Adjustment to Totai Estima#ed Cost -2,871 S�Rhec�es/Assessments Inciuded in Adjustrnent �-142 :dZFBdAI u5e �p Pagc+-3. "�+ :ANWC42@533 Eneorsement �a� : 10/23/2003 w�� L��-��-��µ 14�js ANTHONY'5 PIER 4 7815989321 P.03 �GUARD� � 1 N S U RA N CE Am6uAR�Y��an�compeny G �O � � Policy NumberANWC428g33 � � Renowal of NEW NCCi No. [Z1873] Policy Zntorrnatton Pa9e-R:nal Audit (S'Ype:Actuai Phys�ca!) Exten�ion of Infor�mation Page Schedule of Endarsemonts WC OOOOOOA -STANDARD Pp��y WC OOOOOlA- INFORMATION PAGE WC d004Q3 - EXpERIENGE RATING MODIFICATION FACTOR WC 000406A - PREMIUM DISCOUNT ENDOR5EM�NT WC OQ0420 -TERRORISM RISK INSIlRANCE ACT�NppRSEMENT WC 200301 -MASSACHUSEITS IIMITS OF I,IABILTTY ENDT. WC 200302 - MASSACFiUSETTS-A55ESSMENT CHARGE WC 2Q0303B- MASSACNUSETTS NOTICE TO pp�CyHOLpER END WC 200401 - MASS. PENDING PREMIUM CHANGE ENDOPtSEMENT WC 200405 - MASSACHUSETTS PREMIUM DUE DATE ENDT WC 2006fli - MASSACHUSETrS CANCEL,qTION ENDORSEMENT WC 990002 - PARTI�IPATING ENDORSEMENT lC7�flNAl U�E dA GA :ANWCa28533 Page- 2- Endorsement ate : 30/23J2003 WC890600 lit�—��—�eb4 14�13 f�iTHONY'S PIER 4 7815989321 P.02 GUARD� � o -�� N S U Rr1 N�E AmGUARD Insurane� Company Polity Number ANWG428S33 ��R a u � � � Rs+�wal of NEW NCCI No. [21$73] ��cY Info�rnation P e- Final Audit(T e: Actwl Ph cai C1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBEFiS FIRST ANTNONY'S PIER 4 INC. D9A INSURANCE 6ROKERS 299 Satem Street 4 Standish Road Swampscott, MA 01907 eridgewater, MA �2324 Agency Code: MAMEFI20 Feder8l Employer's iD I�sured is Corparatlon , Risk iD Nymb�r 000062137 �,ocations Othe�Than Above (�-1� 153 Humphrey Street, SwampscoCt, MA d1907 (L2) 9S Oxford Street, Lynn, MA 01401 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Ternninal 23, lAgan Afrport, Boston, MA 02108 (�) 240 Northern Ave., Boston, MA 02110 ,�2] Poltcy Period From May 14, 2003 to August 01, 20Q3, 12:01 AM, standat�d time at the insured's maliing address. [3] Coverage A. Workers' Compensation Insurance - Part One oF this potity appiies to the Workers' Compensation law of the foilowing states: Massachusetts B. Employer's I.iability Insurance- part'f�vo of this policy appiles to work in each oF the states llsted in item [3]A. The timits of our ilability under Part Two aro: Bodily Injury by Accident-each accident $500,000 Bodily Injury by Disease -each empioyee $5op p00 � Bodily Injury by Disease - policy timit $500,000 C• OtMer States Insurence - p�rt�� of rhis polity applies to aii states, except any state�isted in item [31A. and the states of North Dakotb, Ohio, W�shington, West Vfrglnia, and Wyor»fng, D. This pnii�y includes these ehdorserhe�ts and schedules: See Extension af Information Page- Schedule of Endorsements [4� Premium The Premium Basis and, ther+efare, the premium wilt be determined by our Manuai of Rules, CIa55ifications, Rates, and R��y p�ans. All requfred information is st�bf ect to veriryCatiort and change by audit. (Continued on another pagej Tot�i Estimat�ed Palicy Premiym . S - 1�,059 To#al S�rchsrpea/A�.n� � 578 . Total �stirnatod Ca� $ ZZ,637 I�Bd6L.tb,�.4P Page- 1 - aA :ANW�42g533 Endorsement te : �ona/2oo3 wcs90600 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-006 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to _ Anthonv Athanas dlb/a Anthony's Cummaquid Inn at 2 Route bA, Ya.rmouthport, MA in said Town of Yannouth 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. 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 affi�ted their official signatures,this Second day of February A.D. 2005. BOARD OF HEALTH: Bescyr.�tt�t�S. �ji�o�,�`7�. • RESTRICTION: Swimming pool not for guests- p��itscl�/�c��,,,� �/�sce��rt�itc�t Family use only. /�ttLwlct�. B�uuwt, �� s�, R.�v. �v r , . Bruce G.Murp H,RS.,CHO birector of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERNIIT NUMBER: #OS-100 FEE: $150.00 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: Anthon Athanas, 2 Route bA, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31,2005 BOARD oF HEALTH: l3eHy�nri�.h. ('�,oa,/�`�S. ' SEATING: 400 n�,��phy�� v{�(�u.�il Rc+�dwiit� B�i«u�s, C� ��s�, R R.N. , February 2,2005 Bruce G.Murphy ,R S.,CHO Director of Health , , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-068 FEE: $SQ.00 This is to Certify that Anthonv Athanas d!b!a Anthonv's Cummaquid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: Besryr�r� `�. ,�'jwu�iisi, /yl.`�. ' SEATING:4OO ��,t��, v�e�� Ro�ient�.l�nocvrz, L''l�ik � s�, R.nr �r�� , R.�! February 2,2005 Bruce G.Murphy, S.,CHO Director of Heal a • , . . 3aaa�' �� ) AN"1ltONkS � ��';''R.� TOWN OF YARMOUTH BOARD OF�3FA�;�'H F ' � � . -_-��{� ��s APPLICATION FOR LICEN�EkP�R�VIiT-20�� ' ` ; ' _.� � � � s ��,� ' �,-,.. t * Please complete form and attach all necessary documents by December;31, 2003. 7�,�� Failure to do so will result in the return of your application packet; ; T NT• ' � � . - _ � �� L C T N ADD S : - f 6 � > d � v� WN R/C RP RA O .S A ER'S NAME: 8 � a T L � 6� L ADDRESS: / �/" d � 6 � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Fool �peratorjs�an�attacTi a c�py of the certifca�ion to thi� 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 - 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. /`',' _�i Q�/ I�I��se.-� 2. �l,cv�,•e ..�1/�h PERSON IN CHARUE: _ - -- ___ __ _ _ __ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �/�C/?C G� �T6 a I� 2. /`ri�L �rd /� /"'G L� S HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies anc�maintain a fite at your place of business. 1. /y c � ��o v� 2.?.L..•e-� rc t� S 3.��oiro 4. �ri a � t-3r C�.� .,. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY I.ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREQ FGE PERMIT# LICENSE REQUIRED FEE PERMIT# BBcB $50 CABIN �50 _IviOTEL $5� I INN $50 �'0�-005� _CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT S25 1 >100 SEATS $150 0�{-6 1 COMMON VICT. S50 O�{-05� _WHOLESALE $7S RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQ111RED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.R. $200 _VF,NDING-FOOD $20 <25,000 sq.ft. $75 _FROZEN DGSSf:R'I' $35 _TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ 250 .00 **'�**PLEASE TURN OVER AND COMPI,ETE�THER SIDE OF FORM***"* ^ . . �` � . � �� x ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COM NSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED .Q$ 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: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTTON 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUS'1' BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RF_�ULATION� _ POOLS POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: 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 CONSUNiER A�VISO�RY• . Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERiNG POLICv� 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. ��9��1�?��E�12'I'�: _ _ ___ ._ - — _ __ _ ___ _ _ 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 C FF S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),tnust have prior approval from the Board of Health. (,�UTDOOR COO iN .• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �E�G� ��,�I��SIGNATUR�: PRINT NAME& TITLE: 10/22/03 �'v�/G UA R Do Workers' Comnen$ation and Emulovpr' iabilitv Policv I N c u R ^ A'�c AmGUARD Insurance Company � `� r�� C P o l i c y N u m b e r A N W C 4 3 2 3 3 6 1 r � � O � � Renewal of ANWC428533 � NCCI No. [21873] [1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Stan�ish Road Swampscott, MA 01907 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's ID Insured is Corporation Risk ID Number 000062137 Locations Other Than Above (L1) 153 Humphrey Street, Swampscott, MA 01907 (�2) 95 Oxford Street, Lynn, MA 01901 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Terminal 13, Logan Airport, Boston, MA 02108 (L5) 140 Northern Avenue, Boston, MA 02110 [2] Policy Period From August O1, 2003 to August 01, 2004, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the fotlowing states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $5Q0,000 Bodily Injury by Disease - each employee $5d0,000 Bodily Injury by Disease - poficy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in � item [3)A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming, f i � D. This policy includes these endorsements and schedules: E See Extension of Information Page - Schedule of Endorsements � 4J Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, y Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) � � � �tal Estimated Policy premium �tal Surcharges/Assessments $ 9�'759 ►tal Estimated Cost � 3�295 $ 98,054 tNAL E 4V :ANWC432336 Page - 1 - : 08/12/2003 Information Page 1TE WC 000001A P.O. BOXA-H,WILKES-BARRE,PENNSYLVAN�.4 ta�n� THE COMMONWEALTH OF MASSACHUSETTS T4WN OF YARMOUTH PERMIT NUMBER: #04-005 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthony Athanas d/b/a Anthony's CummaQuid Inn at 2 Route 6A, Yarmouth�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 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 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 Fourteenth day of January AD. 2004. . BOARD OF HEALTH: Be�a�rs�t.�. �o+r�,ou, /Fl�S. RESTRICTION: Swimming pool not for guests- n�ttc�a/Nc�Plilit� �/ice��t�'.��t F�iy�o�. RaG�t�. B�, G'� s R�v. - ruce G. Murphy,MP ,R .,CHO Director°�'�I� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTIV�ER: #04-067 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the�eneral Laws,a permrt is hereby granted ta Anthony Athanas, 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD OF HEALTH: Bne�s�- . 'ti�rts,.`h. �j'o�ii�r„ /�9.�5�•f �� ' SEATING: 4OO l+G�C�/�',C��i �tC� C:ltG�!!1//Lls�it Ro/�t`�. Bnv�rc, G�l� � s�, R.�. Januarv 14,2004 Bruce G. Murphy P .5.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-052 FEE: $50.00 This is to Certify that Anthony Athanas d/b/a Anthon�r's Cummac�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo� oF�ai,�: l/3��u./�,��h. ��.t /,��M.�/�.f �� • SEATING:400 N�/YIC�PlLNtOfti� (llC� (:K�H/ftG�it Ro�Ge�t�. 13�x�s, �le� s�, a.n�. January 14.2004 B��G. MUm y, >R.s.>cxo Director of Heal • ' , A-�oN y s J4�Y�k f TOWN OF YARMOUTH$OARD OF HEALTH �------- o �� = ��`�� ;y ��r-�O(b� r� D APPLICATION FOR LICENSE/PER11��I'-2'Q��j �, c��'? ,/ � � `'r..c.,�� d � � ti , E„_l. * Please complete form and attach all necessar��t�oE`�n , y�I� ber 37, 2�0 . Failure to do so will result in the return,of yi�a�i�ip ication pa k��AL H DEF'i�. NAME OF ESTABLISHMENT: /J D �Q/J7A7 lC/G'G /� TEL. ��i{—�� LOCATION ADDRESS: a� G r o O MAILING ADDRESS: � J'Ga77� � Q' 4WN�R NAM�: TAX D E1N r SN - D - � O� CORPORATION NAME (IF LICABLE): /y�a ! /J MANAGER'S NAME: D eiQ I~ TEL. Q �o ' D� MAILING ADDRESS: 4lII J' - d�' D POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required b3�State law. Please list the designated Poo1 IIperato�js)and attach a copy of the certification to this forrn. -- -- - - 1. 