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Home My WebLink AboutApplications, WC and Licenses� � , �� fr_A � L { ��° ,r:R�sC TOWN OF YARMOUTH BOARD OF �„_ - �il � C� - �._ ,,;� APPLICATION FOR LICENSE�,' .�, ��2� '] 2006 � ,,� � �� N0V 1 * Please complete form and attach all necessar��c�ents by Decemb r 3��D� pEPT. Failure to do so wili result in the return��yaur application pac NAME OF ESTABLISF�VVIEENT: �A � TEL. #.5E1� 3 4� J�'S T.� I LOCATION ADDRESS: � �? t��t��j�, S ,.t,� (�_�,� p�� MAII..ING ADDRESS: OWNER NAME:�„��(3�`o�fZ l Tt� ID (FEIN or SSNI� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: RS TEL. #vf6S 3 b Z-�� MAILING ADDRES S: Z`�3 POOL CERTIFICATIONS: The pool supervisar must be certified as a Poo!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 cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these emplayees below and attach copies ofemployee certifications to this form. T6e Health Departmeat 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 a.re required to have at least one full-time employee who is certified as a Food Pratection 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 Gle at your establishmen� 1. V � � �lZ..S 2. �t�.l - PERSON IN CI�ARGE: _ _ . —- _- . _ . _ _ _ _ _ . ___ ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � 1. � t v�-c_ � c� [�G.�� 2. T HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1.��nN2� ��,('Q�..� 2. �i.�.'O�T�/ �Q � �� .� 3. 4. RESTAURANT SEATING: TOTAL#_��" 7.3 OFFICE U5E ONLY ' LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQtJIRED FEE PF,RMIT# LICENSE REQUIRED FEE PERM[T# B&B �50 �CABIN $50 MOTEL �50 _INN $50 CAMP $50 SWIlNIlvIING POOL$75ea. LODGE $50 _TRAILERPARK $100 _WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERM[T# �0-100 SEATS $75 �07'�� _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 / COMMON VIC. $50 �07�00.3 WHOLESALE $75 ' RETAIL 5ERVICE: �RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMCT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZENDESSERT $35 � TOBACGO $50 �O7—U0,3 NAME CHANGE: $10 AMOUNT DUE = S !75•O O '*""•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""• i ; - � ! f � ADIVIIlVISTRATION �f ( Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ` Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LQDGING ESTABLISHMENTS i f i TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be t 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 ofresidence elsewhere. t Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an i aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest u�it as a residence or � dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy ' Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ' POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected � by the Health Department prior to opening. Contact the Health Department ta 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 thereafter. ' POOL CLOSING: Every outdoor in ground svwnming pool Fnust be drained or covered within seven(7)days af closing. i FOOD SERVICE CATERING POLICY: ; Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Departmetrt by filing the required j Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the Health Department. FR.OZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te certified lab. Test results must be sent to the Health � Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waater/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: � _ . QutdQn��oolc��ng�reparation,or tlispla.y�fan�food prgciuctbya retail or food service establis�is praLibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETL7RN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS��ViENT, MOTEL UR PO�L (i.e., PAINTING, NEW EQUIl'MENT, ETC.},MUST BE REPORTED TQ AND APPROVE Y BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI PL . �� DATE: 1 SIGNATURE: ; � s/ E � PRINT NAME&TITLE ; � lOJl7/06 , I � i I 1 . � { . . � � NOTICE NOTICE TO � > TO . EMPLOYEES , ; �,,�` EMPLOYEE M yV The CommQnwealth of � Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washing#on Streefi, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Granite State Insurance Com�any NAME OF INSURANCE COMPANY ADDRESS OF INSURANCE COMPANY WC8741515 04/21/06 to 04/12/07 POLICY NUMBER EFFECT�VE DATES 434 RTE 134 ROGERS & GRAY INS. AGCY, SO. DENNIS, MA 02601 1 800-553-1801 NAME OF INSURANCE AGENT ADDRESS PHONE# _lamPc M Rnnarc EMPLOYER ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to fumish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her .own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related ' injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the " NAME OF HOSPITAL �N-Y AC..