HomeMy WebLinkAboutApplications, WC and Licenses , , � �';�
`' �' : ,''"� � �'��I ,w� r,J .
. � ► TOWN OF YARMOUTH BOARD OF HE�TH �{ ` �'1�
� � APPLICATION FOR LICENSE/P � ����19* �`� ' N C�V 2 � 2,��
� * Please complete form and attach a11 necessary ds �me��s by Dece�ber 1. 8�.� ° �1� ,.�-;-.
Failure to do so will result in the return of�y'our application pac et.
NAME OF ESTABLISHMENT: Q L'�S I i ty T . #���
LOCATION ADDRESS: CS' cCt . �
MAILING ADDRESS: S �
OWNER NAME: �� L �- ' TAX ID FEIN or SSN : �"
CORFORATION NAME (IF APPLICABLE): �..i,C ,
MANAGER'S NAME: ��t� S TEL. # ' "
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Fool Operator(s) and attach a copy of the cei�tification to this form.
1. 2. -
Pool operators must list a minimum of two employees cui7 ently certified in basic water safety, standard First Aid and
Community Cardiopulmonaiy 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 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 foi Food Service Establishments, 105 CMR 590.000.
Please attach capies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file Rt your establishment.
1. .rl'.��� �'���� 2 ��i���j1� ����'N f
PERSON IN CHARGE: ___
�ach food establishmenf must have at least one�ersan In L�axge(F'l�;j ori site during hours o�operation.-
1. �k��p s����o 2. �Ar���� ���G�J I
HEIMLICH CERTIFICATIONS: �
All food service establishments with 25 seats or more must have at least one employee nained 'ui the Heunlich
Maneuver on the premises at all tunes. Please list yaur employees trained 'ui anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will nat use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQL�IRED FEE PERMIT� LICENSE REQUIRED FEE PERMII'# LICENSE RE.QUIRED FEE PERMIT�
B&B S55 CABIN $55 MOTEL �55
INN S5� CAMP S55 _SWIMMINGPOOL $80ea.
_LODGE S55 _TRAILER PARK �105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS S85 —Q3E� _CONTINENTAL S35 NON-PROFTT S30
_>1Q0 SEATS S160 I GOMMON VIC. $60 –�' `�� y WHOLESALE �80
RETAIL SERVICE: —RESID.KITCHEN �80
LICENSE REQUIRED FEE PERIVITT# LICENSE REQUIRED FEE PERMIT# LICENSfi REQUIRED FEE PERMIT#
_<50 sq.n. �50 _>25,000 sq.ft. 5225 _VENDING-FOOD S25
_<25,000 sq.ft. S80 _FROZBN DESSERT S40 _TOBACCO ��5
\AME CHANGE: S 10 AMOUNT DIJE = S /�f 5. 0 G
***�*PLEASE TLR\OVER AND CO�VIPLETE OTHER SIDE OF FOR'VI*****
ADIVIINISTRATION .
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 V�orker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSI7RANCE
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 p 'or to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
_ YES ' NO
M��EL�AND Q'THER,Lt�DGIN�ESTABLIS�MENTS `'
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 af residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as c�efined in M.G.L. c. 64G or 830 CNIR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days
pnor to opernng. PLEASE NOTE:People are NOT allowed to srt m the pool azea until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
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:
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 fromthe Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTTCE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN
TI-� COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD 4F HEALTH PRIOR
TO COMMENC ENT. RENOVATIONS MAY. QLTI A SITE PL N.
DATE: l� (! . . . SIGNATURE: _
PRINT NAME&TITLE: ��-�� ,� , -' CWI����
io,jzvos .
:` :
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��a'�e�-s C°om�ensa�ion and Empl��ers �,a��aility
r���ra�ce �o��Cy Z U f�.I+��-I
ASSURAIYCE COMPANY C3F'AMERi�'A
InfGimaiion�'age
IVCCI Com�sany No.: 121�s Accc�L�r i�vur�tsEA:�ta5ssi��:�_a.oa�-ncx�oi
Branch Poltcy Number Producea Caie FrevRous Pa�icy Numbzr
X.A R�fASSACHUSET'TS(7FFI EWC 027344+9C,O�J i I65D743 ?�F}y
Servicing Addcess P.O.80X 10197 JACK.SON't'�LLE,FL 32247-d1�37
ITEM 1. .Name Insured�nd Mailir�g Address Pracfucer Name and�r�,�c�ng Aadt.ess
GERA[.D SFIBFFIELD Uf3A CAI'E WTDE IN5L?RANCE AGEAiCY,INC.