2, Pool operators must list a minimum of two employees cunently certified in basic water sa£ety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these enlployees below and attach copies of employee eertifications to this form. T#e I�ealth Department will not use past yea�s' reeo�ds. �'ou t��st 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 Saiutary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. 'i'he Health Departrnent will not use pa�t�e�rs'records. You must provide new copies and maintain a file at your estabtishment. 1. 2. PERS9N 1N�HAIZC'iE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTffICATIONS: 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-chokuig procedures below and attach copies of employe�certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'v11T* LICENSE REQL'IRED FEE PER'�IIT� LICENSE REQL'IRED FEE PERVIIT= �B&B S50 CABIIv' S50 _MOTEL S50 I INN S50 _CA:�IP S�0 _SV4'Ii�LVIINGPOOLS75ea. _LODGE S50 �TRAILERPARK S100 _RZ-IIRLPOOL S75ea. FOOD SERVICE: LIC£2+1SE REQUIRED FEE PERMIT� LICENSE REQLTIRED FEE PEI�:�-tIT# LICENSE REQL'IRED FEE PERvi1T= _0-100 SEATS S75 _CONTINENTAL S30 IvON-PROFIT S2� I >100 SEATS S150 / CO;�L'4ION VIC. S50 V4'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PER�IIT� LICENSE REQL�IRED FEE PERVIIT= LICE:�'SE REQtiIRED FEE PER�fIT= _<SO sq.ft. ' Sd� _>25,000 sq.ft. 5200 _VEI`DING-FOOD S20 _<25,000 sq.R. S75 _FROZEN DESSERT S35 TOBACCO S50 NAl�CHA�IGE: sio AMOUNT DUE _ $ ��. c�c� '�****PLEASE TL'R.\OVER a\D C0�IPLETE OTHER SIDE OF FOR�Z***** � r' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRL4TELY 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 customa.rily associated with motel and hotel us�. Transient accupants 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 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. * NOTE: Enclosed Motel Census must be completed and returned with tlus appiication. 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 Depa.rtment to schedule the inspection five(�days prior to ogsning. 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 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 obtasned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor�oQking,�r�g�r��Qn�or dis�lay of any food product by a ret_ail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[1RN THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO PROVED BOARD OF HEALTH PRIOR TO COMMENCEME�iT. REvOVATIONS MAY QU RE A SIT P . . DATE: SIGNAT'URE: PRINT NAME&TITLE: 4� �/r �' �� Y`"� �'� � , io;o n� ACORD CERTIFICATE OF LIABILITY 1NSURANCE D 11/02/2007� PRODUCER Serial# 2429 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KIRKILES&ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COMMERCIAL INSURANCE BROKERAGE LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 273 RIVER STREET NORWELL,MA 02061-2209 INSURERS AFFORDING COVERAGE NAIC# INSURED iNsurteR A: MA RETAIL LMERCHANTS WC GROUP INC. ANTHONYS PIER FOUR INC. iNsuReR s: 299 SALEM STREET INSURER C: SWAMPSCOTT, MA 01907 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. InISR ADD'L POUCY EFFECTIVE POLICY EXPIRATION T N R '�PE OF INSURANCE POLICY NUMBER DAT D A E M D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMGE TO REo TED ce $ CLAIMS MADE � OCCUR MED EXP An one erson $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY ECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acadent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Perperson) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERN DAMAGE $ (Per acddent) GARAGE IJABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: qGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ a DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND X TOCY IMIT �ER EMPLOYERS�uaeiurv 014005031008107 1/1/07 1/1/08 ANY PROPRIETORlPARTNER/IXECUTIVE EL EACH ACCIDENT $ rJ'OO,OOO A OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPlOYEE $ 'rJOO,OOO If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ �JOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS NAMED INSURED:ANTHONY'S CUMMAQUtD IN1V,INC., RT.6A,YARMOUTHPORT,MA 02675 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �0 DAYS WRITTEN TOWN OF YARMOUTH NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL BUILDING DEPARTMENT 'I�4F)ROUTE ZH IMPOSE NO OBLIGATION OR LIABIIIIY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SOUTH YARMOUTH,MA 02664 REPRESENTATIVES. AUTHORIZED REPRESENTATNE ��7�u:t�'.'`."r ACORD 25(2001/08) OO ACORD CORPORATION 1988 "�� y�•�l Hivinurvr'S r1tK 4 7815989321 P.11 ACORDTM C��TIFICATE 4F LIABILITY �IVSUI�A,NCE °�'� � � PRODUCER �,�� ES 8 ASS�CIATES Serial� 2429 THIS CER7IFIGA7E IS ISSUED AS A MATTER OF INFOWNqTiON ONLY AND CONFERS NO RIGNTS UPON TNE CERTiFICATE COMMEliC1AL 1N3URANCE BROKERqGE LL� HOLD�R. THIS CEI�TIFIGATE D0�3 NOT qMEND, EX��ND OR �S RIVER STItEET �TER THE C�VERAGE AFFORDED BY THE POUCJES BELOW. NORWELL,MA 02061-�209 ir�suae� W9URER$pFFORDlNf�C�]yERAGE �� • � nvsu�n: MA RETAII.LMERCHANTS WC GROUP INC. ANTHONYS PIER FOUR INC. z98 SALEM STREET ��' SWAMP3C01T.MA 01907 ' p+suaea c: - n+suR�re o: . ; COVERAGES WSURER E: 7NE POLICIES OF INSURANCE LISTEp gEtfiW HqyE BEEN ISSUEp Tp�{E IRSURED �'REQUIRgWg►��M OR COND171oN OF ANY CONTRAM OR�OTHER DOCUM��WI�RE.�SpECT T�p��TM��F�,�q��qr�B�UED ORG MAY PERTAIN,T}IE INSURANCE AFFORDEO BY 77�ppUCES OESCRI�Ep y�� SUB.IECT TO ALL THE TERM$, p(CWSIONS AND C�NDRIQNS OF SUCN pOUC1ES,AGGREGATE UMITS sHOWN INAy HpyE g�EN REDUCED 8Y PAID ClJWY1$, 7YVE OF INSURAWe� POtJLw NUMBEp N �ENERAL LIABlU11r � COMA�RCULL GEN6RAL W18�riy EACN oCCURR6VC� s CuiMs AeppE �OCCIm a MED D� e�p 8 PBt60WLdMVINJURY s GETPL AGGR�'(E�APPLIEB PER: ��A��TE S POL1Cy P �C � PRD��1{`�, B-CpNppP AOG S AuioeA081tE uABILtTY ANYAl1T0 �CO►i1B�GLE�Ihvi � ALL OWNED AUTos BCHEDULEO AUTOS �L�Y I�t�L�NRy i HIREp AU7'05 NONI,IWNIEDAUTOS B�ILYIWURY = p'ere� a�naac��qeuaTr : ��°ePe�i� a ANY AUTO o ^�'O ONLY-EA ACCtDEN[T S 07t�R'iFiAN F�+aCC 8 • �� AlliO ONLY: � � OCGtJR �CWMS MADE ��RR�'ICE a AOQREGAT� _ DEDUCT18lE � RETENt1oN s . ��EN8A7��►1 AND S �1.OY�ps'UqBI1dTy X ANYPROPRI�pR/pqI�N�C�� 014005031008107 1/1lp7 1/1/08 A OFFIC�D�CLUDED7 EL EACN ACCIDETII7 i SOO OOO If�p,�g�� SPECUIL PR01/�810N9 bqqiy EL OISEABE-pq FJ�(,p� a ��Q OTMER EL OISEASE-POIICY UAIR � �OOO �ACRIPTON OF�BRATIONSILOCq ACDED BY ENDOI� dAMED INSURED:ANTHONY'S CUMMqQU10 INN, INC.,R7.8q,yqRM�U7'PHppRT,MA OZ675 ��RTIFICATE HOLDEFi CANCELU►TION BHou�o ANY aF rrie nBovE DESGR�o POLiGBS BE c�wcRLLED BEFORE 7HE o�iRAnON TOWN pF YARMOUTH �TE 171EREOF,T►{��$gUING INBUR�R WI�� pEqypR Tp Mq�� p �Ys��N BUILDING DEpARTMENT NOTiGH iD THE CERT�FICATE HOLDER Mp,MED TO Tl�{�,eur Fn,u�ro 0o so sNnu_ ��46 ROUTE 2$ . IMpp3E NO 08LICiAT10N OR LA8ILITY OF ANY pND UPON 7}1@�NSUNEq,lTS AGFmB OR SOUTH YARMOUTN,MA 02664 REPRE$ENTp7ryEg, avn�n rtEvr�xranvE 30FZD 26(2001/08) �� ACORp I�I�pORq7�ON 1988 THE COMl�ZONWEALTH OF MASSACHUSETTS TOWI�T OF YARMOUTH PERMIT NUMBER: #08-005 FEE: $50.00 : THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthon�s Cummapuid Inn, Inc. dlb/a Anthonv's Cummaquid Inn at 2 Route 6A, Yarmouthport, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders_ This license is issued iu conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to secrions twenty-iwo 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 Eleventh day of December A.D. 2007. BOARD OF HEALTH: .�E¢e¢It SR� J�..N.� C�L�t ItESTRICTION: Swimming pool not for guests- �� `.�.��[.�[�JiG., �iC¢ ��Lp.It Family use only. .�i�'(l��41[��.��lAWtt, �.�Jl� rli(.uft� � . ruce G.Murph , .5.,CHO Director of H TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-066 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Anthony's Cumxnaquid Inn, Inc , 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD oF HEALTH: .�fe�e�rt S�, �..N-, «� SEA�vG: 400 ��'� '�"��'� ��(�� J�O�i� �.��tl�tWZ� �:C.�12 . Cl�ut C�ce.e,t.�auc�n, J�..IV. December 11.2007 ruce G.Murphy, H, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOU i'H . PERMIT NUNiBER: #08-051 FEE: $50.00 This is to Certify that Anthonv's Cummac�uid Inn, Inc. d!b/a Anthony's Cumma�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers_ This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: �'Eeeeri Sfia�, J2..N., C"f�ai�rcrn� SEATING:4O0 ��F�d .�. .`��i�P�� 1C8 t�ftA.fL J?,o.8errt.�'f�.J`3�uw�r�, C'�cP� , J2..IV. December 11.2007 Bruce G.Murp , ,R_S.,CHO Director of Hea th � - f.Ya � �y ��c�� D .o.�=R o TOWN OF YARMOUTH BOARD OF HEALTH F��s APPLICATION FOR LICENSE/PERMIT-200 ,� D�C 2 � 2006 � * Please complete form and attach a11 necessary;docuir�ents by Decem eht�A � ��T� Failure to do so will result in the return of yo�r'application pac et. NAIV� OF ESTABLIS�-IlVIENT: �. � � � ' � TEL. #1Cl�D�c�i�a�.-��'"d� LOCATION ADDRESS: ' - �' o�!' D �' MAII..ING ADDRESS: .� �c'vT �j` �J OWNER NAME: T ID IN r ' � CORPORATION NAME (IF PLICABL : '� 9� MANAGER'S NAME: 'I'EL. #,�'� ' _ _ MAILING ADDRESS� �1' - 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 m�intain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary 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£�AR�: ---- —__ _ s_ _ _ ___ . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlVILICH CERT'IFICATION5: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE U5E ONLY LODGING: LICF,NSE REQiJIRED FEE PERMIT# LICENSE REQIJII2ED FEE PERMIT# LICfiNSE REQiTIRED FEE PERMIT# _B&B �50 _CABIN $50 MOTEL $50 / INN $50 �v7�O�S _CAMP $50 _SWIl�II�AIGPOOL$75ea. _LODGE $50 _TRAILERPARK $100 WHIl2LPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMtI# LICFNSE REQtIIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 �>100 SEATS $150 � (� / COMMON VIC. $50 Q –Q'f`r _WHOLESALE $75 RETAIL SERVICE: —RESID.KITCHEN $75 LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.8. $200 VENDING-FOOD $20 _45,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE _ $ c�SO-OO '•'••PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM'•*"" ! � ADMINIS'TRATION 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 VtForker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGN�D, OR CERT. !JF 1NSURANCE ATTACHED !� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES__,� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel 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 Qccupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha.11 generally be considered Transient. POOLS POOL OPENING:All swimming,wadin�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(5�days pnor 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�pening, and quarterly therea.fter. POOL CLOSING: Every outdoor in ground swirnming pool xnust be drained or covered within seven(7) days af closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requir�i Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Qutdoor_�ooking,preparation, or display of any food product by a r��l or��l s�rvir.��stablishrr��nt is prol�ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN THE C4MPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO PRO BY THE BOARD OF HEALTH PRIOR TO COMI��NCEME . RENOVATIONS MAY A LAN. DATE: � � � d � SIGNATURE: PRINT NAIViE&TITLE: l� 'U'�� Z , �ox � .� � 10/17/06 . DEC-26-2006 14=12 ANTHONY'S PIER 4 7815989321 P.01 � � /�i��/�' �'vrni+'Ii��2.c�� • • 140 Norther�n Ave . Boston, MA 02210 Phone: (617) 482-b262 Fax� (617) 426-2324 �� A� ' � � �� ' i�� F,r m• r� � � Fax: � � � � Pa es: including Cover Sheet) � r Phone: Date: DEC 2 6 zQQ� �:_ _ CC: Confidentiality Notice: This page and any accompanying do�uments are confidential and protected by law. If you are not tlie recipient stated abo�e, please destroy any pages you may receive and contact the se�der at the phone number listed above. Your cooperation is greatly ap�reciated. Comments: ' ' , DEC-26-2006 14�12 ANTHONY'S PIER 4 7615989321 P.02 ' -- ---� + � � •• •• •��• � � �� v� ��»u4LPv�� Viar fYa VJJ JJVLJ r. 4 � A CORt7 n�*�� „ �,,,�,,�„ . . ... . 1Q131lZD06 PRODUCEit uQEri81# 18� TNle CPJtYtF'ICA1�E i8 ISSI�b A$ � N�►TT�q QF r�ORNA'noN ELFNA KIRKILES di ASS061ATE$ OI�LY ANb CdNFERB NO RIOHT9 tJAON TN� CFR7IF�A'T'E 279 RI1/ER$r��r r+o�,o��, n��s c��Ficdr� �s NaT•AMENo ��r�,a o� AL7LR.TFIE COYERA�E AFFORD�O BY THE POL�'4ES �LLQVU. Ha��, �nn oxae�,izas crmep,aw�es AFFortorK�cavew►ae �H:�e1-s�9�aoo F,q�C 781-s6e�a86 c°'''P"""r MA RETAII MERCHANTS WC GtZOUP INC. a iNsuqE[t � co�rrwr AN7HONW3 P'IER FDUR ING. B 26B SAI.EM STREET 3W�1MP8CpTT,MA p1907 CONPANY i C . . .. . . .. CbuPaNr - , � . . . � . . . TNI818"('0 CEqiiFr THA7 THH ROUCIES OF INSURANC�LLSTEO BELQIN HqYE�E1�t ISS{�p'Tp'fHE INSUREO MAMED IIBQYE FOR 7N E Pd1IGY p�Wpp ' IND1Cj1iEp,NONN'f}{BTANOINO J►NfY R�QUIRE]AEN7,7EqM pR CONOinoN pF nwy C�MrrAacT oR OTMER oocuneEnrrwlrH REePECT T�WM�f�n��s CER1'�FIGA1$iNAY SE f5Sl7EQ OR MAY PERTAtN,TNE WSURAI�/�FFOaDEo B r THE PpLIC�ES OE6CR�8ED HEREIN IS SUB.IECT TO ALL 7HE T�R�IS, E7CGLUBIONS ANU CONDf170N6 OF SUCM POLlC1ES,L��zS 61t01NN Mllr HqyE�EM REDUCEb BY PAr�Cuu�uaS. i�rn � • 7YPE Gf IMSIR�NC� PouCv NUkIBER � wucr��ecnv� aoucv��uno�+ • �►ip IlMwddlYYJ DiIT�IMY�dpJ71'} Uwts ��1 �'�A�� QEMENALAGGRC�C'sATE t G�fEkCINI f�1�RAL l.►�g�ll7�( Pp001lC►S-COi�4pP Afip f C��M� �OCCUR o�RSDW�L�Aw nu�uRr 5 owHER'8 a Ct9NTRACTpq�$PROT ' � ��C�� s , ._._ . . FIAEDAMN�G4�Yoerltr�� t �D FXP (Arb ai4 P��o^) S 1W1dMOa�I.E L�AglUT1� � ANY AUTt'S ' ' G�y61NE0 SR�6LE L1hlfT � - ALt OWNEDAUT�S � � rIw Ry I St�lEOtllEb At1TpS �� NIREDAUT,0.9 • NOiN�OWNE6 AU'iDS (v�fio�efQw1U� L . ~•. _. ... PROP6ZTY OANAGE j c�uuoE uwa�urr AUTO ONLY•FJI/�CC pENT i ANY AUTiO p7t{EftTHAN�O ONLY� -'_ EqGN ACGD�NT Q MiOR�tiATE s E1(CEBJ 11ABILli'� .. � FJ�Cr�DCGJRRENCE i UMBREL(q FDRIyI ' 1LRGREdA7l� 4 o'RiEaTNAN UMe��LIAFOfUs i NORif&Ite COYPI�W1noN ANO . X arw� q �*�Ave�s�r��m r _, a��J'�� e/1/08 ?�tl07 ei,�wcYr�ccmENr a 6DO,OOU � �� ' �k�� . �I.o�S�ee-roi�cr�qA�' s 500,000 w��c�x�,R,a� ��A� �� EL DlaFitSE-FA @NFtOYEE i 8�, D on��a • �C r�w aF o n � �OR INFORh�IATfQNAL PURPOSES QNl.Y � ` ' s�u�o aNrav rr�6 wgare �ueo �oua� ee u►u��, �n�e ' ERMRATIdV �ATE THBR�iOF. 7?IE!�lANO TOMlANY 1M�L EI�pAVOR m pWl ' �'OR fNFORMA'�I�NAL PURPOSES OIVLY — �va ww�► Wone�iv�t�ece��c�.,��EReV.,rEo�o,�ue �; .. ?�T Fw1�unETo wNl_9ucH No1l(�ENAI.L MPpae Mo oet.fMnoN we�u►eRa7r Q ANY 10N� UPON l�!! COMPAM', 17S AO�TB QR R�71�LkTA"IIVea. 6 r ATYE TOTAL P.02 �°1�� °��' � � :� � �` �� . ° � --• �''�„ 1146 IZ��TTE 2� SOL'TF� YARMOLJTH MASSACHliSETTS 02669-44:�1 � � ."' t\y_..�,MATTAGHEES Teleplione (5Q81 398-2231,Ext. 241 — Fax (508) 760-34'72 . . `�L a��ACORAitD�6y9� 'U g Q �4, IZD OF HEALTH . March 27, 2007 Anthony Athanas/Anthony's Cummaquid Inn, Inc. dlbla Anthony's Cummaquid Inn 299 Salem Street Swampscott, MA 019�7 Re_ 2007 License/Pernut Application Anthony's Cummaquid Inn, 2 Route 6A, Yarmouthport, MA Dear Mr. Athanas, Thank you for submitting the year 2007 application for your establishment's pernuts issued through the Health Department. Please note that for the food service and common victualler pernuts,a copy of the Fgod Pra#erctio� Mx�ager's certification, as well as copies of Heimliei Man�ver� c'e�fi�tti�ons aze required to be submitted with the application. 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. 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 note that the Health Department cannot use past year's records, as we are unable to verify if those staf�members are still under your employment. As soon as our office receives the above noted certification copies,we will be able to issue the food service and common victualler pernuts to you. If you have any questions on the above, please feel free to contact our office at (508)398-2231, extension 241. Thank you for your antieipated cooperation. Sincerel , � Mary Alice Florio Principal Department Assistant /maf cc: file �� Pzinted on Recycled Paper THE C�A�IlVIONWEALTH QF MASSACHUSETTS TOWN OF YARMQUTH PERMIT NUMBER: #47-008 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv's Cummaciuid Inn, Inc. d/b/a Anthonv's Cummaquid Inn at 2 Route 6A, Yarmouthport, MA in said Town of Yarmouth And at that place only and e�ires 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 confornuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to se.ctions iwenty-two to thirly-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�ced their official signatures,this Twenty-seventh day of March A.D. 2007. BOARD OF HEALTH: B �S. �it /LI.�., ' RESTRICTION: Swimming pool not for guests- c��S�ic�t, �./V. �u�e��a�ih�stc�st Family use only. Rv�� B�u,�ss, �� a��lux� , . Bruce G. Murp , H,RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT . PERMIT NUIV�ER: #07-115 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�'ieneral Laws,a pemut is hereby granted to: Anthon 's Cummaquid Inn, Inc., 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31, 2007 BOARD OF HEALTH: ,Qr�j u[�s/t�,, �joq�� /rts,�/IiI.n.`h,,, • SEATING: 400 c�ry�c7KG�L� KJI y vlC6(�K�Ihlyl�fL Rol�`�. ��ia�cusL, G� � ��/�a�S� �I�ua�'neessG�u.,i, R.N. � March 27_2007 Bruce G. Murphy ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-074 �E: $�p.pQ This is to Certify that Anthony's Cummaauid Inn, Inc dlb/a Anthonv's Cummac�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affxed their official signatures. BOARD OF HEALTH: B ��' `�`. f�oA�� oss, /dl.n$., ' SEATING:4OO �e�l�¢it e�HG�L� IZJr.� �I[l�(i�lG�ft Rodent�s.Bnou�rs, G� A�ti1��tt �l �_ , R.N. March 27_2007 Bruce G.Murph ,MPH,R.S.,CHO Director of Health • cl��a� � A�v�oNYs ��`;'�R o TOW N OF YARMOUTH BOt�T�D OF HEALT� �v p V 2 � ?D 0 5 ° � �v � - � APPLICATION FOR LIC S�lP'ER1V�I��2006 �ou ' � �� ,,.. � �� 0 z. y . F . �'� * Please complete form and attach a11 n essary documents by December 3 l, 2005. �� F a i l u r e t o d o so wi l l resu l t in t he re turn o f your app lication pac ket. N�� 1 $ Z�� NAME OF ESTABLIS�-IlVIENT: I"1 � , L��IJl7o� d!! TEL. � ��a '�7�0� LOCATION ADDRESS: - i d MAII,ING ADDRES S: � OWNER NAME: G'JZ TAX ID EIN or S : 0 2 CORPORATION NAME ( APPLICAB E • ' ` (� ` � � MANAGER'S NAME: L. # .l ' � MAILING ADDRESS: Q 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 oftwo 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 ProtectiQn Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: -_ _ _ __ __ _- - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operatian. l. 2. HEIlb#E,�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 a11 times. Please list your employees trained in anti-chokmg procedures below and at�ae�i eopies 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 REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 — �INN $50 O � � _CAMP $50 _SWII��IIvIII1G POOL$75ea. �LODGE $50 TRAII�ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQIJIItED FEE PERMIT# �0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 I >100 SEATS $150 #OG�O� �COMMON VIC. $50 �O��o _WHOLESALE $75 RETAIL SERVICE: LICENSE REQIJIItED FEE PERMI'P# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _Vh�NDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �-5��O� `•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" �` � ADNIINISTRATION 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 COMI'. 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:Pernuts run annually from January 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�Il�lENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�ilNG 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 CONIlV�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 paol must be drained or covered within seven(7)days of elosing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certi�ied lab: Test res�tlts must be sem t6 the Heaith - 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 waiterlwaitress 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. DA�: NOV 2 2 2005 SIGNATURE: PRINT NAME&TITLE: C( ' �� I 'r�-'C L} � 09/28/OS ��D 1Norkers' �or,�nen�tion and Emoloye�'s Liabilitv Policv AmGUaRD Insurance Company- A Stock Company SUE�ANCE po��cy N�m�e�aHwcesz�6z �j�� ] Renewal of ANWC�33816 �� r NCCI No. [21873] Policy Information Page Endor�sement _ . ._._._._ __. _,._._.__�...____._ — __ __. ________.____.. _ .._ � [i] Named Insuced and Mailing Address Agency i ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Standish Road Swampscott, MA 019Q7 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's iD Insured Is Corporation Risk ID Number 000062137 ; Locations �ther Than Above � (Li) 153 Humphrey Street , Swampscott, MA 01907 ' (L2) 95 Oxford Street, Lynn, MA 01901 � (l3) RT 6A , Yarmouth Port, MA 02675 � (L4) 200 Terminal 13 Logan Airport, Bosten, MA 02108 # (L5) 140 Northern Avenue , Boston, NIA 02110 _ .�._ __.....___�.__._.�.__.�._.�_ .____ ._,_ __.....r......_.--_._ _�..__., _._.___.,.__ [2] Policy Period From August 01, 2005 to August 01, 2006, 12:01 AM, standard time at the insured's mailing address. , i En+dorsement Endorsement #1, ef�ective on the date shown betow, 12:01 AM, standard time, changes the listed items. All other terms and conditions of the poilcy remain unchanged. WC890415 - Rates - Eff. 06/01/20Q5 , ___.