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Home My WebLink AboutApplications, WC and Licenses � � � ► TOWN OF YARMOUTH BOARD`a��. : � C �� ' "�' '�� 'p� � � APPLICATION FOR LICENSE/PEI�;�i�. � � D�(; � �0 0 8 � p,,-.. � �� * Please complete form and attach all necessary documents by Dece er 8 Failure to do so will result in the return of your application pack . T� ��'�y� NAME OF ESTABLISHMENT: / �3 �a—�. TEL. #�'�'��a-�66� LOCATION ADDRESS: �-� �Cs �--�-�-*-`�-+�" r'- �� " `�` 2-� � MAILING ADDRESS: -�M-�- OWNER NAME: � �--�v�- �cr� ' TAX ID (FEIN or SSN): ^( �,�" CORFORATION NAME (IF APPLICABLE}: MANAGER'S NAME: 5��--v�� TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisar must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. 1. 2. Pool operators must list a minimum of two employees cun ently 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 requued to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary CodE for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wil(not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chaxge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one einployee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' 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 REQL�IRED FEE PER.MIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT� �B&B S55 #4�1'D0 _CABIN �55 _MOTEL �55 II�Ir1 S5� _CAMP S5� _SWIMMINGPOOL S80ea. LODGE S55 ,TRAILERPARK �105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS S8� �� _CONTINENTAL S35 NON-PROFTT �30 >100 SEATS S160 �COMMON VIC. $64 4 —��07 WHOLESALE $80 RETAIL SER��ICE: --RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIKED FEE PERMIT# <50 sq.ii. 550 _>25,000 sq.ft. $225 VENDING-FOOD �25 <25,000 sq.ft.. S80 _FROZEN DESSERT $40 TOBACCO ��5 �a�zE c��rcE: sio AMOUNT DUE _ ��(� **'�*"PLEASE TLTR`OVER A\TD CO'VIPLETE OTHER SIDE OF FO1L�'I*"*** _ � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED 5TATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall genera.11y be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been mspected 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 rnust be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY• Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departmern by filing the required Tempora.ry Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETCJRN TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. _.. DATE: ��`?�D t� SIGNATURE: ,, �,,� PRINT NAME&TITL : �� b�i �I Q lJ/(/(� ..- io,�zvos �'\ The Commonwealth of Massachusetts Department of Industria!Accidents N�NIfb��f 600 Washington Street, f�'Ftoor Boston,Mass. 021I1 Workers'Compensation Iasaraace A�davit:Bailding/Plambing/Electrical Contractors A�Haurt ir��srenitie�: P"kaae 1'RINT kgilrl�r IIaIIIC. �yJ'�, • V�>I I�.�r /V v (�`� � . . address• 7-`�b � �/' ci � �'"� `'`�/ � state. �� zi :� �� hone `�v� -��`- b�b� work site ocation(full address): 0 I am a homeowner performing all work myself. Project Type: ❑New Construction�Remodel Q�.e�i a sole proprietor and have no one working in any capacity. ❑Building Addition v ❑ I am an employer providing workers'compensation f�my employees wo�icing on this job. comwmv aame- address: ciri- uhoae#• ius ca # .. .��. . . �'. , . .: .:::. . �- , s '," . , � :��zi s ,c .,:. . . ,°':� �A ��k 3P ,.'.4'�i-+aF�;..Yr'd.ra4 .:. :-.. . . . :. ,. s...:.. ..,:, � .,'.: Q I am a sole proprietor,geaerai coatraetor,or Lomeowner(circle one)and have hired tbe contract�s listsd below wh�have the following workers'compensation polices: cemwav aaate: addrsas:. city: nbont#: insanrece co. # � _ � - . . ..� „ comnaav'ante: addras: citv nko,e#` ca # . . . �F� . . .. . , . C� . . "` -.;F .�zr-, . . _ : .,., . .,. , � ... . . , . .. ., .