�R�E�ITELl-k1.C1.S�IT�L ADDRESS TO BE POSTED BY EMP.LOYER WC 7506g(2-02)UNIFORM i TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-004 FEE: $75.00 In accordance with regu1ahons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: 7ames Rogers, 62 Highbank Road, South Yarmouth, MA Whose place of business is: Sandba�ers Type of business: Food Service To operate a food establishment in: Town of Yarrnouth Permit expires: December 31, 2007 BOARD oF HE,�I..TH: B`' p� $/. �� , tLI.`�/.,� ��_ ' SEATING: 73 dY�etkl�e�ffG�il� �C./I.� �(��llfl�ril RESTRICTIONS: Disposable Service Only. K/�ff�� , /f��./B?�[viL,�c�:ts1erue NG�ltCR/I7�@hpL(Tf� i4�sis!�'�ieei��sCrr�, R./V. November 22.2006 Bruce G.Murphy, ,R.S.,CHO I?irector of Healtli THE COMMUNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #07-003 FEE: $SQ.00 ' This is to Certify that James Rogers d/b/a Sandbaggers at Bass River Golf Course, 62 Highbank Road, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 200?unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victua.11ers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affxed their official signatures. BOARD OF HEALTH: B�/ ,�`h/. �� ,/l?`h/.,�� • SEATING: 73 df@��I�fIGI�� ./I. (!%CP�ff("i�I/tlJtG�IL Ro�w�it� 8��, G� p��Ll��t �t��.zd�, R.1V. November 22_2006 ruce G.Murphy,MP , .,CHO Director of Health i ! , -- � .� . j THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMQUTH ! BOARD OF HEALTH ! PERNIIT NUMBER: #07-003 FEE: $50.00 This is to cercit'y tt,at James Ro�ers dJb/a Sandbag�ers 62 ��hba�nk Road, SoLth Ya_�-moLth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBLTTION OF TOBACCO PRODUCTS AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This.pet�t is anted� �gorm��y with Article VI f e Sani�y Code of The Commonwealth of Massachu�tts,and e�ifes ll�er 31�2�7 unl�ss sooner suspen��or revoked. No��t�22 Zoos Boa�oF��.�: B �. �'oad��iGl.�., . ��`st�, �.�, v�e�-� Raa�t� g�, et� A�tit�9s�tt �1.�C�'n��, R.N. ruce G.MuiP Y,MP ., Director of Health i `I � � � °�'\ � - _ _ �- , •,�,,,,_�.-i ��u 2 ��' � �f Y Q ` _ L�J 3? ,. _o TOyVN OF YARMOUTH BOARD O�'�EAt,TH � . �� APPLICATION FOR LICEN��%�1�II`�-:2'D06 UEC �� 5 Z005 * Please complete form and attach all necessaty documents by Decem er �,�0�5�„C DEPT. Failure to do so will result in the return of your application pac . NAME OF EST.ABLISHIVIENT: �y TEL. #e�i9� �3��/�Zl�, LOCATION ADDRESS: 2 t MAII.,ING ADDRESS: �t e� e1 OWNER NAME:��(,�'.S ��25 TAX ID(FEIN or SSN�: `�� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: d ,� 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(-�)a:�d attacl�a cop�of thecertification to tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.Q00. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. _ _ �ER�4AF IN CHARC�:- __ _ _-_-- _-, _ _ _ _. - -- - _ __� ._�n�_.� -----�- --- - Each food establishment must have at least one Person In Charge{PIC) on site during hours of operation. � � ��r�� z. i. �� HEFi��eH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and at�ae�i copies of employee certifications to this form. The 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. RESTA SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMI'P# LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 iINN $50 _CAMP $50 _SWIlvIIvIING POOL$75ea. LODGE $50 TRAII,ER PARK $50 WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# j 0-100 SEATS $75 �6_O�.j_ CONTINENTAL $30 NON-PROFIT $25 ; >100 SEATS $150 �COMMON VIC. $50 ob—n�� WHOLESALE $75 � RETAIL SERVICE: LICENSE REQITiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOQsq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25 06-01� ; NAME CHANGE: $10 AMOUNT DiTE _ $ ls� -OO "•"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*"" , f �� "�' , T ADNiINISTRATION � t � Under Chapter 152, Sectian 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal f 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 4R WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ; APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETIJRN THE C4MPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. k � SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- � 10 DAYS PRIOR TO OPENING FOR THE SEASON. j ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i ADDITIONAL REGULATIONS ' � 1 POOLS � POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count 4 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. ` i F r FC?OD SERVICE CONSUMER ADVISORY: Each food establishm�nt which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: - �rozen �sert�must��t�ste�ar�a�c�nt�ly basis by a�a�e certified lab. Tesf resul�s mus�be sent to�eaith ; 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 waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail o service establishment is prohibited. 7 DATE: SIGNATURE: � PR1NT NAME&TITLE: 09/28/OS ( , i � � t ': �-� ?'he Comnionwealtlt of Massachusetls -===_-3 �-- -__ __=- - - = DcpaR�rrent of Industrial Accidents -- N�ei/f�l'M� -= 606 WashiRgton Stree� 7`�'Floor —-,,,� Boston,Mas� 02111 � Workera Com�aahoe Ls�ace Affidav�Bail ' b� � �,. .w. �.