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Home My WebLink AboutApplications, WC and Licenses � ; ;�; � '�=� a�C��av��n . �� k ;� , �� JAN ��so� ,; — TOWN OF YARMOUTH BOARD OF�AY.T� H EALTH DEPT. AY�'p'Y.ICATION FOS Y.ICENSS�'�RMC'P-ZOQ9 *Please aample�Ce farm aad attaah a11 necessary docaunent$by DoceniLar l.S.Z,QQB, Fai�tiro to do so w�l result in the re�turn of your applicattou�µ t. NAME OF ESTASLIST�ivIENT: TEL.# � i-cu"A'3"rON ADDR�S5• "1� � Blockbuster Inc. I �G ADD �C,.�I�- RE: ' TAx ix �. Permits and Licenses`�� RATION NAME g APP�,TCABLE): P.O.BoX 8009 �(`nQ,�� =�'S NAME: �y�,� �,,,�::��rrz� TEi,.#svs-3q�-d,� McKinney, TX 75070 � �G��$� .;ER�cArrorrs: � The poo!sapervi8or must be cerUi�ied A�a Pool Operator,�ts required by State taw. Please list the d�siguaced Pool 4peratoi{s)and attach a copy ef the certificatian to this form. 1. 2. 1'001 operators must list a nlinimum of two loyees certificd ffi basic�ou'ater safety.standard First A�i and Community Cardiopulmoauy Rcsuscitatiou . ase list t6cse empioyees bdo�v mid attac�cop�of esnP�Y'� � �� , certi5cations to this farna.T6e Henl artmen�t wi11 nat use past yeare'rocords. Yau mast provide new � eopies and mAiptaia A flk r pl�ce of b�sineas. �� ;� � �. � �� Zap9 3. 4: �� 26 �! .�� OQD PTtOT'$CTION MAlYAGERS-CERTIFICATIONS: � All food service establisfunents are reyuutd to have at least one full-time employce who i�cerhf'eed ood I'mtectioa Maa$�er,as defined in the State Sanitiary Code far Fnod Service�stabl�xte�ts, I05 590.000. 1'le�ase attach cop�es of cortificaripn to this apglicatirni. The I�ealth Department will not pa yeacs'records. You must provide»�w copiea a�!msintain a Gle at your estAbliut�men�. 1. Z. PF.12.SON 1N CHAItGE: �� Each food establishmeat must have st least one P�rsoa . ge(PTC)on site ciurit►g hours ofapetatioa ', �1�� 1. 2. ! HEIlVILTCH CERTIFICATIONS: ..�- j,� Att EQod service establishments ' ZS scats or morc inust have at leest one emplo cc iramed iu the Iieimlich �� t�o F a��,p�� ► Maaauver oa the}x�emises timas. Please�.st yaur emplayees traiaed ia and-Gho�procedures bclow and ,vV�a� attach copies of emplo ertifications t�r this form. The He�lta�rtment vr�t not ase paat years'records. ��r�p j�`� You must pr�v,d copiea and maintaiH a 61e at yoar place al busin�s. ��J�' � ��.�n- 1. 2. 3. 4. R�STAURANT SEATTNG; TQTAL# . ��, y,� OP'P�C�Yl'SE UNLY r�} / LODGING: vi LIC�T5E REQUIREU FEE PERIu�T# LlCEN3k,�QUIRP,ll F�E PERMIT# IdCENSE RPQV1REl) � PERMTf# i/)�1� � B&B 543 _CABlN $SS � �MOTEL 555 �`!�jf�' y _,_pax sss _ca� sss s�vtt�tavarao�,seoe�. � ,�„�LO1XiE S55 TTRAILERPARK Si05 ,,,,_,VJHICt�.f'OQL $BOep. FOOU S�RViGS: r�i � � 1`/� � L1C�NSER6QUQtED FEE PEttMI'I# UCENSEREQiTQtfiD FEE PF1tbIl7'# T.TC�FtEQ[ARED FEE PE&IfmT�F �, �� _4300 SEATS 585 _CONTTNEN'I'AL S3� _1�OId�PRQFfP S3t► \ � (�V�l � 1tETA1C.SEkVYC�: 5160 ,_CONIIviON VIC. S60 �ESID KTfCE�i S84 `� � D�� LICENSE YtEQtIIFi�n �El"s PEAMCf M Y.TCENSE AEQ'UTCt�'D FEk PERMlT 1f LICENS$RSQUIItEI} FF1: PERbIIT# L<so�.�. s�o ��f >zs,000,y.e. szzs v�mtG-Focrn sas ,�25,000 sq.R. S$0 �FRUZEN I}FSSEkT S40 _TOBqCCO S55 Ka,:�+�ne c7a�,�,.*tc�F: S�a AMOUNT DUE = S S4.t�b •�..PLEA8E 7ZTRN OVF.B/LND COMPLETL�O'fB�R gID�OF YrOYtM��• � wnMon�rrs�.+TTox Under C.hapter 152,Secti�ZSC,Subsoction 6,the Town of Ya�mc�uth is�w requit+ad to hold is�ace or nene�v�t of auy�se or pamit to operats a busin�s i£a p�'eon or company does not have a Certi6catc of Worka's I Campeasa6oa Ins�uwnce. T� ATTAC�D 3�'ATE WORI�R'5 CO1�N&ATxO tJRAl�fC� i AFFIDA�TI'MUST�COMFI.�TED AND SiIGNED,�8 ' CERT.OF INSURANC�ATTACFIRD � fJR �VORRER'S COMP.AF�IDAVIT SIfrTTED AND ATTAC�D Town o£Yarmou�►taxes aod li�muat bc paid P�r to rane�val or issuagce of your per�mits. PI.�ASE CI3FaCIi APPROPTiTATELY 1F PAID: �s rro M4TEI�S A1�TD OTSER LODGYIV'G E9T TItAN�i�1V"r OCCUPANCY: Far putpasas oFtho limitapons afMotel or�lotd uae,Transient aa�tecy sha11 be limited to the tempa�uy and sl�ort t�m oacup�rtCy,c�in�r1Y ead cu�o�y a6sociatcd wit6 mofi�+l and hotd use. Tranaient oacupants must have and be al�to de�uonstrate tbat thay maintain a prinapnl p�e�resl�c.e el�wbcr�. ThtansieQt ucxuP�Y�ff��9 re6er to ca�aaurn►s oocupaacy of not more then tlrirty (30) dsys. �sa aggreg�t c�ttot moro thea mnsts'(90)daYe vvithis►arry six(6)marnh period. Use of a guest unit as a residamce ar dwelWtg u�it shal!not be cousidered tranQieirt. Ocwpaacy that i��ubject to tho�lleotion of Roptn Occupancy Excdse,as defimed in MG.L.o.b4Q�830 CMR 64G.as smendt�sl�all g�aally 6e ao�idered Transie�ot. PdO�.S Pt�OL O�NII�TG:All swionnriog„wadiag snd wlnch hsve beea r�sed flx the sesson m�st ba ins�er,�d ' 6x!the Heahh Ue arhneat r to �. Contact�F�I�a�ta�t w sdsedule the i opectian five(�)days pnor to opening.��;��l.�eople aro NOT atloeved to sit m the poad ar�a�mtil tha pa has baen i�peated and c�ponod. PO4L WATER'�'ESTII�iG: The watec'a�st bo t�tod for ps�domonas,total coliform and�d�rd plate catmt by a Stete aectified lab,prior to opemng.�d quarter�y there�after. PUOY.CWSIlYG:Evay outduor in grou�swim�ing Pool�st be dr$iaed ar oovered witbin sovm(�days of closing. FOOD SEBVIC� CATERII�iG POLICY: Attyoira wLo c�'s within the Tn�m ofY�rmoutL muat nutify tl�Yatmouth Heatth D�#�r thareqtut�od H�mporary�'oe Appliaatiton So�m?2 hout�s prior W the aatered e�uant. Those Sarms aan�be at the �tth FROZEI�T DES�3ERTS: Fra�ez►��tst ba testod ot►a mom�y t�asis by a State oert�ed lah. Test rewilta s�ust be sdah to the Heahh DepaRuiemt. Falure to do so w�l result in the a�spension or revoc�tion of your Frozoa Dassert BermiC u�7 the above te�sms have beea mc�. UU1�IDE CAI��.4: Out�e cafes(i.e.,outdoar se�ng wit�►waiter/wai�ess service),must hsva prior aPPro�l fnom the Board afHeahh, OT7`l�OOR COOKING: Outdoor oaolc�in8.PrePa�on,or diepley of any food product by a re�ait�food savice e�tabii�nt is proMib�Ecd. 11T0'I�C�:Peimita run amayalty fram 7snuary 1 to Daxtnb�31. Tt'I3 YO'C!R RESPOrTS�YC.I1Y TO RET(JRN TEIE CUMPY.ET�R�IEWAL A1rPIdCATION(S)AND 1tBQ[]'i1tID FEE{S)BY��C�MS�R l5,2Q08. ALL RENQVATIONS 'FO ANY FOOD BSTAaI.ISHA�ID1dT, MOT�I, OR POOL (i.e., PAINTING, NEW E4'CJ�Nffi�I',ETC.�MUST B�REPOR'T"ID TO AND A�' B'Y'TH�BQARD O� PRIOlt TU COMMENCENiE�1T. OVATiONS MAY A 5 PLA . DA'1'E: �� . SIGIYATURE: p��,E: - �S ��,� � � i InformAtion aad,Iastructiona� Maseach�tt�Cr�pe�d Laws ctwpt�c i 52 secl�rt 2S requices all e.captayara to pravide worl�e�a'com�erustion for q�cir pnployas. As quotal from t6e"4w",�a�wplr�a�is d�sC�d aa evc[y pasoe ea the a�en+ice of anotb��der any. coniract of hire,oxPnxw or implied,orAt ot wcitteo. Aa r�rplo�rr is defmad��iadividual,Parhx,'r�iP�assnciatioq coTporatim a o�k�l eatiry,or aay two or moc+�of ' the far�sgoiug e:ngaS�xt ln a joint�n�rp�ise.�d iachidiog q�e te6a1 r�t�vee of a dea►xaed employcr.or the�eeeiv�r or tcustee of s�n individual;parmeis4iP,Association�o�htx�ga�e�tity,ep�ploY�6�Ployeea. HorwevCr the owaer of a dw�dGng houre haviu�not aia�t6aa three ap�ctments and wtw residCs thetein,ar tbo occupa�rt of the dwdUipg Iwu�e of �r who emptoys.pecsoos to d�o mainteaance„�roasrrwccian oc�epair wak an s�ch dwreWtqg ba�e vr on the g�+otrnds ar builcting��mt tLcc�eta shall not because af�dt employa�nt be daemod w i�an�emptoyec. MQ�L cbapttx I 52 sodian ZS a�o ststes that aver�►t�b��r�ad li��y�sM M#61�Id t6a L�a�ce�r r�en�tl of a liceue or pat�ait ts operih a ba�ar�or N c�tr�c.��p it t�e�we�ior a�y a�c,ute w�u+Iw..wc prwa�a�eeepesb�e e.ale�e,�or caro,pw.ee w�te itia i�s e�r�e requtrea. Additionalty,nuili�c t6e coanmonwpltri nor uny of ifs poietiea!�6divisi�a�ll�kx into any couuract fac d�e pafrnm�aco of public wat unW�bk evidenee of ea��an�wit�►tim i�c�uanee requireancat�of dds ehaptor i�uve , been�ented to Hte contracdn�authoriiy. . :}:•.,,.r.'�:��..��,.<..�. . . ... �.. ;�. •.. :a 5��' - •,... ,'��F� `5 :s�i-iiT''�''Ik�,"•t'.L.,/:f .�:r"��:%i:'J'Y•;�.1n`;Ny�. '��Ya��. ,�'de{:' .. �~ . . , " • • . � �� • . . � � I�Leqst 6il1 in the woricers'compeosatiort at�davit c�nple�elY,bY eheelciog die box tbaf s�pliea to yair situatias..l�se �PP1Y Cpnp�Y name:addnos�aud phoo�o nutt�eca alang witti a cedifie�e of i�aae sa�sll sPRd�vi�s mmly bo �uubaAitled�t�e UepattmGnt of Iadus�ial A�ccidents fer cwetii�a Af i�u+xancx covasge. A�be wea t�a d�� dsdr t�e�lditvit� The at�davit a6outd bo r�tumed to Wa city or town that the applics�wa fa,tLe pe�mit�licaasre is bci�g r�acl��t�the Oepscmmept of induslrial Accidat�. Shoutd yQu'h�r►e unY 9��S th�"bi�'or if yau sire rCquiced to oMain u woiicere'�ensatioa.policy,Plcase eall We Depa[ttaent st the munbtr tisted betow. (r8•' •e��Jr.r• '"L"�' v�`}..x.. .�i�y�� ..,v -�� i .u.� City�r I'owas , P►�se be sue�c that QLe s!Y"idavit is canplete aad pri�ad legibly. T6e De�au has provided a e�aee at tlte bouam of We�vi1 for you to 6N out in tl��cvoat the Ot�ise of imr�has to o�t yau�prdipg the�plie4nt. lNa�se ba�to fill in the petmiMicea$e uumber which�WiU be u9oc1 as s ref��3umbec. 