HomeMy WebLinkAboutApplications, WC and Licenses�� � � �
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; The Commonwealth of Massachusetts ��►1od1N ���}t�- D�'7-.
Deparhnent of Industrial Accidents �(c f� �6 J.���
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+ 600 R'ashington Street, 7` Floor ����a�� 0
Boston,Mass. �21I1
Workers'Compe�sation I�nraace Af6davit:Bailding/PlambiHg/Electrical etra�.t 1
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°a1he= � HEALTH
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work site location ffull addressl-
❑ I am a homeowner perfornnng all work myseIf. Project Type: ❑New Construction�Remodei
❑ I am a sole proprietor and have no one working in aaY capacity• 0 Building Addition
�I am.a�_�mPl��t�Pcc��� � u��rk�s'cc►mpensatieaa for�Y�asP�aye��re�icing�n-thi�jals�- _
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❑ I am a sole proprietor,geeerat eoatractor,or�omeowner(circte on�)and have}ured die contrectors listed below who have
the following workets'compensation polices:
CO�fl1iP�i�!• ' ' � : . � .. . . .. . � . . .
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cit9• nha�ae S-
ias�raace co. #
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__-- Failmro 6s secore ewer�_as reg�ir�ed a'da 3eetloa LSA ef MGL 152 aa lad q�4e��f ari�ial omaNks�f a�e
, eae Yeara'tmPtireem�t»wr�as dvY penaKia ia the form ot a STOP WORK ORDER aad a 8ne of 5100.YS a day�t de. 1 nndenlud that a
eepy ef His�fa�meat my 6e for+rarded Eo the O�ce otlava�tlo��f the DIA tor covenge veripeatl�s.
l� L do Nt�by certrfy rtader Nie pains aied penallies ofPt+�rrry tliat tAre iwfonwaHon provlded abov�e is brre aad oemct
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o�dal ase�nly do not wrke f�this atea t�6e oomPkted 6Y ehY or fewn�ciai
city or tawn: ptrmitJ�ice�e�
�BnidinE Department
❑chtck if immtdia�e tx.�peme b reqnired : Oi��ng Board
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� "�>=Yak.y� TOWN OF YARMOUTH BOARD OF HEALTH �1 I� <G is ;] �v% , � �'�� � �'�
f.� �,` ,�_a APPLICATION FOR LICENS �VII�,}2081� ' ��✓9 � � L;v� �
- * Please complete form and attach all neces �\ ocu , ece�� er 1 007 � `
Failure to do so will result in the return your��1�ation packe �'��',.�.��-� �:�k=f : ' C
�
NAME OF ESTABLISHMENT: `��(��\� '��--,��,�y TEL. #�,�='n��\�
LOCATION ADDRESS:Q�_ ��Z \�����10��.�,'TC��c���h�
MAILING ADDRESS:
OWN�R NAM�: �� '� ' TAX IN r N • - 'ck.o0\
CORPORATION NAME IF PLICABLE): �'"'�L\� ����-a�
MANAGER'S NAME: ���<,\ �,��� TEL. #��-�1�,3�1�
MAILING ADDRESS:�=� � `C`C�c�',���-����%,�m'Fi �,`c�.�Nc`�`�
. .
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PO CERTIFICATIQNS:
The po upervisor must be certified as a Pool Operator,as required by State law. Please list the designated �
Pool Opera s) and attach a copy of the certification to this form.
-- 1.
Poal operators must list a minim oyees currently certified in basic water safety, standard First Aid and {
Community Cardiopulmon citation Please list these employees below and attach copies of employee ;
certifications to this f . e Healt6 Departtnent wx se past years' reeords. '�'ou must pravide new j
copies and m ' in a file at your place of business. f
I
1. 2. �
4.
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__ . _._ _ ___ ____ _ __ _ _ __ _ �
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 Mana ger, as defined in the State Sanita r y Code for Food Service Establishments, 105 CMR 590.000. �
Please attach copies of certifica�ion to this application. The Health Department witl nat nse past years'rP�ords. '
You must provide new copies and maintain a file at your estabGshment.
I. 2. '
_P��ZS�7N IN�I�A�R�'iE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Departmeat will not use past years' records. ';
You must pro+vide new copies and maintain a file at your place of business. ;
�
1. 2.
3. 4•
RESTAURANT SEATING: TOTAL #
.. • I
OFFICE USE OnLY
LODGING:
LICENSE REQUIRED FEE PER'MT# LICENSE REQL?1RED FEE PER4IIT* LICENSE REQLTIRED FEE PER'�iIT=
B&B 550 _CABIN S50 _1�IOTEL S50
INN $50 CA.'VIP S�0 _SV4I\�I:�IINGPOOL575ea.
LODGE S50 _I'RAILER PARK S100 _V6�-iIRLPOOL S75ea.
FOOD SERVICE: �.�____4��--._.____ __ __ ,
-----�—ST~--„T_� �.
LICEAIS£REQUIR£D FEE PERMIT�? LICEI*iSE REQL'IRED FEE P£�1�11T?? E:ICENSE REQtiIRED FEE PERVSIT=
0-100 SEATS �.75- - � _CONTINENTAL S30 _NON-PROFIT S?�
>100 SEATS 5150 C0;4�fON VIC. S50 �'l'HOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S7S
LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER'�IIT:�- LICENSE REQL'IRED FEE PER'�III'�
_<50 sq.t�. �45 >25,000 sq.it. S200 _�'EI`'DIIvG-FOOD S20
_<25,000 sq.ft. �a75 C>C�I�S'6S� _FROZEN DESSERT S35 _TOBACCO S50
va��c��rcE: sio AMOUNT DUE _ $
� *****PLEASE TL'R\OVER A:�'D CO�IPLETE OTHER SIDE OF FOR�i'�•***
�
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�f4 -
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
APPR4PRIATELY IF PAID:
YES NO
. , . ----
� � I�ER LODGING ESTABLISHMENTS `
� — _
;
i
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�.
Transient occupants must have and be able to demonstrate that they ma.intain a principal place ofresidence elsewh�e.
i 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)manth period. Use of a guest unit as a residence or
i dwelling unit sha11 not be considered transient. Occupancy tha.t 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: En��osed Motel Census must be completed and returned with t�is app�ication.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ed
; by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys
j pnor to apenu�g.
POOL WATER TESTII�IG: 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 wi.thin seven(7)days of
closing.
F04D SERVICE
CATERING POLICY: I
Anyone who caters within the Town af Yarmouth must notify the Yarmouth Health Departme�t by filing the required ;
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department. ,
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health '
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit u�til the
above terms have been met.
OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
i
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohihited. ,
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN �
THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. �
f
ALL RENOVATIONS TO ANY FOOD ESTABLISHIViENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEME�TT. RENOVAT'IO:�TS MAY REQUIRE A SITE PLAN.
DATE: ` SIGNATURE: �
i
FRINT NAME&?ITLE:
�
io;n n� ,
06i19i2908 11:09 MEADOWBROOK�TPA CLAIM DEPT � 15087718280 N0.330 D802 '
•�CORD,� CERTIFICATE O�' LIABIL!`1'Y INSURANCE DA��;9�'
PRODUCER THIS cERT1FICATE IS ISSUED AS A MATrER OF INFORnn�►noN
Wholesale Retail Suppliers Compensation • ONLY AND CONFEI2S NO R�GHTS UPON 7HE CERI"I�iCATE
Corporation HOLDER THIS GERTiFICATE DOES NOT AMEND,EXTEND OR
ALTER TH�COVERAGE AFFORDED 6Y THE POLICIES.BELOW.
PO Box 84-5933 � " �
Boston MA a22845933 INSURERS AFFORDING COVERAGE NAIC#
�Nsu� Drive-O-Rama,Inc. �wsuRERn: �OLESALEIRETAIL SUPPLIERS _ ..
dba Millstore P�oduCts iNsu�t B: , �.
