HomeMy WebLinkAboutApplications, WC and Licenses r
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TOWN OF YA � ��,, ��HEALTH .� h�
APPLICATION R �� T -2002
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* Please complete form and attach all necessary documents by December 31, 2001. Failure to do so will result in
the return of your application packet.
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AME O E TABLISHMENT: s �v N� TEL. # � – �
LOCATION ADDRESS: �a i� c3�r� �� "�'. Y�Q �!f- ����
MAILING ADDRESS: ��n'I F
OWNER/CORPORATION NAME: -�`6 l�:tf3o��
iVLA1�TAGER'S NAME: �lfaWj�S �3 ���/7 TEL. #
MAILING ADDRESS: �Yl3at/�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form. _ _
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The fIealth Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
P��S�I�t Ti�G'�AR��:- __ — __ _—_ - . _ _ __---_------ _ ___� --- __ __ _,
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
,
�. r--��t��ry 2. ����wls `3�e��,�
HEIMLICH CERTIFICATIONS:
All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at�your place of business.
�
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3. 4.
RESTAURANT 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 $50 _SWIMMING POOL$SOea.
LODGE $50 TRAIL�R PAItK $50 _WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIR� FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $75 �'da'�9 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150`::;._ 1 COMMON VICT. $50 7�'"�-O�PB _WHOLESALE $75
— � —
RETAIL SERVICE•
LICENSE REQUIRED FEE PERNI'�# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT#
TOBACCO $20 ¢��` _<Z5,000 sq.ft. $75 �TOBACCO $20 do�- (o
— ��,;,
_<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ I 4 S � O O
*****PLEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 Certifica:e of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
' CERT. OF INSURANCE ATTACHED
�
I WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
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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 RET'LJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
� ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.}, MUST BE REPORTED TO AND APPROVED BY 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)da.ys 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.
_ _ _- ---------- ---——
I+ROZEN DESSERTS: ---
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
' above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. ;
�
DATE: j 1 G� SIGNAT'U .
PR1NT NAME&TITLE: %l-��`Z!�-'S � /��L L �v �/PZ�cS � ;
09/11/O1 '.
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Nn�nTroRD WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6560UB-857X916-3-02)
RENEWAL OF (UB-857X916-3-02)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 80411
1. :
INSURED: PRODUCER:
BASS RIVER SNACK BAR, INC MARSHAL� K LOVELETTE INS
62 HIGHBANK ROAD 396 MAIN STREET
S YARMOUTH MA 02664 PO BOX 836
WEST YARMOUTH MA 02673
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The poficy period is from 03-21 -02 to 03-1 1 -03 12:01 A.M. at the insured's malling addresss.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
�
MA
'=
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"— B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy appiies to work in each state listed in
= item 3.A. The limits of our liability under Part Two are: '
D�
— Bodily Injury by Accident: � 100000 Each Accident '
,� Bodily Injury by Disease: $ 500000 policy Limit
� Bodily Injury by Disease: $_ �o000o Each Employee
— C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
�
� SEE ENDORSEMENT WC 20 03 06
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= D. This policy includes these endorsements and schedules
,-- SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
�
_ 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
�•— Plans. All required information is subject to verffication and change by audit to be made ANNUALLY.
—
, .
DATE OF ISSUE: 04-05-02 NR ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MARSHALL K LOVELETTE INS 25F4J
018528
TOWN OF YARMOUTH ,`
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IMENT
PERNIIT NUMBER: #02-069 FEE: $75.00
In accordance with regulationsprom ulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
Bass River Snack Bar,�., h2 Highbank R�ad, S�Lth YarmoLth, A
Whose place of business is: Bass River Golf Snack Bar
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31.2002 BOA1tD OF xEALTH: �ka�rP�s� �el�i�Faz, ���at�rNra�
s��rnvG: 7s �'e�ja.xi�c?�, y,azdo�c, ?1L.D.. 2/�ee
�S�cTToxs 1F Ax�: Disposable Service Only. �o�eZt� �, el�rk
� �a.�ek 71l�euKa�
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��h i ,Zooa
ruce G.Murphy, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #02-048 FEE: $50.00
This is to Certify that Bass River Snack Bar Inc. d/b/a Bass River Golf Snack Bar
62 HiP,hhank R�ad, 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 2002 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 authonty granted
to the licensing authorities by General Laws, Chapter 140,and amen�nents thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: L��s�, xell�t�c, ��a.r
sEa�G: 73 �����mrdouC�D.. `�/ieee
�a�711�ar�.xatL�
� .Skak, .?Z.