1Le af6idsvite may i�c noWc�t� t�1u 1?e�qont by mat�or FAX uoles8 dhec�d�s t�sve been made. , "fhe Of�iea of inv�tigat'abs wo�ld L7cc t�o�.8wnlc you in�dvance.far you.000poratiioa�d a�uld you bav�e�y qt�lian�. pleaae do�t hesitate to givc ua s c�U. . . . . .... .. � ��...: .- .� � . ... .�.�:...,.. ' . . . . 1��'.,' .. .......!,�)�:.i:i?. K, � _ . . �.i:�.n. ... •' " '� "'�'�1 �" . ..��..:r.�...'y}a�.:t�".F;�:. ... ' ..•\:,�"r 'h�1�::;:i.�"1.K M•;.Yf•";'�.a�..:f:::,;'aN�,� ,L' [Sy�^•!• if. � :".•• .. . . ' . ''r ... :.. . .. .i.,. . �. " �" ��"M,: . i . ,• . � •. :. ; •_ . . ". ' " ' :.:...�.:.'.•.• ��t{�p�'m BL�,�I�E��lC nt�: :;3 �:s�:. �C C:WNWOdWt�1��Of�ISSiCIlY30t1'8 Depaetae�t�!'i�st+ria!'Ac� YI�o�M MNI��MI�. . � " 60!W�Street,T��10�' Boito4 Ms. Il�lll . t��k(617)7Z?�77�9 plroae#:(61?)T27.4908 �xt.40f �� Q�naUC� . � ` �P . ` ACORD�, CERTIFICATE OF LIABILITY INSURANCE page � of 4 09/30/2008 rRooucea 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE willis North America, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 25 century slvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 xashville, TN 372305191 INSURERS AFFORDING COVERAGE NAIC# INSURED gp=D8NC8 OF INSURANCS INSURERA:The Insurance C an of the 3tata of Pea 19429-001 Blockbuster, Inc. INSURERB:Commarca and Industry Insuraace C an 19410-001 1201 Sim Street Reaaiesance Tower INSURERC:Natioaal Unioa Fire Insurance C an of 19445-002 Dnllas, TR 75270 INSURERD:I113aois Natioaal Iasuraace C an 23817-002 - INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AN�CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICYEFFECTIVE POLICYEXPIRATION LIMRS LTR NSR TYPE OP INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DDM' �j+� GENERALLIABILITY GL1872004 9/30/2008 9/30/2009 EACHOCCURRENCE $ 0�� Q00 X COMMERCIAL GENERAL LIABiUTY PR MG ES eENTErenc E CLAIMS MADE �OCCUR MED EXP M one person S EX 111C� PERSONALBADVINJURY S Z OOO O � GENERALAGGREGATE S $ OOO OO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ $ OOO OOO POLICY jRC7 LOC g nuronnosaeunswrr MA CA9725599 9/30/2008 9/30/2009 COMBWEDSINGLELIMIT � 2�0��0� ANYAUTO VA CA9725600 9 30 2008 9/30/2009 (Eaaccident) A X / / j, ALLOWNEDAUTOS AO$ CA9725601 9/30/2008 9/30/2009 gODILYINJURY $ � SCHEDULED AUTOS (Per person) . .. HIREDAUTOS � BODILYINJURY $ NON-OWNED AUTOS (Per accident) � PROPERTYDAMAGE $ � (Per accident) . GARAGELIABILRY AUTOONLY-EAACCIDENT $ ANY AUTO OTHER THAN �ACC $ . AUTOONLY: qGG $ � (,' EXCESSNMBRELLALIABILITY 2226969 � 9/30/2008 9/30/2009 EACHOCCURRENCE $ 2 ��0 �� . $ OCCUR � CLAIMSMADE AGGREGATE S 2 O00 000 $ DEDUCTIBLE $ RETENTION $ H $ A WORKERSCOMPENSATIONAND CA WC4800764 9/30/2008 9/30/2009 X TORYLIMTS �ER EMPLOYERS'LIABILITY � A ANYPROPRIETOR/PARTNER/EXECUTNE AOS WC4800769 9/30/2008 9�30�2009 � E.L.EACHACCIDENT $ 2 0�0 �OQ OFFICER/MEMBER EXCLUDED7 � D FL WC4800765 9/30/2008 9/30/2009 E.L.DISEASE-EAEMPLOYEE S 2 000 000 If yes,describe under SPECIALPROVISIONSbelow E.L.DISEASE-POLICYLIMIT 3 2 OOO OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS � � See Attached CERTIFICATE HOLDER CANCELLATION � SHOULD ANY OP THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE Q(PIRATION � DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3� DAYS WRITTEN NOTICE TO THE CERTIPICATE HOLDER NAMED TO THE IEFT,BUT FAILURE TO DO SO SHALL - IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR *** EVIDSNCS OF INSIIRANCB *** �P 7Nes. AU ACORD25(2001108) Co11:2493369 Tp1:834500 Cert:11437627 OACORDCORPORATION1988 Wt��IS CERTIFICATE OF LIABILITY INSURANCE Page 2 of 4 09/30/2008 Y PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Willis xorth xmerica, xnc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ze centux�• slvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 305191 xashville, xx 372305191 INSURERSAFFORDINGCOVERAGE NAIC# INSURED �DBNCE OF IN3URANCB INSURERA:The Insurance Co aa of the 3tate of Pea 19429-001 Blockbuster, Zac. 1201 81m Straet MSURERB:Commerca and Indust Iasuraaca Com aa 19410-001 Renaisaance Tower INSURERC:National Uaion Fire Insuranca Co aa of 19445-002 Dallas, TS 75270 INSURERD:Illinois National Insuraace C an 23817-002 � INSURER E: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EICCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS � � Worker Compensation: ND, NY, WA, WI, WY Carrier: National Union Fire Insurance Company of Pfttsburgh Policy Number: WC48A0768 Policy Effective: 9/30/08 Policy Expiration: 9/30/09 NAIC-LOC: 19445-001 Workers Compensation: OR Carrier: The Insurance Company of the State of Pennsylvanfa Policy Number: WC4800766 Policy Effective: 9/30/08 Policy Expiration: 9/30/09 NAIC-LOC: 19429-001 Workers Compensation: TX Carrfer: New Hampshire Insurance Company _. Policy Number: WC4800767 Policy Fffective: 9/30/08 Policy Expiration: 9/30/09 NAIC-LOC: 23841-001 Excess Workers Compensation and Employers Liability: OH Carrier: Illinois Natfonal Union Insurance Company Policy Number: XWC4801279 Policy Effective: 9/30/08 Policy Expiration: 9/30/09 NAIG LOC: 23817-002 Workers Compensation: Statutory Employers Liability $2,000,000 8ach Accident; $2,000,000 Each Employee for Disease Commercial General Liability is subject to the following provisions: Additional Insured-Managers or Lessors of Premises - "All persons or organizations leasing premises to you" is included as an insured, but only with respect to liability arising out of the ownership, maintenanee or use of that part of the premises leased to you and is subject to the followfng _',` additional exclusion: l. Any '�occurrence" which takes place after you cease to be a tenant in that premisea; 2. Structural alterations, new construction or demolition operations performed by or on behalf of the "person or organization leasing premises to you". Additional Insured - Primary - However, coverage undar this policy afforded to an additional insured will apply as primary insurance where required by contract, and any other insurance issue to such additional insured shall apply as excess and noncontributory insurance. Additional Insured - Vendors (CG20150704) Included for coverage; Additional Insured - Volunteer Workers (CG20210798) Included for coverage; Additional Insured-Designated Person or Organization (CG20260704) Included for coverage. Coaimercial General Liability and Automobile Liability policies are subject to the following provisions: Additional Insured - Where Required IInder Contract or Agreement: Any person or organization to whom you become obligated to include as an additional insured under this policy as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of Co11:2493369 Tp1:834500 Cert:11437627 TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMElVTT PERMIT NLJMBER: #09-051 FEE: 550.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 ofthe General Lavws,a permit is hereby granted to: Blockbuster Inc., 1070 Route 28, South Yarmouth, MA Whose place of business is: Blockbuster Video 25050 Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l, 2009 BOARD OF HEALTH: .`�EBe¢tt SI��, `J�.✓V., C.'Rtavrnuut C'l�crx�ea ,�. 3G:�'�i�i.e�'c� `tJ,i,ee C.lfav�rnacn ttEs�rlucTtohs: Prepackaged food items oniv. � �. ��ltl1[ttt�� t.uti`'�"�� Januarv 30.2009 B ce .Murp y,MP , . .,CHO Director of Health ; f ... � Yq ��.0�-dU� 0 4 �,`�''' ` s�r, �s TOWN OF YARMOUTH BOARD OF L LL, �'�� .S ^ F / APPLICATION FOR LICENSE/P,��7��, 0 r ��r � .. � q � �� 4�i�5�':� � 3 ��?',� . * Please com lete form and attach all neces `� t �' � w P sa.ry'do�um�ts�y ec�ber 31, 2007. Failure to do so will result in the return o�ybur application packet. � .� NAME OF ESTABLISHMENT: a-�td��c.`, TEL. # LOCATION ADDRESS: /G?D MAILING ADDRESS: Sa-rn�- OWN�R NAM�-/�? �b �r� �•�T:,.� Tt�X ID (FEIN or SSNX� � CORPORATION NAME (IF APPLICABLE : 1 �� , MANAGER'S NAME: � TEL. # yp�-��y--y4� MAILING ADDRESS• , L��,�.�..� ,�� ' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. Tfie �ealth Departtnent will nof use past yea�s' records. 3�0� mus�pravide new copies and maintain a fde �t your place of business. t• 2. 3- 4. 1�lI�AI�IIIII�lR�I��AllRll!