�`-:. ., .. FaBare bo secare aevenge as req�rod�edv Seclba 2SA ef MGL 152 cu Idd b the�Y ef cri�isal pa�aNks of a�e q�b;1,3M.As and/er ox yeara'imptisenme�aa wr�as elvi peealdes la the form At a 3TOr WORK ORDER aed a 8ne at 5109.65 a day agatust me. i aedersta'd t�at a cepy of fhis�at�eat my 6e fonrarded�a tAe O�ce oi lave�tleas of t�e DIA tar ceverage vermaUUo'. I do ytreby certify rtnder NYe paties and pexaltces of pery'ury t/�at the frfor�naefoa proeided eborie Es bzre and rnrrecx s��,��Q na� /��-/o �' �-�`�' '`� �0�.✓�� Phone# J �/� � ��" �� co �� Print nante � . o�clal eae onty do not wtite�m this area to be co�pleted by cily or tewa afficial cNy ar ta�ru: per�e# �� Board ❑chedc if i�me�ale n�spame is reqaired �'s�K QHnitk Depardeent coatad persoa: phene!�; (]Ot4er (avieed Sryt-20IX1) . . . . � . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #09-008 FEE: �55.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Claire Gonet d/b%a Capt Bearse House at 450 Route 6A Yarmouthport MA in said Town of Yarmouth And at that place only and expires December thirty-first,2009 iuiless sooner suspended or revoked for violation of the laws of the Conunon�vealth respectmg the licensing of umholders. This license is issued in conformirv with the authority granted to the licensing authorities Uy General Laws,Chapter 140,and amendments therero and is subject to sections twent��-t�vo to xhim�-tu�o> inclusive> and of said chapter and sections twenty-fice to twent��- seven,inclusi�e,ofChapter 272. In Testimonr'Whereof,the undersigned ha��e heretuito affixed their official signatures,this Thirtti�-first dav of December A.D. 2008. BOARD OF HEALTH: ��EEe¢tL S��t� ✓�..N., C�,UlxtttYft RESTRICTION: Fust Yloor-1 room �aPtt�1lf�C0 .`�. .��PX,� �,,iCe ��%1ltlZp�ft Second tloor: 2 rooms .�ll�� . �KQl�(fK� �:CRXR Q,ruz C�rr�Ecuchz, J2..N. �. Bruce G.Murphy, .S.,CHO Director of Health _ _ _ __ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMEl�TT PERMIT NUMBER: #09-095 FEE: 585.00 In accordance with regulations pronnilgated under authorit��of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a perniit is herebv granted to: Claire Gonet, 450 Route 6A, Yarmouthport, MA Whose place of business is: Capt Bearse House Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2009 BOARD OF HEALTH: ��eeert S/�acf�, ✓2..�., �'f�avcrruut C'N�i�c�Q��e��a .�. 9G�`eiR�ex��eee C'ftcr.i�cnurn RESIRICTION:1Seals Yor euests onl}�. ��E.t7�(�Jl� �. �KO�U�iL� �/ �� .✓Y. December 31 ?OQ8 , ru . Murphy,MP ,R ., HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-067 FEE: S60.00 This is to Certify that Claire Gonet d/b/a Capt. Bearse House 450 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 victuallers. This license is issued in conformity with the authonty granted to the licensuig authorities by General Laws, Chaptex 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto ai£�ced their official signatures. BOARD OF HEALTH: ��Ee�.ert S�, `J�.JV., �'�aix�n�cut REsrRIclTo.lt�: Guests only. ��t�4X(,�i �ICE ��p.NLtttlY/t 'CR>lR �� ✓`Z..N. December 31,2008 Bruce G.Murphy,MPH,R.S.,CHO Director of Health r � ' a E �Jt.Y�� TOWN OF YARMOUTH BOARD 4�:�EA��H �� '�� C� [� � b � � �� _ APPLICATION FOR LICENSE/PERMTi'-&��0'S „ � r r �F�? G 1i N_ ..'1 �E l, 1 7 2��T * Plea,se complete form and attach all necessary dacuments by Dece b ��Q2H D E PT. Failure to do so will result in the return of your application pack . � NAME OF ESTABLISHMENT: /�2iU ��i9�� ` TEL. #,��'.�Z-�4�' LOCATION ADDRESS: �v`�d �- �-� y1�L� t�Z�� MAILING ADDRESS: 1' OWNER NAM�: � • , D��T� TAX ID (FEIN or SSN)• CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��e �a- TEL. # MAILING ADDRESS: �_— POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. ��,� � � 2. (��/ Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of eniployee certifieations to th�s form. The Health Depart�ent will not use past yea�s' reeo�ds. 3�'oa must provide ne�� copies and maintain a file at yot�r place of business. 