______._____ ....�_.�___...___.�._�_____.__ _____.__w.. _._....�_ .__.----- ._.._.. _...._.._.. ._ __�. _ [3] Coverage A. Workers' Cbmpensation Insurance - Psrt One of this policy applies to the Workers' Compensatian C.aw of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to worlc in each of the states listed � in item [3]A. The limits of our liability under Part Two are: � Bodily Injury by Accident - each accident $500,000 Bodity Injury by Disease - each employee $500,000 Bodity Injury by Disease - policy fimit $500,OU0 i C. Other States InsuranCe - Part Three of this poNCy appties to all states, except any state listed in � item [3]A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming. � D. This policy includes these endorsements and schedules: See Extension of Information Paqe - 5chedule of Forms � �._, _�_.. _ _.__��_._�-.e_. �__.__ _._._____._..,_._.,..._._ _._ ._._._._ _._.�_�� __._.�_._.._�.._�__..� [4] Premium The Premium Basis and,therefore, the premium wiii be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. Aii required information is subject to verification and change by ; audit. (Continued on another page) ; .�..., �-...,.�..,.� Tota! Estimated Poficy Premlum � lit,7i4 Total Surcharges/Asse�ments $ 4,OS8 � Total Estimated Cost � i15,772 .....wvn x:r�anr;rmwcw.Mpel�w . . . . .. vremx,..«e++a+h VTFRNAL USE xx Page - 1 - Endorsement GA :ANWC652762 WC890600 ate : 11J17J2005 16 South River Street•P.Q. Box A-H •Wiikes-Barre, PA 18703-042Q.www.e��arri_�nm „ f �� orkers' �omQensatic� na�d_Enr�love�� Liabflitv Policv AmGUARD Tnsurance Company -A Stock Company iNSURAN�E Poticy M�mt�r awwc6s2�ez � (�(�� 1 1 [� Renewal of ANWC533$16 �.�✓�� l�J f NCCI No. [21873] Policy Ynformation Page Endorgement Extension of Information Page Schedule of Endorsements WC OOOOOOA - STANDARD POLICY WC OOOOOlA - INFORMATION RAGE WC 000112 - PENDING LAW CHANGES TO TRIA ACT 2002 WC 000403 - EXPERIENCE RATING MODIFICATION �ACTOR W� OOQ406A - PREMTUM DISCOUNT ENDORSEMENT WC 000420 -TERRORI5M RI5K INSURANCE ACT ENDORSEMENT WC 200301 - MA LIMITS OF I.IABILTfY ENDORSEMENT WC 200302 - MA ASSESSMENT CNARGE WC 2003036 - MA NOTICE TO POLICYMOLDER END�RSEMENT WC 200401 - MA PENDING PREMIUM CHANGE ENDORSEMENT WC 200405 - MA PREMIUM DUE DATE ENDORSEMEN7 WC 200601 - MA CANCELLATION ENDORSEMENT WC 990002 - PARTICIPATING ENDORSEMENT NTERNA� USE xx Page - 2- Endorsement iGA :ANWC652762 WC$90600 �ate : li/17j2005 1Ei SA��th RivAr Ctroct�O /1 Q.... w u _uan__- ^----- ... ..._..._ -^-- THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-QO1 FEE: $50.00 THIS IS Ta CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv AthanaslAnthonv's CummacLuid Inn, Inc. d/b/a Anthony's Cummaquid Inn at 2 Route 6A, Yarrnouthport, MA in said Town of Yannouth And at that place only and e�ires December thirly-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. Tlus 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 thiity-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 Second day of December A.D. 2006. BOARD OF HEALTH: Be�ts�t�. 4'o�ost,/I��. ' RESTRICTION: Swimming pool not for guests- p��c��lu�w�� /�ice��r�t Family use only. R�lt��. B�u,wt, �:L�lufa � �� Sl�, R.N. �l�� , R.N Bruce G. Murphy RS.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #46-020 FEE: $150.00 In accordance with regulahons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Anthony Athanas/Anthony's Cummaquid Inn, Inc., 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2006 BOARD oF HE�,�: Ln�e�,�_ • r',r�in's$. ('r�u�,/I�I._`?S. ' SEATING: 400 /��ifC1�/Y(C�S�LNI(�t, v�e��.� - �s�R.N.� �4.t.z��.,�, R.N. D�t�2.Zoos ruce G.Murphy, , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-016 FEE: $SO.QO This is to Certify that Anthony Athanas/Anthony's Cummaquid Inn Inc d/b/a Anthony's Cummaquid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo�xn oF��..Tx: a�,��h. g�,n�' �s.�f �� • SEATING:4� P��ClJ�j (llC6��ftG�lNl�fL Rod��. B�eocust, G� � s�k, R.N. t4.�� , R./V. December 2.2005 . _ _ Bruce G.Murphy RS.,CHO Director of Health � . c�3��° a�� AN� Ys �'� � ; �,, ; . �°f:aR 0 (;��'��-� TOWN OF YARMOUTH BOARD O HEA '� :��, " r -iC o_. . _ y � 4�`,� f � APPLICATION FOR LICENS 1P.�RMIT- 00 , �"l`�� ' � . �EC 2 1 2004 � � .;�' .. � w✓... * Please complete form and attach a11 necessaxy;d�icuments by c � Failure to do so will result in the re'turn'of your applicah ��T' ; NAME OF ESTABLISHIVIENT: v ' � TEL. # �• � LOCATION ADDRESS: - ' � /' �t " v i¢ CJ �',� MAILING ADDRESS: ' � It� enT>` d'! ' "7 OWNER/CORPORATION NAME: �' s � � � MANAGER'S NAME: D a� TEL. # !J . ' 6,;� MAILING ADDRESS: a - �'� p - 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 capy of the certification to this form. 1. 2, Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS� All food service establishments are required to have at least one full-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 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 employe� e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3- 4. RESTAUR�NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE P�RMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 I INN $50 �Q��Q�p _CAMP $50 _SWIlvIlvIII�iG POOL$75ea. _LODGE $50 _TRAII,ER PARK $50 WHIItI,POOL $75ea. FOOD SERVICL: LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIlZED FEE PERNIIT# LICENSE REQUIlZED FEE PERMIT# _0-100 SEATS $75 _CONTTNENTAL $30 NON-PROFIT $25 I >100 SEATS $I50 0 .. I COMMON VICT. $50 �Obc� WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIlZED FEE PERMIT# LICENSE REQ[JIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOITNT DUE _ $ oZ�j0•OQ "•'•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R R�R 1 • A ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION IN5URANCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, 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 DEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, 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 standaxd 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 clasing. FOOD SERVICE CONSUMER ADVIS�RY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. �'ROZEi�i 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.,outdo�r seating with waiter/waitress service),must have prior approval from the Board of Health. OUTD04R COQKING: Outdoor cooking,preparation,or display of any food product by a retail or faod service establishment is prohibited. NOV � 4 Zpp� DATE: SIGNATURE: PR1NT NAME& TITLE: V l_ S C. 10/22/04 � �� Workers' Comnensation and Emplover's Liabilitv Policv y AmGUARD Insurance Company - A Stock Company IN�V�f�1��E Policy Number ANWC533816 � �("'�j/"'1 � � Renewai of ANWC432336 f`C ti.,l NCCI No. [21873] Policy Information Page Endorsement [1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Standish Road Swampscott, MA 01907 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's ID o4-2316533 Insured is Corporation Risk ID Num6er 000062137 Locations Other Tha n Above (L1) 153 Humphrey Street, Swampscott, MA 01907 (L2) 95 Oxford Street, Lynn, MA 01901 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Terminal 13, Logan Airport, Boston, MA 02108 (L5) 140 Northern Avenue, Boston, MA 02110 [2] Policy Period From August O1, 2004 to August 01, 2005, 12:01 AM, standard time at the insured's mailing address. Endorsement Endorsement #1, effective on the date shown below, 12:01 AM, standard time, changes the listed items. All other terms and conditions of the policy remain unchanged. WC890406 - EXPERIENCE MODIFICATION - Eff. 08/01/2004 [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this poticy applies to all states, except any state listed in item [3]A. and the states of North Dakota,,Ohio, Washington, West Virginia, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Endorsements [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 125,026 Total Surcharges/Assessments $ 4,570 Total Estimated Cost $ 129,596 TERNAL USE RP Page - 1 - Endorsement �A :ANWC533816 �te : 09/24/2004 WC890600 16 South River Street •P.O. Box A-H .Wilkes-Barre, PA 18703-0020 •www.guard.com , DEC-23-2004 14�13 ANTHONY'S PIER 4 7815989321 P.01 . � ► � . ' . . , � ' . .i� � 1 � / � � . . . 299�Selem Street � Swampscott„ MA Q1907 ' Phone: (781) 595-5377 Fax� (78Ij 598=9321 �� (� Q �' �,' �, � 1��.. �r�� n-��vn , . �� t. . � � L.� n .. � .� . ��x; Q �� pa es; includin Cover Sheet phone: �f il� Date: �E� 2 � � � � Confidentiaiity Notice: This page aud any accompanying documents are confidentxal ' and pratected by law. if you are not the recipient stated above, please destroy anY Fages � you may raceive and contact the sender a.t the phone aumlier listed above. .Your . cooperation is greatly �ppreciated. ' �..�-- �- - - � .� a.. .,; Comment�: � � � � u�� 4� �2004 i . r � • �-��/�� .��T.. . . / ., . . � � r }�-� �� l /! � � ' /� � � . � ^ � � IS � �. � l a - � D , � � 1� �� , . �� - �r ��. . � � � .-. . rr�= � - � �� DEC-23-2004 14s13 ANTHONY'S PIER 4 7815989321 P.04 CUARD� �,, _�30�e , 4Y��A�� A� �111I� irr.■�a ��bil-6r�d'�� N S U RAN�� Am6UARD Insurance Company � �O � , , Poltcy Numb��ANWC428533 P ` R,en�swaf of NEW NCCI No. [Zt873� Poli,cy InT�orn�ation Page - Final Audit (T�Pe: Actuatl Physicai) �4] P�'emium (�nt.) Ma�achusvtts Ciassification Code Premlpen Basis: �te Tota1�stirttated � �mated �1� Annuai Annual Remuneration Ptv��tnium � Remunerattan Efrettive: 05/14/2003-�8/Ol/2003 CLERICAL QFFICE EMPLOYEES NOC RESTAURANT NOC 810 13 9 •ig 247 9079 612 6B4 .19 13 g Rate Deviation Increas�d LimNs Emp li�b �037 5 - 8 ExpghgnCe Modiflcmdon 9607 1.009� 13Q Schedule Modi�cation 9896 g . g2 All Rlsk Adjustment Program 988? 