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Home My WebLink AboutApplications, WC and Licenses , . � _ . � !�_�..L�d,Cc-�,- �,�,.w, . _.��. ; };JE Y�k�s TOWN OF YARMOUTH BOARD OF HE,�L� �� , a . . Y��a APPLICATION FOR LICEN$E/PERIV�T-�0�$�� " \� ,/�O V 1 � 2 0 0 7 ,,_��. ; *Please complete form and attach all necessary docum��,z�s by ecember 3 qp7„ � Failure to do so will result in the return of your application packet. � ` ' __e _ _.__ �....._ ; NAME OF ESTABLISHMENT: C:IZ1 A C3�12 � J�'(��5�/�.� TEL. #.��'�3�Z�3�d/ � LOCATION ADDRESS: � J /�l j o w 1--1� . i G� ' / i MAILING ADDRESS: �� ' � />D1 ,1-. /��J �, OWN�R NAM�: �J � ! � ` `''\ IN r N - � MANAGER'S NAME: �'l� J��/� S �_�2.-L� w �s S ,t� i i.l"1 TEL. #.3dg'�Yg'7 713� MAILING ADDRESS: z�,t�1�.� s }�_�A/~if�rA—�1,� p/.as2 l� /��.1� l�7 /�;�_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated __ __Pool O�rator s�and att ch a cnnv nf thP �Prr�firatinn xo,t�is for� _ _ ---- -- - � L 2. , , Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach co ies of em lo ee . p P Y eertificarions to this forr�. T�te Health Dep�rtment w�ll not use past yea�s' reeords. 1'0� �►ust pravid� nev�r 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. Flease attach copies of certificationto this applieation. The He�lth Department wi�l not ase past years'rPcords. You must provide new copies and maintain a file at your establishment. 1. 2 -PER��N�N 5��,��'aE;__ _ _ _-- - __-_. _ -- -- _ _ __ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � , HEIMLICH CERTIFICATIONS: � All food sernice 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-chokuig procedures below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL # �I� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'vIIT#� LICENSE REQL'IRED FEE PER'�I1T* LICENSE REQUIRED FEE PER'biIT= _B&B S50 _CABiN SSO _MOTEL S50 �INN S50 _CA1�IP S50 �SVVI'_�L��INGPOOL S75ea. _LODGE 550 _TRAILERPARK 5100 _�L'HIRLpOOL S75ea. FOOD SERVICE: ' LICENS£�tEQUIRED FEE PERMIT# LICENS£REQUIRED FEE P£I�L'�ZIT� LICENSE REQL'IRED FEE PEI�L'�IIT= J 0-100 SEATS $75 _��C�� _CONTINENTAL S30 _NON-PROFIT S3� >I00 SEATS S150 / CO:�L'�ION VIC S50 �OP>'�3 _w1-IOLESALE 575 RETAIL S�RVICE: —RESID.KITCHEN S7� LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERtitII'= LICENSE REQL'IRED FEE PER1rIIT= _<50 sq.i�. �45 >>25,000 sq.ft. S200 _VENDII`;G-FOOD S20 _<25,000 sq.ft. S75 _FROZEN DESSERT S3� _TOBACCO SSO :v��c��vcE: sio AMOUi�T DUE _ $ i Z S.o0 *****PLEASE TL'R\O�'ER�l.`D CO�TPLETE OTHER SIDE OF FOR�Z***** � � - ; An�s�TTON � � � 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 dces not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE E AFFIDAVIT MUST BE COMPLETED AND SIGNED, QR CERT. OF INSURANCE ATTACHED , OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPR4PRIATELY IF PAID: YES�� NO �V-� - MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUP'ANCY: For pwposes 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 mot�l and hotel us�. ; Transient accupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)manth 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: Enciosed Motel Census must be completed and returned with this application. ' POOL3 POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' ec,�ted by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days gnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a S�ate certified lab, prior to opening,a�d quazterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closin�. � i FOOD SERVICE ` i , 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 obtau►ed at the Health Department. FROZEN DESSERT5: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit urrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval from the Board ofHealth. OUTDOOR COOKING: . . . . _ QutdQpr�Q-91ung,-p�r�Pa.ration,or�isglay Qf any fQ�prnducth�arstail nr food serxice ___ _ _. l NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ; k ALL RENOVATIONS TO ANY FOOD ESTABLISHII�IVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQIIIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RE:VOVATIONS MAY REQUIRE A SITE PLAN. , � .� __ , �I � O SIGNATURE: �1� !�� DATE: �� z- �� PRINT NAME&TITLE: I'�� Z �� '� � . J�e�/C — � �o;o„� p��- s � 1�,�'.��--- • Nov, 27. 2007— 2:30Pa' No, 3555 P....1/2,�o,w,,,� ; ��u C�RTI�ICATE OF LIABILITY INSURANCE iiioi�zoo� rrzoouceR (508)997-6061 FAX (508)990-2731 THIS GERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 439 State Rd. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 � � � � n �' � DD INSURERS AFFORDING GOVERAGE NAIC# INSURED Abbicci Restaurant WSURERA: Arbe��d PI"OLeCtl01'1 Insurance { 43 Ma i n St reet '�v�� L U l�l INSURER B: ; Route sA HEALTH DEPT. �NSURERC: � Yarmouth, MA OZ6�S INSURERD: INSURER E: � COV : ES THE POUCIES OF INSURANCE LISTED BEL01N HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INOICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIf ICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFfORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TNE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' 1ypEOFINSURANCE POLTYEFFECTIVE POLITYEX�PIRATION LIMITS 7 WS POLICY NUMBER GENERALLIABILI7Y 8500025905 08�01�2�07 OH�OI�ZOOH EACHOCCURRENCE $ 1 �� 00 X CONMERCIAL GENERAL LIA8ILITY DAMAGE TO RENTED $ zSO,OOO CLAIMS MADE �OCCUR MED EXP(Pny one person) $ 10,�� A PERSONAL 8 ADV INJURY $ 1,OOO,OO GENERAL AGGREGA7E $ 2�OOO,OO � GENl AGGREGATE LIMIT APPLIES PER: PROpUCTS•COMP/��P qi�G $ Z�OOO�OO POLICY �E�7 LOC AUTOMOBILE LIABIIITY � COMRINED SINGLE LIMIT $ ANY AUTO (Ea actidenq ALL OV�mED AUTOS BODILY INJURY $ SCHEDULED A11T05 (Per person) HIRED AUTOS BODILY INJURY NON-OVVNED AUTOS (Per accidenq $ PROPERTY DAM4GE s (Per accider$) GARAGE LIABILITY NUTO ONLY-EA RCCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: NGG $ EXCESSlUMBRELLA LIABILI7Y EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ $ DEDUCTiBLE S RETENTION $ $ WORNERS COMPENSATIONAND 9083000806 08��1�2007 �8��1�2�08 WC STATU- OTI-F EMPLOYERS'IIABIIITY T RY IMIT A �FFICER�rtv1EM6 R E�LUD D�C�� E.L.EACH ACGDENT $ SOO,OO i If yes,descnbe under E.L.DISEP.SE-EA EMPLOYE $ 500,00 SPECIAL PROVISIONS belrnv E.L.DISEASE-POLICY L iM1T $ 500,00� � OTHER I DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES!EXClU310NS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CE IFIC T HO D C NC O SHOUID ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE THE EXPIRATION OATE THEREOF,THE ISSUING�NSURER WILL ENDEAVOR TO MAIL TONR1 of Yarmouth lO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Li censi ng Offi ce BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 46 Route ZH OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ; 5. Yarmouth, MA 02664 AUTHORIZEDREPRESENTATIVE Krista Hartford ACORD 25(2001/08) F�� (508)760-3472 OACORD CORPORATION 1988 � N�v, 27. 2007— 2: 31P�" No, 3555—P, 2/2 IMPORTANT � � If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.A statement � on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). x If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract beiween the issuing insurer(s),authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. � i � AGORD 25(2001108) I f . , , . . ; i '. TOW1�T OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NIJMBER: #08-003 FEE• . $75.00 In accordance with regularions promulgated under authority of Chapter 94,Sectinn 305A and Chapter 111,Secfion 5 of the General Laws,a pernut is hereby granted to: + _ Cranb Moose, Inc., 43 Route 6A, Yarmouthport, MA Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD oF I�ALTH: 3f.el'eri SR�a�i, J2..lV., C'Rrt�cixnuut CR��u��vic�e�e�`e �.9G�'��`U�,i,ce C�rai�cn�n � SEATING:96 .�.�t�t�(J��J(��YOW�fLa �'CQ![�. Utut��n, `.h?..JV. , , November 16.2007 Bruce G.Murphy, H, .,CHO Director of Health THE COMIIZONWEALT�I OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-003 FEE: $50.00 This is to Certify that Cranberry Moose, Inc. dlbla Abbicci 43 Route 6A, Yarmouthport,MA IS HEREBY GRANTED A COMMON 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 violanon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensing authoriries by General Laws, C�apter 140, and amendments thereto. In Testimony Whereof, the undersigned l�ave hereunto af�uced their official signatures. BOARD OF HEALT'H: 3�,ft $� f�At�i, J2,.N��,�,��(�n' �tu�t SEATING: 96 \7iZiVliKA .T�. a�,/��1�IL�lI.('Jb Vu.e ✓`i.v.GEent t. ✓`3�u�tt, ('!� CZr��i r.�aurn, J`Z. . November 16.2007 Bruce G.Murphy, , . .,CHO Director of Health ��.�-- �18at C.GI - ` '°`;aR� TOWN OF YARMOUTH BOARD OF HEALTH � � � � '� �' M � � i 3� `c APPLICA'I'ION FOR LICENSE/„�ER�IT=�i� �t C j $ 2006 F: /? ' . � \ * Please complete form and attach a11 necessary dt��ur�ei��bt� ce b$��J��2�6pEPT. Failure to do so will result in the refurn oi�y�u�app�ication pac e . . NAME OF ESTABLISHMENT: �bb i�,; TEL. # (.so�) .36.z-3Sol LOCATION ADDRESS:__9_� M,4i� Srn.��r y�mo�, I�orLt� NtA ozb7S ' MAILING ADDRESS: sA-m,� � OWNER NAME: I►'�t2t tiTA $, ��cx�Y Tt�X T�(FEIN or SSN}� � CORPORATION NAME(IF APPLICABLE): CR�q�A� //1c+��, �C. MANAGER'S NAME: /r/y,�i0 /I7R�A�v/ TEL. #(svfl)398-b4a7 MAILINGADDRESS: 93 T�1�l��A-PN �dAa ��..��v« rL�, M� 0�9� 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 atta.ch a cQpy_Qfthe c�ertification to this form. _ _ ___ 1. 2. ; Pool operators must list a minimum of two employees cunently 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 maintain a file at your ptace of business. � L 2. ; 3• 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. , You must provide new copies and maintain a file at your est�blishmen� �� '``� � � --j�A F!�" S L-r�c� � --�' 1. ; ; 1 ��,�� l�/�J 2. 7�°� /`L, _ _ _P��ZS4N Il�C�i�RGE: __ -- — ___ __ _ - _ __ __- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operatian. 1. �1��.to �1P�2��1� 2. �I t e,�+a�ct� �PirZl n� I HEIMLICH CERT'IFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department wiil not use past years' records. � You must provide new copies and maintain a fde at your place of business. 