BARBARA LEE'8 KITC}lEN LLC pL�F30X i2A8
23 S WHI7'�S PA'TH _ WEST'CHA'z'lIAM!�TA 0'?ba��-l288
SOUTN 1 t1R1YIOL''7'�MA 0265�
{508)945-5244
This Tnformation Page,with policy provisions and endorsemen#s,i�°any, complztes this policy.
I[�sured is: LIMI'i'F.�LIABtLT1'Y E�OMPA.NY
Itisk I.D.No: F.E.I.N.: ?
Other Wotkplaces Not Showri Abc��•e: sEE scx�ULE oF INsuR�Ds�.xD Lt7t'.�'i'�o:vs
Tl'Ei�i 2. I'alicy Perioci: From: o1it���2oos To: otio��2cx;� 12:U1 a.xn.�"tandarc�Trm�at th�Insured's Nlaiiing Address
ITEM 3.
A. VVork�rs Corn�erssation Insurance: Part One of the poTicy appl��s to the Wvrkers�'Qmpensatioan Law vf th� states listad hzre
MA
B. Employ�rs Liability [mc�ran�e: Part T'wo of the p�licy appl;es to wark in �ac�a stat� listed in It�m 3A. Th� dimits of aur
liability �der Pan Tuo are:
Aodily In�uuy by Accid�nt $ lqd,OW Each Accident
Balily Injury by l�isease � ---50(),pW palicy Limi4
Budily ln�ury by Disease $ � 100,t100 Each Employee
C. nther States Insurance: Part Three af the policy applies to the states, if any,listed her�:
AI.L S'I'ATES EXCEPT NI3,ON,WA,WV,WY AND TIHOSfi LIST°ED IN 3A.
D. 'Ihis polia;y includes these endorsemeirts and scheduE�s: SEE FFCaRrr%S A��h+DUR5Ew1E�e�1'S APPLICABLE LI��T
ITE:VI 4.
The premium f�ar this p�aticy will be detennine�by aur rnanuals of rules, classificatic�n�,rates<snd rating ptans. All rnformatian
required�n the foll�wing Classification Sch�dule (s}is subject ta ve�ification and cha�ge b� audit.
SEE CLASSIFIt'ATlf7�N SCHEDi)LE
Totat Bsti�mated Stancla�d Premiwn � 514.� If indicated belov��,acljusttrrents of premi�un shall be ma�de:
Prer�aum Uisca�nt $
Expens�Constant $ 318.tJ0 �] r'�nnually
I'remiurn for Endc�rsememts $ IS.�d [� �emi-Ac�ra�aal2y
T"axes ae�d Sur�i�arges $ 30.� [� �uarterly
Total E�timated Anszual Premia�n $ 877.00 �J :vtant�ly
Minimwn Prenn�um $ 2I9.00
Deposit premium $ 877.00
--__.
�ssue Date: �ir�.a,�zc�os tA�sU12�D Cc�PY Countersignc;d By�Authorized Representa e
r„.,..�:..c,. itaa��r..,:,,....r r�..,,,.,.:a,..,f'°....,..n....e<:,,,�r.,m....,,.....
.' . .
rs Co� ensati�n anc� Employers Liability ��JRIC�
�'orke P
Insurance P�li�y
ASSL`1tANCE�OM�Ald'�' o� AMERICA
S�heduie of Insuxeds and Locati�ns
Pc�iicy Number Proc�ueer��e
Branch �'�' 0�734996I)0 116507a3
Iw1ASSACHUSETTS G►FFIC'E
SCHEDi.ii,E UF INSUREDS AND LOCATIOitiS
23 S WHI'IES PA:TH
(�:RA1.D SHF,FF I F.I.D I)BA �,*�I YARA1CYlJTH MA, 02664
BAR1iA,RA 1.EE'S KIT��'N LLf'
�.Ti.l.h.#:
Issue Date: of;to 2oos
WC'y4 00 Q2(F,d. 10-94� INSTJREI�t'OPY
PAUE 1 OF l
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, 'd�' Safety Insuranc� Company
�
2t�CustAm House Street
Bos�on, nna o27+o Bus i.nessowner s Po f i cy
�-eoo-ssi-��oo New B�siness Cec # �rat ion
ir�ct 6iN - !n ured
C1ec ! €�rat ions Effect ive 01f041 �
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�POA009682 Olf t34j08 01/04/09 1� : 01 1�M STA.r�TI31�RI) TIME 31925 <
� �►���tit�;�i.��l� ..
