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Home My WebLink AboutApplications, WC and Licenses � � ' � r TOWN OF YARMOUTH BOARD OF�ALTH ,��'��l' �p'��`�- � � APPLICATION FOR LICENSE/��I��T-200 � ; ; � � L008 r. �� ; �_: ..� �� * Please com lete form and attach all necess d�cuments b Dece er 1 S 2008. .� . _ Failure to do so will result in the return o�your application pac °i=��'��.,...�....R �° '�`�=�'� � NAME OF ESTABLISHMENT: BLVEBb'RIZu MA Na�-- TEL. # s'�g•36� -�6�.n LOCATIONADDRESS: ��g M��N sr va�ounaPo�", M� ez��s� MAILING ADDRESS: s�t H - OWNER NAME:,, Iti . v�c r�2�� Sc�+ H TAX ID (FEIN or SSN): CORFORATION NAME (IF APPLICABLE): MANAGER'S NAME: G�72 p t.,a f.�.a s�V TEL. # 5,6.M� MAILING ADDRESS: s�4 M� As �4 t�a v -- POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. N�,q 1. 2. Pool operators must list a minimum of two employees ctuY ently cei-tified 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' recards. 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 requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON 1N CHARGE:__ _ _ - - _-- - _ Each food establislunent inust have at least one Person In Charge (PIC) on site during hours of operation. l. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all tunes. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will nat 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 LODGIrG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B S55 �� _CABIN �55 _MOTEL �5� m� �>j _LAI�,Ip �55 _Sa'IMMINGPOOL S80ea. LODGE S55 �TRAILERPARK �105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIKED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# 0-100 SEATS S8� �CONTINENTAL S35 ��6,-�—�.� NON-PROFIT S30 >100 SEATS S16Q _COMMON VIC. �60 WHOLESALE S&0 RETAIL SER��ICE: —RESID.KITCHEN �8a LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERMIT# _<j0 sq.ft. ��0 _>25,000 sq.ft. �22� _VENDING-FOOD �25 <25,000 sq.n. S80 _FROZEN DESSERT �40 _TOBACCO 5» ��7E cxA�GE: sio AMOITNT DUE _ � 40 •oo *****PLEASE TUR`OVER AND CO�VIPLETE OTHER SIDE OF FORi1*"'** y r 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 person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED_� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES__� NO MOTELS AATTI OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy sha11 be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CNIR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been mspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLO5ING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health 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. Fa.ilure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. 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. DATE: l l�a.o f a g SIGNATURE: �j,,. !�''�.��..c� ��S.,L PRINT NAME&TITLE: M. ✓l G►�OK liq S CN v H io�zi%os �- ,. �• � The Commonwealth of Massachusetts Department of Industrial Accidents MA�ta/f�lr�adf�s 600 Washington Stree� 7`�`Floor Boston,Mass. 021I1 r Worlcers'Compensatioa I�araece Affidavit:Bnilding/Plambing/EkMrical Contractors Au�lit�u�t ied'a�mat[e�ts _. P�eserc PRINT k�W� �: l4 . ✓/CT 02�/� S C N V l� address: 1!'3$ OLD K►NCt S /-�/C�NiJi4-N city YAXHOUTI�f'I�O�T state: �A zip: OZ��s nhone# SO g' 36.Z• �6.L0 work site location(fiill addressl: SA NLr A S ,4 f3 0 V E ❑ I am a homeawner performing all work myself. Project Type: ❑New Construction❑Remodel Q�am a sole proprietor and have no one working in any ca�city. ❑Building Addition ❑ I am an employer providing workers'.compensation f�my employees worlcing on this job. wmaanv a'me: /31..U�F3 E2 R�/ /4A N 0/�.. �aa�: H�3 8' M��ni s r city: �/R t2 M d UTf-1 P 0 RT, .Nh 0 2,6�.S' o�ae#: S'D 8 •3 6 2 -7 L 2 d ias ca # .. . .. . ... ., . . . . . , . ... . . i, t . •i "1"R?..4�',`f tRA ,uc4 . .: .. ... ...,. , . -:. . ...':. y :.:. -..... . .-:.. <... :: . :. >>.a..:: �..�k : .,. . ❑ I am a sole proprieeor,geaeral coatractor,or�omeowner(circle one)and have lured the contractors listed below who have the following workets'compensation polices: rnmm�av nsmc: address- citv u�oue#• i�saraace co. # � _ , -� aomma�eame: address• citv oliote N- _ _ . _ _ _ -- __- ---- _ — — —-- _- ies # .�'=�.. , . �,. t 'k _ Failete q secare owera�e as reqdred�ada Sedio�2SA�f MGL 1S2 cu ktd b tYe io�dtl�n of cri��ioai poaNia ef a Aae�p b i1,5l0.90 aad/or. one ynts'tasprboom�t as w�aa etvY pwitks in the form et a 3TOr WORK ORDER aed a 8ne d 5190.OS a day agaimt me. 1 and�sbted t�at a cepy of this stateme��ay be forwaMM�o the O�ce sf lare�tlona of t�e DIA for tovenge veri6ealioa. I do henby cer&jy xnder Nre patns awApe�ehies ofptr}rrry thet t�ie infonxadoe provided above fs aue m�d con�ect Signahue , � . U i�-C�t�t�-�� 6'�.t.�h---� Date _�•��6� Prim name /�1. ✓/CTD 21 A 5 C.µU N Phone# S"0� -3 G�• �L 3-d o�cial ase eNy da aot�vrite�this area to 6e completcd by city or Mwn o�cfal city or town• permit/GCeox�1 �BuidinS DePartmen� QLictn�fe8 Board ❑eheck if immt�a�e rxapeme is reqaired �Sdxtmen's O�ce ��t matact petaon: phene#; � (��-�) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-001 FEE: S55.00 THIS IS TO CERTIFY THAT A1�T INl�'HOLDER'S LICENSE is herebv eranted to M.Victoria Schuh d/b/a Blueberrv Manor �t 438 R�iite 6A, Yarm�iith�n�rt, MA in said To��n of Yarmouth And at that place onl�•and expires December thirtv-first,2009 unless sooner suspended or re��oked for violation of the laws of the Common�vealth respecting the licensing of innholders. This license is issued in confornlitp��eith the authoriri granted to the licensing authorities by General Lait•s,Chapter 140,and amendments thereto and is subject to sections t�ti�entv-rivo to thim�-n��o, inchisive, and of said chapter and sections t�aenn�-fi�-e to t�vent��- se�•en,inclusive,of Chapter 27?. In Testimony Whereof,the undersigned ha��e I�ereunto at�xed their o�icial signat�ues,this Fourth day of December A.D. ?008. BOARD OF HEALTH: `.�EP�¢tt S��, �.JV., C�CYI�tt�xt Number of bedrooms: �a�0 .`�. J�.�!��,� ��(CC ��LtCtL I S`Floor— i Bedroom in rear J�P�I� S. �x41(tlt, �;C� 2nd Floor—3 Bedrooms QftfL �¢¢It�`m1�f11, ✓�../V• �'�"�'`'�,... �. .`��t�RiJ Bruce G.Murphy,M H, R.S., CHO Director of Health TOWN tJF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-047 FEE: 535.00 In accordance�ti-ith regulations promulgated under authorin�of Chapter 94,Section 30�A and Chapter 11 L Section�of the General La��s,a permit is hereU��granted to: M.Victoria Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2009 BOARD OF HEALTH: l�ett Sf�a�i, ✓`�..lV., Cf�ai�rf►tan t',ffcir�r�eo .�. 3'fi:�i�ex��`�t�l�iee C'R�wr�rean RESrRICTIONs: Guests on1Y. ✓i,v� �• ✓J�Y4ttl/t� �:G�Jtl� � Qnn C�eerc�cucm, ✓2..iY. ��• �� December 4,2008 Bruce G.Murphy, ,R.S.,CHO Director of Health r , .. , �. p Jt.Y�k TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE�"�R1V�IT-20 : ��`' ��n�� 3 � 2007 �.��`��a � - *Please complete form and attach all necessary�oc��rer�'ts by Decem D E PT. Failure to do so will result in the return of your application packet. � �., NAME OF ESTABLISHMENT: 1��VEBER2y H,4titDr2 TEL. # S'eg- 36�- �L.�.G LOCATION ADDRESS: �i 3 R' ,H�(/�I ST_ V�4¢�e�T H po27, /4.4- o z t�� MAILING ADDRESS: sw,uc. OWN�R NAM�:__ ic.i Vi�To2iA SGH N TAX ID (FEIN or SSN)-�/ CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: GE�2n�e ��2��1 TEL. # SAMF AS ABe�'E MAILING ADDRESS: SA M� AS _G T.4 Er`i«t L�cAr-r ;, POOL CERTIFICATIQNS: 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. N'/a 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commwury Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifieations to this form. The �ealth Depart�ent will not use past years' reeords. �'ou m�s� provide new copies and maintain a file at your place of business. l. �If.�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 Establislunents, 105 CMR 590.000. Flease attach copies of certification to this appfication. The Health Department witl not use past years'rerords. You must pcovide new copies and maintain a file at,your establishment. l. 2. _P�I�S9N IlV�HARGE: - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTffICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the I�Ieimlich Maneuver on the premises at all times. Please list yow employees trained in anti-chaku�g procedures below and attach copies of employee certifications to this form. The Heatth 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 OhLY LODGING: LICENSE REQUIRED FEE PER'b1IT� LICENSE REQUIRED FEE PER'1�III'# LICENSE REQL'IRED FEE PER'�LIT= I BBcB S50 �SO '�Q$-Ol0_C,qg� S�0 _MOTEL S50 _INN S50 _CAi�IP S50 _SV4'IVI.VIINGPOOL S75ea. _LODGE S50 TTRAILERPARK S100 _�V'I-IIRI.pOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FE£ PERMIT� LICENSE REQliIRED FEE P£R,'��IT* LICENSE REQi;IRED FEE PER�fIT= _0-100 SEATS �',75 LCONTINENTAL S30 �30— $'�a7 �vON-PROFIT S25 ,_>100 SEATS 5150 _CO.'4L'��ON VIC. S50 _V4'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERVIIT= LICENSE REQL'IItED FEE PER�IIT� _<50 sq.n. �45 _>25,000 sq.ft. S200 _VENDING-FOOD S20 _<25,000 sq.ft. �75 _.FROZEN DESSERT S3� _TOBACCO S50 NA11�CHANGE: sio AMOUl�T DUE _ $ �p,pp "**•*PLEASE TL'R.