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Home My WebLink AboutApplications, WC and Licenses� �"' � � TOWN OF YARMOUTH BOARD OF HEALTH •� '�� c � � APPLICATION FOR LICENSE/PERMIT-„ 0� �e �� '� ��; � 5 2008 * Please complete form and attach all necessary da��i -,`y Dec�e 1 --Z �M D E PT. Failure to do so will result in the return of y�pur�`pplication pac e . NAME OF ESTABLISHMENT: �n h c�,-� L,c�,,,�5 B a., TEL. #� T ' 3 `�3 3 LOCATION ADDRESS: �,'7 /y1a►hG ,/�✓� � MAILING ADDRESS: � OWNER NAME: �4 n�-t' � l�c�,.c� �J,�ti� TAX ID (FEIN or SSN�: �� CORFORATION NAME (IF APPLICABLE): MANAGER'S NAME: S�m� TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. � l. 2. k Pool operators must list a minunum of two employees cunently certified in basic water safety,standard First Aid and � Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below aud attach copies of employee ; certifications to this form. The Health Department �vill not use past years' records. You must provide new � copies and maintain a file at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food � Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. � You must provide new copies and maintain a file at your estabGshment. � l. 2• ; PE _ON IN CHARGE:_ . . _ . __ _ _ _ -- ! Each food establishment inust have at least one Person In Chaxge (PIC) on site during hours of operation. ; 1. 2. _ HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all tunes. Please list your employees trained in anti-choking procedures below and attach copies af employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. � 3. 4. { I RESTAURANT SEATING: TOTAL # � OFFICE USE ONLY LODGING: LICENSE REQL�iRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT� ' B&B S55 _CABIN �55 _MOTEL �55 INrT S55 _CAMP $55 _SDJIMIv1ING POOL �80ea. �LODGE S55 �OR-OO�o _TREIILERPARK $105 WHIRLPOOL �80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS S85 D� 9�(ll _CONTINENTAL S35 NON-PROFIT �30 >100 SEATS S160 I COMMON VIC. $60 � —67 WHOLESALE $80 RETAIL SER��ICE: —RESID.KITGHEN �80 LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. ��0 _>25,000 sq.ft. $22S _VENDING-FOOD �25 <25,000 sq.ft. $80 _FROZEN DESSERT �40 _TOBACCO ��5 I� AMOUNT DUE _ � 26� . O� �iA�'IE CHAr GE: S 10 � PLEASE TLTR:�OVER AND COMPLETE OTHER SIDE OF FORM*"""`* .***« � � � .�r �,,� � y ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTEi.S AND UTHER LODGYNG ESTABLISHMElV'TS 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 customa.rily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, 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(S�days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected 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 must be drained or covered within seven(7) days of closing. � FOOD SERVICE j CATERING POLICY: 5 Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor sea.ting with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. k __ - - - f NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, 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. � i DATE: (2' � � SIGNATURE: PRINT NAME&TITLE: ---�" - ionvos ' 1 ,� _ I : . � :, ?'he Commonwealth of Massachusetts Departinent of Industria!Accidents � M�CIIfb�� 600 Washington Street, 7`"`Floor Boston,Mass. 02111 � Workers'Compeesation Iesora�ce ABidavih Bailding/plambing/Electrical Contractors �t i�ar�ttrs: ` l"l�se P�INT k�ib�r �: _ I�a�( \�i41�'--,��.I addtess• � - � - ci VV � state: zi : h , � work site location ffull addressl_ ❑ I am a homeowner performing all work myself. Project Type: ❑New Ca�nstruction ORemodel �I am a sole-proprietor and have no one working in any ca�city. 0 Building Addition ❑ I am an employer providing workers'compensation f�my employees wo�lcing on this job. comwnv�e: � �i 1 �1 �� : _ t�T�V _ address• � / �I n/�: � Y� � � � #: �=�"? I--3 i �BB C0' # � ,`.� ,_.' �:.: ,t ,t,_;: . . -: , :=;��-.. ;�,.; '; :- ; ,v..::;'. .,., :.� e r.:� .,.. .::.�..k<F` -::. _�a ,. 'v.r.:�:Ab; .�%:. ',"''�,'`,�t';t.etlrj>'' .. ., ,...: .tv.� � ❑ I am a sole proprietor,geaeral eottractor,or�omeowaer(�rde onc)and have lured the cantrdctots listed below wl�have the following workets'compensation polices: comwrv�amc• address• dtv nhaae#. Iies nce eo. �. , . � <. � ,s,�,a��:: � aomimev�ame: address: i cllY: nLo�c*. __ - - _ — -- -- ---- ---- - -- --------- --— i - - —� -- - -- -- , # .` . ,.v ��.. : . , � , .�;. "" ' . ;r.'�'�:: �.;{��; FaBarc be secere c�vaase n reqairsd iader Seetloa 25A�f MGL 132 cu la�d t�f�-�iti�a�f arWsal pe�aNies�f a�e�p Es t1,S�0a0 a�dhr see Yan'IsPtden�t u we�as dH peeaNia la t6e form s[a STOT WORK ORDER aad a Hne ef S1A0.6S i day a�gainst me. I aadenlard that a �� cepy�f tiis�tatmeot�ay be forwaMed�s the O�oe d lave�atlo�of tke DIA fer�avense ver�caHoi. !do lYdtby ce ' weder tlie d penalli�of perjury tlYet tllre tnfonwelioe provided oboae te dvre awd onmect � SiBnat�re (/'� - Date 'Z�« � Print name �� Phone# ��'-� ��J� os�ial aae onry ao eec..rite m ch6.ra to ne�mpkced ny clty�Ea.va-e�ctai city or tewn: permiHNcenx# f"1_saYain.p�p,�gt ❑check K�me�ale rea�eme is rcqdr+ed �,�� 'e �Sdee�ea s O�ae Qiiealt6 Dcpar�t ce�d peroea: p�o�e#; Q01�er c�� I + THE COMMONWEALTH OF MASSACAUSETTS TOWN C)F YARMOUTH PERMIT NtJMBER: #09-006 FEE: �55.00 ' LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David J.&Janet Vaughn at Lnn at Lewis Bay_ 57 Maine Avenue_West Yarmouth_MA in said Town of Yarmouth and at that place only and expires December thirry-first,2009 unless saoner suspended or revoked for vialarion of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confornvty with the authority granted to the licensing authorities under section hventy-three>of chapter one hundred and forty,of the General Laws,and is subject to the provisions of sections nuenty-rieo to thirty-one inclusive of said chapter. In Tesrimony Whereof,the undersigned have hereto aff'ixed th�ir official signatures,this Ei ilg th day of Januar,� A.D. 2009. ' ��. (�Latt BOARD OF HEALTH: .��Cft S��, , C'I'ua�t� 3�. 5�t��Pi�fex,� 21�iC¢ ('l�a:iatt►itrrt Number of Roonis: 1 st floor,2 bedrooms ��4X��. ✓��if4�lUft� �;CQJlt/� 2nd floor,4 bedrooms Q�ttZ �ite¢It�q.ittri, �,J��, ��t�C�'t�. ��A'�(�¢cS . � Bruce C,�Murphy, ,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT , PERMIT NUMBER: #09-111 FEE: �85.00 In accordance with re�uIations promulgated under autharity of Chapter 94,Sectian 30�A and Chapter 111,Section 5 of the General Laws,a pernut is hereby aa'anted to: David J. &3anet Vau$hn, 57 Maine Avenue, West Yarmouth MA Whose place of business is: Inn at Lewis Ba _ � Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .�feQett S�, �.J�., �'ravrrrrtc�rt C'h'urrr�eo �. 3'Cellc�ex `Uiee C'lf�ixnura J`'��ct �. `�acoiun, C'� ��J2..N. January 8.2009 Bruce G.Murphy, ,R.S.,CHO Director of Health f THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #09-073 FEE: �60.00 This is to Certify that David J & Janet Vau�hn d/b/a Inn at Lewis Bav 57 Maine Avenue, West Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common vietuallers. This license is issued in conformity with the authority granted to the licensmg authorities by General Laws, Chapter'140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their officiat signatures. BOARD OF H£ALTH: ,�f.eeett S�cu `J�..IV., �n' t�a�.r�t:��` SEATIlVG: 10 �� .lL,��l�ICE: �.ru,l,v[lfLl�ft nu u aJD � �f. �.crc�i � .✓►� ��'�`'�'"'�. January 8.2009 B ce .Murph , . H Director of Hea� i I E � i � i � i � i i 4 I E a D f'1'q r' . }J - k� TOWN OF YARMOUTH BOARD OF HEALTH �� : � � APPLICATION FOR LICENSEIPE�� 8 � �� . .IAN O 3 2008 •r��`i . ;rv - *Please complete form and attach all necessary doc�me�� ece�er 31 TH DEPT. Failure to do so will result in the return of your apphcation packet. i NAME OF ESTABLISHMENT: TEL. # ��'7�1'3�� LOCATION ADDRESS: MAILING ADDRESS: OWN�R NAM�: � � TAX ID (FEIN or SSNI- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME. �J�� t � 7��j TEL. #� -�f-- 3 MAILING ADDRESS: S�IF--t E. � — POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s)and attach a copy of the certification to this form. L 2, � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please hst these employees below and attach copies of employee � eertifications to this form. The I�ealth Dep�rtment will not use past yea�s' records. 'Yo� �ust provide new copies and maintain a file at your place of business. l. 2: 3. 4. FOOD PROTECTIUN MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please afitach copies Qf certifieationto this application. 3'he Health Department�vitl not nse past years'records. � You must provide new copies and maintain a file at,your establishment. ; l. V 2. � _ .PER��?I�1 IN.�H�9.R�E_ --.