^RP}ISII�� 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 define d in t he State Sanitary Co de for Foo d Service Esta b lislunents, 105 CMR 590.000. Flease attach copies of certification to this appfication. The He�lth Department�vitl not nse p�st years'records. You must provide new copies and maintain a file at your establishment. � 1 �. i { � __PER�QI�T_IN��: - -- _ - -- - � - --- -- , Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. I l. 2. HEIMLICH CERTIFICATIONS: All faod 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-chokuig procedures below and ; attach copies of cmploye�e certifications to this form. The Health Department will nor use past years' records. � You must provide new copies and maintain a file at your place of business. j �• 2. I 3- 4. � RESTAURANT SEATING: TOTAL # � ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'b1II'# LICENSE REQUIRED FEE PER'4fIT� LICENSE REQL?IRED FEE PERVIIT= _B&B 550 _CAB1N S50 _MOTEL S50 ,1NN �50 _CANIP S�0 l,SVCIi�LVIING POOL S75ea. _LODGE �SQ _1"RAILERPARK S100 _VVHIRLpOOL S75ea. FOOD SERVICE: LICET+TSE 1tEQUiRED FEE PERMIT� LICENSE AEQL7IRED F£E PER'l4IT� LICENSE REQL"IR£D FEE PERViIT= _0-100 SEATS $75 _CONTINENTAL S30 lv'ON-PROFIT S3� >100 SEATS 5150 _CONL'410N VIC S50 V6�-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER�IIT# LICENSE REQL'IltED FEE PERLIIT r �<50 sq.ft. $45 g'�� >25,000 sq.ft. 5200 �'ENDIIvTG-FOOD S20 <25,000 sq.ft. 575 _FROZEN DESSERT S35 TOBACCO SSO NAi�IECHA.'vGE: sio AMOUNTDUE _ $ �5•00 *****PLEASE TL'R\OVER�\D CO�ZPLETE OTHER SIDE OF FOR�Z*w*** t - ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or gemut 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 Ir1SURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: f YES '! NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with mot�l and hotel�s�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vc(6)manth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with this app�ica.tion. 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 to schedule the inspection five(S�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a Sta�e eertified lab;prior to opening, and quarterly tt�erea.fter. 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 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. OUTDOOR COOKING: ___ 4utdeor�aalc�ng;�atio�r,�display ef any food prodt�e-�k�y a-fet�il or foo�se�ee es�Eablis�e�t i��rohibited: - NOTICE:Permits run annually from January � to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIIVIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMME:VCEMENT. RE�VOVATIONS MAY REQUIRE A SIT AN. DATE:�� C��7 SIGNATURE: '; T � . � FRINT NAME&TITLE: � � P n� ��/� � io?nm � I � The Commonwealth of Massachusetts Department of Industrial Accidents N�'I N��1�' 600 R'ashington Stree� f�'Floor Boston,Mass. 02111 Worlcers'Compeasatioa I�sera�ee Affidsvit:Bnilding/Plambiog/Electrical Co�tractors • ��iT te�bh� name: ��-^� _ -_�! !'Z S J-P/ r'�.- atldress• '�^�'� �(��.cL�� C3`� �1 n city � te_ ��— zi : ` �\ phame:.�'/j-'��.�`L-� work site 1 -on ffull addressl_ ❑ I am a homeowner perfornring all work myself. Project Type: ❑New Construciian�Remodel ❑ I am a sole proprietor and have no one worlcing in any capacity. ❑Building Addition �am an eYnployer providing workers'compensation f�my employees worlcing on this job. _�.__ :��'_7��'i�;�i.�`' ' --- _ _- —_ _ — - - - — - - _ _ — coma�av nme . - -�c -_ - _ ��__�"'_. : �aa,�: l C��CU �cf-�-� ��?�' � � #• � ' � Gd� ce. `� # -� -,0 � � . ,. ,�:,�.:�.. -��= .��a� [] I�am a sole proprietor,geseral coatracMr,or Lomeowser(cercl�ow�)�and have hired the contractors listsd below who have� the following workers'c�mpensation polices: comuuv r�• address• citv ohode N• �. # �, �. �I�1R1+�e: �' �Y: Dl0!!�: _ - ___ ----- -- — -——---_ _— _—,_ ___—----— ---— --- ___ _ __. _ # � � _, � ,- - _ • �.,,, y,r- - Faih�eissec�va - �� -- --- — a+�d�pe�allies aNer one years'hepriroeaeat a�we8 as civi ie the fora�of a 3T0!WORK ORDEA a�d a 8ne ef f189.Os a day�t me. 1�dersla'd t6at a npy�f this itatemeet may 6e Ofllcs of laveM�tleffi of the DIA tar average veriAeatlsn. /ro 6entby ct xader tlie � nfPerjr+ry t6�t tbe iwfonx�do�prov�ded ebor�e is t'rre and oervect s�s� �� `�Gt1. �`�_�C17 Print natne �� -_ ��i !'� � � �'1 /L. Phone# '��/��y"y�� effidal ase oNy do eat wr#e�t6is area to be co�Pkted bp citY er tewn o�cial city ar ta�va: p�l�e�e q �Boidi�E DepartmeIIt ❑checic if i�me�a�e rcspe�e is requircd ❑Sdxtmee s�oe ❑Heakh De�rdeat Contad petso0: P�o��i �a' c��-�) r , , 11I�1l2007 01:50 5087608198 SOUTH VARMOUTH PAGE 01 �� i �� O W ° - [ N � � YAR Tr i , ,�►y 1146 RUtJT�;2� � O v � H '' H MArTACMe�S SOUTFI ' ��'°�.�,�`°,br� T'elephone (50$ x`�RMOUT�-i MASSAC:F:[US�TTS U2 F � ) �9&2231,rxc. 24� �'�5] j � D —� �ax (5Q8) 76Q-34 7`� ; $ O A ; OF � E ,� Lr � i ' Nove�mber 20 2007 z� s� ?i a�i � �� , 11�ark P_ �einstein/�Toztheast Maz�agemerrt inc. d/6/a B�ockbuster 1070 Route 2$ SQuth Xarmout�,lk(,A 02664 �e: 2008 A��lica.tior�for Licen�sing Dea.r MX. Fei�stein, Thank you for subm�ttiung the year 2048 re�ewal app�ica�ion £or you� estab�ishme�t's retail �ood ', peamit issued through the Hea�t�Depafine�o,t. However,we a�e unable to�roc�ss the app�ication at i tk�is time because tk�ere was no payment ene�osed. The total amou��due for your l�c�se renewal is � $45.00 , i � Please z'e�mit youx c�eck, �ayable to the Town oFYarz�outh,to the Hea(th DeparC�nent. A,s soon as our oi�ce receives your paya�te�t, we will issue t�e p�rnrit tQ you. If you �ave any questxo�s oz� tbe abor►e, p�ease feel �'ree to corrtact the Hea�ih l�patrment at (508)398-2231, ext. 24X. '�hantG yciu�vx your anticipated cooperation_ i ' Sincerel , ary A�ice�1orio � Principal Depaxtment Assistant cc: file � � U ti� \ V� � `� �`�'�� '� � � � Q-� r--�-� � � . � ` � . � �� ( g��n ��i ��Der TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #0$-019 FEE: $45.00 In accordance with re�arions pmmulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Secrion 5 of the eneral Laws,a permit is hereby granted to: Northeast Management Inc., 1070 Route 28, South Yarmouth, MA Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: 3�e@e�t Sf�ac$, J�.,.IV., C'fl�awrxtta�t � �Ruvc� �.J'�i�'eif�i��ice C'f�iavxnur� REST1uC1'IONs: Prepackaged food items only. .�jlZp��,�� U��C' ee+rr�a�um,'✓2..N. s ; November 30.2007 ruce G.Murphy, ,R.S.,CHO , . „ , . ., _ Director of Health � � , a I I I ! i , ,� s Ca..�a�9 L� � D •O`:�R� TOWN OF YARMOUTH BOARD OF REALT�3 � �`° NOV 2 8 2005 ' Y`: �,�� . APPLICATION FOR LICENSEl�'ERM�'I'=,2�1� `��: ° � j * Please complete form and attach all necessary d�cur�hts by Decem DLPT. a Failure to do so will result in the return i>€�our apphcation packet. i i � NAME OF ESTABLISHIVIENT: ,�.Lac/�hc��.�- TEL. #l�C�"�9'��'`�� i LOCATION ADDRE S S: / '? t� T, ��Y . `Za�nn-,ti,�.�,�,L, �-, c„ � MAILING ADDRESS:--f��m � ; OWNER NAME:�/��l� �� =-�i h�r�-L= T� ID fFEIN or SSNI-�� ; CORPORATION NAME(IF APPLICABLE): ' P�„ ��_ +, MANAGER'S NAME: 2 r► � TEL. #�G� ' �'��.�C-� ; MAII,ING ADDRESS: ;SC,�i�-n�_ a3 ��r.�c,� I � , POOL CERTIFICATIONS: � T6e pool supervisor must be certified as a Pool Operatar,as required by State Iaw. Please list the designated � Pool Op��a�r{s}and att�-&c�y of tl�cert�fica�ion to tl�is€orm. ----- _ 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Axd and ' Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications tQ this form. T6e Health Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. 1- 2. 3• - 4. i I FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� 1• 2. F£�SON�d�I-�t�RGE:-- _ _ __ ___ - - _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � ; l. 2. ; HEIlVILICH CER'TIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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. � i 1. 2. ' 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE IISE ONLY LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQLTIKED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 INN $50 CE�MP $50 _SWIlVAqNG POOL$75ea. ; _LODGE $50 _TRAII,ER PARK $100 WHIRLPOOL $75ea. � FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUTRED FEE PERMIT# 0-100 SEATS $75 _CONTINEIVTAL $30 NON-PROFIT $25 i — _>100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERYICE: —RESID.KITCHEN $75 � � LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMPP# �<SO sq.ft. $45 �?'�� _>25,000 sq.ft. $200 VENDING-FOOD $20 _45,000 sq.8. $75 _FROZENDESSERT $35 TOBACCO $50 I NAME CHANGE: $10 AMOUNT DUE _ $ �S.00 •••••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""' 1 + � , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pennit to operate a business if a person or company does not have a Certificate of Worker's Compensatian 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 pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amendeci, 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 to schedule the inspection five(5�days pnor to opening. PO4L 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 paol�nust be drained or covered within seven(7)days af closing. FOUD 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 wa�ter/waitress service),must have prior approval from the Board ofHealth. OUTDUOR COOKING: Ou_t_door cookingl�reparation,or display of any food�roduct by a retail or food service establishment is prohibited._ _ _ _ __ _ _ _ _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN ' TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SI AN. ; DATE: f,�• ��7 �-,2� SIGNATURE: � � PRINT'NAME&TITLE:1%'I��'K. �- ��i�S%�i� ioii�io6 _ ,_ �_ ,� _ __�__ - (000z-+ms r�� 'p�10❑ =#xs�d :aociad�ea ��Q�Q �� !