1. 2, 3. 4. RESTAtTRANT SEATING: TOTAL# Qlo .�._ OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PBRMIT# LICENSE REQUII2ED FEE PERMIT# _B&B a50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIl1�IIvIlNGPOOL$75ea. LODGE $50 _TRAII.ER PARK $100 WHIItI,POOL $75ea. FOOD SERVICE: � LICENSE REQUII2ED FEE PERMIT# LICENSE REQIIIRED FEE PERMIT# LICENSE REQtJIItED FEE PERMI'T# ; �0-100 SEATS $75 �6"��0( _CONTIlVENTAL $30 NON-PROFff $25 _>100 SEATS $150 / COMMON VIC. $50 � ,0 _WHOLESAL,E $?5 RETAll.SERVICE: —RESID.KITCHEN $75 LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE pEI2MIT# ,<50 sq.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _45,OOOsq.R $75 _FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOITNT DUE _ $ /Z S•OO =*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•'••" , _ '-"'+�*�af I , ` [; � ' ADMINISTRATION j 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 j Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUS�'BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED � �X� E OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � f Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �s J No MOTELS AN� 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 afresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an aggregate of not more than nineiy(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection af Room Occupancy � Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. i f 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 ogening. Contact the Health Department to schedule the inspection five(5}days pnor 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 therea.fter. POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of � closing. FOOD SERVICE CATERING POLICY: j 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 obtamed at the Health Department. FROZEN DESSERTS: Froaen 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 sa will result in the suspension or revocation of your Frozen Dessert Permit until the above terms ha.ve been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR CQOKING: Outdo�r c�king,pr�gar�t��displa.y_of an�foosi_protiuct by a retail or_fos�d seruic��stabli�n�is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-�COMPLETED APFLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVfENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TQ AND APPROVED BY TE�BOARD OF HEALTH PRIOR TO COMIVV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: Z I� � � SIGNATURE: �� PRINT NAME&TITLE: 1�� /(`i C J� �o,�„� p.�� / D��-�— � � Dec. 13. 2C06— ::41Pn — �y • A��a C�RTI�IC�,� 4F LIABILITY INSURA' 'E u�� 1�� 12/13/2 0� PRODUCER (508)997-6061 FAX (508)990-2731 THIS CERTIFiCATE IS ISSUED AS A MATTER OF INFORIWATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 439 State Rd. HOLDER.THIS CERTIFlCATE DOES NOT AMEND,EXTEND OR j , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 . N. Dartmouth, MA 02747 � (� N� � � RERS AFFORDING COVERAGf NAIC# iNsuReo Abbicci Restaurant - „ _ , irrs� eRa: Arbella Protection Insurance 43 Main Street � ,, p�G.�l";8. 200 u.s� Re Route 6A ` ' _ $ ' • . iHs� Rc: Yarmouth, Ma oz67s HEALTH DE RD: ' , , INSI RER E: � COVERAGES i THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA7E0.NOTWITHSTANDING ANY REQUIREMEIYT,TERM OR CONDITION OF ANY EONTRACT OR OTHER DOCUMENT WITH RESPECT TO YJHIpi THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D' TypE OF INSURANCE POLICY NUM6ER Pp��EC71YE POLICY EXPIRATtON LIMITS LTR NS GENERALUABILI7Y 8500025905 08/Ol/2006 08/Ol/2007 �CHOCCJRRENCE $ 1 000 OD X COMMER�IAL GENER?L LIAB LI-Y DAIARGE T��REtJTEO $ 2SO,OO C AIMS�1,4DE �O�CUP. R1ED EXP�P,n��one person) $ 10�� A PERSONAL&ADV INJURY $ 1 ODO OO GE�dERAL AGGR=GATE $ Z�� i C��'L AGGP.EGATE LIMIT PPFUES PER: PRODJCTS-CCMP/CP AGG $ Z�OOO,OO P�LICY jEa LOC AUTOMOBILE LIABILITY COiABINED SINGLE UMIT $ AVY AI.ffO (ca accidert) � A_L�WNED FWTOS j BODiLY N.�l1P.Y $ {� S�FiEOULED RUTOS (�e�p=reon) 1 HIRED AUTOS BODILY NJUP.Y N�t�OdvNEO AUT05 ('e�a�cide�t) $ PROPERTY D?AM.GE ('e�a�cide�[} � ' GARAGE LIABLITY l,UTO ONLY-EA ArCIDENT $ � AVY AUTO OTHER"MRN ,� �A��C $ l+UTOONLti": AGG $ EXCESSNMBRELLA LU181LITY EACH OCGRRENCE $ OCCUP, ❑C�,IMS A1ADE ,SG6R=GATE $ . $ DECUCTI3L= $ R=TENTION $ $ WORKH2SCOMPENSATIONAND 9083000806 �8`�Z�Z0�6 �B�O�.j2��7 �NC�"TP.TtI OTI+ O 1 IT EMPLOYERS'LU1BILfTY E l E4CH ACCIDETtT $ SOO OD A AtJY PROPF2IETOR�PARTNER.'EXECUTIYE OFFICER/MEM�R EXCL�DED? E l DISEASE-EAEMPLOYEE $ SOO,OO f yes,descriGe under ' SPECIP�PROVISI�NS below E l DISEASE-POLICY LIMIT $ SOO,OO OTHER ( I j OESCRIPTION OF OPERATIDNS f LOCATION31 VEHICLES 1 EXC�USIONS ADD�BY ENDORSEMENT!SPECiAL PROVISIONS ; or any and all operations perfornied during the policy period. � i � CE TIFICATE OLD R CA SHOULD ANY OF 7HE ABOVE DESCRIB�POLiCIES BE CANCELLED BEFORE THE EXPIRATIOM DATE TH92EOF,THE ISSWNG IN3URERVNLL ENDEAYOR TO MAIL TOWI7 of Ya rmouth lO DAYS WPoTTEN N0710E TO THE CERTIFICATE HOLOER NAMED TO THE LEFf, At tn: Ba rba ra Bllr fAILURE TO MNL SL�H NOTICE SHALL MPOSE NO OBLIGATION OR UA61LfTY 1146 Route ZH , OF ANY KIND UPON TFE MSURER,RS AGENTS OR REPRESENTATIYES. Yarmouth� MA OZEE4 AUTNORIIED REPRESENTATIVE Krista Hartford ACORD25(2001108) FAX: (508)398-0836 OACORDCORPORATION1988 1 � { 12-18-06 03:51pm From-SOUTHEASTERN INSURANCE AGENCY 50B-79D055P T-264 P.Dt/O1 F-401 � PROq!lCBR _ - -- -�� ••• •■�•�� Zz�l$�ZOOG , (508)997-6061 FAX (5p8}g9p_Zy31 THis CERrrFfGpT�IS�S8UEo qS p TER OF INFORMAYION Southeas tern Insuran[e AgeqCy� TAC. ONLY AND COIyF�R$NO RIGNTS UPO THE CERT1FICATE 439 Stat e Rd. HOLOER.THIS GERTlFICATE bUES NO A�AEND,EXTEND OR p,O, Ro� 7g398 A�.rER n-��covERAGE AFFaRDE�a 7HE pouclEs BELow. N, Dartrt�outh� MA OZ747 INSURERS AFFOj2DING Cp�RqGE '"'s�� Ab �Cc Restaurant • NAIC� iNsuR�an: A��11� Protectian Insu ance 43 Main Street iNsuReRe: Route 6A �NSWRFR C: Yarmouth� � QZ67� INSURER D, INSURER�. Cb RAG S 7htE POIaCh:S OF INSURANCE LISTEO BELOW HA1I�B€EN�S5C1ED TO Tt1E INSUREO MAM�p RgOV�FOR 7HE POLfCY PERIOD t �DiCA7ED,1VOIWITNSTANDING ANY REUUIItEMENT,7ERM OR CONDITiON OF ANY CDNTRACT OR oTHER DOCUMCN7 VVITH R�SPEGT TO wHICM THIS CERT�FI TE MAY BE ISSUED OR na+4Y PEKTA�N,THE INSURANCE AFFORD�D BY TH�POUCIES DESCRIBED HEREIN(S 5U8JECT TO A�L TFIE TERMS,EXCLUSION AND CONDITIONB OF SUCH ! POLtCIEs.AGGREGATE UMffS SFIOwN MAY HqVE BEEN REDUC�O BY PAfp CG,q�Mg, IN$R 7ypE OF INSUR/Ip�CE ' Pa►CY NUTABER pOl�r EFFECTME POLICY EiCpIKATIpN rr�,��;aG►.we��mr 8SOt102S905 08/Ol/Z006 OS/pI/20a1 eacHoccuRR� e urRs� X cout�ERcuu�eNerw.�u�aiuTv DAMAGE TO RE o ��OOQ 0 �cu�iMs Mw� X�occua $ 250,00 A M�o e�u4,,. �, � �a,o: PER80wAL 8 ADv N.IuRY 3 1.000�00 CEM�.AG(3REGATE 41A91T APPLIE6 PER: GENERAL AGt3RE TF S �r OOO�OO 11'OLICr jE� LOC PR�DUGTS-CO►d► /OP/lGG i z.0��,Op auron�o��e uae�u�rr �,NYAI►TO ��81Nf3L Lµ�R 8 r.�L owNeD quTas t Ch�EDULEO AUTOS 8001tY�ta�URY s (Per peraony hiR�p AUTOS N�N-0WryF.O/U/705 60D�LY INJURY (Per accloen�y 9 PROPERTY OANIA � � cP��,u Gawa,E uaearrr ANvnuro AUTO O�ILY-EA A IbEN'� S OryeRTNav �►acc s AUTO ONII^ � _ E7SCF5Sn1P98RELLA UA�tATY �acrt occur�eroc- � O.:CUR �clrqlM6 MA6E ��E�� S Di:DUC71flLE S Rf iTEN710N S � t '"°r�R�c�"'°�"s"no�+�wo 9083p008U6 08 Ol �006 08 Ol/2007 � �aePsorErts�uaeiurr / / / wc srnru. orM- A ANY PROPRR TORJPpRYNERIEXECVTNE E.L.EACH RCCID f g OFFICEwME116ER ExC�upED? SQO,QO %in+s cwscna•Wnaw E.L DISEASE-EA�1 p�pYE = 500,Op SPFCl4t ARDJ�SIONS below OTHER E.L,DISEASE.PO4 Y LIM�IT � 50Q�� DE9CRIP170N OF OI•ERATIDNS I WCATIpHg/yEMfCLE3!E1�CLV9IWJS A�DED BY ENDORSEMENT!SPEC1qL pRWI1SqN8 ANY ANp ALI. OPERA7'IONS PERFORMED DURING POLICY PERIOD —.�_ .%ERTIFICATE i C sNOULO ANY OF THE ABpIfE I��SCRIBED POLICIES BE NCELLED BEFORE TNE ��RATf01d DA7E THEREOF,TFIE ISSUING INSURFR NN ��NOEAVpR 70 NUUL TOWfl uf Yarmoe,th 1� OAY9 WRITT�N NOTtCE TO THE CERTiFiCATE D�R WqAilE.f,}TO 7HE LE�, Heal tl� �epartn�nt euT Fn��.ua�ro wuu�sucH NoncE Br„►c�,upos�,�o ��qnpN oft uaeK.rn Rte 2� Op qp11f KWD t1PON THE INSUqER,ITS AG�NYS OR REpp ENTATIVe&, S Y�rnbuth, MA AUTMOtuzEpR�pRES�NrATryE �oan Mdrt�n �coRv 25(Z00 iroe) FAX: C508)760-3472 • BAC d CdRPQRA710N 1988 � ; , ` � , • TOWN OF YARMpUTg BOARD QF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIVV�NT PERMIT NUMBER: #07-101 FEE: 75.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a pernut is hereby granted to: Cranberry Moose, Inc_, 43 Route 6 Yarmouthport, MA i ; Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2007 BOARD oF HEALTH: Qe `n. �,/yj,�y,� d(-e .�'�_`�lr�, �./V., ?lrQe C�a�ss SEATING:96 R�9PJlL t. Bh4G�� e� P��1�� l.�.��.�d��, R./Y. March 23.20Q7 Biuce G.M y, , S.,CHO Direcfor of Health _ __ __ _ _ _ _ __ __ _ _ _ _ _ __ _ . _ THE COMMUNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-066 FEE: $50.00 This is to Certify that Cranberry Moose Inc. dJb/a Abbicci _ 43 Route 6A,, Yarmouthport, MA IS HEREBY GRANTED A � COMMON VICTUALLER'S LICENSE i In said Town of Yarmouth and at that place only and e�ires December thirty-first 2007 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers_ This license is issued in conformity with the authonty granted to the licensing authorities by General La.ws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto aff�ed their official signatures. BOARD O�'HEAL,TH: L3esr�-.�u� �,5. �, /yl.�., G��u� SEATING: 96 �� s/ZG�Z� ��1 !U((;p (��tGN(�INK,s�L Ro�G�`�. �(3�,u�s, G?l��k /�c�sek/Llc�S�� ! , R March 23_2(�7 ruce G.M hy, , S.,CHO . � Director of Health : � . � a�� Ae��.� i of f R.� TOWN OF YARMOUTH BOARD OF HEALTHu �,,, ,-� �, ,� „ ,_ � - --`o APPLICATION FOR LICENS��:I�lY��-2�06`i `'�''�� `� � � �- '� �, � -�� F: ,,�$ � � ° � �; �, �; 2U05 i * Please complete form and attach all neces do�t`., ' �ec�tnbe 3 l, �0�5:' � , Failure to do so will result in the retu�of your app�ication pack • H E AL r ri L�tI'T. NAME OF ESTABLISHIVIENT: a.l>b r c c� TEL. #��a�)��-3 so/ LOCATION ADDRESS: 43 M��,u s�Er Y�+2movf�►� �O�r+, M� 0�7 S MAII.,ING ADDRES S: S�rnG OWNER NAME: mA'��-�- C� l-hClc.��{ TAX ID(FEIN or SSl�: 0�{^2�28d2$ i CORPORATION NAIV�(IF APPLICABLE): �b�,�'� /YI oosE .