HomeMy WebLinkAboutApplications, WC and Licenses ,
, - .� '�'�r��,� �
�� � TOWN OF YARMOUTH BOARD OF HE�.TH'
� � APPLICATIUN FOR LICENSE/P��I�C�'���o . , ��6� / N 0 V 2 6 z t��i 8
�e . � „m���
* Please complete form and attach all necessary dp��me��Gy Dece�er � � ����•
Failure to do so will result in the return of your applicahon pac et.
NAME OF ESTABLISHMENT: �.� I�I I_ TEL. # � -a3�1
LOCATION ADDRESS:
MAILING ADDRESS: �S�rYI�
OWNER NAME: 1-�C�.l� '�(�( F_. �� �1�1�T Z TAX ID (FEIN or S SNI: ]
CORRORATION NAME (IF APPLICABLE):� � A L �°tl�l� '�RU`�T
MANAGER'S NAME:��I^(11 N� �+RE A�`C TEL. #�'{'���f'�-�J
MAILING ADDRESS: S��l E
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Qperator(s} and attach a copy of the cei-tification to this form.
1. ��:���E-��.� �� __ _ 2. c����-fo� i�r-_� � �v�.�z
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
certificatians 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. � �lU �" 2. h{�1�2�
3. 4. Z
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 Rt your establishment.
1. 2.
PERSON IN CHARGE:
------------—- - -- - --__ _
Each food estabh�ent must have ar 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 times. Please list yaur employees trained in anti-chokmg procedures belaw 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.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�
_B&B S55 _CABIN $55 1MOTEL �5� 6�'���
_INi1 �» _CAIvIF S5� �SWIMMING POOL S80ea. �Q�(��2-�
LODGE S55 TRAILERPARK �105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#,
_0-100 SEATS S8� .,LCONIINENTAL �35 N�_ NON-PROFIT �30
_>100 SEATS S160 _COMMON VIC. �60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. �50 _>25,000 sq.ft. �5225 VENDING-FOOD �25
_<25,000 sq.ft. S80 _FROZEN DESSERT $40 TOBACCO �55
�a��E cx�vcE: sio AMOUNT DUE = S �A--�O
**'"**PLEASE Ti7Ri1T OVER AivD COMPLETE OTHER SIDE OF FORNI'**** � ����Q�j
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ADMINI5TRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �j
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 COMPEN5ATION INSURANCE '
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �
i
CERT. OF INSURANCE ATTACHED '
OR
VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO '
_: MaTELS AI+�D�'i�"�r':I�Ti..�DGi�i"G E�TABLISHIVI�NTS '
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. '
Transient occupants mus;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 thuty (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 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 openuig.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected i
and opened. �
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of
closing. �
I
i
FOOD SERVICE �
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta.med 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 i
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 COOHING: '
Outdoor cooking,pre�aration,or display of any food product by a retail or food service establishment is prohibited. "
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETLJRN
TI�COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2008.
�
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW ;
EQLTIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
DATE: � SIGNAT ;
PRINTNAME&TITLE:
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� The Commonwealth of Mossachusetts
� Departmeat of Industrial Accidents
' �����
I�I 600 Washington Street, 7`�Floor
Boston,Mass. 02111
Worlcers'Compeesation iesar9nce Aflidavin gailding/Plambing/Elcctrica(Cuatrsctors
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��S`��i�on r�,�u�sr
❑ I am a homeawner perfornung all work myself. Project Type: ❑New Constniction QRemodel
[�I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workeis'.compensation f�my employees wo�icing on this job.
cumtr�v�me� ��'�J"��$ -��-V-� ��i�__���� �"` ��:�"���� �.���. _ _
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❑ I am a�le proprietor,�h�c�e�tor,or 6omeowser(circle owe)and have hired�X�e contract�s�listed be� �.���� �
low who have
the followin wotkers'co
coeiearv�ame-
address•
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Fa�are 4o secare owerase as reqat�ed�dv Seetlen 2SA�f MGL 152 cu kad b fYe�.r«���„�,.r.m�,�a ii,ssa.ao�
�Y�'�Prbenmmt as�as eiv/peealtks fa the fors.ta 3TOr WORK ORDER aed a Bne dS160.OS a day agaimt�e. I aedas�d t6at a
cepy�f tii�ftat�may be fonvarded�o the b�oe etlira�of the D1A tor c�verage verisaliea.
I do k y c ' xnder NFe pa e ofPerj tket tlYt i�formallow provided above Es true awd oom�cx
sl ' Date 11' � �I(j� :
Print name Phone#�2��—�G�—[75��1�
official ase only do not write�t�is am ta be ao�pleRed Dy dty er iswn o�ia1
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ClieM#: 19237 2BEACHNTO
, DATE(MM/DD/YYYY)
ACORDTM CERTIFIGATE OF LIABiL1TY INSURANCE „�20�08
PRoouceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATlON
Dawling 8�O'Neil InsuranCe ONIY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agency HOIDEa.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
973 lyannough Rd., PO Box 1990
Hyan�is,MA 02601 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA HBPI@�(SVIII@ WOI'C@St@f IflSUP8�1C@ CO.
Sagamore Realty Trust Corp.DBA Beach INSURER B:
NTown Motel Henry 8�Annette Schultz INSURER C:
1261 Rte 28
INSURER D:
South Yarmquth,MA 02664 INSURER E:
COYERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PON4CY PERIOD INDICATED.NOTWITHSTANDING
ANY REQU�REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY 7HE POLICIES pESCRiBED HEREtN IS SUBJEGT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR N R 'i'rpE OF INSURANCE POLiCY NUMBER �LICY EFPECTiVE POUCY E�RATION UMITS
" /� GENERALLIABILR'Y MPA2J2023 Q�0��08 06/01/09 EACHOCCURRENCE S�,DOD,�aQ
X COMMERCIAL GENERAL LIABILITI' DAMAGE TO RENTED s,��Q�
CLAIMS MADE Q OCCUR ' MED EXP(My one person) SS OOO
PERSONALBADVIWURY a140Q800
GENERALAGGREGATE 32 QQQ OQQ
GEN'L AGGREGATE LIM�T APPLIES PER: PRODUCTS-COMPJOP AGG S2 OOO OOO
POLICY PRO- lOC
AUTpMOBILE UAB�UTY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY IN,lURY a
NON-OWNED AUTpS (Per accident)
PROPERN DAMAGE s
(Per accident)
GARAGE UABI�ITY AUTO ON�Y-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN �
AUTO ONLY: qGG E
EXCESS/UMBRELLA LIABILfTY EACH OCCURRENCE $
OCCUR �CLAIMS MADE AGGREGATE $ .
S
DEpUCTIBIE E
RE7ENTION a $
WORKERS COMPENSATIqN AND WC STATU- OTH-
EMPLOYERS'1IA81UTY
ANY PROPRIETOftlPARTNEWEXECUTIVE E.l.EACH ACCIOENT E
OFFICER(MEMBER EXCLUDEDT
!f yes,describe under
E.L.DISEASE-EA EMPLOYEE $
SPECIAL PROYISIONS 6ebw E.L.DISEASE-POLtGV LIMIT y
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/YEHICLES/D(CLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISION3
Insurance coverage is limited to the terms,conditions,exciusions,other
limitatipns and endorsements. Nothing contained in the certificate of
tnsurance shali be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOI.DER CANCEILATION
SHOULD kNY OF THE ABOVE OESCRIBED POIICIES BE CANCELIED BEFORE 7HE EXPtRAT10N
TOW11 Of Y8t'fl'101ItF1 DATE THEREOF,THE ISSUING INSURER W►LL ENDEAVOR TO MAIL �_ DAYS WRITTEN
1146 Main St NOTICE TO THE CERTIFICATE HOIDER NAMED TO THE LEFT,BUT FAIi.URE TO DO SO SHALL
South Yarmouth,MA OZG�{ IMPOSE NO OBLI6ATION OR LWBILITY OF ANY KIND UPON THE tNSURER,ITS AGENTS OR
REPRESENTATNE3.
AU�IZEp REpRESENTATIV� �
�yM�a�. 4 �
ACORD 25(2001l08)� of 2 #54588 LS1 m ACORD CORPORATION 1988
. , . �
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
' PERMIT NUMBER: #09-011 FEE: S55.00
This is to Certify that Henrv Edward Schultz d/6/a Beach `N' Towne Motel
' 1261 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confortnity wiih the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,3?D and 32E as amended,and is subject to the pro�risions of the Laws of the Commonwealih ofMassachusetts relating
thereto,and upon such terms and condirions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,?009 unless sooner suspended or revoked.
December 1 l.2008 BOARD OF HEALTH: ��¢�¢ft S�ta�� ✓�i .JV.� ��ttrlt
��.0 .�. .�l�,E!�l�el,l� ��[CC ��IltlrlZ
*21 Units;21 Bedrooms; .�i��� �. ��Lt�l[ttt� �;C¢�
1 Manager's apartment included. Q�ttt (�lGP�¢�ry;B1rUNt, �„/�(,
t'.,`'`�`..�. .��
ruce G.Murphy, ,R.S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLTMBER: #09-021 FEE: 580.00
This is to Certifi�that Henry Edward Schultz d!b/a Beach `N' Towne Motel
126I Route 28 South Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At__ Beach `N' Towne Motel - OUTDOOR POOL
1261 Route 28
Saut Yarmout MA
This pennit is granted in confonnity«-ith Article VI of the Sanitar��Code of The Conunon«-ealth of Massachusetts,and
expires December 31.?009 unless sooner suspended or re�•oked.�
_December 11.2008 BOARD OF HEALTH: ��¢�¢tt S�C�� ✓�.,/�(.� ��tA�it '
C.'R�ave�ea .�. .7fe�iR�en `Uiee C.'Peai�enta�n
��ext s. ��uuun, e�ex�
Q.�uz C�'�u�en�Bauim, ✓`�.✓V. ;
�
Bruce . Murp y, ��— '
Director of Health
1 _. �, ; " `
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Clier�t#: 1923T 26EACHNTQ
' ACORD,M �ERTIFICATE OF LIABILITY INSURANCE 0;;�$i��YYYY)
PROWCER THIS CERTIFICATE IS{SSUED AS A MA7TER OF INFQRMATiON
Dowiing 8 O'Neil Insurance ONLY AND CONFERS NO WGHTS UPON THE CERTIFICATE
HQLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
A9���Y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
9T3 lysnough Rd., PO Box 1590
Hyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC#
IN8URED INSURER A Hariaysville Worcester Insurance Co.
Sagamore Reaity Trust Corp.DBA Beach INSURER B:
N'Town Motel Hsnry 8 Annette Schultz INSURER C
c/o Barnstable�aundry,32 Baxter Road INSURER D:
Hyannis, MA d2601 INSURER E:
COVERAGES
THE POLIGIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOQ IND►CATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDEQ BY THE POLIGIES QESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND GONDfiIONS OF SUCH
POLICtES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REQUCED BY PAID CLAIMS.
�7R TYPE OP INSURANCE POUCY NUMBER P6��CY EFF�CTfVE POUCY EXWRATION L{MITS
A 6ENERAL UABIIITY MpA2J2p23 061Q1/QT OGIO�/QS EACH OCGURRENCE $� �Q(�O
X COMMERCIAL GENERAL UABIUTY DAMAGE TORENTED $,��Q�-
CLAIMS MADE �OCCUR MED EXP(Any ane person} $rj QQa
PERSON,4L&ADV INJURY $1 000 000
GENER4L AGGREGATE $2(�QQ(�Q
GEN'i.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $Y OOQ OQO
POLICY PR� LOC
AUTOMOBILE UABILITY COMBW ED SINGLE IIMiT
ANY AUTO ������ $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AU70S
BODILY INJURY �
NONAWNED AUTf�S (Per acddent}
PR�PER7Y DAMAGE $
(Per acadent}
GARAGE LIABIIITY AUTO ONLY-EA ACCIDENT $
ANY AU70 OTHER THAN �ACC $
- RUTO ONLY: qGG $
EXCE3SRIMBRELLA 11ABiLRY EACH OCCURRENCE $
OCCUR ❑CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ S
WGSTATU- OTH-
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PMTNER7EXECUTIVE E.L EACH ACCIDENT $
OFFIGER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $
if yea,desaibe under
SPEC I 1 w E.L.DISEASE-POLIGY IIMiT $
OTHER
DESCRIPTION OF OPERATION3/LOCATIONS i YEHICLES!EXCLUSIONS ADOED BY ENDORSEMENT!SPECIAL PROVISION$
Insurance coverage is limited to the terms,conditions,exclusions,other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be desmed to have altered,waived,or e�ctended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELIATION
SHOULD ANY OF THE A60VE 6E3CRiBED POLICIES BE CANCELIED BEFORE THE EXPIRATION
Town of Yarmouth DATE THEREOF,TME i33UING INSURER WILL ENDEAYOR70 MAIL �_ DAYS WRfTTEN
1146 Main St NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT.BUT FAILURE TO DO SO 8MALL
South Yarmouth,MA 02664 IMPOSE NO�LIGATION OR LUIBILRY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AU7HOIiIZEDR PRESENTATIV�E +
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ACORD 25(2001t08)1 of 2 #SQ422 („$� A ACORD CORPORATION 1988
MAY 23,2007 01:41 page 2
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THIS 5 TO CERTIFY Tt��T TF�POlICES QF 11'+�RANCE U51�8ElOW HAYE 8E�1�TO T1�i�NAWED AHOV�FOR TF�POtIGY PERtOD
If+N]H'..AT�,i+�07UWTkFSTAP�IG ANY REQU�tT,TEF�i OR GOTDIT10i+1 f?F ANY CONTR�T{�i OTHER�4��Tt!RESPEGT 7Q iMi�li Tl�S
CERFFICATE�Y�I�D pR hd1Y PERTAiN,TtlE�A�BY Tt1E POLIGES�SCRIB�f�HEMV i5 SiJBJECT TO J�L THE 7EF�lS.