�!�M��I�A�P�9�❑ W� ��Q ffi� :are�w 6�a 1�aa►�1 io�69 P�Nldsw a9 e�sus�97 s�a1f�i��P ��t�e �r1-�h--h�'�'—�nh #�oqa �ia�� d� •� � ��a u� a�$�s � �� 7a�w�or�pvn a�ut s7 a�oqs P��aoud Wopsw�olw!��N��N�l�MI��r w�� 4��r i 'Ha��+�3 v[a�n��[��o�w w �a d��•ww��w�� •�N P�i '��!��P s Y�'6iltl�riY t P�83�I0 71�IOM lOLS�Jo�3 aR o!� a 6y►a�aa�w�l��a�al sw �N NS`TS q da as�sl��N�J�aNl�4�11 p Ppl�ZSI'[9iNI�V'iZ�S�P0.4��ss a�rw aa�w a.mAs3 � N :sa�c�od aoResaadatoa,sra�oM�aur►Wio3� aweq a[h+�I�l P�I��{t P�[��I P�(�o�Nm)��`j�a�4�►is.�` udold atos e me I � ��.1 / C�'Jz" �� ' � � � .�zo �,��U� 1 . � • •qof scq�uo Sin�o,r�saa�Coidm�a�Cta�;c��.SJa7�OM�TA07d IJ/COi�IIB IDB I �iPFV . ., as a� . �a�o oa an8q P�waa, aic>s 8 me I [apourag0�o��r�ax� :ad�CZ�a, 3[as�Cui�mM tte Saiuuo�zad�+oa�uu$e a¢e I ❑ � �� '� �� oL n :s�� w_ T��S�� cG'-l�� S?�� ' - ..�; � : ',J�--i �� - � � `C� �.�� -YJ'�'� j�( "1'X% / Jl � � :ssaippe ��J��(�i (d� '� /a'� :amea � 1 . � . � � .��_ �t'.� �_, .� .. .:.� .`� -�. �_� .��:,.. �, . , .:-� �W�q��'J Ig�[��9 I!��M��aaaemsq�oq ��.ra�ob — --- IIIZO '�lY`��ll 1oot�,�L ��S u��Y�M O119 ��N�N s�uaP!�a�'tn!.UsnPul.�°�u�aQ s�asnyanssny�,fo y�»an�umrrr�ro�ay,l � a � 1 TOWN OF YARMOUTH BQARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT ' PERMIT NUMBER: #07-012 FEE: $45.00 ' In accordance with re�ations promulgated under authoriry of Chapter 94,Section 305A and Chapter ' 111,Section 5 of the eral Laws,a permit is hereby granted to: Northeast Management Inc., 1070 Route 28, South Yarmouth, MA ' Whose place of business is: Blockhuster � ; ! Type of business: Retail Food Service less than 50 square feet ; � � To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31 2007 BOARD oF HEALTH: B%��/ $. ��°��' /�/.2S. ' ' o1,i►E�e�s eS'fs�rlt, �C✓r., �lsce G�l�slh�slf�ft �sTlucTTolvs: Prepackaged food items only. Ro�eht�f. Bnouwt, �e/t� � �� 4��n��, R.N. i �Jt �� Janua,ry 24,2007 Bruce G.Mutphy, ,RS.,CHO Director of Health � � � � i i r � i I �'� ` ��oa� �Swcu.ov s'�R- � ��e R.�o TOWN OF YARMOUTH BOARD OF HEALTH �� `. ';�$ APPLICATION FOR LICENSE/PERIV�TF., a 6e�� NOV 2 3 2005 ..• * Please com lete form and attach all neces '�oc ~ � `s Decemb r 31 2005. - P - - �!. �� . y , e.__ . , Fau lure to do so w i l l resu l t m t he r e t u r r`�f your app hca tion pac k e t. NAME OF ESTABLIS��bIVIENT: c I�c.r r'�r� TEL. #�l��.�/•yQ�-�7 LOCATION ADDRESS: /�1 U T MAILING ADDRESS:��-vr� � OWNER NAlV�:�C�T'(� �_ 1�►r1� �P i� TAX ID (FElN Qr SSN1:(�: CORPORATION NAME(IF APPLICABLE): — � � MANAGER'S NAME: �,. ,��c�.,�, � TEL. #�7�h-�JG��-�l�- MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ,----- a��acl�-�copy of t�i�-certi�ication�a th�s-fern}. - _- 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. T6e 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 Sa,nitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN CHARGE; --- _ . _ . . _ __ _ _ I Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ; ; l. 2. � HEIlbg,�H CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choku�g procedures below and attae�i eopies 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. I 3 4 RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIN+BvIING POOL$75ea. � _LODGE $50 _TRAILER PARK $SQ _WHTRLPOOL �75ea. i FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 i RETAIL SERVICE: ( LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i _<50 sq.ft. $45 �o�6�� >25,000 sq.ft. $200 VENDING-FOOD $20 ? _QS,OOOsq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25 1 i NAME CHANGE: $10 AMOUNT DUE _ $ NS.� 1 *•*•*PLEASE TiJRN OVER AND COMPLETE OTHER SlllE OF FORM•"""" � i 1 �� , a ADl�ZINISTRATION 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 Compensa.tion Insurance. THE ATTACHED STAT'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN , TI� COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. 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 outdaor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: _ _ _Fraze�rdesserts-�st b�-�este�eri a�erzt�lybasis�y-�State-cert�€ed�ab. �est r��.,'*� �.,,�*'�� *�o the�ea1�r_ _ Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKIlYG: Outdoor cooking,preparation,or display of any food product by a retail r f od service establishmerrt is prohibited. DATE: 7��a�G� SIGNATURE: � PRINT NAME&TITLE:�'1?�,/�� - ��'ir�,S✓�i� �l�/��/Gz'��c�' 09/28/OS , . ----. � � �� __--_� The Comnwnwealth of Massachuset�s �- -� DcpasrtMent of Iudastria!Accidentc P � --_ ___ �'1If�� - _ -_ 600 R'ashingtoa Stree� 7"�"Floor __�,J Bos�on,Mass. 02111 , Workers'Com�aahos Ls�aace Aifid�vi�B'il bu�/Eleetncai b �._. . ,, e.: .,. .�`�`'�x��'-�� m.�s � � _ .� :�� . _ o�trxetors name:�(C�C_"/�2�c.L�/ �P_ f' �: �G �c;, �-r �� S�15'�� YYl[n� siate_ �1-C-� zip f/:�C.�y o�hane# �7�'/�o�J �� work site locati�(fnll addressl_ p I am a hOm�wn�performi�su Work m,�elt: rro;ect T,�e: p xew ca�stn��pttem«iea I am a sole 'etar and have na a�e w in an Buil ' Addition I am an�pioyer prnviding work�s'compensatian f�my employees working on this job. - - ._ _ — -_ _ _ _ _ . ,�: �v r1 ��`I��a�s�{- vrw��a �.v ��f .�✓lC� . � �lorli�t Msnegwn t na. I �- a p�,n� v�u.;, p,l�o� �: p�wol��s �.�_. ``�ll'� c�3 i%--�� :� + ❑ I am a sole proprietor,ge�at costractor,or homeo�r,er(cirde oAe)and have lrited the co�racta�s listed below who have the following woikeis'compensation polices: ss�t�r�e�r: .�� : �; �� I # ; _ � �v-�---. � I �S: �e� � - --- ------_—_ I' --_ _ __---- - — - —— - - -- _ _ - --- � _ __ _. __ FaiM^e r sec�e ar�era�e as reqired uder Sectl�2SA�MGL 1S2 eu Ind N tYe�p�itlN�f�psfNia�f a�e tp a:1,3N.N a�d/�r oDe yeus'Msprha�mt a�weY as pmNka ie the fers sta STO!'WORK ORDER a�d a Are�f S1AO.N a day s�aimt�e. 1 ndnsta�d that a c�py�tlds shle�e�my be !e Ne OAbe�f lm�ot tte DIA tar a e� ra�age v�r�ealMa. I do lYd+tb xnder d ojperJruy dtat tlbe i�fonx4llon provdded abov�e ia lnrs mid c+omct � �8� � � Dan , U�'f,6 T� �'� Pr;m name_L?')� �� `Z �1�-P i�n S J�i n.: phone# �1U! '�.�S/�z>�� effixial o�e ssly ae�ot.vrlce ia rris am te ne aaplaed by e�y.r a�vn.�ial dq'or fs�vn: per�/6cwe# ^�n�De�ent ❑eLeck if�1e n�psese b riq�ed �Bsard �Sde�'s Offiee �11�ar�t ��' P�#' �Ot4Q TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERI��IT NUMBER: #OS-022 FEE: $45.00 In accordance with regu1aUons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permrt is hereby granted to: Mark R Feinstein/Northeast Management Inc., 1070 Route 28,South�annouth, MA Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yannouth Permit e�ires: December 3 l, 2006 BOARD OF HEALTH: B _`h. �o�rs,/�l-`Z►•, ' ��s�, �v, v�e�� 1t�sTtucTTONs: Prepackaged food items only. Q�� 8��. e�� /�� tQst�t��t�t, Q./V. Janua�24,2006 ruce G.Murphy, , .,CHO Dire�tor of Health �''Y� j,rv''_- � �� .x ��o TOWN OF YARMOUTH � [ � ' '� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 � � MATTACHEES � �""��,,,apA,to,b��' Telephone (508) 398-2231, Ext. 241 — F� (508) 760-3472 B O A R D O F H E A L T H I To: Yarmouth Board of Health Permit Holders l�� ; � r� tu� [� D From: David D. Fiaherty Jr., RS. ;��r ,y,��,;� � � �� Hea.ith Inspector � Town of Yarmouth HEALTH DEPT. Re: Federal Tax ID Number . Date: March 22,2005 The Massachusetts Departrnent of Revenue is now requiring that we furnish detailed information to them regazding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIl�i}otherwise known as your"Tax ID Number". This is purely for adminish�ative purposes only. � So� businesses use tl� owner's Social Security Number (SSI� for this purpose. If this is the " case for your establishment, be assured that we will not allow this information to be public � { record. ; Please fill out the fields below and return this letter to � � Yarmouth Health Department i 1146 Route 28 South Yar�nouth, MA 02664 ; T'hank you for your anticipated compliance. If you have any questions regarding this matter, � please do not hesitate to ca11. The office hours are Monday to Frida.y, 8:30 a.m to 4:30 p.m The t�lephone numb�r is 45�8)398-2231,e�.241. . Establishment:� FEIN or SSN: �`/��`�'��' ! Location Address: /(/7� l�� Signature: ��.x� � Print: �e�� O�i��S Title: cl�-h% i /� .5 �,�j�,b/-�._ ,----- i i � � �� Printed on �� Recycled ��"� Paper 1 � ,_ � � �/�(-O�'�7�6 �`9��wc�,g�S'f�K- t. � ;AR� TOWN OF YARMUUTH BOARD QFk H�AL�'H � -'� (� !_�, �_�` � � M � DD � o : .,,,� APPLICATION FOR LICE�S�'E�=2,�05 ' '� � � ��2 ��: 2004 * Please complete form and attach all nece � d ' L�� t by Decem er 0 F a i lure to do so w i ll resu l t in t he r " o fyour app lication pa k�EALTH DEPT. � NAME OF ESTABLISHIVIENT: _oZ.�b�n.�c.t, TEL. #`��d=d�?�' LOCATION ADDRESS: r��o Cu�-�-�ad" MAILING ADDRESS: �i� OWNER/CORPORATION NAME: s.�K ,�'. � %xo1.