�C. MANAGER'SNAME: i�i2atif�'c� g, ��Y �� TEL. #��?i�� 36�-S99B , MAILING ADDRESS:�O /3ox zi 8 C,vmm�Qv i��, MA� 0 2.6 3 7 i E POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ; __ _ __ -- _- __ _ -- - _ ._ l. 2. � Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yau must provide new copies and maintain a file at your place of business. � 1. 2. � 3. 4. � FOOD PROTECTION MAI�TAGERS - 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 Sa,nitary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certifica.tion to this application. The Health Department will not use past years' records. E You must provide new copies and maintain a fde at your establishment. . 1. /l�liGLiCrP� /�:�'i/ii 2• t j PERSOl�_Il��H.�GF' ��_- - - ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. L 2. HEIlb��CH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and � at�ae�i cvpies of employee certifications to this form. The Health Department will not use past years' records. � You must provide new copies and maintain a file at your place of business. � i 1. �'-�9 7�s��r� 2. /�h'1 LU//li�t/ � 3. ,��r��r r�� 4. RESTAURANT SEATING: TOTAL# �S� ` f OFFICE USE ONLY � LODGING: � { LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# ; i B&B $50 CABIN $50 _MOTEL $50 _j INN $50 CAMP $50 _SWIIvIlbIII�TG POOL$75ea. LODGE $50 TRAII�ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 (xo-'O'?� CONTINENTAL $30 NON-PROFTl' $25 >100 SEATS $150 �COMMON VIC. $50 �C�(�—OS� WHOLESALE $75 RETAIL SERVICE: LICENSE REQUII2ED FEE PERMPf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# ! _<50 sq.ft. $45 >25,000 sq.ft. $2Q0 _VENDING-FOOD $20 ! _QS,OOQsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25 i NAME CHANGE: $10 AMOUNT DUE = S I ZS•OO "•••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" I �� ! i i ._ ' � AD1ViINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any lioense o��permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE;Permit�run annuaJly from January 1 to December 31. IT IS YOUR R�SPON�IBILITY TO RETURN TI� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS 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 EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. ADDITIONAL REGULATIONS I POOLS II i /� POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, prior to opening, and quarterly thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to�st 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 obtamed 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 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 ofHeahh. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. � t � , DATE: /�_a y�-oS � SIGNATLTRE: I � PRINT NAME&TITLE: n'1 �E B- G�� ✓�,Si a��✓ I o9�asios .�- � , ; • 11-]8-05 09:32am From-SOUTHEASTEpN INSURANCE AGENCY 508-7900557 T-516 P.O1/O1 F-700 � ��V VCI"Cllrlli Vr LI/y�ILll � 1111�7VI� G 11/1$/2005 � PRODUCER ('S08)997-6061 FAx (508)990-2731 TFIIS CERTIFICATE I ISSUED AS A MA ER OF INFORMATION Snuthe.�s1 e�n Insurance Agency', ��c.' ONLY AND CONFERS NO RtGHTS uPON THE CERTIFICATE � 439 Stata Rd. HOLDER.THIS CERTIFICATE DOES NO AMEND.EXTEND OR ALTER TF1E CdVERAGE AFFORDED BY E POLIGIES BE�OW- j P.O. Box 79398 � N. Dartnr�ufih, MA 02747 INSUR�RS AFFORDING COVERAGE NAIC# IN3URED p6Ticci Restaurant INSURERA; qrbella Protection Insur nce 43 Main Street INSuRERs: Rou te 6A iNSURER C; � Yarmouth. MA �2675 �Nsu�ao: INSURER E; COVERAG THE P01_ICI�°S OF INSURANCE LISTEQ BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POI.ICY PERIOp I DICATED.NOtWITMS7ANDING An1Y REqUIitEMENT,TERM OR CON�ITI�N OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WH�CH THIs GERTIF! 7E MAY 8E ISSUED OR MAY PEIiTP IN,THE INSURANCE AFFORI]ED BY THE PO�ICIES DE3CR16Ep HER�IN IS SUBJECT TO ALL 7HE TERMS,EXCLUSION AND CONDITI�NS OF SUCH POLICIES.�GGREGATE LIMITS SHOWN MAY MAVE B�EN R�DUCED BY PAI�CLAIMS, INSR O' TypE OF INBURANCE POLICY NUMBER ��Y EFFECTIVfi POLICY EXPIRATION UM� oe��uaeiurr 850�0259D5 08/OI/2005 OB/Ol/2b06 �►cH occua� cE � 1,000,00 X COMMERC�AL GENERAI LIABILI'IY DAMAG�TO RE 'ED S ],OO� �CWMS AAADE �OCGUR MED EXP(My on porson) i ],O,� A PERSOwu&An IN�URv S �,000 00 GENERA�A�GR 0.TE S 2,OOO,00 GE��l.AGGREGATE LIMIT APPuE6 PER. P,ROOUCT&-CO PIOP AGG S 2�OOO O�O ]POLICY jE�T LOC AUIOMOBILE W1611.ITY COMBINED SINl3 LIM�T � ANY AUTO t�e eeeWerlt) ILLL OWNED Au7pS BOPII.Y IDWURY $ SCMEDULED AUTOS (Pw pur•en1 HIRED AUTOS BODILY INJURY s IVON•OWNE�A11T03 (Per ecxaenq PROPER7Y 0 y (par ecclaern) �� AUTO ONLY-EA CCIDBNT S �A�� OTHER THAN �ACC E auTo oNir. ac�c3 a DCG ESSIUAIBRELLA LIABILITY EACFI OCCIJRREI CE S �oCCUR �C�AIMS MApE AGGREGAT� 8 S DEOLiCTiBLE S RE7ENTION = S MIORKEIt�:cowPeNsn��wo 90630p0604 a8/01/2005 08/Ol/2006 '^'�ST^T�- �TM• FNPLOYERS'UABILfTY /� ANYPROI'RIETOR/P�►RTNERIFXECUTNE E.L EACNACCIG:NT i S� � i �FF1bERIMEMBEREXCWP6D? E.1.D13EASE- EMPLOYE 5 SOO OOO Ifyes dee�ripe under ; SPECWL I'ROVIS�ONS balew E.L.pISEASE-p LICY LIMIT 5 SQO OO � OTHER I � DESCRIPTIpN OF OPERAT10N5 I IACATION3/VENICLES/EXCLUSIONS ApDHp BY ENDORSEMENT 19PECIAL PftOVIQONS i For any and a17 operations performed during the polity pariod. � � c c SNOIILD ANY OF TF1E AB�VE OESCRIBQD POI..ICI� CANCELLED BEFORE TNE E�cPIR4TIOp W►TE TFIEREOp,TNE ISStlING IN9YRER 1.ENDEAVOR TO MAIL XOMR1 of Yar�nouth 10 pq��N N�7��TQ THE CER71FlG1 HOLDER NAMBD 70 TNE LEFT, Atl 11: Li cense & Sti cker Dept B�7'F416URE TO MML SYCH N071C�SHALL Ip�PASE O OBLIGA770N OR LIA611dTY 1146 Route 28 OF ANY qND UPON THE INSu(il1�175 qGi+NT3 OR R:PRE9ENTATVES. Yarmouth, MA �2664 AUTHORIiED flEPRESEN7nTIVE _ �oan Martin ACORD 25(2001108) ��: C5Q8)398-0836 � CORO CORPORATION 1988 � . � + s ; ' TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-074 FEE: $75.00 In accordance with re�ations pmmulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the nerai Laws,a pernut is hereby granted to: Cranberry Moose, Inc., 43 Route 6A, Yarmouthport, MA Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town af Yarmouth Permit expires: December 31 2006 BOARD OF HEALTH: B is� `�i. /Ll.$., ' ' ��s� �'�, v�e�� SEA�ru�rc:ioo Rc�e�`4. B� G�a A�A�� I.us�' ee.ida.r�, R.1V. January 10,2006 ruce G. urphy, , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-058 FEE: $50.00 This is to Certify that Cranberry Moose, Inc. dlb/a Abbicci 43 Route 6A, Yarmouthport, MA I IS HEREBY GRANT'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commanwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have�hereunto affixed their official signatures. ' BOARD OF HEALTH: Q ' ' �5. /yI.$., G��r�� SEA'rtrrG: 100 �'�,ly� ,/�/� v� K(iGP/7� }�. I��tlfUJlZ, ti�P�R n��M�� ,� , . J�u�y io.aoo6 ruce G.Murphy, ,RS.,CHO Director of Health � • .�a3� � ��' A8�►�� c��. •O`:aR�o TOWN OF YARMOUTH BO .�'.:. A � (� I�S i1 M � oD ��:: ;� APPLICATION FOR LI S -2 QS .. ,.�� DEC 2 0 2004 * Please complet�form and attach � cuments by D e 3�1�8(�24PT Failure to do so will result in t of your applica.tio NAME OF ESTABLISHIVIENT:Cl?AN g�RIZ�) /�'JDOS�' .,8: GG�� TEL # D,� LOCATION ADDRESS� �!�, l��4/l�l ' �- IZ� � 1 L,4/2�p�,,,�-/-� PDIZ.-t M A /rZfe 7�i MAILING ADDRESS: S �M� OWNER/CORPORATION NAME: N � � I"1 D � G. MANA ER'S NAME: i'�A�'LI�-�'�! I TEI,. # � ', MAILING ADDRESS: , , G ` � � POOL CERTIFICATIONS: ��I-� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ; 1. 2. �� Pool operators must list a minimum of two emplo ees currently certified in hasic water safety, standard First Aid and Commuru Cardio ulmo Resuscitation CPR . Plea,se list these em lo ees below and attach co ies of em lo ee cert ficationsto this o. The Healt�De�artment will not use ast ears' records. You must P Y P P Y provide new copies and maintain a file at your place of business. 1. 2 i 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 �nd maintain a fde at your establishment. l. 2. � ; -- ��G�: _ _ - -- — - _ � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ; �/iU�l�LAS T�t� �c �� r1� ��. � ' 1- � 1. X 2. G�}� !� 2i �/ HEIMLTCH CERTIFICATIONS: 3= (; i Ul2G!p �"�S S;��L 1 All food service establishments with 25 seats or more must have at least one employe�e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in a.nti-choking procedures t�elow and ' attach copies of employee certifications to this form. The Health Department will not use past years' recards. You must provide new copies and maintain a file at your place of business. 1. 2. � 3. 4. RESTAURANT SEATING: TOTAL#� ! OFFICE USE ONLY LODGING: I LICENSE REQUIIZED FEE P�RMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# ' BBtB $50 _CABIN $50 MOTEL �50 _INN $50 _CAMP $50 _SWIlVII��IING POOL�75ea. ! I LODGE $50 _TRAII,ER PARIC $50 _WHII2LPOOL �75ea. � FOOD SERVICE: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# i I 0-100 SEATS �75 �3 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 �COMMON VTCT. $50 �O WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIltED FEE PfiRMIT# �.ICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# � <50 sq.ft. $45 >25,000 sq.ft. $200 �VENDING-FOOD S20 �Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 i NAME CHANGE: $10 AMOUNT DUE _ $ 12$•00 ••'�""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•"• ; i f r . L L � � ADMINISTRATION Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ` Town of Yarmouth taxes and hens must be paid pnor to renewal or issuance of your pernuts. PLEASE CHECK � APPROPRIATELY IF PAID: YES � NO NOTICE:Pertnits run annua.11y from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN ' TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. � � SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION?-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL t3R POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; ADDITIONAL REGULATIONS POOLS POQL UPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ' by a State certified lab, prior to opening, and quarterly thereafter. ' POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CUNSUMER ADVI ORY: Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post ' Consumer Advisories. CATERING POLYCY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obta.ined at the Health Department. __�BZ��T BESSE�tTS: -- — -- -- —__ - --- - -- _ - - - - - E Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health ; Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. QUTDOOR COOKING• Outdoor cooking,preparation,or display ofany food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: ! PR1NT NAME& TITLE: �7�1/'2%C �� / � � 10/22/04 � � j I � � � ♦ � _-—----- The eommonwealth of Massachusetts - Departrreent of Ind�sd�ial Accidents � -_ — �C+f/frl�i� -. � 600 Woshisgui�Stree� ?`�'Floor --,,,, Bostrrn,Mas� 82111 workers�com bo.t.s..�ce aeid..�s.ilai�m .:�.,; �.:.� �_,. � =�.� .._. ;��_�, : �,� .., -,��..y.,: Co�haet�ars , .:;�.A r ,�vw.�._ _.� .n��.� ..� ., t. .. e ,._._.... ...,.�,...._ „_.. .e.__.._.e,._. �: 1'�1�i21� ��-4 1-� �v�.��) �g: � �)`'�/� t j�1 .s' � )Z:� ,L� ��N��L1/�I"1 ��rL �' s�te: M� ap�GC�7c`� �# ��"�l��7 D � W i ��i�a�rrnu�s�: �d�3�Z'vf cJ G1 � � p I aa►a h�O,�x,�rf�ning an Waa�m,�lf rm;ecc T,�pe: ❑xew caa�s�ucaa�pRem«iea I am a sole 'etor and have no ane w in an ca Buil ' Additioa � I am an emploYer pmvidi�warkecs'oo��fac my e,mployees woiking�this job. r��sz� I�i D5�`� l.N�, �� _ i �- �3 ��r.,��1 �s� J� �' 1��4 ' �.�,��A�2.1�i�w�'� f�Dn�" 1�-I/� r�� ,��g -'3L�Z 3�'0 � � ❑ I am a sole proprietor,gc�al coatractor,or komeawaer(arde o�)and have hired the co�tars listed below who have ' the following wotkeas'compensation Polices: � � s�r� � i ��ir. . . � . . . . . : . . . . .. . f �. �� . : . .... .. . . . . . � . . � . .. � . . � . .. .. . . .. . .. . . . .. . . ... . . . 1 . � .. . . � . . � f �� M f � Y��i �� .. . .. . . ..�. � ._..._"—_"_"_ ..._ � . . . _ . . ` C I Fail�te r sec�re ervaa�e at req�al a�der Sa1�1 ZSA�f MGL 1S2 eaa lad b IYe i�lpaitiw�tv6nral pntllks�f a�re�p b S1,3M.M aadl�r eae y�ais'imprb�eat as we�as dvi pwiltla ia tie br�ota 3T'Ol'WORiC ORDBR ud a Sae e[S1M.N t day�oe. I ndaslatd fiat a apy sf tYis ataleint my be forward�1s Me Omce�tlav�of tl�DIA Are�e vq'i�ntlN. /ro IYd�eby ceKify�n dre per}r�ry dYe nrfenNr�oa pnovlded obo�+e fs texe owd oan� ; �� I�te Ptim naroe f�' r�/ ` G/ Phone#��:� � �� affidal ax oely do eot wrke i tl�s atea b 6e esmp{aed 6Y dt�'ar l��vn�Clai c#9 or tnvnc per�Nliemse# �� ' ❑c�erk if�me�1e rdps�e is reqa�ed �� OSd�'s O�ee c�� p�."�' Qo� �� ` Nov-23-04 14:56 From-SIA 508 990 2731 T-899 P.001/001 F-694 .,A��D,� CERT�FICATE C.�F LIABlLI7Y INSURANCE oATE�YWGD/YY`f� lI/23/Z004 �� (5Q$)997-6061 FAX C508)990-Z731 TNIS CERTIFICATE tS ISSUED A$p MATTER OF INFORRAATION a�utheastern Insurance Agency. Inc. ONLYAND CONFERS NO RIGNT$IJPQN THE CERTIFICATE HOLDER.THIS CERTtFtCA7�Dp�S PfOT AAAENa,EXTENb OR 439 State Rd. ALTER THE C�V�RAGE AFFQRQED SY TNE POFL[CfES BELpW. P.U. Box 79398 N. Dartmrauth, MA 02747 INSUFi�t�S AFF�RDING CtriIERA�E �� +su�a icci Restaurant ��A Ar�ila Protect-ion �nsu�ance �3 Mai n St reet ��e: Route 6A �r�su�R c� Yarmouth, 1rW 02675 �wsu�zo: iNSURER E: 'ON�RAGES �THE P�UCIE5 OF[NSURANCE USTED BELOW HAVE BEEN[SSUED'FO THE INSURED NAMED ABOVE FpR TIiE P�LICY PERlOD IND[CATED.l�lpTWITNSTANDiN� ANY REQU1}2EMEN'r',T�RM OR GONDITION OF ANY CONTRACT OR 4ThIER DOCUINIENT W fTW RESPECT TO WFi1CH THI$C�RTIFICATE MAY BE ISSUEO OF2 MAY PERTA[P[,TIiE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEkZEtN IS SUBJEGT TO ALL THE TERM$,E!(CLUSIONS AND C�NDITIQN$pF SUCH PQLICIES.AGGREGATE LIMITS SNOWN MAY HAVE BEEN REDUCEO BY PAID CEAIMS. �gR TYPE�WSURANCE POUCY MUM9ER POLM.'Y EFFECTIVE POLICY EXPIRATIOQ! �� ew�uasam 8500025905 08/Dl/2004 08/al/2Q05 EACH OCCURREMCE s 1 000,00 X COMMERCIAL CENERAL 1.�1LITY DAAMGE�RENTEro�nr�o� g ZOII�OO i CLAIMS MA�E Q 4GCUR MED IXP(My ene persan) ; 14: i a ��,��wU� s 1,ooa,ao ; GENERAL AGGREGATE S 2��p ' GEN'L A3GREGATE UM�'r APPUES PER: PR4QUC75-CONPIOP AGG $ Z�(J4O�DO Poucr P� �.oc num�a��ua�u'rv cows�n�m siNc�utiar 3 �,�4 (Es aee�der,e7 qLl OwnEo al1TpS ' BOOILY iWUR�' g � � i St�1E0ULE0 AUTO$ �P��y HIRF�AUTDS 60D1LY IPIJURY NOl�1-OWNED AUTOS (Par saidentl $ PROPER7Y OaMAG� g (PeracddpR) rr►aac,E uasiur� auro an�v-EA nGCia�r s N�rrauro �+acC S DTk6RTHAN AUiO OHLY: AGG S ' �� ExCESS1UNBRELLA LfABILITY EACN ODCURREIV�E 3 OCCUR a CLAiMS MADE AGGRC-�ATE $ � 5 OEDUCTtBLE y � RETENTION $ S f wo�s+aoe�P�+sn�naa nrin 9Q$3000$04 08/Ol/200� 08J01/2045 wc sra�rv- i. � �up�.ovERs w►murr ��R�GRI j p avr PROPwerow�a�ew�icecurrvE EL EApi ACCIDEAIT s 500,OQ � OFFICER1AAFl�ER IXCLUDED? E.L.�13EASE-EA EA�LLi]YE 5 SOO OO M 9PE�".Iw PROVISu ONS oelow EL DlSEASE•PQ41G1'LIMIT t SOO �O i OT}IER lE$�p'hON QF�r+a'hOaS f�BC�aT18NS f V�lIClES 1 E]iCW$IONS ADDED BY b4DORSElfEn7!SPEC7AL PRDVISfON3 For any and all operations per�orrned during the polti[y period. � 4 CATE HOLDER N ? �OU�Au�Y 9F T{1E ABOVE DESCRl660 PpuCIEg BE CANCELIFD 9EFORE THE EXPIRATfON DATE THEREOF.TN61$$(JIN6 IN51/RER WILL FJmEqyQ(�TQ� Town Of Yartnouth l� onrs wRm�nonce ro tr�c�►mr�cn�E+o�aER r�n�n ro-r��Fr, Board Of H�al th surFAu.u�'ro wu�sucH r�ricEst,au.iMPose ra oa,.,Ga-+,aN aR cwai�rr RtQ ZS OF AMY IQ�1D UP�N THE{N5URER.IT3 AGENTS OR REPRESENTATN�5. Yarmouth, MA 02664 e►urHo�erseo�ResErrr,srnE : Kr9sta Hartford j �Co�25{2oo�roa) FAX: (508a362-7802 �UCQRD CORPORATION 99$$ � ; � I ACORDM CERTIFICATE OF LIABILITY INSURANCE iiiz3ii o' PRODUCER (508)997-6061 FAX (508)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Abbicci Restaurant INSURERA: ANI)e��d PPOt2Ctl0�1 I�ISUt'dI1Ce 43 Main Street INSURERB: p _ ROUte 6A � INSURER C: Yarmouth, MA 02675 INSURERD: INSURER E: v w� es DEPT. ' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDiN� ANY REQU�REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' 7ypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION . LIMITS GENERAL LIABILITY 850002 5905 08��1�2��4 08��.�20�5 EACH OCCURRENCE $ 1�Q��QQ X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ],OO�OO CLAIMS MADE �OCCUR MED EXP(Any one person) $ 10�� A PERSONAL&ADV INJURY $ ],�OOO�OO GENERAL AGGREGATE $ Z�OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2�OOO�OO ! POLICY PR�� LOC JECT AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO All OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY ' NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CIAIMS MADE AGGREGATE $ ' $ DEDUCTBLE $ RETENTION $ $ WORKERS COMPENSATION AND 9083000804 OH�OZ�ZOO4 OH�OI�ZOOS WC STATU- OTH- - — ' —__ — -- -- —- cw�r _ s — -500 1 A ANY PROPRIETOR/PARTNER/EXECUTIVE j OFFICER/MEMBER EXCLUOED? E.L.DISEASE-EA EMPLOYE $ SOO�OO tf yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ SOO�OO OTHER ' DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS For any and all operations performed during the policy period. TIFI ATE ER ELLATI N ; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL lO DAYS WRITTEN NO710E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town Of Yarmouth Board Of Heal th BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Rte ZH OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Yarmouth, MA 02664 AUTHORIZEDREPRESENTATIVE ! Krista Hartford ACORD 25(2001/08� FAX: (508)362-7802 �OACORD CORPORATION 1988 � f ,�__ . . - \ TOWN OF YARMOUTH BOARD QF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT ; PERMIT NUMBER: #OS-103 FEE: $75.00 ; In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General I,aws,a permit is hereby granted to: Cranbe Moose, Inc, 43 Route 6A, Yarmouthport, MA Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2005 BOARD oF xEALTH: B�rsis`h. C�''o�,Jl�l.`n. ' SEATING:100 ��e��" �s��v �� R�v February 2_2005 Bruce G.Murph H,RS.,CHO Director of H ___ THE CONiMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-070 FEE: $SO.QO This is to Certify that Cranberry Moose, Inc. d/b/a Abbicci 43 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE � In said Town of Yarmouth and at that place only and e�ires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments�hereto. In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: /.�e�ss«ss �. /GI.�S. G��r��s S�n�G: �oo Av�fi•s�;�A�c��sce G��i�st Ro�t�. B�, G'!�k �� s R�v � � R.�v. February 2.2(�5 � ruce G.Murphy,MP .,CHO Director of Health - : - � , ��r(b1� su �� <, � I � � � �,�5� � �,�,�� ' � � c� �� aM � o �� OF_Y''R 2 � �.o TOWN OF YARMOUTH BOARD O NOV 2 6 Z003 o,. '�y APPLICATION FOR LICENS 04 r , �,,;? :'� a * Please complete form and attach all necessary do � ents by Decemb , , �EPT. Failure to do so will result in the return of your,�pnlication_packet. C� Z-35'a n1 T' 2T� bA ov�' � 0' � S � OWNER/ E: �� P��-��.y': /vl�� /�G MANAGER'S NAME: . : _I ��="TT�q. - C Ic � 2-:3 5 c� ; AD � t� o � � POOL CERTIFICATIONS: The pool supervisor must be certified as Poot Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of th certification tn th�s form. 1. 2. Pool operators must list a minimum f two employees eurrentiy certifted 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 witl not use past years' records. You must ' provide new copies and maintain a file at your ptace of business. � 1. Y� /-�-- 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICA�'IONS: ; 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 witl not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. _ _ __ _ _ _ ____ _ _ - - - - -- . _ _ _ _ _ -_I'El��t-5N IN�I��Z�'i�:- __ _____ - Each food establishment must ha.ve at least one Person In Chazge(PIC)on site during hours of operation. i 1.E`°�,�c�.��''� +� ��.c�Y 2. (M.