BAR�ARA LEE ' � KlTCHEN LLC F�ARQUHAR & �LACK INS AGENCY
2� W� ITE ' S PATH 85 EXCHANGE STR�ET SUlTE 1��i
SOUTH YAF�MOl1TH, MA t72664 `Y�� , �R ���fl�
--------------____-_______ __� ____ � P h o n e : ( 78� ) 5 9 9-22 0 0
Fc3rrn c�f Business: Cosporaticsn __— --_---_
E3usiness Descri�tion: D�;iicatcsse:ns and Sanciwich Sho{�s _
�
In return for the payment af the premium,and subject t.>a!1 of tt�e ceams of thf�palicy,includirag fotms
and endorsernents made a arE hereof we a r�c wirth �iu ta rovici�the iasur
ance ay stated rn thas !gc .
C+DVERED LUC,�TIO�7(�)
LOC:00t,SLDt;001: 23 WHI'�E'S PATH,YARMOUTH,MA (}266q '�"-" --------
PRQPERTY
This tic cc��tains a 55�11? dedactible unless otherw�se s e�ci�ed see additonad�overa�es s�ectio�).
I�GC BLDG COVERAGES LrMITS C3F � VALLIATI�11�7 AIITiJMATIC
N(7 NO INSURANC'E CLAL)'SE INtCRE�►sE
Qdd QOI Pe�nal E'r�P��Y $40,040 Repiarement Cr�st U4 �b
--- i_- LIABILYTY' AND MEDIC�L EBPEN�E3 � �
Except for Fire t,egal Liabedity,each gaicl�laitn for the eo�erages listed t�duces the amaunt of iinsutauce we pcovide
durin the a licable annual riod. P[ease refer to Paca ra h D.4.of the Busineasvwners Liabili �Coverx c Fcrrm.
DESCRIBED COVERAGES � T�IMIT� O�' INSURAATCE
LfABIL.I'�'Y SI,OW,000 PER OCCURRE;tiCE
MF:l�lCAL,F:XPEhfSES S=U,000 PEft�'ERSON
F'tRE L.EGAL LIA$IUTY $100,000 ANY t}NE�'IRE J EXPLUSIUN
ADDYTIONAI, COi�ERAGES / OPTTONAL �O�/ER.A�GES - PR4P�RTY
Thc fo[lflwing addidonal J npdoraai cove!•a�ges arc affordedV ut�dee this g+i�licy.
__ .
Somc covera cs are sub'ect t��eductible§s c�fied i�the lic forna,s.
L�C NO BLI7G NO DESCRIBED CC)VEFt�C�ES LIMI�'3 OF TNSUI�A,NCE
F,DDYTYONAL C�VERAGES ,� UFTIONAL COVEd7AGES - LIA.AILIT�'
'fhc followin additional o tional coverages are afforcled under this policy,
B�scRas�� covE�uGEs I LIra��s or���rstrRa�rrc�
p�t�vM -
Annua! f'remium $1,570
!! Y.� i� J , l� `" �
'.. - ! ,.._- `�;" , 1.�..- �,�..
;ttiu7'ec�Cu�Sy� AU7HOAITFD FEPRESENTATIVE
PAGE 1 OttU3to9 (Pnm Date)
� E A 5 Business: (508) 888-3619
U Home: (508) 398-6813
� - - SllRVEY, INC. Facs: (508) 888-2496
� - 141 ROUTE 6A
SALT POND BUILDING
P.O. BOX 1729
SANDWICH, MA 025G3 �' ��� •�-�-. ,
_ Me�
� �� Z��
January 7, 2009 �V� � - --- _.
Mr. Bruce Murphy
Director of Health
Town o#Yarmouth
1146 Route 28
South Yarmouth, MA 02664
RE: 23 Whites Path
23S Barbara Lee's Kitchen
South Yarmouth, MA
Tight Tank Inspection
Dear Bruce,
On or about January 5�' 2009 we inspected the tight tank at the above
referenced address.
The 3000 gal tight tank was found to be structurally and hydrautically
sound. The two manholes and rims were accessed, the floats and alarm system
were in good working order.
The amount of effluent emanating from the kitchen sink that was pumped
and delivered to the plant as shown on the computer print out for 2007 was
7,108 gallons and for 2008 4,369 gallons.
Sincerel
Edward A. Stone
Cert. Title 5 Insp,
r
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-038 FEE: S85.00
In accordance�;°itl�regulations promulgated under at►thorin•of Cl�apter 94,Section 30�A and Chapter
11 l,Section 5 of th��ieneral La��s,a pernlit is hereb�-graiited to:
Barbara Lee's Kitchen LLC, 23-S White's Path, South Yarmouth, MA
Whose place of business is: Barbara Lee's Restaurant
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 2009 BOARD OF HEALTH: ��fe�en SRtaRe, J2..lV., Cl�aLcnuzn
sEarmrc: 10 C`htax�ee .�. J`rfeeeiltelt�,� `tI�[Ce �'lfcrbttrtaft
RESTRICTIONS: Engineer to submit annual report regarding .l�(3��P11t �. ��itOWtt, :CQXtt
septic holding tank hy Dec�mber l.No fr��olators. Qlttt ��lGP�¢+ft�t�t�r►L� �../V.
