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Home My WebLink AboutApplications, WC and Licenses �. G3CC� L� � ' � '`'Y"k TOWN OF YARMOUTH BOARD OF HEAL ' � �' s� �� ' APPLICATION FOR LICENSE/PERMIT 0� �" ,<;- JUL Z 1 ZUuB . ��r � ,� �. . *Please com lete form and attach all necess � P ary e �► ecembe TH D E Pl . Failure to do so will result in the return o r a�tica.tion packet. � ,_, NAME OF ESTABLISHMENT: � Pq r 1j r ,1 TEL. #,3'"�D�`= �7�=,5�'j`� LOCATION ADDRESS: d4 3 MAILING ADDRESS: S~�,�,� OWN�R NAM�:._1�Gi7�✓ �iri.ra� TAX ID (F�IN or SSN)- CORPORATION NAME (I APPLICABLE): MANAGER'S NAME: � - - TEL. # So - F��'Y�i'3 MAILING ADDRESS: o � - • � o/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Dep�rtment will not use past years' reeords. '�'ot� tr►ust prQvide new copies and maintain a file at your place of business. 1. 2. 3. 4. -�,..�..�,,,.�.�,��...�..l.�.�� 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 Sauitary Code for Food Service Establislunents, 105 CMR 590.000. Please afitaeh copies of certification ro this application. The Health Department witl not use past years'recvrds. You must provide new copies and maintain a file at your establishment. 1. 2. _PERSQN IN�I�1�R�E: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list yow employees n•ained in anti-chokuig procedures below and attach copies of employee certifications ro 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. �. 2. 3. 4. RESTAURANT SEATING: TOTAL # � OFFICE USE ONLY LqDGING: LICENSE REQUIRED FEE PERtiIIT# LICENSE REQL'IRED FEE PERYIIT� LICENSE REQUIRED FEE PER'�iIT= _BBcB 550 _CABIN S50 _MO?EL S50 _INN S50 _CAi�IP S�0 �S��4'I'_�L�ZIi�TGPOOL S75ea. �LODGE SSQ ��01,3 _TRAILERPARK S100 ��1-IIRLpOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LIC£NSE REQLTIRED F£E P£R141T* LICENSE REQL'IRED FEE PER'�iIT= _0-100 SEATS �75 �CONTINENTAL S30 O�'I _NON-PROFIT S35 _>100 SEATS S150 _CO:�ION VIC. S50 R'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER�IIT* LICENSE REQLrIItED FEE PER�fII'� _<50 sq.ft. �45 _>35,000 sq.n. S200 VEI`DING-FOOD S20 <25,000 sq.ft. S75 _FROZEN DESSERT S35 TOBACCO S50 NA1bIE CHA�IGE: sio AMOUI�T DUE _ $ �p. Q(� *****PLEASE TLR\OVER A\D CO�ZPLETE OTHER SIDE OF FOR�T***** � aD�s�TTON Under Chapter 152, Section 25C, Subsecrion 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or gemut 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 Ya.rmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiTPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence etsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vc(6)manth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy thax 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: Enciosed Motel Census must be completed and returned with this application. POOLS PDOL 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 TES1'ING: 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 ciosing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit urrtil 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: Outdoar 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 RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIEENT, MOTEL OR POOL (i.e., PAiNTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMEVT. RE�tOVATIO�TS M REQUIRE A SITE PL _. . DATE: ?/U'D� SIGNATURE: ��` ��` �—�._.. �_..,, _.__.�= PRINT NAME&TITLE:- - "�`c � o o � r� io;um , . � � The Comenonwealth ofMassachusetts Deparhnent of Industria!Accirtents > NNfCINb�l11�i G00 A'ashington Street, 7`�'Floor Boston,Mas� 02111 Workers'Compeesatioa I�snraace A�davit:Bailding/Plambieg/Ekctrical Contractors Ana�ic�rt#�f,��ti�t• P'�aares PRIN`T IegtWv name: C' � (/D�/7�3'O address- � � citv �7�r state• „r�lf� zin• f�or.lyd� phone# c'S^��' �7�'`/lf 6 work site location(full addressl• %S-7�S J'/"� � '�G� y0/'jYt/�/�'' lJ��73 ��a homeowner performing all work mysei . Project Type: ❑New Conslruction�Remodel I am a sole.proprietor and have no one workiitg in any cap�acity. ❑Building Addition ❑ I am an employer providing warkers'compensation for my employees worlcing on this job. campanv aame• address: �" ohaae#- ius ce. � : ,. : ,,... . . , ;. ;: . ;.,, , f . ....,�k x w,,. . ❑ I am a sole proprietor,gener9l coeh-actor,or Lomeowaer(circJc on�)and have hired the comractozs listed below who have the following workers'cnmpensation polices: c�moaav mde• address• citv phox�#- insm^��ce co. # ;;: < , ..: cQmn�v'ame• �• cit�: oiaae#• imEm�aace ca # !��" Fa��e Os more as , _, ,,,, ,, ; .., ,. ,: . ,,i. co�r�e rc9airad aeder Sectle�2SA ef MGL 152 eu lad b tYe��ef cristed peaaltles sf a 8ae tq�b S1,SeY-O�asdler oee Yei�s'I�ti�oameat as w��s dvi pemNies 1n t6c form eta 3T0!WORK ORDER asd a gse o[f160.Os a day�t�e. 1 anderala�d t�at a cepy of thia�atemeat may 6e f•rwarded l�o t6e O1Bee of lave�of the DlA tor ooverage vtri6catlsa. I do hereby erufy uxde NFe parrs aad peeslties of rjr�ry thet ti�e iefor�allon provided aboNe is trxe and comct Signature Date 7�� `"d � Priut name ��h _. , h S pyJ Phone# c'j��"�77l-��pa � offiMlal�oNy do nM�vrite in t�is arei to 6e�mpleted by city or bwn�ffieisi city or tewn: permif/6etase# �Buidin8 DeP�rtmen� ❑cgeck if imme�be respeme is nqmred �n�a8 Board �re QSdect�ea s OtBce eoatact person: p6e�#; �p�� t c,�s�p.zaa+> , . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #Q8-013 FEE: $50_00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is heseby granted to Nancv L.John.9on at Re�hher�r I� 157 F�nv Ave�v West Y�moirtl�_MA in said - Town of Yarniouth and at that place only and expires Dec�ber thirly-first,2008 unless sooner suspended a revoked for violation of the laws of the Commonwealth relating to the lic:ensing of Lodging Houses. This license is issued in conformity with the authority granted to i�e licensing suthorities under section twenty-three,of chapter a� hundred forty,of the General Laws,and is subject to the provisioos of secti�s twenty-two to t6irty-�e i�lusive of said chapter. In Testimony Where�f,the�sig�d have heaeto affixed their o�cial signatures,this Sixteenth day of July A.D. 2008. BOARD OF HEALTH: .`�F�¢R S�pI� �� .� (�RlXtltq�t �.hQX�d �� lC¢�.�QIXf/tlllt J�.'a�rt 3:$rocr�ve, ('.leXk Clnn C��acun,:J�.JV. Euely�e:1'3f�a�ye�o Bn�e G. Murphy, S.,CHO Directar of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #Q8-191 FEE: 30.00 In accardance with re atians promulgated under authority of Chapter 94,Secti�305A and Chapter 111,Section 5 of the Laws,a petmit is hereby granted to: Nancy L. Johnson, 157 Berry Avenue, West Yarmouth, MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To ogerate a food establishment in: Town of Yazmouth Permit expires_ December 31, 2008 BOARD oF�AI,TH: �elen SIEaI� J`�.JY., (.l�ai�rnuut C''Il�axlee ��teUil�c `tJrce C'hawr�naK ��.�, el�,� ��,�..�v. ��.�•�� July 16_2008 Bnx;e G.Murphy, H,RS.,CHO Director of Health I �� -. ��aa �o ��►� � 3•�`�R.�c TOWN OF YARMOUTH BO � � T"" MAY 0 1 2007 �`. .'�a APPLICATION FOR LICEN� � ;� ,.. ,..., '"* ': HEALTH DEPT. * Please complete form and attach all necessary documents by December 31, . Failure to do so will result in the return of your application packet. NAME OF EST.ABLIS�IlVIENT: ��Pc�cl�i�t�-ry�� TEL. #�D��'�—4�0� � LOCATION ADDRESS:�"`�7 ,,��r�.o ,��r'_ W • �G'�"/�� /��' o� 4 7..3 �,nvG aDv�ss: % �` �/" �r�-. o �G o i OWNERNAME: �rc a .-r u� TAX ID EIN or S : � - .�`/� CORPORATION NAME( APPLIC.ABLE): MANAGER'S NAME: ��„ ,� �-�,y � TEL. #T�"d��YD�God G M�Tf ING ADDRESS:__ /��7 ��i~r.� �a c. !�J - �r'�� . r�I�'- o�� 7.3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated __ _��}$��'{s?_"��-�ttach-�capp-af the certificattv�rrta thi�form L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. - PE�SON IN CHARG�: __ __ _ _ _ _ - Each food establishment must have at least one Person In Charge(PIC} oz�site during hours of operation. 1. 2. HEIlb��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-choking procedures below and at�ae�i copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERNIIT# LICENSE REQIJII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# B&B $50 CABIN $50 MOTEL $50 INN $50 CAMP $50 SWIIvIlVID�IG POOL$75ea. I LODGE $50 . ,_�'��'-j� _TRAII,ER PARK $50 _WI-ID2I.POOL $75ea. FOOD SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 ( CONTINh'NTAL $30 `�r i �NON-PROFTT $25 >100 SEATS $150 COMMON VIC. �50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQiTiRED FEE PERMIT# LICENSE REQLIIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VF,NDING-FOOD $20 _QS,OQQ sq.ft. $75 _FRQZENDESSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SO•OC9 *•"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**"* z� 3 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 Compe�s��Surance; T`H� �TTA�ff�H '�'i'�'PE �Oit�ER'S 'C't)l�"�fi��Z�INSURANCE AF��" '�``��'�,�T'�Iy ANl�S�NE�,Q� . ; CERT. OF INSURANGE ATTACHED • OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. F��S��iE�K AP��P�"1'�LY TF P�ID: YES � NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT I5 YOUR RESPONSIBII.ITY TO RETiJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMN�NCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVI50RY: 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: . __ Erozet��iessexts_mustbe tested�an a_�ot�t1�X basis-b3�a-Stat�certi�ied_lah: �'��esu�ts-n�st-be�t tc�th�Hga1�l�__ 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 fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ��:�3� y-0 7 ��c��u�r : PRIN�'��8�'�ITLE: ;��i h� r/�o�� h ��t� 09/28/OS � (NOZ 7�+5�1 .�aq1pQ �1f� :aaci'd�'s�noa •a�p50 Pa�6u a!ac��i�1��l3!�9�❑ 7� A� 'aes�i i°d�p I��N��9��907��la�l�oP �oxn�s�e � //-/L�- o .��. y u ' � :�� Lv- is' , �a►pm a�q s!a�oqn PapMo�d rroprw�oJ�n a y��sMj�finFi�dlo �m arl�d ay��a�wr , aa A'9arv o�7 ` '�l1�+��3 rIQ�t13a��H�ii��WO�1 ai WP�3�9��q��l913a� ��P�I '��!��P t YO'YlIS��A s P�834II0 71�iOM iQLS�3a�3�H!�NN�R��4►�f��c� ��saaa��r�w�•wr��a��zs�c�aw�v��s�� ss a9�o wax e�a.m@id � � � �t :saa�oduo?issaad�aoa sia �► o � aneq cx�,�n+oiaq p�i sroi��{►P�i a`�I I�(��)�Oa�_�`1W�� udold a os s me �A _ - - — .qoCs�q��Sa�Can�saaCoidoQa�Cui.�;aor�esaadaa«>.sra�an�8a�piwoJd ia�Coidm�a ae uae I , ' uo��ppd . Png � i sa ae ar ��n auo ou aneq�xie�. ajas E me I : I��IQ c�o�o�nnaH� :ad�CZ 7��d '3I��n��e Sacuuo,;rad aawaoa�aoq s ,./O ./ :s�e� �. t a�?s . ;.�. 9 //-/ :10 �� ' � • � Q :$ .� . � �,o �ub� - �, � . v � .., , � � � . � .,�°�F �`.��, s� � �. _ _ .. �� ,. � �w �. �� , � �. _ . � . _�� .:i � , s�W�s.Rto'J 1t�WI3/�44. l4tg��P�V aaa�s�i� ,ss��=ra�ob , IIIZ� '��1i`u��S ,•�-_ .rool�� yaa�s xo18�y�M 0119 ' -= -_ � ��M�l�� - - � ,U�' � s�uap�a�i�In!a�.cnPul.j°��d�Q = _ - � '�: suasn�anssnl�.ju q�»an�um�ru�o,7 ar� ==_=-=_= i �� .:. � ' '* - THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-012 FEE: $SO.QO LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancy L.Johnson at Beachberr;r� 157 Avenue West Yarmouth:MA in said Town of Yarmouth and at that place only and expires December thirty-first,2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under s�tion twenty-tlu-ee,of chapter one hundred forty,of the General Laws,and is subject to the pmvisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Wher�f,the undeisigned have hereto a�ed their offcial signatures,this Third day of May A.D. 2007. BOARD OF HEALTH: B �. �a�ors,/Ll$., ' ��s�, .n!, v�e�� aoG�t�B�, G�f�k /��,t�k�f��tt . � �I�us(�'neess�r�cr�, R./V. Bruce G.Murp , H,RS.,CHO Director of He th _ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-175 FEE: $3Q.OQ In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is hereby granted to: Nancy L. 7ohnson, 157 Berry Avenue, West Yarmouth, MA Whose place of business is: Beachberrv Inn � Type of business: Continental Breakfast To operate a food establishment in_ Town of Yarmouth Permit expires: December 31, 2007 BOARD OF HEALTH: B _`h. J�.�., ' �6��S��u.�i, �ice�i�i�irsu�si � Rode+r��.B�tsu�v,s, C� A�k�1�� ,4.��j R.N. May 3,2007 Bruce G. Murphy, .,CHO Director of Health l�'�a'�tQ�,�z• � ��.:Y��' T � � � oF YARMOUTH � ` o oN -� `� 1146 ROUTE 28 SOUTH YARMOUTH MA.SSACHUSETTS 026644451 " MATTACHEES /��J � � � ry��4�ORA1f0�6� ,.y�- Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 . �d b- B OARD OF HEALTH�� = ,., �,�, 2 � i� , � f.�.7 To: Yarmouth Board of Health Permit Hoiders :,�� ? q 2fj;l� HEAl�TH DEPT. From David D. Fiat�rty Jr., R.S. ;��r Health Inspector � Town of Yarmouth Re: Federal Tax ID Number Date: March 22,2005 � The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Empioyer ldeirtification Number(FEIN}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record Please fill out the fields below and reiurn this letter to Yarmouth Heatth Departmern 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any Questions regarding this matter, ple�ss s�o not hes�tate to call. �'he of�ice hours are Monclay to Friday, 8:30 a.m to 4:34 p.m The telephone number is(508) 398-2231, e�.241. Establishment:�J�'4e/�,O�'r'�' .1�'�J° FEIN or SSN: �� .�''% Location Address: /�S�'7 �/'�'� �G � yA'�� ` �� Signature: � Print: /l/�'l�'IC� L, VO�/1<:Sm� Title: �ivrt r�'' , ;� �� Printed on � � Recycl�� a.� �� Pape��;:�� ` �.� . �B�P/`3E�►C�t BE�R.�-`r GuN •Of:aR� TOWN OF YARMOUTH BOA �"��L� "' �� - - _,� � � �� ` rC7 �� D o _. . ,y APPLICATION FOR I��E .,�2005 r ,,- .,? �„,`_ , M��., a. �; �, * Please complete form and attach a11 n " �ents by Decem er 3�1��0�4� 2005 Fai lure to do so w i ll resu lt in t he ": ofyour application pa k�t{EALTH DEPT. NAN� OF ESTABLISHIVIENT: c�! �r�' n TEL. #,�'a� Fo G LOCATION ADDRESS: � e-�-�" u� G�� c.r C�- MAILING ADDRESS: �O 3Si� �- o��/ OWNER/CORPORATION NAME: �lN'. MANAGER'S NAME: '�/D`ir� � rr�.� TEL. #=S�D�o?�'o��y MAILING ADDRESS: S'QinG 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 emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fite 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 applica.tion. The Health Department will not use past years' records. You must provide new copies an 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 trainec� 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 fite at your place of business. 1. 2. 3. 