108 Breeds Hill Road IN3URF1i C: ,
Hyannis MA 02fi01 1NSURERD: , _
iNsu�t�:
C01/ERAGES
7M@ POUCIES OF INSURANCE LISTED gELOW HAVE BEEN ISSUED TO THE INSURED NAAAEDAB�V�fOR THE POUCY PERIOD INDICATED.NOTMTHSTqNDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR 07NER DOCUMENT WITM RESPECT TO�NN�CH 7HIS CER1lFICATE MAY BE ISSUED OR
AAAY PERTAIN,TH��NSURANCE AFFORDED BY THE POLICI�S DESCRIBED HEREIN IS SUBJECT TO A►-L THE TERMS,EXCLUSIONS AND CONDI77oNS OF SUCH
POUC�Es.AGGREGATE LIMITS SH01NN MAY tiA1/E BEEN REDUCED BY PAID CWMS. _,
INSR ��OD' YOLICY NUM9ER POUCY�E 'POWCtl DCPIRATIDN �
tiP_EO __.- . _. J�ATE(MMICb/YY1 ..
OENERAL IJABILJTY I EACW OCCURRENCE ' 3
CGEYO�7E��'
COMMERCIAL GENERAL LIABIUTY i PRE3IAISES fEs ,
CLAIMS�4DE �OCCUR 'M�� °���� $
, PERSONAI.E ADV INJURY :6___,
GENERALACGREGATE i „
GEN'L AGGREGATE LIM�T APPLIF.S PER: PRODUCTS-COMAlOP AGG S ••
_ ( . POIICY JE�L �LOC �, . •-
..,�. AUTOaAOBILEUAB�uTY � �MBg�IN�EDnUSINGLELwt1T s ,
ANY ALfTO
i ALL OWNE�AUTOs BODILY IWURv s
� SCMEOULED AUTOS �P��n� �
� � Hi�o auros _ .Bo�i�v iwuRr s
; ' NON-0WNEDAUTOS ������� ^
� . PROPERTY DANIAGE _
� • . (P6f aCGdOM)
I GARAGE IJABILJTV � ` AUTO ONlY-EA ACCDENT $
i , /WY AUTO I • OTHER THAN �►AGC 5 ,
• AUTO ONLY: AGG i
��a�����y EACH OCCURRENCE 5
OCCUR �CtAIMS MADE A��� _
;
( DEOUCT16lE s �
� RETE►JTION : s
X �a7u- o'rri-
fr IWORKERS C06APEN5A710N AND
i EMvt,o�y 6�qg�tny WC 000623-06 01/01/Z008 01l01/2009 El.EACH ACCIDENT S 500,000
E AM'PROf'R�TORIPARTNERIfXECUTI�E � . � rJQQ Q00
?OFFICEpA1E1ABER FxCLUDED? • E�L.DISEASE-FJ1 EMPLOYE 3 �
� Kyes deetfIDe uWer i EL pISEASE.POLICYLMIT S 5��,��
�SPEGIn�PROv13fON5 Delow _, . '
OTNER
t
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OESCWPTION OF OPEFtA7�N5�LOCA770N3/VENICLES I EXCLUS�ONS ADDW BY EN�IMENT/SYECIAL p����
I
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;
CERTIFICATE HOLDER CANCELLATION '
$IIOUL�ANY OF THE ABOVE DESCWBED POLIqES�CANCBIED BEFORE 11�1E EXPIRATION
pp7�7}�E{y�pF,TNE ISSUIN6 MSURER WILL ENDEAVOR TO MNL 30 DAY$WR�TTEN
NOTICE TO THE CERT1f��TE NOLDER NAMED 70 7YIE LEF7'.HUT P/ULUAE Tp DO SO SMALL
199POSE NO Og�'�N OR LIA91U1Y OF ANY IaND UiON 7HE INSURER�AGEN750R
REPRESENTA7NE$^_
AUTMOR�REPRE5�7'ATNE
ACORD 25(2001/Q$) CORPORA710N 1988
Received Time Jun. 19. 11 : 04AM
�
a`
` TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
i
1 PERNIIT NUMBER: #08-056 FEE: 5.�
I
� In�danoe with n��ons promulgatecl u�suthority of Chaptsr 94,Sectio�305A and Chapter
111,S�5 caf t�e Laws,a permit is hereby granted to:
Drive-O-R,ama, I�., 39 Route 28, West Yarmouth,MA
Whose place of business is: The Mll Stores
Type of business: Re�tail Food Service less than 50 square fcet
� To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31 2008 BOARD oF I�ALTH: ��et SIEaI� `.l�..k.,C�1�uxrmatt
Cl�c�rlee .3� `�ac C!haarRsur�c
J��.5�re�as,
������
Ju1�23,2008 Btuoe G-h+Iutphq, RS.,CHO
l�rec;to�of Healdi
� ��y�'"
°f;aR,�o TOWN OF YARMOUTH BOARD OF HEAL�'H �'�� G3 � r � � DD
�
�' � 3 -��� A P P L I C A T I O N F O R L I C E N S�l P E�I 3'=`�0 0 7 N 0 V 2 O 2006
� Y; .;��
* Please complete form and attach all necessary documents by Decem r 3��0�� UEPT.
Failure to do so will result in the return of your application pac
�/NAME OF ESTABLISHIVIENT: • TEL..#�V�-'7'�����'
r/ LOCATION ADDRESS: Gf/. ,
✓ MAILING ADDRESS:
OWNER NAME:_T�,�:� `�3a R�rt � TELX ID (FEIN or SSlvl�
�/CORPORATION NAME(IF APPLICABLE): `�r;v�_�..�Q,r„�a t�
✓rMANAGER'S NAME: ; �'��tZ��; _-�c -TEL. # 50���7/—�/ v O
�✓MAILING ADDRESS: °�.�-�5 . l (Zi� �
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
l. 2,
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary 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 m�intain a file at your pl$ce of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishmen�
l. e.rrtic n �-�.v'�C 2.
_ ��_ _ ---- _ —_ ____ _ -- ---- --- _ ,
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ;
l. 2.
HEIlViLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcmg procedures below and
attach copies of employee certifications to this form. The Health Department will nat use past years' records.
You must provide aew copies and maintain a file at your place of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRBD FEE PERMIT# LICfiNSE REQUIRFD FEE PERMIT#
B&B �50 CABIN $50 MOT`EL $50
INN $50 CAMP $50 _SWA�IlvIING POOL$75ea.
_LODGE $50 _TRAILERPARK $100 V1�-�RLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIRED FEE PERMPf# LICENSE REQUTRED FEE PERNIIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>I00 SEATS $150 _COMMON VIC. $50 WHOLESAL,E S75
RETAll.SERVICE: —RESID.KTfCHEN $75
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
�<50 sq.ft. $45 �7'�C] >25,000 sq.ft. $200 _VENDING-FOOD $20
/
_QS,OOO sq.ft. $75 ~- ' _.FROZEN DESSERT $35 TOBACCO $50
NAME CHANGE: �10 AMOUNT DUE _ $ �S•OO
•"'••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""'*'
NOV 1 4 2006
►
ADMINISTRATION � �
r
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'vred to hold issuance or renewal !
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's �
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIQN INSUItANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
;
j
CERT. OF INSURANCE ATTACHED
OR �WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK €
APPROPRiATELY IF PAID:
YES NO '
�
MOTELS AND OTHER LODGING ESTABLISHMENTS �
�
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be `
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel 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, sha11 generally be considered Transient.
i
POQLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ecte�i
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days �
pnor to apening. �
�
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count I
by a State certified lab, prior to opening, and quarterly thereafter. '
POOL CLOSING: Every outdoor in ground swimmir�g pool fnust be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY: �
Anyone who caters within the Town of Yarmauth must notify the Yarmouth Health Departmern 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 m 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: '
__ __Q�d�cookin�_nren�,r�tion,or dic_snla��n�_foQd._pro�u�tby_a r�tail or fo�d servise est3hiichment�s prohihitexl ___._ �
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN
"TI-�COMPLETED APPLICATION(S).AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
i
ALL RENOVATIONS TO ANY FOOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW f
EQIJIPMENT,ETC.), MUST BE REPURTED TO AND APPROVED BY TI� OF HEALTH PRIOR �
TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A S PL ._- �
DATE: ����'S�C� SIGNATURE: � �
PRINT NAME&TTTLE:
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ioii�io6
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The Commonwealth of Massachuset�s
Depart�r�e�rt of Indus�rial Accidents �i�;�y � 7 20 07
N�fN�11Mi�
6118 WashiRgton Stree� 7�"`Floor
Bos�o�,`Masv. 02111 :
--- �---- Wb�kers'+Com Yoi��s�unt�tce�d�v� .bi�/Eleetrical:Co�tneters
.� _ �. � � , �.F � �. �� _ �.
v �:�/�-���ZGirii e�` i��[` �'(�►1�r �� !V\i�C �f"��
" address: 1Tl Sc-�3'c����i ��.