___ __ __ ___ _ _ _ ___ ---___ ___- - —- � - - -- _ _ ___—_ — _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i l. � ' 2. � ; HEIMLICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in t�a.Heimlich � Maneuver on the premises at all times. Please list your employees trained in anti-chokuig 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. RESTALTRANT SEATING: TOTAL # �� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'bIIT# LICENSE REQUIRED FEE PER'11IT�* LICENSE REQL'IRED FEE PER'�fIT� �' �B&B S50 _CABIN S50 _MOTEL S50 ' ,INN . S50 _C.A:�IP S�0 _SWP_�LVIING POOL S75ea. LLODCrE S50 �'��. _TRAILER PARK S 100 V4'HIRLPDOL S75ea. FOOD SERVICE: I LIC£T+1SE REQUIRED FEE PERMIT# LICENSE R£QL�IItED FEE P£R'�4IT� LICENSE REQL'IRED FEE PERA�i1T= �0-100 SEATS S75 �oS-!�l S _CONTINENTAL S30 NON-PROFIT S2� >100 SEAI'S � 5150 I CO:bIl410N VIC S50 #O3— _V4�IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER'�IIT� LICENSE REQLrIRED FEE PER1�fIT� _<50 sq.ft. �45 T>35,000 sq.i�. 5200 _VEl`'DP:vG-FOOD S20 _<25,000 sq.ft. a75 _FROZEN DESSERT S35 TOBACCO SSO NAi1�CHA�TGE: S 10 AMOUNT DUE _ $ /7 S•00 *****PLEASE TL'R\O�'ER�i�D COJIPLETE OTHER SIDE OF FOR�i**"�** r « • AD1VIIlVISTRATION 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 COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � ; CERT. OF INSURANCE ATTACHED ' "� OR `-�.rn I� e� W R' � � ORKE S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tu�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YE NO _ -- - MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limita.tions of Motel or Hotel use,Transient occupancy shall be � limited to the temporary and short term occupancy, ordinarity and customarily associated with motel and hotel us�. , Transient accupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. I Transiern occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, aa�d an ; aggregate of not more than ninety(90)days within any su�(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. � * NOTE: Enclosed Motel C'ensus must be completed and returned with this appiica.tion. 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 openu�g. Contact the Health Department to schedule the inspection five(S�days ' gnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a Stat�certified lab, prior to opening, and c�uarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ; closing. ' I 4 I FOOD SERVICE � CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health DepartmeYrt by filing the required ; Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit utrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: l � �.itdo��l 'crrrg;�r��tiar��r display�f amy food praduct by a r�tail or food ser�ice establis�unent is pri►hibited. ! NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR R.ESPONSIBII.ITY TO RETLJRN I THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR � TO COMMENCEME�tT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: ��=3� '� / SIGNATURE: PRINT NAME&TITL � io;o o? ..._ ...:. - � i .. . � t��-��E, �EN� � '' � h y a-Q.mc�zt► F�-�-,� 0�.c� � The Commonwealth of Massac usetts Department of Industrial Acculents � � � � � �r � � �arw�� 60l/ Washington Stree� f�Floor ;�;�� Q '� 2�08 Boston,Mass. 021I1 Workers'Compeesutio■I�ar�aee A�davih Baildiag/Plambi�g/Electrical Coa et�ALTH DEPT. .4�Ne�rt�*tl�nts P'�toe P�1�1T k�ibh , ; �: ��--F- �I,��—�t�( -- � a�s: �� tti ►� �� ; ��,.�.� �1��t�o��a �t�- 1 �p� Z��b��B�# ,.._�- �� ) `��.�� work site locaci�tfutt addressl_ ❑ I am a homeowner performing all work myself. Project Type: ❑New Construceion ORe�nodel � �I am a sole proprietor and have no one working in any capacity. ❑Bui(ding Addition p i�an�pioy��o��a�Work�°compensation for my employees working on this job. :,, � _y: � � ;- �.. ��, ,-�� commav uune: _ _ __ ', ,�: 5'� �'�(�A�t�`� 1�lJ� , �.: �;� �J��r_ Z�n�� I`�irbg ��: _— =Ti 1-.�� ; �� . � � . x� �- �#v��N�� ' i . � .. �_. �. .. . -- . _.. . �: . ..,t .,.+". . r`-`p M ., ❑ I am a sole proprietor,gt�er+l caetract�r,or 6om�eawaer(cirde oRe�and have hired the co�ctois listed below who have i the following worke.�s'compensation polices: � 0 commlav rffie- � address: i div diare�: # { � �- , Y a,� _ ��. i � l'.oa��!: � � � � �; i CiLV' n�ote�t% f # �wrir,�: _ , � F�i.�e��.,�ey�.�aa s«ei.��►.t rtcL is2�..k.a a��.,tuN..t��.f.��a si,s�N�.aror ene�ars'i�rira�.�st m we�as civt peHalliea i.rie fur,t ota sTor woR1e ciRnER a.a a�e.tsle�a asy aplet.ie. I udas�aa t�a cepy�f tl�#alement may be f�rwardalls Ne O�ce ot lave�tlses of tYe DIA fot average vertlieaKn. /do her+tby et ' eder tJ�e s aw�P��+a ofP��ry tJYat tAe i�for�noNon prov�ded obor�e is Irne awd cerrec� �g� nete ,� —"t—O`v Print name Phone# � �f +'�L'�,�� , efficiai ex aaly do sat�vrtte ia t�arei te 6e cempleted by eity�r lnen o�cisl eity or tewn: per�oe�e k Q�id�Department Bsard i ❑check if imme�iale rsapen�e is reqmk+ed �'s�ae QHea1Th Depar�eat ce�act per'soe: pLone#; DOt6Q c��p-�) i THE COMMONWEALTH OF MASSACHUSETTS TOWAT OF YA�tMOITTH � 1 PERMIT NUMBER: #08-010 FEE: $SO.OU � i LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David J &Janet Vau�hn ` �t inn at 1 ewis Bay� 57 a'ne Avenue West Yarr�outh 1�A f � in said Town of Yarmouth and at that place only and expires December thirty-first,200$unless sooner suspended ' or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is ' issued in conformity with the authority granted to the licensing authorities under section tweniy-three,of chapter one hundred and forty,of the General Laws,and is subject to tl�e provisions of sections twenty-two to thirty-one inclusive of said chapter. ' i In Testimony Whereo�the undersigned have hereto affixed their official signatures,this Twen�-eighth day � i of January A.D. 2008. ; BOARD OF HEALTH: .`�E¢�¢�t Slft�� .,.A�., ��,K.(XI�X�'1tA6tt C'�i�+rac�eo �9Ce�.�i�ie�,c� `�1,i,ce C'ftacvr�nax� Number of Rooms: 1 st floor,2 bedrooms - ��3-�� =� 2nd floor,4 bedrooms �i�� -�- � t��'`�.J�Eau�s i , � , ; Bruce G.Murphy ,RS.,CHO I , Director of Health ; ! i � ; i i c • � THE CONIlVIONWEALTH OF MASSACHUSETTS T4WN OF 3�ARMOUTH PERMIT NCJMBER: #Q8-091 FEE: $50.00 This is to Certify that David J. &Janet Vau�hn d/b/a Inn at Lewis Bav 57 Maine Avenue, West Yarmouth, MA IS HEREBY GRANTED A COMNION VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victr�allers. This license is issuec�in canformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affi�ced their official signatures. BOARD OF HEALTH: .�fde_��e�Drt��Slc��au$�r�`J��.�J,V�t.�,��C'R�aiacnu��u�t�� SEATING: 10 , �afl�iJUX.O .7�ti �IiX�l�IKn� �lCS�.(��1tafL 5►Ia�Pxt�.J`3aca.tutt, C"�e�r� Q�nrz C�'xeetel�,aaun,J2..IV. �. Januaty 28.2008 ruce G.Murphy ,R.S.,CHO Director of Hea1 TOWN OF YARMOUTH B{3ARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #08-145 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: David J &Janet Vaughn 57 Maine Avenue, West Yarmouth, MA _ Whose place of business is: Iun at Lewis Bay Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: �E¢IR�t SK�, J�..N�., C'li',awu►►uYtt �R�a�ceee .�9Ceeli�i `llice �'ft�acv�naa�n .�l?a�.8�ent�.J3�vc�v�, C'� � �('�ce,er�Piaurn, J2..N. Januarv 28,2008 Bruce G.Murphy, ,R.S.,CHO Director of Healtii � w = � �,-�r Z�� t�� N �c�,�s�3�r j � ��f s R�o TOWN OF YARMOUTH BOARD OF�1�I� � � (c' � � �_V/ [� � o -'-`� APPLICATION FOR I.]f�C�`N��'. =2 5 � '` ;,. . .;�' �.� �� U�C 1 7 2004 * Please com lete form and attach a11 neces ` do�Y�nents b Dece er 31 2004 Failure to do so will result in the retu�i of your application pa k E/�LTH bEPT, NAME OF ESTABLISHI�IENT: 4 : 1 �-f �.i�.�� ('��•� TEL. # �?1 i - 3�t 3 � LOCATION ADDRESS: S 7 ✓�1��h c �� MAILING ADDRE S S: W e ,� Y a v�w,a:.-�ti /�l 4 O �G 73 OWNER/CORPORATION NAME: �S� �e -t �- �D� v�� Lr�.; �-�h� MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. l. 2. � Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (YCPR). Please list these employees below and attach copies of ' employee certifications to this form. The Health Department will not use past years' records. You must � provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food i 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'reeords. You must provide new copies and maintain a fde at your establishment. � 1. 2. � PERS4N IN CHARGE: _ . -—-- ----- _-- - __ ! Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i � i. J c�„�+ �f�Jfi � �, 2. HEIMLICH CERTIFICATIONS: ' A11 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 I1VN $50 _ _CAMP $50 �SWIlvIlvIIl�IG POOL$75ea. I LODGE $50 �D ��S _TRAII,ER PARK $50 _WHIItLPOOL $75ea. FOOD SERVICL: LICENSE REQtJIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# I 0-100 SEATS $75 �Q,�.��o _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 �COMMON`7TCT. $50 �Q��(o� WHOLESALE $75 RETAIL SERYICE: LICENSE REQUIItED FEE PERMfP# LICENSE REQUIRED FEE PERMI'P# LICENSE REQIJIRED FEE PERMIT# _<50 sq.ft $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ /7�j.00 "•**PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM""•*• �_ �. . k t y � i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth 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 VVORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR , WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YE� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQiJIKED FEE(S)BY DECEMBER 31, 2004. t t I SEASONALESTABLISHMENTSARETOCONTACT'THEHEALTHDEPARTMENTFORINSPECTION7-10 i DAYS PRIOR TO OPENING FOR TI� SEASON. E � � � ALL RENOVATIONS TO ANY FO�D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.},MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ' ; ADDITIONAL REGULATIONS � I 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. ' i k 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 af closing. ' FOOD SERVICE C�NSUMER ADVISORY: Each food estab �shment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior t4 the catered event. Thses forms can be obtained at the Health Department. Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdot�r seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOII�NNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: PR1NT NAME& TITLE: — � E-C 10/22/04 . � _===_� T/ie Commonwealth of Massachusetts Departrneat of Indushial Accidenls - M�e�N ' � _-- - - _ _= 60B WashiAgton Stree� 7"�`Floor _ --�, Boston,Mas� QZIll ' worke�s Com ho.I�s�asce Affi�vit:Ba� • • lecdrical Costractors . �.._, �_. _' � ,. � ��. ._ _, _ e ��_l��-�- � �� c.-�-a r �� nn A� ��S I�ii � aaa�_ �� Y�AI t.�F. �vE � ��r � ��AR.�YtiI'n`)"�N ��- (�(�1.1 �n• ��1��#�–]`I�-�i� r— work site locatia�(full ad�sl- ❑ I am a homeowner performing all work myself. Ptoject Type: ❑New Ca�tn�ctiaa►�Resnadel I am a sole and have no o�e w in an B ' ' Addition ❑ I am an e.mpbyer providi�workers'�ti�fa�my e.mploy�s worlcing a�this job. �a�: _ _ �s dev: . �ite��: �-3 - 9� ,o13 ❑ I am a sole proprietor, ca�tracMr,or�omea��(cirde o�e)and have hired the co�ctois listed below who have the following workers'�an polices: �« di►�: n�i�aae�s � �tv�e: �: S�Y; ¢�prE� FaNm+c a secue ewera�e a�reqaie+ed�der 3eclMa 2SA�f MGL LS2 cn Idid b IYe��f cri�ial pe�in�f a�ae�p b S1,3M.M aadhr ese yeus'ieptbw�mt as we�as dv�patlqes h tre fer��f a STO!WORK OBDER aed a A�e d3160.N a day a6ai�t�e. !odersdad tiat a c�py dt�b staleme�t'ay 6e firwarded�o He O�ce�l�dWs�f tYe D1A tar average verqiealiN. I do 6ertby c xnder tJbe pe�llias of peNxry tlYat NYe h�fonwe�dnn provlded obovr ia hare awd onrnct �� 1l�te _ �1 Print name Phone# '� � effida1 ase only de aot wr#e�thi�am ta be caapieted 6Y eily er inrn o�dal �Y�'�= �t a�i�D�t �Bsard ❑c�ed[if immediah te�pesse b reqired �'s qga 0�11R�� l��' P��, �a' � • ` . .. THE COMMC)NWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � PERMIT NUMBER: #OS-005 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David&Janet Vaua.hn at inn at Lewis Bav_ 57 Maine Avenue West Yarmotth_MA in said Town of Yarmouth and at that place only and expires December thirty-first,2005 unless sooner S�spended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing suthorities under section twenty-three,of chapter one htmdred and forty,of the General Laws,and is subject to the provisions of sactions twenty-two to thirt.y-one inclusive of said chapter. In Testimony Whereof,the undeisigned have hereto a$ixed their official signatures,this Twen,ty-seventh day of January A.D. 2005. BOARD OF HEALTH: B�u�st�. (��A�I.�. ' n�k/{�lar?5�xo�`, ?/ic�C�u`i�uxwc Number of Rooms: 1 st floor,2 bedrooms Qo�Jlt�. Bho�u�t� � 2nd floor,4 bedrooms o�e,le�t e�[scZ�i, Q./�. �I.��d�-� R.N. Bruce G.Murphy, S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #OS-096 FEE: 75.00 In accordance with regu.lations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�'ieneral Laws,a permit is hereby granted to: I � David &Janet Vau�hn, 57 Maine Avenue, West Yarmouth,MA � Whose place of business is: Inn at Lewis Bay � Type of business: Food Service I', To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l. 2005 Bo�OF HE�,�: �er�r,c�$. �/l�l..`n. ' A��a�s� v��,� R�t� B� et� �S�k, R.N. i4.r�rs C�'�srliasr�g R.JV. 7anuary 2'7.2005 Bruce G. Murphy,MP , .,CHO Director of Health THE COMMONWEALTH OF MASSACHU5ETTS TOWN OF YARMOUTH PERMCT NUMBER: #(}5-064 FEE: $50.00 This is to Certify that David&Janet Vau�hn d/b/a Inn at Lewis Ba� 57 Maine Avenue, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common vietuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affu�ed their official signatures. BOARD OF HEALTH: �est�arsut .�. �rct�s,��S. G��s�ss SEA�G: �o n��r�� v� e�� Ro��t�. l��, G!� � sl�, R.�R.�V. 4 . J�,�y 2�.2oos i''' Bruce G.Murphy,MPH, . , HO Director of Health ::� �, �I 6 a,�u//�vN s►�- LEz�lrs/�►Y ��Fe R.y TOWN OF YARMOUTH BOARD OF HEALTH �?� p � � � r M [� D � ''� APPLICATION FOR LICENSE/PERMIT fl01� '' Y: •�? ` � U E C 2 3 200� * Please complete form and attach all necess�y da �s by Dece er 3 l, 2005. Failure to do so will result in the retu d�yo r application pa k�EALTH D�PT. �-:_ NAME OF ESTABLISHIVIENT: Il - G � TEL. #��]1_y�� I LOCATION ADDRESS: � , MAII,ING ADDRESS: '� OWNER NAME: �l� � � :J— �` �`T' T ID or S : — (� C4RPORATION NAME(IF APPLICABLE): `��' ' MANAGER'S NAME: -�� '�-�` �'�-A C7C—,�-1 TEL # `�— -�� [ MAILING ADDRESS: POOL CERTIFICATIONS: j The pool supervisar 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 certifiEation to this form. - � I 1. 2. „ Pool operators must list a minimum oftwo employees currently certified in basic water safety, standardFirst Aid and � Community Cardiopulmonary Resuscitaxion(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new � copies and maintain a tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food -` Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. I��-`��-,� 2- _ PERSQN_IN_CHARGE: ,_ __ _.___ _ ___ _ . _ __.____ --. _ __-- - -1 Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' 1. 2. HED1��H 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 copies of employee certifications to this form. The Heatth Department will not use past years' records. � You must provide new copies and maintain a file at your place of business. . � t ( � � 3. ��;� 4• ' � RESTAURANT SEATING: TOTAL# I � � OFFICE USE ONLY � LODGING: LICENSE REQUIIt.ED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PEI2MIT# � B&B $50 CABIN $50 MOTEL $50 E — + iNN $5� - CAMP $50 _SWIIvIlvII1�TGPOOL$75ea. I LODGE $50 �d6��0 _TRAII,ERPARK $50 _WI-�RLPOOL $75ea. { — I F'OOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMTf# k ! ; �0-100 SEATS $75 O6�'�c'�p CONTINENTAL $30 NON-PROFTT $25 >100 SEATS $150 /COMMON VIC. $50 �6�3 WHOLESALE $7S RETAIL SERVICE: LICENSE REQIJIIZED FEE PERMIT# LICENSE REQtJIIZED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 QS,OO�sq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ /7S.O U *•""*PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••*"" � __ .:--- : ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ' OR 1 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHE� � 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 RESPUNSIBILITY TO RET'IJRN ! TI� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. 1 ' SEASONAL ESTABLISF�VVIENTS 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 TI�BOARD OF HEALTH PRIOR TO COT�IlViENCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. � ADDITIONAL REGULATIONS i � POOLS ; " POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ' by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained ar covered within seven(7)days of � closing. � FOOD SERVICE i { 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 Department by filing the required ' Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the Health Department. FROZEN DESSERTS: ; _ �'r�ze�r�esse�s�us��e�este� o�a�onthly basis by a Sta�e sertified lab. Test res�lts�nus�be s��e�al�h 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: j Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval from the Board ofHealth. � OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: '`Z-2„'�'�� SIGNATURE: PRINT NAME&TITLE: E�, 09/28J05 k � � `� ��-,_� The Comnionwealth of Massachusetls =_-- - " - Depa�rinent of Indashial Accidents =- = N�eiN��r1M� 60�WashiRgto�r Streeti 7`"`Floor -�� t Boston,MQss. 02111 -�� Worl�era'Com�aatioe I�swa�ce A�d�vit:B�ildi�/Pl�m ��< r... d. �. ., t � ��_ .�� .s ��.�; �� „; �� _ ,. y > �� ' o�tneters �: �� ,T �' T��f R 1�uQ—�_��t- _�h/iv .�� o r�� 1., �S: S 7 M�n,� ,�� iP��—_-�.r#o-t.� �'(,� n�,zn�� T T � �'� citv�/P��_T��C',y+"r"� smte• Ai/��/- zip• Q�'�3 nhane# �b� — 7� C ��3 3 wotk site locaria� fall addt+ess- o I�a�„�� worlc myself. Project Type: New Ca�o�� I am a sole ' and have no o�wo ' in any ca ' Buil ' Addition � _ _ ,�';., _..� �� ..��... : � ,,., . _ .. ,. , . . . �I am an empbyer provid'mg wo�lceas'compensatian foz my e,mployees wo�cing ai this job. au�uuv�: � Af P i�-1T�Q.c�.<.1-r'�o� �C1t'*"'/ __ . �=�T��`��-��- � �'��-�;„�J�+, ''fi1^ n��r: �.�'�/ -.3�f.�_ ; ❑ I am a sole proprietor,g�eral ca�tractor,or�omeo�v�er(arde ou�)and have hired the comr�ctors listed below who bave the following worke.rs'compen4ation polices: �t�: �: dts: oLotc li- # �i"�'v....,r�"tf� Y��S..:�..�..e,.� _°L,.. . r.^.-"^4 , ,.,,Y`i_::, Y'',5„ ..... .,ae q ... ;.u., r '�� . r ,rv+. ..i�w �' "'��.,r r:�°"�5"X...,, ,yir- `� , , - �Q�: �F�F: �: {�7!� ._. .._ _ . - _ .__-___.._.___. __.._..__.___._- _._' . . —._____.—._—�_"._.___ .—._—. . _—_ .___'__ _.. _ _— ._...._. —_.___-______—. .. Y . . . ..