5.009�6 -643 • 0 77 .QOQ p Minlmum Premlum �47 Tct Es[Prem 05/14/2Q03-08/01/2003 207 Premium DlscounC Tot Est Standard Premium for Massachusetts � •��`�' 1 12 006 P ic T 15 � Total Est 5tandard Premium for Massachusetts �Z,006 Expsnse Ccnstant MA 0900 53 Minimum Premium Mq $q,� 7otai Estimated Annual Premium 12,059 MA State Assessment 4.500°�6 578 Tota1 Estfmated Cost for ANWC428533 12,fi37 Total Estfmated Cost Prior to Endorsement 15,508 Adjustment to Totai Estima#ed Cost -2,871 S�Rhec�es/Assessments Inciuded in Adjustrnent �-142 :dZFBdAI u5e �p Pagc+-3. "�+ :ANWC42@533 Eneorsement �a� : 10/23/2003 w�� L��-��-��µ 14�js ANTHONY'5 PIER 4 7815989321 P.03 �GUARD� � 1 N S U RA N CE Am6uAR�Y��an�compeny G �O � � Policy NumberANWC428g33 � � Renowal of NEW NCCi No. [Z1873] Policy Zntorrnatton Pa9e-R:nal Audit (S'Ype:Actuai Phys�ca!) Exten�ion of Infor�mation Page Schedule of Endarsemonts WC OOOOOOA -STANDARD Pp��y WC OOOOOlA- INFORMATION PAGE WC d004Q3 - EXpERIENGE RATING MODIFICATION FACTOR WC 000406A - PREMIUM DISCOUNT ENDOR5EM�NT WC OQ0420 -TERRORISM RISK INSIlRANCE ACT�NppRSEMENT WC 200301 -MASSACHUSEITS IIMITS OF I,IABILTTY ENDT. WC 200302 - MASSACFiUSETTS-A55ESSMENT CHARGE WC 2Q0303B- MASSACNUSETTS NOTICE TO pp�CyHOLpER END WC 200401 - MASS. PENDING PREMIUM CHANGE ENDOPtSEMENT WC 200405 - MASSACHUSETTS PREMIUM DUE DATE ENDT WC 2006fli - MASSACHUSETrS CANCEL,qTION ENDORSEMENT WC 990002 - PARTI�IPATING ENDORSEMENT lC7�flNAl U�E dA GA :ANWCa28533 Page- 2- Endorsement ate : 30/23J2003 WC890600 lit�—��—�eb4 14�13 f�iTHONY'S PIER 4 7815989321 P.02 GUARD� � o -�� N S U Rr1 N�E AmGUARD Insurane� Company Polity Number ANWG428S33 ��R a u � � � Rs+�wal of NEW NCCI No. [21$73] ��cY Info�rnation P e- Final Audit(T e: Actwl Ph cai C1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBEFiS FIRST ANTNONY'S PIER 4 INC. D9A INSURANCE 6ROKERS 299 Satem Street 4 Standish Road Swampscott, MA 01907 eridgewater, MA �2324 Agency Code: MAMEFI20 Feder8l Employer's iD I�sured is Corparatlon , Risk iD Nymb�r 000062137 �,ocations Othe�Than Above (�-1� 153 Humphrey Street, SwampscoCt, MA d1907 (L2) 9S Oxford Street, Lynn, MA 01401 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Ternninal 23, lAgan Afrport, Boston, MA 02108 (�) 240 Northern Ave., Boston, MA 02110 ,�2] Poltcy Period From May 14, 2003 to August 01, 20Q3, 12:01 AM, standat�d time at the insured's maliing address. [3] Coverage A. Workers' Compensation Insurance - Part One oF this potity appiies to the Workers' Compensation law of the foilowing states: Massachusetts B. Employer's I.iability Insurance- part'f�vo of this policy appiles to work in each oF the states llsted in item [3]A. The timits of our ilability under Part Two aro: Bodily Injury by Accident-each accident $500,000 Bodily Injury by Disease -each empioyee $5op p00 � Bodily Injury by Disease - policy timit $500,000 C• OtMer States Insurence - p�rt�� of rhis polity applies to aii states, except any state�isted in item [31A. and the states of North Dakotb, Ohio, W�shington, West Vfrglnia, and Wyor»fng, D. This pnii�y includes these ehdorserhe�ts and schedules: See Extension af Information Page- Schedule of Endorsements [4� Premium The Premium Basis and, ther+efare, the premium wilt be determined by our Manuai of Rules, CIa55ifications, Rates, and R��y p�ans. All requfred information is st�bf ect to veriryCatiort and change by audit. (Continued on another pagej Tot�i Estimat�ed Palicy Premiym . S - 1�,059 To#al S�rchsrpea/A�.n� � 578 . Total �stirnatod Ca� $ ZZ,637 I�Bd6L.tb,�.4P Page- 1 - aA :ANW�42g533 Endorsement te : �ona/2oo3 wcs90600 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-006 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to _ Anthonv Athanas dlb/a Anthony's Cummaquid Inn at 2 Route bA, Ya.rmouthport, MA in said Town of Yannouth 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. 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 affi�ted their official signatures,this Second day of February A.D. 2005. BOARD OF HEALTH: Bescyr.�tt�t�S. �ji�o�,�`7�. • RESTRICTION: Swimming pool not for guests- p��itscl�/�c��,,,� �/�sce��rt�itc�t Family use only. /�ttLwlct�. B�uuwt, �� s�, R.�v. �v r , . Bruce G.Murp H,RS.,CHO birector of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERNIIT NUMBER: #OS-100 FEE: $150.00 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: Anthon Athanas, 2 Route bA, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31,2005 BOARD oF HEALTH: l3eHy�nri�.h. ('�,oa,/�`�S. ' SEATING: 400 n�,��phy�� v{�(�u.�il Rc+�dwiit� B�i«u�s, C� ��s�, R R.N. , February 2,2005 Bruce G.Murphy ,R S.,CHO Director of Health , , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-068 FEE: $SQ.00 This is to Certify that Anthonv Athanas d!b!a Anthonv's Cummaquid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: Besryr�r� `�. ,�'jwu�iisi, /yl.`�. ' SEATING:4OO ��,t��, v�e�� Ro�ient�.l�nocvrz, L''l�ik � s�, R.nr �r�� , R.�! February 2,2005 Bruce G.Murphy, S.,CHO Director of Heal a • , . . 3aaa�' �� ) AN"1ltONkS � ��';''R.� TOWN OF YARMOUTH BOARD OF�3FA�;�'H F ' � � . -_-��{� ��s APPLICATION FOR LICEN�EkP�R�VIiT-20�� ' ` ; ' _.� � � � s ��,� ' �,-,.. t * Please complete form and attach all necessary documents by December;31, 2003. 7�,�� Failure to do so will result in the return of your application packet; ; T NT• ' � � . - _ � �� L C T N ADD S : - f 6 � > d � v� WN R/C RP RA O .S A ER'S NAME: 8 � a T L � 6� L ADDRESS: / �/" d � 6 � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Fool �peratorjs�an�attacTi a c�py of the certifca�ion to thi� 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 - 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. /`',' _�i Q�/ I�I��se.-� 2. �l,cv�,•e ..�1/�h PERSON IN CHARUE: _ - -- ___ __ _ _ __ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �/�C/?C G� �T6 a I� 2. /`ri�L �rd /� /"'G L� S HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies anc�maintain a fite at your place of business. 1. /y c � ��o v� 2.?.L..•e-� rc t� S 3.��oiro 4. �ri a � t-3r C�.� .,. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY I.ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREQ FGE PERMIT# LICENSE REQUIRED FEE PERMIT# BBcB $50 CABIN �50 _IviOTEL $5� I INN $50 �'0�-005� _CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT S25 1 >100 SEATS $150 0�{-6 1 COMMON VICT. S50 O�{-05� _WHOLESALE $7S RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQ111RED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.R. $200 _VF,NDING-FOOD $20 <25,000 sq.ft. $75 _FROZEN DGSSf:R'I' $35 _TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ 250 .00 **'�**PLEASE TURN OVER AND COMPI,ETE�THER SIDE OF FORM***"* ^ . . �` � . � �� x ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COM NSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED .Q$ 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: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTTON 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUS'1' BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RF_�ULATION� _ POOLS POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: 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 CONSUNiER A�VISO�RY• . Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERiNG POLICv� 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. ��9��1�?��E�12'I'�: _ _ ___ ._ - — _ __ _ ___ _ _ 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 C FF S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),tnust have prior approval from the Board of Health. (,�UTDOOR COO iN .• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �E�G� ��,�I��SIGNATUR�: PRINT NAME& TITLE: 10/22/03 �'v�/G UA R Do Workers' Comnen$ation and Emulovpr' iabilitv Policv I N c u R ^ A'�c AmGUARD Insurance Company � `� r�� C P o l i c y N u m b e r A N W C 4 3 2 3 3 6 1 r � � O � � Renewal of ANWC428533 � NCCI No. [21873] [1] Named Insured and Mailing Address Agency ANTHONY'S PIER 4 MEMBERS FIRST ANTHONY'S PIER 4 INC. DBA INSURANCE BROKERS 299 Salem Street 4 Stan�ish Road Swampscott, MA 01907 Bridgewater, MA 02324 Agency Code: MAMEFI20 Federal Employer's ID Insured is Corporation Risk ID Number 000062137 Locations Other Than Above (L1) 153 Humphrey Street, Swampscott, MA 01907 (�2) 95 Oxford Street, Lynn, MA 01901 (L3) RT 6A, Yarmouth Port, MA 02675 (L4) 200 Terminal 13, Logan Airport, Boston, MA 02108 (L5) 140 Northern Avenue, Boston, MA 02110 [2] Policy Period From August O1, 2003 to August 01, 2004, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the fotlowing states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $5Q0,000 Bodily Injury by Disease - each employee $5d0,000 Bodily Injury by Disease - poficy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in � item [3)A. and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming, f i � D. This policy includes these endorsements and schedules: E See Extension of Information Page - Schedule of Endorsements � 4J Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, y Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) � � � �tal Estimated Policy premium �tal Surcharges/Assessments $ 9�'759 ►tal Estimated Cost � 3�295 $ 98,054 tNAL E 4V :ANWC432336 Page - 1 - : 08/12/2003 Information Page 1TE WC 000001A P.O. BOXA-H,WILKES-BARRE,PENNSYLVAN�.4 ta�n� THE COMMONWEALTH OF MASSACHUSETTS T4WN OF YARMOUTH PERMIT NUMBER: #04-005 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthony Athanas d/b/a Anthony's CummaQuid Inn at 2 Route 6A, Yarmouth�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 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 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 Fourteenth day of January AD. 2004. . BOARD OF HEALTH: Be�a�rs�t.�. �o+r�,ou, /Fl�S. RESTRICTION: Swimming pool not for guests- n�ttc�a/Nc�Plilit� �/ice��t�'.��t F�iy�o�. RaG�t�. B�, G'� s R�v. - ruce G. Murphy,MP ,R .,CHO Director°�'�I� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTIV�ER: #04-067 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the�eneral Laws,a permrt is hereby granted ta Anthony Athanas, 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthony's Cummaquid Inn Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD OF HEALTH: Bne�s�- . 'ti�rts,.`h. �j'o�ii�r„ /�9.�5�•f �� ' SEATING: 4OO l+G�C�/�',C��i �tC� C:ltG�!!1//Lls�it Ro/�t`�. Bnv�rc, G�l� � s�, R.�. Januarv 14,2004 Bruce G. Murphy P .5.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-052 FEE: $50.00 This is to Certify that Anthony Athanas d/b/a Anthon�r's Cummac�uid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo� oF�ai,�: l/3��u./�,��h. ��.t /,��M.�/�.f �� • SEATING:400 N�/YIC�PlLNtOfti� (llC� (:K�H/ftG�it Ro�Ge�t�. 13�x�s, �le� s�, a.n�. January 14.2004 B��G. MUm y, >R.s.>cxo Director of Heal ��rrL1i803 30�� H.LO�.L�'IdIAiO�QI�i�'�I�AO 1�i2III.L�SV�'Id,��sx• 00'OSZ $ _ �f1Q OL1I� OI$ �� dH� I�i se$ix�ssaa x�zoxa �OZ$ '8'bs U00`sz< sv$ �u��os> OZ$ ,O��dHO.L SL$ '8'bs 000`SZ> OZ$ O��dgO.� #.LTY�RI�d ��3 Q�If1��2I�SI�I��I'I #.LIb1i?I�d ��3 Q�IIf1a�2I�S1�I��I'T #.LIY�i2I�d ��d Q�2IIf1a�2I�S1�I��I'I A .L SL$ �'IdS�'IOHM ��Q.� OS$ ',L�IA I�IOWI1i0�j �%3" z'"�! 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OZI11 �~ ��y W'orkers' Compensation insurance Affidavit ARnlicant information: _ PleascPR � . ,�- am•. 'an: , , a # � � � I am a omecw�ner pert� in;all work myself. � I am a sole proprietor��,a, ha�e no one��ori�ing in am•capacin� � I am an emplo�er pro�idin� w�orkers.' compensation for my employees w•orkine on this job. ! ` ,�' m an • � me• . ` �ddress' ; �: n�u #. v`'a� 6 D , i urance � q � I am a sole proprietor. general contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below� ��ho ha�e the follu�+in: ��orker��,:ompensation polices: n v n e. �� 6v.