'" �tv �v1n� 'ti s�te: n'1� ziP: �aC�D � n�one# ��'" /��F���
T
4./
� R�OI�C S$C IOCffil���B�TCS3):
o ��a ,,,�,���W�m,�� Project Type: ❑New Ca�uctia�n��
I sole and have no o�w in an Addition
, _ __ —, --- - —
.—� ___ -_.._---._
I am an eanployer p�oviding w�eis'compensaton3�az my�pioyees wa �ng on �o .
-- �-- — _ _ _ �L� ��`�
�.S�^
�..-.o�a'h ,� m/� �2 �. ""?,�-�'�'�7'-���}'l�
_� � q� �: _ ;
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W Ce�u.� 1�esS � ��C Oc�n a�-''�
❑ I am a sole proprietor,geseral coatracter,or homeawaer(urde o�)a�have hiced the contr�ctars listed below who have
the followinS v►'orkas'compensation Polices:
�p; ,1��
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F�re a�ec�+e�v�er�e as nqirea.�der satloa 2SA.t MGI.lsz n.laa a u��.tcri.tW pe�.Nies.c a�e�a sl,s�aM aa�hr
see yars'iy�t�t a�w�eY as dH paaltln h 6�ra ota STO!WORK QRDEA aid a da�e�[5169.N a day a�bt ie. I odashsd tlnt a
apy�f trb stale�eet my 6e f�rwarded b �f IaMa�of tl�e D1A tor average veeiAatlaa.
I�fo bereby e o.�Perj�'tN�t dre b�fornr�don prov�de�d oboae ia d�e asd uonr�
✓ s�� n� ---C l`�t 5�v�Q
N ' �� ' �.� L 1
Print name c1 i Phone# ���_ ,���O I V l!
effidH ose on�y a.�c.riite r.cris arn te be c�plaed br eitr.r i�wr.�ial
cily ar tswn: perm�/�ioeme 1� f"t�idia�D�meat
❑e�eck if�a1e napsax ia t+eq�ed ��s p�o�
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i
WHOLESALE�RETAIL SUPPLIERS COMPENSATION CORP
NCCI CARRIER CODE NO. WC 00 00 01A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
i
; .
; 1.The Insured: Drive-O-Rama, Inc: Policy No. WC 000623-7 �
i DBT�: Millsicore Products
! Renewalof: WC 000623-6
j Individual Partnership
Mailing address: 108 Breeds Hill Road X Corporation or
Hyannis, MA 02601 Federal Employers I.D.�
IntedlnVastate Risk I.D.# 027494
Other I.D.#
Other workplaces not shown above: See Schedule �
-
-- -
� - -- -- - _ _
2.The policy period is from O 1/O 1/2 0 0 7 12:01 a.m.to O 1/O 1/2 0 0 8 12:01 a.m.standard time at the Insured's
mailing address.
3.A.Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of
our liability under Part Two are: Bodily Injury by Accident $ 5 0 0, 0 0 0 each accident
Bodily Injury by Disease $ 5 0 0, 0 0 0 policy limit
Bodily Injury by Disease $ 5 0 0� 0 0 0 each employee
C.Other.States Insurance: Part Three of the policy applies to the states,if any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy includes these endorsements and schedules: See Schedule
4.The premium for this policy will be determined by our Manuals of Rules,Classfications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Premium Basis Rate Per
Code Total Estimated $100 of Estimat,gd
Classification No. Annual Remuneration Remuneration Annual Premium
_ _ _- --_ _ _ __ - - _-- See Ite3n-4 . Exte2�sion We 00-0$-01A- _ _ __
_. _ .
Total Estimated Annual Premium$ 8 7,3 31
Deposit Premium $ 21, 8 3 2
Minimum Premium$ 5 0 0 (MA) 73 8 0 Expense Constant$ 2 84
MA - DIA Assessment 0. 040 3,151.00
Premium Adjustment Period: Annual Countersigned by: �
Servicing Office: �OLESALE\RETAIL SUPPLIERS COMPENSATION CORP Date:ll/09/2006
Producer: B�'den Insurance Agency, Inc.
Copyright 1987 National Council on Compensation Insurance.
Original
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiVI�NT
PERMIT NUMBER: #07-009 FEE: $45.00
In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pemut is hereby granted to:
Drive-O-Rama, Inc., 39 Route�28, West Yarmouth, MA
� Whose place of business is: The 1V�ill Stores
�
' Type of business: Retail Food Service less than 50 sauare feet
To operate a food establishment in: Town of Yarmouth
Pennit e�ires: December 3 l, 2006 BOARD OF HEALTH: L� ;�a��- rrs�c`n. (����., '
a�eles� �S'lu�i, /�!JY., 'Uice G�ls�i�,�r�
Rad�t 4 B�«�, Gl�
P����ott
�4.����`�,.,� R./Y.
December 11.2�6 Biuce G.Murphy,MP , .,CHO
Director of Hea1th
i
`� '� �,�'�(, 76�! _ M�=�c.S� ..,
;, ¢
,� of;-R.� TOWN OF YARMOUTH BOARD O�HEA�.`�H�
�
3 - � -'� APPLICATION FOR LICEN :, lPERMIT �,0�16 ,��
°: „'� t .� < ���;� , � � 2005
* Please complete form and attach all nece ' dc�uments by December 31, 2005.
Failure to do so will result in the return of yow application pack�t. - - ;
E
. .
N,A�o�EST��,l� l� :t =��-r , .�; F� a� ��. � r, ��`�L �#'�"��`��;3�r► Fr
LUC;ATION ADT�►RE��� � � ' �"`y �
MAILING ADDRE S: 1\ `
OWNER NAME: � � ✓ i T E r S : � � �
CORPORATION NAME APPLICABLE): �r�v� - (�- 12 u�w�� '
MANAGER'S NAME: TEL. # ���-'��S 1�
MAILING ADDRESS: 0 ( � . � ��
POOL CERTIFICATIONS: ;
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designatai '
PoQI(3�erator(s)and �`-����-�a€-��e e�r�ification to tlus fQrm. _ _____ :- �
l. 2.
4
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and I
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 j
copies and maintain a fde at your place af business. �
1. 2. �
3. 4. i
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
A11 food service establishments are required to have at least one full-time employee who is certified as a Food
ProtectiQn Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. �
Please attach copies of certification to this application. The Health Department will not use p�st years' records. I
You must provide new copies and maintain a file at your establishment. `
,
1. l, ` ��. 2.
I
_. _PFRSQl�I�C�RGE: . _ _ — -----�
Each food establishment must have at least one Person In Charge(PIC) oz�site during hours of operation.
l. � ��n � 2. ..,
i
HEIl'1��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 a11 times. Please list your employees trained in anti-choking procedures below and ;
attae�i evpies of employee 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. '
_ 2. '
1.
3. 4•
I
RESTAURANT SEATING: TOTAL# E
- �
OFFICE USE ONLY '
:
LODGING: i
LICENSE REQUIItED FEE PERNIIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# f
�
B&B $50 CABIN $50 _MOTEL $50
JNN $Sp - _CAMtp $50 _SVI�IIvIIvIIlVG POOL$75ea.
LODGE $50 _TRAII,ER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQUII2BD FEE PERMIT#
0-100 SEATS $15 CON"PINENTAL $30 NON-PROFTT' $25
�>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIREll''F�E- .PERMTT# LI�ENSE REQIJIRED F�E �ERMIT# LICFNSE REQUIItED FEE PF,RNIIT# '
<S�`s ft. '$45 ' �-D�B .;_.�25;U00 sq:ft. ' ' $200 A. : ' ` , VENDING-FOOD $2Q '
� q• —
QS,OO�sq.ft. $75 _FROZENDESSERT $35 `TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ �5•00
*•"""PLEASE TURN OVER AND COMPLETE OTH�R SIDE OF FORM•*•""
�OV Q g 2���3
I ,..
� �
,� .
<
^� , __
i
,
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
I APPROPRIATELY IF PAID:
! YES NO
; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
I
+ SEASONAL ESTABLIS�IMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-
� 10 DAYS PRIOR TO OPENING FOR TI� SEASON.