�'..`'`'�,...✓n• .`���.6
�
�
Novemt�er 26,�2008 f r
Bruce G.Murphy,MPH .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLTMBER: #09-024 FEE: S60.00
This is ro Certify that Barbara Lee's Kitchen LLC d/b/a Barbara Lee's Restaurant
23-S White's Path, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirtv-first 2009 unless
sooner suspended or revoked for violation of the laws of the Common��vealth respecting the
licensing of common victuallers. This license is issued in conforrnity�vith 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: .1�EQe_Pe����t�S� Pcrya��r.,t�/J2� ��.�.i�V�.,���C'/nffc,tiacr►u�u�t_�����
SEATII�G: 10 ��f[GInG�iJ J6. JL��S.CSRYJ[� VICC �..�lC(.lnfILCYII.
S�a.Bent `3. `.�(3�tausn, C'�
Qnrr C�'�ceerr.�cucm., J`�..�Y.
Ei�e�*t J• ��ar�.e�'
No�•emUer 26,2008
Bruce . Murphy,MPH, ., CHO
Director of Health
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Aca�o�, CERTIFICATE QF LIABILITY INSIJRAIVCE °�'�""�'°°�"�""'
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ANY PERSON YNiO KNOWINGLY AND 1MTH INTENT TO OEFRAUU ANY NSURANC�GQMPn�n'oa AhiOTli�FZ PERSON FILE3 AN APPLICATIaN FQR INSURANCE OR
STATBiAENT OF CLAIM CONTi41NiNG ANY MATEWALLY FAl3E 1NFORMA�N OR CONCEALS FOR THE PURP�SE�F 1�AlSLEADING INFORMA710N CONGERNING ANY
FAC7'NW'fFRIAi.THE7tETp�Co14�AITs A FRAUDU�ENT INStlRANC�ACT,vN-IIG�H IS A CRtl�iE AND SUBJEC7S THE PERSON TQ GRIMlFWL AN4[NY:St1Bu�'iANTIAi-1 CIv1L
PENALTIES.(Not appfkaWe m CQ,HI,NE,ON,oK o�,rn ar vr;in DG,11ti ME and'VR„i�suranCe b�nafits may also be denied}
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APPGICA!'R'8 SiGNATURE OATE PFiCWCH{'9 910HAT1�AE NA710NAL PR40UCER NU�IQER
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Aca�a iso tzoarosf
��INS130(aoa� AMS paqezds
TOWN OF YARMOUTI�
BOARD flF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISfIl1ZENT
PERMIT NL7MBER: #08-090 FEE: $75.00
In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter
111,Secrion 5 of the General Laws,a permit is hereby granted ta
Gerald Sheffield, 23-5 White's Path, South Yarmouth, MA
Whose place of business is: Barbara Lee's Restaurant
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 20p8 BOARD OF HEALTH: .�f,�er�S�c�� ,�J2�p..DN�Q.,_�C�'fp�a�,vcnta���rt������
SEATING: IO � JG..�./L(�G��[X�'L� V�lCB �..�s(bl�iltK�IL
�sTTuc`r�oNs: Engineer to submit annual report regarding .�JF�O.�.Pll�3.���K(!l(!/t� (;CPX�
septic holding tank by December 1.No fryolators. Qttl�t � ✓2../V.
t����
1
January 15,2008
Bruce G.Murphy, H .5.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER_ #08-059 FEE: $50.00
This is to Certify that Gerald Shef�eld tilb/a Barbara Lee's Restaurant
23-5 White's Path, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LIGENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensmg authorities by General Laws,Chapter 140, and amendments thereto.
In Tesrimony Whereof, the undersigned have hereunto ai�ced their official signatures.
BOARD OF HEALTH: ./���e_�e��rDt�S� f£�altF£,T/J`���L.��J�V�.�,���'fpfa'i�cnu��ut������
SEAITNG: lO \�fI�VZG�/J .7G. .�.I11�Q�[�llW'[�� V�CC6 ��[I.[l�[�/1L�fL
� 5��it 3.J`3�c�crtfZ, �;�t�
���� �-�-
Jainiary 15,2008
Bruce .Murp y,MP ,R. CHO
Director of Health