4. RESTAUR�N'T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT'# _B&B $50 _CABIN $50 MOTEL $50 _INN $50 _ `CAMP $50 _SWIlVIlvIIl1G POOL$75ea. 1LODGE $50 Q �I _TRAII,ER PARK $50 W�IIRI,POOL $75ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# _0-100 SEATS $75 �CONTINENTAL $30 #€o S-rq 3 NON-PROFIT $25 _>100 SEATS $150 _GOMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ pO•CX� '•'�""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•*• ., _ � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensa.tion 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 p ' r 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 DEPART'MENT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the seasan must be inspected by the Health Department prior to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY• 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. 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. OUTD()OR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE:_� O-s'� _SIGNATURE: � PRINT NAME& TITLE: �9i1'<t4�r �o�� •� �iz''�t � - 10/22/04 -- =��_= The Commonweatth of Massachusetxs � '� Departinent of Industrial Accidents _- - --_ N�tNr1� � ' � 60U Washingto�e Stree� 7`�`Floor r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-013 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancy L Johnson at_ Beachberv Inn, 157 Berrv Avenue West Yarmouth MA 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 relating to the licensing of Lodging Houses. This license is issued in confomuty with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter_ In Testimony Whereof,the undersigned have hereto a�ed their official signatures,this Nineteenth day of July A.D. 2005. BOARD OF HEALTH: B��rti��S. (��/I9�. ' A�� v�e�� =xESTTUCTTo1v: Continental breakfast only. R�G� B��y� � Restricted to 7 bedrooms per septic design. d�e�¢1y �'�y� /Z,J�i �I.�.L!�'�e.zd�,t, R./V. Bruce G. Murphy,MPH,R.S.,CHO Director of Health � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-193 FEE: $30.00 In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Nancy L. Johnson, 157 Be Avenue, West Yannouth, MA Whose place of business is: Bea,chberrv Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2005 BOARD oF HEAI.TH: Ber�.��, ��°�,o,� A9.$. ' nc�isc�(a M�.h` e�iar� 'llrce G'��c Rod�t� B�au� G�l�(a � s� R.n�. �4.��e.,�, R.�v. July 19.2005 Bruce G.Murphy,MPH,R S.,CHO Director of Health , ,; � u��'�°�,. C�c�-�'aC� ��0� f-YA ��LT �� ` R� TOWN OF YARMOUTH BOA .. . , _ . _,o o t "�y APPLICATION FOR L - T -200 A�R , `` .•. ... -�x ., , s 2 ".� * Please complete form and attach all ne ��cuments by Dec ber 3 r,1Qf�:�t�p4 Failure to do so will result in the �� of your application q�TH„ NAME S IS MENT: P �—r� .�T' r� T . # o - - � LOCATION ADDRESS: /�7 �c'rry .�v� �'v, yc�r-�a v�!' IL DD O �� , �c�o WNER/C RPORATION NA E: � L V o �./Q� � MANA ER'S NAME: v T L. #S`a�'a7�oG�G MAILING ADDRESS: �O.C�r.��c' �5�� /�,v�%�r✓_ o��o/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1• 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establisLment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of opera.tion. l. 2, HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 MOTEL $50 _INN $50 ��v-�-�r�I,� _CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 � _TRAILER PE1RK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 – C! _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 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 AMOUNT DUE _ $ �(S„� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** s, d ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED 2� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' Town of Yarmouth taxes and liens must be paid prior to zenewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YUUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS t POOL OPEI�IING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. S'ATFRiNG 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. - OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. nirTn�nR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: 5� �a e� SIGNATU • � PRINT NAME& TITLE: �/'a��`s�t'� 10/22/03 , � ; � The Commonwealth of Massachusetts � � Department ojlndustrial.-lccidents � ; Olflce oll�eslJosdiis + 600 Washington Street ', �•� Bosron,Mass. 02111 �~ �� W'orkers' Compensation (nsurance Affidavit �Rolicant information: Pleese iNTTe�.'1.iir nlmr '"L/�/7 C' 1/ L. �/D/J�lSl7h location� fS s'J �t/'Y"Y �r�G • � � <!/^/�'!. 4• q o�=o1s�O G d �am a homeowner pertorming all work myseff. � I am a sole proprieror�r..'. ha�e no one ��orkin_ in am�capaciry � I am an employer pro�idin�w�orkers' compensation for my employ�ees w•orking on this job. _ comoan�• namr address• sitv: ehone M• �surance co. policy q � I am a sole proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e thz follo��in_ ��orker ;ompensation polices: s4mpanv name• address citv• nhone�• i�surancc co. Rolic�•# s�m a�ny name• �ddress• tih'r ohoee M• insurance co, notieY�f f Failure to secure covera�e as required under Secnoo 2SA of MGL 1S2 ea�iad to tbe iopaitioa of erisi�fl pesdtla of a O�e ap to 51,500.00 a�d/or one yean'imprisonment a�w•ell a�eivii penalNee in the form of a STOF WORK ORDER�sd a lise otS100.00�d�r tpiost me. I r�denta�d t5at a copy of this stuement may be for+wrded to the Ofiiee of Invatig�tion�of tbe DIA tor eoven�t verifiado�. I do.hrreby cerrif}•under th�poi s d naUi�s ojperjury that tl�e injornration providtd abovt is true and conect Signature �.�o?-D� Print name �� 1� L�. �Q�/7SO.f9 Phone At 5��v V G d��' , o(Ticial use only do not w�ite in this area to be compieted by city or towa oAleial ciry or town: Y�M�IIT� _ pereniNieenee M nBuilding Departmeot pLieensiog Board �eheek if immediate responst i�required 261 OSeiectmen'e Ofrce �Healt6 DeQartmeet contact person: phone M;_ �508} 398�?231 eat. nOther ' -:� Y � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #t?4-Q15 FEE: $50.00 LODGING HOUSE LICENSE Tius is to Certify that a Lodging House License is hereby granted to Nancy L Johnson&John A. Grant at Beachberv Inn. I 57 Berrv Avenue,West Yarmouth,MA in said Town of Yarmouth and at that place only and�pires December thirty-fust,2404 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confornuty with the authority grant�to the licensing suthorities under section twenty-thr�,of chapter one hundred and Forly,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Twenty-third day of Iviar�ch A.D. 2004. BOARD OF HEAL'FH: L�e�ru�t�. �, ��S. ' �:��tan�t, v� �� s�c�olv: Continen�breakfast only. Re�ie��. B9ete�va, � Restricted to 7 bedrocxns per septie design. d�e�e�c'�s�s, R,/Y. l4.ttt(��lee�t�st.�, R./�. ~ �� ',y==-= ��4.ft.-,.� �`Is �. Bruce G. Murphy, ,R CHO Director of Heatth � T4WN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FO�D ESTABLISHMENT PERMIT NUMBER: #04-192 FEE: 30.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a pemvt is hereby granted to: Nancy L. Johnson&John A. Grant, 157 Berrv Avenue, West Yarmouth, MA Whose place of business is: Beachberrv Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2004 Bo.�RD oF HEAI.TH: Bes y��fa$, �d,o,b, �(�J, `��,f • p�/�c�1�0�, �/�es(.�u-.r�xar� d�els�s �,. R./Y� �g��.� R.JY. � Apri123,2004 �. � J Bruce G.Murphy,M H . .,CHO Director of Health , � : d r.��(a76 �eo��+sc-ue�t cN N ��='�R TOWN OF YARMOUTH BO 'U H�`ALTH � `_ �o o� '�y APPLICATION FOR LICENS IT-2003 � � � � � �l G D Y • •'� `*�. �1 �VV� * Please complete form and attach all necessary uments by Decem er , Z�� Failure to do so will result in the return of your application pa �jEALTH DEPT. NAME OF EST.,A$LISHMENT: ;,� r�r 6rr�r✓ �s� TEL. #�a� 77/-G��,s"' LOCATION ADDRESS: /s�'T �� 1�� MAILING ADDRESS: .i�f> ,C�uX ,�S/.� t/✓ /�.r'i- !�� G�/ TI N ' n #S o��F�_�v�� D c� � c� cslGS�/ � / - �Go/ rf- S7 r.i- 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 basie water safety, standard First Aid and Community Cardiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ' 2. 3. 4. FOOD PROTECTION MANAGERS - C�,RTIFICATIONS: All food service establishnnents are required to have at least one full-time emgloyee 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. __ _ __PF.R�CC)�j._j�C'�ARL'rF: . Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIIyILICH CE�2TIFICATI NS: All food service establishments with 25 seats or more must hav� at least one employee 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 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $SO _SWIMI��IING POOL$SOea. I LODGE $SO Oc3 "Ol(y �„TRAILER PARK $50 _WHIRLPOOL $25ea �D SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 � CONTINENTAL $30 b�J�II�� NON-PROFIT $25 >l00 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 �TAIL S RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 `TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. a200 _FROZEN DESSERT$35 NAME C NGE: $10 AMOUNT DUE _ $ 80.O0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"�*** � h K , �..._ . . _ ; ADMINISTRATION �Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i of any license or'permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEL� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBTLITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPElvING: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 closir�g. FOOD SERVICE CONSUlV�ER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: _ _ _ rozen esserts must be test—ed on a mon I-y 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. OUTSID�E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: -: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pi�ohibited. .� .- ., �' ,. � �,� ,�j-- _ �� , , � �.;,_., � -^�I f y �1;6,' ' �,�,__�. r7 . DATE: � ��' fi-.� SIGNATURE: J�"? '�-. , r ,:- PRINT NAME&TITLE: ��''��`�� /�'/c�C�' t��'' — 10/18/02 i . '� y • ' "�„��\ . . The Commonwealth of Massuchusetts � � Department ojlndustrial,-lccidenrs � ; Of!lceo/%vest/Ostliis � 600 Washington Street ' �` Boston,Mass. 02111 �� .~ V4'orkers' Compensation Insurance Atfidavit Annlicant informallon: p►essepR -�• namr� ✓G��•�7�y' L q�D/>s'1 d�'7 � G�!//7 %� � � � - J'G� location� /,5 �7 / �t�✓'f-✓ !�`".✓U ttt� �Ci/"�'> 1. �� ; phone� S d� ��/-!'i��.�' ��'I+�m a homecw�ner pert�rmin,all work myself. (�'�( am a sole proprizror�-,a, ha�e no one��orkin_ in am•capacin� � I am an emplo�er pro��dins w�orkers' compensation for my employees w•orkine on this job. somoanv namr address; �t�'� nhone M• insurance co. p�y p � I am a sole proprietor. ;enerai contractor. or homeowner(circle oneJ and ha��e hired the contractors listed below ��ho ha�e the follu��in� ��orkzr �ompensation polices: s4moanv n�me• address• �• insurancc co. �olic�•# som�anv name• _ ------------- ___--- -------_ - -- - — -- address: - ____--- -- �': nhoee M• insurance co. �gn,* t Faiiure to secure covera�e as�equired under Secnoo 25A of MGL 152 ea�lad to t6e iopaidoa of erivi�al peaaltle�of a d�e ap to 51.500.00 a�d/or oae years'imprisonment a�w•eli a�eivil penaltla io the form of a STOP WORK ORDER aed a lise of 5100.00 a day apin�t ma I r�detsta�d that a copy of thH statement may be fonvarded to the Oliiee of inveetig�tion�of the DIA for eovenge veritiado�. /do hrreby ceriif}•under,`th� eins and ties ojperjury rh t injorniation provided abovt is true and enrr�et .� Signature - "�- ' � �� 4� Print name /v�y7C� �_ ��d/7i��L'�vi �� /'c^i/]I Phone 1i �ds� 7��- �L��{S� .- oRcial use only do not w rite in this ares to be compieted by ciry or town oQleial city or town: YA��T� _ permitAieenu M nBuilding Department OLicensiog Board Q check if immediate response is required 261 �Selectmen'�OtTiet �HealtA Departmeat cont�ct person: phont M;_ t508� 398�2231 eat. nOther .. ._� .< ,�.,. � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-012 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancy L Johnson&John A.Grant at Beachbery Inn. 157 Berry Avenue.West Yarmouth.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 relating to the licensing of Lodging Houses. T'his license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundr�and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty:one inclusive of said:chapter. In Testimony Whereo�the undersigned have hereto affuced their:offcial signaxures,this Third day of March A.D. 2003: _ BOARD QF HEALTH: (�`�, i�e�ll�tte�c. �� . . ; ; �r a fa.x�'D: Gfmcdo�, 'f11.D., tiice ' � , *tt�ST�uC'r[ON: Continental breakfast only. �o�rt�, �racwrs,;�� ; Restricted to 7 bedrooms per septic design. �abiic��puria�L` i `sT�ac.�i�, I�!G. � G.Murphy, R .,CHO Director of Health ; � �.-.. �' .,. . . TOWN OF•YARMOUTH , BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLTSHMENT PERMIT NUMBER: #03-165 FEE: $30.00 Yn accordance with regulations pmmulgated under authority af Chapter 94,Secrion 305A and Chapter = 1 i 1,Section 5 of the'General Laws,a permit is hereby granted to: Nancy L. Johnson&John A. Grant, 157 Berry Avenue, West Yarmouth, MA : , Whose place of business is: Beachberry Inn Type of business: Continental Break€�st ; To operate'a food establishment in: Town of Y�rmouth� :: Permit eacpires: December 31, 2003 Bo�oF H�.�,'rI I: �� ,'T�, �el�¢�, �� 'i�c�?�. Cimadauc. 711.Z�,. �1/iee �ot�art�. 6'�uo�c, L� �aaric�71�ar�cotr ��s�. �� March 3.2003 ruce G.Murphy, ,R.S.,CHO Director f H lth a , _, ..___ .. .�. a 1 �-�0 0� TOWN OF YARMOUTH BO if�F HEALTH �:� APPLICATION FOR LICENS /P ti�� x r��r�z�� °✓��' , `` ,( � L �� . * Please complete form and atta.ch all necessary documents by c��-��i �9�c�-Fa' ure to clb��s ..'ll�s�lfxin the return of your application packet. � � �r:,.' E NT: r��^r � _ TE ;;#` Z� - - d � i (�(`ATTnN ADD FSS• /`�-7 �i�✓ /'�D� ,lcJ �r/�!_ fJf',� MAILING Ai>DRESS: ,,,.,5`v�rc� on� O �h r! ,��S MA1�iAGER'S NAME: �/�� L✓ �rv TEL. #S"oi� MAILING ADDRESS: �vX ofG S�/ f�i� /7'lQ oa?Ga/' 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. Poal opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Caxdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must prov�de new copies and maintain a fde at your place of business. l. ��%�```' 2. 