�
i ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT'. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
� ADDITIONAL REGULATIONS
�
�
POOLS
�---—_ - - -- - — _
; POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
i by the Health Department prior to opemng.
i
j 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.
I POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post I
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required
Tempora.ry Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the �
Health Department.
FROZEN DESSERTS: !
_�razen-desserts-must be teste3-cxrx�not�t�il�basis�a ��ate ee�tified-lab.-�s�lts rr3ust be se��#i�e�tl� �
Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the �
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with 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 establishmern is prohibited. !
�
�
;
DATE: SIGNATURE:
I
PRINT NAME&TITLE:
09/28lOS f
�
. . y `�`�� The Commonwea&1�o Massach�setts
,��--___� �'
_
� , T � ;
' TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-018 FEE: $45.00
�
i In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
'i 111,Section 5 of the General Laws,a permit is hereby granted ta
�
i Philip BaronilDrive-O-Rama, 39 Route 28,West Yarmouth, MA
Whos�place of business is: Mill Store
Type of business: Retail Food Service less than 50 square feet
To opErate a food establishment in: Town of Yasmouth
Permit e�ires: December 31, 2006 soARD oF x��.�x: 6 � _`h. ,A9.$., '
o�e�►e�s�i, ���.�, `vyu�e e�i,rs��
R�t� B�, �
A�A���
� �4.�.z�j�� R.N.
January 12.2006 ce G. urphy, , S.,CHO
Director of Health
�� � ' �� fyr�
i ,i• . . ��'�vN_��i
32°�`r R�o TUWN UF YARIVIUITTH BQ�,R'�`�Q � e � � ,c��_� c„ '
� - F
�: �s APPLICATION FOR LI � , �,20�5
JAN 1 0 2005
� * Please complete form and attach all neces r� documents by Decem r �p 4
� Failure to do so will result in the return of your application pac . ��_r H DEPT.
,
� NAME OF ESTABLISHI�IENT: � TEL. #
� LOCATION ADDRES S: 2
MAILING ADDRESS: 1 �\ � (�d2(�
OWNER/CORPORATION NAME: ' ' �
MANA ER'S NAME: �,. #
� MAILING ADDRESS: � � d
i
POOL CERTIFICATIONS:
T6e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
;
1. 2,
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your ptace of business.
1. 2.
� t ;� i ::.i.},�e5r�*t'i. ,�r,u '3,� �e+'�`.' k ��.�',�, 4 , -
. �.,! ,;F� T� rA�? R �� �- ';. �ax ^� 7r:
, ' , ... . , .. �
� ; � +
,
�;
� k. : , ..: .. .
. ,,�- .,: , ...;, � � �
e,. �� ,� � F rp
.�. .. .v.: � 'A�M .. � ..,
,.. "�. j� .�.
v . � . _ '.,. a�r ,. .. . �' ..s . . ... Sy ,v.r� . R..'...*r '
° ��.,, .,a .
.� . .....� . �..t r "u _�. , � . � �, , �.
� ` ' . .. .._.� '. . . n�l� ,. ,�1. � .._ ,..:f.. M '% `.�.Z.A" .—.. .. . . . .. .`:f/.,
. . ., . . . .. :.._-. �.�. _xn...wr�".. ,� . _
.. . . , . _ _ . .A.
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 fde at your establis6ment.
1. 2.
_-PER�DN IN CHARGE:
� Each food establishment must have at least one Person In Charge(PIC) on site during hours o£operation.
1. � 2.
HEIlbILICH CE TIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at 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.
RESTALTRANT SEATING: TOTAL#
OFFICE USE ONLY N Q� � � 2 D D 4
LODGING:
LICENSE REQUIItED FEE p$RM[T# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_ _ _�&�4_ — ,__��. -____---------
_ ^$5�__ _ -----�----
_INN $50 _ �CAMI' $50 _SWIlvIlvIII1G POOL$75ea.
_LODGE $50 _TRAII,ER PARK $50 WHIItLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE pE12IWIIT#
_0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PfiRMIT# LICENSE REQtJIKED FEE PERMtP# LICENSE REQUIRED FEE pERNIIT#
/ <50 sq.ft, $45 �'6 �0 t� >25,000 sq.ft. $200 �VENDING-FOOD $20
_<Z5,000 sq.ft. �75 FR07.EN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOITNT DUE _ $ l�6•DO
'""•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""*•
� � ' � " �
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 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 �
I
�
_ - -- -- - - - _ _ _ - _ _ _ _ _ _ ;
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLIS�IMENTS ARE TO CONTACT TI-�HEALTHDEPARTN�NTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASQN.
ALL RENQVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND A.PPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
i
�
�
ADDITIONAL REGULATIONS �
POOLS _
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �
by a State certified lab, prior to opening, and quarterly thereafter. �
�
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing. �
�
;
FOOD SERVICE �
CONSUMER ADVISQRY:
Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY• �
Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the ;
required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR C40HING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
DATE: I2 c1 L SIGNATURE: cti � -
i PRINT NAME&TITLE- I n
10/22/04
�-.
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�
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�"'°°"'':` _,.,
I , �
l ' �
TOWN OF YARMOUTH
� BUARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: #OS-053 FEE: $45.00
In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 af the General Laws,a pernut is hereby granted to:
Philip Bazoni/Drive-O-Rama, 39 Route 28, West Yarmout MA
Whose place of business"is: Mill Store
Type of business:_ Reta.il Food Service less than SQ square feet
� To operate a food establishment in: Town of Yarmouth
�
� Permit expires: December 31, 2005 BOARD oF HEALTH: Bes�a�sn`?S. (�''o+�clo�c,/1�I.$. •
p���a�� v�e��
Ro6�t� B�, �
�s� R.N.
� �4����� R.N.
February 3,2005 Bruce G.Murphy,MPH, .,CHO
Director of Health
�
; _�
;
�
_ .__ _
.., � � �- uJ an�v a�no Han.��sr��d.�*.«,�
0O'S-h $ _ �IlQ.L1�I[lOWd ot$ •� u ,
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� . .� > The Commonwealth ojMassachusetts '
� � Department ojlndustrial.-�ccidents �
� ; olflceoll�►es�lostliis
600 Washington Slreet
� ,.� Boston, Mass. 02111 �
�'"' "• W'orkers' Compensation Insurance Atfidavit '
;
Aoolicant information: PlessePRIP9T7e�h'1� �
� � �
n m•� �
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1�� _`�-v � ` l�..V 1 ''� __ ohone� ��—J b � �____
� I am a homecwner pertormin;all work myseff. '
� I am a sole proprizror�r.,�, ha�e no one��orkine in am•capacit��
�m an emplo�er pro��din�w�orkers' compensation for m��emplo��ees w•orkine on this job.
- - � - -- ,- . �
t �(�/�C __--- — ---- -----
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m an name•� ( \ ���`l C`� - _ -� _ _ I
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�Jdress• I V� ���'�!. �� ��` \ � �
ciri•• �LA LA � �r���. ehone#:
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insur�nce co �7�� � Q / �`C��-1 1 �-�J'�,'i QI�I�Y►�c..�(.af�licy# �A '7CC�Q�-l�J
� I am a sole proprietor. :enerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu��in� ��orker_� �ompensation polices: ;
S9l��v name• : _
addr «• -
cin�• phone M•
i�sur�ncc co policy#
�moanv name• ---
iddr s••
__ __
_ ---- _ -- -
s�ty• ohone M•
insurance co ��n'� -
•
Failure to sccure covenge as�equired uoder Secnoo 2SA of MGL iS2 ea�lad to t6e iopaidoe ot erisi�al pe�aitia of a tf�e op to Sl¢OOAO a�d/or
oae years'imprisonment as w•efl aa eivil penaltle�io the[orm of a STOP WORK ORDER aad a Aae�SI00.00 a dar Ktiost ma I a�dersta�d t6at�
copy of thh statement may be fonvarded to the OfTice of Inve�tiguiom of the DIA for eovera�e verifkatie�.