EXCWStdI'd5 APm CONDITlOPIS OF$It(�!P�LIC�S LMNTS SHt3WN�AAY NA��I R�BY PAD f,i.AiAS.
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SHOUID/1elY OFTIE ABUVE OES�PW.iqES 6E CANCELLED B£FCRE TNE
TOW1V OF YARMdUTti �ae�nn�a aaae�e+r�aF.rt��a�ea caeva�ar ww.e►�,a�ro�.
1146 FiT 28 �w►rsw�nrrEaer��=on�C���cn��eau�nto�+�r,
S�UTH YARMOUTH,AAH 0266d
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NIAY 22,2007 23:35 Paychex, Inc. page 3
�
; .
; THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #08-042 FEE: $50.00
This is to cenify that Henry Edward Schultz d/bfa Beach `N' Towne
� 1261 Route 28 South Yarmouth MA
� HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
3ZC,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expues December 31,2008 unless sooner suspended or revoked.
January 28,2008 BOARD OF HEALTH: `.�E¢�iL S�� �.,.lV.� �f�tpXt
�'�iG�C6 `.��. `.��.�I�PAG �lte��ttLQtt
*21 Units;21 Bedrooms; . ✓�lt�1►��.��tuft� �
1 Manager's apartment included. Q�ftrt�t¢¢tt�p[[IIL� �..lv.
t:lU�/L�.
�
' Bruce .M hy, . .,CHO
� Director of Health
�
i
TOWN OF 3�ARMOUTH
BOA�tD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IlVIENT
PERMIT NUMBER: #08-152 FEE: $30.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
I 11,Section 5 of the fieneral Laws,a permit is hereby granted to:
Henry Edward Schultz, 1261 Route 28, South Yarmouth, MA
VVhose place of business is: Beach `n' Towne
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2008 BOARD oF�ALTH: �'F.e�ert SRiaR�, J�..IV., C'�ar,i�crnaa
- �f�awc�ee .�.�'G��il�e�c `?lice C!�a�xr�aacn
fl�a�ext�.J`3. �u�cura, e�
Q.rzn f�'�ceerr�8aurn, J2.,.N.
:1'.
J��y 2s,2oos
Bruce G.Murphy,MP , .,CHO
Director of Health
i
;
� *
� + THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #08-071 FEE: $?5.00
rt�is is to certify thac Henrv Edward Schuttz d/b/a Beach `N' Towne
1�61 Route 28 So�th Yarmou h,M�
' IS HEREBY GRANTED A PERMIT
� To Operate a Public,Semi-Public Swimming or Wading Pool
� At Be h `N' T wne _ p
-- � UTDOOR POOL
� 1261 Route 28
out Yarmout , MA
This permit isgra nted in conformity with Article VI of the Sanitary Code of The Comtnonwealth of Massachusetts,and
expires December 31 2008 unless sooner suspended or revoked.
January 28.2008 BOARD OF HEALTH: ,`���/L S�'Q�, �.� (�tLQtt
C1��tnlee �. �CeP�iR�ex `tlice C,l�awrniaca
5?����am�, C'�ex�
Q�uc f�'�ceeir�aurra, JZ..IV.
:I'.
B�u�e � .
Director of H ae lih
1
� ' "'.." � � �. �c.�t `N�Ta�ntE
� ' 2 f�R�.o L TOWN OF YARMOUTH BOARD OF��1►I, I� :Ov,;��
o_ . -�y APPLICATION FOR LICENSE/$�I��N�I�``;''E,0�7� v
F , .,:� t ,� . � �� �AN 1 o zoa�
* Please complete form and attach all necessary'�io�um�nts by E:,ember 31, 2006.
Failure to do so will result in the return o�your application packet.
NAME OF ESTABLISHMENT: aeac��t '" ' `roi,.,,,,� tilo,(eJ TEL. # SOdr'.3�18,Z,3�1
LOCATIONADDRESS: /z6, rtk Z$ So�1-�, ��,�,�..�,�,�-r� . tit,4 p�66y
MAILING ADDRESS: s��,r,� �
OWNER NAME: /�ey�, Edwo, ..�C �' �,�1 F� T�X i� (FEIN or SSNI� ^
CORPORATION NAME{IF APPLICABLE): �'QSQ,�,o,-� �,/dD � 7�s� Ca^-�
MANAGER'S NAME: �/�,s�:h c 2�+d,. � TEL. # S�'. 3 9 fs.Z3 t i
MAILING ADDRESS: /2�t i2� Z� Sa�,Ja. YG�-r•�.v� ./�-�F C.�Zr6 y
,� ,
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Ogerator(s) and attach a copy of the certification to this form.
�. c�r; 5,�,��., s��J� 2. J� s � ;� � t��a d.-,
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach co 'es of em lo ee
. . . Pl P Y
certifications to tlus form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1.��'r1��..� SG�+��� 2. �Jq5vYrir►c /�'*+�y
3. 4.
FOOD PROTECTIQN MANAGER.S - 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 Eood 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 establishmen�
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. `'"
HEIlVILICH CERT'IFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. � 2. "
- �_— — ------- -----_ _ �. _ __ -- ------ ---- -
RESTALTRANT SEATING: TOTAL# —
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B �50 CABIN �50 I MOTEL $50 �`d7–��3
1NN $50 _CAMP $50 � SWIlVIlvIING POOL$75ea. ��'
_LODGE $50 _TRAII,ER PARK $100 WHIItLPOOL $75ea.
FOQI3 BERVICE:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE �RMff# LICENSE REQUIRED FEE PERMCT#
�o / ¢.- oC.�-
0-100 SEATS $75 �CONTINENT� $30 NON-PROFIT $25
_>I00 SEATS $150 COMMON VIC. $50 WHOLFSALE $75
RETAQ.SERVICE: —RESID.KITCHEN $75
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_45,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $50
NAME CHANGE: �10 AMOUNT DUE = S�'Q
'*""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'•""• `Z`�'�O
- ��
� t
�� �
. � .
ADMINISTRATION
�
t
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
–---— --- - -- - ---- _ 1VIOT�LS A1V:�OTHER LClD�ING ESTA�LZ�HIV�NT'S - --
_- �
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall�
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transie�accupants must have and be able to demonstrate that they maintain a principal place of residence 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)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
;
� POOLS I
;
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected '
by the Health Degartment prior ta opening. Contact the Health Department to schedule the inspection five(5�days
pnor to opening.
POOL WATER T'ESTING: 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 PULICY:
Anyone who ca.ters within the Town of Yarmouth must notify the�armouth Health Departmerrt by filin�the required '
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 wa�ter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING: f
Outdoor cooking,preparation,or dis�lay_of any food product by a retail or food service establishment is�►rohibited. E
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPL�CATION(S) AND REQUIRED FEE(S)BY DECEMBER 3 l, 2006.
ALL RENOVATIONS TO ANY POOD ESTABLIS��ENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO COMMENCEMENT. RENOVATIONS MAY REQUIlZE A SI . i
DATE: �� /� 6 SIGNA
PRINT NAME&TITLE: �"�s;.�7ca�� Sy-�i��� D.ae�a¢'�-, .yAH�Ce.•
10/17/06 �
i
I
, a Y
, i ,p��
~ �'� The Commonwealth of Massachusetts
Depart�ent of Indushial Accidents
��r�
608 R'oshi�gton Stree� 7`�"Floor
Boston,Mas� OZlll
__ _-- wo��•c� uoe i.s���.�:s.� • ��a co.ax�
----
_.� . �w., _ ,� _ � ��: ._, . ,�
�• /�'ir C..�wra.i � JG�►v�7�„
�s- /ZC�i �2� 2f
;�y J�u r� �Qv/�ttav� siste- �l�- zip• O 2 E�SY nbaQe# �• 3 Q�•��f
����i��rr,�u�S�- t Z 6� ,el� z�' �a�1�. �a•.��,�► ,�.4 OzEaG y
❑ I a 1�oa�wnea performing all work myself. ProTect Type: ❑New C�stnxtiao�Remodel
I am a sole 'etar and l�ve no one w in an Buil ' Addition
❑ I am an�loyer p�+ovidung wa�s'camp�ti�for my e�ployees worlcing on this job.
m�v�•
,d�ir- olte�e�:
❑ I am a sole praprietor,geaeral coitracbor,or tiomeowter(cirde o�)and have hirad tbe ca�ractors listed below who have
t1�e following workers'compensation polices:
to�e�rit� �.�� �.
�_
� eiaaa#;
c�t►�ries
�
�r- �i�e�t:
Fa�m�e tr sectae errera�e as req�+ed der 3atlM 2SA�f MGL 1S2 eu kad�/Ye brp��f cri�Yal pndlia�E a fe�b i1,3M.N a�dhr
ose ye�s'ispeMa�eat n we�a�cit/pmitles h tre L�ota 31�D!W4BIC ORDER a�d a Sne�f S1i0.N a day��e.1 ndn^�d tbt a
apy it1�ffale�my 6e firwarded�s Ne Odloe�tlave��tt3e DIA trav�a�age v�qfeatlw.
I Jo IYd+eby ca�'y r dre pa�na eud pee�hfes tJYet dYe hefonx�loe provlded aboNe is d�e and c�orrert
�� Date /1//S ,6
Print naa� ✓ C.�� Phonc# .51��_3q�.�c3//-----
effieid m e�ly ds sat wrife i�t�a un b be eomPkhd bY dly er Mwn e�eial
cily or tswa: pe�e� �1�a�et
❑eiedc if imme�ale n�pene b req�l �'�Offioe
QH�Ii Deparl�at
ee�aet paasa: Phwelf; �
ta.i.ea SqR 200C1) .
THE CUMMONW�EALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
; BOARD OF HEALTH
� PERMIT NITMBER: #07-042 FEE: $75.Q0
�
This is to Ce�tify that Sagamore Realty& Trust Corp. d1b/a Beach`N' Towne
1261 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach `N' Towne - OUTDOOR POOL
1261 Route 28
South Yarmou MA
This permit is granteti in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31_2�7 unless sooner suspenderi or revoked.
February 22_2007 BOARD OF HEALTH: B �. /H�., .
���s` �'.��. "���e��
� ,
Rod�t�B� �
� �����
�! � , R./V.
n�cor�olf H�eatth �'
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
- BOARD OF HEALTH
PERMIT NIJMBER: #07-023 FEE: $50.00
7'his is to certify that Sag;amore Realty& Trust Corp. d/bJa Beach `N' Towne
1261 Route 28, South Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and condidons,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and ea�pires December 31,2007 unless sooner suspended ar revoked.
-- February 22.2007 BOARD OF HEALTH: B �. ,/��., ��ytc.�t
. ���s�, ��e���
R�t� a�, �+�
�����
�� Rrv.
� Bruce G.Murphy,MPH,RS
Director of Health
/ � �- � ��- E i
g of;AR,� TOWN OF YARMOUTH BOARD OF HEALTH � � � �� � M '� �
o?� � � -'� APPLICATION FOR LICENSE/PERMIT- 2006 D E C 2 0 2005
� . .;�?
���� ���� * Please complete form and attach a,ll necessary documents by Decem er ��0�.DEPT.
Failure to do so will result in the return of your application pac .
NAME OF ESTABLISHIVIENT: �¢s��� �►� ' %own� /li(o�p�/ TEL. # s�.34ft.Z3�► :
LOCATIONADDRESS: IZC�I 2� 28' , S'o��h `�a��o✓�+. M� o26�y
MAII,ING ADDRESS: /2(>> 121� �-fr�, So��-h Yary�o� . M� oZ66 x
OWNERNAME: �� o� TAXID r
CORPORATION N (IF APPLICABL NEd�..ar� C�,,,� ,IZ
MANAGER'S NAME: � • ,, �` TEL. # so�, 35�. Zs iI
MAILING ADDRESS: /26r R�� ?-8,- So..�1-h I a✓rr,o✓ �/�- �2(�oy
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
at�a.� . . . _
-_ _ _ � _ _--_ __� _ _
--
1. �s�� 1 � .� la� k 2.
Pool operators must list a minimum oftwo employees cunently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitatior�(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Healt6 Department will not use past years' records. You must provide new
copies and maintain �file at your place of business.
�. Jo��h T. S�l�� � 2. GG��;� �p� � ��� S��l �.
3. �cn� �d�e..�� Sc�i� l'� 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
A11 food service establishments are required to have at least one full-time employee who is certified as a Food
ProtectiQn Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
l. h�a 2. n�'P
PERSON IN CHARGE: -_ _ _ -- ._---------- - --------___�_-__�_—---------------- —::
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. �� � 2. +�la
HEIlb�TCH 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 cvpies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQiTIKED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMTI'#
B&B $50 _CABIN $50 ( MOTBL $50 �dL-OZ`j
iINN $50 _CAMP $50 _ I SWIlVIlvIINfi POOL$75ea. �Q�
LODGE $50 TI2AII,ER PARK $50 _WHIRI.POOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
�0-100 SEATS $75 � CONTINENTAL $30 ���Z� NON-PROFIT $25 ,
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RI�TAIL SERVICE:
LICENSE REQUIItF.D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# IdCENSE REQUIRED FEE PERMTT#
�<50 sq.ft. $45 '�`" _>25,000 sq.ft. $200 VENDING-FOOD $20
_QS,OOQ sq.ft. $75 _FRQZENDESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ ��'�j•O O
"•"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•""
/
� ; , �
i
ADMINISTRATION �
Under Chapter l,5�, Section 25C, Subsection 6,the Town of Yarmouth is now requued to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED ,
� OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPQNSIBII.ITY TO RETiJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLIS��VIVIEENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPENING FOR THE SEASON. j
E
�
�
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW f
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR TO j
CONIlV�NCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. ;
1
ADDITIONAL REGULATIONS �
�
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected �
by the Health Department prior to 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. !
s
POOL CLOSING: Every outdoor in ground swimming pool must be drained or cavered within seven(7) days of �
closing. '
{
FOOD SERVICE
�
,
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post '
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departnient by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
�rozen desser-ts�us�be�e�t�on-a m6nthiy basis bp� 3tate certified-iab: -'�est resuitsmus��e s�nt to tlie Heak# - -- '
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 COOI�NG:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited.