3. � 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service esta.blishments 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 aod maintain a file at your establishment. 1. L�.a�'l/�7►mr� f�T�'�icy'I 2. PERSON IN CHAI�GE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEI�'�I 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-ch�king procedures below and attacl�copies of employee certifications to this form. The Health Department will not use past years' records. You�imust provide new copies and maintain a file at�your place of business. 1. 2. �. 4. RESTAURANT SEATIlVG: TOTAL# OFFICE USE ONLY I.ODGING: LICBNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _BBcB $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $SO SWIIvIMING POOL$SOea. / LODGE $50 ��.�`S — poo�-tto�� _TRAILERPARK $50 _WHIRLPOOL �25ea FOOD SERVI�:E: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 jOo1- �'��-19'� _ �CONTINENTAL $30 2.002-�o�-(g$ NON-PROFIT $25 >lOQ SEATS $150 � _COMMON VICT. S50 _WHOLESALE $75 RETAIL SERVICE- LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# _TO$ACCO $20 _<25,000 sq.R. $75 _TOBACCO $20 <50 sq.ft. $45 _>25,000 sq.ft. $200 TFROZEN DESSERT$35 .2oa! = b�80,Od �IAME CHA�TGE: $io AMOIJNT DUE _ $ aao�- � � So.o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��G�•� ��L : i ADMII�TISTRATION 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� 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 QB 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 1�t0 NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPOI�?SIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER�1,2001. SEASONAL ESTABLIS�A�ENTS ARE TO CONTACT THE HEALTH DEPART'MENT F''�R INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY F(JOD ESTABLISHMENT, MOTEL OR PO�L (i.e., PAINTIl�TG, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BO_ARD�� HEALTH PRIOR TO COIVIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i��DITIONAi RFGLn�ATIONS POOLS � POOL OPENiNG:All swimmin�,wading and whirlpools which have been closed for the season r�,t,�t be inspected by the Health Department prior*o 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: Ever�;T outdoor in ground swimming pool must be drained or cove�red within seven('�y days of closing. FOOD SERVICE CONSUMER A�VISORY: Each food establrshment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. , (rATERING POLICY• Anyone who �aters 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 He�.lth Department. � � � . � � � ; x Frozen desserts must �sted on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure�i do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have be�met.� OUTSIDE CAF��: « Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pr hibited. �. ,� DATE: � , s'o-�. SIGNATURE: � �� PRINT NAME&TITLE: i:�/ �`— D��«- c D��sog 09/11/01 ,. �� ` ' The Co»r�nonwealth of Mossachusetts � W Department ojlndustria/.-�ccidents ; OlAcsol/�s�los�iis ; 600 Wushington Slreet , ,•= Bostoa.Mass OZlll " " W'orkers' Compensation Insurance Aifidavit Aoolicant information: Pl sePR namr� ��l/f?C'Y � VOf7/7SOh �/D'/!�'7 � C�i+YY�` location: /.S�� iCJ r''�"�"✓ �Uf� �it� � J�/-/J� . /�4. Qhone p�T�3p-a?�O—¢l.U�� I homeow•ner pzrtormirt�all worlc my�self. �--G� 7 7�G�� am a sole proprietor�r,� ha�e no one��orkine in am•capaciry � t am an employer pro�idins workers' compensation for my empioyees workine on this job. comnanv name• ad c�ress• ciri•: ehane�1• insurance co. �olicy p � I �m a sole proprietor. ;enerai contractor. or homeo..ner(circle onel and have hired the contractors listed below� ��ho ha�e the follo��ing ��orkzr_� �ompensation polic�s: comRanv name: address• . � ci�y: � phone N• insurancc co. nolicr•If comnany namr iddresr sjiy• ehoee AE• insu�anre_eo. �Af Failure to xcure corenEc as required aoder Seerioo 2SA of MCL 1S2 ea�kad to tbe ispai�oteri�i�i pe�altles ot�Au op W S1.SOO.00��d/or o�e yean'imprisonment s�w•ell a�ciril peaaida io the fono o(�STOT WORK ORDER aad a A�t otStoaoe.d.r a.iost me. [�tdeesta�d tlat a copy of thi�statement mar be forw�arded to Me ORice of iavati��tiom of the DtA for eoven�e veriAe�tiM. /do�her y rrif}•under tbe pains rnalties ojp�rjury ai t injorntatioa providtd abov�t is trrte a�d corrtct Signature ' a� � cS Print name �/J�i ��^Q�T7" �d��y G(,�f�/1..5'0�1 Phone N cS`"d�'�`��'l�o� �o . otTicial use only do not M�ite in thia are�ro be completed by citr or bwn oAkial city or tav►n: YA��DT$ _ • peresiNieeax M nBuildiog Dep�rtmeat �Lieensiog Bo�rd �cheek if immediste response is required 261 �Seleetmen'�ORee �He�lth Departmeot contact person: P��p;_ (508� 398--2231 eat. nOther �re�nea J��P1A� � .. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-013 FEE: $50.00 LODGING HOUSE LICENSE 'This is to Certify that a Lodging House License is hereby granted to Nancv L Johnson Inv.Tiust d/b/a Beachberrv Inn at 157 Berry Avenue.West Yarmouth MA in said Town of Yarmouth and at that place only and expires December tlurty-first,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. T'his license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forry,of the General Laws,and is subject to the provisions of sections twenty-two to thiriy-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Twenty-seventh day of August A.D. 2002. BOARD OF HEALTH: �s�. �e�ez �D. C%ando�C, .��ce *xEs'r[uc'rtolv: Continental breakfast only. �a�it jj �?au�x, (� Restricted to 7 bedrooms per septic design. �ct�r�e�'�c�� efe.� .S�ak. ,72. Bruce G.Murphy, ,R.S.,CHO ' Director of Health . Towiv oF Ya�oirrx BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-188 FEE: $30.00 , In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: N ncy I._ Johnson Tnv_ Trust, l 57 Berrv AvenLe, West YarmoLth, MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2002 BOARD OF HEAL,Tx: elca�ed�f, xeP�i��, ��rawc �eeaa�D, j%oad.o�. 71Z D.. `j/iee ,�o�ct� s�a, L?�rk �aa��D�tt �� s�, ��t au�t a� ,Zooa ruce G.Murphy, ,R.S.,CHO Directar of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #01-015 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancv L Johnson Inv.Trust d/b/a Beachberry Inn at 157 Berry Avenue_West Yarmouth MA in said Town of Yarmouth and at that place only and expires December thirty-first,2001 unless sooner suspended or revoked for violarion of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,tlie undersigned have hereto affixed their official signatures,this Twenty-seventh day of August A.D. 2002. BOARD OF HEALTH: 'r�. i�efl�'raa . t��ci��. G�io�rd.arc. .�iee =�S1�ttcT[orr: Continental breakfast only. ,�o�eat� �xotavt, �� Restricted to 7 bedrooms per septic design. �u.�riek��nrot� � $ . .'� , ruce G.M hy, , .5.,CHO irector of Healt TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NiJMBER: #01-194 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: Nancv i.,. Jahnson inv_ Tr�st, 1 S7 Berrv AvenLe,W��t Yarmo � h MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2001 BOARD OF HEALTH: �a�rlea ,`� �eP��, Llr,ai�u,ra.,c �fa�c D. C��. �'K.D., ?/�ce �a�rt� �zou�, � �a�iiek��xo� � s ��t Au�t 2� ,Zooa �ruce G.Murphy, , .S.,CHO Directar of Health . � �'� �� , I� � � � � MG� D ` TOWN OF YARMOUTH BOARD OF H�A3.'�H,,,� � APPLICATION FOR LICENSE/PE QO 't°� FEB 2 ZOOO f-�� '?�"��o' � * Please complete form and attach all necessary documents by Dec��`inb�'31, 1)99�Fail E T n the return of your application packet. �.�y ----------------------------------------------- ---------------------------------------------------------------------------------------------• N F E S N • �c•r/� �, r� # �J - O L TI r G r �`i MAILING ADDRE S S: �a��l �� i1�ii�'i,�r�is .�-�7�. 0��6� OWNER/CORPORATION NAME�, /?�ar�� L �la�s�i.sa� _-- MANAG�R'S N��V1T: �S"c m c� TEL. # 7 7/-//� MAII.,ING ADDRESS: .��ox �3 S�a2 v'�/�/�i.r �'>c'i, a'�?G�l �'OOL CERTIFICATIONS: The pool supervisor mast be certified as a Pool Operator, as required by new S�ate law. Please list the desi�nated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your ptace of business. 1. 2. 3. 4. HEIlbiLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT 5EATING: TQTAL# NON-SMOKING SEATS: TOTAL# ------____�______--_----------------------------------------------------�----------------------------------------------------------------- OFFICE U�E_QNLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 INN $50 CAMP $50 I LODGE $50 Z, - �TRAILER PARK $50 MOTEL $50 SWIlVin�IIlVG POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 / CONTINENTAL $30 y2�-14•� >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESAI.,E $75 RETAIL SERVICE: 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. $200 N At,ME CHANGE: $10 AMOtTNT DUE = S �3 O. �� """""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'"•"" �, - � ; � ADMINISTRATION G LJND�R,C�APTER 15 SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED T�O HOLD ISSUAN��OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HA�E A CERTIFICATE OF WORKER'S COMPENSATION INSUR�NCE. 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��,.s TOWN t)F YARMOUTH TAXES AND LIENS MUST BE PAID►PRIOR TO RENEWAL OR ISSUANCE�F YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO I/-- NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YQUR RESPONSIBII.TTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEM��IVT. RENOVATIONS MA.Y REQUTRE A SITE PLAN. AI�DITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIEMNIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CL4SED FOR THE SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE C�UNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTD�OR IN GROUND SVVIlVi1ViIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLTCY: 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 TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPAR.TMENT. FR02EN�ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN TI-�E SUSPENSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OiJTSIDE CAFES(i,e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MiJST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. �?UTDOOR COQKING: OUTD(JOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII., OR FOOD SERVICE ESTABLIS�IlVIENT IS PROHIBITED. DATE: �?��;�o e SIGNATURE: �� , �y�Z`..... PRINT NAME& TITLE: D�.,rr�r 11/12/99 � ` ` �\ The Conrmonwealth of Massachusetts ' � � Department ojladustrial,-�ccidents " ; OflICO o1/�s�lOstfiis ; 600 Washington Street ' •` Boston.Mass. 02111 � V�y ~ W'orkers' Compensation lnsurance Affidavit A�nlicant information: p►easepRiN97"Tr�,-i.i�r -- ---- �„ n;►m�� /(/C//�L'1/ � I��/�/7SOh Lc�cation: /�'� �/^f-✓ � � ' �c� �Glr/�io v�L, �'1�� ehone q 77/%/9� � t a a homeowner pert�rming all work myself. am a sole proprieror �-� ha�e no one ��orkin� in am�capacin• � I am an employer pro��ins workers' compensation for my employ�ees w•orking on this job. s4mnanr name• address• sitv• 2hons tl• in�urance co, p�Y q � I am a sole proprietor. generai contractor. or homeowner(circ%oneJ and ha�•e hired the contracton listed below ��ho ha�e the follu��in_ ��orkzr� �ompensation polices: �mnanv name• �stdress: cin: nhone ff• insurancc co. Qolic}•# �m�anv name• ad d ress: �'� �hoee 1!• insurance co. ��,� t Failure to secure coveraee as required under Secnon 25A of MGL 152 ea�lud to tbe iopailioe of trisi�al pesaltla ota d�e op to S1�00.00 a�d/o� oae yean'imprisonment a�w•ell a�eivil penaida io the form ot a STOP WORK ORDER aad a Bee of 5100.00 a day apinst me. I a■dena.d mar a copy of thh statement mav be fonvarded to the ORice of tnveatigatioo�of Me DIA tor eoven;e veritiatia. /do hrreby ceni�nder tlrr poirts and penalfies ojperjury that tht injormation providtd abovt is trtre wed eentei Signature ' � a�'�d Print name /(/C�/�c✓ L. �/p�i��'ov> Phone li � 7/`//16 ., olTicial use onl� do not..rite in this area to be completed by eiry or town oAfcial ciry or town: YA��IIT� _ permidlicea�e p nBuildiog Departmeot pLicensiog Board 0 cheek if immediate response i�required 261 �Selectmen'�ORiet �HeaitA Oepartment contact person: phone M;_ �508� 398--2231 egt. nOther .. ,< �,,, , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-164 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Nancv T,_ Johnson, 1�Avenue, West Yarm�uth, MA Whose place of business is: Beachberry Lnn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2000 BOARD OF HEALTH: $al�K. �et�, ��ca�c �Oa�c E. Suf,(,�va�c. �'yl.. ?/�ee �kaGr�rra� ��it� b'a�rac. L� $ -s�oo�tru d' / �u � Februarv 29 ,2000 " Bruce G. Murphy,MPH, .S.l,� Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-13 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Nancv L Johnson d/b/a Beachberr�Inn at 157 Berry Avenue West Yazmouth 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 relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Wher�eof,the undersigned have hereto affixed their official signatures,this Twenty-ninth day of February A.D. 2000. BOARD OF HEALTH: $d�'1L. jretleo. �lrai�.xa�c �oa�c �. S�a�iva�. ,�72. `t/ice L�ra.� =RESTRiC'['lotv: Continental breakfast only. �� • �'� Restricted to 7 bedrooms per septic design. •S +��i� �Y��d<a�� e_�S� � Bruce G. Murphy, MPH, .S., Director of Health �a.ah �r�� 1��r� � . � � °' TOWN OF YARMOUTH BOARD OF HEALTH � � � (� � �I [� pp �' APPLICATION FOR LICENSE/PERMIT- 20� � pEC 0 9 1999 � �� * Please complete form and attach all necessary documents by December 31, 1999. Fail re��v�l��ult n the return of your application packet. ----------------------------------------------------- ---------------------------------------------------------------------------------------_. N F E T S ��'� � # -SS�� L ATI — r � r w� � L D N ' T sS ' �-'� #so8 8S6 D Te.r�- t-w. POOL CERTIFICATIONS:Y---- -----�`-----------------------------------------------_---------------------------------------� The pool supervisor must be cer_tif'ied as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certificati�n 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. lfie Health Department will not use past years' records. You must provide new capies and maintain �fde at your place of business. 1. 2. 3. 