�.-.� address: '/�e �� 2 �!/ e/C � i(/� �/Y � � ci�y: UJ/�i��5 ' ��r`L.' �� o!�one#: O �C> (o /� OG%�� T insur�ncc co. �olic}•�t �/N�JG ��/T� companv name: iddress• Sjly: ehoee 1!• insurancr rn_ Ro�tV� 1 Failu�e to secure coverage as requirrd uoder Secnoo ZSA of MGL 1S2 a�iad to tbe ioposidoe of erisiaal peaaltla ota 6�e op to 51,500.00 a�d/or one yean'imprisonment a�w•ell a�civil penalde�io the form ota STOP WORK ORDER and a line of SI00.00 a day q�iost ma I a.dersa.d c�ae a eopy of thy s ent may be fonvarded to thcOtTice o((nveetig�tion�of tbe DU[or eoverage veriffado�. 1 do hrreb c rri under the poins and nal�ies ojperjury that the injormatinn provid�d ebovt it true and corrrd Signamre su Print name one 1� �G l C7 7t.'J �17�! .- afTicial use only do not+.rite in this ara to be completed by eiry or toan otlleial citv or town• YA�� _ permitAieense p t'16uildiog Departmeat ' �Liceasieg Board �cheek if immediate response i�required 261 QSelectmen'�ORee �Health Department • cont�ct person: phont q;_ �508� 398�2231 eut. nOther ,.. .��. :1!�'. . ' 11/321/02 2�22 PM From= DAVID J• ANDERSON p• 2 of 2 :. a�111:11.f �E�.T��1��'�;�C3�t��$��G�� ,w �� ,, � n E o.�►��, .�,. � ' i `w r . o h ' aii'Sv, � �. a <4..�<>..::..�, d 3��u. '>?.>3'3 ...; r 2 `,..W:X:.'C.:ls..�.:..�..-............v.1i. ...hi-0V�.�!.f.Y.L..+.�.- :Mb;��C.....�...�...?:.a�.'.,> ...,..Y..,.-.... .�..:< e>... ...... - ppcpuct�+ T}i1S CERTiftCATE IS ISSUEO AS A MA'�TEFI OF INFORMATION OWIY AND CONFERS NO RiGHTS UPON THE CEAf1FICATE I10LDEA.THIS CERTIFICATE DOES NOT AMENO,EXTENO OH ALTEA T}iE COVEAAGE AFFOROED BYTHE Members Fi�st Insurance Brokers InC POl1CIES BELOW. Four Standish Road COMPANIES AFFORDING COVERAGE Bridgewater MA 02324 CAMPANY � p` • AmGuard . � .. . . . . . CAMPANY B � �, INSURED LETTER A11tf1Of1�$P1Qf 4, IfiC. CAMPMIY C 299 Salem S'treet �7Eq, Swampscott, MA 01907 �R` D con�P,wY E (ETTER j/��/�;!�J!��!"" � . '..: _.... .. .. ._.. _ ::.- /; �_.. 5 _ . �� '�� " .x.: . ....i.v�.va i�' . .::4.�'ttA� ,+�� ..J. tl.w..k.'.�...W � ...i:j:..:; ..n.. . . ...w. v wY. .. ......... .. ... .::...(:......_...,�r. ?.5..... ..... i�......... . . ..... , n THIS IS TO CERTiFY TkAT THE POUCIES OP MISURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOfl TNE POLlCY PEAIOD INDICA?ED,NOTWITHSTANDIN�ANY REOIl�EMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHEA�OCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUffD OR FAAY PEfiTA1N.TFtE INSURAWCE 0.FFOR�ED BY THE POUCIES OESCRIBED HEFiE1N IS SUB.IECT TO ALL THE TERMS, OCCLUSIONS ANO CON0ITIONS OF SUCH POLICIES.L]MlTS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS. � 1YPE OF INSURANCE . pp�UCy NUMgEq � POUCY EFfECY1VE POUCY EXPINATI�M I L1MlfS Tp . .. . DATE(MM/D0!'(1� DATE(MM/CD/Y1� ' cFHeau w�utv GEr�EHn�nGGaEGATE S COMMFx�CIAL GENERAt,l'ABiLRY PPOCUCTSCAMPlCP AGG f _ CWMS MADE�OCCUF. . .. .. . � . .. . PE•�SOuAL BADY.!NJURY 5 (CWt�r 58 '�^NTr'L4CTORS PFiOT, � �EACH OCCUPPENCE S . . . .... � � ��IF.E DAMAGE�Am/on�6re� S �� . � � IMED.D(PENSE;Anycneccrso�l.S AUT01lO81tE W181UTY I I j CAMBiNcDSINGL �5 ANY AUTO I UMIT I L �u owNe�auTcs � eoe��r�N�uaY ` � I(Per person) f s SCHE�l:LEO AU7C5 i FNPcO AUTCS . � � I BODILY INJUfiY S I NON-0WNEDAUTOS �Per azt�Qer+t) GAFIAGE UnB1UTY � , � ; i IPROPEATY DAMaG'c S E7(CE55 LtA61LITY l � I c�iCH CC:UFficNCE j 5 _ UMBAELLAfpRM � I � �AGGFEGATE �S 1 � I i CT?''eA iFWN UMERELLA FCiL+n � I � I � � � � . � STATUTORY LdMITS � WORI(EA'S COMPENSASION � q �a . ANWC334528 - 8/1/02� 8/1/03 EnCHaCC:GENT s 500,000 Ia�sEr,sE-wr�cv�err s 500,00(1 ENPlOYERs'W6i�ISY . , ,�,� D'�SEASE-EACH EMPLO•E_ 5 on+Er+ j � ! ' i i j I ` , i DESCPWSION OF OPERATIONSlLOCATIONSNEHIClF5i5PECIAL iTEMS " Cummaquid Inn CEAiiFtCA'f'E.HOLDEf� . ? . .. ' ' CA.I10ECtATION..:;, `" `. `'',: . . .. :... ,.. .. .::. SHOULD ANY OF THE AbOVE DESCfi18ED POlIC1E5 6E CANCELLED BEFORE THE � D(PIRAT{ON DATE THEaEOF. 7HE ISSUING CGMPANY WILL ENDEAVOA TO MAIL�_DAVS WRIT7EN NOTICE TO THE CERTiFICATE HOLDER NAMED TO THE lE��, 6LiT fAII.URE TO MAIL SUCH NOTiCE SHAL�Ih1POSc NO 08LIGA7ICN OA LIAB1lITY OF 'f KINO UFON THE COMPAh'�.ITS AGENTS OR REPRESEN7AiIVES. :��<�AUTHORIZEO RE SENT TIVE � �n�+"!N /�/ Z/�.v. L%��t!'/� .. ! ..._,,. .. . . .. _ :.: .� � ...:; - ... , _ . : : ' ` 9ACOR000RPORATfON'i9� ACORO?S-S(7f9o) .�. . .. , . .. , , ..:<. .. _ THE COMMONWEALTH O�'MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-005 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthony Athanas d/b/a Anthony's Cummaquid Inn at 2 Route 6A,.Ya.rmouthnort 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 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 secrions twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereo�the undersigned have hereunto affixed their official signatures,this Thirteenth day _ of December A.D. 2002. BOARD OF HEALTH: �r�ed�, i�el�. C�u� �cla.ictss 2'�. C�iozd°"c, �1L.D., `l/ice ,�o�t 3. ��, � �a�rrck�D�ott � S �yl. ce G.M hy, .S.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #03-053 FEE: $150.00 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: Anthony Athanas, 2 Route 6A, Yarmouthport, MA Whose place of business is: Anthon�s Cummaquid Inn _ _ _�ype of�usiness:- - __-- __Food Service - _ __ --- ____ _ _ To operate a food establishment in: Town of Yarmouth �� r�. �elBil�i, av�.xa« Pernut expires: December 31, 2003_ BOAItn oF��,�: ��9 y�� D �� SEA'rn�1G: 400 �� , ��a__� �j� iW� �Q�GG� //GG(/O�llll� f7'�J . 1C•�• December 13 ,2002 R.S. CHO ruce G.Murph , , , Director of He h � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #03-031 FEE: $50.00 This is to Certify that Anthony Athanas d/b/a Anthonv's Cummaquid Inn 2 Route 6A, Yarmouthport, MA IS HEREBY GRAN`l'ED A COMMON VICTUALLER'S LICENSE 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 la.ws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensmg authorities by General Laws, Cha.pter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. _ _ .BOARD OF HEALTH: �faalea� xelftke�, L'�rak_ _ SEATt11G:400 �e.cfa�cur D• G�i°�rd°�c, �IL.D.. ?/iee ,Z�Z'odact 3. �nou�c, �� at�riek'fllcD�att �f�S Z'.7Z. � December 13 ,2002 ruce . wp y . ., Director of Heal / cb�f�"Zo-��s �90 Jan-10-2002 12:08pm From- �Zp�2 �� T-283 - � � $ 2a35c (1S'a �4T�� Q � � � Q � � � �' TOWN OF YARMOUTH BOARD O,�,H .� �Q N 2� 2 2�D2 APPLICATION FOR LICENSE/�� T ;� ��., H ALTt� EPT., * Please complete fozm and attach all necessary documents by DeCemb�t�'31, 2001. Failur t he return o f your app lication packet. ' ''� A F E TABLISH TEL. # — � , � i� �( � O I j C'..,- � 7�� N E: �I A D � POOL CER'I'IFICATIONS: �kpl��I��O��t�e�,y�y�t�p�,I�td`:�d��st��bl�y,. Please list the designated Poo Operator(s)and attach a eopy of the certification to tlus form. 1. 2. Pool operators must list a minimum o�two employees currently cerafied in basic water safety, standard First Aid and Community Cardiopulmo�ary Res g$e below and attach cQ�ies of �� ,,� + ��•�;�]Qp u. 1�� '� � A . �. �.��1�{Ir!�,�� :Q . , _ . .., ' - ess. ,�'� . , ��. � �. �.,. 1. 2. 3, 4. . _ i _ .. ,. .. ,� ,;,,� N1�1(��i�Il41x..I1�:''.'Q��A'��'```,.. '��; I All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manage�', as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this ap lication. ,�,�'� �'�'4I�'�:�I��i?�i��G��V.•:�.��q�� a .��,..,,, � �;��;�,�r�� : � � �.�� -�--°��.�n . 2. �y��, . . . . ,. c ood establishment must have at least one Person Tn Charge(PIC) on site during hours of operation, 1.� ��cis'e��'=—�"►D.n 2.�r �r.G�r-..,.c 1`-{G ..��c�-►��'1 -+:I•-'»w�;..n'.;�.-•�hi :1��."��AT,�-'�i(�irti5;;� •� � � . . e-' ' : ` R �� All food service establishmen�'th 25 seats or more must hAve at least one employee trained in the Heimlich Maneuver on the premises at all dmes. Please list yvur em loyees trained in anti-chotang procedures below and attach eopies of employee certifications to this form. ,'��r��$�;;;w1;AA�D9��91�r:�a��+�°pas�t�.�o�iiro�',��,�s. Y°��d'�lG��'a:�,�'��►�ao�t,�11�t�R!;n��b�°�p�o�.�puaa'�:a�;bas�i�5a�,,t 1. 2• 3. 1-�I c...�-k T--1�t ��a 1 �� 4� -- RESTA NT SBATING: TOTAL#�� ` \ J�n-10-2002 12:D9pm from- T-283 P.003/005 F-427 / .� j i i � � I,�C1NC, . LICENSE RGQ�LD FEG PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIR�D T�E iP�RM1T# ,MO�'EL �50 ' 8&B SSU �CABIN S50 . �� SSO �-� �C� �50 _SWiMMlNG POOL SSOea �, LODGT; SSO �T(tAILER PARK S50 ,WNIRI-PO4L S25eal._ EQOD��JL� LICENSE REQUIRED FEE PERMIT� LICENS�1tEQUIRED FEE PERMIT� LICENSE REQUII2ED PEE �PERMTT u 0-]00 SFr1T5 S75 _,COMINENTAL S30 �� NON-PROFIl' $ZS i �>�DO SEATS S150 �a�� COMMON VICT. $50 �. 03-0� _WHOLESN.E $7S � � v �• LICENSL• RlyQUIR�D FEE PGRM]'t'# LICENSE REQUIRE� FEE PG[tMIT# LICENSE REQUIRED FEE PERMIT t► <25,000 sq.ft. S75 TTOBACCD FZo `TOBACCO �zo �—, — �� <Sa sq,ft. S45 >25,000 sq.tt. $20� JFROZEN DESSER't$35 � � AMOC7IVT DUE _ $ �M�CHAIVGE� $10 •�ai+ pLEasE TURN OVER Al�COMPLETE OTI{�R StDE O�'FORM"*" I' Jan-10-2D02 12:09pm from— T-293 P.004/005 P-427 ' � ' , ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of an�y license or permit to opeiate a business if a person or company does not have a Certifica:e of�Vorker's Comperisation Insurance. THE ATTACHEb S�'ATE WORKER'S COMPENSATION' INSU$,ANCE AFFIDA�IT MUST BE COMPL.ETED AND SYVNED,OR CERT.OF INSUR.ANCE ATTACHED_� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens musc be paid prior to renewal or issuance of your perm�ts. PLEASE CHEC�C AP�'ROPRIATELY IF PAID; YE'S � NO � NOTYCE:Pennits nw annual�y&om January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETUItN THE COMPLETED APPLICA'I70N(S)A.ND REQriJIltED F'�E(S)BY DECEMBER 31, Z001. SEASONAL ESTAHLISHQv�NTS A,�tE TO.�OIVTACT�HEALTH DEP,ARTMENT FOR INSPECTION 7=10 DAYS PRIOR TO OPEN]NC�FOR THE SEASON, ' ALL RENOVATIONS T� ANY FOOD ESTABT.ISHMLNT, MOTEL OR POOL (i.e., PAIlVTIl�I'G, 1VEW EQUIPMENT, ETC.), MUST BE 1tEPORTED TO AND APPROVED BY THE BOARD O�'HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A ST�'E P�;AN. � i , . ... . . . .. . _._.... ... ... i i i � � � Jan-10-2002 12:lOpm From- T-2A3 P.DD5/005 F-427 / HLL111V1�IA1� M.IrUL•A I illl�l�l � '�1 POOLS � i �OOY.4PENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to Qpening. , POOL'WAT�R TESTIlVG: The vvater must be testcd for pseudomones,total coliform snd standard�plate count by a State certified lab,prior to opening, aad quarterly thereaft�r. . , FOOL-CLOSINGs�Every-outdoor�n ground sv�ri:mming.pool must be drai�ned or covered within seven(7)days vf closing. � FOOD SERVICE � ' '' � CATERIN POLICY• � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departinent by filing the reqwred Ter�lporary Food Service Application form 72 hours prior to the catered event. Thses fo s can be obtained at the Health Deparbment. � FROZEN'bESSERTS: : Frozen desserts must be tested on a montlily 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 vf your Pro2en Desserc Permit until the above terms have been mef. � ' ; QUT,S3DE(YAF�S: I Outside�afes(i.e.,outdoor seating with waiber/waitress service),mu. have prior approval from the Boartl of I3ealth. OUTDOOR C OKING: � i Outdoor cooki.ng,preparation,or display of eny fovd product by a r�tail or food service establishment is prohibited. I I a�o ti- � DqTE: SIGNATURE: � PRINT NAME�t TITLE: � �o��Y�-i (�, �4 c'�34 N A S' `��76�-t- D��.._.