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� TOWN OF YARMOUTH BOARD OF HEAL � � � �� ' APPLICATION FOR LI�i�T3E/P �-"� ����� { - _ ��� ; r DEC 0 S 2010 .. *Please completc form and attach all necessary��Y`�` S 2 :�p Failure to do so will r�sult in the retum o�your applicat�on ipac . =' _-�� �wr^�_ � � ,..,�.�._�, �.�_��. NAME OF ESTABLISHMENT: QC �e'�`� �'/l/l TEL. # S'�a'F`?TF-�'/9-3 LOCATION ADDRESS: i^�" tr r MAILING ADDRESS: d S/•�►2 • fl� Oa?G Q . OWNER NAME: 4r1 c' soh - � CORPORATION NAIVIE(IF PL�CABLE): MANAGER'S NAME: �/j� �t.;t TEL. # •� 4�da f MAILING ADI?RESS: , �� v�,� G{/.; .¢�--.y-�. A. e,r ,3 POOL CERTIFICATIONS: T6e pool supervisor must be ce ' I�tw. Please list the designated Pool Operator(s)and attach a c„ 1. � �� � � �:,:�� . � Pool ope?rators must list a� First Aid and Communi Cardio . . cerdficatioas to this " ro�lnew capit�s and main �, �, 1. 3. y �,... �� FOOD PROTEC � ��� �� ��k��^° �, � f� � ` dasaFood Protcca� M : � ,� � � 59Q.pQQ. Plaase�tt��s af Gert�fica � yean'recorcis. Yon mu�t prov�ew n re , ,� : u _� , � v �. �. , 1. _� `?� � � a �. � PERSON IN CHARG � ��� � � -�.� � � � � � � .,, � , Each food establishment _ at least one Ferson Ti�. 3 ge( ` site during hours of operation. 1- 2. HEIMLICH CERTTFICATIONS: All food, sen+ice establishments with 25 seats or more must have at least one emploxe�e traincd in the Heimlich Maneuver on the premises at all rimes. Flease list youre�nployees trained 'm and-choking proccdur�s lxlow and attach copies of employee certificadon,s to this form. The He�lth Aepstrtment wiU aut;use past:yeytrs' recards. You mwt provide���ie$swd�t�t�n a�ile at your place of business. ' . 1 : � Z � � •�r�_.,�,. , , 3. ��% 4: _ „w , . , � � � � � �� �� � r� . � k � . � � �-0 �� ,, , � . .. ' , x � � � z, ; .. RESTAURANT S�� � ��'� � � °' �� � �.. 4 � °� _ - _ � ����n..w ��. y r� ; � p � � � �� u. ,..,_' .� yr w�, �' . �� `� ���,. � � ��� ��� � . t �.....� x �;,'� .E�� y.. LQDGING: ��,= ��..� ���� ,, ����.�����I� '�6'�' ,b; , � LICENSE, � ���� D �FEE PERMIT�# �� D FEE PE ��� PERMIT# _ S55 S55 ���� r � �r :, ° w. . r . .,_"..�..�. �, �m.; $55 � S55 ta.��$$Oea. LODGE S55 I " Y _TRAII,ERPARK 5105 ^Wf�;PUOL $80ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LI ENSE REQUIRED F�E PERMIT# LICENSE R�QUIILED FE� PERMff# _,0-100 SEATS $85 �CONTINENTAL S35 ��� NON-Pl'�.OFIT $30 >100 SEATS $160 _COMMON VIC. S60 �WHOL�SAL£ S80 RETAII.SERVICE: �RESID.�CITCH£N S8� ;...�...' LICENSE REQUIRED FEE PERMiT# LICENSE REQUIIZED FEE PERMtT# LICENSE R�QiJIRED FEE PERMIT# _<SO sq.ft. SSO >25,000 sq.R. 5225 _VENDING-FOOD S25 - _Q5,000 sq.R S80 _FROZEN DESSERT S40 ,�_ TOBAC�O S55 NAME CHANGE: sts AMOUNT DUE � S�D�� '"""PLEASE TURN OYER AND COMPLETE OTHER SIDE OP FORM"w+'• An u r �ox . . � .. � : . 