4. �Il1�iL,ICH�ERTIFICAT�ONS: /U-�� 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 af 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. RESTA�.JRA�iT SF,�TING: TO-T�I,# -NON-�Iki��I�T�'s-S�A�:TCI�'�L,#— -- . _ _ _ ------------------------------------------------------------------------------�------------------------_--------------------------------------• OFFICE U,,�E�ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRED FEE PERNIIT# $&B $50 _CABIN $50 INN $�0 JCAMP $50 �LODGE $50 y?�-7 �TRAII�ER PARK $50 MOTEL $50 _SVV]�IMING POOL $SOea. VVII�LPOOL $25ea. FOOD SERVICE: LICENSE REQUIKED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 �CONTINENTAL $30 y?.�—�j I >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # <50 sq.ft. $45 TOBACCO $24 <25,000 sq.ft. $75 FROZEN DESSERT $35 >Z5,000 sq.ft. $200 NA�ME CHANGE• $10 �f AMOUNT DUE = $ �x I� "••*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""" � - ......_.... . .. .. . ....._.......,....,__.._,,.:._ f � ' ADMINISTRATION ` � UNDER CHAP _TER 15�, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED TO i�OLD ISSUA�C� OR RENEWAL OF ANY LICENSE QR PERMIT TO OPERATE A BUSINE55 IF A RER�ON OR �Q1�IP�NY DOES NOT HA�E A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. 'TH��TTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN �F YARMOUTH TA7�S AND LIENS MUST BE PAID►PRIOR TO RENEWAL OR ISSUANCE QF Y�UR PERMITS. PLEASE CHECK A�PROPRIATELY IF PAID: YES 1/ NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASOATAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENTNG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE�tEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATION5 PUOLS POOL QPENING: ALL SVVIl��IMING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CL4SED FOR THE SEASON MUST BE 1NSPECTED BY TI-�HEALTH DEPARTMENT, AND'TI-�WATER TESTED FOR PSEUDOM4ATAS,TQTAL COLIFOR��I AND STANDARD PLATE C�UNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDDOR IN GROUND SVVIlI�INIIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN('7)DAYS OF CLOSING. FOOD SERVICE rATEIZTNG POi TCY: ANYONE WHO CATERS WITHIN T'HE TOWN OF YARMOUTH MUST NOTIFY TI-�YARMOUTH HEALTH DEPARTMENT BY FII.ING THE REQUIRED TEMI'ORARY 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 MONTHI.,Y BA5IS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI-�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN THE SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,TI�ABOVE TERMS HAVE BEEN MET. - OUTST�T E CAFE�; OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �TST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOI�iNG• OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTAB ISHMENT IS PROHIBITED. q 0 DATE: / 6 GI ( SIGNATURE: PRINT NAME& TITLE: � Ci (�Ir 1� �U� t.� 4. r (/�t/h�'-IJ~ 11/12/99 . j � .. The Conimonwealth ojMossachusetts � � Department ojlndustrial.-�ccidents ' o OJ11C001/aYCS�O��IIt ; 600 Washington Street ' •� Boston.Mass. 02111 �~ ��y W'orkers' Compensation Insurance Affidavit n m•. (/�� locatian: I �� {.,�2��(,f �V e t • , f�(�� a �"1�,o � D `7 � S—� � t�m a homeowner p rt�rming all w�ork myse f. (�/1 am a sole proprieror �::� ha�e no one ��orkin� in am� capacin• � I am an emplo�er pro�i�iins w�orkers' compensation for my�employees woricin¢on this job. m an � n � �� ` a�ldress: �S7��e��v'e � �i��' �"'� 1 /a I��i► t�G( �—�L�� nhone M• �� /�� b�(� � insurnnce co. po��y� � I am a sole proprietor. generai contractor. or homeowner(circle onel and ha�•e hired the conaactors listed below ��ho ha�e the follu�.in: ��orker_ �ompensation polices: s4mpanv n�me• address• citv: ohone M: insurancc co. oolicylt _ t�R�r?'rtamr: - ------- -—------- ad d ress: citv: nbone It• insurance co. �� • Failure to secure covera�e as required under Secnoo 25A of MGL lS2 ea�iad to the ioposidoe olerivi�d pesdtles o(a 6�e ap to 51,500.00 a�d/or one yean'imprisonment s�w•ell a�civil penaitia io t6e fo�m of a STOP WORK ORDER aad a tiee of SI00.00 a d�r tpiost ma I r�dersta�d t�at t copy of thi�sqtement mav be fonv�rded to the ORce of tnve�tig�tiom of t6e DIA for eoven�e veritiqtio�. 1 do hrreby cenif}• der th�par and rn 'es ojperjury that�ht injormation providtd abovt is ntt[ co ct Signature ate � � ` Print name �1� �Dr b�'-'��C�-1 Phone� 7� S G `S�g .- ofticial usc onl. do not..rite in this area to be completed by citv or town oAfeial ciry or town: Y�M�DT$ _ permitAicense N nBuilding Department �Lieeosing Board �check if immediate response i�requi�ed 261 �Selectmen'�OtTitt �HealtA Departmeot contact person: phone M:_ �508} 398�?231 est. nOther .. < �„� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-51 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 t 1, Section 5 of the General Laws,a permit is hereby gtanted ta K. C'TabrielB_ Karlin/J_ Ross, 157 Berr; Avenue, West YarmoLth, MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH: �d nl. �et�ea, C�rca.� �foa�,c �. Sullt��. �72.. ?/tcc L'�aac ,�o�ie�rt� �, L� �� December 17 , 19 99 Bruce G.Murphy, H, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-7 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to K.GabrieUB.Karlin/J.Ross d/b/a Beachberrv Inn at 157 Bem Avenue.West Yarmouth.MA in said Town of Yarmouth and at that place only and expires December thirty-fust, 19,29 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issue� in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Seventeenth day of December A.D. 19 9�. BOARD OF HEALTH: ,��id'� �etYed, L'��aac �Oa�ec �^. Su�lltuaa. ,�72.. `l/1ce �4avu�ca.t •xEs'1'R�C�'totv: Continental breakfast only. �o�att�. �rou�, �� Restricted to 7 bedrooms per septic design. $ �ooy(ied d'�a�e,�� F ' ruce G. Murphy,MPH, .5., O Director of Health .� . �aClr►b�rr��nr� � : �; ., QCC� L� OML� D • TOWN OF YARMOUTH BOARD OF HEALTH t ApPLICATION FOR LICEN �%P � 1�519' '�'�. �U N � $ j�� ,{ �� z a .`� y, � e * Please complete form and attach all necessary documents by ece��1,�9�`°' i� E T �I.re lt in the return of your application packet. -------------------TABLI---------------------�--- ��--�--------------------------------------E---�Dg----�gS;G� O A I N S: S e��` w � C RAT N N • � �-%� roi r- �'� os ER' � �f L. # '7'1 `�sb � �s' ��r �e. (iC/� �{ In-. �i ---------------------------------------- pnnL C'ERTIFICATIONS: The pool supervisor must be c ie as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cun'ently certified in basic water safety, standard First Aid and Commuiuty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus 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. HFIlVILICH CERTIFICATIONS� All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcmg procedures below and attach copies of employee certifications to this form. The Health Department witl not use past years' records. You must provide new copies and maintain a frle at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# --------------- --------------------___------------------ - -- ___ -— - ----- --��ICE�3E-�i�L�- ------ -- __ LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 I LODGE $50 �� TRAII.ER PARK $50 MOTEL $50 _SWINIlVIING POOL $SOea. WHIIt,LPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 �CONTINENTAL $30 '�/� >100 SEATS $150 N()N-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SE�tVICE: LICENSE REQUIRED FEE �ERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ �- *'"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R R f\R f � ADMINISTRATION � • , UNDER C�3APTER 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 STAfiE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR. CERT. OF INSURANCE ATTACHED - � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED _ TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK�PROPRIATELY IF PAID: YES �� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATTONS TO ANY FOOD ESTABLISF�VVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SV�VIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON NI[JST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �ATERi1�TG POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NQTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. �:OZEN 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 WII,L RESULT IN ___ SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS — — -- - - - - --- - - - HAVE BEEN MET. - OUTSIDE CAFES: OiTTSIDE CAF'ES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD SERVICE ESTABLISHIVIENT IS PROHIBITED. � DATE: /Z— Z° g g SIGNATURE: PRINT NAME& TITLE: � � ��r/r� Gy �/r' D w�� ' �. . � � The Conimoawealth of Mossachusetts � W � � � Department ojlndustrial,-1 ccidents o Olflce ol/�s1/osdiis 600 Washington Slreet ' •� Boston,Mass. 02111 '� ��y W'orkers' Compensation Insurance Affidavit Annlicant information: Pfees�PR�7'Teir,'� mmr� �� (TPl'�f'"� � a .o � _ �/�I^ '�`� , cit� !/(/ � _/ ��U G/ � / c A G��i � � phone#S� 8' rJ`7/ �;�� I a a homeowner pertorming ali work myself. f am a sole proprietor�r,� ha�e no one��orking in anv capacity � 1 am an employer pro�idin� w�orkers' compensation for my employees w•orking on this job. om an • n �'G3� ��/'� � address• c.� / � /� v' E', ; .; G�/ o �t �, � G26� �..S� '7� � �s�� insurance ca Dolicy# � i am a sole proprietor. oeneral contractor, or homeowner(circle one/ and ha�•e hired the contractors listed below «ho ha�e the follo«in� ��orker� �ompensation polices: companv name• address c1.y: phone#�• insurance co. yolicy# comqany name: -- - - ----- __ _-------- -- ----- — ---- _ —-- - address: . . -- - c�: nhoee M• insurance co. �N Fsilure to secure coverage as�equired under Sectioo 25A of MGL 1S2 n�lead to t6e iopaidoo ot erioi�l pe�altla of a A�e op to 51,500.00 a�d/or one yean'imprisonment aa w�ell a�civii pena�da io the(orm of a STOP WORK 0[tDER aad a liae of 5100.00 a day qaio�t se. [a�denta�d that a copy of thi�statement may be fonvarded to the Ofiiee of Investigation�of the DIA for eoven`e ve�i8tatio�. /do hrreby cerJij}�un tr rhe poins penalti s ojperjury that tht injorn�ation providtd abovt is trtte and eontd Signature � � /z— Z b � Print name Z� �� }'��- Phone�l � �� 7�`'� '� �' / ., o(Ticial use only do not write in this are�to be completed by city or town ofllti�l ciry or town: YA�� _ permitAieense p nBuildiog Department �Liceasiog Board �check if immediate response is required 261 QSeleetmen'�Ot'fiee (508} 398�2231 egt. �Health Departmeet contact person: phone 1!;_ _____ nOther Ire.�ised i,o5 P1A1 • . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-18 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Gabriel/Karlin/Ross d/b/a Beachberrv Inn at 157 Berrv Avenue.West Yarmouth_MA in said Town of Yarmouth and at that place only and expires December thirty-first� 19 99 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affi�ed their official signatures,this Twentv-second day of June A.D. 19 99 . , BOARD OF HEALT'H: Fd�L. �et�ed, ��ca�s �oa�s �, Su�ivaa. ,��l.. ?/�ce L'�vr�ra�c *xESTtucTTON: Continental breal�ast only. �o�rt� b�7oukc, �� Restricted to 7 bedrooms per septic design. .$ -'�fou�ed d" ce G. Murphy, MPH, .S HO Director of Health TOWN OF YARMOUTH . BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-192 FEE: $30.00 In accordance with re�ations_promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 3 of the General Laws,a permit is hereby granted to: (',ahriel/Karlin/R�s�, 157 Rerr� Avenue,, West Yarm�►rth, MA Whose place of business is: Beachberry Inn Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31 1999 BOARD OF HEALTH: �d�L. �e�. �� c �. S�a�vax. ,�.72.. 2/lc.ce L�� a�att� �i'aou�wc. L� s�� June 22 , 19 99 � ruce G. Murphy, , . ., CHO Director of Health . ��• �'� � �,.,�a.;�,,,, :�c�► ��, . . , � • �� .: _ � � . � � � . ��^�r�". �� .�� li L . � ��. . .;' ., �� TOWN QF YARMOU'I"H APPLICATION FOR LIC�NSE /PERMIT - 1998 J U L 0 6 1998 Fl�:n,�;�-; !,,;=�T. .._.__ , .._..__._... *Please Complete form and attach all necessary documents by December 31, 1997. Failure to do so will result in the return of yout application packet. N--------�-----------------------T----- - --------- ��----- - --�--------------#--------�-/---G � S: c� `' v L t'l�o 6 ING DRES ��t O O a �r� �� D� , �-! E :s� `7 .S`6/ rr �e �r H e�2 6 POQL C�RT�F�.CATIONS: /�G� Pool Operators must list a�unir�ufn of t�vo employees currently certified in basic water safety, s#andard first aid and Com�nunity Cardiopulmonary Resuscitation(CPR).Please list these employees below and attach copies of employee certifications to this form. The Hea�th Department will not use past years records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4, HEIMLICH CE TIEI��TIONS; �,G! r .All food service establishments with 25 seats or more must have at least one employee trainned in the Heimlich Man�uver on the premises at all times. Please list your employees trained in anti- : choking procedutes below and attach copies of employee certifications to this form. The Health De�artment will not use past years records. You must provide new copies and maintain a file at yaur place of business. l. �. 3. 4. RESAURANT SEATING: TOTAL# NQN SMOKING SEATS: TOTAL # D �IC IJS��lYb� _ _ . --- - _ _- . �,ODGING: LIC. REQLTIRED FEE PERNIIT# LIC. REQLJIRED FEE PERNIIT# _B&s �so c�srN $so +nviv $so c� $so �LODGE $S0 �Ia—"I� �TRAILER PARK $50 T MOTEL $50 _ SWiM POOL $$Oea. ,_WHIRLP04L $25ea. ��?OD SE VI��: L�C. REQTJIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# 0-100 SEATS $75 l CONTINENTAL $30 �.�2 >100 SEATS $150 ___^`___ NON-PROFIT $25 ._COM. VICT. $SO WHOLESALE $?5 8&�Al� S��tVIC:E: LIC. REQUIRED FEE PERNIIT# LIG REQIJIRED FEE PERMIT# _<50 sq. ft. $45 TOBACCO $20 _,.