� , . , ., _ . . _. o�hxetors � :r=;��.,,�� :.� .�, �.� ,, ,� �� ,4 .,- .,. � � xr name: add�ess: te• l, v�rork site locatia�ffnll addressl• �/4'v1it�C ❑ I am a homeowner petfonning all wark myseif. Ptoject Type: ❑New Ca�a�QRe�nodel I am a sole and have no a�e w in aa Bui1 ' Addition ❑ I am an e�nployer�oviding workers'compensati�far my e�nplayees worlcing ai this job. .w�ts �. �l ❑ I am a sole praprietor,gaenl costractor,or hamoow�er(urc%oue)and have hired the comr�ctors listed below wh�have the following wotkers'compensation Polices: �; dis• oia�e�k- #� �11HY1�l; �; dRYt ��` —- -------- -- ------ _-- -- — - _ _--_ --- _ _— ---- -- -- -- - � - - . Faila�e M aecm a�aa�e a�reqi�+ed uder Sali�a 2SA�E MGL 1�eu Ind q tl�e irpaWw�f cri�Yal pe�alKes�f a fe�p b t1,3M,N a�dl�r ase ye�n'ie�tireeaeet as wU as in the fer�•f a STd!'WORK ORDER a�d a IIre ef S1M.M s dty�sae. I�ednslaad tliat a apy ef tlde�ta�m�at my 6e Umce�f Im��f tie DIA for ave�rase veeiAatlsi. !do IYerrby c �rnder NYe awd ' nfPerjx�'tI F�t dbe iufenw�tou prnrPded abone ie true aud onr r SfBna�ue �� i 7,J � t� �rY Ptint A Phone� �4'"(��{ �� ' e�ial ase oaly de eat�vr#e i�t�a am b 6e e�plaed bY eit7•r Mwn efficial c&y ar tawn: perm�oe�e IR ❑c�ed[if imme�ale rdpssx is reqaired ��t �sdxlsn's Ol�oe cenhct persen: phe�e g, ��t t�s.w-ma+) � � i I TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-061 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to: James Ro�ers, 62 Highbank Road, South Yarmouth, MA Whose place of business is: Sandba�ers Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2006 BOARD oF HE�,�'H: Be�syanri�rs�S. (�''onc$o�,/LI.�. ' SEATING: 73 n�/��/}y�� vj��,��`y xEs�ucTtorrs: Disposable Se�vice Only. Qo�it� B�iiiu�rs, � ��'�k, R.N. �J�f�'�e��, R.N. December 16_2005 � Bruce G.Murp , H,RS.,CHO Director of H th THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-047 FEE: $50.00 This is to Certify that James Ro�ers dlb/a Sandb ers � at Bass River Golf Course, 62 Highbank Road, South Yarmouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALT'H: Be�yc�,rsrs`�5. �'ohd,o�,/�l.`h. ' SEATING: �3 ��.t��, v�e�� Rod�r�t� B�«�, C� �Sl�, R./V. �4.��, R.N. December 16 2005 Bruce G.Murphy, S.,CHO Director of Health 0 i � j � � , + a f i THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH � BOARD OF HEALTH ; PERMIT NUMBER: #06-014 FEE: $25.00 � ThiS is to C�tify that James Ro�ers d/b/a Sandba��ers 62 �b�nk Road, South Yarmouth M�4 1 IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBLTTION OF TOBACCO PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�eerr�t i�s��t�in2�orm�'tv with Article VI�f Xhe Sanitaiv Code of The Commonwealth of Massachusetts,and Xp �ss sooner suspen ea or revoked December 16_2005 BOARD OF HEALTH: Biest�-.�ust�ti �r. (�o�rC,/�$., ��, v�e��.� a�t�e�, et� � �'l�k, R.N. �I.u��, R.N. , �.�� Director of H�eaIYT • •, ; i } ;��2��..,�0�3 -�.� , �� , °`�-'4� TOWN OF YARMOUTH BOARD OF HE�� , �� ` . � 3�' _ ",o �"� "�, _ � ) v' o _. �;-`� APPLICATION FOR LICENSE/PE �P R ` �Q u'� � • ..•''? �� ;,' . :",� * Please complete form and attach a11 necessary d �' ;�ecember 3 , 2 0#1EALTi� �.itp� � ; ,�,.. Failure to do so will result in the return of y ��ap ca.hon packet. �. ____ �' . , NAME OF ESTABLIS��VVIEENT: �' TEL. # LOCATICIN ADDRESS: �Z i MAILING ADDRESS: � OWNER/CORPORATION NAME: �ivkl,t,t�a �'�O��P►�'S MANA ER'S NAME: —� � TEL. # — c ) MAILING ADDRESS: �'{� /N # : t� z �— c� 7�/�.�? �'� POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid ' and Community Cardiopulmonary Resuscitation (yCPR). Plea.se 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. i FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food ' Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ! Please attach copies of certification to this applica.tion. T6e Health Department will not use past years' records. ; You must provide new copies and maintain a fde at your establishment. ' � ' 1. %�I�l%u,�l�l`,� ��a,g�� 2. PERSON IN CHARGE: j Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. '� � l. �� i o��, 2. ' � HEIlVILICH CERTIFICATIONS: 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 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. l. ✓ �.1 2.�,M. �.� I� ICo(�if� , 3. > �� 4. RESTAUR�INT SEATING: TOTAL#� ' OFFICE USE ONLY LODGING: LICENSE REQiJIItED FEE PERMIT# LICENSE REQIJII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 INN $50 CAMF' $50 _SWIIvIlVIIl1G POOL$75ea. LODGE $50 _TRAII,ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQUIIZED FEE PERNIIT# I 0-100 SEATS $75 O � �B _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 I COMMON VTCT. �50 OS�' WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQIJIRED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 ��O�(j NAME CHANGE: $10 AMOUNT Di]E = S �J'rC�•� '"'�•*PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM""••" _ — _ _- `�__ _ _ r�- . 