� ��.L. Q �2 � (�J � , HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ' Maneuver on the premi_ses 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. f You must provide new copies and maintain a file at your place of business. ; 1 4 2� ��J:— 2. ��ni t� , 3. �02 t o —t`�-sS-f�� 4. ��t� �N�� RESTAURANT SEATING: TOTAL# 7`� OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# , _B&B $50 _CABIN $50 _MOTEL S50 � _INN �SO _CAMP S50 _SWIMMING POOL�75ea. LODGE �50 TRAILER PARK S50 WHIRLPOOL S75ea. EOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; �0-100 SEATS S75 D��O _CONTINENTAL S30 NON-PROFIT S25 ! _>100 SEATS $150 �COMMON VICf. S50 �O�-Oa--'r( _WNOLESALE a75 f �TAIL SERVICE: � � F LICENSE REQUIRED FEE PERMIT# LICENSG REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 _<50 sq.ft. $45 >25,000 sq.ft. 5200 _VENDING-FOOD $20 � — � ,<25,000 sq.ft. S75 _FROZ�N D[:SSL'RT S35 _TOBACCO S25 � NAME CHANGE: a�o AMOUNT DUE = S_( 25.0� *'�***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****� , � . • ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's 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:Permits run annualty from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORT�D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO C�MMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL��ULATION� �.�__ _ 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 CONSLI FR VISORY• . Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ' CATERiNG POLICY• ' Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the ' required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. -- - - -- _ _— -— --- - Frozen desserts 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. OUTSID� G F�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. i OUTDOOR COQ iN • Outdoor cooking,preparation,or display of any food praiuct by a retail or food service establishment is prohibited. � / ,-- /� DATE: � � 1 �S !� 'j SIGNATUR�: � � PRINT NAME& TITLE:_�cG� /��.�,� ; _. � � 10/22/03 ; ; E � . , . � . The Cornmoawealth of Massac/rusetts � � Department ojlndustrial.-�ccidents � a Ofllceol/�s�l�s�iis � 600 Washington Streel ' ,,•' Boston, Mass. 02111 ~ �� W'o�kers' Compensation lnsurance Att�davit ARoiicant information: P'►eesePRa'a't'T�eh'�r n�mr� M ��" � -�t �C-�� - Lucatic�n- � ,� I'�� l �� o�� t� �l'T'1.�'�v U��l�� I 1_�' ��`b� ehone� JO�'r�G^�_l d � � I am a homecw�ner pertorming all w�ork myself. � ( am a sole proprieror �r.,�, ha�e no one «orkin_ in am•capaciry �I am an empioyer pro��din� w�orkers' compensation for my employees wor ine onthis job. � - , _ � rr� � m a n • n : �2 `.7�L. �iV�, � � 1 GC. : address: ��) � �� !'�-`�-�'� \ �� A" �/� -�yj� �D citv: �1"��UZ��O� r �<a! � nhone�• � 7� � �� ( i�su��nce co. tt�Zc3�\� IN� . �q�d� Rall.SY# C��i�� aj � � I am a sole proprietor. generai contractor. or homeow�ner(ci�cle onel and ha�•e hired the contractors listed below aho ha�e the follu�+in_ ��orker� .ompensation polices: s9moanv name• i"`�► �� address• citv• ohone fl• insur�nce co. �olic}•# comnanv name• U V��-- — -- —--- _-- _ _ _---- ._-- — __ ------ �d d ress• titv: ohoee M• i insurance co. �p��,� • Failure to secure covenge as required under Secnoo 2SA of MGL 152 ea�lad to tbe iopaipoa of uisi�tl ptaaltle�ota 6�e ap to 51,500.00 a�d/o� ' oae yean'imprisonment as w•efl a�eivil penaida io tbe torm of a STOP WORK ORDER aed s Ase otS100.00 a dar apimt m�. i asdersta�d t5tt a i eopy of thy statement mav be fonwrded to the Of'liee of lavestigadom of the DIA for eoven�e veritiatio�. � f /do hrreby cenif}•under ena! 'e rjyry that t injorniotion provided above Is 1rWe o�td orrect . Signature 1�7 /� �l �� Print name L��` 1 � • \�.\ � one M � �'��z- ~3�� i ! .. aRcial use onl� do not..�ite in this area to be completed by ciry or town olfleial � I ciry or town: y�M��T� _ permitAlceese k nBuildiog Departmeot ' check if immediate�es nse i�re uired ❑Lieeosioe Board � � Q 261 �Seleetmen'e Ofiiee �Healt6 Department contact person: P�o��p�_ (508} 398�?231 ezt. nOther { _ � i .. .�. <,�,; ' ' Nov-iQ-03 D6:OIpm Fram-SOUTFEASTERN IMSURAMCE Af�NCY 508-T�C0667 T-128 P.02/p2 F-045 � , �� 3 _ 2c�o L�, ssur dnte: SiJ20iO3 . --- ---------------�._............_.._.__._.,...._.......!__,...............�__.---.........----_. Producer; rhis eprtifioatR is iss�}ed aa e �qtt�r } infor�, jon onlr ipd onfers � no ri hts upon the eertificate halder. �h'a cartt Pic�te doea no� eareud, SOUTHEASTERN INS RGCY I ax4fn� �r alter the c�vrra�e effotded by �Ae pol i �es be}or. 64! NAlN St �.---- ------WMPIiMI�S�AFFORUlM6 �Ol1�RA6E '------------w------ NY'AFlNIS AR 01601 -�--------T- - --- ----------�......�..- ---�----------------- Cade: 5ub-codr I Ca Ltr A: f�tBELIA P�TECi1flN + _._.__�............................._.........�----...,.----......-----,.................._._..--------- •--�---,----�-------- Inaured: fo Lt� 9: ABBICCt RESTAURANT .�..,...Co l.tr C:.._�___..--.--_----------- ----------.R__------ --- . . . . -- - —._._..-- Y�RRAOUTNPORTtN MA 01615 Co Ltr D: AABEtLA PRO]'ECifON � .. . ,Co I.tr'E:��----------__.........�------ ---�-------------•---- ['OVTsBAQffi Tt�: ia t� certify that palici�s of insur�nce 1iet�d b�lar h��e tieen icsu�d }o the insu�eA nae�d �b ve fe� he polic priod iriiceted� notwiths#�nding enr requirr�a�t, tero or condition �f enr coptract or other dacu�a�►t v�t�i rrspec �!o �h'c� t�iis cErtificate �er be issued or bar •rl4i�, th� insu�aac� afford�d by the peficifs d+�efibed h r�in is su��ec #o il� the tQns, e�:lusioes, and coaditioas of tic�i polici�s, Liaits shoan �af haue bes� r�dueed b� paid cla4Aa, __..........------.�....,---------------�_..--------...._�_..,.---------------------------------------------- ---�.__...._....__�., �a i ( � Palioy � Policy 1 ltri Trpt of Iaaurance ( Polic� hr�bfr OffPctivt date �xpititi�q date! RII fia ta i� thausands ----•_.......---�------------------.,..,_------..�..._.....�_------�--------------------------------__.---- ---------..,,�,....---•-- : A ; ER L I.lAB}tITY BSOOQZ5445 8�01�03 B/Ol/Q4 ��era� aaara ate �Rmerrinl oen�r 1 I ia�i I ity r�d�c a-ootp�aps agg�r�: � � rner�s�i coatractor"��crot er ona!/ndverti: ng iq,; P ac� occurrerael 1,400 � i e; danegr; 50 � ��+dicaf expease. 5 ___...,....---��------..._.................•---------�------.....------------------------------------------ ------..�.�............ iAU OM08IL� LIpBtLiTY i I IC�abIinvd ! � pn auto Sid�iir in=itrr i AI� aanrE autos i SQheduled auto: I ��lrein�ir� I Ni�ed aetot Non-o�ned auto: I ( {P�� oci�an�); f 6arege liabllitr � � I ! Property daNege; � .... .-----,-�--•------------------......-----...._ I�X�fSS L[A9I1.1TY ---..I..._._-------------.--------------�-- ----- -c�---................___ Athrr tR�n urobrel ia fatM ! � � � i Occ rr�wca Aggtesate ---�-----...,. � D ...........---------D-------------------..,...,.--�------------------------------ ..... ..__�........._._.-- �iORKER'S�NPENSRTIQN 9083000 8/Q!/03 �/Ot/04 Statuto �------ --�----- - ..--___. ENPLQYEit�' lIRB[tITY � ach accid}t�tJ� -r+_: isease�palicy liRitf ' iseaareach a�ploree� ----�.......---...,.-----------------------...._ QTtIER � -----�-----------------------.._..-----l-------_...�_. ..—_..,._.......... I � j i � � � ---•--,.,_..,..........�---------_-.-----.......-�-----_�..._--------------------------------_____.�_.. _._�...,,............� A��tiption if aperaEi��:iioatio�sioehicles�resteiCfl115/SpRCIItI it4as; c�.�riFicaT� sor�n� CA�nc�ZiaT�Or� 5hoµld anr of the aboY deser�bed ppl ici�s be f¢ elled b�fore the lpy p y M lRPiratioR dBtP �hlNtD�, the iosuing ca�penX r�Ip t1f�E�VIF �0 id�80UTE�28uiy ��I 10 ��jf YTIttlA 11tICQ t0 the eer�rf icot holder na�pd ta the SOlIiN YARIlOU�H MA Q26W i ieft, but fr�lue ta �eil rueh notiee shai ��paa no obligatiAn �r liebilitr of atT kind up�r tha corpd�y� ita ��en! o� r�present�tiaas. I- -----,,........ ----._�........�.�----- ------------------ f putho�i:�d raptQsentatiye: ; � JOfiN M NRRTlN JA i � ----------------..._.......,..-•----------...._....------...�.-------,----------�-------------------- i 4/8fTM ------------------- i � . . ; + TOWN OF YARMOUTH BOARD OF HEALTH ; PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-039 FEE: 75.00 In accordance with re�u.1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: Cranberrv Moose, Inc., 43 Route 6A, Yarmouthport, MA Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31. 2004 BOARD OF HEAI.,TH: L�eitfa�xsst�. C'��ll.`7!. p��`��, v� e�„�.� SEATING:100 Rv�f'. B�l�JWNfy � � Sl�, R.N � r � D�t�2_2003 �,-�.= ,� ruce G. Murphy, s.,cxo Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT N[TMBER: #04-029 FEE: $50.00 This is to Certify that Cranberry Moose, Inc. d/b/a Abbicci 43 Route 6A, Yaxmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place oniy and expires December ttiirty-first 2004 unless sooner suspended 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. In Testimony Whereo� the undersigned ha,ve hereunto affixed their official signatures. BOARD OF HEALTH: /3er�ru��,/�hS. /yl.�'I. G��iaviNsa� SEATIlVG: 1� AO�f/!�K'i�/!�/C�L7�+�f�K'.� ��`��JIL l�c�i�r�t�. �6�, G� ' � � , R.N. ��2_Zoo3 _ �-�� / � � ruce G. M y,MPH ;, , HO � Director of Health i : , ., �,��. .--� �;��''--��--aR.y TOWN OF YARMOUTH BOAR�� ' G,S � � I�� (1 �un �� l� ' � � � ='� APPLICATION FOR LICE11�� }� =2 i . °::,, .,s .f� � : �� d�`�° 1 3 2002 � ��• * Please complete form and attach all necessar�docuiments by Decemb r�� DEPT. Failure to do so will result in the return�f your application pac .I, .I.. -- -_ � # -o .. �- � t Q'1��o A ► 42.6 A T � R. p � �NA(JFR'�N,4ME: ��l�L�£Y'T'�4 �C1C�'c,� TEL. # �-36z-3So f ' MAii,iN(�AT�DRFSS: SA�M.�'r_ ' 7' �Q� I'' The pool su rv or must be certified as a Pool Operator,as required by State law. Please list the designated ', Pool Opera.t rf r�ertifica�i�t�this furm._ _ _ _ 1. 2. I Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - C�RTIFICATIONS: All food service establishments are required to have at least one full-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. l.�U � �t ,�.� 5`��v� K, 2. _ ��a�-��: __- _ ___ _--- i _ _ _- - -- _ _ _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I , 1, 1�.`'T 1� �GIc�L 2. �'.'`'. t o YZG�1��v��l � HEI LICH CERTIFI�ATIQNS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich E Maneuver on the premises at a11 times. Please list your employees trained in anri-cholang procedures below and�� ; attach copies of employee certifications to this form. The He�lth Department will not use past years' records. ; _ You must provide new copies and maintain a file at your place of business. ; �. ��..- G..��s� 2�'��y �-�as��.L.. � 3. 