March 1 ,2002
ce G.Murph ,MP R ., O
Director of IIealth
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #02-006 FEE: $20.00
This is to Certify that Bass River Snack Baz Inc.d/b/a Bass River Golf Snack Bar
62 Highbank Road, South Yarmouth.MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTTON OF TOBACCO PRODUCTS
AS PER'THE YARMOUTH BOARD OF HEAI TH TOBACCO REGLTT ATION
This permit is gxannted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires Dec;ember 31.2002 unless sooner suspended or revoked.
M�� i ,aooz BOAxn oF�ai,�: �ka�� x�. L,�a�a,�
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� Sl�k. ��l.
ruce . urp y . .,
Director of Heal
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; Towrr oF Y�x�ou�Boax�oF a�a,�,TH � � � � � M � �
=g APPLICATION FOR LICENSE/PERMIT,`2000 ,4� D E C 2 8 1999
� .` �
* Please complete form and attach all necessary documents by Decem��;r 31, 1999. �ail ��F�-buQf-�$sTilt i
the return of your application packet.
--------------------------------------------------- ----�°'�--------------------------------------------------------------------------•
F ES S M I✓�R �/ ,C # �.3 -/�
L ATI �5' . ' Q'�
�ILING ADDRE S S: ���t�
OWNER/CORPORATION NAME� ('S, R SNi�k bgR �vG
MANAGER'S I'1AME• �i 'fl��l�s �3 /��„/!y TEL # S3��/�a�
MAII.,ING AUDRESS: ao✓�- T
- - ----- ----------------------------------------•
POOL CERTIFICATION�-
The pool supervisor mast be ccrtified as � Pool Operator, as rec�uired by new State lavr. Please list the
designated Pool Operator(s) antl attaeh�copy af the certification to��us 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 atta.ch copies of
employee certifications to this form. The Heatth Department will not use past years' records. You must provide
new capies and maintain a file at your place of business.
1. 2.
3. 4.
HET_MTJICH CERTIFICATTONS:
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 yt�ur employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. -5 / 2. ,� �ie����� �t9-5h� ..
3. �aA! 4,
_R�STAURt�NT SEATIl�TG: _TQ��#�-��--. _ATL�T-���I��T�-���T�: TQ��-#--�_ _ _ _ _;
--------__----_-------------------___-------------------------------------►-----------------------.��_------------------------------------ ;
OFFICE U5E ONLY '
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# �
B&B $50 _CABIN $50
^INN $50 CAMP $50 i
LODGE $50 TRAILER PARK $50 '
MOTEL $50 SVVIMMING POOL $SOea. i
� i
WHIltLPC/0L $25ea. �
FOOD S RVICE: — �
I
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ;
i
LO-100 SEATS $75 y?,�IL•l17 �CONTINENTAL $30 '
a
>100 SEATS $150 � NON-PROFIT $25 �
i
�COMMON VICT. $50 �_�� _WHOLESAI.,E $75 ;
RETAII. SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I�
;
_<50 sq.ft. $45 �TOBACCO $20 K.-�� �
_<25,000 sq.ft. $75 FROZEN DESSERT $35 i
. — �
_>25,000 sq.ft. $200
IYAME GE: $10 k
AMOUNT DUE = $ 1�� -�
a�x�e■ �
PLEASE TURN OVER AND COMPI,ETE OTHER SIDE OF FORM•"""
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i ADMINISTRATION � �
UNItF,�GHAPTER 15�1, SECTION 25C, SUBSECTION 6, TI-�T�WN OF YARMOUTH IS NOW REQLTT�RED � i
'�O HOLD ISSUANC� OR RENEWAL OF ANY LICENSE �R PERMIT TO OPERATE A BUSINESS TF A
�ERSO�T: OR C4$VIP�,�NY D4ES NOT HAVE A GERTIFICATE OF WORKER'S COMPENSATION I
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 l�F YARMOUTH TA7�S AND L1ENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERNIITS. 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. i
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SEASONAL ESTABLISHMENTS ARE TO CGINTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TQ OPENING FOR THE SEASON. �
�
E
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTINCr, NEW ;
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO ;
CONIlV�NCEIV�NT. RENOVATIONS ME�Y REQUIItE A SITE PLA1�T.