�� 1' ,�zt�.,f- �, MAN�_ER'S NAME:`�� , EL. #�SC�'`��Cl"1 MAILING ADDRESS:,��irxe: ; ' POOL CERTIFICATIONS: ; The pool supervisor must be certified as a Pool Uperator,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 emplo ees currently certified in hasic 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. j 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. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. ' PERSON�N EHA1t�E: ___ _ _ _ __ _ _ __ _ __ - -- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures t�elow and attach copies of employee certifications to this fonn. 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. RESTALJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEB PERMIT# � BBcB - $50 - �A$�T $50 MOTEL - �Sfl _ _INN $50 `CAMP $50 _SWIIvIlVIIl1G POOL$75ea. � LODGE $SQ TRAII,ER PAIZK $50 Wf�RLLPOOL $75ea. ! FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQUIItED FEE PERMIT# � <50 sq.ft. $45 6��0 �- _>25,000 sq.ft. $200 �VENDING-FOOD $20 _<25,000 sq.ft. $75 �FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE = S �S;Od """"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" .� � i 1 r' 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 Compensa.tion 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 ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.I1'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT'THE HEALTH DEPARTN�NTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-� SEASON. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MLTST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CQNSUMER ADVISORY: Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY• Anyone w o caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. �RO��1��E�+�S:-- --__ _ __ _ _ _ _ _ ___ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDDOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: `��°. b2 � oZ�y SIGNA ` PRINT NAME& TITLE:/��r�� r�� F� �r�s✓-e�r1�,e�.s icler�y`' 10/22/04 1 . . ' �' ---�_ ' —=_� The Commonwealth of Massachusetxs i -_� -�- Dtp�rineAt of Ind�strial Accide�ls _ - NN�/Nrw� � -_ _ = 600 WashingtoA Stree� 7f"'Floor ,, Bos�oa,Mas� OZIII � Worlcera'Com�e�sados l�s�aaee Affidavit:Bail ' ' ketrical Coetracbors � name•�IA1�l� i2 ��u ,n 5 i EL, � a�r�g• lo �l�9c u S� �/'��/�� -<i� �� i city �-�4JClJ�i't- ,�"-� zin Go�`�l nhone# �/�/"��`/�g� � work site locati�ffnll addressl• � o ��a�,��,�,��,,� ��T,,�: oN�,��o�� I am a sole 'etor and have no a�e w ' in an ' . Buil ' Addition [�'f�am an e.mployer p�+oviding wadce,cs'compeacatian far my empiayces warking�this job. _ _ - - -= - ao�od.��r6-�/(3C�1�1�u�>�,v� _ . � �; 1G 70 �_c�-�r� d�' � �-.�ra�rr�auh`�- ��:�.'S"L�l �Z'4��'/�u� � � I am a sole ❑ P�'Pnetor,g�al ea�tracter,or�omeowaer(cirdt out)and have hired the co�acta�s listed below who have the following wake�s'�on polices: i 1 �r� i � � 4�• nia�e�; �: � dtY• ��!, i ___ ____ -- _--------- --_ --- — - — -- — � -------—-_ _ � Fail�re M xc�t crvera�e as reqi��ed uder 3ee1�2SA�f MGL 152 caa kad b IYe ie�paitl�a�f crh�ial pnaltles�f a�e�p b:1,SM.N a�d/er �e yan'iwprbonmmt as we�as dvd pe�aNks ia t6e fir�of a 3T0!WOR1C ORDER a.d a�re atS1N.M t day apidt ae. 1 ndaslaud that a apy�f tib sla�eseat my be 1s Nc OAke of Im�of tl�e DlA ta�avrrase va'Uiatiy. /do ha�aby xnder tlre penaldea ofperjwry NY�t tAe iwforiw�io�provlded aboNe is rrxe rtnd oow+ert �� n `�?��.�d�y i Print name_{�I K1(2 K �. r�.P�n� r A• Phone# �l-�/f�C��"y9� effidal ase only ao eot�v►�ite i t�s arn te 6e mopleted bY dlY ar lrwn�Cial cny°r tew°' � Departmcnt �Bsard ❑chect if imme�ale reapeme b reqmed �SdMaea's O�oe P�� ' �De�ar�at R.ised sc�c�� ' < y � ! � THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. i � ; CHANGE IN INFORMATION PAGE i I j INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST ; NCCI Company Number: 20605 AUDIT PERIOD: ANNUAL � POLICY EFFECTIVE DATE: 10/O1/04 POLICY EXPIRATION DATE: 10/01/05 � Policy Number: 02 WB RL9023 EndorsemeM Number: 02 HOUSING CODE: ICl � o Eifective Date: 10/01/04 Effective hour is the same as stated in the Information Page of the policy. o Named Insured and Addres�: NORTHEAST MANAGEMENT, INC. D/B/A BLOCRBUSTII2 VIDEO 0 6 BLACKSTONE VALLEY PLACE ! o LINCOLN, RI 02865 � M i o FEIN Number: 050403490 PRO RATA FACTOR: 1.000 I a PRODUCER NAME: STARKWEATHER & SHEPLEY INS BRR,INC PRODUCER CODE: 090162 � N It is agreed ihat the policy is amended as follows: � o IN CONSIDERATION OF A RETURN PREMIUM OF $1,072 IT IS AGREED THAT: { o �` N (A) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 8017 FOR INSD Ol � ST 20 LOC 01 � � FORM NUMBERS OF ENDORSIIriEN'PS ADDED TO THIS POLICY AT ENDORSEN�IT — ISSUE: WC000420 WC000420 = — FORM NUMBERS OF ENDORSEN�]TS REVISED AT ENDORSEMENT - ISSUE: WC000406A _ _ � — � � � — � � � � = � = = STARICWEATHER&SHEPLEY _ tNSURANCE BROKERAGE�� Countersigned by � Authorized Representative Fam WC 99 00 06 A (1) Printed in U.S.A. Page 1 (CONTINUED ON NEXT PAGE) Process Date: 10/0 7/0 4 Policy Exp�ation Dffie: 10/01/0 5 ORIGINAL � Lv vic i nru u� �ICORD,� INSURANCE BINDER lo/oiio4 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDfTIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. � PRODUCER P�NE 4 O 1-4 3 5-3 6 0 0 C�P�Y BINDER# C N Ex : � F^� No. Hartford Ins Group 02WBKL9023 EFFECTIVE EXPIRATION Starkweather & Shepley �e►� nMe oa� nMe � PO Box 549 10/O1/04 12 :O1 X PM 10/O1/05 X 'NOOON 1 Providence, RI 02901-0549 � THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY I CODE: SUB CODE: PER EXPIRING POUCY#: 1 AGENCY 319 5 5 DESCRIP710N OF OPERATIONSNEHICLES/PROPERTY nncluding Lxadon) � C TOMER ID: � INSURED Northeast Management, Inc. Massachusetts Workers Comp � 6 Blackstone Valley Place, Suit Lincoln, RI 02865 { ! � COVERAGES LIMITS � TYPE OF INSURANCE COVERAGEIFORMS DEDUC716LE COINS'h AMOUNT � PROPERTY CAUSES OFLOSS BASIC � BROAD �SPEC } _ i ( j GENERAL LIABILITY EACH OCCURRENCE S � DAMAGE TO $ � COMMERCIAL GENERAL IIABILITY R D PREMI CLAIMS MADE �OCCUR MED EXP(Any one person) $ � PERSONAL 8 ADV INJURY 3 i GENERALAGGREGATE $ i RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/0P AGG S AUTOMOBILE UABILJTY COMB�NED SINGLE LIMIT 3 I i BODILY INJURY(Per person) S ANY AUTO � ALL OWNED AUTOS BODILY INJURY(Per acad�t) $ _ � SCHEDULED AUTOS PROPERTY DAMAGE S i HIRED AUTOS MEDICAL PAYMENTS S { NON-0WNED AUTOS PERSONAL iNJURY PROT S I ; UNINSURED MOTORIST S i 5 � AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION� STATED AMOUNT E i OTHER THAN COL: OTHER GARAGE LJABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT 3 AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE $ i UMBRELLAFORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE fOR CLAIMS MADE: SELF-INSURED RETENTION S X WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $�O O� O O O �� E.L.DISEASE-EA EMPLOYEE 5..+O O� O O O EMPLOYER'S LIABILITY "� E.L.DISEASE-POLICY IIMIT �.+O O� O O O SPECIAL fEES $ C��n�� TAXES S OTHER COVERAGES ESTIMATED TOTAL PREMIUM S NAME 8�ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUjj�iOyR�ZED R�EPR�ES�NT�VE ��,�/�/_� _ �d� / 1 �.�� ✓�`�`m'� ACORD 75(2001/01)1 of 2 $$2 7 2 9 7 NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE MBB O ACORD CORPORATION 1993 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #OS-022 FEE: $45.00 In accordance with regulations promulgated under authoriTy of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to:. Mark R. Feinstein/Northeast Mana�ement Inc., 1070 Route 28, South Yarmout MA Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 squaze feet To operate a food establishrnent in: Town of Yannouth '; Permit expires: December 31. 2005 Bo�oF HE�,'rI-I: Be�ry��$. �/yl._`n. ' � ��a��, v,�e�� ; xESTIucT�olvs: Prepackag�food items only. /2p�eh�� Bhou�g el�Z ; �S!� R.N. �� Q.N. a , f ; J�uary 19,2005 ruce G.Murphy, S.,CHO Director of Health t � I a i i i , ! , i � ! � � � , � i i � i � { � � � ( � p. � �r a��e�. w : � .�. "`��`�`° P��.oc�.�usr�e- �O`;''R�. TOWN OF YARMOUTH BOARI�O �SL H 3r � � -� APPLICATION FOR LICENS,,E , -2004 ��, � � � °: .;,,;= Y �� l� � C� � 0 '� I� r� * Please complete form and attach all necess "V oc 9 ents by Decem er�,t,1i�OQ3� � .,.:t,� Failure to do sa will result in the return `` our application pac et. _ LOCATION A�D FS • dolo 2*�ag S Y�-2.. �ILING ADDRESS• QWNER/CORPORATION NAME• �� r�i��iL, MANAGER'S NAME• T i # � MAILING ADDRESS• POOI,CERTIFICATIONS• , The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ' Pool Operator(�arid attach a copy of t�ie certification to this torm. 1• 2. Pool operators must Iist 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 �ears' records. You must provide new copies and maintain a file at your place of business. ' 1• 2. ' 3. 4, FOOD PROTECTION ANAGFR - 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. , l. 2, _ -_--- -- -- ' ��SON Irt CHA Z�GE: __ _ _ _ _ _ . Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HFLMI ICH 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-chokin�procedures below and j 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. r { 3• 4. � � F TA RA�1T EATIN : TOTAL# l � OFFICE USE ONLY �.ODGING: � LICENSE REQUIRED FEE PERM(T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $SO _CABi'�i $50 _,�IOTEL $50 I —� $5� _CAMP $50 _SWIMMING POOL a75ea. � _LODGE �50 _TRAILER PARK S50 _WHIRLPOO[. �75ea FOOD SERVI �•� i � LICENSE REQUIRED FEE PERMIT# LtCENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $SO _WHOLESALE $75 �TAIL SERVI LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRED FBE PERMIT� LiCGNSE REQUIRED FEE PERMiT# `�<50 sq.ft. $45 a� _>25,000 sq.R. $200 _VENDING-FOOD �20 _<25,000 sq.ft. $75 _FRO7.EN DESSER"P S35 _TOBACCO S25 NAME CIiANr,F� a�o ^ AMOUNT DUE _ $ �5.00 *'�***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � ADMINISTRATION Under Chapter 152, Seetion 25C, Subsection 6,the Town of Yarmouth is now reyuired to hold issuanee 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 COMPENSATI�N INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � /� YES `� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPON5IBILITY TO RETURN THE COMPLETED APFLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTI�N 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 OPEI�IING: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 outdoar in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORYs Each food estabtishtnent which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERING PQLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporaty Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ZEN I)ESS � • � ------ _ - -- - - -- -----_ _ 'rozen desserts must e 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 CAF�S• Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retai or food service establishment is prnhibited. nc�. � DATE: �vt�- ��SIGNATURE: ` . PRINT NAME&TITLE:1'}')�L�l1 ,�, FP,/��S✓P�w 4�/2t`�/�'�� 10/22/03 T w t � The Conimonwealth of Massachusetts ; � � Depa�tment ojlndustrial.-lccidents � a 4fllceolleves�l�sd�is ; 600 Washington Street '�,N ��•` B�sron.Mass. 02111 W'orkers' Compensation Insurance Atfidavit � �,m� G�l!�1 G/� C�L / .� location• �U � C� �CX.t.�� ' ttt� �J - -lJ1Q.j"l�Y7GL�-�1 rYk� phone q �� c/7!� �� I am a homecwner pzrtormin;all w�ork myseif. ; � f am a sole propriztor �r.� ha�e no one ��orkin_ in am•capacin� � • � �/I_am_an�mplo�er prai i�ino,w�orkers'_com�ensation fQr my employees w•orking on_this job. � compam• name�/ fU�i�P�-�� _ f U ! � .7ddress: IO �l fC � Q �iQ_�/}�G1 �{ '�'� �.ap� tih�: �) l�C /h,� � � l}`o��,l� nhoneq ��l �J�c�y` y�� ' �sur�nce co /� �i��1^pQ A91lSY# a� � �j�a_Qp� 3 I i � I am a sole proprieror. general contractor. or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e ` the follu��in_ ��orke�_� �ompensation po.liees: comnanv name• ad d ress � � c�n: nhens!f insur�nce co. R�}•# ; comoanv name• - ----- as�dress: - -- - — - { �'� nhQn�,+� I j insurance co. ��,* • Failu�e to secure coveragt as required under Secnoo 2SA of MGL 1S2 ea�iqd to tbe iopailioa ot erisi�al pesdtla of a 6�e op to SI�00.00 a�d/or oae yean'imprisonment a�w•ell a�ciril penalda in the form of a SfOP WORK ORDER asd a IiarotS100.00 a day apin�t ma I r�dersta�d t6at a copy of thh statement may be fonwrded to tbe Otliee of lave�ti�adom of tbe DtA tor eoven;e veritfeado�, I do hrreby e '}•under rhe pai cnd penal�i�s.ojpery'ury that ttie iajornralion provedtd above is true and conect Signaturc � 1�L� fi e.�-Ll,J,3 ate _1�i / , Print name/��,Lk ,C� ,��//?�jit" Phono K .�U/�c�'�y-yQ(1D .- o(Ticial use only do not w rite in this arta to bt compieted by citv or town oAltial ciry or town: Y��IITQ _ per�nidlieeax M nBuildiog Department �Lieensio6 Board Q check if immediate respoese is required 261 �Seieetmen'�ORiee (508 3 QFlealt6 Department contact person: � "-� phone K:_ __� 98��31 �:xt. nOther �---� — .. < �,,, TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�NT PERNIIT N[JMBER: #04-023 FEE: 5.00 In accardance 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: ' Northeast ARanagement Inc., 1070 Route 28, South Yarmouth, MA Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 square feet . To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2004 BOARD OF HEALTH: Bs�c�ri�rs.`�. �j'�, /�l.$. ' /�a��la_`?�e�atl', ?Jice C�u�rc xEs'rxtc'r[oNs: Prepackaged food items only. R�� B ___ x , __ _ ___ _ e�e�t S�ia�sy�./� _ _ : December 17.2003 ruce G.Murphy, S.,CHO ' Director of Heaith i � , 1 � , 1 � ; i f i ! � � � ' A�-"`�aR,,� TOWN OF YARMOUTH BOARD QF°�iE�TH [� `L r„ j:�� `J �, � 3 o � ='� APPLICATION FOR LIC�N�SE/� �'�- 00 j � , .;s � ° �.�o�i�� '.�i' 1 9 �� ,w � ; * Please complete form and attach a11 nec ' � �uments by Decem e , �Q�? ' Failure to do so will result in the re of your application pac ��-C �"� DF�'T. ; . ; ; „ . _ .� �, P�- .,.: : ,. ,� �,z ct� � ,..,. .. . . .�, i � ^� �Q C� i , f , . _, ,v � _ � � � �. . � :�., % ti�°Cc- 'T 'l, � ,d1,T � �,<< � ��.-f� .� � U-Y� �y� I4[✓ � � _i�:( -i� 1 'e � G�i-;►� � �.,:..�. ; � � i i POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,�s required by State law. Please list the designated ! -FooY Op�rator�s�-ari� att�h a copq of the certificatiorr�+o ti�ts forrn. - - -- 1. 2. Pool opera.tors 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. i l. 2. 3. 4. ; , � �90D PROTECTION MANAGERS - CERTIFICATIONS: All food service esta.blishments are required to have at least one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.000. ' Please attach copies of certification to this application. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. ; a 1. 2. I � -- -��RSON IN��SE: _ __--_ _ _ _ _ -- _ . - - __ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. L 2. HEIMLICH CERTIFICATIONS: All food service esta.blishments 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 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 RESTALJRANT SEATING: TOTAL# i � OFFICE USE ONLY LODGING: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWI1vflvIING POOL$SOea _LODGE $50 _TRAILER PARK $50 _WHIItLPOOL �25ea FOOD SERVICE: I� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 �TAIL S�;RVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _TOBACCO $20 <25,000 sq.ft. $75 �TOBACCO $20 I <50 sq.R. $45 . 3��'/ _>25,000 sq.ft. 5200 FROZEN DESSERT$35 �TAME CHANGE: $10 AMOLTNT DUE _ $ ��J.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** r � ' ADMINISTRATION i 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 ATTACHEL� 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 � � � �� .;�►�'�� ., � ,;� �F�AII3; :, YE� `� �fJ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBTLITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozeri ctesse s mus e es e on a monthTy basis by a�cerf�cTTaTi:-'I'est results must�be sent to t�e HeaTtfi 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),�ust have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepara.tion,or display of any food product by a retail or food service establishment is prohibited. DATE: /�J I��U.� SIGNATURE: PRINT NAME&TITLE: � � 4 Q�'P�'/ 10/18/02 i � . : . ., . • � The Conrmoawealth ojMassQchusetts � � Department ojlndustrial.-�ccidents � a Ofllceol/eres�los�liis � 600 Washington Street ' ,,�` Bnston.Mass. 02111 �'" '�� V4'orkers' Compensation Insurance Affidavit �Rnlicant information: P►essePRIN9'TTe�7,ia � namr� rY10.1��th }'�'� �e( Yi.57-c�/rc� � L�cation: �� ►4c��5 l� r�..�,I� �� c�C��' c��a � - � �it� �1.�'1��1v�. � �i�a-� Qhoneu �lGl��;�y y�� [� I am a homecwner pertorming all work m}�seff. � � I am a sole proprieror �r.� ha�e no one ��orkin_ in am•capacin� - �] I am arr emFtm�er pro�idme w�orkers' rompensation for my emptoyees w�orking on[hi3 job: comnanv name:�� f C�LKbU.SJ `e�� ddress: �d �� ('1t,l.iCA � �i �itv: .l. ��y�rmc�c.�.7'I`. nhone p• �f7�k�' :��1��>.�� Ke �sur�nce co. ri'1��-r Qoli�y# �� p 9v�oa -�� I am a sole proprietor. :eneral contractor, or homeow��er(circ/e one/ and ha�•e hired the contracton listed below ��ho ha�e the follo��in_ ��orkzr� .ompensation polices: companv name• address• � citv• �hone H• ' insur�ncc co. oolic}•# � S�R�v name• i a�dresr c�yr ehoee M• insurance co. �olier N t Faiiu�e to secure coveragt as required under Secdoo 25A of MCL lS2 ta�Iqd to t6e i�paidoe ot erisi�l peaaltla o(a d�e ap to S1,500.00 a�d/or one yean'imprisonment a�w•ell a�eivil penaida io the form of a STOP WORK ORDER aad a Aae of S100.00 a dar apin�t me. t a�dersta�d t�at a copy of thh statement may be fonvarded to the Ofliee of inveatig�tioro ott6e DIA for eovenge veriSadoa ; I do hrreby ceni • nder the poins d penalties of perjury that tht injorniatinn provedtd above is true and eorr�ct � �� ,. � � . - ,,,� �� , � w. �-� �. �rn d� � '�' ,,�%�� '��"� �� .. olTicial use onl� do not w�ite in this area to be completed by eitv or town oAlcial city or town: Y�M�IIT$ _ permitAieeme p I�Buildiag Departmeot �Lieeasiog Board ; �cheek if immediatc response is required 261 ❑Sdeetmen'�Oliiee I �Heatt6 Depanmeot i contact person: phoae M;_ �508� 398�?231 ext. nOther � .. ._� < �,,. s ` ` � ; TOWAT OF YARMOUTH I BOARD OF HEALTH i PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #03-029 FEE: $45.