�---r�/� 09/l 1/O1 � _ � , , � � u "� _. � �J'' }' s ORKERS' COMP�NSAT�N AND EMPLOYERS LIABILITY INSURANCE POLICY a n l.-�� INFORMATION PAGE Charter . - . Policy #: WC19629A Renewal Of#: WC11385A Carrier: ATLANTIC CHARTER 1NSURANCE COMPANY Bureau File #: 062137 N.C.GI. #: 29211 Interstate #: Federal ID #: 1. INSURED The Insured: Anthony'S Pier Four Inc. d/b/a Anthony's Pier Four 299 Salem Street Swampscott, MA 01907 Other workplaces not shown above: Please see attached "List of Locations" Insured Is: Corporation 2. POLICY PERIOD The policy period is from 8/Ol/Ol to 8/Ol/02 12:01 AM at insureds mailing address. 3. COVERAGE A. Workers' Compensation Insurance: Part Two of the policy applies to work to the Workers Compensation law of the states listed here. Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except Monopolistic State �nd states. D. This policy.includes these endorsements and schedules: Please see attached "Forms Schedule" 4. PREMIIJM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. PREMIUM BASIS CODE N0. CLASSIFICATIONS TOTAL ESTIMATED RATE PER 5100 ESTIMATED ANNUAL REMUNERATION OF REMUNERATION ANNUAL PREMIUM PLEA5E SEE ATTACHED "SCHEDiTI,E" Minimum Premium$ 219 Total Estimated Annual Premium$ 70,671 Massachusetts D.I.A. A ess ent $ � 3,994 Name Of PIOduCeT Members N�rst Insurance Brokers Countersigned by: ` �,..1 _ ;�m.� Servicing Office Date: � (� �� Four Standish Road,Bridgewater,MA 02324 INSURED'S COPY �. " � LIST OF LOCATIONS tlant�c a Charter Policy #: WC19629A . . The Insured: Anthony'S Pier Four Inc. d/b/a Anthony's Pier Four Other workplaces not shown in Item 1: 1. Anthony'S Pier Four Inc. d/b/a Anthony'S Pier Four 140 Northern Avenue Boston, MA 02110 2. Hawthorne By The Sea 153 Humphrey Street Swampscott, MA 01907 3. Anthony'S Cummaquid Inn 22 Main Street Rte 6 Yarmouthport, MA 02675 4. Anthony'S Athanas Trustee 75 Atlantic Avenue Swampscott, MA 01907 5. Hawthorne By The Sea 95 Oxford Street Lynn, MA 01901 6. Anthony'S Pier Four Inc. Logan Airport Boston, MA Towx oF�Yax�ou� 1146 Route 28 South Yarmouth, MA 02664 508-398-2231 FAX: 508-398-2365 a,X transmittal to: 1�n (�c,��s�� fax: � �� i -- �� 132. 1 from: Yarmouth Health Department date: Saaan � �; 2�� Z. re: �-1�.�� 'ec�-��s pages, including cover sheet: S NOTES: � �i�.e�sG r�o1�e, l�� c�Ir� �� -��s � —t��.. �..�; � � � C�,�� e�� rn��fi � �r��1�.� : �l�t. Y`t��-fi 1�-�, S i � �� . � � �� - G�� . �� - ��,� � n ��-, �c � JRN 10 200� 10: 18RM HP LRSERJET 3200 p. l , � � i , 294 Sa1em Strest � Swampscott,MA,01907 � Phone: (781)595-5377 � Fax: (781)598-932I ax ��2 _ . �.�! ��sa� Fa�c: � 3g'cF-4�� Pages: (including Cover Sheet) � Phone: ��/- 3��s"�7? Date: / /a o Z- Re• CC: � Confidentiality Notfce: This page and any accompanying documents aze confidential and protected by law. If yau are not the recipient stated above,please destroy any pages you may receive and contact the sender at the phone number listed above. Your cooperaxion is greatly appreciated. . Comments• ��ff�o .�s �"�a"' . ��.� a�0 �c �v��•C.5` , �vl�..��- �c��J��- �J�.� c.�/��.c�s' �sv�-.r�� (�? .e�.� ' d��c9cl,� -�� ""�r�S ..�5 �d T �l��> c�J� �� . �� y��. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-003 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv's Cummaquid Inn, Inc. at 2 Route 6A. Yarmouth.�ort,MA in said Town of Yarmouth And at that place only and expires December thirty-first,2002 unless sooner suspended or revoked for violation of the Iaws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thiriy-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testnnony Whereof,the undersigned have hereunto affixed their official signatures,this Twenty-seventh day of Februarv A.D. 2002. BOARD OF HEALTH: r��. ZeP�'s� ' ��D. C�o�rdo.i. .�iee ,�a�eZt� �7au�c, L� �a#iel¢�t�e�itcat� � '$ �� ruce G. Murphy, , .S., CHO Director of Health TOWN OF YARMOiJTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-062 FEE: $150.00 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 ta Anthonv's , mma��i inn, Inc",� RoLte 6A,YarmoLthr rt, MA Whose place of business is: Anthonv's Cummaquid Inn. Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2002 BOARD OF HEALTH: �� r��. Ze�e�c, ��ur�c SEATING: 400 �fQolt�s�D. C��, 7?�D., �/� ` �o�rt� �'zau�n, elerk �a�rick�e2onot� �� s�, �� Februa,rY Z'7 ,2002 " Bruce G.Murphy, ,R.S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-045 FEE: �50.00 This is to Certify that Anthony's Cummaquid Inn Inc _ 2 Ro � e 6A, YarmoL h�or, 1`�A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��a�e¢�f, �e��, L�ca.� SEA'rnvG:400 �1a�.c?}, Gi°�cd°.�, yjL.D., `1/iee ,�c�ct? �, L?f�ark �a�rie��7,1PcD�rotL� �� S ��l. February 27 ,2002 Bruce G. Mu hy, , R.S.,CHO Director of Health � — —_ —�,..� _,,,..,a.,.. r fiLO�/0,� �1-/0-#� 800--1 D� �.:: '1d�C! W1ld�W � ° ` � � }'�, r* j{�' N � �� Ot�t � v �R�� k�g � �� ... . . . � w. r a "' r's, "�,� �`;�;`°:.� � �IAQ3l � �1 �1 � � M �v � �� f� i i�%�A�A�G"Ci' I TOWN OF YARMpUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O 1-120 FEE: $150.00 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: - Anthonv'S C'ummaa �id Inn, In�,,,� R�(�q� r -o � }��, ��A Whose place of business is:_ Anthonv' Cummaauid Inn Inc Type of business:_ Food Service To operate a food establishment in: Town of Yannouth Permit expires:_December 31 2001 BOARD OF HEALTH: �d�Z �et�'ed, �lu�ufr� SEATnvG: 400 C�� l�i. �/iC� (�l�gt� �� March 7 ,2001 f� �� "�' ruce G. Murphy, MP .S, ��O Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #01-008 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthonv's Cummaquid Inn Inc at 2 Route 6A Yarmouthnort. MA in said Town of Yarmouth 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 Seventh day of March A.D. 2001. BOARD OF HEALTH: �d'I� �¢�., C�ia� �iarr�ed �f, i�el�. �f/�ce (�,`iaur�,c� �o�i�� r4�vo�. (� %��iC�s�e� � �.� � . .�. � ruce G. Murphy,MP ,R. ,CHO Director of Health s � '� � � � � O . �� " A v � � o � �,� •" � o•� o i �e� . � N V,� 0 � � �`� � � a � � �n � � 'v� W .��„� � � `� .��'� E-� � �.'" � .� °� .(�p� � �� 3 .. � W � � �„� `G C�`�C�� z � � � °' '� � � � � U ti W � �� • � � � H ~ ¢a Q� � � ; � � ° � A� � � „ .��.�o � �a o-�� H � � � zW �, � �� o � � �a � 3 � �? � �¢ a ��•� �, �, w � �� . x x �, � �, ,,a�..,,� „ �,, aa �� U d � � �aU a°,o � � � O 3 � � �5 � o�a � � 3 o �Z a'� � ZQ ,� � �o:�� " O OH � �.�H � .� aa � � � � � � � � �t p b�°�� V �� c�� U � �o � � � W � � �.�•.r 'r x o � >•� o � � � �' o� � W '� ��° � °' � � �G r� O,� O � � N ✓ � � � U•� � ^ V � �"° a�i ° c � o H � �� ' � � � ,� },,,�;- •N � � � �N �� ,.,, v� p N �.+ f'' � � a � .� �,� ° � � ? ; '1 1Tr�'1�1 i�J�; �.l 4VYlYY1C"iGI�iLl �r`l l') ' [� c, �-G: r"' R �:;:r �� TOWN OF YARMOU�H BQARD OF HEALTH ' � APPLICATION FOR LICENSE/PERMIT-2000 0 E� � 7 �9g9 C,Iz��R77 �Z6�°-- , * Please complete form and attach all necessary documents by December 31, 1999. Fa F '� in the return of your application packet. -------------------------------------------------------------------------------------------------------------------------------------------------• T�A� OF ESTABLISHIVIE�TT: Anthonv' s Cummaquid Inn, Inc. TEL # 508 362 4501 LOCATION ADDRESSJ 2 Rt 6A 1VIAILINGADDRESS: 299 SAlem St. Swampscott;�I��1�3(S7— OWNER/CORPORATION NAME: Anthony' s Cumma�uid Inn, Inc. MANAGER'SNAME: Robert Athanas TEL # 781-595-5377 MAII.,ING ADDRESS: 2 9 9 S a 1 em S t r e e t Swampscott,MA 01907 � -- -------------------------------• POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as reqaired by new State law. Please list the designated Pool Operator(s) and attaeh 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 usc past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMI,ICH 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 c�rtifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. 1 Catherine McKeon 2 3. 4. RESTAURANT SEATING: TO�'AL#400 NON-SMOKING SEAT�;TOTAL# 2?5 - - ------------------------------------------------------------------------------------------------------------------------------------- -----------• OFFICE U�E QNLY LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 i rr�v $so yZK-8 caNrn $so LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlVIlVIIIVG POOL $50ea. WI�LPOOL $25ea. FOOD SERVICF" — LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# ,0-100 SEATS $75 CONTINENTAL $30 � � >104 SEATS_ _ _ $1� ��K- �(¢---___ _ — �I�AT-�'�4�� —---_ $25 �COMMON VICT. $50 Y2 t�-y� _WHOLESALE $75 RETAIL SERVI E• LICENSE REQUIRED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 >25,000 sq.ft. $Z00 NAME CHANGE• $10 AMOUNT DUE = $_�J(J'�u9 "*"""PLEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM""•"� �� ADMINISTRATION � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOUTH IS NOW REQUIREB' TO H4LD ISSUEINCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR� CO�VIPANY 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 l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE(7F Y4UR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES xx NO lYQTICE: PERMITS RUDI AI�INUALLY FR41�I _J�LUARY _1_ TO DECEN�BER 31. IT IS_ YOUR _ - RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIVV�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR'THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COIVIMENCEN�NT. RENOVATIONS MAY REQUIItE A SITE PLAN. �1DDITIONAL REGULATIONS PO�LS POOL OPENING: ALL SVVIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTN�NT, AND T�-iE WATER TESTED FOR PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE C4UNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlv1IlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(?)