___.__...____�--__-T______ R . . __— ... _. ,,, .. ,.. .. :::.. , .; � �, . . .....�- . , t .. � . k . . . =,.k s ._.- .,.: t, sr''a f ��{+�,�; '�''�.�,L-��n��s��X�. ;i. ,�z''.��;�.�#"Y'� :. �.. '�:,,� ,.. Failore M scc�e owerase n reqai�ed ieder Seelio�gA�f MGL 1S2 eu leai b IMe i�itlN�f at�ial pa�aNia��f a�tip b i1,3M.M ud/sr � 0ae yeats'Imprbonment is we9 as dv�pwities la the form Ata 3T0!WORK ORDER aed a ene dS160.Os a day s�aieat oe. 1 mdeasla�d t6at a cepy ef tlis stihment maq be forw�ardcd M tAe(�Ice ef lave�tlsas ef t6e DIA for eovenge veri�atl�a. I ro JYenby cer�rfy r Nie alties of rrry tNat tbe iwfor�waHo�pro�ded abov�e is bTre and c+ornct �8�� Date I('G�J"C�'7 Print name � Phone# �VIL�'� �_�„_�y�� s�cial a�only do not w�rite ia this arei to be eompkted be c&Y or Mwn a�ciai city er tewn• pern�iH�ice�e# ��n� ❑eAeck Kimmedia�e iespeme is re4�� ❑Sde�es s O�ee QHeaMr De�atiment rnntact person: pheee#, DOthv c�s�p.zom� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-010 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David J &Janet Vaughn at nn at T wis Bay 57 Maine A�enue West Yarmouth.lv(A in said Town of Yazmouth and at that place only and e�ires Decxmber thirly-fust,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confornuty with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and forty,of the General Laws,and is subject to the pmvisions of sections twenty-two to thirty-one mclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Second day of Februar�_ A.D. 2006. BOARD OF HEALTH: I.� �S. o�t,A��•, � .��st� ��v:, v�e�� Number of Rooms: 1 st floor,2 bedrooms '. Ro��. B�uws, �Jtl�a \ 2nd floor,4 bedrooms . p�� f4�sst��d�.�, R.l�. ruce G.Murphy, H, S.,CHO Dire�tor of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT , ' PERMIT NUMBER: #Ob-136 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: David J &Janet Vaughn, 57 Maine Avenue,West Yarmouth,MA Whose place of business is: Inn at Lewis Bav Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2006 BOARD OF HEALTH: B �t�t_`n. �o�,Jl�-`?S•, ' a��s�l��esy$�i, ./�., �/uae�s�i/u�sws RuL�t 4 Bnouw�, G'l�uf� ��a�� Februa�2,2006 ruce G. Murphy,M , .,CHO Director of Health � , � ; THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH I PERMIT NUMBER: #06-083 FEE: $SQ.00 This is to Certify that__ David J. & Janet Vau�hn d/b/a Inn at Lewis Bav 57 Maine Avenue, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �B �ist �S. , /f/I.�/S�.,� �G��iirss ��nis/t , �� n, SEATING: 10 e!'f'��l�fP.iL C�K�i�j JI.� _(/K7P �ifZt�/lNf�s�Z Ro��. �Bnou�ss, G� /�c.�iic�/�c$e� �4 �'j , /l./V. February 2,2006 ruce G. Murphy, , ., HO Director of Health � r _ _ �, IN�► �T L�w(S $aY ��`;�R�c TOWN OF YARMOUTH BOARD OF HEA�,T� '�� o _. . ., APPLICATION F4R LICENSE/PER1V��' '2� �! �� JAN 0 � �� , .,s °� �� : * Please complete form and attach all necessary documei�ts�liy�ecemb�r 31,2006. Failure to do so will result in the return of your application packet:� NAME OF ESTABLISF�VIENT: ' TEL. # �S'� ( "?J��J3 LOCATION ADDRESS: � MAIL,ING ADDRESS: � i OWNER NAME: � T' l� T r � CORPORATION NAME{IF APPLICABLE): ; MANAGER�srr�: ��Ac�T \9A�bNN �L. # - - � 33 � MAILING ADDRESS: ��1 YY1�I�E �=ll9C- �/� ��..1�(�'11�1 YY!{�. ��,�j T, � POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operatar,as required by State law. Please list the designated 1 POOI QjJeT�tOT�S}8A(��aCh a rnnv nfthp�rtifiratinn tn thie fn,�.+,. _ �l i 1. 2. _� Pool operators must list a minimum of two employees currently certifled in basic water safety, standard First Aid and � Community Cazdiopulmonary Resuscitation(CPR). Please hst these employees below and attach copies ofemployee � certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. r 3. 4. � f � FOOD PROTECTI4N 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 Cade for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmen� l. ��l i�-�" ��A'�,N1� 2. ' � PERSOAT IN CH�RGE: -- - - _ _ _._ __ _ _ __- _ _ _ _ � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' l. � V 2. HEIlVILICH CER'TIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ' Maneuver on the premises at 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 fde at your place of business. 1. 2. ' 3. 4• f RESTAURANT SEATING: TOTAL# I� i � --� � O�FICE USE ONLY � ; LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE T2EQiJIItED FEE PERMIT# LICENSE REQUII2�D FEE PERNIIT# ' B&B �50 CABIN $50 _MOTEL �50 INN $50 CAMF' $50 _SWA�ffvIIIJG POOL$75ea. I LODGE $50 �FD7�O� _TRAILER PARK $100 WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMiT# LICENSE REQUIItED FEE PERMIT# � 0-100SEATS $75 �D7-(�f6 _coN�n�xT�. $30 NON-PROFIT $25 . >100 SEATS $I50 �COMMON VIC. $50 ��Z7-01� WHOLESALE $75 ' RETAIL SERVICE: —RESID.KTTCHEN $75 LICENSE REQUIIiED FEE PERNIIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# . �<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _.FROZENDESSERT $35 _TOBACCb $50 NAME CHANGE: $10 AMOITNT DUE _ $ I7S•OO •'••'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""'* , :�...--..-.� ADMINIS'TRATION Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af 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 CUMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � ox ! WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO i MOTELS AND OTHER LODGING ESTABLISHIV�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 must have and be able to demonstrate that they maintain a principal place afresidence eisewhere. i � Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an ; a e ate of not more than nine 90 da s within an six 6 month eriod. Use of a � � tY� ) Y Y O p 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. i 1 POOLS , POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ecte� ; by the Health Department prior to opening. Contact the Health Department ta schedule the inspection five(5�days ; pnor to opening. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ' by a State certified lab, prior to opening, and quarterly thereafter. , _ i POOL CLOSING: Every outdoor in ground swimming pool�nust be drained or covered within seven(7)days of I closing. � j ''� FOOD SERVICE CATERING PQLICY: 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 rior to the catered event. h T ese fo Health Department. P rms can be obtained at the FROZEN DESSERTS: Fro2en desserts must be tested on a monthly basis by a Sta.te 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 Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fram the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product_by a retail or foo�i servic�establishment is RroWbit.ed_ r � � i NOTICE:Permits run annually from January 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RETCJRN � THE COMPLETED A.PPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS��biENT, MOT�L 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. i , C DATE: �� I63/o7 SIGNATURE: PRINT NAME&TITLE: i ion�io6 I ^4,� ..+��i .. ` � � The Com�nonwealth of Massachusetts j Departwrent of Industrial Accidenls �� 600 Woshuzgk►�Stree� f'�'Floor , Bosto�,Mass. 02111 � -- ------- wo��c� uod i��n�a.�:s.� • • �co■a�� . : �e � _ _ � ,n�, _, . �fl � � I t �� I.,` � 8�LC33: C � :�J �— WO S1tC 1 � ��iC33: � am a homeown�perfomning all work myself. Projed Type: ❑New Ca�ructia�ORemodel am a sok and have no a�w in an Buii � Addirion � • � ❑ I am an ernployer providing workers'co�o�for my e.mployees wa�cing on this job. ---- -- _ ` — _ � �� — ; � �il��: i ❑ I am a sole proprietor,ge�sl co�tracber,or iiomoow�er(cerde ow�)a�l have himd tbe co�ractors listeti below who have the foilowing workeas'compe�ation Polices: �.� r.._.. � , �r. ul�r�• � a�r�t�+�• .._..,.��„ �3 � ��f= — - ----——— Faihrre 1�aec�e�era�e as reqtired a�der 3ecWa 2SA�t MGL 152 en Ind b tl�e irpaitM�f cr6�iu1 pmMies�f a�e t�b i1,SN.M aadhr ou years'isprba�at as weY as dv�pmltln ia tie for�•ta 31'O!WORK QRDEA aad a Au e[t10S.M z day aaaird se. 1 nde+slard tiat a apy�t fib�ta�my 6e firwarded/s Ne Omce atlav�ot tl�DIA t�r osv�ra�e v�Aatlw. 1 ro lYa+eby c � �e ��ofr�3Wm u�.r r�e a��o��rbo��a��a Qo,� Signa�ure " Date �"' `"� � I Print name Phone#��I—�.TT:J� efficial nse only ds aet�eiite in t6is area te 6e c�pkted by dty ar/r�va�61 cily or te�vn: �� Bsatd ❑chedc if ime�iale raposse b t+�qaired �'s O�ee ��p�t c�d perssa P��+ �� (,�.�oa s.�c ma+� t � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � PERNIIT NUMBER: #07-007 FEE: $50.00 i � i LODGING HOUSE LICENSE j � This is to Certify that a Lodging House License is hereby granted to David J.&Janet Vau�,hn I at Inn at l.ewis Bay 57 Maine Avenue West Y rin�Lth_MA � _ ; - i in said Town of Ymmouth and at that place only and expires December thirly-first,2007 unless sooner suspended or revoked far violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing autharities under section twenty-three,of chapter one ' hundred and forty,of the General Laws,and is subject to the provisions of sections twenty-two to thiity-one inclusive of said chapter. In Testimcmy Whereof,the undersigned have hereto aH'ixed their official signatures,ttus Third day ; of April A.D. 2007. � BOARD OF HEALTH: B �S. J��S•, ' ' ��l��t�.ls, ./Y., ?