\OVER A\D C0�IPLETE OTIiER SIDE OF FOR�T *�,��,. � s g: ._ 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. TH.E ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND S�GNED, OR CERT. OF INSURANCE ATTACHED ` OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taues and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES C:,/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�: Transient accupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. 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 six(6)manth period. Use of a guest urut as a residence or dwelling unit sha11 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: Enclosed Motel Census must be completed and returned with this application. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State cettified lab,prior to opening, and c�uarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme�t 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 ofHea.lth. OUTDOOR COOKING: - putd�or coaicing,preparation,ar display of any food praduct�y a re�ai�flr food service esfabkshr�ent�s-prehi6ited. N�TICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSISILTTY TO RETURN THE COMPLETED APPLICATION(S)AND REQiJIRED FEE(S)BY DECEMBER 31, 20Q7. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEME�iT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � 7 SIGNATURE: �Q ��s�— PRINT NAME&TITLE: �-- � ia;o o� r � The Commonwea[th of Massachusetts Department of Industrial Accidents ' MAfe�/irrr�Hf� 60� Washington Stree� f�'Floor Boston,Mass. 02111 Workers'Compeasntion Iaseraace Agidavit:gaildieg/plambing/Electrical Contractors ' �"�re P�IlV'1'�blv /iTnr�in � y� ..., V.v.r7 .. i,v r� . - DBillC_ L']�._If -� �c �c `'l /�/41vOQ.. . . . . -- ` address: �f'�8 �1.[i/AI ST• �iri �/�It.M D UTN A 0�-T, state• /�/.� zin �2 �$' nhone# 'SO� .3`._ ��i.La work site location(full address): ❑ I am a homeaw�r perfornung all wark myseIf. Pro�ect Type: ❑New Construction ORemodel � I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensatian far my employees working on this job. _ comwav�ame:_ l`3 L V��3 E�272 V �d/V d _ - - ��'�� SA��tI& AS A 30VG c3tv: ��# �' # ��r, ►�t;6 �w,.�f. �, �-": �I am le rsl eostrsetor,or�omeowaer(�arcle o�re)and have�.tbe com�tors ' somn.u,v eame• :ddress: citv �# in co. # �mev'aws• �• �: �� _ _ -- ias — - #_ _ - -__ ��i1�6i�RlF�. , ,.: FaBore b xcm+e oe�vva�e as reqsired uder 3atloa 2SA ef MGL 152 caa lad b IYe�itloa o!'cdsiai pe�aNies�f a�e�p b t1.3AY.A�a�d/�r o�Ye�rs'imprboameet as w�eR as dvY peealtlea in the fors of a STOt WORK ORDER aed a 8pe ef 5189 OS a day apinst sse. I aedastind Unt a cq►y e[liia�a�emcat may 6t fet�rarded te the Omce ot lgve�qeffi Af t6e D!A for caverage veMAcadoe. !do hereby cer(ify xnder tGe pains and penelties ofPer}rrry t1Yet tJbe i�foranatio�pro�ded abor�e is trxe mrd c»rrect Signat�c�e �h � �.,,1._.._. nate /•Z-�3/f o� Print natne /y • �C TO/2/I� S t� �-1 U I_I Phone# S08'- 3 G� - 3 6 3� official ase oniy do not w�ite in thia ara to be compieted by dty er�wn o�cia! city ar te�vn: Pa'mif�ense# �guidieE Department ❑c�eck if imme�ah reapenx is requQed �H�$�� 's� pn,;��°' phe�#; �ei �t �; . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-010 FEE: $Sfl.00 TffiS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to_ M.Victoria Schuh d/b/a Blueberrv Manor at - 438 Rnirt 6A Yarm� � h?c�rt, MA in said Town of Yarmouth And at that place only and expires December thirty-first,2008 unless sooner suspeaded or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders_ This license is issued in confonniry with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to secrions twznry-two to thirty-two, inclusive, and of said chapter and secrions twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto ai�ed their official signatures,this Twenty-third day of_ January A.D. 20(18. BOARD OF HEALTH: ��It Sf�� ,,,A(.� (�yf�tt�Z Number of bedrooms: (,�if�A .�. `J'�E�Ql,G� v�(�CE ��lX#1Ztllt 15'Floor—1 Bedroom in reaz - ��(i��P![��.��llttttft� �:C¢!� 2°d Floor—3 Bedrooms �� ,�( �,."..'�"�.�"��' Bruce G.Murphy ,R.S.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISIiMENT PERMIT NUMBER: #08-127 FEE: $30.00 In accordance with re�arions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby granted to: M.Victoria Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: Blueberry Manor � Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD oF HEALTH: 3�eft SPeaPi, J2„N., C'.�iicri�una�t ��'� .�. ��£e�P��exC,� `�1�ice C'��uauvttita,►2 RESTRICTIONS: Guests only, �� _��n' :C� �C�c�rt�a[,[nZ, J2..lV. i�acr�,eb January 23 �008 Bruce G. Murp H,R.S.,CHO Director of He t� , . BWE�E�(2.R.Y MANafZ •O`;;�R� TOWN OF YARMOUTH BOARD OF HEALTH �Q� 2 0 o� ";y APPLICATION FOR LICENSE/PERMI�-2Q87`�� : ., .;:� ' �vU � 2007 * Please complete form and attach all necessary documents by ecernber 3�, �006. Failure to do so will result in the return of your application paci�et. NAME OF ESTABLIS��VIENT: / ,y� ��. TEL. # SO�-3��- �b� LOCATION ADDRESS: tc �� s� MAILING ADDRESS: c��„Y OWNER NAME: �(.t. lfiG�o r�'a Scl.�.�.�G.. TAX ID (,FEIN or S SNl� ��-�' CORPORATION NAME{IF APPLICABLE): MANAGER'S NAME: G�u-Qe� l�.ose.rr TEL. # s�vr►� a< a!�o vL.. MAILING ADDRESS:___ Sam� ses abo r�, 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. AlfO �i o o� 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 wiil not use past years' records. You must provide new copies and m�intain a file at your place of business. 1. 2. � � .��` (c nM !� D 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 Establisl�ments, 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 establishmen� 1. Nf� 2. PEI�S9�F I��H�RG�� _ - _ ___ _-- - - _ _ __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CER'TIFICATIONS: All food service establishments with 25 seats or more must have at least one employee traine�i in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-cholcing 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. lUa {`c sfGuc.rG�-�-a f 2. 3. 4. RESTAURANT SEATING: TOTAL# O�'FICE U5E ONLY LODGING: LICENSE REQtJIRED FEE PERMIT# LICENSE REQUIIt.ED FEE PERMIT# LICENSE REQUII2�D FEE PERMIT# I B&B $50 �� CABIN �50 _MOTEL $50 • INN $50 Ct1MP $50 SWIIvIMIriG POOL$75ea. LODGE $50 TRAILERPAI2K $100 WHIItLPOOL $75ea. FOQD SERVICE: LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# 0-100 SEATS $75 1CONTINENTAL $30 d 7� � NON-PROFIT S25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL 5ERVICE: —RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIItED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _<LS,OOOsq.ft. $75 _FROZENDESSERT $35 _TOBACGO $50 NAME CHANGE: $10 AMOUNT DUE = S 80•� •"•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""" ADMINISTRATION Under Cha.pter 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 COMPENSATIQN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. !JF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: /V�/a no �w��i/oy�ts YES NO MOTELS ANp OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short terrn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha.11 generally be considered Transient. POOLS POOL OPENING: All swimming,wadin�and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspecfiion five(5}days pnor to operung. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtasned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: 4u�r_�QQking,prEparation,or display of any food product hya retai�or food service es�ablishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESP4NSIBILII'Y TO RETiJRN THE COMPLETED APPLICATIQN(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: /z�z cj Io,6 SIGNATURE: �ji. �.�..��i.c.� ��,..� PRINT NAME&TITLE: �i. �c�R�� U t� io�i�io6 , � The eommonwealth of Massachusetts Department of Indus[rial Accidents > �/ef�i� 600 R'ashirigton Stree� 7"�'Floor Boston,Mass. 02111 - _ Workera'Com�aahos I�m�aaee Affidavit:Bail biw�lectrical Co�tnetors .. ,. :: .� � �:, ..,. �: «s�<��'� e� . �„� *�t��` � . . . _.. �� : ,� , i/c�nrr u- S�ltiu,�- a��s: H 3� �!!u'h .�'� . ��l� d/,� c�itv 7 m o u f/,.,�o r�f— s�te: �1 A ziP: �Z�S` nhcxie# ��-3 b.