<25,000 sq. ft. $'15 ____FROZ. DESSERT $35 >25,000 sq. ft. $20Q AMOUNT DUE — � ��J , � - � _ , , + ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SLTBSECTION 6, THE T�WN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEW.AL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPAI`�1Y DOES NOT HAVE A CERTIFICATE OF WORKER'S COMI'ENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMP�NSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES ANA LIENS MUST BE PAID PRI4R TO RENEWAL OR ISSUANCE OF YOUR PERMTTS. PL SE CHECK APPROPRIATELY IF PAID: YES 1�10� NQTICE: PERMITS RUN A►NNUALLY FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)�3Y DECEMBER 31, 1997 SEASONAL��TABLISHMENTS ARE TO CONTACT�'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�IG FCUR THE SEASON. ALL RENOVATIONS TO ANY F04D ESTABLISHMENT,MOTEL QR POOL (i.e. , P.AINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TU AND APPROVED BY THE BOARD OF'HEALTH PRIOR TO COMMENCEMENT. RENpVATIONS MAY REQUtRE A SITE PLAN. ADDITIONAL REC�tTi�ATIONS POOLS POOL OPENiNGr: ALL SWIMMIING, WADING AND WHIRLPOOLS WHICH HAVE$EEN CLOSED�'�R'�'HE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRI+�R TO OPENING. POOL CLOSING: EVERY OUTDOOR IN GROUNI3 SWIIvIlVIlNG POOL MUST BE _ _ D�lf��3�R C4�ERE�1 WITH�T SE��N(�') D34�T5 OF CLCl:�IN�. - _- --------__--------- -__ _ __ FOOD SERVTCE CATERING PU�ICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEAI.TH DEPARTMEI�TT B�'FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION F(�RM 72 H4URS PRIOR TO THE CATE�2ED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. �,I�O��T D�SS TS: FR�ZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST R�SULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATI�N OF YOUR FROZEN DESSERT PERMIT UNTTL THE ABOVE TERMS HAVE BEEN MET. OLITSIDE CAFES: OUTSIDE CAFES(i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. �UTDO�'.L C�OKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. � a DATE: O � SIGNATURE: , r PRINT NAME &TITLE: E' �� G . d t.�/�i�G' 1?�lGj�� /� � 10/97 � page 2 of 2 -- __._ _.��._._._ _ ��.. --- _ �.: __ '_ � � � The Commoawealth of Massachusetts � W Department ojlndustrial.accidents T o Olflceo/%ves�losUiis � 600 Washington Street ' yOy BOS�O//� Mass. 02111 � � y�♦ W'orkers' Compensation Insurance Affidavit m• � /r � i j � �: /' v � - �, G� � Y"1�1 a t� D 6 � � 8 �� i� � I am a homeowner pertormin�all work myself. �am a sole proprietor�r,,i ha�e no one��orking in am•capaciry � I am an emplo�er pro�idins w�orkers' compensation for my employees workine on this job. � om n •n � address: s �� e � ; .. oi� D�t (.h G�6� a• S� insurance co. po�i�y q � I am a sole proprietor. general contractor, or homeowner(circle oneJ and hace hired the contractors listed below «ho ha�e the follo��in� ��orker�� :ompensation polices: ; sQmp�nv_name: address citv• Rhone#i• insurancc co. Aolicv# com a�ny_name: - __ _ _ . _ __ _-- _ _ _ _ _ _ -- _-- - a�d ress• ciri: Fhoee ; insuraas�s4. ��y� Failure to seeure coverage as required under Sectioo 25A of MGL l52 ea�lad to t6e ioposidoo oferioi�l pesdtla ota ti�e ap to 51,500.00 a�d/or one yean'imprisonment a�w•ell as eivil penaldn io the form of a STOP WORK ORDER and a ffoe of 5100.00 a day a=ainst ma [a�dersta�d t6at a copy of this statement may be forwarded to the 01Gee of Invatig�tion�of t6e DU for eoven`e veritie�tb�. /do hrreby cenij}�u r ihr pain d pe lties o jury tbat tht injormation providtd abovt is trut an eo e � G 9� Signaturc � Print name � �� Phone� �� .. olTicial use only do not write in this area to be completed by eiN or town oRicial ciry or town: Y�M�IIT� _ permiNicea�e q nBuildiog Department QLicensiog Boud �eheck if immediate response is required 261 �Stlettmen'�Ot'fiee �Health Departmeot contact person: phone p;_ �508� 398--�2231 eat. nOther Ire��szd iAt P1A1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-192 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: _ CTabriel/Karlin/Rocs, 157 Berrv Avern� ., Wect Y rmo � h� 1��A Whose place of business is: Beachberrv Inn Type of business: _ Continental Brea`kfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 1998 BOARD OF HEALTH:�d�/. �et��, C'�r„r►Q,� �oaa� Jallivan�Ke./7•� �ice l.�irmart. lC 6art.}. /�rown� �[erh abrioLLe�ako[d�r�../�tooped �c�e aCou�h[e�n Ju�y 14 , 19Q� ruce G. Murphy,MPH, .,C ` Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-16 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Gab 'eUKar in/Ross d/b/a Beachberrv nn at 157 Berrv Avenue West Y r•+out�MA in said Town of Yarmon and at that place only and expires December thirty_first, 1928 unless sooner suspended ar revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the suthority granted to the licensing authorities under section tweniy-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-iwo to thirty-one inclusive of said chapter. In Tescimony Wher�f,the undersigned have hereto affix�theit official signatures,this Fourteenth day of 7ulv AD. 19 9�. so,�oF�,�rx: �'d�1'/. �ot�, ��. �oan� �u6fsvan� K.//.� Vice (�lutirrrucn 'RESTRICTION: COIItlIIBIIte1 bie8lCfast oIIly. Ko�ert,}, p�iwwn� C.[erk abriaL[a�a�o[e��oo�oe� ic�o[O oCou��[in ruce G. Murphy,MPH,RS. CHO Director of Health T � - . Q�G.C.� �eNf�/ �-rv1� ^� ��*,. �L,{� �t z. � � �� x>�;r : �/" , <,t,.a:4 '; r'.- �"'3��'� � � Y �j�� r �L H G3 �, C� � TOWN OF YARMOUTH � � C� D APPLICATION FOR LICENSE / PERMIT - 1997 ,�AN 0 3 1�97 * Please Complete form and attach all necessary docu.ments by December 31, 19 �'T• so will result in the return of your application packet. -------------------------------------------- --------- --- ----------------------------------------------------- NAME OF ESTABLISHMENT: �'�� ' �!�'�' TEL. # - �� ADDRES : Li =� v`!" v� � � •-Vj�t MAILING ADDRESS OWNER C RPO IONNAME: �'d � ` �i`c . , �S ��o;�� MANAGER'S NAME: � c - �i��. E .# ' � LING ADDRESS: S �-rT' v�. - v� - -- - ----------------- POOL CERTIFICATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and Community Cardiopulmanar�_Resuscitazion(CPR�.Pl�ase 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. l. r��i � 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti- choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years records. You must provide new copies and maintain a file at your place of business. 1. !�l? �� 2. 3. 4. RESAURANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL# ------------------------------------------------------------------------------------------------------------------ -- _ ____ __-- -- _ - -- — — -------AF��-��-�A1��___ _ LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQLTIRED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 CAMP $50 � !LODGE $50 q�� TRAILER PARK $50 _MOTEL $50 SWIM POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LIC. REQLTIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $3 q�-ll7 _>100 SEATS $150 NON-PROFIT $25 _COM. VICT. $50 WHOLESALE $75 RETAIL SERVICE: LIC. REQUIRED FEE PERMIT # LIC. REQUIRED FEE PERMIT # <50 sq. ft. $45 _TOBACCO $20 <25,000 sq. ft. $75 _FROZ. DESSERT $35 >25,000 sq. ft. $200 AMOUNT DUE _ ��r G� 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 PERMIT TO OPERATE A BUSINESS IF A PERSONOR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION 1NSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. P�LEASE CHECK APPROPRIATELY IF PAID: YES 1/ NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQiJIRED FEE(S) BY DECEMBER 31, 1996. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENI1�iG: ALL SWIMIVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MCTST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPENIlVG. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMNIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. . _ _ - --— _ OUTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS�IMENT IS PROHIBITED. �� DATE: � � � SIGNATURE: � � �: PRINT NAME & TITLE: ��C� /'1 1�C'��G�'( L'I,1°v'c..<.� i�EE !— °Yy��tia��`' c 9 /96 page 2 of 2 � � �. � The Commonwealth of Massachusetts � W Department ojlndustrial.-lccidents T ; Olflce ol/�sl/�sthis � 600 Washington Street ', •` Bnston,Mass. 02111 w ,�,� W'orkers' Compensation Insurance Affidavit Annlicant intormation: PleasePRilQTTe�r.'�d�c n�m•: '�` ��✓� � C �on: � ' � v�' �G'' � +-�� .��p" .Vc�. j/t.�, �'�d'�M�G'� d;L��/_j cit� Rhone# ��t / l" U'J �Cj ��a homeowner pert�rming all work myself. am a sole proprietor�:;� ha�e no one ��orkine in am•capaciry � I am an employer pro�idins workers' compensation for my employees working on this job. comoam• name• address city: phone q• insurance co. ,policy# � I am a sole proprieror. general contractor, or homeowner(circle onel and have hired the contractors listed below ��ho ha�e the follo��in��orker_' �ompensation polices: companv name• address• c�': phone#: insurancc ca policy# comnany name: _ ---- -— ----- -- -- ----— ------- ------ address: -- ------------ c�: Rhone#• insurance co. pofiey ff Failure to secure coverage as required under Sectioo 25A of MGL 152 eaa lad to tbe iopoeitioo of erimi�al pe�altia of a 6�e op to Sl*500.00 a�d/or one years'imprisonment as w�ell as civil penatda io the fo�m of�STOP WORK ORDER and a fine of 5100.00 a day ae�inst ma I a■dersa.d ma�a eopy of this statement may be forwarded to the OtTiee of(nvatigatiooa of t6e DIA for eovenge veritieatio�. I do hrreby certif�under�he parns,arh�penal�s ojpe u that t/rt injorn�ation providtd abovt is trtte and co tct / Signatur � �� '� � ate � �✓� �� '`( � �� // Print name �""/_'> � �.'- i Phone# ��O ' / � � ��7 ., oRcial use onl�• do not write in this ara to be completed by ciKor bwn oflicial city or town: y�M�IIT� _ permitAicense p nBuildiog Department pLicensiog Board �check if immediate response i�required 261 QSelectmen'�Offiee �Health Departmeot contact person: phone It;_ �508} 398�2231 ext. nOther Irecised i;95 P1A1 ♦ i p r NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 97-12 �50.00 ........-•-•-.........r.� ....... of ----YARIv�DUl'H LODGING HOUSE LICENSE '' This ia to Certify that a Lodging House License is hereby granted to ----•................................. ........_..KIN GABRIEL, T. ROSS,._ B...KARLIN DI��A$�A,��..�N�L.............................. . . .... a� 157 BERRY AVFNUE, WES'I' YARMOUTHz_.MA-------------------------------------------------------- ' in said.................��Q�I..__. and at that place only and eapires December thirty-firet 19.4T.. unless sooner �suspended or revoked for violation of the laws of the Commonwealth of i Massachusette relating to the licensing of Lodging Houses. � This licenae is iasued in conformity with the authority granted to the licensing suthoritiee under section twenty-three, of chapter one hundred and forty, of the General Laws, and is + ' I aubject to the provisions of sections twenty-two to thirty-one inclueive of said chapter. ' ; , IIn Teetimony Whereof, the underaigned have hereto a�'ixed their official signatures, : thie.__..24TH-•-•--•-••-•....dap of....-----•-----------�.E��RX--•--•............ . ..... .. A. D. 19.4.7.... ,,� •------- ��Ae+a.-+R.-. •............. .... , , --- ... .. , ...-----•- -... ----•-------------•---• --�'- �~ -- -- - --- Licensing � .......--- -•--• ............... ............._..._...._..---....------ . .... ._. . ; ......... ----� .1�!�-�5........:..... Authoritiea _ .. . J�_�J •- --------�--•-- --- .. i .....-•-----•-•f'--- --•-•--• .......................... i / G� �d�`'' FORM S 547 A.M.SULKIN,INC.-BOSTON (817)542-5858 ,/�' . • (OVER) I v `' \7 � NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 97-117 $30.00 ............T.�.. of .. . YARMOUI'H ..................... Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. ...--- ..... ...JANUARY. 24,.. 19.97.. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter I 11, Section 5 of the General Laws a Permit is hereby granted to: ... KIN GABRIEL,. T:.ROSS,. B:.KARLIN, .157 BEFZRY AVFNt.IE, WFST YARIvIOUTH..... Whoseplace of business is ..B��Y.I�,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Type of business and any restrictions ................�I�r�T-:B��T ,,,,,,,,,,, �. ........ To operate a food establishment in ..................YAR�JTH........................... (City or Town) Yermit�Expires .. .D��.31,....19.97. �`RFSTRICTIQ�i: ..... � � �� CON'!'INFNrAL BREAKF'AST' ONLY...... .j!�!�,Q`..-�.�. Board ,c �j��, of .......L�:tt�!!r!!..��.. .�:� Health ,/A/ �. FORM738 A.M. 9ULKiN COMPANv •••••• ••�w�`I,C�� •�••��VVVY-... �� 1 TOWN OF YARMOUTH BOARD OF HEALTH ;a� ��` �'�� ^ - ~ APPLICATION FOR LICENSE/PERMIT_- 19g6 � �� ---------------- - -- �� .� � -------- ------------- ----------------------------------�----- NAME OF ESTABLISHMENT:�_�,,�t��/ �� ____ TEL. NO^`_�� _. - / � ,p r �'��u�_- ADDRESS_._�,��_�5,.��- � ----,.--- - � MAILING AllURESS (IF DIFFERENTj : � ----- _ _. ___._ _ �..__.�._._._- OWNER/COR�'ORATIOIV NAME:--��(f_!�C / ..Q_._� � -- - MANAGER'S NAME_--��G7�� C-' _ TEL. NO!_ _ ----_ MAILING ADDRESS: � v� �� `� RESTAURANT SEATING• TOTAL �_ __ NON SMOKING SEATS 2'OTAL # _ • �/ � . Under Chapter 152, Sec: 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 Co. does not have a certificate of worker's compensa�ion insurance. The a�.`_ached State Workers' Compensation Insurance Affidavit �st be cou�leted ancl signed . Town of Yarmouth taxes and liens must be paid prior to yenewal or issuance of your permits. Please check appropriately if paid: yes ��_ no_ _ ----------------------------------------------------- All food service establishments with 25 seats or more must have at lease 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 their certifications^ 1.--------------------- ��"f � ^ 2 __ � 3. _- 4• ---- Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and Corrununity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to rnis form. v /-�/ 2. 1._�--- ----- ----�------ _.__ -- ---- - 3. __ _ _ _ 4•-_- _ ----- ------------------------------------------------------------- OFFICE USE ONLY LICENSE REQUIRED: FEE: PERMIT #. LICENSE REQUIRED: FEE: PERMIT FOQD SERVICE _ MOTEL $50.00 � 0-100 SEATS $ 75.00 CABIN $50.00 __^ ��OVER 100 SEATS $150.00 TRAILER PARK $50.00 � _ ` NON-PROFIT $ 25.00 � INN . $50.00 ��CONTINENTAL BREAKFAST$ 30.00 �� LODGE $50.00 � COMMON VICTUALLER $ 50.00 CAMP $50.00 � SWIMMING POOL ( ) $50.00ea. � VAPOR BATH/ ( ) $25.00ea. __ � WHIRLPOOL RETAIL FOOD SERVICE Less Than 50 sq.ft. ,prepackaged candy,gum,soda,chips $45.00_� LESS THAN 25,000 sq. ft. $ 75.00 � MORE THAN 25,000 sq. ft. $200.00 �_.