/u;e�ls��nwt Number of Rooms: 1 st floor,2 bedrooms R��Bho�t, � 2nd floor,4 bedrooms �� fQ�ut�'?�re�t�, Q./Y. Bruce G. Murphy H,RS.,CHO ' Director of Heal TOWN OF YARMOUTH BOARD 4F HEALTH � . PERMIT TO OPERATE A FOOD ESTABLISHMENT , PERNIIT NUMBER: #07-146 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: David J &Janet Vaughn, 57 Maine Avenue, West Yarmouth, MA Whose place of business is: Inn at Lewis Bay Type of business: Food Service To operate a food establishment in: Town of�armouth Pernut e�ires: December 31 2007 BOARD oF HEALTH: B y `.�. ,��•. a��l�$ju�.�i, �ic�C��rs Rad�t�.Bn� G'l� - /k��M�Se��t ,4.��d�.�, R.N. Apri13,2007 Bruce G.Murphy, ,RS.,CHO Director of Health � � < � . THE COMMUNWEALTH OF MASSACHUSETTS ; TOWN OF YARMOUTH i PERMIT NiJMBER: #07-093 FEE: $50.00 This is to Certify that David J. &Janet Vau�hn d/b/a Inn at Lewis Bav 57 Maine Avenue, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at thax place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respeeting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �e arsa $. ��1., ��cst SEATING: 10 ��"s�, .n+., v� e�� Ro�z�`�. 13�ucu�, G� /�c�iic��c�1� �I� � , R.N. April 3,2007 Y ce G.Murp ,MPH ,CHO Director of Health �""r"`�/,,�r- �°�.Y�� ' C7WlOT UF � A. RMO [JTH � - � ° 0 � �'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS U2664-4451 � MATTACHE 9s� 'r 7 elephone (508) 398-2231,Ext. 241 — Fa.x (508) 760-3472 � � ��A�ONAIF��b� � , �U b B o � R L O 1' il L' � L 1 Yl tn j l� (G; +��n '�-_._ To: Yarmouth Board of Health Permit Holders APR � 4 2005 From: David D. Flaherty Jr., RS. ;� � Health Inspector ✓D r HEq�� pEPT Town of Yarmouth Re: Federal Tax ID Number Date: March 22,2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Empioyer ldentification Number(FEIN)otherwise l�nown as your"Taac ID Number". This is pwely for administrative purposes only. Some businesses use the owner's Social Security Number (SSl� for this purpose. If this is the case..for your establishment, be assured that we will not allow this,information to be public record. ` - �Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 1 South Yarmouth, MA 02664 f ; Thank you for your anticipated compliance. If you have any questions regarding this matter, ' glease do not hesitate tq call. The�ffice ho�rs are Mor�day t� Friday, 8:30 a.m. to 4:30 p.m. The � telepho�number is(508)398-2231,e�.241. Establishment: t h�'�. �� G wr s ��-r FEIN or SSN: �(� �� ; �. Location Address: 5 � ��n� V I Signa.ture: �-- I r Print: ��f d .� V�U S � Title: O � v��i' .� ,. I �� I � � .. i �� P;',�'`��, on I �� ed ' r I _,._.�,,,.,,,,,�.� ,,_...R . ' � � � �� /�� Q 4 YA �IJN QtT��W15 D °..r:R�.o TOWN OF YARMOUTH BOARD QF:HEALTH � I �:: ;,;� APPLICATION FOR LICENSE k'�200 p � , �_ � ' D � (� D ;- � r- c� c� � * Please complete form and attach all necess � s by Dece b��, �OQ32�� Failure to do so will result in the return'o �ouf'application ck . � j • n G, , i � � �.00ATION ADDRESS: S� /hc�.�nL v j,�I , '�� r n� �,-� � c� r�3 �� ? �3 � �AILING ADDRFS�• S� r1� ' � �ER/CORPORATION NAME� �I4 n�. �- �,��;,;d �jui, y �,� � MANAGER'S NAME• S G M � TE # MAII,ING ADDRF �Cc M� POOL. CERTIFICATIONS• The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated i Pool Operatoc(s) an�i attach a copy of the eertification to this f�rm. 1. 2 Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I 1. 2. 3. 4. FOOD PROTECTION A AGERS RTIFICATIONS• All food service esta.blishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ' Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. i r 1p 1. ��'i 1�� V Ci��i �1 2. P�I�S�N 1N CHARCTF`� _ _ __ _ __ _ -- Each food esta.blishment must have at least one Person In Charge(PIC)on site during hours of operation. � � r 1. �Gn �� V�iv � n 2. HEIMLICH CERTLFICATION�• 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, RFSTAURA�iT SEATINC'�: TOTAL# �,ODGING: OFFICE U�F ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —B&B $5� _CABIN $50 _MOTEL $50 --�N $50 _CAMP $50 _SWIMMING POOL$75ea. �LODGE $50 �O —QOa' _TRAILER PARK a50 _WHIRLPOOL $75ea. FOOD SERVIC • LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' I 0-100 SEATS $75 �O`��O?� _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 I COMMON VICT. a50 ��—�(�Q _W[-IOLESALE S7g ' RETAIL SERVI • ; LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRED FEE PERMIT# LICBNSE REQUIRED FEE PERMIT# _<50 sq.ft. �45 _>25,000 sq.ft. $200 _VENDINC,-FOOD $20 _<25,000 sq.ft. S75 _FROZEN DESSER't S35 _TOBACCO S25 NAMF CH,AN F• $10 AMOUNT DUE _ $ j"]-rj ,("� **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* � ; I � .F - : ".' � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'ved 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 5IGNED,OR CERT. OF INSURANCE ATTACHED\'J Q$ 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: ` YE``J NO NOTICE:Permits run annually from January 1 to December 3 l. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2003. i F r SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. � i 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 ctosed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: T'he 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. j ; FOOD SERVICE CONSUMF.R ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtamed at the Health Department. �FR+OZE D�SS ___ _ _ _ _ � 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 wilt result in the suspension or revocation of your Frozen Dessert Permit until the ', above terms have been met. ! OUTSIDE CAF�S: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. � OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ', � � �a o--� pATE: SIGNATURE: � PRINT NAME&TITLE: —' �` 10/22/03 � �C��`,`�� ,�� \�`v��,`�''� ��'c, ti'�':N'\��.�:��c �S.zitie�,��\.`�'v, \� ��\;.`.:��`�\ \S+vz@.��`.��:. .. -. � . ,... . . -r� � '`�.\v�ti �\ \ '�� . . y ..�, � z \ \`'��'�.�� ,1e;,.r� � v � ��N � �� . �\ . �� ,, , r r �.a\ -.v�� ti t `�� .' r� `. \ ; `.� .\ . w�w�\`�.�� V�, �' ...' ,,,,,.` • ��y - 4.c £ � ; \ < . < �� t �+.`tti k� � a.�..xa.��..`."?,�'\`S�S?`n 31��:'s,. 1 �, e � +, �� :..a�.,'� v`.�`�..t_ � .�. n�t; .�,r�b:.��.� .�.,�_,. � � �k �� ^►"'t . r�' �� - - -;..�� . i.� r�•�� "= - s ,.r.. � �. r�' � .'�.1 • • �• ti�' s.��.�. �• �� ,� � � • - � . � � ,• -�� a� " �� • " � r� �• ��, r•�. ,'.�. -��-;� � ��c r• 1 . ! •� r ��. r. - � , � 1 r � r�. r 1 •r � .�.•� , - ti r'�.r�C a"u'C�Elc' r`"�. .�.�ti-� ua V`��"�}' '4�+4„ `� . �"��"" :`�p,.+:,X�%" -4 '''sF `�,a+ {".�'�`. `k.� �< .v�: �• r��w.t`t`;�;` w �??��:��.;' X�r,.�; ti�`�-. .�.,a v i. w k�.� , r�.�'r!<:k� ��2�z:, �;�`::t,� �� .�'L�„ti.:� \�� '` '��`�'.ti\;� '��'*..��\ ��t' . 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Kti,y{.l�.cy . � ��"�' \ tY" a., k '�• .. • ,ti .... :• �.�r' =� .� ��,x n� ❑� -�•,:- � � � � ��._ .e � _ _ t�� • :� � � � � � �. ` � _ � � ro- ' . �,a� � .� .' � r � .t- •�,.� �_ '�. _ . , � � � �� I J II ^ � �'~�� j �'' - `yy��. �. / � THE COMMONWEALTH 4F MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-002 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a I,odging Hause License is hereby granted to David&Janet Vaughn at inn at Lewis BaX 57 Maine Avenue_West Yatmo�h_MA in said Town of Yarmouth and at that place only and expires December thirt.y-first,2Q04 untess sooner suspended or revoked for violation of the laws of the Cornmonwealth relating to the licensing of Lodging Houses. This license is issued in confomuty with the authority granted to the Iicensing authorities under section twenty-three,of chapter one hundred and forly,of the General Laws,and is subject to the pmvisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony VVhereof,the undersigned have hereto aff�ed their official signatures,this Twenty-second day of January A.D. 2004. BOARD OF HEALTH: B a��i��e�� Number of Rooms: I st floor,2 bedrooms Qpde3t� QnpuNg ��7t�{a 2nd floor,4 bedrooms �s`e�t c��,(y� R,/�, � Bruce G.Murphy, .5.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-077 FEE: $75.00 In accordance with re�ations promulgated under autharity of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the eral Laws,a peimit is hereby granted to: David &Janet Vaup,hn, 57 Maine Avenue, West Yazmouth, MA Whose place of business is: Inn at Lewis Bay Type of business: Food Service To operate a food establishment in: Tawn of Yarmouth Permit expires:_December 3 l. 2004 BOARD OF HEALTH: Be�,r�c�xi�t�1. fj'onc�oK, /�0.`2S. • l�r.�ic�a�1ea5��t�xol� ?