�--�-�� work site 1 '� fnll addcess: I am a Iwmeow�performing all wark myself. Proje�ct Type: ❑New C.aa�structio��R�nodel I am a sole 'exor and have no one w in an Buil ' Addition : _.. . _. ❑ I am an employer providing w�kers'compensatio�f�my employeRs working�this job. �Y�' __ _ ._ �; chv- �iNoas M• � ❑ I am a sole proprietor,ge,eral eo�tractor,or�omeow,er(cirde owe)and have Irined tbe co�actots listed belovr who have the following workeis'compensatian polices: �� , !!�'s. dt+r; �� S�IYT.�i ddr�• eitvz �„e�Os Fa�rc a aee�e o�era�e as reqairoa.e�er sec�ea 2Sr►.[MGI.lsz n.kaa a t�hrp.itls..reri�Ya�pe.aNin.t s 9�e�p a sl,sM.e�a.dhr eae yean'im�riwi'mt a�we8 as dv�pmpies ia the fora ota 3TOt WORK ORDER a�d a�ee otSla6i.Os a d�y ataimt re. I�sbed t6at a apy�f t6b�ta�emeat my 6e ferwarded!s Ne O�ce of lave�atloaa of 1!e DIA tar avvage veii�atiy. I ro henby ceKify xnder t1Ye psfns m�d pena/des of perjr�ry tAiat tlYe iwfonw�lo�provdded abov�e is bue awd oarnrk , � �-' _ / n ,, Signature �i��eX.i2c.� ��-c_bC�,K. Date 1Z12-1/6,� P,�;m� �_l�icra9e�� N rbo�# 5�g�3��. �� e�dal e�oNy ae�ot wrlte�this area te 6e c�pleted 6Y e�y ar 1r�►a e�al cNy or tewn• Per�t/�ceese# �Boid�Depart�ent QLioe�Bsard ❑chc�ic if immd�ia�e respeax is reqa6ed �Sd�'s O�ce ��De�tismt ceataet Per's0a: Phese R, �n' (��-�►) . , . ' THE COMMONVUEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLTMBER: #07-010 FEE: $50.00 TffiS IS TO CERTII'Y THAT AN INNHQLDER'S LICENSE is hereby granted to M.Victoria Schuh d/b/a Blueberrv Manor at 438 R�iite 6A, Yarmoi�th��rt, 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 respecting the lieensing of innholders. This lieense is issued in conf 'ty with the suthority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,tlus Thirtieth day of March A.D. 2007. BOARD OF HEALTH_ B '��' utt�. /GI.�., ' Number of bedrooms: o��t�s c>'�t�i, ./V., vsee �iaih�ita�t 1�Floor—1 Bedroom in rear Ro�wJt�� B�ior,wt, �� 2na Floor—3 Bedroom5 . n�cl�a/��PJt�� i4�ut(�'�iee�,r�su�c, R.N. Bruce C"r. Murphy, , .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-134 FEE: 30.00 In accordance with regulations prrnnulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: M.Victoria Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: Blueberry Manor Type of business: Continental Breal�ast To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 l, 2007 BOARD oF HEALTH: ,l3 `h. �a�,o�s, 11�1.`11., ' dfe��e��i�i, ./V., ?/:ce G�lsr.�vrrsr��s RESTRICTIONS: Guests only. R��`�� /�/.�js?4l�lL, �:(�J�e /�"W�fC�/!'l�S�PJ2pl� i4�us�j'�ieesrGa,rs�, RJY. March 30,2007 Bruce G.Murphy,lvtP , .,CHO Director of Health �j(o`(� d� 3w Mara2 F_Ya 2 0. ,:_R,y. TOWN OF YARMOUTH BO F�� : ., GL L� � ''� r �% I� DD 3 =� APPLICATION FOR LICENS�� Of °: �'? ; ��: � � ��N 0 3 2006 �� * Please complete form and attach all necess�i�y documents by Dece 31,200 . Failure to do so will result in the return of your application ALTH �EPT. NAME OF ESTABLIS��VIVIEENT:��u�bG�'rN �! yr er TEL. # .�OR -36.2-�6�0 LOCATION ADDRESS: 43F1 �/a�h Sf- C2fc 6,4)_v�Q�/��ar t, M,4 Qz��S-/�sS MAILING ADDRESS: (. �m� ) OWNER NAME: �/ . I/j'�b��'G Sch t,�� TAX ID CFEIN or SSN1' CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: S�vru tze s�n TEL. # Sv8-3 6�-�6�o MAILING ADDRESS: (S�Yri c Cc 5 aboV�) , � POOL CERTIFICATIONS: N/A The pool supervisor must be certified as a Pool Operator,as required by 5tate law. Please list th�designated - �oal Operator(s) a�attaett a eepy e€the eertifieat}on to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protectian Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN CHARGE: ____ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIll�,�CH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and at�ae�i t,ropies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z. 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE UNLY LODGING: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# �B&B $50 �O(,�OOa CABIN $50 MOTEL $50 _INN $50 _ _CAMP $50 _SWIlVIlVIIlIG�OL$75ea. _LODGE $50 _TRAII.ER PARK $SQ WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# �0-100 SEATS $75 ( CONTINENTAL $30 ��Ib NON-PROFIT $25 >100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQiTiRED FEE PERMIT# LICENSE REQIIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<Sd sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SO�00 "•"""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 hald issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES I/ NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQLTIlZED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. 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 wtuch 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: Frazen ttesserts inu�t be tested on a monthly ba�is by-a State e�rtified lab. 'Fsst festt�s�st be sent to t�e Hea1t�- Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. DATE: 1��3/ �d� SIGNATURE: � O� �� PRINT NAME&TITLE: M• V�c�Q►� SG�+��F , o WIU��. 09/28/OS _-_`�� The Commonweahh of Mwssachusetts '�_-__�___::i �� _ _ DepartmeRt of Ind�strial Accidentc _- = M�fN�� __ - -- 600 Washington Stree� f""Floor --,,,e'� Boston,Mass. 02I11 wurkers'com�aahua I�a�aace Affiaavic:Boild�oglPl�amb�/E � . .a , r :�_� leetncal ,_> �; �, a , � ,� �, aa�,4. � � ,.- �..:._... _ , ._. 'o� � r ' ?>r �-�.. ��oz� ,x.�. ,'i.�'rc't w �'�. -.�t=c.�„; .a,�'�H��.�' ��,, �'�c��;�'`"' ''a �: M . v�crnrZ��a- s H addnss: T3LU EBL�1?IZu �1,�4/JOR� 4 3$ �CtI�FIIJ ST• ��c b �(� ��c� �/R�t o u r►� Po�e,T' �n• M 4 ao• o Zb}s �# Sa 8-3�a-}6 z.o work site locati�(fnll addressl: �S Q.Y!'i C G,5 4 6 o vt� ❑ I am a homeowner perfornung all wozk myself. Project Type: ❑New Caatstructiaa��Reanodel I am a so le 'etor and have no a�e w ' in an ca ' , guil ' p�it�n _ , ,w ❑ I am an empbyer pcoviding worlcers'compensati�fo�my employee.s warlcing on this job. ��e: �: �'- olte�c#�. ❑ I am a sole proprietor,geaeral co�tractor,or�omeo�ra�(earde o�)and have hired the contractois listed below who have the following w�k�s'c�mpensation polices: �: dir• �g. # �_�_ �• s�: __��. , �; .,., ,, . FaYare b xc�e+e w�va�e as req�e+ed uder Secfi�i ZSA�[MGL 152 eu ind b IYe hrp�itl�i�!'criwid pnaNia�a�e�b S1,3N,M aidl�r one Yean'Im�►rba�ment as we8 as dvll pe'altl�ia the forai ota 3TOt WORK ORDER aid a��f 5160.M a day�t me. I oadersbnd t6at a apy ef tiia�tale�ent mq be ferwaMed ro tAe OIDce�lm�Da ef tlu DIA tor avenge vq'meartlei. /do hentby ceKijy xnder NYe pmfns mer patsTliea o.�Per,�rny'dYat dYe iwfer�aallo�provlded eboae is true a�d cor►�ecx si�.�_C��.��• �s.�,�• Date /Z/�J o s' r P,�� . vi��v�a se,waH Pbo�# �a8- 36a- ��.o efficiai ase anly do eat�vrke ia tYb am te 6e cempleted bp city er iwvn e�ial city ar te�vn: P�� Ba_�d�s Department ❑e�eck if immaKah respene is reqa�ed �,s O�ffia Phene �H�Depat�t m�ad pas�: #� �� tTMvi+cd Styt 2003j THE CQMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-008 FEE: $50.00 TffiS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to_ M.Victoria Schuh d1b/a Blueberrv Manor at 438 RnntP 6A, Yarmc�uthi nrt�, l��A in said Town of Yarmouth And at that place only and e�ires December thir[y-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony�Vhereof,the undersigned have hereunto affixed their official signatures,tlus Third day of February A.D. 2006. BOARD OF HEALTH: B �.,r�i�st�, ,/�I.�S,, ' Number of bedrooms: c��%�ess e5'�, �sce e�tc�t i�Floor—1 Bedroom in rear /��B��y� (� 2na Fioor—3 Bedrooms n��tic�/Kc�eh�o� ' fQiut�j�ieehcL�c�s, R./{� Bruce G.Murphy, , S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-145 FEE: $30.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the neral Laws,a permit is hereby granted to: M.Victoria Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31. 2006 BOARD oF HEAL'rt-�: B �, o�,�yJ,�'y,, • ��'st�, k�.�., v�e�� s'r�ucTTorrs: Guests only. /Z�61, B�y (� /��iiic�1�c�e�ito� �4�� , R.N. February 3, 2006 ` ruce G.Murphy,MP , .,CHO Director of Health o�°Y�� t.dwco,:�z. �� ..: ♦�o TC� WN OF � Ala1�IOUTH o - . - -� -� �-�- �- 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 MATTACHEES� � � ��-0pOqA�EDEfl� Telephone (508) 398-2231,Ext. 241 — Fax (508) 760-3472 B OA1tD OF HEALTH To: Yarmouth Boazd of Health Permit Holders ��._._.----- From: � David D. F�rty Jr., RS. ;�� ' ' ' �_-; �_c; Heahh Inspector � TownofYarmouth "`�K � 9 �pQ5 HEAL I��i (��pT. Re: Federal T�ID Number i�ate: March 22, 2UU5 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 Employer ldentification Number(FEIl�otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 South Yannouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, F�eas� ao r�ot hes�iate to calt. The of�'ice bours aze l�Ronday to Friday, 8:30 a.m. to 4:30 p.m The telephone number is(508) 398-2231,eart.241. Establishment:�t�e.�Gr-��r-�y FEIN or SSN: /�� Location Address: �� M�t.�r� S.