1• 2. 3. 4. �,�.�..��..,.��„�.��, �� FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies Qf certification to this application. The Health Departrnent�vitl not use p�st ye�rs'records. You must provide new copies and maintain a file at your establishment. 1. (�a�//'� �/Ll�� 2. �P�R�SJI�T.�1�I�1�R�E:__ _ _ _, ____ --__ __ _- _ ___ _:._-- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. (�"�a�/�� =��/'�T 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking proce�ures 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. i. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE OhLY LQDGING: LICENSE REQUIRED FEE PER1v11T# LICENSE REQL'iRED FEE PER'1rIlT# LICENSE REQL'IRED FEE PER'�fIT= / B&B SSO �o�-oa� _CABIN S50 _MOTEL S50 _1NN �50 _CAi1�P S�0 �S�VI'�LVIPVG POOL 575ea. _LODGE $SQ _TRAILERPARK S100 _V67-IIRLpOOL S75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# I,ICENSE REQL?IRED FEE P£I�AiIT* LICENSE REQti IRED FEE PERVIIT= � 0-]00 SEATS S75 "�OS O� _GONTINENTAL S30 NOIv'-PROFIT �25 _>100 SEATS S150 / C0�4L'�ION VIC S50 O° _��IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMTI# LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PER�IIT- _<50 sq.ft. �45 T>?5.000 sq.ft. 5200 VENDING-FOOD S20 _<25,000 sq.ft. 575 _FROZEN DESSERT S35 _TOBACCO SSO �va.�c�►vcE: sio AMOUNT DUE _ $ /7S. 00 ***«'PLEASE TL'R\OVER A\'D C0�IPLETE OTHER SIDE OF FOR�1****� � s ' ADMINISTRATION Under Chapter 152, Section 25C, Subsecrion 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, QR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �s �/ rro MOTELS AND OTHER L4DGING 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 us�. Transient occupants must have and be able to demonstrate thax they maintain a principal pla.ce of residence etsewhere. 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 this application. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required 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 ta the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit umil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: putdoc3�e�ok�ng,�epa�ation,or display of any food product by a retail or fooc��ervieeestablishme�is�rohibited. NOTICE:Permits 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, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIVIEENT', MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEME�iT. RENOVATIO�tS MAY REQUIRE A SITE PLAN. DATE: I��D �" SIGNATURE: PRINT NAME&T E: �g ��J'� ��>�� lt�30 0? 1 R . � The Commonwealth o Massachusetts � Department of Industrial AccidenLs � �� 60(/ Washington Stree� f"'Floor Boston,Mas� 02111 Workers'Compeesation I�araace Affidavit:Bailding/Plambiag/Elech-ical Coatractors lf�: �p�i�'� � t name: �l�/�_t� �17/� "� ��7/� �LS�s'�� l,L�� address: T(� 1L--� �{j Ct' �itv /`r/�-+��.�1ZL��jj� state• �D'[�t�- zin•�G�(o /J ohone# ��' `'a� '-� � work site location(fnll�ldressl: � � (o,�"i �/%��tC f�� /� �� ❑ J�n a homeowner performing all work myseif. Project Type: New Caistruction�Remodel (�am a sole proprietor and have no one working in aziy capacity. ❑Building Addition ❑ I am an employer providing wozkers'compensation f�my employees wo�Ccing on this job. I eamuanv�me: _ - - _ _ _ _ _.___ _ ._--- _ addreas- citv: ul�e#• . .. '.�.: :�.. :'. ... .. �.-� -e._t< :.=..: , , i- . - , uifA 46 .,��Pi'�rmd_ „ � I am a sole praprietor;geaeral coatraetor,or�omeowaer(circle awe}and have lrired the contractors listed below who have the following workets'c�mpensation polices: coe��a.v�ne; �ldress: citv : �#. ies co. # �: S�Y: oke�e#. - - - -- -- --� _ — _ ---------_ _ — -- # —— —_ ___ _ _ _ FaBare M aecarc aereraae��atder Sectlsa 1SA ef MGL 152 cu le�d b IYe t�p�a ef ardial pnaNia�a��p b SI,SM.M a�dl�r, oae yein'imprboament as we8 as civi pemities in t6e Lra of a 3T0!WORK ORDER aed a 8ne af 5100.YS a day�t�e. 1 aedentand tlut a cepy ot tYia�temnt may be fonvardM 10 the O�ce of lav�qaffi af t6e D!A tor esverage verfAntba I ro he►�eby cerfijy ander lire pains oied pexalties of perJrny tbat Nie infor�nalloe prouided abo►+e is b�e and oornct signature Dan ��-,/3T�D-7� Print name __ � � c.