/ice C'��+c RoLe�r�t� B�v,r, �� R./V. January 22.2004 Bruce G. Murphy, .5.,CHO Director of Health � i ; THE COMMONWEALTH OF MASSACHUSETTS � i TOWN OF YARMOUTH PERMIT NUMBER: #04-060 FEE: $50.00 i � This is to Certify that_ David&Janet Vau�hn dJb/a Inn at Lewis Bav � 57 Maine Avenue �est Yarmouth MA IS HEREBY GRANTED A j COMMON VICTUALLER'S LICENSE In said Town of Yannauth and at that place only and e�ires December thirty-first 20(?4 unless sooner suspended or revoked for violation of the laws of the Cammonwealth respecting the licensing of cammon victualler's. This license is issued in conformity with the authority granted to the Iicensing authorities by General Laws, Chapter 140, arid amendments thereto. In Testimony Whereof, the undersigned have hereunto a�ed their official signatures. BOARD OF HEALTH: $e�c��rrurss �S. �jr'rv��t /Gl�. G'�r�st SEATING: 10 ��,��,� s�� e��, Q�PRL �. /Li�tfN�/XL� Ci�PJta � st� R�v. January 22.2004 � Bruce G. Murp ,MP .,CHO Director of Health � � ��z78 t8o . . �.� 3�av �Ys� : �n+N aT c�wts g�y ° o�'r R,y TOWN OF YARMOUTH RD OF °' G3 L� c- 3� � ``� APPLICATION FOR LICEN �� _ � � `',��r �� D r; .? �r� ';� a�, •.. ...., �`�.� {�� * Please complete form and attach all necess oc � s by Decembe 31�Z00� � �� Failure to do so will result in the return�your application pack . �i��L-r-a.� ��,F=�,�. �T�,�,ViE OF_ESTABLISHMENT: 1 n n ct t �S �s Ti a�, TEL. # '7�I - 3`�3� LOCATION ADDRFSS• 5? /�'l a ►n� ��. We 1 f h'�rrn c:v t G, C� �G 7 3 MAI�T_Nr ADT�RESS: SG,w�� OWNER/CORPORATION N�ME: �� } ��n e-t- �j�v� �n MANAGER'S N�ME: S Q rv�� TEL. # S G r►� e. MATT.iN('7 ADDRESS: S�.m� POOL CERTIFICATIONS: �� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated -Pe��p�atvr(s)and a#�ac�a�p�o€�hhe certification to this form. ' 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscita.tion(CPR). Please list these empioyees below and attach copies of employee certifications to this form. The Health Department will aot use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fu11-time em�loyee 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. Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. U I I I IF TI • 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' reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SE�: TOTAL#�� 5 LoncIN�: f�FFICE USE ONLY : LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOT'EL $50 INN $50 _CAMP $50 _SWIMMING POOL$SOea. I LODGE $SO O�G�3 ^TRAILER PARK $50 _WHIRLPOOL �25ea. �QOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# • LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 �'�3�5a �CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 �COMMON VICT. $50 #�8'�i�d36 _WHOLESALE $75 �FTAIL S�RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# „_TOBACCO $20 <25,000 sq.ft. $75 _TOBACCO $20 <50 sq.ft. $45 _>25,000 sq.fi. �200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOITNT DUE _ $ �� *****PLEASE TURN OVER AND COMPLEI'E OTHER SIDE OF FORM***** � 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 OR _ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and Iiens must be paid prior to renewal or issuance of your permits: PLEASE CHECK APPROPRIATELY IF PAID: _ Y NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002. � SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�HEALTH DEPARTMENT FOR INSPECTION 7-10 � DAYS PRIOR TO OPENING FbR THE SEASON. ' f � 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. i ADDITIONAL REGULATIONS ; POOLS POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected -'i 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. � 4 POOL CLOSING: Every outdoor in grou.nd swimming pool must be drained or covered within seven(7)days of ; closing. j 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 Department by filing the required Temporary Food Service Application form 72 haurs prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: ' Frozeri desserts must be fested on a morithly basis by a State certified Iab. Test resul�s mus�Ge sent�o the Hea�h � Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ' OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: I I�o��'�� SIGNATURE: PRINT NAME& TITLE: ' 10/18/02 , .�S . . "�\ � . . . . The Commonwealth of MassQchusetts � � Department ojlndustrial.-�ccidents � o Otllceo/I�reslJos�liis 600 Washington Street ' ` Baston. Mass. 02111 . � " °�y V4'orkers' Compensation Insurance Atfidavit ' Annlicant information: PleasePRiNTTe�.'Wi� namr � n� �� I�UJ�S�� ' locati�n: �� ( �1.`�F C"'1l� . , s �, 3 # - 33 �� I am a homecw�ner en�rming all work m}self. � am a sole proprizror�-.a. ha�e no one uorkin� in am•capacit�� 1rn�`�{ ��_� �.1 � I am an employer pro��in;_workers� compensation for my employees w�orking on this job. ; comnam• name• �ddress• ,: ciri•• nhone il• insur:►nce co. poli�,y# , � I am a sole proprietor. :eneral contractor, or homeowner(ciicle oneJ and ha��e hired the contractors listed beloK ��ho ha�e the follo��in_ ��orker� �ompensation polices: com a�nv name• address• citv: RhStne M: insurancc co. Folic}•# com a�ny name: _ __ __ _—_ _--- -- - _ _ _ ____ - ----- —__ — ---- address• ---_--. e�: ohoee 1t• insurance co. pOBey it t Failure to seeure cover�;t as required uoder Secnon 2SA of MGL 1S2 ea�Ind to tAe iopaiooa ot erisi�al pesdtla of a O�e op to 51,500.00 a�d/or one yean'imprisonme�t a�w•ell a�civii pendde�io the form of a STOP WORK ORDER aed�Aae of 5100.00 a dar tpio�t ma [a�dersta�d t6at a copy of tAh statement may be fonvarded to the ORce of Iavestigatiom of the DU for eoven;e veritiad�. /do hrreby cenij der th�pa'ns an pt allies oj ery'ury thw�l�t injornmtion providtd abovt is tnre and eoned Signature "�'1�� Print name one M `_�\9J�� l�� .- o(licial use onh do not write in this area to be completed by city or towa oAlcial ciry or towe: Y�M�DT� _ permitAieea�e M nBuiidiog Departmeot �Lieeasio6 Board �eheck it immediate response i�required 261 QSeleetmen's OfTiee �Health Department contact person: pAont M;_ �508� 398�?231 eat. nOther .n...Y � :t 'J1�.� . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-003 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David&Janet V aughn at Inn at Lewis Bay. 57 Maine Avenue.West Yarmouth,MA in said Town of Yarmouth and at that place only and expires December thirty-first,2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and fiorty,of the General Laws,$nd is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereo�the undersigned have hereto affixed the'v official signatures,this Seventeenth day of December A.D. 2002. -- ----_._ ___ ___ .__ ____BO�D UF HEt�'�i:—-ei(canlee--�s�.--i�elll�i,__�rafir��ca�c.____ -- _ - --- �e�c D. �jio�cdo�. 711.?�,, �1/ice ` Number ofRooms: lst floor,2 bedrooms ` �a��. �a'�oar�c. � . 2nd floor,4 bedrooms �a�ttck�e�cotS _ :, .. � . �� ruce G.Murphy R.S.,CHO Director of Hea1 TOWN O�YARMOUTH i -; � , . '�.: BO� OF HEALTH ;;�; ;:� , . : : , .; PERMIT TO OPERATE A FOOD ESTABL�S�NIENT PERMIT NUMBER: #03-058 ��. FEE: $75.00 In accordance�1ith regulations promulgated under authority of Chapter 9�-�ectiot�305A and Chapter 111,Section 5.of the General Laws,a permit is hereby granted to: David &Janet Vaughn, 57 Maine Avenue, West Yarm�uth, MA ;. Whose place of bus�ness is: �mn at L��is Ba .; . , . y ��.� ,� . � �ee� ��g � � � � � To operate a food establi�rnent in: Town of Yarmouth -;:'.;- Permit expires: December 31. 2003, BOARv oF�.�LTH: �aalea;{� xe!l��,c, ��awc �5'i�c�D. G%�daMc, �1lG.D.. �!/ttc� _ �o�e�rt�. �no�C, � �aaizek??ldD� �ele�e S ,�.�1. December 17 ,2002 ruce G.Murphy, R.S.,CHO Director of Health 1 � � � . ! THE COMMONWEALTH OF MASSACHUSETTS � i TOWN OF YARMOUTH PERMIT NUMBER: #03-035 FEE: $50.00 This is to Certify tha.t David&Janet Vau�hn d1b/a Inn at Lewis Bay 57 Maine Avenue, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2003 unless sooner sus�nded or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. 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"`�� I am a sole proprieror�r..'. ha�e no one ��orkins in am•.capacity � I am an empioyer pro��din� w�orkers' compensation for my empioyees w•orkine on this job. _ _ _ _ _ . _ _ _ _ _ � S�mCanLname• - { I ��ldress � �k• phone t1• ; insur�nce co policv# - ; , F � I am a sole proprietor. generai contractor, or homeowner(circle onel and ha��e hired the contractors listed belo� �tho ha�e + the follu��in_ ��orker� �ompensation polices: ; i vn i ni�ress• cin Qhone M• insur�ncc co polic�•# , � m n n m r. ` ,dd ress• siiy ohone M• — �n��rance co �1'* • Failu�e to secure covera�e as requ�red under Secttoo 2SA of MGL 1S2 n�Iqd to tbt ioposidoe o(uisi�al peadtln o(�d�e ap to Sl¢00.00 a�d/or one years'imprisonment a�w•ell a�eivil penaltia io the form o(a STOP WORK ORDER aed a tfse of 5100.00 a day Kaiost me. t a�denta�d tbat a copy of thH statement be fonvarded to the Otliee of Invesdgftiom o(t6e DU for eoven`e vet�ifieatio�. I do hrreby cerrij}� der tbe poins und prnalties ojperjury thm th�rnjorn�ation provid�d abovt it true and eoned Signaturc �o�l�-1 I0� � — ScS� 711 3`�� Print name c� � one N � � ., oRcial use onh do not r►�ite in this area to be completed by city or towe otflc'til citv or town• Y�MODTQ _ permitAicenx N nBuildiog Department . — �Lieeasiog Board �theck if immediate responst i�required 261 ❑Selectmen'�OlTice �Healt6 Departmeot ; contacc person: phone 1t;_ �508� 398�?231 est. nOther 3 � : ; , � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-009 FEE: $50.00 � LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to David J.Vaughn at Inn at Lewis Bay 57 Maine Avenue West Yarmouth-MA in said Town of Yarmouth and at that place only and expires December thirty-first,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confomuty with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Sixteenth day of A,g�t A.D. 2002. BOARD OF HEALTH: ��led�s�, i�d�Z, ��c�iq�c �D. G�iazalac. D., `l/ice Number of Rooms: 1 st floor,2 bedrooms �o�it� b'noto�at, (,(e�rk 2nd floor,4 bedrooms �u�tlek'�e��rot� � � �� ruce G.Murphy, R.S.