��,�'yyl p k-�'�,pa�"-�'� �f�' Q,26 7S �f �Signature: � •� Print: M. Vi c�2�p �CH-Ut.�t Title: ��rr1.�.e�� .� �� Printed on �� Recycled �� Pager .;,,a � : �� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMQUTH PERMIT NUMBER: #OS-008 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to__ _ M.Victoria Schuh d/bla Blueberry Manor at 438 R�nte 6A, Yarmnnth?�rt, MA in said Town of Yarmouth And at that place only and e�ires December thirty-first,2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned haee hereunto affixed their official signatures,this Fifth day of April A.D. 2005. BOARD OF HEALTH: �Bes�sls�S. L�'c�s,JLI.$. ' Number of bedrooms: nG�/�c�PJu�, vsce��s��ih�t��t 1$`Floor—1 Bedroom in rear Qu�wlt�� 83o��t, �� 2na Floor—3 Bedrooms d�ele�t cS��i, R./{� f4�t�t�'�leert�crit, R./�. Bruce G.Murphy,MP .,CI�O Director of Health ._ � � , , . � �� Bu�EPirc(ur-`f MkNaR- ��`:''R o TOWN OF YARMOUTH BO � � , AI: o_ -�y APPLICATION FOR L��1��E -2005 [�� r r� ��; , � .;. -� � . .;? `_ J ..•• * Please complete form and attach a11 necessary documents by Decemb r 31�r��0g. ;� 2 n 05 Failure to do so will result in the return of your application pac t. NAME OF ESTABLIS�IMENT: Bfu�� TEL. #S'OP•3t t•�Lzo LOCATION ADDRESS� 43$ Maa'h St V�i�►�ou}�ber�, N� A26�s" MAILING ADDRES S� Sk rr�c. OWNER/CORPORATION NAME� ✓�cft�w�`i Sch kb MANAGER�s N�� Gu-atd Ros�h TEL. # So8-.�t 2 -�'L z.o MAII.,ING ADDRESS' if 3 d �ta.t'n St G1arrHau td.�ar f r.tr.4 02 6�S 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. N/q 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 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. T6e Health Department will not use p�st years' records. You must provide new copies and maintain a fde at your establishment. 1. 2• PERS41��t��E: - ---. _ _- - _ - - ----- -_ __ --- __ Each food establishment must have at least one Person In Charge(PIC) on site d�ring hours of operation. 1. 2� HEIlVILICH CERTIFICATI4NS: 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- RESTAti�RANT SEATING: TOTAL# l�o resta,c�r�.w�`"' OFFICE USE ONLY LODGING: LICENSE REQiTIItED FEE P�RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � B&B $50 O �UOS CABIN $50 MOTEL $50 I1�iD1 $50 _ CAMP $50 _SWIIvIlVIING POOL$75ea. LODGE $50 _TRAII.ER PARK $50 WHIRI.POOL $75ea. FOOD SER'VICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS �75 �CONTINENTAL $30 O i (r NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PBRMtT# LICENSE�REQUIRED FEE PERMIT# I.ICENSE REQUIl2F,D FEE PERMIT# _<50 sq.ft. $45 ` _>25,000 sq.8. ' $200 �VENDING-FOOD �20 � ,Q5,000 sq.8. $75 �FROZEI*1 DE55ERT,$35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ SO•�O •"'�'�'�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 ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensatio� Insurance. THE ATTACHED STATE WORKER'S ��MPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETEp ANp $IGNEp, OR ,. � •, � - . . , , � . , . . CERT. OF INSURANCE ATTACHED OR � . , .. � . .: , . V WQRKER'S COMP. AFFIDAVIT SIG�NED 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 RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENTFORINSPECTION?-10 DAYS PRIOR TO OPENII�IG FOR THE SEASON. ALL REN4VATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POQL UPENING: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 clpsing, FOOD SERVICE C�NSUMER ADVISQRY: Each food establishment which serves or sells rea.dy-to-eat,raw or undercooked animal products are required to post Consumer Advisories. •� CATERING POLICY: Anyone w o 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. F SE��S• _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or faod service establishment is prohibited. DATE: �2I�_� SIGNATURE: � � � w ��, PRINT NAME& TITLE: /k ►ri C rp rt i A S�ttuM, 4 Un�r 10/22/04 r � �� The Commonwealth of Massachusetts � �� Department of Industrial Accidents --_ = N�I ffr1�M�M� � - - - - � 600 Washingto�e Stree� 7`�`Floor —,,,�° Boston,Mass. 02111 , �.a< -,..., .. � .,,.,n� Workers'Com�eesahoa Imsar9aee davih Baild�a�lPhh°°�bia� � �- �f� ��,�� ,. x ,� „� _. �'^��. �� COBl1'�CtU�B �:�'��,W �r�`' '�;3 .c ,.�e_£x ,�'�.� �,4. "'_ �: M v��ra2« scMuH address: �3� itI A/N 51' ��ri VAK�teu�Po�u- ��- .yA ap- o26�s ►�# ra8-�da- �620 � si�e�ocaa� rnu a�S: I am a homeow�r performing all wak myseif. Project Type: ❑New Ca�ructio��Reanodel I am a sole 'e�or and have no one w ' in an ca ' . Buil ' Addition . . :. ._�,, �. .;:. � � ❑ I am an employer providing w�keis'compensati�fa�my employces wo�cing�rhis job. ooatt�v�� BLV FB�'Q12C. A�A-MD 1�.. �: 'F38� �t(R/l�r ,Sj'. �: : ��rr.Houn�perr.r- M�t oz�,��- �� so�- 6z• �b.2.� � ❑ I am a sale praprietor,geieral eoatractor,or komeew�(circle oue)and have luied ihe co�ractors listed below who have the following workers'compensation polices: � c�: ��• #� �s�• �• c�itr: ��. ---- __- - ----- __- __ # ,: _:, _r, • . �: .r Fa��e e.�ecge owera�e a�reqared.�der satloa zsA.t MGL ls2 e�a le�a b tte isp�io.ef c�.iul pnallia.c a 8�e.p a s1,sM.M a.ar.r ose yean'Impriea�nmmt as we8 as dvY pe�al�s ia t6e fera�ef a 31 d!WORK ORDER aad a Bae af S18l.M a day a�nt oe. I�derahud that a cepy st tYis�a�e�ay be for�varded on the dAice�laved�tlom of fke DlA for ceverage veri8eatle,. I do 6errby callfy xnder tGe pal�s rtxd peiuJties of per}riry thet tbe i»fonne8oe provided oboNe fs Irxe awd onrn�ct Signatare . U ' • /�'t�-o..6... Date (2/3/�D� Print name M• V/C r1J'2l A S'L�•t�N Phone# Sb�-3�,2- ��Lp effiMiai ase oaiy do eot wrife�this area to 6e c�piaed bY dlY ei'I�vn ei�ai cily or ta�►n: Permif/�oeese# �Reidtns]�t ❑c�eck if Immediah respesx is ralaind �1i�E BsaN ra �Sdee�n s O�ce �persan. �#; ��t • - THE COMIIZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NiJMBER: #OS-008 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to_ M.Victoria Schuh d/b/a Blueberry Manor at _ 4�8 Rout 6A, Yarm�»thi�rt,,VIA in said Town of Yarmouth And at that place only and expires December thirty-first,2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confornuty with the authority grant�to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimorry Whereof,the undersigned have hereunto aflixed their official signatures,this Third day of February A.D. 2005. BOARD OF HEALTH: Qesr��ri�rs�. �j�,/��S. ' Numbe�-of bedrooms:2nd Floor,3 bedrooms n�Tscl�/�c��J�to�, Qfice e��st �s�R�v �v�� , R.�v. �; Bruce G.Murphy, S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIV�NT PERMIT NUMBER: #OS-132 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted ta - M.Victoria Schuh, 438 Route 6A, Yarmouthport,MA Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2005 Bo�oF x�AI.Tx: l�e�y�xiss�. (�'o�or�,JyJ.`h. • ��+�� v�e�� RESTtuCTTONs: Guests only. R'o/Lwl�G}. B�t�7w/R�st �� dnYP�c�u'�t, K./V/� 1Yil/L��fNJI� /C�. February 3. 2005 Bruce G. Murphy ,RS.,CHO Director of Health . :� 6""""' ��p�i�l ' 1 �, �°`:AR o TOWN OF YARMOUTH B�SA�RD�1F HEALTH ��, �i��A�"��"`; � P i. , �� '�� APPLICATION FOR LICE1�fiS�IP�RMi'�°=2004 i s 0 ,, . �i �' �•.. ..••""� � � .. �� j Z��3 �� * Please complete form and attach all necessary documents by December 31� 2003. ; Failure to do so will result in the return of your application packet. ; ._,H�i�t_�_�-1 L��'�".___, 1�AME OF ESTABLISHMENT• gluth�Yru � v�or TEL # Sb 8-3G 2 -�b ZO LOCATION ADDRESS• 43$ A.(a.,`K S1� �AILING ADDRES S: �/�.v vn ou f�C�. �o r t �f� Oj 6�S O WNER/CORPORATION NAME• VI c to r►'t 5�1�u H MANAGER'S NAME: Tc�r u R o s c n TEL # 5o S �3 6 2• �6 2. n MAILING ADDRESS: s�ime t4s a b ov G POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Qpe�atar(s) ar�d at�aeL ��opy�f t�'�e certificati�n t� tr;s �or,i. 1. 1�f i�t t�10 bno I 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 wilt not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. IV/,� 2. _ __ . - _ _ _ Y��SdN�N CY�A�UE: - _ Each food establishment must have at least one Person In Charge (PIC) on site during hows of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. N/a Y�o re s+a.�.�rtw��' 2. 3. 4. �TAURANT SEATING: T�TAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED EEE PERMIT# LICENSE REQIJIRED FF,E PERMIT# L(CENSE REQUIRED FEE PERMIT# 1 BScB $SU O�E'-�( _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE• LICENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FGE P�RMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS a75 �CONTINENTAL $30 O�I— _NON-PROFIT a25 >100 SEATS $150 _COMMON V[CT. S50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSF.RGQUIRED FEE P6RMIT� LICENSE REQUIRED FEE PERMIT# _.