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 INSITRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR , CERT. OF INSURANCE ATTACHED I 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. PLEAS�;: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, 2004. �, SEASONAL ESTABLISHMENTS ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION?-10 DAYS PRIOR TO OPENING FOR THE SEASON. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ', TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �'I ADDITIONAL REGULATIONS I POOLS ! i POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected I by the Health Department prior to opening. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of closing. FOOD SERVICE CONSUMER A,DVIS�RY: Each food estab ishment which serves or sells rea.dy-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be ' obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut 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. OUTD04R COOHING: Outdoor cooking,preparation,or display of any faod product by a retail or food service establishment is prohibited. i I DATE: SIGNATURE: PRINT NAlV�& TITLE: 10/22/04 i ' � ' -=---� The Commomvealth of Massachusetxs __- - �_-__ Deparhrient of Industrial Accidentc -- �� - - - --�- 64B R'ashiRgton Stree� 7"�`Floor -- ,,,�., Boston,Mas� �ZIIl " workers'com�aacio■I.s�ee Affiaavic:Bm1 • I�hrkal cu�traetors � ., .� a ._,, �. ,. , ,. :.�, ,��' . ,, ,� .�,�..v . name• �J��I�'�G:�S � ��Q�� _ address: C� '�3 -S : �Z � .� ��i��r�,u�S�- � z /�i�rf �� IZc� S�4 �/A2 wlou7E-( l'1��} 1J z 66� ❑ I am a homeowner perfornaing all work myseif. Project T : ❑New Ca�uctiari�R�nodel I am a sole and have no a�w in an Buii ' Additiion � I am an employer pcoviding w�'compensati�fa�my employees wcrrking�this job. a�v�� 11�.��14(�g F�l� �.: �z t�t�� R��l�� .��R _ ;�2�>�/ ,!�� ❑ I am a sole p�roprietor,geaeral tractdr,or komee�va�(circle oAe)and have hiird tbe ca�acto�s listsd below vrho have the following workers'compensation polices: �: �: i c#v: ni�e� � �lY�; �#: : i'�lYt ¢iloi!�- � Fa�are�.see�e er�e at rey.ind.�der sectl.a 2SA.t MGI,ls2 eu leaa b n�e hrp.�iuH.f Qi.i.d p�.ta�.e�a t1,sM.M aadhr �Y'�'��s eM pm�qn ia tre fir�ata 3T01'WORK ORDER a�d a 1�ae dS1AaN a day aphet ie. I udetstatd th�t a apy of tYis sta6e�e�t my be fenrardcd/s the Omoe e[Im�of the D1A t�r av�a�e v�a'I�atlei. I do 6er+eby c�xnder NYe �ea�of ptrg�r�ry tllrat dYe irrfo�a�to�provlded aboae fs�rxe asd onrre�� 8�'� I�te �� Print� - Phonc# �f��' ��T �,.a/ effichi ase oely ds aet wrke ii t�s area te be os�Pkf�d bY e&Y er l.wa�1 eit7 or te�vn: per�e!f �� ❑c4eck if?m�me�ale respesae b t�a�eed �s�oe ceatad persaa: p�g� �� p�.�a s�c zoas) ' ; � APR-21-2005 09�30 ROGERS AND GRAY 5087604622 P.01i01 � G� INSURANCE ��' � AGENCY,INC. • �► � � 1 � G3 � � i� � `tiJ' L2 [� Depeadll6re Prrsonn!Jervire Siacc 7906 /A3tt/'dI1CN• 8c IimnluyeR I3enrfilr ,yP�S � � �DU5 � f7��.�� i�C��. April 21, 2005 Town of Yannouth � ATTN: Health Department ''/, � D�vid Flaherty �- 3yFs�1)�3�° ��"�' RE: James M. Ro�ers d/b/a Sandbaggers Please be advised, James M.Ro�ers d/b/a Sandbaggers has applied for Workers Compensation Insura,nce Coverage on April 15, 2005 through the Massachusetts Workers Compensation A►ssigned Risk Pool. As soon as possible, a certificate of insurance will be sent to the Town of Yarmouth d.irectly by the insurance company. If you have any questions,please feel free to contact me. Sincerely, rn. ��.R- Donna M. Pearse Assistant Sales Manager 434 Rte. t3+i T61 LOGaI: SOD-39&7880 PO Box 1801 Toll Free: 800-Sfi3-1801 So.Dennis,MA 02660�1607 F=az lane: 508-3�-1393 www,Rc�gersGray,com _ ,� , TOWN OF YARMQUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-178 FEE: $75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the tieneral Laws,a permit is hereby grant�cl ta _ James Rogers, 62 Highbank Road, South Yannouth, MA , Whose place of business is: Sandba�ers Type of business: Food Service � To operate a food establishment in: Town of Yarmouth i Permit expires: December 3 l, 2005 BOARD oF HEALTH: B/� �t$� r. ��°�,oa��I.`7�. ' SEATING: 73 /�4'o�i��/I'1�3��, v�e��.� x�s�ucTTolvs: Disposable Service Only. RoGd1t� Bh�irikt, � � s!� R.N. ��d�.«� R.N. A.vri122.2005 Bruce G.Murphy,MPH,R.S.,CHO Director of Health l i . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-109 FEE: $50.00 This is to Certify that_ James Ro�ers d/b/a Sandba�ers at Bass River Golf Course, 62 Hi�hbank Road, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the ' licensing of common victuallers. This license is issued in confornuty with the authonty ganted 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: Be.r�.nrsu`h. C�''ov�,�,r�,�N.�S. . SEATING: 73 A��x�� v�e��-� Ro�t�B�x.isi, G�le� ��k, R.N. �1.�l�'�.