DATE: �� �S/� SIGNATURE: �` �
PRINT NAME&TITLE: ��t�-ts�� � �7����'�or,S �2aa��
09/28/OS
f
_ _ _ _ - _ __ .:.
,
. » , :
`� The Comnionweatth of Massachusetts
�� �� Depa�rine�t of Industrial Acciden�s
_-_ N�faM��
- - - _- � 600 Washingto»Stree� 7�"'Floor
_ v.
Bos�o�,Mass. 02111
worl�era'com�aaho�Ls�eee Affi�vit:B� bi�iccdncal Co�hxeters
� � . .>:, t, .� - ,.,�
�� � :x a�..��_ =. . �,�.�,� �,�`�:�s
�: C�i1 S �-o�ol.-c.� Sc�+.� !�'Z
addtess: �2-�0/ �� Z�
�i cSa�� `��r+�o.�� smte: /VI�— zip: O Z6 6 `1 ylione# S 68r 3 9dr ?.-�31/
work site locatim►(fnll a�resst- /26� 12� �' c5p.��1�-G, Ya...y+c�✓a'Li M/d- 0 2.6 6 N
❑ I am a homoowner perfortning ali work myself. Project Type: ❑New Ca�a�QRemodel
I am a sole 'etar and have no one w in an ca ❑ Addition
. . ,, _ �
_ ./
I am an eanployer providing wo�lc+eas��a�fac my e�loy�s working asi this job.: � '
- - - _ _ _ , _. . . _ ---
: �c.car»or� �e�►-1 � �' ���-���. d1�� �c,� 'a � rv��
�± 0
�: �ZC�� lei� �
ccev. .�5�'0✓�-1� Y�.�o��i �e�: sb� 39 fs Z�>>
/4 �M M J�ua I Z» v /w v�L.�_: ��. �OO S/�'�b/ ZOO y
❑ I am a sole prcyprietor,ge�eral custracber,or homeowaer(circJe o�e)and have}rired the c�racta�s listed below wlw have
the following workers'compensation polices:
c�e��,;
�e
�.�� ��
�►�.
�i
��ts: ��: ,
Falt�re M secvs arvera�e as iey�ed uder See�a 2SA�f MGL 132 eu Iaid b/te isp�itlw�f cit�id paaNla�a�e�p b=1,SM.N a�dlir
e�yean'Imprbes�mt as weB as dN pmWa ia tbe fira�ota STO!WORIC ORDER aed a�e dS1A�.N a dap a�aairst ae. 1 a�ders�ud that a
apy of f�b�fa�my be fir�arded�s Ne Omee�[Im�tl�dys�t tY�e DIA hr qv�a�e va�eatly.
I ro hd+eby cer�Fjy rnder Nie pelws rtw/peul�ea o perjrry dYat tlie urfora��ioa pravided arboNe fa bxe rt+�d onrnct
Sigoature Date /S �
Print name l�`1✓/S k�n�cr -s � l� Phone# �� 3�l'� �•��j
.�dal ese on�y ao e�..,ite�cria u+ea ta ne o�mpl�ea nr eitr�e.wa eeH�al
c�y or tsws• permirl6oeme p f 1B�De�ar6mest
�Beand
❑e6tdc K imme�ale n�psase is reqaQed �'s O�te
���
ceatact persau: p�ae#; �
t��a s��c 2aa+�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-029 � FEE: $50.00
This is to Certify that Sa,�amore Realty& Trust Cor�d/b/a Beach `n' Towne
1261 Route 28 South Yarrr�outh, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issu�l in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,3 2B,
32C,32D and 32E as amended,and is subject to the pmvisions of the Laws of the Commonwealth of Massachuseetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2006 unless sooner suspended or revoked_
January 31,2006 BOARD OF HEALTH: B r�rni�t�. ,/��., e��s
a��t�r,a�'ls�ls, �ice G���ss
R�� B�, Lt�
�����
nice G. hy,M S.,CHO
� Director of Health
TOWN OF YARMOUTH
� BOARD OF HEALTH ,
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-121 FEE: $30.00
In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Sa�amore Realty& Trust Corp., 1261 Route 28, South Yarmouth, MA
Whose place of business is: Bea.ch `n' Towne
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Pernut e�ires: December 31, 2006 BOARD OF HEALTH: B .`1S. , /l�.`�., "
a������ls�ls, �?Jr'ce G�lsar��
Ro�t� Bncu�, �
n��r��
r , R.�v.
January 31,2006 �
Bruce G.Murphy, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-058 FEE: $75.OQ
This is to Certify that Sa�amore Realty& Trust Carp. d/b/a Beach `n' Towne
1261 Route 28 South Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach `n' Towne -OUTDOOR POOL
1261 Route 28
South Yarmouth, MA
This pemut is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�ires December 31.2006 unless sooner suspended or revoked.
January 31,2006 BOARD OF HEALTH: B �. /��., '
a��`�r�, .�, �e��
R�t�.B�, e�,�
�����
�4� , R./V.
B ce .Murp y,MP ., H
Director of Health
,
: ' Cr�,.��� �'� � �'TOu1X1E '
.f_Ya � � � � � � �sD :
2° ,r:R�o TOWN OF YARMOUTH BOARD OF
�: . Y`'�,�� APPLICATION FOR LICENS� �,s, ' S MAR 1 4 20G5
4
* Please complete form and attach a11 necessary m y December 1, �TH D�pT
Failure to do so will result in the return o '� application packet.
NAME OF ESTABLISHIV�NT: ��� 'N ' To w h� TEL. # SOa'r• 3 G15-. Z 3��
LOCATION ADDRESS: l 2 6 i i2}e. Z&� + S o„� �Q,-.����k, r ,M� c�y�6 y
MAII.,ING ADDRESS: 1 Z 6 / rpJt, 2,�. So,s�l• rav,�-•c.�.��I�h � ,�t.t�4- tJ266 t/
OWNER/CORPORATION NAME: Sa�,G•„�,•� R�; l�-y f' T��s� C'���r�.
MANAGER'S NAME� C l,r;s 1b.o l►t�. S c�l,..,I�z- TEL # c-o� . 3 9& .z s��
MAILING ADDRESS: /2 �/ !�� Z$ . ,S e��-t, �/c�.�,a,�� su�l- c-7Z�6 �!
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. �+/t��d�o�c✓ S� �� � �"'z 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 no# use past years' records. You must
provide new copies and maintain a file at your place of business.
l. Jos�,�� � �d la�� 2. 1��,��, S��� /h.
3. 4.
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this applica.tion. The Heatth Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
l. 2.
_ _ P'ERSOI'�fl�CI�ARG�:-- ____ _- —-- -- _ _ _ __ __ _ ._ _
Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation.
1. 2.
,
HEIlVILICH CERTIFICATIONS:
All food service establishments with 25 seats or more rnust have at least one employe� e trained in the Heimlich ;
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures t�elow 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 fde at your place of business.
l. Z.
3. 4•
RESTAURt�NT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
B&B $50 CABIN $50 I MOTEL $50 O ��SSJ
_�NN $50 _ CAMI' $50 I $WIMMING POOL$75ea. �0 ^Q?I'
LODGE $50 TRAILER PARK $50 WHIItLPOOL S75ea.
FOOD SERVICE:
LICEN3E REQUIRED FEE PERMI'P# LICENSE REQjJIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMI'P#
0-100 SEATS �75 �CONTINENTAL $30 � � �01 _NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 WHOLESAI,E $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PF'RMIT# LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRF.D FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. 5200 �VENDING-BOOD $20
_Q5,000 sq.ft. $75 FROZEN DESSERT S35 �TOBACCO $25
NAME CHANGE: $10 AMDUNT DUE = S /S�.O�
'""•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""""
� �
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
of any license or permit to 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
AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yazmouth taxes and liens must be paid prioF to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE:Permits run annua.11y from January 1 to December 31. IT IS YOUR ItESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAi.,ESTABLIS�-IlVIENTS ARE TO CONTACT TI�HEALTHDEPARTMENTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR TT-�E SEAS4N.
ALL RENOVATIONS .TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opemng.
POOL WAT'ER TESTING: The water must be tested for pseudomonas,total coli�arm and standaxd plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CQNSUMER ADVISORY:
Each food estab ishment which serves or sells ready-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
reqwred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
F�����N DES�ER3� I
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Permit until the
above terms have been met.
i
OUTSIDE CAFES•
Outside cafes(i.e.,outdo�r seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING• i
Outdoor cooking,preparation,or display of any faod product by a retail or food service establishment is prnhibited. ±
�--,
DATE: /Z /Z SIGNATURE: ��— !
PRINT NAME& TITLE: /iS �� S�f� � �
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10/22J04 �i
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__=-_--� The Comnamvealth ofMassachusetxs
DepartmeRt of Indus�rial Accidents
� __ - -- N�eiNr�l�s
� __- === 6r►R wasl,inga►,r sa,ee� �"'Fioo�
- �
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` Boston,Mass. 02111
J Workers'Com�ttws Ls�sace Affidav�t:Bail ' lectr�eal Coatracton
v .. �. :�; .�,,._ . . ,< ., .
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name: ��f�iS�GO�i� ✓ � • JC61 u�7 Z
address: �Z6/ IQ'�G� �
citv S'. y r.»s.�i sm�: MA- zip: O Zb 6 Ynbane# S�Sr- 39 fi•L 31/
work site locati�(fnll addressl:
p I am a�„�perfo�i�au Wa�C m,r�l�: Pro;ecc T,rpe: ❑xe�,c�s�caa�pR�aaea
I am a sole and l�ve no a�ne w in an Buil ' Additi�n
am an�ployer providing w�ke.rs'cflnupen�tian fa�r my�nploy�s working�this job.
S�_, �� �,_T�.�'e�- �'�/b�al QN�i"1 !�� � �L
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�.sQ�� t� .-.�,-,o.�-ti�, Nt� 0�.�6 y ,�: ra�- �9g�-z� �L
1M ��..i � ���rx. e: wM�.- �'a�oS���O�Z�
❑ I am a sole praprietor,g�eral co�tract+�r,or Lomeawser(exrck ou�)and have}rited the caabractois listed below wlw have
t}�following workers'compensation polices:
�ILL�F.�
�'s._
I��Ys D�t�:
�
QOffi�i�!_
�:
� 11�0�l�L _ .-- —_ _ --
Fa�re�s sec�re errera�e a�req�+ed uder 3a�a L4A�E MGL 1S2 aa k�d b tl�e��f eeiwid pniallia�f a�ae��t],3M.N a�d/�r
ex y��n.p,�c�we�as d.��e ue�r..ra s�ror woxx oteo�x a.a a m�e.[siee.».a.y��.e. i oaasa�a m�a
apq�f tl��faleseit my be firwaMed M tYe(l�a�f l��t tYe DIA hr average v�lieatly.
I do he�neby c r dlre and of pery�rrry tAitt dYi info�r�io�prov�ed eboae is hare axd cor�
si nan �Z /z y
Printnaa� � � +!�✓ � . st-���TZ Phone# .t��• 34�`. 23//
effidai ax�ly do aat wrke ia tYis am ta be e�plaed 6Y dt9 er b�ra s�cW
dty ar te�vn: # f�B�t D�amt
�Beard
❑cbedc K�ah rapsnse h reqaard �Sdxfae�'s O�ee
��t
co�act pet'ssa: �e#; �Ol�a'
(TMvieod Sqt 200Ci) �
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This endorsement is attached to the pWiq indicated below and is effective on the date slated herein,at 12:01 AM.,standard time :
al the address ot the insureci as described in the i�ormation page. .
Policy No. Safety Group Exp+ration Daie of Poticy Effeciive Date of Endorsement Endorsement No.
W MZ 8005177012004 0500 04101/2005 t�8/01/20(W 004
Issued to AddiGonai Premium Return Premium
Sa arnore Realt &Trust Co .dba Beach N' Tawne Motel 35.0(3
ISSUEd BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
BbUND BY: ckavanaugh 07/13/2�Q4
PI.AC'IiVG OFFICE 804
KIN[J OF AUDIT: cotinters�yned
�
horized ReOresentative
III
._ _ _ . _..�,�.' __ ._ . .__ ._.. _ _ _
., w:�� .� __-_:��,�,.,„,_ �..e� .. . _ ,..� . .�...� ��.�- � ` _ _ .,..____._...,.,_ .�__....6,..,=.n._. .�_._�. .._......_ _ .- —�._..._�,._. ..
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T'HE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-OS 1 FEE: $50.00
�is is to Certify that Sa�amore Realtv& Trust Corp. dlb/a Beach `N' Towne
1261 Route 28 South Yarmouth MA
• HAS BEEN GRANTED A LICENSE TO
• OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2005 unless s�ner suspended or revoked.
March 16.2005 BOARD OF HEALTH: Beit�ts�t�. ��,/��. �i�st
n�����, v�e�-�
R�t� B�o�, �
� ��'l�, R./V.