<50 sq.ft. a45 _>25,000 sq.ft. $200 VBNDING-FOOD $20 _<25,000 sq.ft. $75 _FR07.EN DESSBR'f S35 _TOBACCO �25 NAME CHANGE: a10 AMOUNT DUE _ $ 80.00 **"**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 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 SIGN�D AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: N/,¢ rco �mploYccs YES � NO NOTICE:Permits run a.nnually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing. FOOD SERVICE CONSUIV�R ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERING 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. FR4ZElY�ES.� ��,5� - _ ___ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE C�F�'�: Outside cafes(i.e.,outdoor seating with waiter/waitress service),g�ust have prior approval from the Board of Health. OUTDOOR COOKiNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , DATE: ��.�3 t /0 3 SIGNATURE: � � ��— /��-� PRINT NAME& TITLE: w1• V��-�R�� s c�-�� I-{ 10l22/03 � The Commonwealth oJ'Mossachusetts � � Department ojlndustrial.-lccidents ; 011lce o/%res�l�sdiis � 600 Washington Slreet ' -` Bnston, Mass. 02111 w,, �,� V4'orkers' Compensation Insurance Affidavit Aoniicant information: P►essePR '� nam�� V l�TD R..1{� 5� L�cation: RI U�I�u-►rt,� A.(d..�.�rv- � $ �Cc.vt�� Sf'• �L� u/�.YVVtot.�f-�. �D►r1-' �'1� 02��S o�ne u Sag � 3`.z• �` �.-o � I am a hc�mecwner pzrt�rmin,all work myself. � I am a sole proprieror �r,�. ha�e no one��orkin� in am•capaciry � I am an employer pro�idins w�orkers' compensation for my employees w•orking on this jub. �omnanv namr address �t�'� Ahene tf• iesur:►nce co. ooiicy# � I am a sole proprietor. generai contracto�, or homeowner(circle onel and ha�•e hired the contractors listed below �►ho ha�e the follu��in: ��orkzr .ompensation polices: s4moanv name• address ��'" phone#1• iosur�ncc co. Qelicyll como�nv name• �ddress• sth�: nhQee+�• insurance co. ��eY� t Failure to secure coverage as requi�ed under Secnon 25A of MGL 1S2 n�!nd to t6e iepaidoa of erioi�i peadtles of a O�e op to 51,500.00 a�d/or one yean'imprisonment s�w•ell a�eivil penalda io t6e lorm of�STOP WORK ORDER aad a tiat of 5100.00 a day atainst me. [a•dersn.d ma�a eopy of thi�statement mav be fonvarded to the 0liice of Inveatig�dons of tAe DU for eovenge veritieado�. !do hrreby cerrif}•under rh�pains and prnal�i�s ojperjury that 16t rnjorntation provrd�d abovt is trtte and contci Signaturc �• �.t� '<�-�t:�c.u.�• D�� _/L�3/��.3 Print namc lK_ V/L�2,[14 S UfU #� Phone 1l .S�8 -36 a -o i F'3 ., o(Ticial use onl} do not+►�ite in this area to bt completed by titr or town ollleial ciry or town: YA��IITQ _ permiNieease N n8uildiog Department �Liceosioe Board �cheek itimmediate response is required 261 �Seleetmen'�OtTice �HealtA Department cont�ct person: phone 1t;_ �508� 398�2231 eat. nOther .. .� <�,.� s y THE COMMONWEALTH OF MASSACHUSETTS T�WN OF YARMOUTH PERMIT NLTMBER: #04-011 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to M.Victoria Schuh dlb/a Blueberry Manor at 4'i8 Rnute 6A, Yarm�uthnnrt, MA , in said Town of Yarmouth And at that place only and expires December thirty-first,2004 unIess sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in confomuty with the authority grant�to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Sixth day of February A.D. 2004. BOARD OF HEALTH: ,Bes�ni�c�. 4r'o�,/yl.�. ' Number of bedrooms:2nd Floor,3 bedrooms nc.�htc�a/ye��►�tato�, �/i�e ��,athyrc��t �s�R.�� Bruce . Murp , ,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHIVIENT PERNIIT NCTMBER: #04-132 FEE: 30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 3QSA and Chapter I 11,S�tion 5 of the General Laws,a pennit is hereby granted to: M.Victoria Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: Blueberry Manar Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2004 BOARD oF HEAI,TH: B�yc.�r�u�_`?l. �Cjo�ors, /�$. ' /�c.�iuc�(a/�fe�� 7llce ��i�x�s RESTRICTIONS: Guests Oril�+. Rp�� BJjp�,Wy e��y � s� a�v. February 6, 2004 � Bruce G. Murphy, H, . .,CHO Director of Health ,� - �.12�a886 �'80°p � �fr R.r� TOWN OF YARMOUTH BOARD,C�FHL�"ALTH �� o� - � -'� APPLICATION FOR LICEl�TSE1F�.R�VIIT''?-2003 D E C 3 0 2002 � . .,? � * Please complete form and attach all nece ' c�c>e�ments by Dece drl t2if6�DEPT. Failure to do so will result in the�e�f your application pac et. NAME OF ESTABLISHMENT: j�1� r b�r�^U ��n r- TEL # S'0 A -36a - �6� N 3 S , �— M�- d� a—' �IAILING ADDRESS: Sav»e. OWNER/CORPORATION NAME: �t . 4�e ci-nr I�� Sc.G,u,tn L��IAGER'S NAME: C�e.��,�.P� �.os e�, TEL. # 50 8 -�6 a- �6�a �I�A�.ING ADDRESS: �ctm� as a bavc_ POOL CERTIFICATIONS: The pool supervisor must 6e certified as a Pool Operator,as required by State law. Please list the designated Pc�o}f)perat4r(s}at��si2 a copy�fthe certification ta th�s form. l. lJ�,� 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: �`� �'o�tine.i�f�-� l`3rc��f-- All food service establishments are required to have at least one full-tirne em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 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. _ _- AR_�A C�[1�T�N(>��RL3�._ . _ • - --_ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIIyILICH CERTIFICATIONS: /✓�,� All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Iiealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PE�tMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# �B&B $50 �� —CABIN $50 _MOTEL $50 _INN $50 � _CAMP $50 _SWIMMING POOL$SOea. _LODGE $SO _TRAILER PARK $50 _WHIRLPOOL a25ea. FOOD�FRVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 I CONTINENTAL $30 ��/ �NON-PROFIT $25 � >100 SEATS $150 _COMMON VICT. $50 � � _WHOLESALE $75 �TAIL SFRVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $'75 �TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ SD.OQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"�*** __ _ � ,_ . _..,....._,... .....,__. .,_. , _ � ; � r , ti ADMINISTRATION 'Under Chapter ��2;�ection 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 '��i� �o Cri►ployees CERT. OF INSURANCE ATTACHEL� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. 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 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 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 C,ONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Fro�err d�ssertsmust�e tested on�montlrlybasis by��tate ce�tified lab: Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: /��30 0�-- SIGNATURE: � ��c.�(�c.c..— �--�-�-�� PR1NT NAME&TITLE: N � v«To Rl� S�/�� d�N��'�TO2- 10/18/02 _ ,-.� ---1--_ - . ' � The Commonwealth of Mossachusetts � � Department ojlndustrial.-lccidents " o OlJlce ol/�s1l�sdiis � 600 Washington Slreet �(/'� �� / �� ' •` Bnston.Mass. 02111 �� p � ~ v�y W'orkers' Compensation Insurance Atfidavit Aoolicant informallon• p��SepR��.-},� n�mr� L�ation: c�t� phone q � I am a homecwner pertormmg ai1 w�ork myself. � I �m a sole proprieror��,�, ha�e no one ��orkin_ in anv capaciry � J �m an emn��pra��din� w�Qr{:ers' compensatiQn far my empioy�ees w•orking on this job. - - comnam• name• �ddress: citr nhone t1• insur�nce co. p�Y q � I am a sole proprietor. generai contractor, or homeowner(circle oneJ and have hired the contractors listed belo� ��ho ha�e the follu��in_ ��orkzr� ;ompensation polices: s4moanv n�me• address• zitt; phons�• insurancc co. polic}•# t2mnanv name• _ _ - -- - - ---- _ __ - ______ _ _ — _ _ a�drcss: cih+: _ oboee 1i• insurance co. ��eY� e Failu�t to secure coverage as required uoder Secnoo 2SA of MGL 152 n�Ind to the iopaidoe oterisi�al peaaitles of a O�e ap to Sl¢00.00 a�d/o� one yean'imprisonment a�w•ell a�civil penalda io tht form of a STOP WORK ORDE'it�ed a 4ne of 5100.00 a dar apinst ma I a�denta�d t5at a eopy of this statemen[may be fonvarded to the OIGee of Inve�tiguiom of the D!A f�eoven;e veritfado�. I do hrreby c rtif}•under r6�poins and p l�ies ojperjury that the injormation provrdtd abovt is true Qnd correct Signature - �2�,.�d�� Print name �T+��(� 'el L, _ �lSS��_ PhoneAt v�i��bZ�7 .ZU .. o(Ticial use onl� do not w rite in this area to be completed by eih or town oAltial city or town: Y�M�IIT� _ permitAicenx p nBuildiog Department �Licensiog Board �eheek if immediate respoese i�required 261 �Sdectmen'�ORee �HeaitA Departmeet cont�ct person: phone q;_ �508� 398-�2231 eat. nOther .. . <.,,, ��YA�� TOWN OF YARMOUTH � _.' � � y ll/6 ROUTE 28 SOUTH YARMOUTH MASSACHUSFTTS 026C4-4451 � MnrrAcnees" 'x Telephone (508) 398-2231,Ext 241 — Fax(508)398-2365 � M��RVOIIATt0�6j9 1/�� C1 (�-v BOARD OF HEALTH � � � I� OMC p February 5, 2003 FF� � 0 z0�13 M. Victoria Schuh d/b/a NEALTF-; pFpT. Blueberry Manor 438 Route 6A Yarmouthport, MA 02675 Dear Ms. Schuh: Thank you for submitting the 2003 application for your establishment's bed & breakfast and continental breakfast permits issued through the Yarmouth Health Department. However, we are unable to issue your permits at this time due to the application being incomplete. All sections of the application are to be completed in full, as required by the Board of Selectmen. The following question was not answered when you submitted the Application for License/Permit: Town of Yarmouth taxes and liens must be paid prior�renewal or is uance of your pernuts. Please check appropriately if paid: Yes �� No . �� •Y.dzl.