�/�.��l Phone# (>C� ��,Z. — o�-;� � e�cial nse only do not wrke ia this arn to be csmPk�M bY dtY er Eswn a�cial city ar to�vn: pern�ifAicense# OBaid�Depariment ❑cheek if immediah respenx is nqaircd ❑Sdectmea s Offioe ,�at,et p�s�: p�� O�Im nqnr�est c�s�.ma+� �tha' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-007 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Claire M. Gonet d/b/a Captain Bearse House at__ 450 Route 6A. Yarmouthport.MA in said Town of Yarmouth And at that place only and expires December thirty-first,2Q08 unless sooner suspended or revoked for violation of the laws of the Commonwealth respechng the licensing of innholders. This license is issued in conformity with the authority granted to the licensing suthorities by General Laws,Chapter 140,and amendments thereto and is subject to secrions twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereo�the undersigned have hereunto affixed their official signatures,this Twenty-eig,hth day of December A.D_ 2007. BOARD OF HEALTH: `.�ee¢rtt S�af�, ✓�..N.� C�R�cv�rt.A.rt RESTRICTION: First floor-1 room �a�E6 .`�. `.��,� ��ICC��Lllft Second floor. 2 rooms :I��O�'QIY��L(!tG►IZ� �:C�ll� � �ltit l�f�Qeit�'lI[.lftt� �.,.lV. Bruce G.Murphy,MP .,CHO Director of Health _ _ _ _ TOWN OF YARMOUTA BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NLTMBER: #08-057 FEE: $75.00 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Claire M. Gonet, 450 Route 6A, Yarmouthport, MA Whose place of business is: Captain Bea.rse House Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 $oARD oF HEALTH: .�fe�eit SR�a�t J`�..Ar., C'R�aiXnsan C'f��_a�yc�P�e�`�o 3�.J�e�P.�i�e�cC�iee C'ffaixr�tart RESTRICITON:Meals for guests only, u�lusu�3��.��/AtUtL� � Clrtn C�eert�acettt, fl�..N. December 28_2007 ruce G.Murp , ,R.S.,CHO Director of Hea a , � ' � THE COMMONWEALTH OF MASSACHUSETT� �owzv o��au�oirrx PERMIT NIJMBER: #08-057 FEE: $50.00 This is to Certify that Claire M. Gonet d/b/a Captain Bearse House 450 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 violation of the laws of the Common�vealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty 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: �'�e�eri Sf�acf�, `J�..11r, C'Hcavattan xEsrx�cTTOJrr: Guests on1y. C'Ffa�c� .�.J'�e�i�e�c `�Iice C.'R�avcnuut �3.:�3�u�cr�n, C'�exP� �ce� , J�Z..N. December 28.2007 � ruce G.Murphy, , .5.,CHO Director of Health s �� o TOWN OF YARMOUTH � - � � � +`"'j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 � MATTACMEES � Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 � h��9VORATt��6j9� 'U B O A R D O F H E A L T H �, ;, G� � .�` ' - �� .� To: 2007 Yarmouth Board of HeaIth License/Permit Holder J�I� � 3� 2U07 From: Yarm�uth Health Department ��-i � `��• Re: T�Identification Numbers Date: 7une 14, 2007 The Massachusetts Department of Revenue requires that the Health Department furnish to them detailed infor�nation regarding all permits and licenses that we issue. One of the required details is to provide a t� identification number, whether it be an establishment's Federal Employer Identification Number(FEIl�or, in the case of an individual's license, a Social Security Number (SSN). This information will be used by the Health Department purely for administrative purposes only. Since you did not enter this information on your business application, would you please fill out the information below and return this letter as soon as possible to: Yarmouth Health Department 114f}Route 28 South Yarmouth, MA 02654 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to catl. The office hours are Monday to Friday, 8:30 a:m. to 4:30 p.m. The telephone number is(508) 398-2231, e�. 