4. R�STAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _B&B $50 _CABIN $50 _MOTEL $50 � _INN $50 _CAMP $SO ,_SWIlVIIvIING POOL$SOea. j � _LODGE $SO ^TRAILER PARK $50 _WHIItLPOOL a25ea. � I FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i ,/ [ ,�0-100 SEATS $75 � (� �OO`i _CONTINENTAL $30 NON-PROFIT $25 j I >100 SEATS $150 I COMMON VICT. S50 Q � _WHOLESALE $75 � RETAIL 5ERVICE: i i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# ^TOBACCO $20 <25,000 sq.ft. $95 �TOBACCO $20 i <50 sq.ft. S45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 ( NAME CHANGE: �io AMOUNT DUE _ $ I 25.Oo � � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�*** r _ + � � c ,_ 4 ADMINISTRATION � � � . f ., ; Under Chapter 152, Se�tion 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ';� of any license ar permit to operate a business if a person or company does not have a Certificate of Worker's ; Compensation Insurance. THE ATTACHED STAT,E 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 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 ESTABLISF�IENTS ARE TO CONTACT TI�HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment 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 to the catered event. Thses forms can be obtained at the Health Department. __FROZEN DESS�RTS: Frozen desserts must�e teste�on a monthIy basis by a State-certi�iedlab. �`est results must� sen�to tY�e�Ieaith 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 Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. ,, ', . ___�...- ,� � �� DATE: � 2 � d� SIGNATURE: �� •�=� ��' '� l� V �c PRINT NAME&TITLE: M�.�£"t"I�� t-t\Ct�.`��!.`�R�5 L c�,��U 1 i 10/18/02 � a Nev-04-02 01:4�p� Frc�-SIA 5Qe g6� Z731 T-G4� P.Q02/O�Z F-65Q A,�Q.R. t��, CERTt�IC�4TE �.1F LIABILiTY INSURANCE ' �;o r o�z � (Slt$)997-5061 PAX (5� 991- 28 ��TB ED A�A MA Of INFOf�II► SOUtheiSt�r'n InStuE'iu1C8 fAc:V, Zn�C. ONLY AND CAlI�S NO Rli�Flfs L�ON Ti��TE a9 liOLOER.TH�CER'TNRCAtE�i�T AYENQ�EXTEND OR 662 Slata Rd. ALTE�THE�,►�OltD�8Y 7H�p0l��S BE�Cw. P.O. Bax 79398 ii�URERS�FORDiNG COYE�►G& � w. Oar�th, M�1 02747 �ar�v � R�alty Truzt ranberry nt. wsu�e.t 5t. Paul Firt a�►d Ntarine Insur Routa fiA ,rr�s�ee: Arbella PrataCti 43 I�:in St�'t 3 - � aYBu�c: � Y�tr'mou'�f� 1dA OZ6?5 � '� �'� Nsu�c aL9iJ�7ER E �� TFiE PO�-#1taSi1lR+�tiPiv$L�S7ED Bt—l..�N NkYE B�1 IS�iJEO T�'f1iE 1NbUl'�l�SA1A��B�IE fdR THE P;�ICY • �� ANY T£i�d�i G{3NCtTbO#i OF AN'Y�'��OR OT`�D�CUMENT Wi�R�.�PECT TO WhI�N 7F'd5 t�,Y�fiTR�i.THc l�11�t�7ED 8Y THE POtB(�fd DESGRIBED Her't�Mi(S S'tJ8JEC7 TO Al:TitE TERWI.S,EXCZU8MJNS AND CONDR10N8 tN�SU• POLiCt�S;JlG�3A1'�i.11�3'S SHti�M�lN tdAY i#R1�E BEEDI R�DUCED BY PAIO CiAIMS. T�! TYnC GF� lOLW'�'�E�! �p1►T8 �,,,�„ 1ib23TQ �o z � a��+oi !l�CHOCGVRRENix S i.000,00a �X caw�u s�w►��aa�arr � F��ua�v«,_�+! s 50:db� i ' 'CWNiB t;1tOl' �fiCl�t� � I IY�EXV OMOR'soN 6 1 � � � � � PGR3WIAl.S HD�11+.t�1RY b �.� {10�i , I � r�cn�wcc�w�,te 3 2 000.000 ��etarE c�a�r,�Kxa�t. � aaooncra•cam�,ar aa3 s 2 000 �OU �vac.�cr i�� e.oc �a,�Lus�:m � �ssw�.�urms y n�n atrrc � �u.ormt��srras � � ��a��u�`r s �Si��sotn.ED.rvsrOS 4 NIREO AUTOS � � �80�71�Y tW�RY S Pl4N-4wnip Ki7TQ3 � (�K smemn� � tRCP�RI"f t�1LIAG� � . �Plf� GANK�UAY�J'iY � A:lid CI�IIY•E!►AGC:DENT S �wv,3u�ro � � Q�+c.a�wvn a•��tc a , ; auro o�r. �� ouxss u�m , � �occ�� ' oc�uR ❑ouwas� j � �'�'E s,.,._ � -- � ��DUCTiBiE � � f r�arr�vna�v s z waac�es�st�,ar�m 83flC0802 0$/01l20Q2 OB Q 20Q3 ' X R �.oYrKs'ua�m i ¢i.ei►c►+r�caoe�tT I� SOQ.OW . $ , � � <<.o+sc�•ueMv _ s SOb 00� [4 oifihti PCY'r'Y 1 NMr 9 �1 Gi'M!R , � ' � i RECEfVED , ; oesc�n��oPe�w�tonSrLorr► Aanm sv efwo�tt�a+TrsaEau r�wvis�s NOV 0 5 2Q02 � L4CENSES &PERMITS C'eR'TtF1Cl47E ti4LD�R i �o�ai,t�.�aEo:aist�t��Es'tta: CANCELLAT�Oi�I ; + s►taii.c,wv oF��aove a�tGR�a r�x�s�C�tx��D��s�aE � DfP�A.11QN DATE T1�R80F.Tkl�IEfIJi�COl�rA1�KWNrI 6P�DnAVOR TD AWl TOM�1 G� Y�i'1N0'v�t �GAYS YI�ITTBi I�TICE TD TFE.^,ER7iRCATE�LDLht NAAAED?0 TME LEa?'� Li certssl�eriai# Dtpt. evr r,a�:�e To,er��,►�r,r�a�,�:.��ae r�o auoA�na+ae wa�urv Rcute 2a �abn wao�n� ,�ao�+n �TArvr�. Yarq�outh, wl 02654 w�+� Ta Karr.n r ' � �T fAX: (508)398-2365 RpORATlON 198 � f i � ' , . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #03-003 FEE: $50.00 This is to Certify that Cranberry Moose, Inc. d/b/a Abbicci 43 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2003 unless — �oone�suspended_or_rev�ked f�r violation of the la.ws of tlie Commonwealth respect: the , licensing of common victualler's. This license is issued in canformity with the authonty granted to ; the licensing authorities by General Laws, Chapter 140, and amendments thereto. ; In T�stimony Whereof,the undersigned have hereunto affixed their offcial signatures. ; BOARD OF HEALTH: ��anP,ed s� ��, ��aNc : ; . SEATING: '100 r�6YtlGfQIKfAIG L/. ��. �IG.L/. . VGCe ��uA�lJt�ltQ�L � e� /��` 1{ !G�� • �i�'r� i �a�iick�lc�e�xa� ; � � �_ , �� ._.� , �72. � � i November 19 .,2002 ruce . uiP Y� ., Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NLJMBER: #03-004 FEE: $75.00 ' 1 In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter ; 11 l,Section 5 ofthe General Laws,a permit is hereby granted to: ' i Cranberry Moose, Inc., 43 Route 6A, Yarmouthport, MA ' � Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth ' ; Permit e�ires: December 31. 2003 BOA�oF��,�: �ka�� Zelltken �a.vr.rc�c ' ��. c��. �c D., v� � SEATING:100 1�0��. �, � � �aartc�7�Dea�uott ' ��c.Ska�. ,��l. ' i November 19 ,2002 ruce G.Murphy,MP R. . HO i Director of Health � `' A B B i �-�--� �a� " OUTH BOARD OF HEALTH ��.i�� a..�r�w.w.ar+ . i P N FOR LICENSE/PERMIT-2002 ---------� �.s�s�/ �'i�s� Q � C� ra � ��? I� :�� * Please complete form and a ch all necessary documents by December 31, 2001. ailt��t�i �o�o��re lt in the return of your application packet. `�C F AM ESTABLISHMENT: � oo a � TION D �rr � r i � D 26 Z � � MAIL G ADD SS: �S � I Q.��T � sc cuN�, l� RR a�'�. IVC , AGE 'S N �� 4- TEL. # Z--3 a 1 ING RESS: I`�, � �T= Mo�Tl� f I ' The pool supervisor m st e certified as a Pool Operator,as required by State law. Please list the designated - Pc�-4p€rate�(s ��tific�tie�-�e thi��- --_ - ---- _ - 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. ; 1. 2. ' 3. 4• , FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service esta.blishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. ' You must provide new copies and maintain a file at your establishment. i. � c LL �T�1�i�tt� 2. - __- _��IN CHAR�E:--- _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. , 1.��-'Tl Pt- �tC�G�.�� 2. C��io v�G �a ��S-1��2:1_ HEIMLICH C�RTIFICATIONS: All food servic� tablishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the ises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of emp ee certifications to this form. The Health Department will not use past years' records. You must provide ne opies and maintain a file at your place of business. , 1. (Z � 2. ��,.. ��N �� . 3. 4• RESTAURANT SEATING: TAL#� OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _ _ __. _MOT'EL: --- -$5A-_ _ — INN $50 _CAMP $50 _SWIMMING POOL$SOea LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED. FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75` ;�r _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $I50 � J COMMON VICT. $50 � _WHOLESALE $75 <s.� RETAIL SERVICE: '�� LICENSE REQUIRED FEE PERMIT�;�, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. S45 >25,000 sq.ft. $200 FROZEN DESSERT$35 ' NAME CHANGE: $10 AMOUNT DUE _ $ l 2 S.�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . � � �' � , � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED� � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; ADDITIONAL REGULATIONS 4 r _ 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 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 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. Thses forms can be obtained at the Health Department. FROZEN DESSERTS. __ ------__ __ _ -------__ __ i � Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health ; Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. ' OUTSIDE CAFES• ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus have prior approval from the Board of Health. ; , OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i � DATE: l!< l 3/d� SIGNATURE: �'' i PRINT NAME& TITLE: � U /U � ; 09/11/O1 i 1' .. ♦ � . . . . . . �� The Commonwealth of Massachusetts � � Department ojlndustrial.-lccidents o OJ11ce cll�est/osdiis 600 Washington Street ' �� Bnston.Mass. 02111 �"' ��y Vb'orkers' Compensation insurance Affidavit ARnlicanE intormation: PlessePRiNT'iesh'}�t n�mr CJ«CIvU�Y �05� �NC • �� a�+6icci Is�cation: A3 Maln�trpe+ Y�rmouth Port, nnA o2s75 r� �,t, t,e one M,�JG Z"� S� 1 � I am a homeowner pert�rmin�all work myself. � I am a solz p.roprieror �r,', h��e no one��orkin_ in am�capacit}� �I am an emplo�er�ro��dino w�orkers' compensation_fo�mv'em�lo��ees w•orking on thi �ob. __, ____ _ - — -- _ _ , -- — �omnam• nams• �K�f�I ��L�R.� f"IC30�`c7�Z��,I� fl E�p t� ( , address: �� ,�� 1 �( �" `�l �/� �! / 2 titv• Y�RI"l�� \'R �i \ �; + t'I'► ��e�� ahone M• 7b � � �5d � insu�ance co. �� H`t' 1'RST�:�'t o N �� d • �oiity# �Q��QQ�� I am a sole proprieror. _enerai contractor, or homeow�er(circle one! and ha�•e hired the contractors listed below ��ho ha�e ' the follu�.in_ ��orker_� ;ompensation polices: zom�anv name• address citr: nhone M• insurancc co. polic}•�! �m�ny name• tddress• �itv: nhoee M• insaraessso. noliev ff i Failure to sccure coveraQe as required uode�Secnoo 25A of MGL IS2 ea�lad to t6e iopaidoe o(erivisN pesdtles o(a 6�e op to Sl¢00.00 a�d/or one yean'imprisonment as w�ell a�civil penalHe�io t6e form of a STOP WORK ORDER asd a liae of SI00.00 a dar apin�t ma I a�dersta�d t6at a copy of tha statemrnt mav be fonvarded to the 011iee of Imeuigadon�of t6e DU for eoven�e veritfutio�. 1 do hrreby cenif}�under r e pains and prnalti�s ojperjury that the injornration provid�d abovt is bue and co ct Signature � l( �f`j 4 � Print name T ��3 � �.