/do hrreby cerrijj•under rhe ains and ptnalties ojperjury thot tht injornmtion providtd abovt is tnte aad contd
Signatu/r�
Print name _Phone N
.- olTicial use only do not M rite in this area to be completed by eiry or town oAleial
citv or town• Y�M�IITA _ permitAicease M r't8uilding Departmeat '
• - �Lieeasio�Board
�eheek if immediate response is required 261 QSdeetmen'�Ottiee
�Hnith Departmeat
c n ac ptrson: - � - . . phoneM:_ �508} 398�?231 eat. nOther
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' � R
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLI5HMENT
PERMIT N[JMBER: #�(14-053 FEE: 5.00
� In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pennrt is hereby granted to:
Fhifip Baroni/Drive-O-Razna, 39 Route 28, West Yarmouth, MA
i
i
" ' Vt�hose place of business is: Mill Store
i
I Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yar�auth
Pernut expires: December 3 I. 2004 BOARD oF HEAI.TH: Be�i�$. �'mld�oa,,�l.$. '
pa�J�c$e� ��S e�o�ix�.-.,r�
���R�.�Y�
����� R.A+
1vl�rch 5.Zoo4 ruce G.M hy, , .,CHO
Director of Health
� �i��i
! �-.-R,� TOWN OF YARMOUTH BOARD � ��iEALTH ��' p�
� 'c � � U V � I�
- `_�''c APPLICATION FOR LICEN F�€�1VIIT-2003
°�::, „�:� �� F E B 1 $ 2003
* P(ease complete form and attach all nec�'l = �rriients by Decem er 31, 2002.
Failure to do so will result in the re ot your applicat�on pa kdI�EALTH DEPT.
IS �Dr`v-e O ' +P . # 5 v F -�ftod�
D S • T�e �-�s 1Nes � �
MAILING ADDRESS• 10 � i�r�e� � \-�;11 � � 1-E�.r � v. +n'i s E M IA- u�-�c/
OWNER/CORPORATION NAME• b���-� �' 2�� �l� M�l l S�o�-� S
' -7 -.,3�1�
MANAGER S NAME• 1�,e.v� �.2 nr�d�n� TEL. # SUFs �S
1VLAILING AI)DRESS• RT-e a ss� (1(�0�.��. �T �.��2ST `�, c. v n„�+u�,,
� POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a_copy of the certification to this form. _ ;
1. 2•
' Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
' and Community Cardiopulmonary Resusc�ta�ion (CPR). Please list these employees below and attach copies of
employee certifications to this forrr�: The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2• ,
3. 4•
FOOD PROTECTION MANAGERS - CERTIFICATIONS•
All food service establishments are required to have at least one full-time employee who is certified as a Food
li hments 105 CMR 590.000.
Protection Manager, as defined in the State Sanitary Code for Food Service Estab s ,
. �
Please attach copies of certification to this application. The Health Department will not use past years records.
You must provide new copies and maintain a file at your establishment.
l. 2.
,----�� J - -------------__ __�-- _.__- �_- _ _- .�_.....��---—- --__— __-
Each food esta.blishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2•
NF1MT 1['H CERTIFICATIONS•
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
- res below and
t' chokin rocedu
Please list our em lo ees trained in an a g p
Maneuver on the remises at all times. y p y ,
P . �
attach co ies of em Io ee certifications to this form: The Health Department will nof use past y
ears records.
P P Y
ile at our lace af business.
nd maintain a f
You must provide new copies a y p
1. 2•
3. 4.
RFSTAURANT SEATING
: TOTAL
#
OFFICE USE ONLY
LODGING:
• LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FGG PERMIT#t LICENSE REQUIRED FEE PERMIT#
B&� $SG • _CABiN $50 _MUTEL $50
INN $50 _CAMP $SU _SWIMMING POOL$75ea.
� WH[RLPOOL $75ea.
LODGE $50 _TRAILER PARK $50 _
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
0-100 SEATS $75 _CONTINENTAL $30 TNON-PROFjT S25
>100 SEATS $150 COMMON V(CT. $50 WH�LESALE $75
— — _ —'
RETAIL SERVICE• '
.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEG PERM[T#; _ LICENSE REQUIRGD FEE PERMIT#
�<50 sq.ft. $45' �63-OGO _>25,000 sq.ft. $200 _VENDING=FOOD $20
_<25,000 sq.ft. $75 _FROZF.•,N DF,SSFRT $35 TOAACCO $25
NAME CHANGE: $�o AMOUNT DUE _ $ �1�, On
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
,
FE� 0 3 2003
I
. _ _
�..�.. ....�.;- �
. : '
i __._ _._ . �
' ADMINISTRATION � � `
r
Under Chapter 1.5�2,:�ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
o�an�-lieense or pe�`mit 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 MU5T BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
2 �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ,
�,:. :
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permit $ � �
_ `��P�: � ::: �
NOTICE:Permits run annually from January l to December 3l. IT IS YUtiR I�E�PON5I1B�iL,ITY T0�E'I�1TtN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002.
�
SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 :
DAYS PRIOR TO OPENING FOR THE SEASON.
y
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.
� � � � �
E
ADDITIONAL REGULATIONS �
I
rooLs
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins�tected '
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 5tate certified lab, prior to opening, and quarterly thereafter. '
t
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of �
closing. �
�
FOOD SERVICE '
CONSUMER AD'VISORY: j
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERI�G POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses farms can be
obtained at the Health Department. '
;
7'rYZO��i�1�ESS'�R�: - - _ _ ._ _
- _ _ __ _ _ _- - --
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.
�UT� SIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
#_`�: . '�. ..�,� v3 �: `��` `
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The Conimonwealth ojMussQchusetts
� � Department ojlndustrial.-1 ccidents
� ; Of1IC001/�slJ�sd��s
600 Washington Street
' •� B�ston.Mass. 02111
,
' ~ �� W'orkers' Compensation Insurance Affidavit
Annlicant intormation: P►esseFRiNT'Te�.'i�
�
n�mr� 1 ' 1� , � ��d'(��
I_ucation� ,'C"'f` a �S? � �O� 1('MaK,�� /1'1 �- CJ o�(0-7 3
cit� phone� �Q�-7��-3�l S�
� I am a homecw�ner pertormin,all w�ork mpself.
� I am a sole proprieror��,a, h��e no one ��orkin� in am•capacity
�am an empioyer pro�i�ing w�orkers' compensation for my empioyees working on this job.-
:_
, :.-�� - _ _
comnanv name: M\ � � `J C.J Y'P g .
.�ddress: 1 G �l �Y2-e(�.S � � � � 1Ct�l
sitv: 1-�v► G�t/� 1/� 1 S ehone tf: ��`�iS-= �� l —'8') O d
insurance co. LV�U�?SGZ�Q���rn�` SV�(>(� IU� C p o�1� Y# � (�_V�J�a�--3'L
� I am a sole proprietor. ^enerai contractor. or homeow•ner(circle oneJ and ha�•e hired the conrtactors listed below �tiho ha�e
the follo��in_ �.orkzr:� �ompensation polices:
companv n�mr.
address•
ti�: phone M• '
insur�ncc co. nolicv#
com a�ny name•
___ _---- -- -- _ ------ --- - - —
address•
ciri• Rhoee M•
insurance co. �x�f
t
Faiiure to secu�e cuveraee as required under Secnoa 25A of MGL lS2 ea�lad to tbe iepaidoa o(eriai�i pe�dtle�of a d�e ap to S1,500.00 a�d/o�
one years'imprisonment as w�ell a�eivil penaltla in the form of a STOP WORK ORDER�sd a tiae of 5100.00 a dar apin�t ma I asdersts�d tbat�
copy of thy statemen�may be fonv�rded to the OAiee of Inve�tig�riom of t6e DIA for eoverage veriQatio�.
!do hrreby cerrij}�under the pains and pertal�ia ojperjury thet ll�t injarniation provided abovt is tnte and correct
Signamre � -�-Y�L ��,�v�+" Date a--���1 G 3
Print name .1 �� Q v.,��V�-O Phone N '�(J�_ 7 �"�� ��
_• o(Ticiat use onlv do not write in this area to be completed by ciry or town oAleisl
ciry or town: Y�M�� _ permitAieense M nBuildiog Departmeet
�Lieea�iog Board
�cheek if immediatt response i�required 261 QSeleetmen's OtTice
(508) 398--2231 �t, �Healte Department
contact person: pho�t lt:_ _ _ nOther
.. ..� < a,,:
�
i + �.