�.�� (If question is not applicable,please indicate such.) Please answer the above question, and return to the Health Office so that we may issue your 2003 pernuts. Thank you for your anticipated cooperation in this matter. Sincerely, ,,��'G� Mary Alice Florio . Principal Department Assistant /maf cc: file � Printed on ( Recycled � 3 Paper THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #03-015 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to M.Victoria.Schuh d/b/a Blueberrv Manor at 438 Route 6A. Yarmouthnort. MA in said Town of Yarmouth And at that place only and expires December thirty-first,2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. T'his license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereo�the undersigned have hereunto affixed their o�'icial signatures,this Fifth day of February A.D. 2003. BOARD OF HEALTH: (�iFa�rled'r� zelll�i, ��c�avuua� Number of bedrooms:2nd Floor,3 bedrooms Se.c�D. Gd"ond.o.c, '��., 2/u;e �a�e�ct�. �ioae�c, � �adrick�llc��tot�.' '�elea �k, ,��l. B ce G.Murphy, ,R.S.,CHO Director of Healt TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #03-155 FEE: $30.00 In accordance with regulafions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: M.Victoria.Schuh, 438 Route 6A, Yarmouthport, MA Whose place of business is: $lueberr,y Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2003 Bo.�oF��,�: (,�lca�rled�f. �elG�i, ��u� �e��D. G�,mcd.o.�. 711.D.. 2/�ce �s'r�ucT�oNs: Guests only. ,�a��t�. �a'�rouwc, �� a.a�k�KeD�tt �ele.i Sl�. ��l. 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Mass. 02111 �'~ '��~` V4'orkers' Compensation Insura�ce Affidavit ARniicant information: P►ess�PRiNTT�� namr l�l. V fG"7'"D�( G— �I f,� /if --- loc�tion: `T�lJ I�I C'i ✓! � ��.t.l�rN� u.?'11.O�t� /-//`f- �/,��i5 phone q�S��d �( I am a homeowner�rmmg ail w�ork myself. � I am a sole proprieror _r,', ha�e no one ��orkine in am� capaciri� � I am an empioyer proti�din� w�orkers' compensa[ion for my employees w•orkine on this job. comnan�• name• �ddress ��t�" nhone If• insurance co. oolicy tt � l am a sole proprietor. :eneral contractor, or homeow��er(circle one! and ha��e hired the contractors listed below �tho ha�e the follo��in: ��orkzr �ompensation polices: comoanv name• asldress• citv• ohone#!• insurancc co. ooli �•# s4mo�nv namr. _ _ _ __ _ _ _ . . -- _ _ __ _ _ __ _ --- addresr �'� ohoee�E• insurance ca �,{� ' Failure to secure coverage as required uuder Secnon 2SA of MGL 152 e��iad to tbe iopositioe o(eriminl pesdtles of a O�e op to SI�00.00 a�d/or one yean'imprisonment as w�ell a�civil penalda io the lorm of a Si'OP WORK ORDER aod a tiee of 5100.00 a day a�ainst ma I s�denta�d t6at a eopy of thy satement may be fonvarded to the OlTice of Investig�dom of t6e DlA for eoverage veri8eado�. /do hrreby certif}•under rhr pains end prnal�ies ojperjury that 11�t rnjo►nration providtd abovt is trtit and eor►ee� �• .. (' � Signature �� U Gc,�� 7�/,�.�-�.. Dau ��08'f G L Printname M. ✓/G�2lfl` SCt�f'UG� Phonel! �8'3��.• 7�`� .. otTicial use only do not M�ite in this area to be completed by eih or town otffeial city or town: Y�M�IIT$ _ permitAicense q nBuildiag Department �Licensiog Board �check if immediate response i�required 261 �Selectmen'�Otiict �HealtA DepaRmeot contact person: phone N;_ �508� 398-�2231 ext. nOther , ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH , PERMIT NLTMBER: #02-007 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to M.Victoria Schuh d/b/a Blueberry Manor at 438 Main Street/Route 6A, Yarmouth�ort,MA in said Town of Yarmouth And at that place only and expires December thirty-first,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealtli respecting the licensing of ixuiholders. lfiis license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty- seven,inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Fifteenth day of March A.D. 2002. BOARD OF HEALTH: '�f, xePli,l�, Number of bedrooms:2nd Floor,3 bedrooms �x.t..,c�. G�c'oada.�. .�lce �a�iP�ct j? �a'aotvs�. (� �a�iic��1ZeDauxot� � s �� ruce G.Murphy, H, .S.,CHO TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-085 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: M_Victoria Schuh, 438 Main Street/Route 6A, YarmoLthnort, MA Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEALTH: �kanfea�f. �d.�i�i, �cavuxa�a �ee.t�D, yando�c. 71�D., `�/1ce RESTRtCTtoNs IF A1vY: Guests only. �v�jl f�'�, (� �a�rick 7'�eDezoxat� � s , .� March 8 ,2001 � ruce G. 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C: 3 w ; A � • -\ The Commoawealth of Massuchusetts = W Department ojlndustrial.-�ccidents � > O1llce ol/av6sl/�stliis " �� 600 Washington Street � Boston,Mass. 02111 '��n 7��'"' "'v`'y W'orkers' Compensation Insurance Affidavit N/� �O^(�ypGUt�L�� - --- -_�--;-.__-, p'Ieas�PR11aT'ie�i't� - m•: o . �` ohone� _ � 1 am a homeowner performing all work myself. � I am a sole proprietor�r� ha�e no one��orkin� in am�capaciry � I am an employer pro�idins workers' compensation for my employees working on this job. om an ` n me• address• �� ohone k• insurance o. °�� # � I am a sole proprietor. _eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed belo�� `ho ha�e the follo��in��orker�� ompensation polices: m nv n e� ress• �� ohone#• insur�ncc co oolicv# m a n m : ��, nhone tl• oofiev 1f ' Failurc to secure coverage as required under Seetion 25A of MGL iS2 ae lad to tht impoaition of trioi�l peoaltla of a tioe op to 51,500.09 a�d/or one yean'imprisonment a�w•ell a�civil pena�tiea io thc torm of a STOP WORK ORDER aod a fioe of 5100.00 a day ae�inst ma i s�dersta�d tbat a copy of thi�statement may be forwarded to the OtTice of Investigadoos of t6e DU for eovenge verititatio�. I do hrreby cer�ij}•under/he poins and penaltie perjury thal Iht injon»alion piovided abovt is true a►�d eorrtet Signature � Print name GL�el � Phone� S � �� ., otTicial use onl� do not..�ite in this ares to be completed by city or town oRiciil citv or town: yA��D� _ permiNieease# nBuildiog Dcpartment . — OLicensing Board �check if immediate response is required 261 ❑Selectmen's ORee �Hralth Departmeat phone q;_ �508� 398t2231 ezt. nOther contact ptrson: '"— Irecned i;95 PJA1 ` �I�aH�o.�o��a.zTQ . OH��.s. � dY�i�,iqd.tny�•rJ a�tu , .Q+. .�,�� , � �'u� '�'''�°�� °a` ?d'��xr� �/fi ��y��i ��i�a�'�� s�uooapaq£`ioo�d Puz:suioo.ipaq3o aaqumN �r�� •�� ?LG p3 ��.zd�3o ax�og "IOOZ 'Q'd 4��Y�I 30 ,{ep y�q ig si�`sam��u�is isio33o nat�pa��o�unaiaq an�u pavSis.tapun at�`3oaiayM�iuoun;sas ui 'ZLZ�a�d8q�30`anisniout`uanas -�uann�o� ang-�uann� suoi�aas pue ia�d�q�pcBs 3o pue `ancsniou� `onn�-�ay� o�onn�-�uan� suoc�oas o��oafqns s�puE o�aiay�s�uatupuau�pu�`Obi�a�d8q�`sk+�Z i�aua��Cq sai�uo�ne�u�suaoit a�o�pa�u�.��uo�nsa��tn��iuuo�uoo u�panssi si asua��i styy •siapioquui�o�u�suaoci ac��ui�adsa.��teannuounuo�a�3o snn�i a��o uoi��ioin io3 paxona.�.�o papuadsns.�auoos sseiun i OOZ`��3-��1��aoaQ sa.�dxa pu�,Ciuo a��d�8y��pud t{�nouue�3o un�oZ pIES LII VT�I �o �nouue� �9 a�n 21/�aa.z�s ui�J�i 8£t� ;� �ouey� aqanig 9JP��I�S�uo��iA•y� o;pa;ur,.��cqa.�aq s� �SI�i��I'I S�2i�Q'IOH1�ll�II i�i�y`v'H1.1�.dI1.2I�� O.L SI SIH.L 00'OS$ ��3 600-IO# �2I�gL�If1t�I.LII^i2I�d H.L110L1RI�'1�30 I�IAAO,L S1..L�SI1H��'SS�I�t�O H,L'I��AAI�iOL1iNt0� �H.L TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-131 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 pemut is hereby granted to: M Victoria Schuh "2O "'� � �+'�P+�^"+"6A Yarmo�thnort MA Y.JO Iv! �� z � Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To opera.te a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d�l• �et�ed• ��s �c��t� �'�iu�� C�i,ca�t RESTRICTIONS IF ANY: Guests only. e� �,,��, .�, �C�G � !/• ��r"a'"�`' Mazch 8 ,2001 / ruce G.Murphy,MP .5.,CHO Director of Health i � ° ,'� ��. � �'f� � � �� "`� � TOWN OF YARMOUTH O�,�ALTH APPLICATION FO�;,.� �� tMIT- 2000 D E C � 0 1999 . � :�'�� ,�1�°�� HFALTN QgPT. * Please complete form and attach all necessary documten�s by De�ber�31, 1999. Fa.il e o o so will result in the return of your application packet. ; ------------------------------------------------------------------------------------------------------------------------------------------------• NA� OF ESTABLIS�NT- $LUE$E2RU �-t�4�rO t2._ TEL # 5'08•362-76 2 0 LOCATIONADDRESS� �138 M iN s��rr.