�4.����, R./V
Bruce G.Murphy, ,RS.,CHO
Dire�tor of Healtli
_
1'HE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-079 FEE: $75.00
This is to cercity that Sag,axnore Realty& Trust Corp. d/b/a Beach `N' Towne
12b 1 Route 28. South Yazmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach `N' Towne -OUTDOOR POOL
1261 Route 28
South Yarmout MA �
This permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2005 unless sooner suspended or revoked. .
March 16.2005 BOARD OF HEALTH: B �. �o�oa,/��., '
P t�il9a��t, ?/r�e��-.�
Rod�t�B�, �
d���'!�, R.N.
�4�� , R.N.
ruce G.M Y, •,
Director of Health
, ,,�>:,..�
. M . '
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' TOWN OF YARMOUTH
�
j BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #05-164 FEE: $30.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the erai Laws,a permit is hereby granted ta
Sagamore Reatty&Trust Corp., 1261 Route 28, South Yarmouth,MA
Whose place of bu'siness is: Beach `N' Towne
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2005 Bo�OF HEAI,TH: B `.75. �/�1.21., .
na��e�` �ro�, ?ltce G�lsavr�t�
�����C'l�r�
� . R
March 16 2005
Bruce G.Murphy, ,RS.,CHO
Director of Health
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$���YA�� TOWN OF YARMOUTH
� _ : °
� � `'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 0266¢4451
� MATTACHEES ��7
� �DAOORA1t0�6� /p Telephone (508) 398-2231, Ext. 241 — F�(508) 760-3472
��
B O A R D O F H E A L T H , < '; � , ti� " :
�
To: Yarmouth Board of Health Pemut Holders `s'����"�` � � 2��'�
HEALTH DEF'�" �
From: David D. Flaherty Jr.,RS. ;�D� �"'T���
Health Inspector �
Tovcm of�azmouth
Re: Federal Tax ID Number
Date: March 22, 2005
The Massachusetts Department of Revenue is now requiring that we furnish detailed information
to them regazding all permits and licenses that we issue. One of the details that they require we
send to them is every establishment's Federal Employer ldentification Number(FEIN}otherwise
known as your"Tax ID Number". This is purely for administrative purposes oniy.
Some businesses use the owner's Social Security Number (SSN} for this purpose. If this is tt�
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 Departmerrt
1146 Route 2$
South Yannouth, MA 02664
Thank you for your anticipated compliance. If you have any questions regarding this matter,
� p�ease do not hesiiate to cat�. Tlie 6�ce hours a��ree M�rr�day tu Fr-i�y, 8:34 a.�.to 4:3��.rr�. �'�€
�
telephone nu�mber is(508)398-2231,e�rt.241.
Establishment: �� �'"o•e- �e4� �T��EIN or SSN: �
� 6/� :,� �I
� Location Address: �2(o Z�
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Signature: `'�-`.
' Print: / `'�lrisft�Dl�- -sc���� Title: G���'G � /"/avlc► e �-
�� Printed on
( Recycle
� 3 PaPer
` �f c.��3�l �s � � �°
� o�'e R.� TOWN OF YARMOUTH BOARD T Q -`�� � �-� � M � �
�
F . �;� APPLICATION FOR LICEN � 00 ,;, 1 c� � � ���
..•
* Please complete form and attach all nec d ents by Dece d��t�Q�EPT.
Failure to do so will result in the ret of your application p .
NAME OF ESTAI3LISHMENT• ��a�� �/` T wn� _Q� TEL #�ros 3y�z3/
LOCATION ADDRESS: ��6/ /f1.�,N Sf ��t z�), S- /�„�.��IX�, Oz G�`�
AI �'am� - —
WNER/ RAT ON NAME: e.��i ` �Tvwn a
A ER'S NAME: C� � o � 5��� t� TEL. # S0� 3`��'Z 3/
1VLA�LING ADDRESS. s�e
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. �hr.`sT�h� Sc�� l�� 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
;
1. �h� S� ��fZ- 2.
3. T� S l,� 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service esta.blishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
l. 2.
PERSON IN CHARGE:
--
Each food establishment must have at least one Person In Charge(PIC) on site during hours of opera.tion.
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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50 �MOTEL $50 ' O��O�
_INN $50 _CAMP $50 �SWIMMING POOL$75ea.�o�f-cO�j
LODGE $50 TRAILER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 I CONTINENTAL $30 �r�J--�-r-k-.�� NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE RE UIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT#
Q Q Q
_<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20
<25,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ �SS O�
**'�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�
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� _— _
- - 1
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ADMINISTRATION
i
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal �
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's i
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �,
AFFIDAVIT MUST BE �OMPLETED AND SIGNED,OR I
CERT. OFINSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ✓ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR 1NSPECTION 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 CUMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
4
f
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. �
E
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 esta.blishment 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 Depa.rtment by filing the
required Temporaty Food Service Application form 72 hours prior to the catered event. T'hses forms can be
obtained at the Health Department.
FROZ�j DESSERT�
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), us ha.ve prior approval from the Board of Health.
QUTDOOR COOKING:
�
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �
I
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DATE: � / �vc� SIGNATURE: !
PRINT NAME& TITLE: �`i,.�J ,��e� �S'c �� /� ✓�a�►c�
10l22/03
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The Commonweulth of Massachusetts
� � Department ojlndustrial.-lccidents
; Otllce ol/eres�losdiis
600 Washington Street
� .� Bnston.Mass. 02!11
�'"' "�y W'orkers' Compensation Insurance Affidavit
Aoolicant information: PlessePR�'TTe�'l�io�
n�mr� ��l�I✓`/ ��h v /�
location: �JC��w� h /!/ / /�7c.c//!c�i'/lc���/ �l C� �d.r;� �f �iCf ZS)
, # s'� �'-t�z 3//
� I am a omeowner pertorming all work myself.
� ( am a sole proprieror�:-� ha�e no one aorkin_ in am•capaciry
� I am an emplo�er pro��dins w�orkers' compensation for my empioyees w�orkine on this job. _ .
compan?• name• /iE"'Ci�h /�/ '/cl�.vv�c� i'/�O/G/
�ddress• �Z�� i'I"l Gt« �7� �/1 / z�/
a���� �e� 3�$-z 3//
insur�nce�o policy�
� I �m a sole proprietor. generai contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed beloH ��ho ha�e
the follu��in: ��orl:er�� :ompensation polices:
sompanv name•
�ddress•
�y. Rhone f1•
insur�ncc co Rolic}# —
�qmnan�name• `
iddrea�• _- _ __
Sj1Y• ehoee i!•
inenr�nr��n DO�tY* -
1
Failure to secure coverage�s required uoder Secnon 2SA of MGd.IS2 n�iad to tbe iepaidoe ot criaivl pe�dtln of a d�e op to Sl¢00.00 a�d/or
one yean'imprisonment�s w�eil a�civil peaalda io the form oi a STOP WORK ORDBR�ed a Aae of 5100.00 a d�r Kaimt me. t a�denta�d t6at a
copy of tA'n statement mav be fonv�rded ro the Ofiice of Inve�tig�dom of the DU for eoven;e verititatio�.
/do hrreby cenij}�under the pains and penalti�s ojp�rjury thot tht information provrd�d abovt is tnu wtd eont
Signaturc pam l� � 2 dC�
l /S' �8 3 -t 2 3//
Print name �e!%t/'% �����/ �� Phone N l � �
o(Ticial use only do not w�ite in this area to be completed by eity or town olliei�l
ciry or town: YA��DT$ _ ____ __ permiNiceau p n8uildia;Department
�Lieeosiog Bo�rd
�cheek if immediatt response i�required 261 �Seleetmen'�OlTiee
�Hea1tA Department
contact person: phone N;_ �508� 398�?231 ezt. nOther
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j ab�d sizt 8LL sos ��N 0 '� 2004 6T=II vooz'�o �nr
� �����. ��� r HEALTH DE �
���7��'� �ERTIFI�A'fE C1F I.tAE�[LITY IN�URANCE o$�,�"�'"'
PRODiJCER TH{�GE�'tTIFICATE IS FSSUEO AS A(NATTER O�'iNfQRINA.T1pN
Dowling&O'Neil In�ur�nce ONLY AND CbNFERS Nt3 RIGHTS Ui�C1N THE CERTiFiCA7E
HOLDER.THIS CERTIFlCATE DOES PIOT AMEN[?.EJ�TENR AR
AgencY.f�c- AI.TER TFiE GOVERA43E AFFQRpE[#BY THE PO�iC1ES BELOW.
222 West Maln 5t.PC��ox 19�9�D
Hyann�s,MA 02601 INSURERs AFFORD[Nti COVERAGE NAlG#
INSURED ttd3URE�tA�. Harteysviife Warcester Insurance Co.
5huitz�acche�nge Trust At8 Sagamor� ,Ns,mE�e� A.1.M.Mutual insurance Compa�y
ii+eaity&Tru�t Corp.DBA Beach N'T�►wne ��U�c;
�zsi Rout�2� �Ns�,r�n:
Sauth Yarmouth,MA 02B64 iNsur��;
COVERAGES
TFiE PC7LI�IES OF INSURANCE UST�C BEL4�N NAVE BEEN ISSUEQ TO THE fMSURED NAMED A�UVE FOR TfiE POLICY PEFiI{7p INpiCATBD.NOTWITMS7AN�ING
ANY itEqU1REMENT.TERM OR GbIVDITION pF ANY COPJ7RACT pR()TW�R Ot'1�IJMENT W1TH RESPECT TO WHICW TH15 C�RTI�ICA7E MAY BE�SSUED OR
MAY PERTAIN,THE IP1Sl�RANCH AFfQRdED BY TH�PCN.1ClE$pE$CRI8EIJ HEREIN IS SUB�ECT TQ ALI.YME TERMS,�CLUS{t�IJs AWO CONDII'f4NS OF SUGH
Pl�&I�IE$.AC,rGftEC,ATE LIM175�M1QWN MAY HAVE�E�!REQUCED HY PA1D ClAIMS.
LTR N TYP!OR t!lSURANCE P�001lCY NUM6ER Y EF E DAC� �RA ����9
P
A GEWEAALIiABItaTY BINDER218474 0Bi01/d4 �BJ01105 �►cHoccu�n�c� s�d04000
� GOMMERCIAL tiENERA4 47l�BILI'tl" D R{iE TY7 RENTED S'��4 O�O
CLAIMS MAO@ �OCCUR MBO 6XP(Arry qne�Wt�sON $$ � .
P6RS9NAl&ADV lNJURY a1 QAO OOQ
� �@NERN.ACaGREG4TE 8`2 DOO OOO
�. ��N'L AGf',,t26G`,ATE llM1T APPUES PEft. P1�JOU�TS-COMPlOP ACCa S�'(,I�C)QOO .
P4UCY EC7 ��
AUTOM08iLE LIABtLiTY � G4MBIh1ED SIN�LE 4�MlT
ANY AL1TQ (Ee 9CCi4BR0 �
� ALL OWMEP AUT9S 6¢DYLI�M�URY
� SGNELH1l.E�AUTt53
tPeruersony s
N�RED AIfPOS B4Q1LY INJURY $ .
NON-CJWNEi7 AUYpy tpEr 8CCt08n11
pROpERTY DAMRGE 5
(Per xu+lent}
�ppp{�upg�{��-y AUT4 9N{,Y�EA AGGIDENT $ .
ANV AUTQ OTNER THAN ER ACC 3
AUTO CSNt.Y; A(� 3 �
EXCESSIUMBitEUAt.iM81LYfY EAi:HpCCUF2RENCfi S
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t�}��. . ��Q'`� t� NOTICE Tt3 THE CERTIfl�"A7'�l�LOER NAMED TO THE LEFf,BUT Fl41WRE 70 DO SO$NA6L
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BUARD OF HEALTH
PERMIT NUMBER: #04-064 FEE: $50.00
'rhis is to certify t1�at Beach `N' Towne Motel
1261 Route 28, South Yarmouth,MA
HAS BEEN GRANTED A LICENSE TO �
OPERATE MOTELS
This License is issued in conformity with the authority grantsd to the Board ofHealth,by Chapter 140,Sectians 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts r�elaring
thereto,and upon such terms and c�ditions,and to the rules and regulations in regard to said Motels�licensed as adopted
by the Board of Health,and e�cpires December 31,2004 unless sooner s-uspended ar revoked.
June 3.2004 BOARD OF HEALTH: Be�,ci�$. �sa,/�$. e�ir�ira�
p��r�� v�e��
Ro��t� B�au� Gl�a
� s� � R.N.
ruce G.Murphy,MP , .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-103 FEE: $75.00
This�to cerafy that Beach`N' Towne Motel
1261 Route 28, South Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Pub6c Swimming or Wading Pool
At Beach `N' Towne Motel -OUTDOOR POOL
1261 Route 28 �
5out Yarmou MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusett.s,and
eaipires Deceffiber 31_2004 unless soaner suspended or revoked.
J�me 3 2004 BOARD OF HEALTH: B $. �j�//��., '
P����� v�e��
Rod�t�.e� �
�f�Sl.�, R.N.
� R.N.
�� .M� ,
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT T�OPERATE A FOOD ESTABLISHMENT
PERMIT NLTMBER: #04-196 FEE: $30.00
In accordance with re�ons promulgated under autharity of Chapter 94,Sectian 305A and Chapter
111,Section 5 of the Laws,a permit is hereby granted to:
Beach `N' Towne Motel, 1261 Route 28, South Yazmouth, MA
Whose place of business is: Beach `N' Towne Motel
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit e�ires: December 31. 2004 BOARD oF HEALTH: B $. �A�l.$., '
����il�c$�, ?/�Glr�
Rod�t�B�, �
�� R R.N.