�}-�_��S�,� 0��. �A-fl��.�_ Phone M ��Z. � ?7 S a � .- olTicial usc onh do not M rite in this�rea to be completed by eih or town oflleial ciry or town: Y�M�� _ per�nitAicense M nBuildiog Department pLieeasint Board 0 cheek if immediate response is required 261 �Selectmen'�OtTiee �Hnit6 Departmeot contact person: phonca;_ �50�) 398--2231 ezt. nOther r � ACORD CERTIFICATE OF LIABILITY INSURANCE °A��MM'°°,�, �, ii/t�/iooi PRODUCER �508)997-6061 FAX (508)991-3283 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Southeastern Insurance Agency, Inc. HOLDER.THISCERTIFICATEDOESNOTAMEND,EXTENDOR 66 2 5 t a t e R d. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 INSURERSAFFORDINGCOVERAGE N. Dartmouth, MA 02747 INSURED Tara Realty Trust INSURERA: St. Paul Fire and Marine Insur Granberry Moose Inc. INSURERe: Arbella Protection Insurance ROute 6A INSURERC: 43 Ma7tt Street INSURERD: Yarmouth, MA 02675 INSURERE: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TkiE-P��I�IE:!€S-B€SCRIBED HEREIN.IS SUBJECT TD ALL THE TERMS,EXGLUStONS AND eONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER DATE(MNVDDIYY) DATE(MM/DD/YY) LIMITS GENERALLIABILI7Y K00923697 08/O1/2001 O8/O1/2002 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(My onefire) $ 50,000 CLAIMS MADE �OCCUR MED EXP(My one person) $ 10,000 A PERSONAL&ADVINJURY $ 1,000,000 GENERALAGGREGATE $ 2,000�000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Z,000,000 POLICY PR� LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL ONMED AUTOS BODILY INJURY $ (Perperson) SCHEDULED AUTOS HIRED AUTOS BODILY WJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE UABILITY _ _ AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: pGG $ � EXCESS LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ ' RETENTION $ $ i WORKERSCOMPENSATIONAND 083000801 O8/O1/2001 O8/O1/2002 TORYLIMITS ER ' EMPLOYERS'LIABILITY E.L EACH ACCIDENT $ 500,000 B E.L.DISEASE-EA EMPIOYE $ 500,000 E.L.OISEASE-POLICYLIMIT $ $00,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS or any and all operations performed during the policy period. CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER CANCELLATION SHOULD ANY OF THE ABOVE DESCWBED POUCIES BE CANCELLED BEFORE THE EXPIRA710N DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL �_DAYS WRITTEN NOTICB TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Tow n o f Y a 1'mo u t h BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR LIABILITY License/Permit Department ; R o U t e 2 8 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR PRESENTATIVES. I Y a r m o u t h, M A 0 2 6 6 4 AUTHORIZED REPRESENTATIVE ? Helen Ga ne ' FAX: (508)398-2365 ' � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-001 FEE: $75.00 ' In accordance with regulationspromulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Mariet�R_ Hickey/ r n Maose,43 Main Str_ret/_R_oL�te 6A,YarmoLthrxi�i ,MA Whose place of business is: Abbicci Type of business: Food Service To opera.te a food establishment in: Town of Yarmouth Permit expires: December 31.2002 BOARD OF HEALTH: r?�. xelltkoz. ?�. Cjoado�c. .D.. `l/�ee �a�r.�ra�c sEATuaG:loo �o��er�t� l�raaw�. �trk �A��ltk�e�Ozi�wo¢� Januarv 24 ,2002 ruce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-001 FEE: $50.00 This is to Certi#'y that Marietta B. Hickey�Cranberrv Moose d!b/�.Abbicci • " > '; _ 43 Main Street/R�ute 6A}Yatmouthn�rt,lV(A ' IS HEREBY GRANTED A ,: CW�MON.VICTUALLER'S LICENSE . , ; , - In said Town of Yarmouth and at that place only and expires December thirty-first 2402 wiless sooner suspended ar<:revoked for violatson of the laws of the Comm�nwe�lth resgectiun.g the . . ' ' mmon victualler's. This license-is-i ' ' with the authority granted _ � ' to the licensing authorities by General Laws, Cha.pter 140,and amen ents thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ��4�, i�el°�'r�, L�xa� sEnTnvc: �oo i'� 2�. Glo�alo�c. I�G.�. . `l/ice ��a;�ra�c - �� , �� ; �a�uek e�r«�cot� J�24 ,2002 - ce G.Murphy, .S.,CHO ; Director of Health : �;� �j�� o d � � TOWN OF YARMOUTH BOARD OF G� :`� D E C 2 1 2000 � "g� �;;. APPLICATION FOR LICENSE/P 2 HEALTH DEPT. * Please complete form and attach all necessary documents by Dec r , 2000. Failure to do so will result in the return of your application packet ��_ -------------------------------------------- e f�A��(L�!�oo��-—� ---------------------- --- ------------ T � � e� ► �s 2�� o� ��2.- �o�� T fZ 6 u^7- �2'— �'I O 26 7 � � 4.. ' - d� O Q� � ci t'J 2- -------------------------------------------- �'OOL.CERTLFICATIONS: The poal aupervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Op� r(s)and attach a copy of the certification to this form. 1. �� -�-- _ __ _ �. Pool opera.tors must list a minimum of two employees ciu�rently certified in b�sic water safety, standard First Aid and Community Cardiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past year�' records. You must provide new copies and maintain a file at your place of business. 1. �/�-- 2. � -3. 4. LMT.ICH� TIFI ATIONS: All food service establishxnents 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 atta�ch copies of employee certifications to this form. The Health Departmeat will not use past years' reeords. : You must provide new copies and maintain a file at your place of business. ' 1. '�L.P�t�1 ��-A►M�A1�� 2.��v�.-. 4�.t�.Q�r�SC ' 3. 2� C-�, 4. i � RESTAURANT SEATING: TOTAL#�� NON-SMQKING SEATS: TOTAL# �;5� � -------------- ------ -------------- ----------------------------------------------------------�------------------_.._�....----------- ___ - — - --_— _ - -- -�`.—_ QFFICE USE ONLY —' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! _B&B $50 _CABIN $50 _INN $50 _CAMP $50 ; LODGE $50 TRAILER PARK $SO — � MOTEL $50 SWIMMING POOL $SOea. ' WHIRLPOOL $25ea. FOOD SERVICE: � ' NOTE: Per the new 105 CMR 590.00(1 State Sanitary Code for Food Establishments,the effective date for � food protect�on manager eertification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � . � �0-100 SEATS $75 �Ol�07 _CONTINENTAL, $30 � _>100 SEATS $150 NON-PROFIT $2S ; 1 COMMON VICT. $50 �d(-0'� WHOLESALE $75 � RFT�iI. SF.RVIGE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $'75 TFROZEN DESSERT $35 � � >25,000 sq.ft. $200 Nt�MF(''HANGF,; $10 E AMOUNT DUE _ �2 5 .00 � $ '�****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�*** � �i r � .._ � � �.�. � � �� : � � �� ADMINISTRATION � , � ` � P � �" '��# i�# 1 s��--;�� ' �ncber�hapter i��;�tion 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 i OR � - i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Perm�its run annuatly from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN I � THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. i ; SEA50NAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR]NSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENO�ATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; ADDITIONAL REGULATIONS � POOLS � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opemng,and quarterly thereafter. ; , POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered withixi seven(7) days of closing. ' FOOD SERVICE � NEW�TATE SANIT�$RY CODE FOR FOOD ESTABLISHMENTS• ' The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR ; Sg0.003(A)(2), food esta.blishments 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 effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement ; of Consumer advisory,Food Code 3-603.1 l,will be implemented January l,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories. � C'ATF.RiNG POII�ICY: I' Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Deparbment by filing the ' required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be ' obtained at the Health Depariment. �_ —— ----------— — — — _ _ _ _ _ __ _ __ . � �tOZEN DFS�Ei_tT5: 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),rnust 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. DATE: 12� 2��d � SIGNATURE: � PRINT NAME&TITLE: � A f'L/ r��. � � �v�� I ilii6ioo �'�F i�b�Nl f-- i , _ r 3� � The Commonwealth ojMassachusetts ' � W Department oJlndustrial riccidents ; 01/IC0o1/OY�SI/��IIt � 600 Washington Street � V y�y BOS{Oh�Mass 02111 W'orkers' Compensation Insurance Atfidavit Aoolicant information: Pleas�PRIPTT�'bi'ic namr: ��1�L'T�T-"I't �r ��+��GY locati�n: 43 Main St1'eet Yarmouth Port, MA 02675 �it� phone# g'�,Z— 3 S a( ; � I am a homeowner pzrtorming all work myself. � I am a sole proprietor�r� ha�e no one«�orkine in am•capaciry C�I am an employer pro�idins workers' compensation for my employees w•orking.on this job. l�r� , - -- - -- -- - ' � mpan�nam : �, 'R..� �ac9 c � � �� 5Y v 12,� ; address• �'� �"L�11� S� , S�t•; J�NISJc.��O'�,T. M,-��7S nhone#: 'a7�� Z-"?J✓e'Q i b insur�nce co t�'1�CJ��L l� ��6��10►S j N5< � � policy# �O��7�� oC7 i � I am a sole proprietor. general contractor, or homeowner(eircle one) and ha��e hired the contractors listed below «ho ha�e the follu��in��►orker� �ompensation polices: �om{�anv name• ; 3ddress• ! ��i�y: phone#• � insurance co ,�.plicy# ' com a�ny name• - _ _ _ _ __ _-------- _-- _------- addresa: -__ _-- c�: �boee It• insurance co. �ofiev# Failure to secure coverage as required under Secdoo 25A of MGL IS2 ea�lad to tbe impoeitloo of erisi�al pesaltla of a A�e op to fi�S00.00 a�d/or one ynrs'imprisonment aa w•ell a�civil penaltiea io the[orm of a STOP WORK OItDER aod a tiot otS100.00 a day apia�t ma [a�denta�d t6at a copy of this statement may be forwarded ro the OtTice of Investigatiow ott6e DIA for eovenge verititatio�. ! I do hrreby cer�ij}•under th�poins an enalties ojp jury tha t e injormation provided obovt is true atid eoneet Signaturc � % 2!�/� � Print name �c.�.�i1�- �. cGt�� one�l��l��^ � S� � � ., oRcial use onl� do not w�ite in this arn to be completed by eiN or towa ottieial city or town: y�M�DT� _ permitAicease 1! nBuilding Department �Licensiog Boud p check if immediate response is required 261 �Stlectmen's Ottiee �H-alth Departmeat contact person: phone q;_ �508� 398�-2231 egt. nOther (rev�sed 3;95 P1A1 � , DEC-20-00 14:26 FROM: ID�50B7900557 PAGE 2/2 . : Gr,�r�rrT' r, x�'�5.