3 �`i ,. Under Chapt�1 S�,-S������e�t�,�e T��f��rm�th i�rto�w.�q�r+ed t�hoki is�or�wal of any licenst or p��r`r�,���►bu�r���i;�����rp�r t���t'�tr�e s Certificate of Warke�'s Compe�s�tivn,.:���# �h�!�'T�4����`'�!�-4��3�'i����4T1'ON Il�T3U�R�NCE � ° �iVI'I'"�IU51`��.�[f11+�"�!'�����;��: �LL w:�.: , . � y �� � . � n.. � , �� � CERT. C�1NS�tANC�AT"T�� � �. b � �� -- � � � � �� �� � � _: �flR . _ . VV'�R�'S COMP. AFFIDA�I''I'5IGrNED ANT)ATT1�� _..Y� � _ . .. _ , , , � � ,� . : � n : � � .. � � � . . , � _ Tawn afY�mrr�h t�� �-m�rt t�paid pribr to renc�al cn Ys��e c�fyvunr�. :PL'B�SE t�SCIC APP'�+�I�TLL'Y'�xPl� :_. �.. �, , . , , . , ,r .ee, _t.� � ; ,h� . .. _ ��.� ��� _ � �,.,. .r � �, �. . : � T`1i►A�'��P� ���im�ntvccaYpmwya�be li��#o� �� '����e. Tri�'rir�� �" �1�+� Tra�nsi+ent �m;. �-, ."��_�.�. �ate af" � .�s�reslile�c�e or ��. ' . �; �A�Y ,. E�cc��.ss.d . Tram�e�t. � ������x � :� by�1�+e� �' (� � ., �,� P�`���1l�$- h ., .� . � �';� and ' � �: , ., < . . ,,�. .: r , � �� ������� y ° � � �' s�dari e c�nt � t � �, �`��► ���. � �_ r« � z� : ,�z � �. POOL C'�0S7N�:Ever�outdoor in ` . . must be drained c� �ae�v�cn closing. ` t7�days of Ft�OD SE�ttVICE CATERING�'t�I.tC"�t: , : i;� ��� ArYyone w�to�e�a��fi�n of�''�tm�h��o�'y ttw Y�tnc���������� �ti ��r� Temporary Faod 5ervice Applicsticm fimm'�hcn�rs�m�r ta tbe t��t�l�4'i�Oe � . �tt� Health Department. � � �� .� .� � -�°��s� � ��, e } :�+()�ZEN�D►ESSER . ,�.: � , a: �� � r � - �, M . r. : � ,��.. ..����� �.� _. _�,� ; � . h, � �>: � Fr��rt d�ss�tts � � � �._�� � • by a ���� � � .��ent�tu t�e�i�1th� , � nep�nent. F -� � . p��� ��� I � , � .�� A�QVC t�'fri$ IIq ��'�'���ii��'+�3���rVr������", � :� ��.,,�r � �r:��� ` �' . � • r � � �:�� � " ��. �, . � �: '�' '� �a �� � �tl�aC�CAfCB �'1�"lt ��C$ ���1. C �; �'+�j OUTDt}OR � y ��� � �� +D�tt��r cook��; food product savice esttitb� ���� � , : e � . � . - �. , _ � �. _ � � _ :: �o- � � ��. 3 � �; �•���:.� ,�"�� �� �� N(�T'tCE:Pernnts run a�n�ally from 3anuary 1 to Decembet 31. IT IS Y4UR RESPON3�[1TY T13�'�"��' THE�(JMPLETED R�WAL APPLICATIO1wT(5)1�3 R�QIf1�tED FEE(S)BY bECEMBER 13,Zt�'9. . � ALL RLNO�'AfiIONS T� ANY F40D ESTABLIS�IlVl�.�N�; MOTEL OR POOI. (i.e., PAIlV1'INC�� NE1�V EQIJIPI��;�TC.),h+It'JS�'HE REPQRTET3 TC!�IND 1�'PRflVED BY TI�BOARD OF HEALT� �.tCiR. TO C4MME1�'C�;'N`T.' REI�TOVATIONS MAY REQUIRE A SITE , ` DATE: /:2 - ''—/�� SIGNATtJRE; . ,: , ��/ Pl��`NAME&TITLE: V d .� : � r�2 ovns�o9 I � p�M +m' r i I���.. I I I�'II I �� I f� . p � _� ��'rtz c f � .. � ... F:: '.... �_ $ '.',".�b � .. . �;, �-. �� � � ,��� �� k�� �. n � ' �� ' 3; . f�. . .' ' . ;.,i . ,.' � � . � . . .,x � `� 3 �.,. � . ���. . .. -. 