�
ADDITIQNAL REGULATIONS
i
POOLS �
POOL OPENING: ALL SVV�[MMING, WADING AND WHIRLPC)OLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE WATER TESTED FOR '
PSEUDOMONAS, TOTAI.GC3I,IFORM AND STANDARD PLATE COU1�T BY A STA'T�GERT�FIED Lt�B,
PRIOR TO OPENIlVG, AND QUARTERLY THEREAFTER.
POOL CLOSING:EVERY OUTDOOR IN GROUND SVVIlVIlvIING POOL MUST BE DRAIN�D OR COVERED �
WITHIN SEVEN(7)DAYS OF CLOSING. `
FOOD SERVICE
CATERING POLICY
ANYOI�TE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI-�YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH
DEPAR.TMENT.
FROZEN DE�SERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTII�NT. FAILURE TO DO SO WII.,L RESULT IN TI-� �
SUSFENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,TI�ABOVE TERMS HAVE
_. . _ _ i
BEEN MET. [
OiTTSIDE CAFES:
OIJTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �1�HAVE PRI�R
APPROVAL FROM TI-�BOARD OF HEALTH. ''
OI1TD(�OR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
; SERVICE ESTABL SHMENT IS PROHIBITED.
DATE: ��� � SIGNATURE:
PRINT NAME& TITLE: ���10�✓ ,f� ����y ���S ,
11/12/99
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The Commonwealth ojMassachusetts
' � � Departmenl ojlndustrial.-iccidents
� � 011lceo/%s�l�s�liis
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� 600 Washington Street
' •` Bnston,Mass 02111
Q��/ V��.
W'orkers' Compensation Insurance Atfidavit
nam• 1/L` � ..".� � ���� � l.�
I_ucation� �i/7� �/�j�-�}If�� �
tit� c�� ��"I\ � � ��Lo� 7" phone�tl tJL �����50
� I am a homeowner pertormmg all work myself.
� I am a sole proprieror�r.� ha�e no one ��orkin� in am•capacit��
�am an empio�er pro�idins workers' compensation for my employees w�orkins on this job.
comoan�• name•
�d ress:
citr..
nhone�•
iesu�ance ca olicy!�
� i am a sole proprietor. generai contractor. or homeow�er(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the follu��in_ �+orker� :ompensation polices:
s4m�anv name:
address•
citv•
nhone#1•
insurancc co. Folicy!1
s4moanv name•
tddress: _
sl�: ohQne_tf.
insurance co. �,�
,
Failure to secure coven;e as required under Seceoo 25A of MGL 1S2 ea�lad to tee iopaidos o(erivi�d ptadtle�o(a Ou op to 51,500.00 a�d/or '
one vean'imprisonment a�w•eil a�civil penaltia io the form of a STOP WORK ORDER aad a Oae of SI00.00 a dar qsin�t ma [a�dersta�d t�at a
copy of thy statement may be fonvarded to the Oflice of[nve�tig�tiom of t6e DU tor eoven�t veriflado�.