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN T'HE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQITIRED 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 RES�JLTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN TI-� SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERNIIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),�,Z�T HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. QUTDOOR COOKING� OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLIS�-IlVIENT IS PRUHIBITED. DATE: 11/17/9 9 SIGNATURE: �. PRINT NAME& TITLE: Robert Athanas, Manager 11/12/99 � '�"� ::':::::::::::::i::::;;::::2:::;:;::;;;;:::::::::::::::::::i:::';%:;`::;:::::::::::;:i;:::;::::;::::::.'::3�::::2::::':`::';::::;:::;:::;::::;::::;::::::;::::::::::::::::::::';:::::::::;:::::;::::;::::;::;::>;::::::::::::::;::::::;::;::::;::::::;::::::::::;:::::::;:'::;::?:::::::':::i::::�;::�:;:::::;:::;�'::?:':::: i::;::::::;::ISSU:;::;:;::;:::;::::: ':�'�;:::::::c::::':.::::::::'::.:::;�;:.:i.:: i>: \ E DATE(MM/DD/YY) �::::a �� ::::::: : : : : :: : : : :::: : :::: : : : :: :::: ::: : :: :::::::::: : ::::: ::: : ::: : : .:: �.�� :.::.��:��'��-� .��:.t.�� :::.::: ::.:::::::::::.::.:.::::.:: :: �::>::............. :;::::::>::>::>::>::>::>::»>::>::>:;::::«<:::»::::>::<;;:<::>::::>::>::>::>::>::>::>::::>::»::>::»>:::::>::::>::»::>::>::>::»::»::»>::>::»::>::>::>::>::>::>::>::>::»::>:::<::»>::>::>:<:::»::><:::::::<::<::>::>::>::>::>::>::>::;:::>::>::>::>:::;:::>::»:<::>:>::.>::>::»>:::<:>::><::: 11 /9/99 PRODUCER�::•::•....................................................................................................... ... .... . . .. .. .. :: : �: :: :: :: .::.::.:::::: : ::: ...THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE David J. Anderson DBA POLICIES BELOW. Members First Insurance Brokers, Inc. COMPANIES AFFORDING COVERAGE � Standish Road — Bridgewater, MA 02324 COMPANY �R p` Atlantic Charter Insurance Company COMPANY B INSURED LETTER COMPANY Anthony's Pier Four Inc. dba �rreR C Anthony's Pier Four COMPANY p 299 Salem Street �rreR SWB.TIIrJSCOt�� MA O�9O7 COMPANY E LETTER �.�i'`��Qf�.�;:::;::i:::::::i:::::iii;;i:ii;:::i::;::;`:`::;::::;::%[::i::::;::;::::;:?;EEE;EE;:i:::iiE;E:E:;::::::;EEEEEEEE;;;E:;EE;E::#i?;fE:?;�<E;:`i:::;':EEEEE;E:EEE:EE:;:Eii;;�::::>:;:::?:::;:i;:<:>Eiii::i;E::EE<:::::E:;::::::;::::;::;:::;::ii::ii::>;::::;::::::::::;i::;EiE<ii:i::?EE:E:::EEEEEE;::E`:;:iis;i?i::::;::::::;:::?;:::::;:i:ii:;::;::::;?i;::::;::;::EE;::;:::iii;:ii:;EEEEEE;E;:i;EEEE::;:;:i:::;:::`E::;i;:;i:;EEE:::: :•::::::::::•::::.�::::::::::::::::::.:::::::::::•::::::::.�::::.:�:;>;::;;;::;:�:�;:�>;:;:o;;>r,;r,;r:o-::�>:............... .. . .. .......................... ... ......................::::::�>o->o->o->::;:::o::;:::>::>:�s:a;>:a:::<:»:::::::;o-:::::::.:::::::::�>:�:SS;;:::;5:4;5::�::�::;;;:"L:�1:=:?i:?i�::i':i:;;:x:k::::�i�ii:;;:i:;'.;;;ii;.;`:i"i;;;�'i;': THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TypE OF INSURANCE POLICY NUMBER P�LICY EFFECTIVE POLICY IXPIRATION �TR DATE(MM/DD/YY) DATE(MM/DO/YY) UMITS (3ENERALLJABILITV GENERALAGGREGATE $ COMMERCIAL GENERAL UABILJTY PRODUCTS-COMP/0P AGG. $ CLAIMS MADE�OCCUR. PERSONAL 8 ADV.INJUFY $ OWNER'S 8�CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.IXPENSE(Myoneperson) $ AUTOMOBILE LWBiLITY COMBINED SINGLE ANY AUTO LIMIT $ ALL OWNED'AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-0WNED AUTOS (Per accident) GARAGE LIABILITY PROPERTY DAMAGE $ IXCESS LJABILITY EACH OCCURRENCE $ UMBRELLAFOFM AGGREGATE $ OTHERTHAN UMBRELLAFORM WORKER'S COMPENSATION STATUTORY LIMITS X AND WC0513�+A 8/1/99 c��Q �CH ACC�DENT $ ��U� EMPLOYERS'LIABILJTY DISEASE—POUCY LIMIT $ O�O DISEASE—EACH EMPLOYEE $ � OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS .�::.p::..:�..:.:C:,::::::��:{.,+..�..,.::.��,.;..:.::::.:..:;::::.�::::;:i:::::;:;i::i:iEEi?;ii:i:ii:::i::::tEEEEi::i:i:;:i::i::;;:;::::::iEEEEi;:::::::i::;i`:;;?;:;::;::::::::rii:iii:::::::;::::;:i::%':"::,::.::.;�:.,.:;:i`::�..:':":`�:�::�i;::;:::::::iEEiEEEi;i:i::ii;:i:i:?ii::i:::::::::3:;i:;::;?:::::::E::i$i:::::::i::i::i::;?:;i:::::::::;E:it:::i:;i:;;i:i:::::i::;;::;;:::;::::::::::::;;::::::::;:::::::::::;:;::i::i::: ....�¢i.r;F'.,�„{T.4r�-'r..'� . . ...::..:...............::....... : .. . ................:.........:::::::::::::::::::.�:::::::............................::::.:::::.�.�::::::::::::::.::::::::::::. ..................................��3:E�::::::::.�::::::.;;;:.;>;>;;:.;;::,:;::;;;....:.:.:.:..................................�i� L�# ......................................................: ..................................................................... ......................_...::::.:::::,:,,::.:.:::::::::.....:..........................:.:.:.�:::::::::::::................................�.......'€�N:.::::::::::::..........................................::::::::::.:::..................................... _............;;:.:.........._..,,,..::::.:::::::::,:,:,,,,,:::::::,:,,,::::,,,,,:.::.::,,,::,.....;:«<._<:;;;�:.;�::.;�.:.:.:«<.:,.>�;..:«<;:.<;.,.;�,.«;«.:.:.:.;.:..::.;_.>:<,<:,<>:,<::<:,«::::.::;;:.:: : SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWI1 Of' Ya.Y'TIIOUtrl '•� IXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO P.O. BOX 1150 ' MAi� �� DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE South Yarmouth, MA 02664 � �e�, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY ND UPON THE COMP , ITS AGENTS OR REPRESENTATIVES. :::>:i AUTHORIZED REPRE ATIVE Attn: Licensing Dept. :A��:,::::,_::.�:,,::.:.,,.:,,.;:: <:::>:�>::<:>:<:�::«:;::::::::>:<::<�;::`:<;<::;::::::::>::::::<:::;:<:>>::::««;«:::::::>:<:<:;`;:>>:::>::::::>::::::>::::::>:<::::::>;::><:<'::::>::::>::>�::::<:::::>;;:::::;;>:<:>::::::>::>:»::::>::::>::::::>::::::>::;�:;�:::::::::::::>::::>::>::::::::>::»::::>::::>::::::>:::::::.:::,;..::;:::::::>:::<;::::; .::;;:.,.,.;-;:::;;..:.;.;:>: ..:. ��.5.€�''1� . ........ .>. .::: ;: . ...:.;;:.;:.;:.;::.;.::.:.;::::.::.;:.;>:.:.:.;.;:.:::.;::.;.;:.::.:;;..::>::>::>::>::>::>::>::�.::,::;:;:;:::>::;::>::>::>:<:>::::::.;:.;:.;:.;:.�:��Cit�::�O�P�##R�Tl�RN.��4. . � � The Commonwevlth ojMassachusetts • � � Department ojlndustrial,-�ccidents T o Ofllce ol/evestlpstliis 600 Washington Street ' ` Bosron, �lass. 02111 w,, �,�' W'orkers' Compensation Insurance Atfidavit Aoniicant intormation• p►��epR��,-�,�,,r n;,m� Anthony' s Cummaqu��lt': Inn, Inc. Is�cation: 2 Rt 6A �� Yarmouthport ,MA ohonea�08-362 450� � I am a homeowner perr�rmin,all w�ork myself. � I am a sole proprieror �:-� ha�e no one ��orking in am•capacin� (��I am an emplo�er pro��din� w�orkers' compensation for my employ�ees w�orking on this job. comoanv �ame: AnthOny' S Cummaquid Inn,Inc. �dress: 2 Rt 6A �;t�•: Yarmouthport,MA nhonetl• insurance co. AtlantiC Charter Ins. Co. p�Y#WC 05134A � I am a sole proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ �corker_ �ompensation polices: sQmoanv name• address• �-�'� ohone#• insur�ncc co. Aolic�•# comoanv name: �ddresr �'� ohoee�• insurance co. nofieX�E t Faiiure to seeure coverage as requlred uader Secaoo 25A of MGL!S2 ea�iad to the ioposidoa of eriviad peadtle�of a 6�e op to Sl¢00.00 a�d/or one yean' imprisonment a�w�ell aa civii penaidt�io the form of a STOP WORK ORDER aed a Ifne of S100A0 a day apio�t ma I a�dersta�d tbat a copy of thy statement mav be fonv�rded to the OI'Iice of Investig�tioo�of tbe DIA for eovera;e veritfatio�. /do hrreby cerri •under tbe pnins ,id pertal�ies o qitqt that!ht injormation provid�d abovt is tntt atd eor►�ei S�gnacure �--� 11/15/9 9 Print name gobe�t Athanas Mana�er Phonek 508-362 4501 .. o(Ticia! use onl. do not..�ite in this�rea to be completed by ciry o�town oAleial city or town: Y�MDIITQ _ permttAiten�t p n8uildiog Department pLieeasiog Board �check if immediate response i�required 261 �Selectmen'�ORtt �Heait6 Department contact person: phoneq;_ �508) 398-�2231 ext. nOther .. < .,,,. � �� Y�� 'I' O �TN OF YAR �VIOUTH � o � �-�-� � y i � Fr, iz<�� rE-: �� i-�rri�_�Ei��c�t��rr�f ��T��ss:�ct�t tiF:�-rs u?r,�,�t-�,�t�i �MATTACMEES � _ ,��"`OAooa.no�e'"� Telcphcmr (�0�� i9�-�Zil. EsL1�1 Fas (�O�i) ;9�-��6> B O A R D O F H E A L T H To: Anthony's Cummaquid Inn 2 Route 6A Yarmouthport, MA 02675 " �� From: Mary Alice Florio, Principal Department Assistant + i �,,U '-` Yarmouth Health Department (,�(,l�' /- Date: December 15, 1999 Re: Year 2000 Renewal Application Thank you submitting check #6977 in the amount of$250.00 to cover the fees for your year 2000 permits issued through the Health Department. However, we are unable to process your inn, food service and common victualler permits since we have not received your completed application,proof of worker's compensation coverage and Heimlich certifications. For your convenience, I am enclosing another application for your completion. Please fill out both sides of the application, and return it with the completed worker's compensation affidavit (or a certificate of insurance from your insurance agency) and Heimlich certifications to the Health Department. Once our office receives this information,we will be able to issue the inn, food service and common victualler permits to you. Thank you for your anticipated cooperation in this matter. /maf enc. cc: Anthony's, 299 Salem Street, Swampscott, MA 01907 file � Printed on ( Recycled � S Paper , THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH PERMIT NUMBER: Y2K-8 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Anthony's Cummaquid Inn, Inc. at 2 Route 6A. Yarmouthport. 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, 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-seventh da of December A.D. 19 99 . BDARD�F HEE�I.TH: �c�� ,�e�e6� C.�i,airman �oan� �ulliva�c� K.I'/.� Vice C,hairma�z Ko�ert� �rown� (,ler� a�riella�a�ol.��y-J�tooPe� • ��0' ��,� - ruce G.Murphy,MPH, ., C Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-86 FEE: $150.00 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: Anthon�s C'umman�id inn, inc_, 2 R�Lte 6A, Yarmo � h,n�rt, MA Whose place of business is: Anth n 's Cumm i In Type of business:_ Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �el��, C'�t�,r►a,� SEATING: 400 . �oan C�. �ullivary �� Vice l��irma KoberE.}. p�rown� C,lerh abrielle�ahol�hc�-Jdoo d ic � u��lin December 27 , 1929 ruce G.Murphy, MP .S. HO Director of Health , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-46 FEE: $50.00 This is to Certify that Anthony's Cummaquid Inn Inc Ro � 6A, Yarm�Lth o}�,rt, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE 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 common victualler's. This license is issued in conformity vv�th the authonty granted to the licensing authorities by General Laws, Chapter 140; and amendments thereto. In Testimony Whereof,the undersigned have hereunto �xed their official signatures. BOARD OF HEALTH: �c�� `�ette�, C'�iairman SEATING:400 oah� �ul[ivan, �i'/., �ice (..�zai�man obert� �row�x� �lerh a�rielle�akol�kr�-..J�too�oes ' hael O� ou [in December 27 , 19 99 ruce G.Murphy, MP , . ., CHO Director of Health