�, R.N. Apri122_2(�s ; Bruce G.Murphy,MPH,RS_,CHO ': Director of Health I f . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #US-040 FEE: $25.00 �'his is to c�tit'y tt�at James Ro�ers d/bla Sandbag�ers 62 H��hb nk Road, So�th Ya`rmo h�� IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�eer�t i�s�ant�u�� nform��y wrth Articls�e�of the Sanitaru Code of The Commonwealth of Massachusetts,and e� s er 1."l�5 uni�ss sooner ded or revoke� Apri122.20Q5 BOARD OF HEALTH: Besrfc.�tt�. (��"'scw,e'�//��., p�� v�e�� ; R�� 8� � � � �, R.a! �r�-.�, R.�v. Bruce . urp Y,MPH,R ., Director of Health ...�... �� . J fh,� S�0 �RGCs��,S f.�,a �.�v �z�;;: R.� TOWN OF YARMOUTH BOARD OF HEA�I i�. I ..._�_ ..m __ra _.�..� �� APPLICATION FOR LICENSE/P ��Ad' o., .-,� � ��.�' � �� '`• � ..••''?' ,� L�l. �i 1 �� s �"' �� ,�• * Please complete form and attach all necess ��c ,�i s��ecember l, 2003. Failure to do so wiil result in the ret "„f yo��lication packe F-IEALTH DEPT. � � —�_�d� C D S • a- l� 1� � . ��•..�_ c�7a.�� e.J �Ac�c A ER' AME• T MA�LING ADDRESS: POOL CERTIFICATIONS: T6e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poc�l Operator(s)and attach ��opy of th�e certifcati�ra tc� thas f�rm. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies �nd maintain a file at your place of business. 1. 2. 3. 4. �OOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �C"��'-z-� �n f��'� 2. :PERSON IN CHARGE: ..�_ - -- ------ — -- — �--- — - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �v��'-`-`> Cj�ic� 2. HEIMLICH CERTLFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��..��.�..� C��'�. 2. 3. 4. RFSTAURANT SEATING: TOTAL# -V�' OFFICE USE ONLY 1.ODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE PERMIT# B&B $50 _CABIN S50 ,_MOTEL S50 INN $50 _CAMP $50 _SWIMMINC,POOL$75ea. _LODGE $50 _TRAiLER PARK S50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# �0-100 SEATS S75 �O�''�0 _CONTINENTAL �30 NON-PROFIT $25 >l00 SEATS $150 �COMMON VICI'. SSO '��'Osj _WHOLESALE S75 RET,r1IL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. 5200 _VGNDING-FOOD $20 _<25,000 sq.ft. S75 _FR07,EN DESSGRT S35 ( TOBACCO �25 �0( NAME CHANGE: $to AMOUNT DUE _ $ l50.p0 **"**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 � 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 MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ✓ � v�� k WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � � Town of Yatmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ' YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR iNSPECTION 7-10 � DAYS PRIOR TO OPENING FOR THE SEASON. ' i � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT, �TC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. s �DDITIONAL RFGULATION POOLS POOL OPENI1rTG:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. k f 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. E FOOD SERVICE CONSUMER AI)VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERt_N�P�LICY. Anyone who caters within the Town of Yarmoulh must notify the Yannouth 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. � _ . - _ _ _ _ f 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� c��s: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COO iN =• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � �, � DATE: `Z ' � �.�� SIGNATURE: ' PRINT NAME& TITLE: � � ; �� 10/22/03 � - � f � • ' NOTICE OF ASSIGNMENT � ; EMPLOYER: RICHARD MCINERNEY & ANDY GERARD DBA COMBO I.D. STATUS OF EMPLOYER SANDBAGGERS PUB 000364304 Partnership ; 62 HIGHBANK ROAD ; S YARMOUTH, MA 02664 COVERAGE GROUP I � 0364304 The Waiver of Our Right to Coverage under this assignment Recover rrom Others Endorsement applies to Massachusetts is available on Pool policies. operations only. For coverage Contact your agent for details_ outside of Massachusetts, contact the appropriate Pool or Plan for that state. AGENT ROGERS & GRAY INS AGCY INC ��E�MP�' �� 640 IYANOUGH ROAD RT 132 TRAVELERS INDEI�IlJITY CO OF ILLINOIS PRODUCER: gy�JIS, MA 02601 MS JACKIE DENNIS P 0 BOX 3556 ORLANDO, FL 32802 (800) 842-9886 AGENCY FEIN:042254905 CLASSIFICATION OF OPERATION CLRSS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION -------------------------------------- ----- -------------- ---------- ---------- RESTAURANT-NOC 9079 $22,000 2.19 $482 EMPLOYERS LIABILITY 100/100/500 9845 LOSS CONSTANT 0032 $18 STANDARD PREMILTM � _ __ . _.-__ ----- -___ --_ ________ _ ��0 EXPENSE CONSTANT 0900 $244 TERRORISM CHAR.GE 9740 $� ESTIMATED ANNUAL PREMITJM $751 DIA ASSESS. 4.5$ OF STANDARD PREM. $23 EST. ANNUAL PREM. PLUS ASSESSMENT ------$774 INSTALLMENT BASIS: Annual RE(atNRED DEPOSIT PREMIUM $774 COMMENT.