/do hrreby cenij}•und the peins a d p na! ' ojperjury that 1ht infornration provrded obovt is true aad oritd
Signaturc � �
ate
Print namc r � � one li�� "�l��
.- olTici�l use onl� do not r.rite in this area to be completed by eiry or town oAieial
ciry or town: YA��IITfI _ permiNieense N nBuildiog Department
pLieeosiog Board
�eheek if immcdiate response i�required 261 �Stlettmen's Oliitt
�Healt6 Departmeat
contact person: P�a��p;_ (508) 39842231 eat. nOther
.. � �,,,
I � DEC.2�.1999 12�42PM �OVELETTE INSURANCE N0.300 P.2i2 I
� on'fE(�auupwm
i '/?J1�1�
�� • THIS C�RTi�ICATE IS ISSUED AS A �IA7T�R OF INFOpMA110N
� ONLY ANC CONF�qB NO qIRNTS UIWN TH� C�RTII�ICATE
1N���hd1 K. I.ovelnts 1e� I1�y HOLDER. THIS CEt#TIFICAT� DOES NOT AI�END� EXTEND OR
88e M�in �et E A E I
P�O. Bu 888 ' COYPA bING VE Q
N�st YaAaio4th N4 0267a
coMPnNtr
p ��aTeRN c�su4Lrr �Na co
�Nsu�p
CW�'ANY
Bass A�1/er SA�Ck B�r UIC B
� yl�hb�ek Ropa �P�,
sowh r�,�nou�, MA OZS�4 C
coh�Par�
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1HIS IS TO C�RTIFY 7HAT 11iE POLJCIF.S Of IN3UAANC� lJ3TED 8E1DW HAVE 6EEN ISSU�TO THE INSURFA NAM�p ABOVE FOR TME POUCY P4RIOP
INDICATED, NOTWfTHSTANDINCa ANY REQUIFl�MENT, TERM OR CONpf110N oF ArIY CONTRACT OR oTH� DOCuM�NT WI'111 Fi�.SPEC7 TO WHICH THIS
CEq71RCA1E MAY e�ISSUE� OR MAY PERTAIN, 71-��INSUFWNCE pFFORD�p 9Y TyE POUCIES DESCRIBFL HERFJN IS BUBJ�CT TO At1 THE TERMS,
1 A DI SU I 1 MAY CEO ID 5.
L1ti 7'YP�OR MBUFANC2 POLICY NUNlBi POLJCY EFfECTIV� PO�ICY RxPIRAT�N �,�
DATE (MMIpD/YY) GA7E d�4DD/�M
GENBaAI.LU�6I.ITY QENEAAL AOGRCOAIE S
COMNEACIAL GETFPAI.IIABR.ITM PRODUCTS•COMP/OP AOG �
GAIMS MAP� �OCCUR P�SONAI.d AbV� RY S
OWNBi'3 B CONI'RACTOR'S PROT EAChI OCCURR�ICB 8
FIFlE OAMACi� qte 1
MEO DCP one rea� s
AUTOMOBp,�LIA9NJ7Y
�� COM91N80 SMVaI,E LIMIT �
��D�� �OILY INJURY 1
8qiE0ut.Eu AU'f03 0'et perao�
WIREO AUTOB 90DILY W.NRY
NON�OWN�P AU110s Q'er exldenp 8
PROPERIY DAMAGE 9
����'�� ONLY.EA pCCIP�IY $
r,r ,� • t
'��1D � o�a�TM�w a�rro a�r; ,� � � ��¢
eacr+nccivarr s
aGc��aatE :
������ �J1CH OCCIIppENCE 6
UMBFI9IA FORM AOt�IEQATE S
0T11�1 iHAN uW�RB-LA FCI�ht s
EIY�'LV►eILRY ON AND �A - .,, .r t;s... . � ,; ,
' � Nc354-10-94 01/99/99 01/19/09 ��M AOGDENi . a 100,000
p�q�,�� �N� EL O�sFas�-POUCY 4MIT s 500,000
�' °� a o�-EA qNRoveE s 100,D00
oTFIEA
sNA�cK R Op R�TI����w'�
BHOULD ANY OF THE ABOVE OESCFI9ED POLICI�4 eE CANCg.LEp @�7HE
���/$.ALTN E�IRATION DA7E THEAE�,THE 19BuMo COMPANY wl{.�9VDEAVOfl 70 MAA.