,
June 3.2004
Bnx;e G.Mwphy, S.,CHO
Director of Health
�
� � r�
-_._. ���� ¢
`' �`'�R.� TOWN OF YARMOUTH BOARD O�I�EALTH � � � � � M C� DD
32 -'� APPLICATION FOR LICEN /�.�RMIT-2004
°�- ..s �� ,� , NOV 1 3 2003
... ...- �: , � - � °
* Please complete form and attach all necess ttocu�nts by Dece epc{��y�2��3nEpT.
Failure to do so will result in the return ,�your application pa .
• � s��
N S • �' '>-
MAILING ADDRESS: ���g
O R S 8 �'�C
E ' NAME: � C �7v� �
MA D S • � Ro v5,� � � , !I-�2 r.�-iG v%H. D�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Op�rator f sj���ch a c�py�f tt�e c�rt:ficatiori ta�this form. _ ____ __ _ _
l.a�1. �H� C . �3,� 2 G�E SS 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� �� G. Bv�G-� 5� 2.�'vz-�*��� � � aeG-�;�
,
3. 4.
_ _
F(�OD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
,_-- �r�ON�ni7;�P�:--- - ----—__---__ . _ _ __ _ __ _
Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation.
1. 2.
H�IMLICH 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 certificatians to this form. The Health Department will not nse past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
Loncnvc:
OFFICE USE ONLY
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $54 _CABI�1 $50 �,MOTEL $50 �d�(-o I�
_INN $50 _CAMP $50 ,�SWIMMING POOL$75ea. �"�a�
_LODGE $50 _TRAILER PARK �SO _WHIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 I CONTINENTAL a30 ��� NON-PROFIT S25
>100 SEATS 5150 COMMON VICT. S50 WHOLESALE S75
RETAIL SERVICE:
LICENSE REQUIRED FEE PGRMIT# LICENSG RGQUIRCD PGE PF,RMIT# LICGNSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_C15,000 sq.ft. $75 _FRO"1.EN DESS[:R"f S35 _TOBACCO S25
NAME CHANGE: $to AMOUNT DUE _ $ I55 .00
**'�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•"
i
�
��
� ,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
of any license or permit to 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 V
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE:Permits run annua:lly from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETtJRN
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 I�F(sULATION
POOLS
POOL OPE1�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
CON�UMER ADVISORY•
Eac�ood establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERNG PQ,�ICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form ?2 hours prior to the catered event. Thses forms cari be
obtained at the Health Department.
___�i (17.FN iIFCCFRTC•_________
- - - ____ -- - - - - -- ____- - -- - _--
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 sa will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE C FFS:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),xn.ust have prior approval from the Board of Health.
OUTDOOR COOKIN ._
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
� -� �
DATE: // � SIGNATU �
PRINT NAME& TITLE: � �' � � - �v R(r��S 1 /.rj l.�,t�7�
10/22/03
� � �f r
_ The Commoa wealth of Massach usetts ;,� ��, �� _� i; M ;� D
� � Depa�tment oj lndustrial,-1 ccidents
� ; Olflce oJl�resllostliis N 0 V 1 S 2003
� 600 Washington Street HEALTH DEPT.
' ,•� Boston.Mass. 02111
� ~ �� W'orkers' Compensation Insurance Affidavit
Annlicant information: P►essePRil�TTrd."iJir
nam�: ��A-G� �Al �l'l v A'� G�j�F'/ .
a �on: Z . �
�it� � • 1�"�ILL/ T����Q.`L� tl�1 ohone���'3`'�r fi�J �
� I am a homecwner pert�rmin,all work myself.
� I am a sole proprizror�:-� ha�e no one��ori:ine in am•capacin�
�( I am an empioyer pro�idin�workers' compensation for mv empioyees w•orkine on this job.
----- _ - _ _— � - -
s4mnanv name: .� .S 1� .� NL �,.�1"GZ ����,i1•� ,,,�,vy�f �/�"��''�
addr��2 � �— 7" �
O� a•�' ' �
�
i uranc . N RGUtI �'NSVR19�A1G� CO � � `7��,�
� i am a soie proprietor. :eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu��in_ ��orkzr�� ,ompensation polices:
companv �ame•
address•
csy: �hone�:
insur�ncc co. yolic}•#
com�an,y name•
_ -- -- -- -- _
add res3•
titv: oboee M•
insurance co. neBev�f
a
Faiiure to seeure coveraee as�equired under Secnoo 2SA of MGL 152 ta�iad to tbe ioporitioe of erioi�l pesdtla of�O�e op to 51,500.00 a�d/o�
one yean'imprisonment a�w•ell a�eivil penaltle�io the form of a STOP WORK ORDER�ed a lise of 5100.00 a dar Kaiost me. I s�dena.d mae a
copy ot thh statement may be fonvarded to the ORice of tnve�tigadom of tbe DIA for eovera`e veriflp�.
/do hrreby cerrij��under the poins and penalfies ojperjury that Iht injor ' n providtd above is brre oRd eorred
Si namr �r- � � � O ��
g t
Printname��G�1�� �„ aU2 ��''''�7 3R�'� > D��/� Phonelt.Ji'D���J����� � �
.. o(Ticial use onlv do not..�ite in this area to be compieted by eity or towa oAleial
ciry or town: Y��� _ permitAiceese M n8uiidiog Department
�Liceosioe Board
�cheek if immediate response i�required 261 QSeiectmen'�Otrce
(508) 398�2231 eat. �Health Department
contact person: phone N; _ _ nOther
.. ._� <a„,
'ACORD�, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
10/30/2003
PRODUCER THIS CERTIFICATE IS ISSUED AS A MA7TER OF INFORMATION
HART INSURANCE AGENCY, (NC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
240 MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO BOX 700
BUZZARDS BAY, MA 02532-0700 INSURERS AFFORDING COVERAGE NAIC#
INSURED RSB, inc. � .� . �NsuReR A: NORGUARD INS CO 31470 '
1261 Route 28 iNsuRea e:
South Yarmouth, MA 02664 iNsuReR c:
INSURER D: . .. . . .. . . ...... _ . . ..
IN$URER E: � � �
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIMTHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
DAMAG
COMMERCIAL GENERAL LIABILITY PREMISES Ea accurence E
CLAIMS MADE �OCCUR MED EXP(Any one person) $
PERSONAL 8 ADV INJURY $
_ _ _ _ GENERALAGGREGATE 3 _
GEN'L AGGREGATE LIMI7 APPLIES PER: PRODUCTS-COMP/OP AGG 3
POLICY PRO- ��
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT S
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-0WNED AUTOS (Per acddent) $
PROPERTYDAMAGE $
� � � .. . . . �...� ..�:..(Per accidenQ ..... .. . ... . �. � .
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO ,;: OTHER THAN EA ACC 5 r
< AUTO ONLY: ' _AGG S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR �CLAIMS MADE AGGREGATE $
a
DEDUCTIBLE S
RETENTION i 3
A WORKERS COMPENSATION AND RSWC435801 08/01/03 08/01/04 �STATU- OTH-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ �JOO OOO
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ �JOO OOO
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ �JOO OOO
OTHER
DESCRIPiION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION _ `
SHOULD ANY OF THE ABOVE DESCRIBED POLJCiES BE CANCELLED BEFORE THE EXPIRATION
TOWN OF YARMOUTH on�THeReoF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O_ DAYS WRITTEN
��4B RT 28 - NOTiCE TO THE CERTIFICATE HOLD�R_Nq►�AED JO THE LEFI,BUT.FAILURE IU DO SQ SHALI
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND.UPON THE INSURER,ITS AGENTS OR
S YARMOUTH, MA 02644508-398-0836
. � REPRESENTATIVES.
AUTH IZED REP SENTATNE
tv
ACORD 25(2001/08) �O ACORD CORPORATION 1988
�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-025 FEE: $75.00
This is to certify that R S B �nc d/b/a Beach'N Towne Motel
1261 Route 28 South Yarmouth MA
IS HEREBY GRANTED A PERNIIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach'N Towne Motel -OUTDOOR POOL
� 1261 Route 28
Sou Yarmout MA
This pernvt is gi-anted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cpires December 31.2004 unless sooner suspended or revoked.
December 4 ,2003 BOARD OF HEALTH: B �. �,��., '
������, v�et��
. — --- ---- _.Rod�t.�B�ow�, Gle�
___ _ ___--
��Sl�J.� R.N.
ruce . um ,
Director of Health
a �
j THE COMMONWEALTH OF MASSACHUSETTS
{ TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-014 FEE: $50.00
This is to Certify that R S.B., Inc. d/b/a Beach'N Towne Motel
; 1261 Route 28, South Yarmouth,MA
� HAS BEEN GRANTED A LICENSE TO
� OPERATE MOTELS
� This License is issued in canformity with the authority granted to the Board of Health,by Chapter 140,Sec:tians 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adapted
by the Board of Health,and expires December 3 I,2004 unless sooner suspended ar revoked.
December 4 ,2003 BOARD OF HEALTH: B�c�w�. �j�, /��. e��t
A���� v�e��
_ Rod�t 4 8� �
_ _ _ -- - - �_3��,_R.� __--_ _ _
Bruce G.Murphy,MPH, S. HO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-050 FEE: 30.00
In accordance with reg�a�s promulgated under authority of Chapter 94,Section 305A and Chapter
111,Sec6on 5 of the C a1 Laws,a pernut is hereby granted to:
R.S.B., Inc., 1261 Route 28, South Yarmouth, MA
Whose place of business is: Beach'AT Towne Motel
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2004 BOARD oF HE�,'rl i: ����iNc`D ���/�$., .
a�t� e��e��
� $�, R.n�.
December 4 ,2003
. Bruce G.Murphy, S.,CHO
Director of Health •
� � t ��, �..� �t31
'� ���P>E1iCN iV TowNE
,. �; �r ;
� 2�f;�R,y TOWN OF YARMO '� `_ I�bF HEALTH � L� (�� ��� ( 'u' � �
o� - -'c APPLICATION FO � : ��"IPERMIT-2003
`` � ....:? ' � ��`�� � � ���?
�.
* Please complete form and attach all necessary doeuments by Decemb 3l 2002.
Failure to do so will result in the return of�our application pack t.��1��`T�f DE�T.
NAME OF ESTABLISHMENT: D�A�f r 'N -r,�,N�. �bT�'L- TEL. #5"oA-3 9�� �-3��
LOCATION ADDRESS: IZG / �� iL� Snu�� �i�ltMavT� . wlft� dz GG�
MAILING ADDRESS:
QWNER/CORPORATION NAME: R S.B �.v�
MANAGER'S NAME: I,?/�-t�� G . �?,+ E'� # -3 - .f6 7
MAILINGADDRESS: ,�x_ :G f�r�.`v�� �.��v� �W: R —ri� �ft �aL�`3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Po�l Oger�tor(s)-and attach a�op,y of the_ceriif�ation tQ th�s form, _ _ --
l:l?A-L-i�� C , 't?v�G-t� 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 Heaith Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1.�v�Ar�aE 13vRG-t�..5 2. /�f�L���} G � 13v 6�G�'.SS
3. 4•
FOOD PROTECTION MANAGERS - CERTIFICATIONS•
All food service establishments are required to have at least one full-time employee wfio is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
' You must provide new copies and maintain a file at your establishment.
l. 2.
-- ., — - -
-- -
_ _ ---,_ -
PERSON IN CHAR.GE: �-- - _____--__—____ _._ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2•
HEIMI,ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RF,STAUR�NT SEATING: TOTAL#
OFFICE USE ONLY
�,,ODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FGF. PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $SO _CABIN $50 �MOTEL $50 d� 3"D!a'
_INN SSO _CAMP $SO .�SWIMMING POOL$75ea�"��
_LODGE $50 _TRAILER PARK S50 _WHIRLPOOL $75ea
FQOD SERVICE: ;
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSG REQUIRED FE6 PERM[T#
_0-100 SEATS $75 LCONTINENTAL $30 �O�j-�-O�LO _NON-PROFIT $25
>100 SEATS $I50 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE: • -
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�t L{CENSE REQUIRED FEE PERMIT# '
_<SO sq.ft. S45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_<25,000 sq.ft. �75 _FROZGN DESSF',RT S35 TOI3ACC0 $25
NAME CHANGE: S10 AMOUNT DUE _ $ /SS.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"****
I
�
i
, _ _, � �R
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED ;
� `
' P. AFFIDAVIT SIGNED AND ATTACHED Y '
WORKER S COM
Town of Yannouth 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 i to December 31. IT IS YOUR itESPUNSIF3ILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. ;
i
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPART'MENT FOR INSPECTION 7-10 �
DAYS PRIOR TO �PENING 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 RFGULATIONS i
I
�
;
� POOLS '
POOL OPErTING: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
�QNSi1MFR ADVISORY: �
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
('ATERNC 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.
�
—��VLJ1'Jl� JA A � Y�7� __—_. _—_—__—_._._ '_—_._—...__. .__ _ ..._..— ____—'_._. . . . . . ____—__..__._.__.—._ . ,
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 f
above terms have been met.
OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�ust have prior approval from the Board of Health.
OUTDOOR COOHING•
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
� �.: � � � � �-�
� D� �
s
�aa_�����- _ E �
�� r::,��, �, ��>��,� ,� ����� ��.����.,��f� � e t���z G-� �S ��R�S i� �'y�� I
I _. . . .e , b4 .. '� '
�U/�V/U�
i
� � �-
' ' �
The Conimonwealth ojMossachasetts
� � Department ojlndustrial,-�ccidents
� o oJ�caoll�estJostliis
: 600 Washington Street
'�N �.,.'` Bnston.Mass. 02111
N�'orkers' Compensation Insurance Affidavit
Annlicant intormation: p►easepRll�'T'Te�,-s,irr
namc t�S � :t NC �/..tr�C� . ��'/�-�,•,t 'n/ `101u�/t �'1 7f'�-.