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #OZ-141 FEE: $30.00 In accordance with regulations promulga.ted under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: David J_Vaug]�, 57 Maine Avenue, West Yarmouth,MA Whose place of business is: Inn at Lewis Bav Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31,2002 BOARD OF HEALTH: ��s� x�i, (,�kaur.rra�c �e�cfa.ici.�c D. G��azaloa, ?1t.D., �/iee ,�o�� toaavc. L� �a�ttek'I1�e�er�rott s��leu S�Eak, ,�'�l. May 16 ,2002 B ce G.Murphy,MP . .,CHO Director of Health . .� � I��;�.f, t.,.. ��' , _',:' TOWN OF YARMOUTH BOARD OF A APPLICATION FOR LICENSE ��; � � � � i�`' �� -��=A�..�,: ��;:•ti��- * Please complete form and attach all necessary docwnents by De � 31,2000. Faili[�r�'ttSZib'�o wi resu in the retum of your application packet. NAME OF ESTA i.iSNMF1vT�� n n G-� �.e1�.�s�rj3��--~---��-----�-T��2 7 I - J�3 3 ,.�..� I�OCATION ADD FI��S ,__S� 1"l�� qv 1,�_ Y�r-��t►� L�II.ING ADD F.�S� S? M��n c A.� 1� � �'G,�rn u�-t h � A inN NAAiiF• �v.�d --� L 4v 5.jnv, _ , ' v.d hh S? � � �t'�rmc,�-f t, POOL CERTIFICATIONS.---------------------------------w�_�.._.��__—_____------------------- --..�_.�..�_. T6e pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Opera.tor(s)and attach a copy of the certification to this form. 1. 2 Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR), Please list these employees below and attach copies of employee certifications to this form. The Health Dep�rtmeat wil! not use past years' records. You must provide new copies and maintain a fite at your place o#'bustnesa. 1. �� 2. 3. � 4. HFIML.IC_H CERTIFI ATIONS• � . All food service establishments with 25 seats or more must have � least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees 'ned in anti-choking procedures below and attach copies of employee certifica6ons to this form. T6e Health Dep ent will not use past years' reeords. ' You must provide new copies and maiataia a file at your plaee of b�iness. � 1. 2. 3. 4. � RESTAURANT SEATING: TOTAL# NON-SM4KING SEATS: T TAL# -------------------------------------------------------------------------------------------------------�- -------------------___��--- o�ic�usF o_ NL.Y `�, � � � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E FERMIT# _B&B $50 _CABIN $50 ^�1N $SO �CAMI' $50 �LODGE $50 � -Ol �TRA.ILER PARK $SO _MOTEL $50 lSWIMMING POOL $SOea. FOOD SERVICF.. �"' WHIRLPOOL �25ea. NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,tN�e effective date for food protection manager certiftcation is October 1,2001. , LICENSE REQUIRED FEE P�RMIT# LICENSE.REQUIRED FEE�,�PERMIT# ____0-100 SEATS $75 �CONTINENTAL, $30 � ►1--�89 � _>100 SEATS $1 SO NON-PROFIT $25 ----�-_ _COMMON VICT. $50 �WHOLESALE $75 BET�i.�. �.�F.RVIGE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# 1<50 sq.ft. $45 TOBACCO $20 _�Z5,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 � LYAME C AN �• $10 AMOUNT DUE _ $ SD.C� **"�*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**«"* �►,. r � � � ' � .�, ADMINISTRA,TION " Undier Chapter l 52,Sectio�►25C, Subsect�on 6�`t�Town of Yarmauth is now required to hold issuance or renewal � of an� 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 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:Pernuts nm annually&om January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT T�IE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG 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. ADDITION,�i�,FCULATIONS PpOLS 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 Sta.te 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 �1EW STAT� SANITARY COD�,FOR FQ� .STARi I$,�IENTS• The effective date for food protection manager certification is October 1, 2001. As stated in lOS CMR 590.003(A)(2), food establishments must have at least one person-in•charge who is a certified food protection manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000. The e�ective 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 imp lemented January l;2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories. CAT . iN PQL,ICY• Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Degartment 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. FRO� .�N D�� :�T� Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE C FFiC� � Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. � QUTDOO�,�,QOKING• Outdoor cooking,preparation,or display of any food product a retail or food service establishment is prohibited. ; � DATE:_ ��l v�o+ SIGNATURE: � PRINT NAME& TITIrE: ��,;� 3- c�,u 5�,� i,�,� e� f 11/16/00 � � . �� The Com�nonwealth of Massachusetts � � Department ojladustrial.-�cciden�s ; olAceoller�sl/os�Iiis ; 600 Washington S�reet ,,•� Boston.Mass 02111 �� W'orkers' Compensation lnsuraace Aftidavit i Annlicant information: P►esscPR�'i�r ! o�mr� �G.V�C�. � - VrttJ4 �1h # v ; location: �J' � (�4 ��e Q� � �ii� � ��c�M U lr'�Iti �C�, pj�one fl �� i �� ['3 3 � I am a homeow�ner pertorming atl worlc myself. ; �m a sole propri�tor=:;� ha�e no one��orkin_ in am•capacit}� � 1 am an emplo��er pro�iding workers' compensation for m��emplocees uorking on this job. j �omoam• name• � �ddress- � ciri•: � ohone ii• ' i�surance co. oiicy q � I am a sole proprietor. general contractor, or homeowner(circle one/ and ha�•e hired the contracton listed below� ��ho ha�e the follu�cin_ ��orker_� .ompensation poli�es: _— --. _ _ '� sQmpaav n�me- address• I • citv: � - �hone It: iosur�nce co. �olic�# I como�nv name• �'' � , ; iddress• ' � titv: Rhoee 1{• i ins�trance co. peiien It Failure to secure covera�e as required under Sectioa 2SA o(MGL 1S2 n�lad to tre i�paitio�oteri�i�i pe�dtles at a Qae op to 51.500.00 a�d/or j oae years'ia�prisonmeat aa w•dl as ciril pea�idt�io tAe form o!a STOP WORK ORDER aed a!he etS10s.A0 a dsy Kaiast me. I a�de��d t6at a copy of thH statemeat mav be fonvarded to tAe OAice of lavatigatioo�of tse OIA for eoven�t veri8pdo�. ' . � /do•hrreby ctni re der the pains and penaltia ojpery'ury tbot t/ts inJorinotfo�provided abovt�t ttue aitd corrrct ��al - � � Signaturc 0 � Print name �V�� 1C.0 S�h Pfione�! � ��'� f .. oRcial use ool.• do not w ryte in this are�to be compleud by eiry or towa oAkLl � ciry or tow�n: y�DT� _ • per�eitAieeax M nBuildiag Depirtmeo� � �Lieeasiae Board ' �chtek if immediste response ie required 261 QSeleetmen'a Otiiee (508� 398�?231 �t, �He�ItA Depanmeat con�ac:person: pAoee N:_ __ _ nOther Irn�SeC�ot P1A1 . . t � � .. �. � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #01-189 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: navid J_Vailg�, 57 Maine Avenue, West Yarmouth, MA Whose place of business is: Inn at Lewis Bay Type of business: Continental Breakfast � To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2001 BOARD OF HEALTH: �d� �e�, ��u� L��ed`�f, i�e1�. �/ice L��A,i�torca�c ��art� ��, C� �a��D� e.�ya� Qnda�. .`I�. August 10 ,2001 ruce G. Murphy,MP .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O1-014 FEE: $50.00 LODGING HOUSE LICENSE 'I'his is to Certify that a Lodging House License is hereby granted to David J Vau_ghn at Inn at Lewis Ba� 57 Maine Avenue West Yarmouth MA — in said Town of Yarmouth and at that place only and expires December thirty-first,2001 unless sooner suspended or revoked for violarion of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their officiai signatures,this Tenth day of August A.D. 200 L soaxD oF HEAI.TH: �d 7� �eued. 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' � � � The Commonwealth ojMassachusetls � F W Department ojlndustrial,-lccidents ', = a Ofllcso/I�s�ost/iis ; � � 600 Washington Street < �, �,,� Boston,Mass. 02111 " '"' W'orkers' Compensation Insurance Affidavit Anniicant information• ��u��T-� - q- 1 n�m� �1�11� Cf� LY�.t%�s {,�Q� / c��►�e � c �1�2Q��'l ��°�'rvY f iocation �7 �C�1'rlf� ��'��U� � Y o -}�1-� /�%� � ; 3 # _7� ' � 1 am a homeowne pertorming aU work myself. � I am a sole proprietor�r� have no one��orkine in any capaciry �( I am an employer prm i�ing w�orkers'_com�ensation for m��emplo��ees working on thisiob. �m�an� name �I'lYl Cl� �i.l�'15 ��1 �ddress �7 ,��.A 111e �`-1 V� it v"��-'5# VQYi'Y1�E3U 1 ' 1 ohoneq• .