241. Establishment: Captain Bea.rse House FEIN or SSN: ��'� �� -� Lacation Address: 450 Route 6A, Yarmouthport, MA 02675 Signature: Print: ��d� j f�[�-�?�i�'I��- Title: ��-�� Printed on ( Recycled � y Paper � � ^ �*� aF�qR y �j � �. , 2 �. � TOWN OF YARMOUTH BOARD OF H -�� a � � � od � D ' �: ;� APPLICATION FOR LICENSE/P '��,�� "��b�' JUN 1 2 2007 * Please complete form and attach a11 necessary dpc�rrie�s by December 1, 2006. Failure to do so will result in the return ofy�iur application packet HEALTh� �EPT. NAME OF ESTABLISHIVIENT: �J'/1) ��i�1?.8� (,r�C� TEL. #S��<��/ LOCATION ADDRESS: �,SZ� �o� 6Yc!?` �- `�,� / MAILING ADDRESS: �a�- /,',m I OWNER NAME: U aa'r--� M- C�vN�� TAX ID t�'fi�I�d�r��1• E-c�t� ; � CORPORATION NAME (IF APPLICABLE): ', MANAGER'S Nt�ME: � lA�%�-c._ �1i1. o ti/� TEL. # 8'�- �-�.a-o� MAII.,ING ADDRESS: �Sa� �- 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, standa.rd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificaxions to this form. The Health Department will not use past years' records. You must provide new copies and m�intain a 61e at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Pratection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certifica.tion to this application. The Health Department wili not use p�st years'records. You must provide new copies and maintain a file at your establishmen� . ' 1. 2. G L..A-�-_2�. ��.��r PERSON IN CHARGE: Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of aperation. 1. 2. HEIMLICH CERT'IFICATIONS: 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 emplayees 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# O�FICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQtJIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# I B&B �54 CA$IN �50 _MOTEL $50 INN $50 CAMP $50 _SWIlVIIvIl2�TG POOL$75ea. _LODGE $50 _TRAII,ER PARK $100 WHIItLpOOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE pERMIT# LICENSE REQUII2ED FEE PERMI'I# / 0-100 SEATS $75 �D � � _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 / COMMON VIC. $50 �67-I10 _WHOLESALE $75 RETAIL SERVICE: ��..,�5'�" uw I —RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE RE�lU1RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,<50 sq.ft. $45 >25,OOd sq.ft. $200 _VENUING-FOOD $20 _45,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE _ $ f 7� pd :"`•"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM r�-�, l S ..... i�» �n�;�.� .., �,-v�T � � �� t ADMINISTRATION ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to aperate 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 tu�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATEL�IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS 'TRANSTENT 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 ha.ve 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 uMit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. PQULS 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 Department ta schedi.�e the inspection five(5�days pnor to openuig. POpL 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 Town of Yannouth must notify the�armouth Health Department by filing the required Temporary Foad 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 manthly 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 Boazd ofHealth. OUTDOOR CDOKING: Outdoor cooking,prepazation,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 RESPONSIBILITY TO RETLJRN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMEN'T. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � /v7 a SIGNATURE: PRINT NAME&T : � � f' t �- � 10/17/06 t i.. �a ' � The Commonwealth of Massachusetts Depart�ent of Industrial Accidents > N�.'INi�� 600 R'ashiRgton Stree� 7�"Floor Bostoa,Mass. 02111 -- workera'Com�sahoe I��aeee ABdavi�Bril b�/Elecd�icat Co■traetors _� _... ,.,.,� ��, _ �, ,n. :-�� ,:. �� -� � ;�� ,�� ,_, _ t�.. � _:.-.. 4 �, name: E_..-�t97�U ��s�� (.l�� address_ � �(�C..CJ � i � drz� : rt-- � _ 2� �362r �--�� work site locati�rfnu addressl- ❑ I a homeowc�perfomoing all wak myself. Project Type: ❑New C�uc�oo�Remodel am a sole 'etor and have no o�e w in any ca ❑B ' ' Addition ❑ I am an employer providing w�kers�campensacion faz my e,mpioy�s working ar►rhis job. �• �� d�+�; ��z ❑ I am a sole proprietor,g�eral co�tracter,or komeowter(cirde o�)and have hired the contr�ctors listed below who have the following workers'compe�sation polices: �u►�� ..,.�_.. ,�.� � c�y: ol�a�e#: � �t��rune:, �: � _�� FaYae Is sxere ervera�e a�requi�al uder 3ali��ZS�A ef MGL lSt c�Ind b tl�e�..u�.r�w�.r��.�a si,s�,� �ye�,��r�nc�.Ra u d.��m u�r.n er.sTor woxic o�n�a�.�.rsiee.oe s a.y�mc.e. i�ma�.c. cepy ef tib�atesat my be finvaMal b the Odice�iav��f tl�e DIA ter average vtriAatlee. r do bd+tby cer�ijy,rnder tJre pa}xs rtna pe,ulaes o.fP�ejrry t/ut th�inf,foriwafio�provWed oanr�e is fr�re ana oar�ec� / . �� Date �'//�� Print � 1�� Phone# �l�`...�,�.' e�eiN ase ealy do aet�ite�this area te 6e ampkted by dty er lawn offichl �'�� # �Beidi�D�eet ❑eheck if imme��e respeeae is re9a�r� �Sdects�a a 016ee �� e: Phwe#, � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-182 FEE: $75.00 In accordance with regu1ations promulgated under authorit}F of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Claire M_ Gonet, 450 Route 6A, Yarmouthport, MA Whose place of business is: Captain Bearse House Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit exp�res: December 31, 2007 BOARD oF HEaI,TH: `J3en.jamirt l�. . JI�L.l�. ., C'Pu�cvcntart � .��e�e�e_n��`Sf�a�lc, ��,��`��}"i�c��e C'R.acvinurn RESTRICTION:Meals for guests only. ��W�u�lu. �.��4LU�lZ� �.,L��►ti ` J af�ucf� .Mcl�enma#t Qnn t�aceercBauxn, ✓`%.lV. June 14.2007 ruce G.Murphy, ,R.S.,CHO Director of Health THE CONIMONWEALTH OF MASSACHUSETTS TOWN�F YARMOUTH PERMIT NUMBER_ #07-110 FEE: $50.00 This is to Certify that Claire M. Gonet dlb/a Captain Bearse House 450 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COM1120N 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 violahon 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 thereta In Testimony Whereo� the undersigned have hereunto affi�ced their official signatures. BOARD OF HEALTH: `J13ert�a�rttin 1�J��u, .A�l.�., C',PavJtttu�crt xESTRIcr�o.n•1: Guests only. .`��t SRtacfE, ..N,, `U[ce(.'�'iavutuut � I�cr:B�ex�E s.J�3�cocruz, c�cP� J�J�tcl)extnatt , :/�..N- June 14.2007 Bruce .Murphy,MPH, .5.,C Director of Health ' ` THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-013 FEE: $50.00 . THIS IS TQ CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Claire M. Gonet d/b/a Captain Bearse House at _ 450 Route 6A Yarmouth�ort MA in said Town of Yarmouth And at that place only and expires December thiriy-first,2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respectmg the licensing of innholders. This license is issued in conformity�vith the authority granted to the licensing authoriries by General Laws,Chapter 140,and amendments thereto and is subject to secrions twenty-two to thirty-two, inclusive, and of said chapter and secrions twenty-five to twenty- � seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Fourteenth day of 7une A.D. 2007. BOARD OF HEALTH: �¢tL�p,ttUU�t 1�, .JI�.1�., C�Lp�`L RESTRICTION: First floor-1 room .��'' eC/Z S��i ��CC��ta/Z Second floor: 2 rooms ,�,/�t��/3�� (� �tltXlC�.I�QJI�fIEQ� Qf1ft yXR�fl�(Xl.l�it� � . Bruce G.Murphy ,R.S.,CHO Director of Heal