�rovrHpoRr, M,g o2�� M�1.iL1NG ADDRE S S: SA�� OWNER/CORPORATION NAME: M, v �ca-o 24,4 5 cµuN MANAG�R'$NAME: �t-�rr.a�,Z DS�tJ TEI. # 5/a N E' � MAII.,ING ADDRESS: 5/a�E R s ,q soV� POOL CERTIFICATIONS: The pool supervisor must be ccrtified as a Pool Operator, as rer�aired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. 1. N/,4 2. Pool operators must list a minimum of two employees currently certified in basic water sa�ety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifica.tions 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. HEIMLICH CE�TIFICATIONS: 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 yaur 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. -- -�tE�a'�AURANT SE�TING: TOTAL# _ - NON-SMOK�G SEt�'FS: TOTAL# ____ __ _- _ _— --- ------------------------------------------------------------------------------�-------------------------- ------------------------------------ QFFICE USE QNLY �.,ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $so Y2k•IZ caBnv $so INN �50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIIVIlVIIlVG POOL $SOea. V�LPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU]RED FEE PERMIT# _0-100 SEATS $75 i CONTINENTAL $30 2Kf� 2. >100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 � WHOLESALE $�5 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ �jO-�- """"'PLEASE TiJRN OVER AND COMPLETE OTf�R SIDE OF FORM""`"" �I�/J � ADMINISTRATION ' UNDER CHAPTER 152; SECTION 25C, SUBSECTION 6, TI�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. T$E ATTACHED STATE WORKER'S COMPENSATIUN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR. ' CERT. OF INSURANCE ATTACHED � WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED TOWN t�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APP PRIATELY IF PAID: YES_�� NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT I5 YOUR RESPONSIBILITY TQ RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FE�(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMIENT FOR INSPECTION 7-10 DAYS PRIOR T(J OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL �R POOL (i.e., PAINTINC, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTNIENT, AND'THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE C�UNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUNI) SVV]INIlVIING POOL MUST BE DRAIlVED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYOI�tE WHO CATERS WITHIN TI-�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII.ING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPAR.TMENT. FROZEN�E S� ERTS: 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 THE SUSPENSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE _ __ _ BEEN MET. OUTSIDE CAFE,S: OtJTSIDE CAFES(i.e., OtJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. OUTDOOR COOKING: OLTTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD SERVICE ESTABLIS�-IMENT IS PROHIBITED. DATE: 2 �� q 9 SIGNATURE: PR1NT NAME& TITLE:� ��Se ti I�a k a u�.Y 11/12/99 � �' � The Commoawealth ojMassachusetts � � Department ojlndustrial,-1 ccidents . � o Olflceol/eves�lpstbis 600 Washington Street ' ,= Bosron. �lass. 02111 ` �~ '�� W'orkers' Compensation Insurance Atfidavit Aoolicant information: P`►easePR '� n�m� M. V I L'ia Q.l� SGµV � lucation: �3LU�l13EQ.[2:1.1 /yA�N012_., y 3$ MA1N ST • � MA 42.6 5 a Sog -36Z• 7d?o I am a omeow�ner pert�rmin;all w�ork myself. � f am a sole proprizror �r.,a. ha�e no one ��orkin� in am•capacit�� I am an employer pro��din� workers' compensation for_m�empin��ees�•orkine on this job. — comnam• name• 't3LV�AE"'tLRL/ M/41`tOR-- address: �13A Mi4tIJ Sf. titv: �1141U-i0U Tt+p 0►t-�' 1�I Ati- oz6}�' nhone q• S�F1 • 3�z- 767.0 insur:►nce co. UTIC./� ��y# � I am a sole proprietor. ;enerai contractor, o omeowner circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ ��orker ,ompensation polices: s4moanv name• ��ess: ��" ohone t!• insur�ncc co. R,�J�}'# comoanv name• addresr citv: ohoee+�• insurance co. ��n,� t Failure to secure coverage as required uoder Secnou ISA of MGL 1S2 ea�lad to tbe iepaitioe o(trisi�l peadtles o(�O�e ap to 51,500.00 a�d/or one yean'imprisonment a�w•ell a�civil penaldee io the form of a STOP WORK ORDER asd�tiae of 5100.00 a dar tpiost ma i a.dersn�d cha�a copy of thy sqtement may be fonvarded to the OfTice of Inve�tig�uom of the DU for eovera`e veritiatio�. I do hrreby cerrif}•under rh�p�arns and ptnalties of perjury thar tht injormation provrded above is trrre and conrct Signature � . fJl��u-�., C�� Date /l�2 Z f 9 � Print name /�(• V/GTflf�R SC.FI�vI�-- PhoneN �8'3� Z-'?(e� ., ofTicia! use onl� do not..rite in this�rea to be completed by eity or town oAleial ciry or town: YA��DT� _ permitAiceau p nBuildiog Department �Licensiog Bo�rd � check if immediate response i�required 261 �Selectmen'�ORee ESQ8 3 �HealtA Departmeat concact per3on: p�p��p�_ �_� 98��31 egt. nOther .. � < ��„ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' PERMIT NUMBER: Y2K-12 FEE: $50.00 . THIS IS TO CERTIFY THAT AN � INNHOLDER'S LICENSE is hereby granted to M.Victoria Schuh d/b/a Blueberrv Manor at 438 Main Street Yarmouth�ort MA in said Town of Yazmouth And at that place only and expires December thirty-first,2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with theauthority granted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-five to twenty-seven, inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Twentv-fifth day of Januarv A.D. 2000. . BOARD OF HEALTH: �c�� elEea, C�cairman Number of bedrooms:2nd Floor,3 bedrooms �oa�z� �u[[iva�c, �r/., Vice C,�ia��man Kobert.}. �rown� C,ler� abrielle�ahol��c�-�ooPe� ' �e[�� ou�hlin ruce G.Murphy, MP , . ., CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-142 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: M_Vict�ria Schnh, 438 Main Street, Y rmo � h=�rt� MA Whose place of business is: Blueberrv Manor Type of business:__ Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2000 BOARD OF HEALTH:�'�� gt��, C'�tr,�� oan� �u[�ivaa, K.�/•, �ice (_.hairma RESTRICTIONS IF ANY: Guests only. Kobert,}. �rown� C,fer� abrde[le�akoldkr�-J�ooPe� ic �� octg�lin January 25 ,2000 Bruce G. 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� The Commoawealth ojMassachusetts . ; w � Department ojlndustrial.accidents o Ofllce olleves�lost�iis � � 600 Washington Street � .` Bnston,Mass. 02111 �'"' "«/ W'orkers' Compensation Insurance Affidavit A,n�licant infor�++�*��• ��s��T�� ;�mr� V ICTOf'1 A SG-W I{ location: y 3g MA I N 5 i �c. 4 A-ru�l o v n-t I�D�-�' M!�- ��.r6 �3" phone# �� - ,3 6� -o/�'.3 � t am a home��wner pert�rming aU work myself. � I am a sole propriecor �� ha�e no one ��orking in am•capaciry � I am an employer pro�idiri� workers' compensation for my employees w�orkine on this job. _ _ -- _ -- com�an�• name: 13LU�73e,��1 NA�'1iz— address: L1-38 �/A►N �T � citv: 1'�U U tT-i PO)u- �A- Q �.-b �S' q. 50$- 3�d�- �� insurance co. �olicy# � I �m a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below «ho ha�e the follo��in� ��orker� �ompensation polices: comp�nv name: address. c�t�-. Rhone�• insurancc co. polic�# - comgan�name: ---- -- - - -___ ------ _ __----_ _ ---- _ _ _ _ _ --- — -- �ddre§s: -----— ��,: nhonc M• insurance co. :"�•-� Failu�e to secure ruverage as rcquired under Sectioo 25A of MGL 1S2 ese lad to tmt iopaition of erisi�tl ptaaltla o!a O�e op to 51,500.00 a�d/or one yean'imprisonment as w•ell as civil penalda io the form of a STOP WORK OItDER aad a tine of 5100.00 a day a=aiost ma 1 aadersn�d that a copy of thy st�tement may be forwarded to the OfTiee of Investig�tiooe of the DIA for eoven�e veriAestiw. I do hrreby certif i•unde�rhe pains and penallies of perjury thal tht injor►nation provided ebovt is ttwt and eon�eG Signature� U.n%c�u�. � �� '�3�� `� Printname /�'�. Vf�� Phone�l �o� -3�dz� nis3 ., o(Ticial use onl� do not.►rite in this area to be completed by ciry or lown otlleial city or town:_ yARMOIITQ _ permitAiceese N nBuilding Department - �Liceosing Bo�rd 0 check if imrtrcdiate response is required 261 ❑Seleetmen's Otifee �Health Departmeot contact personr phone p;_ �508� 398--2231 egt. nOther Ire.ued i,95 PJAI THE COMMONWEALTH OF MAS5ACHUSETTS • TOWN OF YARMOUTH PERMIT NUMBER: 99-10 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to Victoria Schuh dlb/a Blueberry Manor at 438 Main Street, Yarmouthport_ MA in said Town of Yarmouth And at that place only and expires December thirty-first, 19 99 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with theauthority gtanted to the licensing authorities by General Laws,Chapter 140,and amendments thereto and is subject to sections twenty-two to thirty-two, inclusive, and of said chapter and sections twenty-frve to twenty-seven, inclusive,o:f Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signatures,this Ninth day of February A.D. 19 99 . so�o��ai.Tx: �'d�/. �Bc�, c��,� Number of bedrooms:2nd Floor,3 bedrooms �oan. � �u6f�van,K.