��-7 7 �^ ��-� � �nsur�nceco �1CQ �I��u�1 �"'ns�ranc� �� policy# �� f�� ' � i am a sole proprietor. �eneral contractor, or homeowner(circle onel and have hired the contractors listed below �`ho ha�e ' the follo«in� ��orker�� ompensation polices: : m nv n e• a dress �� ohone�• insur�ncc co nolicv# m n na ohone if• s Failure to secure coverage as required under Secdoo 25A of MGL 1S2 aa lad to t6e iopaitioo oterisi�al pa�dtla of a ti�e op to 51�00.00 a�d/or one yean'imprisonmeet as w�ell as civil penalties io tde form of a STOP WORK ORDER asd a tint of 5100.00 a d�y apiost sa 1 a�denta�d Mat a copy of thu st�tement may be forwarded to the ORee of Investigation�ottht DIA t�eovengt vehtiadw. /do•hrreby cerrij��under rhe pains ond enalties of perjury that the rnfornwtion provided abovt is tn+t and eoned Signature "C�^ ' su 1� /� a� Print name ��1 Z�t C�� Phone Il 5�g'��1�� _ ., o(Ticial use onl� do not M rite in this area to be completed by city or town oliicial yAgMpiIT� permitAicease t� nBuildiog Department city or town• _ - �Liceasiog Board 261 OSelectmen'e OlTiee �check if immediate response is required �Hcalth Departmeot phone p;_ �508) 398--�?231 ext. nOther contact person: — (rcvised i;95 P1A1 �Isag�o io�oanQ OH� �. .�< <�ft�dmy�•�aoni � I OOZ` � .�� , ��.,!� !T, �""ov ��ma�`� f�c� a�ro�,�n�� a?�'/� �u�� ! �''�� '�� p3 �H.L'I��H 30 Q2i�'Og 0 i Q a Q :sa.�idxa�iu.uad � �� um ,j, :ui�uaun�sijq�sa poo��a�r,�ado oZ � g � a i� :ssauisnq�o ad�Z , � :st ssauisnq�o a��jd aso� :o�pa�ura�,Cqaiaq st�tuuad E`sn�EZ t�aua�ac�3o S uot��aS`I I i �a�deq� P��'SO£uot�oas`y6 ia;d�q�3o�uo�ns iapun pa�E�inmold suoi;�ln�al i�in�aou�pio��ui 00'0 �� 660-t0# �2I��Nifll�I.LIJ�i?I�d ,LI�I�LIIHSI'I�'.LS�Q003�'�.L�'2I�d0 O.L,LII�1Ri�d H.L'I�'�H 30 Q?I�'Og H.LIlOL1i2I�'A 30 I�tAAOs THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #01-009 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to George&Elizabeth Latshaw at Inn at Lewis Bav. 57 Maine Avenue.West Yarmouth.MA in said Town of Yarmouth and at that place only and expires December thirty-first,2001 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Second day of March A.D. 2001. BOARD OF HEALTH: �d� �ett`ed, C�rctuc ��an��f. �a�, `�/ice ��ra;ur�ao� Number of Rooms: 1 st floor,2 bedrooms �o�i�� , � 2nd floor,4 bedrooms %��i� d �.� ��. ' ruce G. Mur y, H .5.,CHO Director of Health� � p � �� " TOWN OF YARMOUTH BO �$EAI,T'$ GR� I� � � O �I � �U APPLICATION FOR LICEN �=;200, (�a�{{_��q' ,�A� O 3 2000 * A ,y� �,nJ`�� $V �/' T � Please complete form and attach all nEcessary documents by December 31, 1949. Failur the return of your application packet. . L I F E ----------------�----T-------�----------;5---- -----------------------------------#------_--i�-------_. i qrrnou p MAILING nnuF�� samc N � _ e _,._, , Q # 0 -7 1- D i �fe + Z POOLCERTTF'ICA I�NS��-------------------------------------------------------------------------------------------__------------ � The poot supervisor must be certified as a Pool Operator, as rer�uired by new State law, Please list the j designated Pool Operator{s�a:tid attae�t a copy o€the certificat'ran t�-tlus fo�n:- - - 1• 2. Pool operators must list a minimum af two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and atta.ch 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. NF ICH�FRTiFTC'ATTniv • All food service establishments with 25 seats or more must have at least one employ+ee 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. T6e Health 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. ' __ RESTAU1tANT SEATING. '�DTAL# _ -�11�-�4I�:I�C�i'�:--��'A�#-____ � _ ___ _ __ ---------------------------------------_------------------------------------_-�--_----------------------------------_----_-----------__---___. OFFICE USE NLY LODGIlVG• LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 I LODGE $50 �-� �TRAILER PARK $50 MOTEL $50 _SWIMIVIIIVG POOL $SOea. FOOD SERVI .F.� WHIRLP(�OL $25ea.. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 �CONTINENTAL $30 YL�.-t�l�. _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 � _VVHOLESALE $75 3ETAII. SFR E• ' 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. $Zpp ; NAME CgANGF• $10 AMOUNT DUE = $�—" "`""PLEASE TURI�i OVER AND COMPLETE OTHER SIDE OF FORM •fIIRRR i V' � { � _ ..M-- � ADMINISTRATION b� , :UNDER CHAPTER 1$2, SECTION 25C, 5UBSECTION 6, TI-�TOWN OF YARMOUTH IS NOW REQUIRED ;TO HOLD ISSUANCE OR RENEVVAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A `.PER.SQl'�i:QR�:GCIMPANY DOES NOT HA�JE A CERTIFICATE OF WORKER'S COMFENSATION r INSURt�NCE. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � l WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/ TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF ., � Y4UR PERMITS. PLEASE CHECK PROPRIATELY IF PAID: YES� NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN T'HE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 R DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-iIVIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUII'MENT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS Mt�Y REQUIRE A SITE PLAN. ' A�DITIONAI,REGULATIONS POOLS POOL OPENIlVG: ALL SVVIlVIlVIlNG, WADING AND WHIlZLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-iE HEALTH DEPARTMENT,AND THE WATER TESTED FOR PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlvIlV1IlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. E � i FOUD SERVICE � (`ATERING POLICY� � ANYOl�TE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII.ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI-� CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DESSERTS• FROZEN DESSERTS MUST BE TESTED ON A MONTHI..Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPART141ENT. FAILURE TO DO SO WII..L RESULT IN THE SUSPENSION ORREVOCATION OF YOUR FROZEN DE5SERT PERMIT UNTIL THE AB�VE TERMS HAVE BEENIVIET. __ —__ ___— -- -- _____-- _ _ . _ _ _ _ Q�JTSIDE CAFES: OIJTSIDE CAFES(i.e.,OUTDOOR SEA'TIl�iG WITH WAITE1t/WAITRESS SERVICE),MUST HAVE PRI4R APPROVAL FROM TI-�BOARD OF HEALTH. OLTT�OOR COOKI�iG: OUTDOOR COOKING,PREPARATIDN, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS��VIENT IS PROHIBITED. DATE: 1 Z D � SIGNATURE: PRINT NAME&TITLE: �I I�.Q{�� l.at�ha� ��.�ne� 11/12/99 �\ " F ' The Conrmonwealth ojMossachusetts � � � Department ojlndustrial,-1 ccidents � . T " O/flceol/�rest/os�liis � ' �� + 600 Washington Street � ' ` Boston, Mass. 02111 �1N ��' ! W'orkers' Compensation Insurance Atfidavit Annlicant information• pq�tepgp��,� n m•� E f � �/�/ � �` I�cation: �7 /V141�i�P �ti _Y117� • , 2 f ar � -7 1- 3 � ( am a homeow� er pert�rmin�all w�ork m}�self. � � I an� a sole propri�ror�r.,a, ha�e no one��orkine in am•capacit�• � I am an emplo�er pro�idino workers' compensation for m�_emplo��ees workine on this�ob. _______ s4mn�n�• namr TYIYI � Le.wl, ,_�/ ^ � address: �J7 MQ1Y1'c� /�V�feYl��'� s�t.�_ �n(PSi- �lnrrn� `�h 5�R- 77l -�43� � ehone 1! i�surance co. ��iCQ NQT1� Qr�.I �,�V 1"Q Y1C`2. �,Qji�y te 2��l��(� � I am a sole proprietor. generai contractor. or homeowner(circle onel and ha�•e hired the contracton listed below ��ho ha�e the follu�.in: �.orker_ :ompensation polices: �om�anv name• a�dresr titv• Rhons q• insur�ncc co. ��.� �m�anv namr address — ---- � — sid�: nhone_i�. insurance co. �,� a Failure to secure coverage as«quired under Secnoo 25A of MGL lS2 a�iad to tme iepo�idoa o(crisi�fl pesaitla of a d�e ap to 51,500.00 a�d/or oae years'imprisonment as w•el)as eivil penalda io tbe form of a STOP WORK ORDER aad a lise otS100.00 a day tpio�t me. i a�dersa.d cha�a copy of th'n statement may be fonv�rded to the 011ice of Inveati��tioo�otthe DIA tor eoven;e veriAutio�. !do hrreby cerrif}�under rhe pains and penal�ies ojperjury that t/rt injo►mation providtd above Es lrtte and eorred Signature ^ . p�,(,(� D� 12/2��q� Printname Elizabe`l'h �'�" �V�/ PhoneM �"'17�-�q_�� .- otTicial use onl� do not..rite in this�rea to be compieted by eiry or towa olfleial ciry or town: YA��IIT$ _ permitAlcee�e N nBuilding Department pLiceasiog Board ❑eheck i�immediatt response i�required 261 �Sdectmen'e ORee �Healtb Department contact person: phone M;_ �508� 398�2231 eat. nptfier .. ..� < �,,: - THE COMMONWEALTH OF MASSACHUSETTS , TOWN OF YARMOUTH PERMIT NUMBER: Y2K-12 FEE: $50.00 LODGING HOUSE LICENSE T'his is to Certify that a Lodging House License is hereby granted to Geor�e&Elizabeth Latshaw at _ The Inn at Lewis Bav 57 Maine Avenue West Yazmo�+h MA in said Town of Yarmouth and at that place only and expires December thirty-first,2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-two to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Twentv-fifth day of Januarv A.D. 2000. BOARD OF HEALTH: �i`� �alfs�, C�uiirmaa �oan� �u[livan, K.�/•, Vice C�hairman Number of Rooms: lst floor,2 bedrooms Ko�ert� �rown 2nd floor,4 bedrooms a��ie�le sa�o��y-�ooPe� ��O�o�,.��,� Bruce G.Murphy,MP ,R .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-145 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: (�eorge& Fli�aheth T a tha��v, 57 ll� in Av n � , Yarmo � hY�� 1��A Whose place of business is: The Inn at Lewis Bav Type of business:_ Continental Bre� t To opera.te a food establishment in:_ Town of Yarmou h Permit expires: December 31 2000 BOARD OF HEALTH:�'d�f. .�et�, C'�"�n �oaa� �u�[ivaa, ��, Vice l,hairma /`Co�art� 9�rown, �[erk �//dris[le Ja�OG��y-..J�oo � � � u��[irc Januarv�,2000 ruce G.Murphy,MP R.S. O Director of Hea1th �