�
I TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
, PERMIT NLJMBER: #03-060 FEE: $45.00
1
; 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:
Drive-O-Rama, 39 Route 28, West Yarmouth, MA
� Whose place of business is: Mill Stores
i
' Type of business: Retail Food Service less than 50 squaze feet
To operate a food establishment in: Town of Yarmouth
� Permit expires: December 31, 2003 Bo�OF�,�.�: ��� ZdU�c, ��aac
i _ . �'G�c�ri�c?�. G��do�c. �JlG,9.. ?/lee _
,�o6�t�. �'�, �
�a�tck�eD�ott
��s . �n
.
February 18.2003 ruce G.Murphy, . .,CHO
Director of Health
Aua-05-i002 09:3Tam From- T-341 P.002/0 3�F�1 �
� ' I
a v t���vr a euu�av v a aa a+vcaav.va� �--�y
' „ APPLICATION FOR LICENSE/P - AUG O S ZOOZ
. - 5.,�.� .far,; A � '°.;l3.
*Please complete fozm and attach all necessary documents by December 31,20(�i. F, �"�� DE PT.
the return of your appLcation pecket. �'�''I�o.f��.✓'
J,
�,.,,,�. ,.,,,.��..,,�.��.�,.,-,�. { ,�,� s��-Ml Lt� S � _T. # �-��I—Ss1o8
i e �i a i
� `/ �w n n n.tr w nr�u�ee l�S� l�i r �e s ,�-, �1 �L.� , {�L-u�t 1n�n�. �,An U�-d��fo r'i 1
��O R/ O PORATION NAMF• p 1�'��,r, S C�a�ro►n.�� �
�etas�:�o•civeu.rF- - 'TF,r#
a,teTi tt�rr �nnure�. �.. �
i
POOL CERT1FjSA?IOZI�:
Th�pool aupem�or muet be certified as s Pool OperAtor,�required Iry State law. Please list�designated
Pool Operator(s)aad attach a copy of the ccttification to this form.
1. 2. �
Pool operators must list a minimum of two employees cwrendy certified in basic water safety,stan�First Aid
aad Community Cazdiopulmor�vy Resuscita#ion(CPR). Pleese list tbese emgloyoes below aad att�ch oopies of
employee certificahons to this foim. The Health Departpnent will not use paet yeus' recorda You�nuist
prov�de new copies smd maintain a Sle At your pbtce of busmees.
' 1. 2.
3. � 4. �
FOOD PROTECTION MANAGERS-CERTIFICATIONS:
All food service establislunents are required to have at lcast one full-time employee who is certified as a Food
Protection Manager,as defined in the Sts2e Sanitsry Code for Food Service Establishmeats, 105 CI�iR 590.000.
Plesse aiisch copies of cettification to this applicaaon. The Health Deg�rtmeat wid not uee�mat yeara'ruot�..
�ma
You mu�t provide new copies and maintaiqa•5l�atyoar establishment I
1. 2. �
I
PF,$�O�tN CHARGE:
Each food�stablishmart must have at laest one Person Tn Charge(PIC)oa site during hours of ope i tiaa.
�
1. 2. !
HEIB�,C CE_TIFICATIONS: �
All food service establishments with 25 seats or more must have at least one employee traiaed in�he Heimlich
Maneuver on'the prestsists at all times. Please list youremp loyees traiaed in antt-choktng procedurfs bclow aad
attach copies of employee certificauons to this form. T6e Health Depar�aent will not use pnet ye�rs reeords.
Yom m�st provide ne�v copia and maimtain a file at yonr p1Ace of bnsiness. I
I
1. 2.
3. 4. �
�
!. BESTAURANT SEATING: TOTAL# ;
— ■ - -- �w�i.�����i�ww��i
Q�jJSE O1�LY �
����
LICENSE REQU[RED FEE PERT�QT N LICENSb REQUIItED FEE PERMiT il L[CENSE ItEQUIRED FF� PERNIl'f�
Bd�H SSO ^CABIN S30 _�+LOTEL SSQ
11VN SSO _CAI� S50 _SW�QG POOL SSOn
`LODGE SSD _fRAR,EA PARK S50 _WFIDiI.POOL SZSca
�
F4QD SERVICE: �
LICENSE REQZJlttED FF.E PERMIT# L10EN3E REQUQtED FEE PERMCf tM LICENSE REQUIR�D F�E PERMII#
,TO-t�SFATS S?5 �COMII4EN1',�1t, S30 NON-PROFIT S25
,
>!00 SBA1'S SI50 COMMON VJCT. S50 _WHQLESALE S75
BLTe�.,�E8Y1�E�
I
1.ICENSE REQiJ1RED FEE PERMIT ti GICENSE REQUIRED FEE PERMIT# LICENSE RFQUIItED PERI�IIf#
_'f98ACC0 920 QS,000 sq.ft. S75 TOBACCO S
, �a50�q1t. S43 �6a_��>25,000:q.it 5200 FRO�IJ D£SSERT S S
�
r� S10 t�Movrrr Du� = S -IST`�
•""`PLEASE TURN OVER AiVD CONIPLBTE 07'[;ER Sm6 OF FORM+•+"• �
1
{ .- Aut-05-2002 09:38am From- T-341 P.003/003 F-101
ADMIlVTSTRATION
• Undar Ghaptes 152,Section 25C,Subsecoion 6,the Town of Yannouth is now required to lmld iss or renewal
of any license or permit to operate a buswess if a persoa or campany does not have a CGrtificane, f Worker's
I � Compensarion Insurance. THE AT"TAC'RED STATE WORK�R'S COMPENSATION IN§UItANCE
; AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR I
CEAT.OF]NSURANCE ATTACHED ' ,
� /
NORKER'S COMP.AFFIDAVTT SI(3NED AND ATTACHED ✓ � '
Town of Ya�mouth taa�es and liens must be paid prior to renew�'al or issuance of your petmits. PLEA�E CHECK
APPROPRiATELY IF PAID:
�( YES� NO
i�
NOTICE:Pertnits run annually from Janumy 1 to December 31. IT IS YOUR RESPONSIBII.ITY RET[JRN
THE COMPLETED APPLYCATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2001. j
i SF..t�SONAL ESTABLISI�ITS ARE TO CONTACT THE HF.AI.TH DEPARTM�N1'FOR JNSPE�TION 7-10
I DAYS PRIOR TO OPENIIJG FOR THE SEASON. '
' ALL RENOVATIONS TO ANY FOOD ESTAHLISFIIVIEN?, MOTEL OR Pf94L ti.�., Pi�IIviTtNG, NEW
EQUTPMENT,ETC.),I�itUST BE REPORTED TO AND APPROVED BY THE BOARD�F I-IEAI'TEi�PRIOR
� 1'Q CONAZENCEMENT. RENOVATiONS-MAY.REQimtE A SIT$PLAN. •
�
AU�AI A�' A'�otvs
� � , ,
! POOLS
; i
� POOL OPF.NII�G:All svvunmiag,wading and whu'lpools which have been clostd far tlu season muct be iuspxted
by the Health Depmrtment px�or to openuig. ' .
POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total colifoim.aad stendand plate couat
1 t�ereafter.
I b a State cerofied lab 'or to o and quarter y.
, P�6� .
Y PI► .
' POOL CL05II�TG:Ev'esy ouMoor in groimd swimming poql must be drained or covered within seveh(7)days of
closing. � , �
, FOOD SERVICE
C'ONSL�R D SORY:
Eech food establishmern which strves or sells ready-ta-ea�raw or undercooked animel prodUcts are required to post
Consumet Advisories. . ,
. . .
CATER3NC.POL•ICY:
Anyone who caters withia the Town of Yarn�ou�h a��natity the Yazmouth Health Deparament by filing the
reqwred Temporary Food 3ervice Application foFm 72�hours prior to the catered evrnt. T�ses fbrms can be
obtained at the Health Department.
.. �
FA�Z,F,1�[D . •RT. :
_ Frozen desserts must be tested on a monthly t�sis by a State certified lab. Test results must be sent o the Health
Departrnent. Feilure ta do so will result in the su�peasion or.revocation of your Frozen pessert Pe 't uatil tlte
above ternis have been me� .`
QUTSIDE CA� . �
Out�ide cafes('�.e.,outdooa�seating with wait,ertwa'sOress secvia),i�l�ave Pr�oa'a al finm the Bo�rd of Health.
i
�UTD09 C�OKING: �
I Outdoor cooking,preparafioq or display of any food, a or 'ce e ishuient'� pro6ibited.