Locatian: ��- �f l !KT '� �
�t�J � yi�/�N�I�� �i f'f f /�/�'z - G' �./� ;� ehonea .�Of�- 39�'� l�
� I am a homecw�ner pertorming all w�ork my�self.
� I am a sole proprieror�r.,�. ha�e no one��orkine in am•capacit�•
� I am an emplo�er pro���ing workers' compensation for my employ�ees w•orking on this job.
_ _ _ _ ____ -- __ -- _ -
comnam• name• h� 5. ;a. �',o�t � ��1r�d a�'��.� �11 T�k//1�� G�i'O T�L
lddres5: �2 [: � /� / ��f�
S - '�r�w i tl . �� �. - — z /
Q . , ,�
"i � � �� � # :� D
� I am a sole proprietor. :enerai contractor. or homeowner(ciicle one/ and have hired the conaacton listed below ��ho ha�e
the follu��in_ ��orker� �ompensation polices:
comoanv name•
a�d ress
citv• phons�!•
insur�ncc c9. �elic�•#
comeanY name•
- - - --- --- — ------ --
— ---_ ---- -- -- -— ---_
id.dtess:
�'� nhoee+�•
insurance co. �Y�
•
Faiiure to secure coveraee as required under Seenoo 25A of MGL 1S2 a�iad to tde iopaidoa o(erioi�i pesdtlef of a 6�e op to 51.500.00 a�d/or
oae yean'imprisonment aa w•ell a�eivil ptnaide�io the form of a STOP WORK ORDBR aed a liae of SI00.00 a dar apinst ma I a�dersta�d that a
topy of thy statcment may bc fonvarded to tht Ofiice of iaveni�atiom of Me DIA tor eoven=t verifiado�.
I do.hrreby cerrij�•under tlre pains and prnalti�s of per} ry that tht injorn�etivn proveded ebove is trtte and corr�
Signatur ' ' 1 /� �-
Printname�/����UR(.<<Jl7 Phonell ��'�1�� � �.�� �
.- otTicial use onh do not w rite in this area to be completed by eiN o�town oAleitl
eiry or town: YA��DT$ _ permitAicenx M nBuilding Departmeot
�Liceasioe Board
❑check if immediate response i�required 261 �Sdeetmen'�ORa
pHealts Dcpanment
corttact person: phone M:_ �508) 398t2231 eat. nOther
,n...�. :< '.�I�I .
1
� , ;
�;:�`"`::;;�.:>:<:;�;?.,,.;;;��.;. FORM: WC 00 00 01 A
EDITION: 1/94
� ...... ...._. ...<:;:;_�:;';;:,:::::::<:: Page 1 of 1
� Pro/'e.csional Liabilily Insurm�cc
i Comjxrny ofA»ierica
I WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
Information Page
NCCI 18937 Policy WC20007106 Prior NEW
Company No. No. Policy No.
� Individual � Partnership � Corporation
1. The Insured: Fed ID#:
Mailing Address: Other workplaces not shown
RSB, INC.
1261 ROUTE 28
SOUTH YARMOUTH, MA 02664
2. The Policy Period is from 08/01/2002 to 08/01/2003 at the insured's mailing address.
3. A. Workers' Compensation Insurance: Part one of the policy applies to the Workers' Compensation Laws of the
states listed here: MA
B. Employer's Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The
limits of our liability under Part Two are:
Bodily Injury by Accident S 500,000 each accidentBodily Injury by Disease S 500,000 each employee
Bodily Injury by Disease S 500,000 policy limit
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
PA, NJ, DE, MD, GA, NY, NC, SC, VA, CT, IN, IL, MI, AZ, and MO
D. This policy includes these endorsements and schedules:
WC000001 WCOOOOOA WC200302 WC200303B WC200306A WC200301 WC�00601 WC200401
WC200404
4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Code No. Premium Basis Rate Per 100 of Estimated Annual
Total Estimated Annual Remuneration Premium
Remuneration
Hotel All Other Einployees, Sales& Drivers 9052 52,000 2.32 1,206.00
Premium for increased limits Part Two, if a licable 50.00
Total remium sub�ect to the ex erience modification 0.00
Premium modified to reflect ex erience modification of 0.00
Merii Ratin -63.00
Loss constant
Construction Credit
Other remium char es
Total Estimated Standard Premium 1,193.00
Premium Discouni, if a licable 0.00
Ex ense Constant Char e 244.00
Total Estimated Premium 1,437.00
De t. of Industrial Acc Assessment 4.50% 54.00
Minimum Premium 223.00 Total Estimated 1,491.00
Cosi
Deposit Premium 1,491.00
Na
Se / ,
Countersigned by _ ��
July 25, 2002
� j a
�
1
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-012 FEE: $50.00
'rhis is to Certify that R S.B. Inc d/b/a Beach'N Towne Motel
1261 Route 28. South Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonwealih ofMassachusetts relating
thereto,and upon such terms and condirions,and to the rules and regula6ons in regard to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked.
December 6 ,2002 BOARD OF HEALTH: �i(ia�tled ,'r�f. i�e�, �ia�'irixa�c
_ _ . �'e�fa�ni.�D. G�imrda�, 71r D�, �ice �z+xa�c
,�aBast�. b'+Coacac. L�
�a�uik 71lcDr�r.xoz�
'�el�uc.S�a�(c, �'.�1. .
ruce G.Murphy, .5.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS.
TOWN OF YARMOUTH . :�
BOARD OF HEALTH
PERMIT NUMBER: #03-020 FEE: $75.00
'�'his is to cerrity that __ RS.B.. Ina d/b/a Beach'N Towne Motel - ,
1261 Route 28, South Yazmouth. MA
IS HEREB�GRANTED A PERMIT
To Operate a Public,Se�ni-Public Swimming or Wading Pool
At Beach'N Towne Motel -OUTDOOR POOL
1261 Route 28
_ __ __ .�Qnrh varmni�thl�A ,
This permit is granted in conformity with Article V,I of the Sanitary Code of T'he Commonwealth of Massachmsetts,and
expires December 31.2003 unless sooner suspeaded or revoked.
December 6 ,2002 BOARD OF HEALTH: (��, i��ex, ��a�c
s� D. G�w�rda.�. 711.D.. 2/icc
,���� 8'�rat�aic, (�l�rk
�aartek�Daukatt
� S , .�1.
ruce G.MurP Y,MP . .,
Director of Health
�
. , �
� TOWN OF YARMOUTH
�� BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
i
� PERMIT NUMBER: #03-040 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:
� _R.S.B., Inc., 1261 Route 28, South Yarmouth, MA
Whose place of business is: Beach'N Towne Motel
Type of business: Continental Breal�ast
To operate a food establishment in: Town of Yannouth
Pernut expires: Decexnber 31, 2003 Bo.�xn oF�,�,'�: Lk�fea�, zefl�kat, �ifa�a�
_ _ _�i�fa.xt�c�: C�%�. 7JlG.D.. ?/lce .
,�o�t�. �raaa�c. �
�a�?1�Der.�
� S . .7Z.
December 6 ,2002
ruce G.Murphy,MP .,CHO
Director of Health :
�.T � 6EAct�`N ToWN€
#� ���` TOWN OF YARMOUTH BOARD OF HEALTH
,
" ` APPLICATION FOR LICENSE/PERMIT-2002
�
� * Please complete form and atta.ch all necessa.ry documents by December 31, 2001. Failure to do so will result in
ithe return of your application packet.
NAME OF ESTABLISHMENT: ��,�.,.� TEL. #So�'-3 y8���i//
L TI S: z L
MAILING ADDRESS: , —"' DZ. G
� O R/ I , �
MANA ER'S NAM : TEL. #.s"' --� --� 7
G DRESS: ,
�OOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
_ �ne+�sy-a��l�e-eea-t�€rea�ion to this fo�n. __ _ _
1.� e �f.f,���n 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 fde at your place of business.
1,� T �. ���i�/� 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.
i You must provide new copies and maintain a file at your establishment.
1. 2.
P'E;RSOI��T Ci�RG�: . __ __ _ _
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
1. 2.
i
! HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 �MOTEL $50 Oo�-06
_INN $50 _CAMP $50 �SWIMMING POOL$SOea� �OZ-(3 l�'
_LODGE $50 _TRAILER PAItK $50 _WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 �CONTINENTAL $30 �FO a—D7J� NON-PROFIT $25
_>100 SEATS $150 COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_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 _ $ I3D.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
a � '
e
1 � 1
ADMINISTRATION y
i
i
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 �
�
WORKER'S COMF. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_�� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�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 OPENINGs 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. "!
E
i
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
C'ATF,R�NG POi.ICY:
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.
__- -- _
_-- __—___ . ___----__ _ __
._. —_ —
F1��ZENDE��ERT�---
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),mus have prior approval from the Board of Health.
OUTDOOR COOKING: i
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. `
i
�
e
� � �".,,.� SIGNPrT�JRE: ,:
�"�`f"'��I�&TITT.E: . � � T '
09/11/O1
t - ' �
The Conrmonwealth of MassQchusetts
� � Department ojlndustrial.-�ccidents
� ; Ofllceoll�s�lostliis
600 Washington S�reet
' ` Bnston, Mass. 02111
.
� " ��y W'orkers' Compensation Insurance Atfidavit
Annlicant information: Pless�YR
nam� l�, -S� d/, Y/N.�, f�/�"'lG�. ��i�.r� �IYt �.c.i.,..P ���0��l�J
�
a �on: � � ► �'
���� / // /`• 1 � ��•1 . /VI /�/ � O��IY � ehone� S�?�' %!!/ ��� {��
a I am a homeowner pert�rming all w�ork myself.
� I sm a sole proprieror��,', ha�e no one��orkine in am� capacit�•
�I am an emp�over pro��dins workers',compensation for my emplo��ees w•orkin�on this job. _
comnan�� name: R. �7� `�• �'/✓C � lr��EA-G � � N %DLtl N�. 1�11 / �1
. �
address: `��� R� ��
citv•�� /Kd UT� . �f�— /�7i �� � rthone q•�����R ' Z�� �
insurance co. � A-S T�f.? i11 �A'S L't?-I-�TJ' Aolicy# WG 99�D �0�3
� I am a sole proprietor: �enerai contractor. or homeowner(circle anel and ha��e hired the contractors listed belo� «ho ha�e
the foll���in_ ��orkzr' .ompensation polices:
com�anv name:
address•
citr•• ehone q•
insurancc co. ,�olic�•#
com�v name•
address: _ _ __ -
citv: ebone M•
insurance co. ���f
a
faiiure to secure covenge as�equ�red under Secnoo 2SA of MGL 1S2 cae Ind to tbe iopwidoa of erisi�al peaaltle�of a d�e op to Sl¢00.00 a�d/o�
one yean'imprisonment a�w•ell a�civil penalda io the form of a SiOP WORK ORDER asd a liae of 5100.00�dar Kaiott m� [a�denta�d t6at a
copy of thy statcment may be fonwrded to the OfTice of Inve�tig�uon�otthe DIA for eoven�e veritia�io�.
I do hrreby cenif}�under the puins axd prnaUies ojperjury ehat tl�e inforn�ation provided abovt is trtre and eor►taG
Signatur � � //�/�l/D �
�
Print name l�l�l���' �, U[J�fr�'� (1e ��t �'S 1���� I J Phone N s'�8 —�l���
.. olTicial use onl� do not w�ite in this�res to be compieted by eity or towa oAleial
city or town: YA��DT� _ permiNieense M nBuildiog Department
�Lieensiog Board
Q check if immediate response is required 261 �Seiectmen'�OtTice
�Hea1tA Departmmt
contact person: phoneN;_ �508) 398�2231 eat. nOther
� � �� - �
� Ead�ern Cadcuz��y
325 Donald J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729
(NCCI Carrier 16942)
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
INFORMATION PAGE
Policy Number: WC99 708023 Bureau File#: 195019
FederallD#:
1. Named Insured/Mailing Address;'
R S B, Inc. Legal Entity: Corporation
1261 Rt 28
South Yarmouth, MA 02664
fnsured toca�ion RttcTresses�-�
_- __ .
- -
- - _ _
_ _ ___ _ __ .
1. 1261 Rt 28 South Yarmouth, MA 02664
2. Policy Period:
The policy period is from 08/01/2001 to 08/01/2002 12:01 A.M. Standard Time, at the insured's
mailing address.
3. Coverages:,' ,
A. Workers' Compensation Insurance: Part One of the policy applies to the Workers'
Compensation Law of the states listed here: Massachusetts
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed
in item 3A. The limits of our liability under Part Two are:
Bodily Injury by Accident 500,000 each accident �
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except those listed above in item 3A and ND, OH, WA, VW, 8�WY.
D. This policy includes these endorsements and schedules: Refer to Attached Schedule
Total Estimated Annual Premium: $1,616.00
By
Date: 07/19/2001 orized representative)
MK
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-009 FEE: $50.00
'rhis is to Certify that R.S.B.,Inc. dlbla Beach'N Towne Motel
1261 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornrity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,
32B, 32C, 32D and 3.2E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or
revoked. '
March 1 ,2002 BOARD OF HEALTH: �ut�tled�r�. i��i. (��eziaaxct�
��aaci�s?�. G�io�tclo�c. '�IlC.?�.. 2/lce (�a�
,�a�t� �cor�c, eP,ezk
�a�rtek�e�
� .S ; Z
ruce G.Murphy, , .,CHO
Director af Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-012 FEE: $50.00
This is to Certify that R.S.B.,Inc. d/bla Beach'N Towne Motel
1261 Route 28. South Yarmouth�MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-PubGc Swimming or Wading Pool
At Beach'N Towne Motel - OUTDOOR POOL
1261 Route 28
South Yarmouth.MA
This permit is granted in confom►ity with Article VI of the Saz►itary Code of The Commonwealth of Massachusetts,and
expires December 3 t.2002 unless sooner suspended or revoked.