4 4 ; . �!�`� "���, •���'. �rt� . lt-r}' . . 3 .�"�. -�i.� . . " .4�9.. . " _ '. .. .>:>�c _;��, >r r.... .o-,:c� . . . , _ , ,... , � . .. .. . . . . . . .. _ . t� ..e 't:-.'.� 4 y,i�S�.t,��" ..-',t. 'Vr . a r.�� ..j . .�.. . .. . . . � z . �:.. . � :: . ,� ... �� , >. �.,;.,. � . . . . . . 3_ • .. �z ��►`'` :� ��_ ���. ; . . _, ..., .. � ... v'�Si ...�,." . ,-.��-�c'xa+Y.h�a> a''ct��.�'..h,���.�`a���ss?P"�+�`i'+�=k^ez`�� .•. . , . ,. � : . . � .. Fain+s w�rs erwe.s�e as ie�irsi WQ seai�.2sA.rlijGl.RS�e�re�i a iie C.j.�t�w..rerr"rri.l�ea.Me;.cs ire.�fr i1,sM�il►s�Wr , , Ne�rs"6r�r�t a�r�aer eM Marlfirr t�tlrt li�r a[�STOT M"O�IC OADBR aY a ire�[f1M N t h�a�,�Y�t�e.1�fYt s , a��W1�r�tnr��e�,M�MMtt11�t1I�{�eMipl�rer[�rMAI`ranwirr�e�alt�rt. � . . <_ t�fe�oer�j�ter t�rr�ttrwl��fl�e�t tbs t� �ktsw � �r� l� N��tift�aM*r b p+rs rw�oa�cR" . g�, /!/�tl . • m` S e l /o�-- 7 `/� . . . . �� ,.. ,_.; . . ., Pcint name� ��`���`�`7�'�'��,� �� � �, w •,. x ..., -: �� , �itlne� d�utwtifeiEfibareaMit�l�dl�'�MwlsA�cit'., . . ves.r aw� ° �� �a� p�ea�r��r.� ��,� c..hu�e,�,.c �i,�;.,t N : - �� �: ,�, . . f��� .. . , THE COMMONWEALTH UF MASSACHUSETTS T�WN OF YARMOUTH PERMIT NUMBER: #11-Q04 FEE: 555.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancv L.Johnson at Heachberry�� 157 Berrv^,Avenue_West Y�r_m_ouLh MA in said Town of Yarmouth aud at that place only and expires December thirty-first,�O l 1 unless sooner suspended or revoked for violariou of the lav�s of the Cammonwealth relating to the licensing of Lodging Houses. This license is issued in conformiry with the authority granted to the lieensing authoriries under section riventy-three,of chapter one hundred forty,of t2ie General L$ws,and is subject to the provisions of sections twenty-t�vo to thirty-one inclusive of said chapter. In Tesrimany Whereo�the undersigned have hereto af�'viced their official signatures,ihis Fourteenth day of December A�D. 2010. BOARD OF HEALTH: ��!l�tYtt J�p�I/t�IL-Sf1tl��� (��Xl�X�tttA#i J �nr�re�.¢ault, `Uice C'Rururrtt�ut ►t .uc `t!1' ' C'.�'nvur.de�c III, C!� �J�oe��� � ruce G.Murphy, ,R.S.,CHO Director of Health TOWN OF YAI�MQUTH BOARD OF IiEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #11-1Q0 � FEE: �35.00 In accordance�vith regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Nancy L. Johnsan, I57 Berry Avenue, West Yarmouth, MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To operate a faod establishment in: Town af Yarmouth Pernut expires: December 3 l, 2Q 11 BOARD OF HEALTH: ��ttAttt�fic�lZfttlt-SrnitR�, C�tuut .J .`�'uet�eecu�t, `viee C'`lfcu�er►uzrc ►uz 2v- • e. s,���, e�� �� , .M.�. December 14.2010 ruce G.Murphy,MPH, .S.,CHO Direetor of Health