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Northeast Management, 1070 Route 28, South Yarmouth,MA Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 sc�uare feet To opera.te a food establishment in: Town of Yarmouth Permit expires: December 31, 2003 Bo.�xD oF HE�,TH: ��'s?�. Z�ka�, Lka.tc.�ca�c — -- __ . _ __ _ -_ _____ ___ _ e�cc�c . . .D.. `l/iee �s'1'�cr�oxs ��: Prepackaged food items only. ,�o�t�. �ioaa�, efe+ik �astfek�c�eairiotr r. _ _ . �efe�S'�c, i�� _ 7anuary 9 ,2003 ruce G.Murphy,MPH, S. O Director of Health ` r ��^ , t f3�.00K(3U S't�1'L TOWN OF YARMOUTH BOARD OF HEALTH ' ' � , APPLICAT��OI�.I(��r��ERMIT-2002 ;j;�U {-��G�1�_',�i`! "�� 1`� � � f � * Please complete form and attach all neces �`�� d ' �� n��`�-��mber 31, 2001. Fa�lur�t��'a�o�so�v��su in the return of your application packet. `�`�'r ,�`Oys 93�/ � s�s � !-3�A1_T�--� DEPT. NAME OF ESTABLISHMENT: �i a c. �� b�t sTe te. � TEL. #c 5Gd-��'1�� LOCATION AI�DRESS: ��c� ��e �� 5= �ir�-r�� rn�. �� MAIL G ADDRESS: C O ION �?K . � '- � �r2 �� ' � . MANAGER'S NAME://.�nC y �lu,�a�Co TEL. # MAILING ADDRESS:«7c7 .�T�d� �5: �,�,�.�,�u,�`�f. �.� POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. � _ __ 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary 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. i a FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service esta.blishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ; Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. ; _ __ PERS0IV IiV�HARGE: — - - - _ _-- -- - - - --- _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: ; All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at 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 file at-your place of business. � i, 1. 2. � 3. � 4. ; j RESTAURANT SEATING: TOTAL# l 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 _TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 <25,U00 sq.ft. $75 _TOBACCO• $20 I <50 sq.ft. $45 �l �Q/Q _>25,000 sq.ft. $200 FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ �S.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** O� —� .+..� 'P f-� • ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED ST�TE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMF. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta��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 January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS�IlVIENTS 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. A�DITIONAL REGULATIONS _ _ POOLS POOL OPEl�iING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE �ONSUIVI�R ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ('ATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS• ' 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. QUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ��'� SIGNATURE: ` PRINT NAME&TITLE:�j,�f; � �/�.�/�/� /�e��/Q°P�7� 09/11/Ol • � � . . . F �� The Conrmoawealth of Massachusetts � � Department ojlndustrial,-�ccidents �� " y Of11Ce01/�StJ�fIJ�/t , � 600 Washington Street ' -` Bnston. Mass. 02111 �" '��y V4'orkers' Compensation Insurance Affidavit ARolicant information: PleascPRI1�TTr�.'hTir � namr� �� . �1�iY�J �-�'/ fZ � Lucation• �+ �I �C)�S f�`� �l ��1 �� -SCr ��E � � � c�t� C, l ri1 C C�-h.�.. �. 2, (J,�'�,� �one a /��t1��3Y`y�Ulj a I am a homeowner perturmin,all w�ork myseif. � I am a sole proprieror �::,', ha�e no one�.orkine in am�capacit�• (�I am an emplo�er pro��in� µ�orkers' compensation for mv empioyees w•orkine on this job. s4mnan�• name: �C�C ��.��V�� ddress: �� 02�' � ciri'• �. "(.A ��')'l�LL�h �� _ nhone t1• L �e (�'" ��J " cla4.�� i r insurance co. ,�C�YYL.YPl2 �✓1 ,� R,g�y t! ��r��c � " (� � I am a soie proprietor. generai contractor, or homeowner{circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follo��in: ��orker �ompensation polices: s4mnanv name• address citt�' nhone q• insurancc co. Qolicv# �moany name• ---- --- — — -- . - -- - - addrcss• Uh'� nhoee M• insurancsso. p�� • Failu�e to seeure cover�ge as requlred under Secnoo ISA of MGL 1S2 ca�Ind to tbe i�opaidoe of erioi�i peealtles o(a A�e op to 51,500.00 i�dJor one yean'imprisonment as w�efl a�eivil penaltla io the form of a STOP WORK ORDER aed a tiae of 5100.00 a day qainst ma t a�denta�d tbat a copy of thH statement may be fonv�rded to the Ofiice of lnvestig�tiom of t6e DIA for eoven�e veriliudo�. /do hrreby ce ' •under rh�poin nd enal�ies ojperjury�hat 16t injornratio�providtd above is ttWe ond corrtct Signature ' � ��l�e ��r/ Print namc�Y'fL � _ �} yl��o� � Phone K ��(!/ 'c�'�5�-yFl� ., alTicial use onl� do not w�itt in this�rea to be complettd by eity or town oAleial ciry or town: Y�M�DT$ _ permitAitea�e p nBuildiog Dcpartmcat pLiceasiog Bo�rd 0 check if immediate response ie required 261 �Seleetmen'�OtTice �Healt6 Departmeet contact person: phone N;_ �508) 398-�2231 egt. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-010 FEE: $45.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Mark R Fein� in/No h a� Man�g m n , I_�„ 1070 Ro� P�R, South Yarmnnth,, �A : Whose place of business is: Blockbuster Type of business: Retail Food Service less than 50 sc�uare feet To operate a food esta.blishment in: Town of Yarmouth Permit expires: December 31 2002 BOARD OF HEALTH: eka�rcled� ,'��, ��ra�c b�e�c�D �.mrd,a�c. �L D.. `�/icce REST1ucT�olvs tF a�1vY: Prepackaged food items only. ,�o�e�rt� �zotovc, L� �a�iick 711c�� s�. .n March 8�2002 ruce G.Murphy,MP ,R. .,CHO ,' Director of Health ; _ i I ; i � i i � � � � I , {��I�ri�i0us+�r v�deo ' �' ,i TowN oF YA�ou�ra BoaRn oF��t:T� � G3 � � � � M � � '' APPLICATION FOR LICENSE T-2000 a�0 9 D EC 1 199 �� 6 � ��'�� g `�: `� 3'��'� PT.. * Please complete form and attach all necessary documents by Dec�rpbef 31, 199�Failure the return of your application packet. �- �� NAME OF ESTABL�S�� NT �.L.<iGk�r� �"T�^ Y�d e� ----------------------------TEL #��SCf�'��-�''��. L(QCATION ADD.�SS:>o�G ��ru�T"� �� LING ADDRE,�S: 5�-�-n �e /7!/,� ,aS J ax,�' MA�TAG�R'S NAME: �-ht,u 9�?u r r rf� TEL. #��i$'v' r�'G�GO MA.II,ING ADDRESS: t'��,e POOL C�',�TIFICATIONS: The pool sapervisor must be certified as a Pool Operator, as required by new-State lav►�. Please list the designated Pool Operator(s�and attach a copy of the certification to this form. 1. 2. Pool operators must list a minitnum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. ��ICH SERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. �S'£��JRANT SEATING: TOTAL# _ _ - --N��-�MOI�Tf-S�ATS:-TOT-t��- __ _ _ __ _ ------------------------------------_--_---------------------- --------•---�------------------------------------------------------------------• OFFI E U,�E S?NLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWINIlVIlIVG POOL $50ea. WHIRLPCIOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $'15 CONTINENTAL $30 >100 SEATS 5150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq.ft. $45 ` '� �,3� _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 ?25,000 sq.ft. $200 1�IAME CHANGE: $10 AMOUNT DUE = $ �I'CJ — *"`""PLEASE TURN OVER AND COMPLETE OTI�R SIDE OF FORM"'•"" _ ��:...`. , V� � , ADMINISTRATION t � IJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-�TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE �R PERMIT TO OPERATE A BUSINES5 IF A PERSE��F' OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSUR�NCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MU5T BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACI�D � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE(�F 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 TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISIIlV�NTS ARE TO CONTACT THE HEALTH DEFARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTINCr, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMI��tEN�ENIENT. RENOVATIONS MAY REQUIItE A SITE PLAN. �DDITIONAL REGULATION,� POOLS PO�L OPENING: ALL SV'VIl�IlVIlNG, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPART'MENT, AND T�-lE WATER TESTED FOR PSE�3�4A�E}�h4S,�'QTAL COLIFORM AND STANDARD PLATE COUNT BY A S-TATE CER3'��D LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SVVIlVIlVIIlVG POOL MUST BE DRAINED OIt COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF Y�RMOUTH MUST NO'TIFY THE YARMOUTH HEALTH DEPARTMENT BY FII,ING 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 I�ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTrvIENT. FAILURE TO DO SO WII.,L RESULT IN TI-� SUSFENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TI-�ABOVE TERM5 HAVE - BEEN MET. _ _ . _ Oi,TTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM TI-�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FO PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLISHMENT IS PR4HIBITED. DATE: 1��Q/� 5IGNATURE: PRINT NAME& T'ITLE: /�Il�l�k �. ��Pir�S Tr��rc. �C)W w,e� ) 11/12/99 � f ! � � J !1 � _ The Conrmonweulth of Massachusetts � � � Depa�tment of Industrial.