Mazch 4 ,2002 BOARD OF HEALTH: 'r� i�elli�rez,
�D. C%�. .�iee
,��ct? bnor�, L�
����ez�xo�
�� s�. ��
Dir ctor�of Ha lt� � �
T
i TOWN OF YARMOUTH
; BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
�
' PERMIT NiJMBER: #02-073 FEE: $30.00
F
i In accordance with regulatians promulgated under authority of Chapter 94,Section 305A and
; Chapter 111,Section 5 of the General Laws,a permit is hereby granteci to:
� R_S_R_, inc_, 1261 R��te „$,� SoLth YarmoLth,,MA
� Whose piace of business is: Beach'N Towne Motel
Type of business:_ Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2002 BOARv OF HEA1.Tt�: �anfe�s� xe�Fez, ���r�,c
�ewc�D, ymcd.a�ac. 79�D., `�/�ce
,Z�adact� S�ora�, (�lezk
�a.�ciek��xo�
s'�ef�c .Slca�. ,��l.
March 4 ,2002
Bruce G. urphy, .5.,CHO
Director of Heal
� � _ a�
r � �� B�Gtt'NToW� Mo�... �
� 2 �' � q
.� . � � , , � . 6
TOWN OF YARMOU BO���(��HEA,�T�H�� � � �G �� � M I� �
APPLICATION FOR LICENSE/PERMIT-2001 DEC O 7 ZOOO
. ►-i�A LTy D PT.
* Please complete form and attach all necessary documents by December 31, 2000. Failure to do•so� in
the return of your application packet.
--------------------------------------------------------------------------------------------------------------------------------------------- �
N?�11�:E OF EST�RLISI-��FNT• ��A� L�-l� n� �ui�✓F w�e•T c L T„�L # 3 48-z�!/
2 � r �-
MAILING ADDRESS: .S`� ,�/if-/��to,.-� tt��/,�-� O y(�G ,
OWNER/CORPORATION NAME• 1Z s ��v � _ _____
' ti� u lt � � �
G�z �,, . 1 � T /�!1 `
�
-------•------------------------------------------------------------------------------------------------------------------------------------ i
POOL CERTIFICQ���ONS: E
The pool supervisor must be certified aa a Pool Operator, as rec�uired by new State law. Please iist the ;
designated Pool Operator(s)and atta.ch a copy of the certification to tlus form.
i. �p-�. ��' L, i3 v e2 L-� v S 2, ,'
Pool operators must list a minimtun of two emplayees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies of
employee eertifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your plaee of business. ;
1. ��Z��.i�fi 3 v�2 �� sf 2. ,
3.f v�q-NNf r3�/RLr��J 4• i
�IMLICH CERTIFI�ATIONS: ;
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 j
attach copies of employee certiftcadons to this form. The Health Department will not use past years' reeords. �
You must provide new copies and maintain a file at your place of business.
'r
1. 2• '
�
3. 4-
RESTAURANT SEATING: TOTAL# NON-SM4KING SEATS: TOTAL#
-_--�_�.,.��..___��_�.�_,�,_,�__�_---...�,..�...----- -----------�-w_.,� r -
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ',
B&B $50 _CABIN $50 '
iNN $50 _CAMP $50
LODGE $50 ' TRAILER PARK $50
1 MOTEL $50 �O 1-d0 1 SWIMMING POOL �4� $SOea.�01-b l 0
_
WHIRLPOOL $25ea. '
�OODA �FRyICE; �
NOTE: Fer the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for
food protection manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 ( CONTINENTAI, $30 �0/-0
>100 SEATS $150 NON-PROFIT $2S
COMMON VICT. $50 _WHOLESALE $75
RFTA�L.SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
_<15,040 sq.ft. $75 TFROZEN DESSERT $35
_>25,000 sq.ft. $200
NAl � C��.� $10
AMOUNT DUE _ $ 130 .�0
� *****PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM***''*
�
�
¢ .�.� �
r__ �_.. . ,
� ADMINISTRATION
Ur�der�hapt;e�,1,52,�S�ction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any liceirse 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
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of�armouth ta��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 31,2000.
SEASONAL ESTABLISHQ�✓�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR IlVSPECTION 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,and the water tested for pseudomonas,total coliform and standard plate count by a State
certified lab,prior to opemng,and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
IYEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS•
The effective date for food protection manager certificallon is October 1, 2001. As sta.ted in 105 CMR
Sg0.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection
manager. T�us provision is effective one yeaz from the da.te of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement
of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories.
CATERING PO�.,ICY:
Anyone who caters within the Town of Yazmouth 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._ ;
. _ _ _ ___ ___ - i
FROZFN 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.
OUT�inF.CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boa.rd of Health.
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: ��(T�� SIGNATURE• 4 � �
/' �
PRINT NAME& TITLE:�y-y. �y � . />v tt(,-� �S l�I?�5 t D E�v� �
11/16/00
�,
, .. � :
The Commonwealth of Mossachusetts
M W Department of Industria!�ccidents
� o 011lceoJ/ar�stl�stlfiis
� � 600 Washington Street
� Boston, Mass. 02111 '
�'"` " y' Workers' Compensation Insurance Affidavit
Annlicant information• ��u��T��
mm� (\ -5 .� � /✓� !J� � GL ,��R G � r/ `7"D r,u N X !��"7-�
location• /Z � � %�� �-�
��.T'/,/}�/Q f�'1D !/1^� w1�9'� �� l!� phone��GS�P�'�CJ S1�--�'� l�_
� I am a homeowner pertorming all work myself.
� I am a sole proprietor�r� ha�e no one���orkine in am�capaciry
� I am an employer pro�idino workers' compensation for my employees working on this job. '
compan� name ���-G� � �DkJiV� �"1d ��Z-.
�ddress /� �i� ��` �-�
�i S� ���i?-1/JVT`tf- �� ohoneH•.�o8 '3 �8 -- Z�j �/
insur�nce co �A 5 7"�,2 I✓ policv# �1/� 4� 70�� L3
� I am a sole proprietor. �eneral contractor, or homeowner(circle one/ and ha�•e hired the contractors listed below «ho hace
the follo��in���orker�� �ompensation polices:
m nv n
dre :
� ohone�•
insurancc co. li �#
m an n
� ohoee It•
ootiev 1!
Failure to secure coverage as required uoder Seetioo 25A of MGL 152 ae lad to tbt iopaifioa o(erisi�al pe�altla of a dae op to S1.S00.00 a�d/or
oae yean'imprisonment as w�ell a�civil penaltia io the form of a STOP WORK ORDER and a fioe otS100.00 s day�`�io�t ma I a�denta�d t6at a
eopy of thN statement may be forwarded to the Otfice of Investigatiow of the DIA for eovenge verifiutio�.
t do•hrreby cerrij��under�he pains und penalties of perjury tbat�he injorniation provided above is true and eoned
Signatur • � � /� ' v��
Print name �f}���� � ,�U 2(r��S l�12�5� 1�,�i+/ � � Phone� ✓`�0`a �7✓' ��'�-,3 �!
., olTicial use only do not..�ite in this ares to be completed by city or tow�otticial
ci or town• Y�M�IITQ _ permiNieease e nBuildiog Departmeot
�' �Licensiog Board
�check if immediate response is required 261 OSdectmen's Ottiee
�Hcalth Departmeat
phoee p:_ �508� 398=2231 egt. nOther
contact person: �—
Irevued 3;95 P1A1
.
�i�ag�o.�o��anQ
OH�`'S'2I`HdY�I`�qdmy�•�a�nig
iooz` r
.�� . .� �„x�v.l�
�', 0 �'��°'•'?lG
�►'� '1°'„�� ��°�
art�xr�r,r�� a?�/1, 'a�'s�,'�a�'��;�r��
���� '�f �p3 �H,L'IV�-i 30 Q2I�'Og I 0 a :sa�dxa�iuuad
�o unn Z :ut�uauzustlq�sa poo��a��.�ado oZ
g uaui u :ssautsnq�o acLiZ
ja y� Z �uo�e :si ssautsnq�o a��eid aso�
:o�pa�u��Cqaiau sT�iuuad�`snneZ i�aua�ac�3o S uoi�as`t i i �a�dsq�
P�NSO£u�?l�S`b6��d�i�3��uocj�n�.aapun pa3e�inuio.� suouEinSai�tn�a�uepio��ui
00' ���3 iZ0-i0# ?I�gY�if1N,LIJ�i2i�d
,Ll�i�yliHSI'I�.LS�QOO,���Z�'2I�d0 OZ.LILII2I�d
H,L'I�'�H 30 Q2I�'OS
H.Lf10i�1i2I�1i 30 I�IMO,L
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #01-008 FEE: $50.00
This is to Ce�tify that R S B , Inc d/b/a Beach'N Towne Motel
1261 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Boazd of Health,and e�cpires December 31,2001 unless sooner suspended or
revoked.
January 26 ,2001 BOARD OF HEALTH: �� �e�ed. (�'�tcivt' �tt�
�t�t�d�. /��i�l�. �tCe �%�icR�t
��(I� � ��lOf�floL, �iu'"'e
�tie�ra� d ',C'c�
�e.t�a.xia �. . 711.D.
Bruce G.Murphy,MPH,R.S.,CHO
Director of Health
,
, � �-r�-.. ., ,
• 4
THE COMMONWEALTH OF MASSACHUSETTS �
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #O 1-O 10 FEE: $50.00
1'his is to Certify that R S B Inc d/b/a Beach'N Towne Mot 1
_ 1261 Route 28 South Yarmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach'N Towne Motel - OUTDOOR POOL
1261 Route 28
South Yarmou MA
This pernut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
January 26 ,2001 BOARD OF HEALTH: �� �¢t�ed, �u�vr�lr�y
��anF,ed'�f. �a!�i. �/ice �ra�uc�xa�
�'o�ie�it� i'�, L�
��l�l d '1'
� D ��. ��
Director of He Ith � �
„ ,--��-�,
�ac h'N iaw r�,Mot-�i
�
4 TOWN OF YARMOUTH BOARD UF HEAI�TH '' �v � l'' � � � � �
'
� APPLICAITON FOR LICENSE/1'ERMI�-2000 ��O ; ��� p 9 1999
. � 3� �
��30�'
* Please complete form and attach all necessary documents by December 31, 1999. Failure to�`
i the return of your application packet.
NAME OF ESTABI,.�SHIVIE�TT: ��A-c l�--rn T�� tv�v� ----w1 a T�' L----------TEL # 3Q9-� � l/ �.
LQCATIQN ADDRESSJ t�G / G� � y
L R�r T tf �!�• �L�
T N S � �L
' /z E S # '7 - I
MAII,ING AUDRESS: /,�- �r�� (J 5�' � N. �R w!v ��fi` e'`�t�-- d�4 7 3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law, Please list the
designated Fool Operator(s)and attach a copy of the certifica�ion to tlus form.
i.�f1a ��� �i e • i3vRG-F55 2.
� Pool operators must list a minimum of two employees currently certified in basic water safety, sta.ndard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Plea.se list these employees below and attach copies of
i employce 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. Rp-��� C $v 2l�fj�',s 2. SvZR,�N� /3v2G-L� 45
3. 4.
HEIlbiI.ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking 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 fde at your place of business.
1. 2.
3. 4.
RESTALAtANT 5EAT�IVG: TO�'AL# NON SMOKING SEA��: TO�'A�,� - -- -
--------__�__--------------------------------------------------------------�-----------------------------------------------------------------�
OFFICE U,,�E „_0�,.,Y
LODGING•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
INN $�0 CAMP $50
LODGE $50 TRAILER PARK $50
I MOTEL $50 `�2k�(� �SWIlVIlVIIIVG POOL�o� $SOea. �_
WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT#
�
0-100 SEATS $75 I CONTINENTAL $30 �,c-53
; >100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $45 TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35 �
>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE = $ I��”
"'•'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM~��R R
('�
�: '
r ._. . . ...._. _ �
s
ADMIl�TISTRATION
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW R�QUIRED
TO,HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS TF A
PE�S(�N- �� :COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATIt�N r
1NSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT �
MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED
�
VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MIIST BE PAID PRIOR TO RENEWAL OR ISSUANCE dF
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(5) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
�
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HE.ALTH DEFARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENTNG FOR TI� SEASON. j
�
:
ALL RENOVATIONS TO ANY FDOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO �
COMMENCEMENT. RENOVATIONS M�Y REQUIRE A SITE PLAN.
AI�DITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SVVIlVIlVIING, WADING AND WHIRLP04LS WHICH HAVE BEEN CLOSED FOR I
�
TI�SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND►THE WATER TESTED FOR
PSEUDOMONAS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE G�I�T�IED LAB,
PRIOR TO OPENING, ANn QUARTERLY THEREAFTER. �
I
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIIlVG POOL MUST BE DRAINED OR COVERED '
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
�ATERING PQLICY�
ANYONE WHO CATERS WITHIN'THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH
DEPARTMENT BY FII.ING THE REQtJIRED 'TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO 'THE CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT THE HEALTH
DEPARTMENT.
FRQZE�.�E SS ERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI-�HEALTH DEPARTI1r�NT. FAILURE TO DO SO WII.,L RESULT IN THE
SUSPENSION ORR�VpCATION OF YOURFROZEN DESSERT PERMIT UNTII,THE ABOVE TF.�tMS HAVE ;
_
_ -- - _ _ -- G
BEEN MET.