�, Vice l,�,al.,�..,aa Ko�ert� i�rown� l�ferh abrieLle Jahol�kt�-.htooPee � �el � ou hlirc ruce G.Murphy,MP RS. O Director of Health TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-133 FEE: $30.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Cl�apter 111,Section of the General Laws,a permit is hereby granted to: Vict�ria Schuh, 438 Main Street, Yarmouths ort, MA Whose pl;ace of business is: Blueberry Manor Type of business: Continental Breakfast To operal:e a food establishment in: Town of Yarmouth Permit expires: December 31, 1999 BOARD OF HEALTH:�d�/. �at��, C��.��. oan� �ui�an,K.//., Vica t��irman RESTRICTIONS IF ANY: Guests OIIIy. �o�art� �rown� �ler� �'�/brie[le�a�ofehcf-�ooPea r,c Odou��lin. Februar 9�,, 19 99 ruce G. Murphy,lvlPH, S., O Director of Health , a �i �t�-L�'�1 �1'�C'/l`� J TOWN OF YARMOUTH BO.ARD OF HEALTH � L� �rP ''�� " ';' '`; L� APPLICATION FOR LI��PI��'� 199 �lAN 1 2 19�8 � ,' �� r� '. � �. f � � � � �' ME�LI'f-t EPT. *Please Complete form and attach all necessary documents by I�ecember 31, 199 . so will result in the return of yout application packet. N�t �QF ESTABLIS�MENT: �L�lE8ER1� Md NbtL_ TEL� # 57�8-36.2- 76•i-� AD�RESS: , 438 MAIN_ST 1%A I�NOUTl+ �02T� �/A oZ.67S �I,�G„�DDRESS SA M E �— O�R/CORPORATION NAIVIET M. V►cro�e.�A sc�u H– MANAG'rE�'��TANIE: G�4e.n 2os� TEL.# S��tC MAILING An,�RES S: SA ht E- !�S A ES e V E , ,B�OL CE�T�FiCATIONS:------------------------------------------------------w-------------------------- Pool Operators must list a minimum of two employees currently certified in basic water safety, skandard first aid and Community Cardiopulmonary Resuscitation(CPR�.Piease list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years records. Yoa must provide new copies and maintain a file at yuur place of business. 1. 2. 3. 4. ,��IMLI�CH CE�TIF�,�A_TIONS: All food service establishments with 25 seats or more must have at least one employee traineti irx the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti- choking procedures below ana attach copies of employee certificatians to this form. The Health Departnxent will not use past years records. You mu�t provide new copies and maintain a file at yoer place of business. 1. 2. 3. 4. RESAiJFtANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL # OFFICE,USE ONLY LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQtJIRED FEE PERMIT# �B&zB $S � Q��'� CABIN � $50 _INIv $50 .,,_CAMP $SU "LODGE $SO �TRAILER PARK $50 T MOTEL $50 _. SWIM POOL $SOea. _WHIRLP�(?L $25ea. FQOD ��V��: LIC. R�:QUIRED FEE PERNIIT# LIC. REQUIRED FEE PERMIT# 0-100 SEATS $75 �CONTINENTAL 3�0 ��' >ll)0 SEATS $150 NON-P'ROFIT $25 CQ►M. VICT. $SO WHOLESALE $75 � �E�Y��E: LIC. RFQtJIRED FEE PERMIT# LIC. REQLTIRED FEE PERNIIT# �,<51) sq. ft. $45 �TOBACCO $20 __________ ,r<2:i,000 sq. ft. $75 FROZ. DESSERT $35 ._„_>2:i,000 sq. ft. $20Q AMOUNT DUE – �� O y ADMINISTRATION UNDER CHAPTER 152, SECTIQN 25C, SUBSECTION 6, THE TOWN C1F YAR.MOUTH IS NOW REQUIRED TO HOLD ISSUANC� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WQRKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S CUMPENSATION I1�SURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TC}WN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRI4R TO RENEWAL OR ISSUANCE OF YOUR PERMITS. P ASE CHECK APPROPRIATELY IF PAID: YES 1�t0_____r NOTICE: PERMITS RLTN ANNUALLY FR�M J.ANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED AFPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 1997 SEASONAL�STABLISHMENTS ARE TO CONTACT�'HE HEALTH DEPARTME1�Ifi FOR INSPE�TION 7-10 DAXS PRIOR TO 4P�IVING FOR THE SEASON. ALL RENOVATIONS TO ANY F04D ESTABLISHMENT,MOTEL 4R PC30L (i.e. , PAINTING,NEW EQUIPMENT, ETC.),MUST BE REPORTED TCl�AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIl�IENCEMENT. RENpVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL R.EGULATIONS POULS POOL OPENiN�: ALL SW�MiVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FQR'�HE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIC�R TO OPENiNG. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIlVIING POOL M�JST BE __ �11�#INFl2-�►��VE�ED WITHIN SEVEN(7') T�AYS O�-�bD�II�1G._ _ ____ _ ___.__ _------_._ - FOOD SERVICE -ATF�TN��S?.�,I Y: ANYDNE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPAR'TMEI�TT BY FILING THE REQtJIRED TEMPORARY FOOD SERVICE AP'PLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FRO ,��N D�SS TS: FROZEN DESSERTS MUST BE TESTED UN A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST R�SULTS MUST BE SENT TO THE HEALTH DEP.AR.TMENT. . F.AILURE TO DO SO WILL RES[JLT IN THE SUSPENSION OR REVOCATICIN OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. ()LITSIDE �1�FFS: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), N�ST HAVE PRIOR APPR(JVAL FROM THE BOARD OF HEALTH. Q�TDQOR C(JC)I�iNCx: OUTDOOR COOKING, PREPARATICUN, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: 1,�.j9.$�_ SIGNATURE• � v , PRINT NAME & TITLE: M. V r Gro�u A s c�w�i aw N�R-- 10/97 page 2 of 2 i J � _ The Commonwealth of Massachusetts M W Department of Industrial,accidents T o Olflce o/I�rest/os�iis 600 Washington Street ' •� Bnston, Mass. 02111 �~ °��y W'orkers' Compensation Insurance Affidavit ARoficant informallon: P►easePRll�'1'Ti�d.'i� nam� M, lf I C.1�11ZtA S C.k+a H— Location: �3t_U��iZIG�.1 l�1/�JnK.. - 43B 1�1A/N ST � u �0 �.� 0.'Lb�S� phone# S"U8 •36�-7 6� � I am a omeowner pertormin�all work myself. � I am a sole proprietor�^,� ha�e no one ��orking in am•capaciri� � i am an emplo�er pro�idins w�orkers' compensation for my employees working on this job. comoan�• name• address cit�: ohone H• insurance co. Qolicy# � I am a sole proprieror. _eneral contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below «ho ha�e the follo��in� ��orker� :ompensation polices: companv name: address ��y: ohone tt• insurancc co. Aoligy# �om�any name: address• [itY: Fhoee#• ies�rance co. potiev�f � Failure to secure coverage as required under Sectioo 25A of MGL 1S2 eae lad to tbe ioporidon o(erisi�al pesdtla of a ti�e op to Si*500.00 a�d/or one yean'imprisonment ss w•ell as civil penalde�io the form o(a STOP WORK ORDER aod a tioe of 5100.00 a day a=aiost ma I a�dersa.d mat a topy of thy statement may be fonvarded to tht ORce of Inveetigadoo�of t6e DU for eovengt veri8utio�. /do hrreby cerrij}�under the puins and penalties ojperjury that�he injornwtion providtd abovt is tnre and eontet Signature �- O�•.- c��tic.o-�-- Date _T�'9 S Print name �'I • V/GTO�GI/� SUf1J 1-� Phone�l S�� '36 Z ' 76 � .. olTicial use only do not write in this a�ea to be completed by city or town ofllcial ciry or town: Y�M�IIT� _ permit/lieense p nBuildiog Departmeot OLiceasiog Board �check if immediate response is required 261 �Sdectmen'�Otfiee (508� 398�Z231 egt, �Health Departmeet contact person: phone#;_ __ _ nOther (re��isxd i;o5 P1A1 � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-5 FEE: $50.00 THIS IS TO CERTIFY THAT AN INNHOLDER'S LICENSE is hereby granted to _ M. Victoria Schuh d/I�/a Blueberry Manor at 438 Main Street Yannou h ort,MA in said Town of Yarmouth And at that place only and expires December thirty-fust, 19 98 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of innholders. This license is issued in conformity with theauthority granted to the licensing authorities by Generai Laws,Chapter 140,and amendments thereto and is subject to sections riventy-two to thirty-two, inclusive, and of said chapter and sections riventy-five to twenty-seven, inclusive,of Chapter 272. In Testimony Whereof,the undersigned have hereunto affixed their official signahues,this fifteenth day of January A.D. 19 98 . BOARD OF HEALTH: �d� .�eltee� ��i.airman Number of bedrooms:2nd Floor,3 bedrooms �oa.� � �u��an., ��, Vke C/zui�� Ko�ert.}, p.�rowrc� Crler� abrieLte�ahol�ht�-J�tooPed ' ��0' ��. .�Ltc� ruce G. Murphy,MPH,R.S., O Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-94 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 395A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: M Victoria Schnh, 4"�R Main StrePt� Ya�th}��,1y1A Whose place of business is: Blueberry Manor Type of business: Continental Breakfast To operate a food establishment in: Town of Yannouth Permit expires: December 31, 1998 BOARD OF HEALTH:��f. �gf.��, C'�tr�,� �oan � �ullivan� K.//.� Vice (�hairm.an. RESTRICTIONS IF ANY: GlleStS ollly. Kobert ,}. O�rorure, l�[er� a�rielle�ahoG�hc�-.Jdoo�oed ic�el oCo lirc Januazv 15 , 19 98 Bruce G. Murphy,MPH,R.S., H , Director of Health