�, Coverage effective 12:01 AM on �4/08/03 DATEOFNOTICE: 04/10/03 PREPAREDBY: Theresa Schofield EXT 542 * * VOLUNTA3tY DIRBCT ASSIGL�N'J.' * * LETTER ID: 4 0 0 2 7 3 COPY: EMPLOYER The Workers'Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street� Boston, MA 02110 i TQWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A F�OD ESTABLISHMENT PERMIT NUMBER: #04-070 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: Andrew Gerard, 62 Highbank Road, South Yarmouth, MA Whose place of business is: Sandba.�gers Pub Type of business: Food Service To operate a food establishment in: Town af Yarmouth Pernut expires: December 31. 2004 BOARD oF HEALTH: Bne�arsr�c/`.1�. �j'anc�i��f�l�l._`h�.� �� ' SEATING: 73 N�/17�6�/lt0�� !ltC6 �:ftl'sKMLGlL �sT�t1c'r[otvs: Disposable Service Only. Ro�� B?�t�ir�t, � � sr�, a.�v. January 14,2004 Bruce G. Murphy, ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TQWN aF YARMOUTH PERMIT NUMBER: #04-055 FEE: $50.00 This is to Certify that Andrew Gerard d/b/a Sandbaggers Pub at Bass River Golf Course, 62 Highbank Road, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2U04 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common vicEualler's. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. BOARD OF HEALTH: Be�w�s`i,.`�. �`�o�d.,to��c/,f�/�.1�5.f �� SEATING: 73 P�/�l��3/1Kifiq (/%C6(:isG��1/1Ll�il Ro�� +�. ��+r.aa, G�le�a d� s'�1�. R.1V. January 14,2(?04 ruce G.Murp y, , .S.,CHO Director of Health � i � • � • i J THE COMMONWEALTH OF MASSACHUSETT5 3 TOWN OF YARMOUTH ; BOARD OF HEALTH ' PERMIT NUMBER: #04-019 FEE: $25.00 This is to cercify that Andrew Gerard d/t�/a Sandbaggers Pub 62 '�hha,nk Raad, So�th Ya_�no�th,MA IS HEREBY GRANTED A LICENSE j For SALE AND DISTRIBUTION OF T�BACCO PRODUCTS " AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This. r�t isp�anted u�� orm��y with Article VI f e Sani�y Code of The Commonwealth of Massachusetts,and expt� lleceihber 31.Z� uni�ss sooner suspenc��or revokei3. Januarv 14.2004 BOARD OF HEALTH: 8e�o�r�ti�t�. (��/��., . n�tic�(a A�lc�f�, ?/ios��raic Ro6�r�t�. Bnou�c, � � Sl�k, R.N. ruce G.Murphy, ., Director of Health _ _ �� .-, : �. ,: �..<. .�; . , ... . �:, � _, %� �� _. � �' � � � � � � of��R�, TOWN O�YARMC)UT� $�,ARD TH i , ,o , ° .s ` APP��CATION FUR LIC�N �g� APR � ��. 003 . . � ;.. ;. F'.. * Please compl te fbrm and attach all nec d entsby Dec,�emb r �(�N D PT. ` Failure o do``so wi11 result in the re �af our application packet. ; � ; �. .�, . , u..t C SoP` ��1�-(�� ' a-� �6�; S �..�¢_ c..s� �.t , Sc�c.� � � "-' � �c � � ' 1�.. �. S'o� -6�`LS' G.o�� , v.2 bZ� POOL CERTIFICATIONS: , ' � � The pool supervisor must be certi ed as a'Pool Opera�to�r,as required by State law. Piease list the designated , � Pool Operator(s)and attach a copy f the certificafion ta this form. ; ; . . . _ Ag , � 1• � � � � w�:h ��,,. . ��2, � � ��.,,- � i Pool operators must list a minim of two employees currently certified in basic water safety, standazd Fi t Aid � arid Community Cazdiopulmon�ry esuscitation(CPR). Piease list these employees below and attach co�ies of employee eertifications to this fo . 'I�he Heatth Depa��tmen# v�ill not use past years' records. You must provide new copies and maintain a file at your place of busines�. � L '2. � 3. :A�. . , ; All food service establishmerits ar required to have.at least one full-time employee who is certified as a Food ; Protection Manager, as defined in e S'tate Sanitary Cade for Food'Service Establishments, 105 �MR 59U.000. Please attach cflpies of certification o this application. The Health Department will not use past years' re�eords. You must provide new copies an mai�utain a,f le at�oNr es�blishmen� , 1. � � �,.. � ,2. ' . . , : ;� , PERSON IN CHARGE: Each food est�blishment must hav ; at least one Person In Ct�ar�e(PIC)on site during hours of operation. 'i 1, ��w �' � 2. ,� cr-� �,`"�L�.��. � . < _ . � HEIMLICH CERTIFICA IT o1vs: ; ' , A11 food°serv�ce establishments th 25 seats or more must have ,at le�t'one empioyee trzuned in the H 'mlich Maneuver on the premises at all ' es. kPlease Iist your employees;trainei�in anti-choking procedures bel w and ! attach copies of employee certificat ons to this fprm. The Health I�epart�nt will not use past years' rejcords. ' You must provide new copies an maintain a file at your p�ace of busine�s. I i ` � i l. \c�c�.aF Z ��t... �h 2. I! '� ' � 3. ��• , � � RESTAUR.4NT SEATIl�IG: �TO L#� � �� . � � � �i � � ,�,�_ �� _ ; � ...,, OF�CE 1�SE ONLY ' ' � i WDGING: ', • LICENSE REQUIRED FEE PERMIT# LIGENSE REQUfRED FEE PERMIT# WCENSE REQUIR�O FEE PERMIT# j B&8 �SO �CABIN SSO ,,MOTEL �SO i � — . ; _INN $50 GAMP SSO _SWIMMING POOL S�Sea. i — i �LODGE $50 i TRAILER PARK a50 WH[RLPOOL S75ea E � FOOD SERVICE: ; . .; � ; I . . , �. . .� � f LICENSE REQUIRED FEE PERMIT#' LICENSE REQUIRED FEE ''PERMIT# 'LICENSE REQUIRED FEE `PE I I'F# ( 0-100 SEATS S75 �D — _CONTINENTAI. $30 �' ,�� _NON-PROFIT �25 ; >100 SEATS $I50 �COMMON VICT: S50 .�6 —WHOLESALE �r�5 _ , I �ETAIL SERVICE: . f � I LICENSE R�QYJIRED FEE PERMIT# 'LICENSE REQtIIR�D FEE `PERMI'�'# LiCENSE REQUIRED FEE PERMIT# I _<SU sq.ft. ` ' S4S _>25,000 sq.ft. , 5200 ' _VENDING-FOOD �2Q � �f _<25,U00 sq.ft. $75 ,, :� ;` ��".