__ FROZEN DESSERT SOFT-SERVE ICE CREAM $ 35.00 TOTAL DUE $ �C,�,�C� TURN OVER TURN OVER TURN OVER TURN OVER PAGE 1 OF 2 � ADDITIONAL REGULATIONS: � , c � CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NO`.PIFY 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 MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE) MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. FAILURE TO OBTAIN PRIOR APPROVAL FROM THE BOARD OF HEALTH WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FOOD SERVICE AND COMMON VICTUALLER PERMITS. OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. EVERY OU�'DOOR IN GRAUND SWIMMING--POOL MUST BE DRAINED OR COVFI�ED WITHIN SEVEN (7� DAYS OF CLOSING. RESULTS FROM POOL WATER TESTS BY A STATE CERTIFIED LAB MUST BE RECEIVED BY THE HEALTH DEPARTMENT PRIOR TO OPENING. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e. , PAINTING, NEW EQUIPMENT, ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. 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, 1995. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPT. FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. APPLICATIONS MUST BE COMPLETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE ABOVE TERMS HAVE BEEN MET. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. j. O D�TE�� - - _ SIGNAT�- � ' --- �- — ;- - - - - PRINT NAME & Title � ��,��,�//`/ � �l�t/�I� �i1Gj �� - .�- � � IMPORTANT: TF�SSE APPLICATIONS 1�JST BE C:OMPLE�m IN FULL AND SiJBMIZTED ON OR PRIOR TO D�II2 31, 1995 OR YOU WILL BE SU&7ECT �O AN ADMINISTRATIVE HEARING. 11/95 PAGE 2 OF 2 i �. w : � The Commonwealth ojMassachusetts ' ^ W Department ojlndustrial.-iccidents � o Offlceolleresl/pst/iis � 600 Washington Street .= Bnston,Mass. OZlll "�'" "•y W'orkers' Compensation Insurance Atfidavii , n m�: � r.� � � � — location: � S�� ./7 �.r�� c/� G�G'� � , �, � `7�/' S1� � t am a homeow�ner pertorming all w�ork mysel . ;p� I am a sole propriztor �:-� ha�e no one ��orkinc in am•capacin� ,_ _ " � I am an emplo�er pro�idin� workers' compensation for my employees workine on this job. compan�• name• �ddress• Sitv: Qhone q• _ ��ur�nce co policy# � I am a sole proprietor. _enerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below �tho ha�; the follu��in� ��orkzr� .ompensation polices: companv name• �ddress• S!�" phone f�• — insur�ncc co Qolic}_# com a�ny name• A�id ress• citv• �hone If• - �4sY� - e Failure to secure cove�age as required under Secdon 25A of MGL 1S2 eia lad to t�e imptaidon of erimiaai ptoaltla of a Ooe ap to Sl¢00.00 a�d/or one years'imprisonment as w•ell as civil penaldes io tAe form of a StOP WORK ORDER and a tioe otS100.00 a day apiosc ma I a■dersn.d mac a copy of thH statement mav be forwarded to the OtTice of lavestigatiow of the DU for eovenge veritieado�. 1 do hrreby certij}�un r rhe pains a , enal s ojperju t at 16t injorniotiv»p�ovidtd abovt is trut artd eo tet Signature ` U au 2 � �J Print name Cai � ��*� Phone�l 'T�.��— .- officiai use onl. do not..rite in this area to be completed by ciry or town otTicial - city or town• Y�M�IITQ permit/licenu q nBuildiog Depsrtmeot pLicensing Board �check if immediate response is required 261 ❑Sdectmen's Otfce OHealt6 Depu-tmeat contact person: phone q;_ �508� 398--2231 egt. nOther — . � NUMBER THE COMMONWEALTH OF MASSACHUSETTS FEE 96-5 $50.00 ��..---••--•----. of .__..._YARMOiJTH ... .. •-----•-------------------•-•--•---•-----•-......_.. LODGING HOUSE LtCENSE ' This ia to Certify that a Lodging Houae Licenae ie hereby granted to ................. , ------•-------•------ GABRIEL, KARLIN, ROSS__ 157 BERRy AVENUE, WEgT yARMpUTg ................•----•--------- •• ._.._..-------•----•-•- .............•----••--------•-----•------------------•---...--••------..... BEACH BERRY INN - at ------••................................•-•-------•-...._........_.._...---•---•-----•--.._..._. ._..--------•---•----------------------------•---•--------•----------- in said ..Y�MOUTH _ and at that place only and expires December thirty-first 19_96. i unlese sooner ,euepended or revoked for violation of the laws of the Commonwealth of Massachusetta relating to the licensing of Lodging Houaes. This license is issued in conformity with the authority granted to the licensing authorities ( under section twenty-three, of chapter one hundred and forty, of the General Laws, and ie subject to the provisions of aections twenty-two to thirty-one incluaive of said chapter. IIn Testimony Whereof, the undersigned have hereto af&xed their official signaturea, thia--•--27th-•.............. day of....DECEMBER --�-...---•-•................ � D. 1995__. - • •---• - . . -• � ----•--•-•- . --•-• ...: .. ... ..... ..... , ' ........... .. _. . " -------•------ - ' •--•---•--•-••-- I • - --- --- --�" :•-•--•-•---•-• Licensing ............. . . ---•---- -•- - - -- - - - ----------------•-•- ......_...__ Authoritiea - .. -- -•+..rr-•-• --- -- - ---- - ----•--•---...... ..•••..._.__. -••-•-••-•-•, ..--- --••� . _.._..."•'-...... `4 I FORM S 547 A.M.SULKIN,INC.-BOSTON (617)542-5858 (OVER� �� . � NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 96-6 $30.00 ... ....��. .. ... of ...YARMOLJTH ............. ........ . Board of Health of PERMIT TO OPERATE A FOOD �STABLISHMENT Permit No. .96-6.... .. .. .DECEMBER.27 . 1995... 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: GABRIEL, KARLIN� ROSS 157 BERRY AVENUE, WEST YARMOUTH .. .. ...... .. .... .... .... ........ .. .... ...... .... .... .. .. ...... ................. ....... . Whose place of business is ..BEACH BERRY INN.. ....... . . . .. .. ...... ........ .... ...... ... T'ype of business and any restrictions FOOD SERVICE—CONTINENTAL BREAKFAST . To operate a food establishment in .Y`��H... .... .. ... . . . .. ...... .... .. .. .... .... ..... (City or Town) Permit Expires , , DECEMBER 31 19 96 , � � s� � ! � Board .. .. . .. . ... • of ,., . . , � Health - FORM 738 A.M. 9ULKIN COMPANY - � •••• •~/�•• �.• t�� i,�~� '; � : „ � TOWN OF YARI`90UTf1 F30� UF HEALTH APPLICATION FOR LICENSE/PERI�9IT - 1995 �K.� Z6� � �� , -------------------------- ------- ----- --------------------- • ------------------------�------ I NAME OF ESTABLISHMENT: �� TEL. NO. (j� � ', ADDRESS: J'� i MAILING ADDRESS (IF DIFFERENT) : ! O[nINER/CORPORATION NAME:. ��. v`/� � MANAGER'S NAME: ��/7��9�-7 �j, f� TEL. NO. �� / �CS 6 '� � MAILING ADDRESS: ��jJ,�� RFSTAURANT SEATING; TOTAL # NONSMOKING SEATS TOTAL # i. { Under Chapter 152, Sec. 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,Co. does not have a c:ertificate of worker's compensation insurance. As part of renewal or issuance of your permits, you must attach a copy of your certificate. If not applicable, please explain: ' �..�-�--��G:.e.v� ! ; Town of Yarmouth taxes and liens must be 'd prior to renewal or issuance of your permits. � Please check appropriately if paid: yes_� no ; � i i ----------------------------------------------------------------------------------------------- ' All food servicp establishments with 25 seats or more must have at lease one employee trained in ' the Heimlich Maneuver on the .premises at all times. Please list your employees trained in ' ar�ti-choking procedures below and attach copies of their certifications. 1. 2, 3. 4. Pool Operators must list a minimum of two employees currently certified in basic water safety, standard first aid and Coirm�unity Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. 1. 2. �. 4. ----------------------------------------------------------------------- OFFICE USE ONLY LICENSE REQUIRED: FEE: PERMIT # LICENSE REQUIRED: FEE: PERP7IT FOOD SERVICE MOTEL $50.00 0-100 SEATS $ 75.00 CABIN $50.00 OVER 100 SEATS $150.00 TRAILER PARK $50.00 NON-PROFIT $ 25.00 INN $50.00 �C CONTINENTAL BREAKFAST $ 30.00 �, �_LODGE $50.00 � CON�70N VICTUALLER $ 50.00 CAMP $50.00 SWIMMING POOL ( ) $50.00 ea. RETAIL FOOD SERVICE VAPOR BATH/ ( ) $25.00 ea. LESS THAN 25,000 sq. ft. $ 75.00 WHIRLPOOL MORE THAN 25,000 sq. ft. $200.00 FROZEN DESSERT SOFT—SERVE ICE CREAM $ 35.00 TO`I'AL DUE $ �c; ,c�z_i �URN OVER TURN OVER TURN OVER TURN OVER Page 1 of 2 , � � ` �< ADDITIONAL REGULATZONS: �� 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 CATERID EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. 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. OL'TSIDE CAFES: OUTSIDE CAFES (i.e.� 0UTD00R SEATING WITH WAITER/WAITRESS SERVICE) MUST HAVE PRIOR APPROVAL FROM THE BOARD-OF HEALTH. FAILURE TO OBTAIN PRIOR APPROVAL FROM THE BOARD OF HEALTH WILL RESULT IN THE. SUSPENSION OR REVOCATION OF YOUR FOOD SERVICE AND COMMON VICTUALLER PERMITS. OUTDOOR COOKING� PREPARATION� OR DISPLAY OF ANY FE)OD PRODUCT BY A RETAIL OR FOOD SERVICE FSTABLISHMENT IS PROHIBITED. EVERY WTDOOR IN GROUND SWINIlNING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. RESULTS FROM POUL WATER TESTS BY A STATE CERTIFIED LAB MUST BE RECEIVED BY THE HEALTH DEPARTMENT PRIOR TO OPENING. ALL RENOVATIONS TO ANY FOOD FSTABLISHMENT, 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. 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� 1994. SEASONAL ESTABLISHMENTS ARE TO GONTACT THE HEALTH DEPT. FOR INSPECTION 7-10 DAYS PRIOR TO OPENING E'OR THE SEASON. APPLICATIONS b9UST BE COMPLETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE ABOVE TERM.S HAVE BEEN MET. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR Z�0 REOPENING. _ __ .� - ___ _ _ _/.��,/7 �� ...�,'1 . . DATE � SIGNATURE ��L�/' / � PRINT NAME & Title ��/"a'j�� r/ I�'rANT: fi�'.SE APPLICATIONS I�JSr BE ��LETID IN FULL AND SUBMIZTED ON OR PRIOR TO D� 31, 1994 OR YW WII.L BE S[TBJF�CT ZO AN AL�I_�S"lRATIYE I�ARING. 11/94 � � � , , :.� � � (�omnw�wealt� o� ��aa�czchu�et� 1Je�arfinenf o��ndtt�fria[�fccutertf� '' 600 I/Vcs��zirudfon�tre¢E. James J. Campbell �o�fo�, �a��ac�Zusett� 02l 11 � � Commissroner ' Workers' Compensa ion Insurance Afftdavit , I, � � f/c „ , (�icensee�permiuee> with a principai place of business at: �J `� �a cu isnwztv) do hereby certify under the pains and pena[ties of perjury, that: () 1 am an employer providing workers` compensation coverage for my employees working on this job. InsurancQ Company � Poiicy Number 1 am a sole proprietor and have no one work�ng for me �n atry capactty. () 1 am a soie proprietor, generat contractor or homeovi►ner (tircle one) and have hired the contractors listed below who have the following workers' compensation policies: Contraaor Insurance Company/Poiicy Number Contractor Insurance Company/Poiicy Number Contraaor Insurance Company/Policy Number () 1 am a homeowner performing all the work myself. I underscand that a copy of this statement wiil be forwarded to the Office of Invesrigaqons of the DIA for coverage verificauon and that failure co secure coverage as required under Section 25A of MGL 152 ca�i lead to the imposicion of criminai penalties consisung of a fine of up [0 51,500.00 and/or one years' imprisonment as well as vii p ies i e form OP WORK ORDER an a fine of S 100.00 a day againsc me. Signed this � day of � , 19 �� Licensee/Permittee . Buiiding Department Licensing Board Seleamens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-7Z7-4900 X�03, 404, 405, 409, 375 , se ' o NUMBER *�STRICTION:CONTINENTAL BREAKFAST ONLY FEE THE COMMONWEALTH OF MASSACHUSETTS 95-5 $50.00 .......�........................ of ..--------YARMOUTH---•---......._..._...........-•---•-•-------- LODGING HOUSE LlCENSE � This is to Certify that a Lodging House License is hereby granted to ...................................... ._KENNETH__GABR�EL.c...a.�7.--��X'Y--AY�._x..JIV.....Y...-•-------••------------------------------------------------------•-••-----.... ac __.Beach Berr.Y..,Inn...................•-------•--- . �c-:. ....---• --------------•---•----._.......----•-•--------....-------------------.....--•----..........__. in said ._.Xr�(1701d�.1................... and at that place only and expiree December thirty-first 19..��. nnlese sooner �suspended or revoked for violation of the laws of the Commoawealth of Massachusette relating w the licensing of Lodging Houaes. This licenae is isaued in conformity with the suthority granted to the licenaing suthorities under section twenty-three, of chapter one hundred and forty, of the General Laws, and ie i aubject to the proviaions of sectiona twenty-two to thirty-one inclusive of said chapter. i IIn Testimony Whereof, the undersigned have hereto affixe their of�cial signatures, i this---Ninth------•--•----._day of---.�'lay............................••-•--•----.....----- . .... �A�. D. 19.�,5... ' � .�a.�n►--�+�- � -•-----•......................................... ........ -...----•------ � ' •-----•-•-----..._. .. .-- -- -- - ...._.. __....-•-•- ----... Licensing � _.._..----•- I _...--••----...- • --- ---'-.�-- . . .. .. ..... ........ �� " Authoritiea i -•.............. _...-• - • -- - --• � � ..._....----•-----•........ ................•--•---- ----. ............... ........ � FORM S 547 A.M.SULKIN,�NC.-BOSTON �ei»saz-sase . f''�� "� (OVER) I I � l- �� r:.- EXTRACTS FROM GENERAL LAWS, CHAPTER 140 SECTION 22. "Lodging House", as used in sections twenty-two to thirty-one, inclusive, shall mean a house u'here lodgings are let to four or more persons not within the second degree of kindred to the person conducting it, and shall include fratemity houses and dormitories of educational instimtions, but shall not include dormitories o( chari- tablz or philanthropic institations or convalescent or nursing homes licensed under section seve�ty-one of chapter one - hundrr,l and eleven or rest homes so licensed. r�s amended St. 1960, c. 740; St. 1965, c. 171-1973. SECTION 23. Licensing authoritie� may grant ticenses for lodging houses which shall he for the penod provided in section four, and shall charge for each license such fee, not exceeding twenty dollacs, as the city council or select- men ma; establish, otherwise the same shall be granted without charge. Said authorities shall enforce sections twenty- (our to thirty-one inclusive,and shall prosecute all violations thereof. $ECTION 24. �4'hoever conducts a lodging house without a license shall be punished by a fine of not [ess than un� hundred nor more than five hundred dollars or by imprisonment for not more than three months or both. � �.,.,. _t — �` �� --�>. �,�r"� .s� �. � ` , i 11 _ • . r � � NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 95-6 . $30.00 . ...