46 AQ T�' Z8 � 10 ppyg�No7WE TO THE cF.�rt1FICAIE Ho{.pE�t WqMEo Tp TFIE I.EF7,
SOUTN VqAMOUTM N� ps�e4 0UT FAIl.iJ1�E TO MAM.g11CN NOTIG�S�iWa,INNOSE NO 091,I3A1�ON pp UAB�Lm'
OF ANY KING UPON 7M� , AOOJTS OFl R�ITATNE.&
�U'fH
r or K, �errr
�
TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-117 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
1 I 1, Section 5 of the General Laws,a permit is hereby granted to:
_ Rass River C'T�lf Sn k R r, 62 Highbank Road, S� � h Yarm� � h, 1��A
Whose place of business is: Bass River Golf Snack Bar
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2000 BOARD OF HEALTH:���/. .�et��, C'�tr,��
SEATING: 73 �oan� �ullivan, K.!"/., Vice C,�irma
RESTRICTIONS IF ANY: Disposable Service Only. Kobert� �rown, C,lerk
abrie[le�a�o%�i�-�ooPed
ic��0 oCou�r�lin
Janua,ry 21_,2000 �
Bruce G. Murphy, MP ,R. , CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-63 FEE: $50.00
This is to Certify that Bass River Golf Snack Bar Inc d/b/a Bass River Golf Snack Bar
- fi Highbank oad, S� � h Yarm� � h,1��A
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity unth the authority granted
to the licensing authorities by General Laws, Chapter 140,and amendments thereta
In Testimony Whereof,the undersigned have hereunto�xed their official signa.tures.
BOARD OF HEALTH: �'��J. `�slte�, C'�aa�,nan
SEATING: 73 �oaa� �ullivarg K.�, Vice ��irman
o�ert..t. p�rown, C,�rk
a�rie[!e�a�oGs�iy-.�tooPaa
��l �o��l�.
J�u�2 i ,Z000 �
ruce G. Murphy,MP , . ., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-31 FEE: $20.00
This is to Certify that Bass River Golf Snack Bar Inc d/b/a Bss River Golf Snack Bar
62 Hi�hbank Road South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
January 21 ,2000 BOARD OF HEALTH: �c� ///. �eltea, ��tairma►t
�oan� �u6livan� K.I'/.� Vice C..�irman
Ko�ert.}. 9,rown
�ad rie6le�a�ol��y-�ooPee
�ichae[�� ou��[in ,
ruce . urP Y� • ,
Di�ctor of Health
1
i .. - -� �ass 12�vek-C�olf' ��nu�fe.l�r_
1
, ti
�_ : . �� �i � � � � � � �
TOWN OF YARMOUTH BQARD U�Ii�AL� '�''�,
� APPLICATION FOR LICENSE/PE_ ?� 1999 w �
�� , , DEC 2 8 1998
� K n_
* Please complete form and attach all necessary documents by December 31, 1998. Faalure �
the return of your application packet.
-------------------------------------------------------•- ------------------------------------------------------------------------�--
TABL S !!lf v�v/ # c3� — �d,6
O ATI N D S• 01 w � O
MAILING ADDRESS: �� �� Y
�WNER/CORPORATION NAME: 3,R. J�P/AGC t3AR ,�,�v� �
�N��ER'S NAME� �tt�1�s 3 �f'g�I TEL # �i9s�F
�.AII,ING ADDRESS: ���r�
-----------------------------------------------------------------------------------------------------------------------------------------
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as recXuired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tlus form.
1. 2.
-
Pool operators must list a minimum of two employees currerrtly certified in basic water safety, standard First Aid and
Commwuty Cazdio�ulmonary Resuscitation(CPR). Please list these employces below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a fde at your place of business,
1. 2.
3. 4:
HEIlVILICH CERTIFICATT(�NS:
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
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 place of business.
1. �(e�z f'1fi� G�7-5'�f , _ 2. %�'�j J osr/}3.S
3. 4.
RESTAURANT SEATING: TOTAL#�3 NON-SMOKING SEATS: TOTAL# /� ,
--- ------------------- --------------------- ------ -------------- ----
--_ __ _ ..____6F���-��E BN�� _
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50
�
�INN $50 _CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SV'V][NIlI�IING POOL $SOea.