I �
' � DATE: �S��Q�xSIGNATURE.' ../
�?RIIV7 NAME 8t TITLE: ' .` � Q vl��-
� r �,
09111/01 I
I �
I
{ � A ' �
� The Conrmonwealt/r of,i�lossQchusetts
� � �
''� ` � Department ojlndrestrial.�ccidents
{ � Olflcaol/e,►�s�IOsdiis
0
� : � 600 Waskiagton Street
; , •
,- Bnston, �tass 02111
� ' y '�� w'orkers' Compensation Insurance Affidavit
i M .
n1m�� /� I ( � � ��(7��S
�a�n� /� f • Z�
�t� li✓ ` y Gt r�'L�0 J fi� ehone�t 7 7 f 3�/�
� ( am a homeo�ner pzrtorm�n,all work myself.
� I sm a solz proprircor�-� ha�e no one���orkin_ in am•capacit�• �
•
�am an emplo��er pro�i�iino workers' compensation for mr•employees woricine on this job.
comnam• nam • �� �' rs'�/',�S
. _
0
�dress: /O � g/rCG d S�' �i�� /�,� � . -
�irv: �/t.r ah n i s: 77/ $lO��
nhone+� "
� . �v l sa% S ,,
insuranceco. /0 C /�i ���e�:P� /� �io . eoticv� �COD06Zj — �a
7�'-`•-
, � I am a sole proprietor. ;eneral contractor,or homeowner(circle oneJ and hace hired the contractors listed beiow ��ho ha�e's.
tht foilo��m� �� �:��
. , ;.: , .;
orktrs ;ompensation policrs: _ }� �
-
� .�, y.0 �
_ •: , a;, �� � ,., �. :�,�.
�;
comnanv�ame. „ . �� x '`� �..°�.'�F1'� �.�";'�Tf���`" �mo-+�¢�f� �^ s.�r��¢�S�`> 'u���€�
� �a a
. -, :�.. .. � .,., ; . ..... . : .� -. � .. . .. ,.� �.:� .. �� '
k 4 F
address: z� '�' ' .,
�•: �v 7- � ��,,� �� �o��. � <,�� ��,, xR�
c�n' hon N
, . : ;, . ; , . . _ , .
insurancc co. Reli�} �
comeanv name� . _. � .,..� . -
tddress: , . .
, , -
. ,, -
�, ..
, , . r , .,, �, ,
, , .,. ,.
siiY: � . , : , � .. . .� � ,. ._�. �
ehoee+�
, : ,-T�: �r.�=�; �t fl«,. �.�:a ,
insuranee co. �II�� �
•
Failure to secure coveraee as required uoder Secnoo 25A o(�NGL 1S2 n�Ind to tbe i�pwiooa o(erisi�al peaaltle�of a A�e�p to t1.500.00 a�d/or
OAt YtSR'imprysonment a�w•dl a�civil penaldea io tAe form of a SfOP WORK ORDER aad a Aae o�SI06.00 a dar qaisst st I r�dersoud t�at a :'
copy of thy statemrnt msv be fonvarded to the Ot'(ice of invesdption�of t6e OIA for eoren;e veriffatfo�, ' .
I do hrreby certif}•under tht pains and ptnaltits ojptry'wry that the injormation providtd abov�t is tt�te a�d cor►eet +
Xl� • .., , > �
Signaturc�� p�� ,f�3��A3-
Print name _ �e�� IL cJb�✓ti� ' Phone N 7'7/�1c9 a
.• o(Ticial use onh• do not Nrite in this�rea ro be completed by tttY or tow�a oflletal � �
s � s.�
tlfV O��ONfI' ��Y�II� +• • �.�-�i ��� � `:x"�� .� -��,��� ,�' :. r
' _ • — , - permit/lieea�e M 'nBuddio`Departmeot
' ' � � �° s'.'%.�'. " .,�=_ �• ...:�. a �2�,'f,°�,�a 9 ik. � �t .9 .�ys .rt"-� '`�i'+"3
�.1�lllfl0�B01f��� x�-;� � �� ":
Q cheek if immediate response i�reguired ;.•, � , a {_:v OStittfsnen'�Ofliee ' '� ` '
� � `�� ° �' ��� �� � � 267.� _.' �Hea1t�A pepartment " '` �
contact pe�son• phone M� �(508) �398�?231 ext r�C�ther '
. .ii:^ , .ayr' ;�,t n° :.�-r�'„ a+%.; �v.' .� ;'s:� a :��;i,�.,,,� ;f V k� 4�.:;�.� f,
`* �•
. . . • . ' _ • �� � .:e . � :.
. . _ ' . , . � . t Lr�,�r'.B:}�'
�Y�,�, � sro���
� � � . - . :�.
tiMmfshe�'F�uinitur'e. 1�obdenware .Cra+ts �
� - 548-�71>-8100
� .. . ,, � _
�` 10 B EE��L Rb. �HYAIVNI�, MA d'26Q�"�"�` , �' '�A�a0$-7_71-828D
August 7, 2002
Yarmouth Health Department
1146 Route 28
South I'�;rmouth, MA 02&6�
Dear David Flaherty, Health Inspector
Mill Stores hereby certifies that all of our employees are covered by Workmen's
Compensation insurance as required by the Commonwealth of Massachusetts, Maine,
New Hampshire, and Connecticut.
Our W�rkmen's Compensation policy i�held at the Mill Stores Corporate office located at
108 Breeds Hill Road, Hyannis, MA and is available for inspection.
Mill Stores Workmen's Compensation policy is valid and in force. This affidavit is signed by
Philip J. Baroni,Presid�nt of Drive O Rama, dab Mill Stores and notarized.
Yours truly,
�Cl/�-`�JC�t.1�,�n i�u��
Barbara Burke
Office Manager
SvbscrEbed and Swom to befor�m�
t is �'#$�day�.c�f �4t.c. "��3C'�oL .
_ - . ,� , .
_. .
� � �
iviL�AR.PINA-LINDSAY,NQt�ry PubliC
�� , ; .: .. � .
��/a � o3
All Solid Wood • All Solid Value ;
,
�
�
� � �
� TOWN OF YARMOUTH
� BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLJMBER: #02-065 FEE: $45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
PhilitzT. Ba_r�ni/l�rive-O-Rama_ 39 RoLte 2R, We�t Y rm� � h, MA
Whose place of business is: Mill Stores
Type of business: Retail Food Service less than 50 square feet
To operate a food esta.blishment in: Town of Yarmouth
Permit expires: December 31,2002 BOARD oF HEAI,TH: elcanPea� ze�!P,�Z, L��c
t e.r�i�c D. C�iond.o�. �11L.D.. 2/�ce
�a�act� �aoao�. L�
�aatic���tilrot�"
�� s�. ��
August 12 ,2002 B ce G.Murphy, , .5.,CHO
Director of Health
�..
, ,
, ,.�
� �d ,
`� i l 1 �C—
. TOWN OF YARMOUTH B(�" `Y(�� AT:TH � � � � � � � �
APPLICATION FOR LIC�N
���iT-Z000 DEC 3 0 1999
� ',. � ���S 3����E�"
* Please complete form and attach all necessary documents by December 31, 1999. F H A in
`the return of your application packet.
------------F ES-------------------------/1'1 i l I--s--�-�------------------------------------------------#---------_3--------_.
L A I �'- W � ,�' ov o �73
��4ILING ADDRES$� Io$ Bre�. 5 Ni� I k Nuu►�n�s n�R o,�6v �
N Oriv -o- Gt c -
' ' C, � OWS� � # '77/-8/Op
lY�AILING ADDRESS: /.�R $�' s fl:I 1 i2 - 1-Fti an w�,S � /►1 f� o Z-6a�
- - - ------ ------------------------------�.
POOL CERTIFi ,ATinTTS.
The poot supervisor must be certified as a Pool Operator, as rer�uired by n�w State law. Please list the
designated-Pool O atar(s) and ��tach a copy af the certificatic�n ta t1�s forrn: - --
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water sa�ety, 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
j new copies and main in a file at your ptace of business.