�N........ of .....YARMOI?'��. ...... ............. Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT ,�� Permit No. ..95-5. .... MAY 10�....... .. 19.95.. � � In accordance with Regulations promulgated under authority of Chapter 94, Section 305A � and Chapter I11, Section 5 of the General Laws a Permit is hereby granted to: i KENNETH GABRIEL, 157 BERRY AVENUE, W,y, � .......... .. ... . ........ .... .. .. .... .............. .... ........ ...... ............ .. .. . i Whose place of business is . . .B�CH BERRY INN i Type of business and any restrictions .��TINENTAL.BREP,KFAST,,,,,,,,, ,,,,,,,,,,,, ,, ,,, Tooperateafoodestablishmentin ...T.��. OF_YARMOUTH,,,,,, ,,,,,,,,,,,,,,,,,, ,,,, ,,,,, (City or Town) Permit Expires DECEMBER.31,,,,, ,,,, 19.9�`. .��Q - � �� .. .. . . .Ryr�r.c f�l• •• ,. .... oard � � � of � ,, ,, ,,,. 1.��ll�+�iti( �i • ��i��l�'�t/j'`.� Health FORM 738 A.M. 9ULKIN COMPANV �••�•� �• •� �� M �� Y � � . � � _ .- -___ �'' . ' ��. •� ' 7.'OWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 1994 cK �3bs �'�. .ti ----------------------- ----- --- --------- ------------------_---------------------------- NAME OF ESTABLISHMENT: � TEL. NO. �7 ! ADDRESS: � MAILING ADDRESS (IF DIFFERENT) : OWNER/CORPORATION NAME: MANAGER'S NAME: � TEL. �NO. � �tn r�� 'fTn (5'�o Y'i '7 �7� 8 t��=f -- - _ --- -- __ ____ _ _ __ -- - MAI L IAIG A�DR�.SS: ---- - _ ---- __ � _-- -- _ __ RESTAURANT SEATING; TOTAL # NONSMOKING SEATS TOTAL # Under Chapter 152, Sec. 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 Co. does not have a certificate of worker's compensation insurance. As part of renewal or issuance of your permits, you must attach a copy of your certificate. If not applicable, please explain: � Town of Yarmouth taxes and liens st be pa�.d prior to renewal or issuance of your perrnits. Please check appropriately if paid: yes_ / no ------------------------------------------------------------------------------------------------ Al1 food servz�� estat�lishments with 25 seats or more must have at lease one employee trained in the Heimlich Man�uver o.z �:.he premises at all times. Please list your employees trained in anti-choking proceaures below and attach copies of their certifications. l. 2. 3. 4. 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 forri. 1. 2. 3. 4. ------------------------------------------------------------------------------------------------ OFFICE USE ONLY LICENSE REQUIRED: FEE: PERMIT # LICENSE REQUIRED: FEE: PERMIT FOOD SERVICE MOTEL $50.00 0-100 SEATS $ 75.00 CABIN $50.00 OVER 100 SEATS $150.00 TRAILER PARK $50.00 NON-PROFIT $ 25.00 INN $50.00 �CONTINENTAL BREAKFAST $ 30.00 �� LODGE $50.00 �- t CONIMON VICT[JALLER $ 50.00 CAMP $50.00 SWIMMING POOL ( ) $50.00 ea. �#�T __-_ _ -___—___ iL�{y��_�n_amzzl /_ \�1t M � t11 _ .__—Vl-SI"Vi� �tt�1T3J--C -T 'r�J.W--CQ. ..�_�-�._ . .._ LESS THAN 25,000 sq. ft. $ 75.00 WHTRLPOOL MORE THAN 25,000 sq. ft. $200.00 FROZEN DESSERT G� SOFT-SERVE ICE CREAM $ 35.00 TOTAL DUE $� TURN OVER TURN OVER TURN OVER TURN OVER Page 1 of 2 �.,� � ,�., � 4 ' 4 fi�; � . { � t ;� . � �` �:� `; � ;�` ADDITIONAL REGULATIONS: CATERING POLICY: ANYONE WHO CATERS WITHIN THE 7.'OWN 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 F'ORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TFiE HEALTH DEPAR7'1KENT. FAILURE TO DO SO WILL RFSULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OI7TSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE) MUST HAVE PRIOR APPR�VAL FROM THE BOARD O� HEAIrTH. FAILITRE TO OBTAIN PRIOR APPROVAL FROM THE BOARD OF HEALTH WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FOOD SERVICE AND COMMON VICTUALLER PERMITS. OUTDOOR COOKING� PREPARATION� OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. EVERY WTDOOR IN GROUND SWIN�7ING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. RESULTS FROM POOL WATII2 TESTS BY A STATE CERTIFIED LAB MUST BE RECEIVED BY THE HEALTH DEPARTMENT PRIOR TO OPENING. ALL RENOVATIONS TO ANY F'OOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC. ) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY Z'O RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31� 1993. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPT. FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. APPLICATIONS MUST BE COMPLETED IN FULL. FAILURE TO DO SO WILL RESULT IN CLOSURE OF YOUR ---�STAB�ISHMENT- iJNTIL THE ABOVE TERMS HAVE BEEN MET. A HEARING BEFORE TH� BQARD OF HEALTH MAY BE R�UIRE'�D PRIOR TO REOPENING. DATE NAME & TITLE G� �"'t� �'iC..� � SIGNATURE a ?.NIPORTAD]T' 7.'EI�SE APPLICATI�iS L�TSr BE OOI�LGTED IN L�tJLL ADID SUBMITPED �i Olt PRI�2 �O DBCF��t 31, 1993 OR YOZJ WILL BE SUBJF,CT Z�O AN ADMINISTRATIVE I�:ARING. 11/93 Page 2 of 2 „ � ,,:. • NUMBER FEE I THE COMMONWEALTH OF MASSACHUSETTS $30.00 94-28 . ...T�N.... .. ... of ...Y�IRMOIJTH... ........... ...... Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .94-4 ... .. OC'I'OBER 28,. .. .. 19. 94. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter i l l, Section 5 of the General Laws a Permit is hereby granted to: ,,KEIJNETH,GABRIEL� ,157.BERRY.AVENUE�, ,WEST YARMOtJTH... ...... . . .. .. .. .. . . .. .. . Whose place of business is . BEACH ,BERRY.INN...... .. ........ ....... ... ........ ..... . ... Type of business and any restrictions ,�D SERVICE – CONTINENTAL BREAKFAST To operate a food establishment in . .��N.OF ,YARMOUTH ,, ,,,,,, ,,,, ,, ,, .. .. .. . (��or�Town) Permit Expires .DECEMBER.31� ..,iq94 .. J� Tl� . ~ � S .��- �i .. ...�?`�: : Sc_”�� Board .. ....�� .�•�b Health FORM 738 .. . . ..�lil�r,��. • y..�i��`� • A.M. 9LILKIN CO�IFANY w ��'�� n � � >. NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 94-4 $50.00 .....�N....---•••-•-•--•----•---- of .._..YARMOL7'I'H...............••----....................-•----.... LODGING HOUSE LICENSE Thie is to Certify that a Lodging House Licenae is hereby granted to ...................................... KENNETH GABRIEL ...--------••-•----•---••..........................•---•----._...._.......-------...--•---..........._..--------•--------_..-------....--------•----...-----........-------• at .BEACH.BERRY_.INNi..157..BERRY.AVENUE�---jn1EST.YP��QjJ'�-----------------------•-•-•-------•------------• in said._.�ST.Y`��----•-• and at that place only and eapiree December thirty-first 19..94 nnleae sooner •suspended or revoked for violation of the laws of the Commonwealth of Massachusetts relating to the licensing of Lodging Housea. This license is iasued in conformity with the authority granted to the licenaing suthoritiea under section twenty-three, of chapter one hundred and forty, of the General Lawa, and is I aubject to the provisiona of sections twenty-two to thirty-one inclusive of said chapter. IIn Testimony Whereof, the nndersigned have hereto affixed their og'icial aignatures, this----�I�_.F,,I�HTday of..---QCTIIBER.-----•---------•--------•............ . .•..- . D. 19.94... � .� -- ------..` ------------ - ---- -• ----._._...--- --...._._....--•- �j�� -—r -•-• •-- �.�r�-•�--- - Licensing --.._._...-•------• -•---••----- ------•- .• -- ----------------•�•---...-•----• Authoritiea ............./.""----•-•-• --- -� : -......_.._..---------•- ............. . .... .�_ .... ..__.... ..__ ......._......... I FORM S 547 A.M.SULKIN,INC.-BOSTON (817)542-5858 �4`(/� (OVER) 1 � t � e.. s i � - i ^ � oF Y�� n o� �.� �K� I8�G 8v� APPLICATION FOR LICF�NSE/PERMIT - 1993 --------------------------------------------------------------------------------------- Name of Establishment: ��>s�,�►��y�f �y�' Tel. No. : Address: s`" /� �r +�� , (`�� G v� t�v c�t..+� O ,� G � i r v ' Mailing Address(if different) : � i Owner/Corporat ion Name: �) �� j �M� � I Manager�s Name: s� Vy-� io Tel. No. : � 7 f � �G � � � Mai 1 ing Address: J S� � P�v�lr' � �v�. �'�/ y��,�,� u C, �,('� � , Restaurant Seating: Total # l�l� Nonsmoking Seats Total # /'1,�_ � __ . _ _ _ ------------------------------------------------------------------------------------------ Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is now required to ho.id issu�,nce or renewal of any license or permit to operate a business if a person or Co. does not have a certificate of worker's coa�pensation insurance. As part of renewal or issuance of your permits, you must attach a p�y of your certificate. I not applicable, please explain: � Town of Yarmouth taxes and liens must be pai prior to renewal or issuance of your permits. Please check appropriately if paid: yes no ---------------------------------------------------------------------------------------------- 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 their certifications. 1. ' � i � r 2. 3. _ __ _ 4. _ _ _ _ Pool Operators must list a minimum of two employees curr�ntly 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. 1. `7 , 2. 3. 4. ---------------------------------------------------------------------------------------- OFFICE USE ONLY LICF�iSE RDQUIRED: FEE: P�2P'1IT � LICENSE RF7QiJIRED: FEE: PERMIT # FOOD SERVICE MOTEL $50.00 0-100 seats $ 75.00 CABIN $50.00 . over 100 seats $150.00 TRAILER PARK $50.00 Non-profit $ 25.00 INN $50.00 _��f)IvTINENT�L nREr�,F:P'A�$ 3G.t33fi _� �_ ----'----�'� . �� -------Z��G�-- �.��..-_— -� COMMON VICTUALLER $ 50.00 CAMP $50.00 SWIMMING POOL ( ) $50.00 ea. RFTATL P+OOD SII2YICE VAPOR BATH/ ( ) $25.00 ea. less than 25,000 sq. ft.$ 75.00 WHIRLPOOL more than 25,000 sq. ft.$200.00 FROZEN DESSERT ' soft-serve ice cream $ 35.00 �p� � $J�� ZURN OYER ZVRN OVER TURN OVER TURN OVER � _ ...��- ADDITIONAL REGULATIONS: 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 DFSSERTS 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 CAFFS: Outside Cafes (i.e. , outdoor seating with waiter/waitress service) must have prior appzoval from the Board of Health. Failure to obtain prior approval from the Board of Health will result in the suspension or revocation of your food service and common victualler permits. Outdoor Cooking, Preparation, or Display of any food product by a retail or food service establishment is prohibited. Every outdoor inground swimming pool must be drained or covered within seven (7) days of closing. Results from pool water tests by a state certified lab must be received by the Health Department prior to opening. All renovations to any food establishment, motel. or pool (i.e. , painting, new equipment, etc.) must be reported to and approved by the Board of Health prior to commencement. Renovations may require a site plan. 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, 1992. Seasonal establishments are to contact the Health Dept. for inspection 7-10 days prior to opening for the season. Applications must be completed in full. Failure to do so will result in closure of your establishment until the above terms have been met. A hearing before the Board of Health may be required prio to reopening. DATE � NAME & TITLE �Gl/J L' � (/�� G"'�� i�w��~ � � � � SIGNATURE �,�� --1� a AIDS A3�AR�S.S "DID YOU RNTOW..,?�� In a study to determine possible causes of AIDS published by FC&A publications� researchers discovered dried urine in bowls of unwrapped mints located by the cash registers at restaurants. Urine is transferred from hands onto the restroom door hanc�lP� and_ anvthing e�se that is touched, including the unw�apped-car�d�._____�_. ____._. !__ The Board of Health has established a policy prohibiting the distribution of unwrapped candy as a "thank you" in uncovered dishes. Those food service establishments who wish to continue to provide after dinner mints to their customers are required to provide individually wrapped candy. 11/92 .. ��R�� . ; NUMBER FEE � THE COMMONWEALTH OF MASSACHUSETTS 93-28 $30.00 . . . . Town ........ of ...Yarmouth... .. ................. ' Board of Health of _ PERMIT TO OPERATE A FOOD ESTABLISHMENT , . Permit No. .��-�...... ,,June.l�........ 19. �3. 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: ...K. Gabriel�, 157. Berry Aye.,,,W.Y. .. .......... .......... ............ ........ ... . Whose place of business is . .Beachberry Inn. .................... .. .................. ... � � Type of business and an}• restrictions ,,Continental Breakfast. Only.. . .. To operate a food establishment in ,,, Town of Yarmouth . . _ (City or Town) December 31, . Permit Expires ... . . ...... 19.93. .� � ....... ....�. ...... .. Board ........ •�.. . of ......... .. .....f"�,...... alth ' . F�1� A.M. �UIKtN CONP�NV � ••••••••• �fL/l ••�� .. �� 1 ♦ � .. �� . . . �.. f . . � -. . . , . . . . , . . . . ..- _ . , . . , . �.� ., ... . . . � , , ... _ . . : ' . . , . : . � .. . . . .�? . . „ - . , . . , . .__- - ..._. _ .�._.�_.._ _..�.-..- - .e _ _ � . � I ' I ; NUMBER FEE ' THE G�MMONWEALTH OF MASSACHUSETTS ; 93-4 S50.00 ...�.Town .. of .y......Yarn�outh . LODGING HOUSE LICENSE T'hia ii to Certif� that a Lodring Honee Licenee ia hereby Eraated to . .._....._.. R.__Gabriel,.. 157 3erry_ A:e-�..West Yarcnouth....... _.. _..w..._ � n � Beac�berr� Inn�__15 i 3erry Ave.�._W-Y�......... _... ... ............ � in eaid ..�chbem��___sad at that place onl� and ezpuss Dceemba thirty-first 19.93_. i �leee sooner •snapended or reroked for violation of the Lws of tbe Commoawealth of � ldassachueeua rtlatiar to the �ieenaing of Lodging Housea. � This lieenee is ieeaed in coniormity �ith the suthority graated to the lieeneing =uthorities i IInder eectiaa twent��ree, of e�apter one hundred and fom, of the Geaeral L�rs, and is ' aabject to t�e provisioos of secr�ooa tweatT-two to thirty-one inctuaive of said chapta. i In Te�moay �eof, the andereigned have hereto aBized their o�cial signat�ues, j u'is_..Pir��-•--._._.._day of. J�1�.--- •----..�............ _ D. 199.3.... ; ' ,�a.nr�-..,�.— , . ...._�_ . .... .........--- .....- --•--�.. - jl��••- ' > " ' nsing .------------ ....... t_�------•-•-�---�.._ -✓b�� ' � � AuthoriticP ..-•-------........�...-•-•--- �-- ..._ ........_. . � .. ...---�............. �' .-1--•- ...---- --... ......__`_.5..� •,n sc:�a �' t"� T—"' {OVER) FO�+`+1 S 5�' J�M �_lJ(iN ;hF -B:':—.'