WHIRI.POOL $25ea.
�OOD SERVICE: —
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
1 0-100 SEATS $75 _� CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
l COMMON VICT. $50 _� WHOLESALE $75
RETAII.SERVICE:
LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# `
_<50 sq.ft. $45 � TOBACCO $20 Q9"� I
____<25,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200 �
►
NAM HANGF: $10 i
;
AMOUNT DUE _ $ I�-I 5�' �
"""•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R��k i
�
_._. _ .. V i
i , .
!
ADMINISTRATION
: UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOUTH IS NOW REQUIRED
i_T(J..HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A
PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. THE ATTACHED 5TA'�E WORKER'S COMPENSATION INSURANCE AFFIDAVTT
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND L NS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK OPRIATELY IF PAID:
YES NO
NOTIC�: PERNIITS 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�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION �
7-10 DAYS PRIOR TO OPENING FOR THE 5EASON. I
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAIlVTING, NEW
I
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
i
POOLS 6
POOL OPENING: ALL SV�TIlVIMING, WADING AND WHIRLPOOL5 WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE WATER TESTED FOR
PSEUDOMONUS,TOTAI.COLIFORM AND STANDARD PLATE COLTNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEI�TING, AND QUARTERLY THEREAFTER. '
POOL CLOSING: EVERY OUTDOOR IN GROUND SWJMIVIlNG POOL MUST BE DRAINED OR COVERED ;
WITHIN SEVEN(7)DAYS OF CLOSING. �
FOOD SERVICE
CATERII*TG POLICY: !
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH �
HEALTH DEPARTMENT BY FII,ING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION ;
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� '
HEALTH DEPARTMENT.
FRO�EN DESSERTS�
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST "'
RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN !
THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSER.T PERMIT UNTIL THE ABOVE TERMS '
— - ---- ---_ _ - _ _ _ _ j
- --_ - -- - _
- — --- _
HAVE BEEN MET.
OUTSIDE CAFES:
OUTSIDE CAFES(i.e.,OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), ,1VIIJST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD
SERVICE ESTABLISF�VIENT IS PROHIBITED.
DATE: l �� �/ 5IGNA
TITLE: �lfl'S � � ��- �R£S�
rRINT NAME k �� �—
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PRQDUCEH THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORAAATlON
ONLY APID CONFERS NO RIQHT8 UPON THE CERTIFICATE
Marshall 1[. Lovelette ►ne agcy HOLDEq. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
896 Msin St�ee! ALTER THE COVERAQE AFFORDED BY THE P CI 8EL W.
P.O. @Ox 836 COMPANIES AFFORDINa COVERA(3E
West Vormouth MA OS673
COMPANY
p EASTERN C6SU/LLTY ►N$ CO
INSURED COMPANY �} � � 2 � Rp 2 D
Bess Rtve� Snack B�r Iea �
W IS u is
B2 Nigh6ank Road COMPANV FE B 0 8 1999
$outh Ye�mouth MA 0g664 ___.�.._._.,......�.....,. _�_._........._..,.. —
°0""P^""' HEAL7H DEPT.
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THIS IS TO CERTIFY THAT THE POLICIES OF INSUflANCE LISTED BELOW HAVE BEEN ISSUEO TO THE fNSURED NAMED ABOVE �OR THE PQUCY PERI�D
INOICATEb, NOT4VITHSTAMDINQ ANY REQUIREMENT, TERM OR CONDITION OF ANY CONT'FiACT OR OTHER DOCUMENT WItF! HESPECT TO WHICH TH15
CERl'IFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORpEp 6Y THE POLICIfS DESCRIBED HERdN IS SUBJECT TQ ALl THE TERMS,
EXCI.USiONS AND CONDITION F UCH POLICIES. LIMITS 3HOWN MAY HAVE BEEN REDUCED BY PAID Cf.AIMS.