�'�'itOZEN"�fF�SE�t�` 3"�,' � - � `�� ' � — r ,. , S i ,�., I TOBACCd �..5 ��'t� NAME CHANGE� s�o - I . .' � AMOUNT DUE - $ /Sd.Q O � . �`� �i ` ' � *"*"•PLEAS�T11R1Y�YER,�ND COMPGETE OTHER SIDE OF f'ORM***"" , ; , _ - �� -----_ � � � - �� ,.._.:...,.�---=-y— �� i _ �. '� ,. v ._ _ __ � .�. � � _ '_ . . �. . ' .. . .... ' � �. .. . . . . ' .� � E i ; � ♦ . ADMINISTR�TION � i ` �.. ,'� '�,`� _T t . hold issuance or�newal �S�-�S�ct�on 25C, ubsechon 6,the Town of Yarmouth is now requsred to of any license or pernut to operat ::a bus��ess if,a person oru ca pariy does not have a Gertificate of VV�orker's ar Compensation Insurance. THE ATTA�HED'STATE �O R'S COMFENSATION INSUI��A,NCE , AFFIDAYIT MUST BE CQM� ETED AND SIGNED,OR � - II � � � � � �� . � � � � � � ERT. C�F�1NS�RANCE ATTA�CHED � � � � � � � i � � � � � � � % . � � E - I� , � � � WORKER'S 4MP. AFFIDAVIT SIGNED AND ATTACHED ; �_ Town of Yarmouth taxes and iiens must be paid prior to renewa�l or issuar�ce o�your permits. PLEASE CHECK APPRCIPRIATELY IF PAID: _ YES .� NO NOTICE:Peimits run annually fr 'm January 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATI N(S)AND REQU��tED F,�(S)BY DECEMBER 31, 2002. ; S�A�ONAL E5TABL�SHMENT ARE TO CONTACTTHE I-�EALTH DEPARTMENT FOR 1NSPECTTQN 7-10 ' DA�S PRIOR TO OPENII�TG FQ .T�i��SEASp�i� �.;,;:; s� .;,. ;, ° � ,P, { ,. _ >. ,o t- �' a. . ALL RENOVATIONS TO,,,A�� F04��'�,�,�'ABLISI�MENT; MOTEL OR POOL (i.e., PAINTIN , NEW O1�RMENCEMENT. REN AT"IONS MAY RE UIRE A,' P�O� TO C Q SITE PLAN. � ' , , EQUIPMENT, ETC.), MUST'BE REPORTED TO AND APP�4VED BY THE BOARD QF HEAL H'' ;. , I _. _ � ; _ � , � . . . ��.'a_',c '� . � � - • ._ . �, � . . �� . . . . .. . . .. , . � . . � . . . .. . i . . { . � � � . � � � . . . " . _ . - � � � ' � l � � . .� . � . � . . '... � � ' ... . . . - �� . . � . - . , , � . . � . � � ��.. � i A��ITIONAL REGULAT�ONS 4 , ' � � �QOLS ._,� ' I � � ,.� POOL QPEN[NG:Al�l swimmin�,wading and w�ir.lpools which have been closed for the season must be ir�spected j b�the Health Department prior to opening. � ; � POOL WATER TESTING: Th w�te�'�i�iu.st be}�sted ftir pseudomar�as,total�coliform and standard pla��te count i by a State certified lab;prior to o nin�, e�st quarterly�thereafEer. ', � ,. � ,?�s.� ,� �a��,` �_� ti r � . , � , . _ . _ _ .:�. � � � � POOL CLOSING: Every outdoo in ,c�ii3'�v�rhming pool m�"st be drained.or'covered within seven(7)�days of closing. r . �� _ �. � FOOD SERVTCE , �ON&[�R DVI�O�Y; � , i uire to st Each food estabhshment wluc,n se es or sells ready-to-eat,raw or undercooked anunal products are req �i po Consumer Advisories. I , ; ; ' I ,;:w.� ... , ; �� CATFR��NG 1�OLI�Y�. � Anyon� vi�ho caters within the T wn of Yarmouth must notify the Yarmouth Health Department by f ling the t ; reqwred Temporar� Food Servic Application form 72 hours prior to the catered event. Thses forms can be obtained�t the He�tth Departmen . ! � � : . , ; � , . � FRQZF�T D£�',�.i" .R ; Frozen desserts must be tested a�n a month��basis by a State certified lab. Test results must be sent to the Health Department. Failtire tq dfl so wil result,��;the�'su�p�nsi�� or F��oca�ion of your Frozen Dessert Permit until the '� above term�have been�met. ;`� ' '� _ ., __ � ? < �.;,ky � � � � � � • � �;&�,' �� ..�� ,�.�.r , �; � � � � ' Outside es(i.e:;owtdoor seating�vith�va�ter/waitress service),�have prior appmval from the Board o�Health. � Q��'�'DOO�i CO il�T('e i -, Outcioor cooking,prepatatton,or 'spl��y of any food product by,��re�ail or food service establishment is pro�ibited. i -- i �= 3 � � _� � � Zi � f C ` ; DATE: �. �IGNA JRE. � � , � , PRINT N.'ME&Ti TI.��: �c�c�tr �;'^�. �-�''" � : :�.� ; , . � �i 10/18L02 � ;.,, , . , , . f ; � { .,, . � . �. � � � �s ,� ' �., ,, ; ,. , f ��.._:..:�_ � .� —� � ..� `� � . � cJl�'? M f�l+�`� 7/� The Conrmonwealth of Massachusetts ��' �� Department oj lndustrial,-1 ccidents � o Ofllceoll�stJostJiis 600 Washington Street ' ` Boston.Mass. 02111 �� ' N v• W'orkers' Compensation Insurance Atfidavit Aoolicant intormallon• p��Sepgp��,� nam�: �yl�I-N`!J 13/� G—(rT TI S '.� 1/ 13 Luc�ti�a� �/� S 5 � 1 V'C I"� �i-o �/= [° o v 2 S2 c�t� �one� �o � - 3`J& /�a.6 � I am a homecw�ner pert�rming aU w�ork myself. � I am a sole propriecor�� ha�e no one��orkin_ in am•capaciry � am an employer pro�idins workers' compensation formv employ�ees w•orkine on this job. s�mnan�• name• SA�+/b �1� �i-G-�Q,$ acidress: �o „`� � / C.�J��3 �+Y� R /► zitv: V ✓� ,�_��T�/ �i/� phone�f• t'A e � 3 9 � � / `� d (,� ; iosurance co. � o �2< -i- P�- �2 yc�y oolicy# � I am a sole proprieror. general contractor, or homeoK�ner(eircle oneJ and hace hired the contractors listed below ��ho ha�e ' the follo�.in_ ��orkzr� .ompensation polices: ', somnanv name: �bwv p � � �12 711 bvT!-� address: �Z�F '2 � �/J}YMOvy�.