�'F .^1i' �iyt:ti?�:A��:-%� L 11 •4, i i [;sua dst=: �2�:��^�^ . __"�...o.'-"'-�'."'e'-��"--."��"'�'-......-'---��""---------""'--------"�'"'�'�_��...'-��_�..�.R"r.. PL9�BC47: i =�iS,Gs"iii�>odii iS i� pqY dS x !M#��@i 8T`,i&eLiS'si;"ri+ :i.i� eFi�i `"r'niii'+�� : { �� t a:2•••t i�u� ao¢sv i�v" ii fi�E e �r�4 'v3F�S.4. 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TOWN OF YARMOUTH BOARD OF FIEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-077 FEE: $75.00 In accordance with re ations�promul��under suthority of Chapter 94,Section 305A and Chapter 111,Section�f the Generai�aws,a permit is hereby granted to: — Marietta B Hickev/('ranbenv ll�no�,4� ll�ain 4tree !Ro� 6A, ' -- ,t ��re . Whose place of business is:_ Abbicci Restaiira„t Type of business: Food Service To operate a food establishment in: Town of Ya`rmrn�t}� Permit expires: December 31.2001 BOARD OF HEALTH: Sd�lG. !' �a�a�`ze�'�i�� s�arwG:ioo �'o6at� � �k �ad 0:�' �e�cfa�D. ��, 711. . February 15 ,2001 Bruce G.Murphy,MPH, . ., HO Director of Health R�I�H 30.�o��Q OH `'S'2I`HdY�I`��t�L1i'J a�n.i ,¢� � � . IOOZ`�� !�', 0 ?��'�?lG �►'� '"'� �x� ��;v �r� •��x ��;�v oo� :��.�5 �� '�� G�'3 �xi��3o ax�og •sam��ts reiaz�o.�ay�pa�o�unaaau an�pau�Ts.�apun aq�`3oaaa��uou�sas uI j •o�a.�a�s�ua uau�pue`p{,j ,�a�d�� sn��aua��q sa�uo�n��uTsua�ii a�o� � pa�u��r�o�n�a��inn�ntuo�uo�uT pansst si asua�ii siq,i, •s�iai��u�uowiuo��o�ins�za�ti aq��uq�adsas t��annuounuo�a��o snnEi a�3o uou�iotn�o�paxoria.�.�o papuadsns iauoos ssatun I OOZ�-�Rii saqiva�aQ san xa pue�juo a�eld��pu��nour.r��o unnoZ p�s uI �SI�I��I'I S�2i�'I'I�'ILL�IA 1�IOIAIL1t0� �'Q�J.1�IN?IJ�H�2I�-I SI �t • .H g . ��qi�3�a�o�sT s�y S ��3 t� - :?I�gY�if1N.LIY1RI�d H.LflOL1t?I�'A 301�tAAO.L S.L,L�Sf1H��SS�'Ni 30 H.L�'�AA1�tOL1iL1i0� �HZ ,��lC'�' I � � . ;.;� ; TOWN OF YARMOUTH BOARD OF HEALTH ,u`��0� ,� APPLICATION FOR LICENSE/PERII�IIT-24Q0 � G� C C� [� � N/ [� CaQ . �,�� n�r iqqq * Please complete form and attach all necessary documents by December 31; 1999. Fail re t'd`�S ��1T"i'�^Sult the return ofyour application packet. HEALTH DEPT. ' NAME OF ESTABI,�S�IlVIENT �P BB i ec l-----------------------------------------------TEL # �Ok 36Z 3 SD 1 LOCATION t�DDRESS� �3 2 i E.. [�A- y A-�Z�,Q.,.,ZI�{ r�o2T,�„�2� 0 Z,b7� MA�LING Ai�DR�,SS� r�rn � OWNER/CQ�'ORATT_(�N NAME: C�2�,►,��i2 yy P,.�a c��,�- ��►�. MANAG�R'$�Q�_1'�.p�Q-I ti�A- 3. l-� t,s,(C�� TEL. #Sa� 36Z 3 Sb( 1�A�.�.,ING AUDRES S� �3 2-7 S� Coi4 �r4rt.m Oz,T6-! �o�T iYI f!- Q 26 7 S r- �'OO�C�TIFICATIONS: The pool supervisor must be certified as a Paol Operator, as rec�uired by new State law, Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and atta.ch copies of employ�certifica.tions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or r�ore 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 fde at your place of business. 1. H'�t C-h Arv►;A,�r 2. ' 3. 4. R�STAUR�NT SEt��IN�: TU�A�,-#--�� A �A'FS: '£U��#��--.�r - ---- _ � -----------��____--------------------------------------------------------*---------------------___--_------- - -------------------------- OFFICE USE O�,Y �ODGING: LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRED FEE PERMIT# B&B $SO CABIN $50 INN $�0 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlVIlVIIIVG POOL $SOea. . WI�tLPOOL $25ea. ; FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 � '�2 �,CONTINENTAL $30 >100 SEATS $150 NON-PROFIT �25 ' �COMMON VICT. $50 ��,�.-(d(o WHOLESAI,E $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO � $20 � _<25,000 sq.ft. $75 FROZEN DESSERT $35 ______� ; ?25,000 sq.ft. $200 �TAME CHANGE: $10 AMOUNT DUE = $ I�� """'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•'••" �' ; � \ t 4 .,.., „ ADMINISTRATION ,� � t�Jl�ER�CHAPT�R 15�, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YAItMOUTH IS NOW RFxQT,.JIRED I '�O I�G??,L,�,ISS�,T�TCF OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS TF A FERSt�N �OR "C�JMP�INY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION ' INSiJ�A1�10E...'� �TTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT � 1V�UST BE COMPLETED AND SIGNED, OR --' CERT. OF INSURANCE ATTACHED ''' . � VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF Y�UR.PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � � NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR ; RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEFARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEl�TING FOR THE 5EASON. I ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT MOTEL OR POOL i.e. PAINTING NEW � � t , , EQUIPMENT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS Mt�,Y REQUIRE A SITE PLAN. '; ; � . ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIlII�IMMING, WADING AND WHIRLPOOLS VV�IICH HAVE BEEN CLOSED FOR � THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR � � - PSF>I�(�A�OI�AS,-'�QTA�,COLIFORM AND STANDARD PLATE C�UNT BY A S'F3ATE GERTIFIE�LAB, � PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SVVQ1�I11�IIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WI'I'HIN TF�TOWN OF YARMOUTH MUST NOTIFY'THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR T(? TF� CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT T'HE 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 DEPART'MENT. FAII,URE TO DO SO WII.,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DE5 SERT PERNIIT UNTIL TI�ABOVE TERMS HAVE _ __ _ __ _ _ __ � BEEN MET. E i OiJT��E CAFES: � OiTTSIDE CAFES(i,e., OITIDOOR SEATING WITH VUAITER/WAITRESS SERVICE), MLTST HAVE PRIOR i APPROVAL FROM TI�BOARD OF HEALTH. �UTDOOR COOKING: ' OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: ��' 2-� 9� SIGNATURE: ' � � � , � ` PRINT NAME& TITLE: JI l2 � ' �" ' �� 11/12/99 ' I _ _ ,_.._ _-----Y-�.___,,._ !� e f � ' �`'" The CommonweQlth of MassQchusetts i s � � Departrnent ojlndustrial.-�ccidents � � o OfJlceol/erest/oslliis �; 600 Washington Street ` Bnston.Mass 02111 7�,I V'y'y �. V4'orkers' Compensation lnsurance Affidavit ARniicant information: p►essepRil'�7'Ti�.-hi� namr� C� ( 1 ' � ��,3� (/'I'V/�l ! . lucation� '�f !� � 14 ��3`R—j'1�� 2� . cit� `��.3'✓1�81��" ��l?/�T— phone a �d� �(oZ 3�0 � � I am a homeow�ner pert�rming all work myself. � f am a sole proprieror �:-,a, ha�e no one��orking in am•capacit}� �I am an emplo�er pro�iding workers' compensation for my employees w•orkin$on this job. ! _ _ - — . ___ , cQmnan�• name• �'R�'�6 4'Q.�A/ !'�� 1 n , 1, � /� 1�� 1 � � e address: �.� �T� li�/4 ciri•• �19,11_�'✓L 6-�S�6� �I� /Z/1 �� I � �!'� �;� nhonep•„�a� ��Z 3S� I iosurance co. /42-��,1,�.� ��1T�I ! 0� oolicy# �T8 R3��C��S C/ �' ' � I am a sole proprietor. generai contractor, or homeowaer(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e ; the follu��in: �.orker�� .ompensation polices: s4moanv name: � address• ��" ehone t!• insurancc co. �olic�•# s2moanv name• address: _ �ti': nhnee+�• ' insurance co. ��eY� � Failure to stcure covenge as�equired uoder Secnoo 2SA of MGL lS2 ea�lad to t6e iepaifioa o(erisi�i pesdtles of a d�e op to 51�00.00 a�d/or ' one vnn'imp�isonment as w•ell a�eivil pendda io t6e form of a STOP WORK ORDER aed a Ifae otSI00.00 a dar Kaiost ma I a�dersta�d t5at a � copy of thy statemrnt mav be fonv�rded to the ORce of ievatig�pom of t6e DIA for eoven�t veritftatia. � /do hrreby certif}�under�he peins d prnal�i�s ojper�ry that tl�e i rneation provided abovt is trrre atd eorrect � i , �,, Signature ��/�"'I � ,�.� , Print name oneM �B� �� Sf� � i f 1 .. o(Ticiat use onl� do not��ite in this area to be completed by ciry or towa oAleial i city or town: Y�M�IITQ _ permitAieease a nBuildiog Departmeot + �Lieea�io6 Board � �cheek it immediate response i�required 261 �Seieetmen'�Otlice �Health Departmest contacc person: phone 1t;_ �508} 398�?231 ext. nOther i .. _ �,,: � _ , NOV-30-89 12:5? 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'.................�..^_..�.... .�r..�.....�...... --------------^--------------------------------�-------------- t��. .�. .,. ! � i � i � � , � I t ( ( ! -�--�---------------------------�----------------------------------------- - D4fCflftt9a hf L+�ttA.f!?IISfI6Sd}!QA5�44hiCI4S�TlS�tICt!Q6SfF�QCJfl� lff�5: , � ak� a�� rti�� rions C�TIFICATE H�LDSR CANGELLATYUN fi S!!�a►d}Qr a{ tf�g nbrv# d�crjbtd,00lic'sss Re �r.cr!!td �r�Rc, +ti. __---- _. _ ----- . tz iratian �te ther o.'— e ��t��x ,te�paer p�.? '�dear4t te - - •_- - �- - - - ---- -. � . --- . : w .__ - . . _ ._ OF�I�. -.. � � :� f�� ors o na� sr we �c�'s ! ��P�ss �o i�l�q�#�� a* _: ��.1� � � �!�lt�F�; �� Q0; kltll� lpC�r f�� ,9lP4�r �rc asaa{c ar rop�FBEA±!{'InpS� s�t�! �u� � a_�d � ----------------------------------�____._____...---=-------------- � Aafheriz�d repr�sa►tafive: i l SCOS'r u LG�E �A -¢�---------------------------------------------------------------------------------------------------- ; . ; � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-121 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: C'ranh rr;Moose Tnc_� 43 RoLte 6A,Yarm�Lth�rt, 1lRA Whose place of business is: Abbicci Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �at��, C'�tr,�n SEATING: 100 �oan.� �ul[ivaa, K.//., Vice C,fzairma �o�ert� �rown, (_.lerh a�rie�le�a�Zo�.��-.�o Pea � �0' ouy�� : ��u��a ;z��o __ _ _ _ ruce G.Murphy, .S., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-66 FEE: $50.00 This is to Certify that Cranbem Moose Inc d/b/a Abbicci _ 43 R� � fiA, Yarmo � h o�rt�11�A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE ' Iri said Town of Yannouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authority granted to the licensing authorities by General Laws, Chapter 140,and amen�ments thereta In Testimony Whereof,the undersigned have hereunto�xed their official signatures. B�ARD OF HEAL.TH: �'d� `�st�� l.�irman SEATING: 100 �oan� �ul�ivaa, ��, Vice C..�zairmaa obert.}. /�rourn, C..lerh a�rie6la�a�OG��y�tooP �ael �[in Janua�y 21_,2000 ruce G.Murphy, H, .,CHO t Director of Health r