�
i j 2
� 3. 4.
HEIMLiCH�F�R_TIFICATIONS:
All food service establishments with 25 seats or more must have at least ane employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employ e certifications to this form. The Health Department will not use past years' records.
You must provide n copies and maintain a file at your place of business.
i
� 1. 2.
3. 4.
1 RESTAURANT�EATING: -TOTAL# � NON=SMUKINC�-SEATS: TOTAL�# _ _ 7�`-'_- _
, _-------------__------------------------------------------- ---•---------�--------------------------------------- --------------_______.
, --- -
OFFICE USE QNLY
I.ODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50
1NN $50 CAMP $50
LODGE $54 . ��� . TR�A�:ER PARK $5+�
, _MOTEL $50 SWIl��IlVIING POOL $SOea. ,
WI�LPOOL $ZSea..
FOOD SERVICE: —
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 � NON-PROFIT $25
_COMMON VICT. $50 � WHOLESALE $75
RETAII. SERVICE•
LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
�<50 sq.ft. $45 y2 - _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35
>25,000 sq.ft. $200
IYAME C A GE: $10
AMOUNT DUE _ $ 4Gj-'
*""'"PLEASE TURN dVER AND COMPLETE OTHER SIDE OF FORM•""'•
� !
�.p'My ` ADMINISTRATION � , .
UI�TDER�HAP'I'ER.152,s ECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED�,
TC) HOLD ISS�.J.�NCE �R RENEWAL OF ANY LICENSE C1R PERMIT TO OPERATE A BUSINES5 IF A
PE�Sfll�`OR ��l't�'�iY DOES NQT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
1NSURANCE. 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 (3F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK AI,;I�ROPRIATELY IF PAID:
YES �� NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQLJIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTM�'NT FOR INSPECTION 7-10
DAYS PRIOR T4 OPETTING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ;
EQUII'MENT,ETC.),MUST BE�tEPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO
COIVIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i
!
f
�I�DITIONAL REGULATIONS
POOLS �
POOL OPENIlVG: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR
____ PSEUDQMONAS, TQTAL CiJLIF�RM AND STANDARD PLATE COUNT BY A STA'T�GERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
�
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlvIl��IING POOL MUST BE DRAIlVED OR COVERED ;
WITHIN SEVEN(�)DAYS OF CLOSING. �
�
�
FOOD SERVICE
CATERING POLICY: '
ANYONE WHO CATERS VVITHIN THE TOWN OF YARMOUTH MUST NOTIFY TF�YARMOUTH HEALTH '
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 �
HOURS PRIOR TO T'HE CATERED EVENT. THESE FORMS CAN $E OBTAINED AT TI-�E HEALTH �
DEPARTMENT.
FROZEN DE S�ERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN THE '
SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE
- _ BE�N IVI��- --— ----
--- -- _ __ _ _ _
- --- _ __ _ - ---- _ _ ,
OUTSIDE CAF� :
OIJTSIDE CAFE5(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
QUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD
SERVICE ESTABLIS�-�YIENT IS PROHIBITED.
DATE: I 2 2�r °��i SIGNATURE:
PRINT NAME& TITLE: � v b� �+-o ,�,C�� „t✓n �LQ�
11/12/99
, ' . "� �\
' The Commonwealth of Massachusetts
� � Department ojlndustrial.-�ccidents
� � a olflceol/ar�st/os�iis
I 600 Washington S/reet
` ' ` Bostvn, Mass. 02111
.
V
~ �� W'orkers' Compensation Insurance Affidavit
Anolicant information: p►e�sepR '�•�•
nam�� /rl !�� 7�✓�S
Lacation: �� Y �
tit� (/V• 7�l✓�l7'LD(,��- phone# 77.5 J����
� I am a homeow�ner pertorming all work mysdf.
� I am a sole proprizror�r.� ha�e no one «orkin_ in am•capacin�
.
�am an employer pro��din�workers' compensation for my empio��ees w�orking on this job.
- -_ _
_ __ _ _ ----
- ---- - -—_-- _ _ _
. _-- _ __--_
—--_ _
� S��S _ -
s4moan�• name: � � r
address: J � g B 1r{.Q�d S ����� /e�l •
iitv: ��1 Q h i'l l�f ehone M• 77�� 8100
i_r��ur�nceco W�10lCtal,e �/�E�1��_s�leD�1�Lr� C�7 CDT �o�1Cy!! L✓Gd�D��3 ��
� I am a sole proprietor. :enerai contractor. or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu��in� ��orl:zr �ompensation polices:
somoanv namr
��dress•
citv• nhone q•
insur�ncc co. Folic}•�
�moanv namr
_--- _.�—_____ —
-- -- ---
_ _ _ _ ___.
iddtess:
sitv: nh�II�t�.
insurance co. ��,*
a
' Failure to secure cover�ee as required under Secnoo 2SA of MGL 1S2 ea�lad to tbe iepoeitios o(erisl�i pe�dtla of a O�e op to 51�00.00 a�d/o�
oae yean'imprisonment a�w�ell��eivil penaida in the to�m of a STOP WORK ORDER aed a Aae o�S100.00 a day qtiott ma [a•dersn.d ma�a
copy of thia statement mav be fonw�ded to the OfTice of Investig�don�of tbe DIA for eoven�e veritftati�.
/do.hrreby certi}•un er the ins and penal�i�s ojpery'ury thar rl�e injornration provrded obovt is trtr[aitd evrrect
Signature J�����"'�'w g`t
/�� �
Printname � 1\v6i v�.�0 onell '�'7/•—�C� �
�
.. olTicial use only do not..�ite in this area to be completed by eiry or town oAfeial
ciry or town: Y�M�IIT� _ permit/licenx a nBuildiog Departmeot
OLiceasiog Board
�cheek if immediate response i�required 261 �Stiectmen'�Otfce
�HesltA Depanmeat
cont�ce person: phone M:_ t508� 398�2231 egt. nOther
,n. .��. � .< :11,�,
' TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-44 FEE: $45.00
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:
l�rive-n-Ram , Inc_, �9 R� � R, West Yarmo� h, MA
Whose place of business is: Mill Store
Type of business: Retail Food Service less than 50 square feet
j To operate a food establishment in: Town of Yarmouth
� Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. ��1��, C'����,�
�oan� �ullivan� K.�� Vice l.hairma
Ko�erE.}. p�rown, l,lerh
a6ri�Lle�a�ola�Zc�-...�toope�
ichael oCou�h[in
i
January 25 ,2000 ruce G.Murphy,MPH,R.S
Director of Health
- - -----• ••-. ���4u���r sucn empio��ment be deemed to be an empio}er.
�iG[_ �I�a�rer I�� ;«ti�,,� _: a�;�, ;tates that e�•en- state or local licensing agenc}•shail n•ithhol
�ene���al of a license or permit to operate a business or to eonstruct buiidings in the common ea� �ssuance or
:�pplicant ���ho has not produced acceptable e�•idence of compiiance xith the iasurance coverage re ui red`
.�ddici�,nall�, neitlier the comrnc�n��ealtli nor an�• of its political subdivisions shall enter into an}•contrac9for the
pertormance of public ��ork until acceptable evidence of compiiance tivith the insurance re uireme
brc:n presented to the cuntractin� �uthorit�. 9 nts oFthis chapter ha�e
.�ppiic.:nts
Please till in the workers' compensation affidavit completely, by checking the box that applies to�•our situatian and
S��Pp������= c�mpan} n�mes. addres; and phone numbers as all affidavits ma�• be submitted to the Department of
lndustriai Accidents for contirmation uf insurance coverage. Also be sure to sign and date t6e affida�i�
attida�it siiould be returned to the citv or to��n that the application for the permit or license is being re uestedThe
not the Department of industrial .�ccidents. Should vou ha�•e anv questions regardin¢the "faw"or if ou are re uired
to ohtain a ��orkers' compensation polic}�, please call the Departmeni at the number listed beloa•. 9
City or Towns .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a ace at the
the a�davit for you to fill out in the event the Office of Investigations has to contact ou � �nom of
be sure to fill in the permidlicense numixr which wiii be used a�a rcfq,ence���,The����g the appiicant. Ple�se
the Department by mail or FAX unless othec an�an � ��s maY be ceturned to
gements have been rnade,
,-,,.. .,��_ ,.. . .