� %�l/� citv• phons M• , insurancc co. pelicy# �m�anv name• addrcsr �itv: �hoes�• insurance co. �geY� t Failure to secure coveraee as required uoder Secnoo 25A of MGL 1S2 n�iad to tbe i�paidoe ot crisi�l pe�dtla o(�O�e op to 51,500.00 a�d/or oae ynn'imprisonment a�w•ell a�eivil peaatNa io the form of i STOP WORK ORDER aed�lfae of 5100.00 s day apinst ma I a�dersta�d t�at a copy of thy statement mav be for.wrded to tht Ofliee of 1ave�tigaGoo�of the DU for eovera�t veritfeatio�. /do hrreby cerrif}•under rhe peins and ptnalties ojperjary that t6t injorntotion providtd abovt is tnte wtd cor►td ' Signature 1 ` /'Y�G -�iti � D �- O 3- d3 Print name ► �rli'�-�2..0 � � � /t/ C iV�i- one�Y��'� a��rd- Lc57s ' ., oRcia! use onl� do not w�ite in this area to be completed by citp or town oAlei�) ciry or town: Y�M�IIT� _ permitAieeou N nBuildiog Department ' pLieeasiog Board Q eheek it immediate response is rcqui�ed 261 �Stleetmen'�OlTiee (S08 3 ❑HealtA Departmeat contact person: phone N;_ _"} 98--�31 eat. nOther .. < a�A, I APR-16-2003 10�43 ROGEF'S 8 GRI�`r`�HYAI*M�I I S 1508 i'904403 P.F71/01 . THE INSURANCE CENTER QF GAPE COD �� (� � r+ �X ��I3.�T�j..�]R.�iNC�' AGENCY, INC. � r ti � D8�7eTIt1G�e Paf'doT1Ql SlTViC4 SinCC l� April 16, 2Q03 Richard McInernty and Andrew Geraru dba Sandba�aers Pub 62 Highbank Road South Yarmoath, MA 02664 Re: Warkers Compensation Covera�e-• Sand�xggers Pub Dear Mr. Gerard: Per our cc�nversatidn today, Workers Compensation coverage has been applie� for throu�h the Massachusctts Workers Compensatian Assigned Risk Plan and they havc advised that the assignment has j�lst recently been issued (under Combo 1D #0443G�4304). Coverage i�as been placed through Travelers indemr�ity Company efY'ective 4/08/03 to 4108/04. A certiftcate of insur�nce has ve�n requested for the Town df Yarmoutti (Nealth Dept) and should be received shortly. Should you have any c�uestions, please c�11 ma at (SOS) 7�Q-4422, Sincerely, NV Mina L. Vaughan Account M�nager Hyannis�fficc HYM1Ni3 DENNIS OpLEANS FALIAOUTH &W lyerouph Fioad(Fte.132) 434 fiti.134.P.O.Goat 1 i01 111 FQe.BA.R.O.9AY 309 84 UaviS SUeItS(REB.2E) Hyeflfd■,MA 0¢601-1 S89 So,Dinn�q MI!026fiQ�1601 �deanS,W►02553-03� FaiMOl�ffh,MA 025�0�3919 (soe)rrs�oo�� (sos'a9easao �sos�zss�oi i o (sos)�ae.rrao ¢�z�f�'r7'$-0966 Faot(50�394-1393 p�c(roe)240-7827 Fiot(SOp)iae-'13�.7 SAHnWk�i PLYMOUTH RNANCiAL SF�{V{t6S 280 REB.1 SO d�COIUh iiaad,P.O.Oox 1��2 347 CO�M't Stroat,P.O.Ho�c 3700 UfY,Muakh 8 ArriuiFiOt $0.SatldwlcR,MA02d44•'l33Z Plyrnoutl�,MA02361�3700 43a iioa.t34.P.O.BOK 7801 (SOi)00l-1400 (508)746-005G So.Da�trtif,MA 02880-1 fi01 Fax fsoe�eea�s� ;eoa�24a� (5D8)398-796a�B00)553•iaa� __. �. ._.._,......,...., T�T� P.01 �_ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #03-183 FEE: $75.00 In accordance with regulations promuigated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Generat Laws,a permit is hereby granted to: Andrew GerardlRichard McIneme , 62 Highbank Road, South Yarmouth, MA Whose place of business is: Sand Ba��ers Pub at Bass River Golf Course Type of business: Food Service To'aperate a food establishment in: Town of Yarmouth Permit expires: December 31, 2003 Bo.�oF��,�: �kanfea s?�. xell�kat, �ka.�,r„ra�c sEa�rnaG: 73 : �e�cfa�xt�D. C�.oad.owc. 711.D.. `I c/ice xES'rlucrlolvs: Disposable Service Only. �o�it j1, �'xo�wy, (�,�e�rk �a�'tlC��t�cot`r � S�. .� , Avri1 16.2003 ruce G.Murphy,MP .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-106 FEE: $50.00 This is to Certify that Andrew Gerard/Richard McInerney d�Wa Sand Baggers Pub at Bass River Golf Course, 62 Highbank Road, South Yaimouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE ' In said Town of Yarmouth and at that place onty and expires Dec+ember thirty-first 2003 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 confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. . In Testimony Whereof,the undersigned have hereunto affu�ed their o�cial signatures. BOARD OF HEALTH: L� r'�, i��keZ. �kariu�ra.a s��rnvc: 73 ��r�a.xt�c?�. �%mrale�c. 7K.D., `lltce �adert� �. � �a#��De� � , R 7Z. April 16.2003 ' � . y, . ., Director o Health i F ! a e THE COMMONWEALTH OF MASSACAUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #03-046 FEE: $25.00 This is to Certify that Andrew Gerard/Richard McInemev d/b/a Sand Bag�ers Pub at Bass River 62 Hig,hbank Road, South Yarmouth, MA IS HEREBY GRANTED A LICENSE • For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS; ' AS PER THE YARMOUTH BOARD OF HEALTH TOBA�CO REGULATION. This, e it is ted' rmt�with Article VI f e Sani Code,of The Commonwealtl�of Massachusetts,and exp�es�ece�iber 31�2��un��ss sooner suspen�e�or revo�. April 16,2003 BOARD OF HEALTH: (�r�, i�dl�. (�xa� ; �'e.rfa�xl�,c D. C�aada�c. 'I�C.D.. 2/iee " ,�oBe�rt�. �'roaac. (�lark �aartck�leD� � S .7� ruce G.M y,MP , . ,C Director of Health