TVPE OF INSURANCE POLICy AIUMBER POUCY EFFECTIVE POI.ICY EXPtl7AT10N LIMTTS
LTR OATE (MM/DD/YY) DATE (MMlb�/1'Y)
GENERAI.LIABILITY QEN�RAL A(iQREdATE S
COMMERC�AI QENEHAL IIABILITY PFlOOUCTS-COMP/OP AOQ S �
CUIIMS MADE �OCCUR PERSONAL 6 ADV INJURY S
OWNER'3 8 COMRACTOR'S PROT EACH OCCUfiRENCE $
FIFiE OAMARE(My ona tire) 5
MED IXP(M OnB rapn) E
AUTOMOBIt,E LIABILfIY
COMBWEO SIN(ilE LIMtC S
ANY A2IT0
AI.L OWNED AUTOS BO�ILY INJUflY
SCHEOULE�AUTOS ����) E
HIRED AUTOS BODILY R�.NHY
NONAWNED AUTOS (Per accidenl) S
PROPERiY DAMAOE S
OARAGE LIABfLITY AU7'0 ONLY-EA ACCIOENT $
arev auro orHEa n��w Avro oa�r:
EACH ACCIDENT s
AC�IGREGAIE E
EXCES5 1.W81LITV EACH OCCURRENCE S
UMBRElLA FORM ���� S
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W�C 81TA� OTH- ::::::::::;<Y;:i?;::;>�::::;:;:;:';<:::i:;;>
�WORKERS COMPENSATION AND ,� � >:.<; ;:;:;':
EMPLOYERS'LIABILITY uC354-10-44 01/19/99 01/19/00 �.�CH ACCIDENT S 100 000 ,
A THE PROPAIETOR/
P�E���� INCL 0.D13EASE-POLICY LIMfT $ 500�000
oFFic�s�we: ncc� 0.DISEASE-EA EMPLOYEE s 100,000
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SNACK BAR OPERATIONS
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9t/1LOlN� DEPARTM6NT ��wanoN oa�n�a�oF,'INE ISSUINCi COMPANV WIU.ENDE4VOR TO MPJL
TOWN OF I/ARNOUTl/ �� DAYS WRITfEN NOYICE TO THE CEATIFICATE HOLDER NAPAEO TO THE LEFT,
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-17 FEE: $20.00
This is to Certifv�hat Bass River Golf Snack Bar
62 Hiehbank Road South Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBAC O REG TT�ATION
This permit is granted in contormity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31. 1999 unless sooner suspended or revoked. �
December 18 , 19 98 BOARD OF HEALTH: ��� .}etEee, C,�airma�z
�oan � �ul[ivaiz, K.�, Vice (�hairman.
KoberE,}, �rown
�abrielle�a�o�hc�-.J�toopes
' hael O� »u�hlin
�
IIICC
Director of He�alt�i � �'
TOWN OF YARMOUTH
� BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 99-57 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:
l�ass River('rolf Sn ck R r, 62 Highh nk Ro rl, So � h Y rmo � h, R�A
Whose place of business is: _ Bass River Golf Sn ck Bar
Type of business: Food Service
To operate a food establishment in:_ Town of Yarmouth
Permit expires: December 31 1999 BOARD OF HEALTH:�d�f. �et�e, C'�c�,,,a,�
SEATING: 73 �oan C�. �uLlivan, ��, Vice l,hairmaa
RESTRICTIONS IF ANY: Disposable SeTvice Only, fCobert�}. p.�rown �fer�
/ aD / D� /'
abrla6[e�ahol��tf-�/doo ed
ic O� ou��[irc
December 18 , 19 98
ruce G. Murphy,MPH RS. HO '
Director of Health
�
_ �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: 99-33 FEE: $50.00
This is to Certify that_ Bass River Golf nack Bax
- f� Highbank Road, S� � h Y rm� � h, R�A
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�ires December thirty-first 1999 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 authonty granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
Bo� oF��.�: �d� �6��, c�����
SEATING: �3 �oan(�. Jul`ivan� �//.� Vt�ce l..�irman
KoberE�}. O�rouiit, l�lerh
abriel[e�akoG�ht�-�toopee
� hael O� u �Lin
December 18 . 19 98
ce G. Murphy,MPH, ., O
Director of Health
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