-N '� __— ---._____ — ` y�t\ . — _ �� !; . '� � � � � � Z�Oih�i OF YARMOtTi'H BC�1RD OF HEAL.TH __ � APPLICATION E�OR LICENSE/PE�tMIT - 1992 Name of Establishment:----------�rP,�-----------~-y-N----Tel. No..N------------------� � `' f Address: S e V t"s � �!" �tn,Q!� � `7 ;: Mailin Address: q � I ; Owner/Cor ration Name: � � � Manager's Name: S (� �/},� � Tel No • �� g�� ; Mailing Address: � Check One: Seasonal ' Year Round . �. Sea.sonal establishments are to contact the Health Dept. for inspection 7-10 days prior to opening for the season. -------------------------------------------------------------------------------- Under Chapter 152, Sec. 25C, subsection 6, the Zbwn of Yarmouth is noW tequired to hold issuance or reneWal of any license or permit to operate a business if a person or Co. does not have a certificate of worker's co�ensation insurance. As part of renewal or issuance of your permits, you must attach a copy of your certificate. If not applicable, please explain: yj�'QC . yJ� � IM /J/D l� E'�,r Town of Yarmouth taxes and liens must be pai prior to reneval or issuance of your permits. Please che�lc ap�r�priai:��y if �ia-i:�: yes �no.- - . _ ---- Handicapped accessible requirements, in coQQliance With all federal, state, and local laws, ' must be inspected and apprp ved by the Yarmouth Building Inspector. Please check appropriately if in compliance: yes // no -------------------------------------------------- � � LICENSE REQUIRED: FEE: PERMIT # LICENSE REQUIREU: FEE: PEEtMI'1' # , FOOD SERVICE CK1I'EL $50.00 0-100 seats $ 75.00 CABIN $50.00 over 100 seats $150.00 TRAILER PARK $5U.OU Non-profit $ 25.00 INN $50.00 '� CONTINENTAL BREAKFAST$ 30.00 ;,�-� .',_' _�LQDG� $50.00 9`� COMMON VICTUALLER $ 50.00 CfiMP $50.OU SWIMMING POOL ( ) $50.00 ea. RETAIL FOOD SERVICE VAPOR BATH/ O $25.00 ea. less than 25,000 sq. ft.$ 75.00 WHIRLPOOL more than 25,000 sq. ft.$200.00 FROZEN DESSERT $ 35.00 Tprr�, � $ � � / / , G' � , According to the State Sanitary code, a food service establist�ment with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Pleaee list your employees that are trained in anti-choking procec3ures below__iat�.ach • _—____ _ - - _ _---_ -- a�ditic3�-�hee��f ;�ec�sSaPp�.—___ _ 1. 2. 3. r 4, Pool Operat��must list a mi ' na.mum of two employees currently certified in basic: water ' ��p�y, s�andard first aid and Community Cardiopulmonary Resuscitation (CPft) . Attach copies ot employee certifications to this form. Your permit will not be Processed without �his infc�rmation. Please list these employees below. l. 2. 3. 4. TURN OVER TURN OVER TURN OVER TURN OVER ,, ,� � � AdditiorLal Regulations: .- ; �;� .� _ j i CATERING POLICY: Anyone �►ho caters within the Z}a�+n of Yarmouth must notify the Yarmouth 9 i Health Department by filing the required te�orary food service application form 72 hours � prior to the catered event. These forms can be obtained at the Health Departlnent. ' i *FROZF2] 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 vill result in the suspension or revocation of your frozen dessert permit until the above ternis have been met. OUTSIDE CAFGS: Outside Cafes (i.e.� outdoor seating vith vaiter/Waitress service) must ' have prior approval from the Board of Health. Failure to obtain prior approval from the � Board of Health will result in the su��er�si� �� e:�ocat��n of your food service and c�n � victu,a].ler penaits. Outdoor Cooking, Preparation, or Display of any food product by a retail or food service establishuient is prohibited. Every outdoor inground swiaming pool must be drained or covered within seven (7) days of closing. Results from pool vater tests by a state certified lab must be received by tt�e Health Department prior to opening. All renovations to any food establishment, motel or pool (i.e. , painting, new equipment, i etc. ) must be reported to and approved by the Board of Health prior to coRgnencement. Renovations may require a site plan. ° iQOTICE: Permits run annually from January 1 to December 31. It is our responsibility to return the completed application(s) and required fee(s) by December 31, 1991. Applications must be completed in full. Failure to do so will result in closure of your establishment until the above terms have been met. A hearing before the Board of H lth may be requ red rior to reopening. DATE � � � � SIGNATURE � , , , SIGNATURE C �pt � (/- 1 (� Print Name & Title 0 � �l �i � 11/91 ` i { � , ; ; � � � :: � _:. , _ _ , ,:�, , _ . .�.,._� ,_.....< , �_.�_� k '• � ;.�.....,. .:..�_�_. _«��....+.�e.c.'�v'n�._.. , �.:�.�.�.w.. -'�' �v,...:.�-:a:....a.��.._.. . . . ,�QY .�1 � ' . . -'� ,{ T'y�,�_ �� i S� IvUMBER *R* FEE '�• THE COMMONWEALTH OF MASSACHUSETTS 92-129 $30.00 ,TOWN ...... ... of .YARMOUTH ............. . ...... - Board of Health of • ; . _ PERMIT TO OPERATE A FOOD �STABLISHMENT � ..a Permic No. .9�-1.��... ..JulY..9t...... 19.92. �' In accordance with Regulations promulgated under authority of Chapter 94, Section 305A � ' � and Chapter I 11, Section 5 of the General Laws a Permit is hereby granted to: �� Keruleth.Gabri�l...1.57..8erry..A�e..R.We�t..Ya�'mouth........ ..... .. Whose place of business is ..Beachberry..Inn . 15? Berry Ave: , West .Yarmouth .. .. .... .. . . .... ......*.. . . ... . ... .. .. . Type of business and any restrictions .Food__Service;,-; Continental Breakfast On y •� To operate a food establishment in ..West_,Yarmouth .............. ............ "�'L, (�Or Tow� ' _ Permit Expires R��nl��'..��.�. .19��. � p �� .� d . :. . .... . : �' f FORM'38 A.M. 9ULKIN COMPANY • •• ••�••• • •• ••r•••• � ( � �� ' NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS ` : 92-4 $50.00 . TOWN _.. of .....YARMOUTH _,.. LODGING HOUSE LICENSE ' Thia ie to Certify that a Lodging Houee License ie hereby granted to _ _..........._�....._.. Renneth Gabriel si �.5.Z...,H.e��y...��.�_..FV�S.k...Y�,rmouth.�__..MA�_. 02673 -----...._.............. in said B e a c h b e r ry__I n n. and at rhat place only and expires December thirty-firet 19 9�.. unlesa sooner •suepended or revoked for violation of the lawe of the Commoawealth of blassachusetta relating w the licensing of Lodging Honees. This license ie isaued in conformity with the authoritp granted to the licenaing authorities under section twenty-three, of chapter one hundred and forty, of the General Laws, and ie I eubject to the provisiona of aections twenty-two to thirty-one incluaive of esid chapter. " , I In Tea�ony Whereof, the undersigned have hereto a8ixed their ot�'icial eignaturea, this---.....-9---------------••---dap of....J u lY.._.....-----------..._......----.._.....--•----........... A. D. 19.9�.. t� . .. ..... ................... ...•-•• -- -•-•-• --- � ? _ � ' � .. __. .. ----•. .... __.... ...... _ -•---• :'�1-----/ . •- •- -•..__.... � ••-1- ,�}'-�• �.•. • �IIS1IIg � I - -•-••- ••-• ••----........�..-�---• - • • - ---•-- •-......._ A ties,. U � � -----•-•---•----...-•-•----•---- �--._.�._......-•---------------•- ---• - • - I , � �; � �•-�----- � � ...........................� ----�.....---------.;.. ....-•- ------ -�...------.....: , . . FORM S 917 A.M.SULKIN.INC.-BOSTON (817)SA2-SB58j�� v`� , •V�� ,� � 1• ,f I r 1 /� �� ) � t I ? (� �- I 1TAla , 1'l ' � f �!t/ d�I. 1 t �1 ..• .. i .,,�-. ' TOWN OF YARMOUTH BOARD OF HEALTH ; �' � APPLICATION FOR LICENSE/PERMIT - 1991 • { � : . r ----------------------------ll! �I-------------- � --------------------_----------------- ,�� Name of Establishment� �� G-�� Tel. No. • �.�� l'�''��°�, ; � Address: \" r- � �,,. � _. � '.� � ,�, ,• Mailin Address: �� c� � � '� � �,�� f�� :,;.� �O r s�.;�.�';� _ .;�'�,,_,s Owner/Corporation Name: �� (p"'� �? y�-� � � Tel. No.: �� 1 ( S i i�'` ,,.'. : /" /� �'.,��'i Manager's Name: � (./�G � +r" N� � :��'1 �j Mailin Address: / S j� ��-/�` ✓� lOC/ , � G'+v' l^-�r.� ' � .i .' .��5 Check one: Seasonal � Year Round '�+.i Seasonal establishments are to contact the Health Dept. for inspection 7-10 days prior ,'"�'' to opening for the season_ . �•;: "'''•' -------------------------------------------------------------------------------------- ,-;�;.a�:: � ';�::��< Under Chapter 152, Sec. 25C, subsection 6, the To�rn of Yacinouth is now required to hold •;��;�`��`�; issuance or reneWal. of any license or pecmit to operate a business if a person or Co. does �'� ��'� not have a certificate of worker's con�nsation insurance. As part of renewal or issuance , of yo�s permits, you must atta h a copy of your certificate. If not applicable, plea_�e , , explain: f'C v �,u-. ,r� v ,,�J e-C .;:: �. '� 7.b�rn of Yaruioutti taxes and liens must be paid or to reneWal. or issuance of your permits. �,;��.;; Please check appropriately if paid: yes no i";Y��;:' . `.'� � Handicappec7 accessible requirements, in conQliance vith all federal, sta�e, and local lavs, �;.,;`��';; must be inspected and approved by the Yarmouth Building Inspector. Please check appropriately 'q'.,:',�'' if in cvaiQliance: yes no -------------------------------------------------------------------------------------------- �':`��,� LICENSE REQUIRED: FEE: °PERMIT # LICENSE REQUIRED: FEE: PERMIT# MOTEL $50.00 INN 5 0 CABIN $50.00 �LODGE $50;00 � • TRAILER PARK $50.00 CAMP $ 0 , ADDITIONAL LICEN.SGS: FEE: PERP1IT # , SWIMMING POOL $50.00 each VAPOR BATH/WHIRPOOL $25.00 each : �C7I�1IY3EIvTHL $30.0 f.- a BREAKFAST ZOTAL DtJE: $ �'Q_ (�� , Pool Operators must list a minim�.an of thro emQloyees currently certified in basic �,rater safety, starx�rd first aid, and CPR. Attach copies of �Qlayee certifications to this form. Your permit will not be processed vithout this infotmation. Please list these emplayees beloW. 1. 2. %'�' 3. 4. a�}.::'. . Every outdoor inground swi�ing pool must be drained or covered Within seven (7) days of closing_ Results from pool �rater tests by a state certified lab must be received by the . Health Department prior to opening_ '� NOTICE: Permits run annually from Januacy 1 to December 31. It is your responsibility • to rettsn the comQleted application(s� and required fee(s) by Decenber 31, 1990. Applications "--mus�G-e�om�Iet� �n i�3:__ ��le�r€-�$-da-se-��--�� i��-��asnrr� nf vni�r_estaFali,�tunent -- tmtil fihe above te�►s have been met_ A hearing before the Board of Health may be required prior to reopening. All renovations to any motel or pool (ie_ painting, ne�r equipaient, etc.) must be reported to and approved by the Board of Health prior to comriencement. The renovations may req ' . a site plan. . � . •• DATE �� SIC�]A7.'[7ftE 9/90 � � .. ' � � . ,< -� NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 91-6 $50.00 ..._ of ...-•---.YARMOUTH .._......��.----••---....---•- ...--•----------------------------------•-••--......... LODGING HOUSE LICENSE This is to Certify that a Lodging Houee.License ie hereby granted to ...................................... _ KEN GABRIEL ......................•---......------------------•-----.....--••----••----.._.._.._..__._..._....-•-----------....----•-----------•-------...-----...-------.... 157 BERRY AVENUE, WEST YARMOUTH, MA at .............................................................•-----•-----.._._....---•-•--•----.......----...-----........_....._..----•--....._..__...-•---..__...... in said ..BEACHBERRY__INN.____ and at that place only and expires December thirty-first 19.__.._.. unlese sooner •suspended or revoked for violation of the law*e of the Commonwealth of Massachusetta relating to the licenaing of Lodging Houses. This licenae is iasued in conformity with the authority granted to the licensing authorities under section twenty-three, of chapter one hundred and forty, of the General Laws, and is ( aubject to the provisions of s�ctions twenty-two to thirty-one inclusive of said chapter. IIn Testimony Whereof, the undersigned have hereto aflixed their afficial �ignatures, this.._FIFTEENTH----._. dap of......---JANU i?`�' =�.�, -•-----....... A' : �.91_... -- - .4� _._ . ,., . --,m rn a _p $ �: .: � �:� ---- ...... .. __.... � �.�...j_..- •�---•- ' . _ ....'..�r � j +"f�'.�.+`�.4�.. `� �"c�3�'� L1CCII31IIg _....... � ' ; �.� ;- _... � -- .--�__ -c.� :�-•�'• Authoritiea -••----• ••_�--......---•---•-�-•--....-- --- . .. .......... . • -----•--------••--• , , ;, " ...._..._.._.�_._Y..._uS................... _ __�►.._ ....... + �t f�-. . �...." "' I ,�I�. �.€� t� r �;� ��?:�' FORM S 547 A.M.SUIKIN,INC.-BOS70N (817)542-58�Q^"�e y,,,,,_ (OVER) �' s ,�- .,�,�--� { ' �'"'/ `� ' �� t.,�-�.r.{,�, �� . � �t`� � I 1 �T � ( ------- *R ------ i I PIUMBER FEE ' ( 91—�'] THE COMMONWEALTH OF MASSACHUSETTS $30.00 � .....T��-----••----.....- of •-•---YARMOUTH ': i E,'oar:l of Health of � i ; � PERMIT TO OPERATE A FOOD SERVlCE ESTABLISHMENT � i 91-6 JANLTARY 15, 91 ' Permit \o. .---••-•---:-••_._..-•-----• ...------•-------•-•-•••----.._.19--••---- � , iIn accorclance with Re�ulatiuns promulgated uncler authority of Chapter 94, Section 305A I , and Chapter lll, Section � of tlie General Laws a Permit is hereby granted to: I ' KEN GABRIEL,___157 BERRY AVENUE, WEST YARMOUTH, MA ' � ...-••--...••-••••--.._...•--• ------•-•-•---•..............•--._.....••---._.....••- i I --•-••--•.._...----•---••----•-••••------....-•---•--•---•--••---•-•-•--•• ' Whose place of l�usine,� is ..BEACHBERRY_.INN Type of business ._.FOOD_.SERVICE ' I -----�-----�------------------------------•-------...------•---•--...-------....-----•-•------._.._._..__... I � To operate a food ser�-ice establishment iu .._.'�-'04`7N_.OF..YARMOUTH___._ � ....•----••••-••- ------s--- -•--•-•---... i . (City or Town) � � �� ; DECEMBER 31, 91 -� �' • ' ; ; Permii Expires .--•---••-----•--•-••-••--•--•-••-•--•-•----... 9-•-•J� ��-..�-`Z i ' *RESTRICTION: ,� � � F �_�. f _ � � ; � * CONTINENTAL BREAKFAST .---=-�-->.J�.,:',�. ,�. ::..:__,r�..-,:-----••-+':,- �'' •- f. , . : r �..-�-. f �-- oard ! , � •-- - ---- --- -- -- ---,.,. _ - ._�� -- � I' .. .... ....................... ...... of I ...----•--- -••-•----- , � ... .-----•--a�-•---:�---•-----• - •--- - - - - --._`....__...--- Health ; _... ; � ' .- �-------- ' ---' --- �1ot�.-------- i ' I- FORM S 738 A.M SVLKIN.INC.-BOSTON �..�� N�� I ° � � .} • i /� ��