QUT�E CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
�UTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD
SERVICE ESTABLIS�IMENT IS PRUHIBITED.
, l
DATE: I �' 7 l SIGNATURE:�(��� � �j� ���-�„��,�J
PRINT NAME& TITLE:,��-G��/�7� �, �C�/� ��5� C�!{ �s r 17�/1/7/ �
11/12/99
: ` �
The Commonweulth ojMassachusetts
. � � Department ojlndustrial.-lccidents
" ; OJ11C001/OYCS�Of�IIt
I : 600 Washington Street
' •` Bnston. Mass. 02111
�'~ v•y W'orkers' Compensation Insurance Affidavit
ARolicant information: PleesepRiN7'Ti•�.'i.s�
— �
n�mr�JJ�`!-G� vt-i %!9 Gv A/� �O T t L
lucati�n: j2-�i � � ��
�tt�_�'f�.�/�C!�9/� ll�� , � /�- �, �7 7i�1�1�"f ohone q �'��- Z 77� /
� t am a homeow�ner pert�rmin,all w�ork myself.
� f am a sole proprieror �::,', ha�e no one��ori:ing in am•capaciry
�, F am an emplo�er prot��in� warkers' comp�rtsatian for my�employees w•orkine on this job. "
comoan�• name: �i ,`i , l,�i , �it�G C��.�rGl �7l��C� Yy+ TdGvN� °'tlpT�L.
.�ddress: ���/� � T � � '
ciri•: �� ���i�10 V / � GYlf�` /�Z��/ 6 hon .�04f� �J '�(�—� 3��
�
ir�surance co.�.¢Ci?�R� ,policy# fJ-/— W G� /DO�7Jr'L�-
� I am a sole proprietor. _enerai contractor, or homeow�er(circle oneJ and ha�•e hired the contractors listed below «ho ha�e
the follu��in� ��orkzr �ompensation polices:
s4m�anv name:
address•
citv• ohone t!•
insur�nce co. elic}•#
comoanv name: - ___ _ - --_-- _ _ _ __ _
____. _ __ -------
ad d ress:
�'' nhoee M•
insuranse co. potiev M
t
Failure to secure coverage as required uoder Secnoo 25A of MGL 1S2 ea�lad to the iepaitioa o(crivi�al peadtles o(a d�e op to 51.500.00��d/or
one years'imprisonment a�w•ell as civil penalda in the(orm o(a STOP WORK ORDER�ed a Ifae otS100.00 a diy Kainst me. I s�denta�d tbat a
copy of this statement mav be fonv�rded to the Ofiice of Investigatiom of the DIA for eoven�e veritindo�.
I do hrreby cenifj•under the pains and prnalties ojperjury that t/rt injormatinn provrdtd abovt is trrte and eorieet
Signatur�/��l'rL.t�/� � • �/��_t,� !. f�l�-/ Date /Z ��/��
Print name �f�� t�-� e. , �U � lr�`J s Phone 1l ��O � Z 1 l��
.. aRcial use only do not+.�ite in this area to be tompleted by eitv or town otlltial
ciry or town: Y�M�IIT� _ permitAieense p nBuildiog Department
�Lictosiog Board
0 eheck if immediate response is required 261 �Seiectmen'�Otlice
�Hesltb DeQartment
contact persan: phone N;_ �508� 398-2231 eat. nOther
' ,... ,< �1��,
, THE COMMONWEALTH OF MASSACHUSETTS
� � TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-16 FEE: $50.00
This is to Certify that R S B Inc dJb/a Beach'N Towne Motel
1261 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the I,aws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins sa licensed as adopted
by the Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked.
December 20 , 1999 BOARD OF HEALTH: Gc` ��/. �ettea, C�cairman
�oan� �u[livan, �i"/., Vice (�hairman
Kobert� 9�rown
adrie[le�al�ol��Z�-�oopee
ichae6 � ou hdin
Bruce G.Murphy,MP , R. CHO
Director of Health
�I
l
�
�
�
THE COMMONWEALTH OF MASSACHUSETTS
� ` TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-25 FEE: $50.00
This is to Cercify that R.S.B.. Inc. d/b/a Beach'N Towne Motel
1261 Route 28. South Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach'N Towne Motel - OUTDOOR POOL
1261 Route 28
South Yarmouth. MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
December 20 , 1999 BOARD OF HEALTH: �c�� �eltee, C�iairman
�oan C�. �ul[ivan, �//., Vice C,�irman
Kobert� �rown
a��iedle�a�ola�y-✓�tooPe�
hael � o [in
I'UCe . }�� � .
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-53 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:
R_S_R_,Tnc.�]26l Route 28� South Yarmouth, MA
Whose place of business is: Beach'N Towne Motel
Type of business: Continental Breakfast
To operate a food esta.blishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�'d�/. �gtt�, C'�t.��.
�oa►c� �ul[ivan, K.//., Vice t,�irma
o�ert� �rown� C�ler�
abriel[e�a�ol.�kr�-.J� ��
. �
ic ou��[in
December 20 , 19,2Q
Bruce G. Murphy,MP ,R. CHO
Director of Health
� � . i.r �, ... � � . Y�:1�NJ1G-b
W,y,y�, ga,� �._. �. . ..
1 � ;'� j�F .� � �26�b (� L� G C 0 M � D
° ' TOWN OF Y�I�M��T��4ARD OF HEALTH
DEC p 1 t���
APPLICATION FOR LICENSE/PERMIT- 1999
HEALTN DEPT.
* Please complete fornl and attach all necessary documents by December 31, 1998. Failure to do so will result in
the return of your application packet.
-------------------T�-I-----------------�--G�------------�N-------------T��---------------#-3-------------�--
O A I N S: 2 /
• � ' f� 02-
OWNER/CORPORATION NAME� 6P . 5, B� ��t�'C
R' : i? r� �: �� !�G-�s . #f����o--zt �
M.�I1�.G ADDRESS: �� G iz o v s E � .r�• dt�• + /�'��1a vT� G�l�,��3
�OOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to this form.
1. � l� � %� � G , f�vRG-��.� 2.
Pool operators must list a minimum of two employees cun'ec�tly certified in basic water safety, standard First Aid and
Commurnty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to ttus form. The Health Department will not use past years' records. You must provide new
copies and maintain a fde at your place of business.
1. �- /� o ri� �� � 2.
�� � � � �
3.�5� �.�-w �v �' � � R l-� 5 4.
HEIMI,ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-cholcmg 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 frle at your pl�ce of business.
1. 2.
3. 4.
RESTALJRANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
.__ __ - ---- - _---
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LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
B&B $50 CABIN $50
TNN $50 CAMP $50
LODGE $50 TRAII.ER PARK $50
I MOTEL $50 �_ �SWIMIVIING POOL $SOea. Q�(-3
WHI�LPOOL $ZSea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT #
0-100 SEATS $75 �CONTINENTAL $30 q q-�9
>100 SEAT5 $150 NUN-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAII.SE��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
<50 sq.ft. $45 TOBACCO $20
^<25,000 sq.ft. $75 FROZEN DESSERT $25
�25,000 sq.ft. $200 �
NAME CHANGE: $10
- AMOUNT DUE = $ I�`
""""�'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•""
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ADMINISTRATION
UNDER Ck�APTER 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
PER50N OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. THE ATTACHED STA'Y'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED,OR.
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES_� NO
NOTICE: PERnrIITS RUN ANN[JALLY FR�M JA�TUARY 1 TO D�CEMBER 31. IT IS YOUR
RE5PONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY I
I
DECEMBER 31, 1998.
SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION ;
7-10 DAYS PRIOR TO OPENING FOR THE SEASON. �
�
�
ALL RENOVATIONS TO ANY FOOD ESTABLIS��VvIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COn�IlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULAT�ONS f
I
POOLS '
POOL OPENING: ALL SVVIMMING, WADING AND WHIRI.POOLS WHICH HAVE BEEN CLOSED FOR
TI-� SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT,AND TI�WATER TESTED FOR :
- P5EUD4NfQ�tIS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPElVING, AND QUARTERLY THEREAFTER.
I
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED �
WITHIN SEVEN(7)DAYS OF CLOSING. !
t
FOUD SERVICE f
CATERIl*�G POLICY:
ANYONE WHO CATERS WITHIrT TI-� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPARTMENT BY FILING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO TI-� CATERED EVENT. 'TI�SE FORMS CAN BE OBTAINED AT THE
HEALTH DEPARTMENT.
�07_,EN DESSERTS:
FROZEN DESSERTS MUST BE TE5TED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN
-��TJS�ENSI(2ri(�R RFVO�ATI_ON_OF YOURFROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS
-- - — —
HAVE BEEN MET. — __ ,
OUTSIDE CAFES:
OUTSIDE CAFES(i.e.,OIJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
i
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD i
SERVICE ESTABLISHMENT IS PROHIBITED. i
i
DATE: /� / � SIGNATiTRE� � � GG��
PRINT NAME&TITLE: �� A 3� n ��S � RFS '�C�i� � �
��
1
a � - � ,,
. �
� ` _ The Commonwealth of MossQchusetts
� W Department ojlndustrial,-fccidents
� a Ol11ce ol/�s�losdiis
� 600 Washington Street
' ,.= Boston, Mass. 02111
�~ �� W'orkers' Compensation Insurance Affidavit
A,Rnlicant information: p'Ie9srpg�i�'r�
_-..�_�_�
n�mc: �.��-GfI vy, `I�Gv N� �r`lo T,� �
a 'o • 2 � /� T. �7l
. , � 2 0 6�!`/,� p � -� /
� I am a homeowner pertorming all work myself.
� I am a sole proprietor��� ha�e no one ��orkine in am•capacin�
�I am an employer pro�idino workers' compensation for my employ�ees working on this job.
- , ^' _
comnan�� name• �. �� � • L /�G '
�ddress: ��-� � T � �
�t���/�-l1P/tiv (�%� , �?'�- ��-(��T—nhone q• 31�ff� 3/�
insur�nce co. FR`� ?.�/i It/ C�.$ (/H� � 7,y l R,�y# 61�G 7� /00 275�F�-'
� I am a sole proprietor. general contractor, or homeowner(circle onel and ha��e hired the contractors listed below �`ho ha�e
the follu��in� ��orl:er' �ompensation polices:
sQmRanv_name•
address:
S1y: phone q•
insurancc co. Aolicy#
s2m�nv name•
__------- -- --- - --- _ _
- --- ----- - _-_ __-- - -
a�dress• -- --- — - - -- ----
ciri: nhone M•
ie�y�ance co. yQj�y�
Failure to secure coverage as�equired under Seedoo 25A of MGL 1S2 e�a lad to tbe i�paidoa of erioi�al pe�altla of a li�e op to 51,500.00 a�d/or
one yean'imprisonment u w•ell a�eivil penalda io the form of a STOP WORK ORDER aad a fiae of 5100.00 t dar a�aiost ma t a�derstt�d t�at a
eopy of tha statement may be forwarded to the Ofiice of Inveetigatiom of the DU for eovenge veritiestia.
/do hrreby cer�ijy�under the pains ond penalties ojperjury thot�he injor►rmtion providtd abovt is true and correct
Signatu � ate ��• - � '��v
Print name/� i�� �'� (_ . �li R G'-e �j 5 ���L�-3 / Zj�'�t47� Phone# ���' 7' l7 � r
.. otTicial use onl� do not..rite in this area to be completed by ciN or town ofllei�)
city or town: Y�MODT� _ permitAieense k nBuildiog Departmeot
�Licensiog Boud
❑check if immediate response is required 261 �Stlectmen'�Otiiee
QHealth Department
contact person: phoee#:_ (50$� 398�2231 egt. nOther
Im�ised i,95 PIAI ^
/ `
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 99-19 ' 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:
RS_B ,,,,j�„ 1261 R�Lte 28, South YarmoLth,MA
Whose place of business is: Beach'N Towne Motel
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth �
' Permit expires: December 31. 1999 BOARD OF HEALTH:���/. �et��, C'�tp.��
, oan� �ulliva�,��s Vice C��irman
obert Je . 4�rown, l,terh
abrielle�a�Zol��i�-J�toope6
ic�al � ou hlin
�� December I S , 19 98
ruce G. Murphy,MPH,RS ,
Director of Health
� THE COMMONWEALTH OF MA5SACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: . 99-4 FEE: $50.00
'rhis is to certiTy that R S B Inc d/b/a Beach'N Towne Motel
1261 Route 28, South Yarmouth�MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted
by the Board of Health,and expires December 31, 1999 unless sooner suspended or revoked:
December 15 , 1998 BOARD OF HEALTH: �c�� ..tettee, ��iair►narc
�oaa� �ullivarc� K.�, �ice l�hairmstn
�obert JD . 4,rowa
a�rielle�a�iof��rf-J�ooPed
elOoC u �llwz
ruce G.Murphy,MPH,RS CH
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-3 FEE: $50.00
This is to Cer6fy that R S B , Inc d/b/a$each'N Towne Motel
1261 Route 28, SOtth Yarmc�nt� j�,�
I IS HEREBY GRANTED A PERMIT
' To Operate a Public, Semi-Public Swimming or Wading Pool
At Beach'N Towne Motel O OOR POOL
1261 Route 28
South Yarmouth 1��
This permit is granted in conformity with Artiole VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31. 1999 unless sooner suspended or revoked.
December 15 , 1998 BOt�RD OF HEALTH: ��� �eltea, ��air��c
. � �oaa G. �ul[ivart.���, �/ico (.,�irmarc
Kobert,}. �rown
a�aie6le�akole��-..J�fooPe�
�c al O oC �lin
Director of Heal� � �