-�ccidents T ; OI1lceoll�s�ostlyis ' 600 Washington Street ' •` Bnston, Mass. 02111 �'~ ��y W'orkers' Compensation Insurance Affidavit ; ARnlicant information• p►easepR -�• namr� �� lo�K�jc.�S)e 12 Y►c�-� lycation: IO'7CI �p-t�`e o�' � �it� U�?IE�gu.�"� ehone� )-V CJ�-f��Oo�!'ICl � ( am a homeow�ner pen�rming all w�ork myself. I � I am a sole proprieror �r.,: ha�e no one ��orkin� in am�capacit�• . _ ; - - _ -- j (�I am an empio�er pro�i�ins w�orkers' compensation for my employees w•orkine on this job. � ; comnan�•name: I7G'/�Th tGGc S J �Iq J�1 i�l�`P/!'"l'1 G�'''1 .�-/� L , lddress: !s 1�J�L�-� IC ��?r-e /A-� l� �� ,/ �J7�' o1G� �i�f': �1 Y7 �b-�- l� --1- nhone N• l✓U� "��y'yQ� �i�r surance co. ��'J�U�.1Pl�S �_s�'1 S pQ!!Sy# �� /7/��l�" G� ' �7 , � I am a sole proprietor. :enerai contractor, or homeowner(circle one/ and ha��e hired the contractors listed beloµ �ti ho ha�e the follo«in� «orker� �ompensation polices: i � comoanv name• i I { address: i ��n�' phone M• , insur�ncc co. poliey# � � � --- - � -- —_ i s�mnanv name• - _-_ _---_ -._ � -- ___ ---- 1 tddress: �h'� eboee 1!• insurance co� �p�eY* a Failure to secure coverage as required uoder Secnon 25A of MGL 1S2 ea�iad to t6e iopaidoa o(erisi�l pt�dtles of a d�e op to 51,500.00 a�d/or one years'imprisonment a�w•eil a�eivil penaldn io the form af a STOP WORK ORDER asd a fiae otS100.00 a day a�aio�t ma i a�dersta�d tbat a copy of thH statement mav be fonvarded t the OlTice of Investigatiom of the DIA for eoven�e veriBatio�. l do hrreby cerr f}• der the peins prn !i�s ojpery'ury that tht injor►natioa provided abovt is tnte and eoneet i , � ` Signature �- � � Ja � (,� �Q�j ; I A� � Print name I�144121� �Q 1 Yi 5 i t'�� Phone At tiCa't '�'� y�w s � i ' .- oliicial use onl� do not..�ite in this�ra to be compieted by city or towa oAleisl a ciry or town: Y�M�IIT� _ permi�/license N n8uildiog Departmeot ' pLieeasiog Board ' �check if immediate response i�required �Seieetmen'e 0tliee " r (508) 398�2231 2eat. �Heait6 Department contact person: phone M;_ _,� _ �'10ther .. ._� < ��,; � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-31 FEE: $45.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: N�rthea�t Management, 1(17� Rnnte�8, South Yarmouth_ MA Whose place of business is: Blockbuster Video _ Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2000 BOARD OF HEALTH:��/. �et��, C'�irman �oar�� ul`ivan., �//.� Vice C.�irm.a RESTRICTiotvs IF AtvY: Prepackaged food items only. /`Cobert.�`. O,rown, l.le.� a�ri�ll��al�oL��i y-�ooPe� ///ichae[ oCo hlin � December 23 , 19�9. ruce G.Mutphy,MP CHO Directcxrof Health .�_— ------ { ._ _ __ . _ � � . i � I � i � i II � Jan-19-89 04:12pm From—?OWN ADMINISTRATORS OFFtCE +5U83981365 T-163 P.02/04 F 0� � � C� 0 1v/ � D � . � �` , TOWN OF YARMOCJTH BOARD OF HEALT�I �.� E.� �°'�`'� � ' � APPLICATION FOR LICENSE/pERMI'1'�.� .' : " F E B O 4 �999 r .. •p(ease complete form and attach all necessary documents by December 3�, 1998.:F�+1�� ie��TH D"c•�='T. the return of your application packet. „��__�_ _______ __ _ 6 �_�_�__ .� loLK �� i��e ��c� � T D � DD� a�- m� ; �� ' ER' � p ? _, t2.L:f1 �.– -- -- --____-------------------------- — Pr�u�r rFRT'�I�ATIONS: The po asPup�Oaor rnn(a j and att ch a copy of the ce�cfi ation t ttns form6� nsvv State txw. Please list t6e i d perat°r ! ��..P�- 2. � L I Poo1 operators must list a mimmum of twoe�loyees aicrentlY cect�ied in basic water safety,standard First Aid aad ' Commututy Cardio�ulmonary Resusata�on(CPR). Please list these employees below and attach copies of et�loyee certifications to tlus foim.The Health Department wi11 not us�past ye�us reeorda. You mutt provide ae�r cop'acs auc�maia ' a�le at your pl�tce of busmess. � 1. 2' ' 3. 4. � �_Il��GH CE�I�ATIONS: ��e Heimlich All food senrice estabLshmems with 25 seats or more must have at least oae employee n' Maneuver on the premises at all times. Please list your employees trained in anti-cholang procedures below and attach�pies of employee certifications to this form. The Health Department wiil not use pxat yeusr records. You m+�st prov�aev�'copia and matintaiu a file at your place of business. 1 � 2. i 3 4, ' RES7AURANT S�ATING: TOTAL# NON=SMOKING SEATS:TOTAL# ___ __ OFFIGE USE ONLY �ODGING- � LICENSE REQCJIRED FEE PERHIIT# T,TCENSE REQUlltED FEfi PFRM[T# B&8 sso cAanv sso � _�rrrv sso _c� sso � LODGE S50 _TRAII.ER PARI{ S50 MOTEL S50 �SWIIVIlVIII�iG POOL SSOea. VVFi1RLPOOL S25ea. ! FOOD SERVC�CE- LICENSE REQUIRED FEE PERMY2# LICBNSE REQUIIZED FEE PERMiT# 0-100 SEATS S75 _CONfINENTAL $30 >100 S�ATS 5150 NON-PROFIT $25 COMMON'VICT. S50 WHOI.ESALE $75 RETAIL SER��: f 1 �-e v t�p–��Rrl JY UI�.�- LICENSE REQUTItED FEE PE12I�IIT# LICENSE REQUIRED FEE PERNIIT# ,�<50 sq.R. S45 Q�� _TOBACCO S20 <25,000 sq.R. S75 �'ROZEN DESSfiRT �25 >25,000 sq.ft. 5200 �r��c tvG�: Slo AMOUNT DUE = S �� w""PL1�'A58 TURN OVBR AN11 COMYLEx'E OI'Bl.S SIDLr OF FOWM1��••• t 91/22/1999 14:30 5982264250 R CUDDY INS PAGE 01 , .. „ r--T.. , ..�.., • . ... . ....,. <.:<,>A< . �i .... .r.h:::.:< ..... ;:�'....e. .:k" :):Y' . ..............:................ ... ........:.,..:.... �.::.�.t� .... •+"�:�:.;a:n:r ... ................ .....<.<.K. � .....:,. .r�� s. � .�-::� :m: ` E(M�M .�. >::.,. ,E . . ..<... .. . .,,�. . :;r•.<.• .:. "`�� ' : . i�� DAT iDDlYY) �$ . :�� .... . . . : �.� ' : .. :, o>:� : : . ;.: :: 'r . . +:<; . .i:A^ is:T: �jri.:�:'{.h`:>;; ..� k i. ? R�r.� i cj��q:� �a . a�K: `��'� .;i,�V� 22 99 :_: � `��`;::��i�. ,`':�,f�: ��:�: oi� / :.: ACO,R �°�. -'. : �: :. ;�:.��-:�::,:�� ..«f. —��, ��'�. ..:.-.. ...��.�: ��— . ..: .... r.. �: :::.:. . .... ..:.... ,.�.�. .... ........ ...:..::...:.:.k�:...�rM..........,: ;..�....�. .., :�.::�::::::..:..::.�h..r.. .�::.:7:..:r;:,.:�:,nt,.�.:�.r .. . ..::.:.>:..,:..>:.:..:.:::�:�.�..::�.;.::.:.��,..,.�.::.:...:.�:..�...:�::..�:.>..:.. ..... .:.... :..�.:........ ....... . .. P�� THIS CERTIFICATE IS ISSUED AS A MA'fT.E OF INFORMATION ONLY AND CONFERS NO RIQMTS UPON T� .CERTIFICATE Riahaidaon-CudBy Ins ]1gaCy Iac HOLDER.THIS CERTIflCA7E DOES NOT A: :ND, EXTEND OR 8 Park Straot - P.O. BoX 388 ALTER THE COVERA�E AFFORDED BY THE tOLiCiES BE�OW. Attleboro MA OZ703-0388 COMPANIES AFFORbING G; VEAADE COMPANV Jolus M. Cuddy A lcamper Inaurance Coa a.nies '' pnon wa 50 - -5Z5_2 PoxN • ' NJSUR6D � COMPANV 3 s '� I j coMr�nr � � I Northeast MBria►gemeat, Inc. 6 Blaekstone vallsy Placa COMPANY Liticoln RI OZ865 � �� .. ... ::.......:.>K�>::...:..........::.:.::<::.:.,>:..:::.::.::;::;:.:��:>::�- .. :......: :. • �x..:.::<.,:.:.:........::..:...:.. .� :;:': . . ...... ....:.. .::. . . . . .....<.....:...:,�.,.. ..... ..:�:..,.,:r�:a�w::. L::t a: -�� . :...e..'' • . ......... ....... .. ..... ... ..a. :x . ....... ,.... .. ...m:..r r........�.:..... . .xea . .n ..... . ... ...>... ..:...:::R�::k:>`.:::.� riMV!l'Re� . .. ....... ... ,. ......sv ...n . . .. .<.>. .. ... ... ..... .. .:. .. .... :�f:�i .i . , r...i . ......... i..9. ...s.. ... . . .. .. ., r..e.. .... ...... ...... a:f:4�; . . .t....an�........ # i `!('...<v .,..... . . ....�. . :.:;..r.......:t:•::.:.::�q....:..:.....�::;.,. . 4�. .+.a. .M. .....r.....:... .. . . .......... ..,rK..v....e.:... . .y �. .,....1....R R�9:.:.+Y.-...:. ' � f �. .:.......... ..5..� .n.w... .. •.. ..i.. �<.,5...:.:. .+ ..>.>..,.:>�. . . . .<..a....t.. .v.. :...... .N...� .r ....... . ....s ....... . . .... ..T rvnr..>........... .L. > ... .. .... .. .. ...... ..K......,r •. .. .::...:.............��% .. �,a:n . .. � % ...�....... ... ..'..::�f:�.. `' �,y�� , .........:.:...�.� .' �..::r.:H.>.:i.'v,<:::::;: R:r�ra�...�:..�.,.. r ;,��;�,�,I�Av�1,..}7r;>:�..>:.�..::n�:,d4:.n::.:.:.:�.:�.�..`�•:`.�.:5:•.:r<•.....�.....................:.,tr.t:��:�.......:...:.:...... .....::.:.......::........ . . ...... ! THIS I5�T0 CERTIFY TMAT THE POUCIES OF INSURANCE.LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A90VE FO� 'f1E YOUCY PERIOD i INDICA7ED,NOTNITHSTANDING ANV REQUIPEMENT,TERM ON CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH REi cCT TO WH�CH THIS ' CEp71PICATE MAY 8E 18SUED OR MAY PERTAIN,THE INSURANCB AFFOAQED BV THE POLIGIES DESCRIBED HEREiN IS SUBJECT Y� 4lL THE TEpMS, ! EXCLUSIONS ANO CONDITIONS OF SUCH POlIC18S.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. yp OOUCV NUMteR �OLICV E�IVE PQUCY fX►IM'Ct6A1 � i.NNITS LTR TY�OF INSURAHGE pATE.(NIM/D01�'YI DATE IMM/DCl�I i GEMEAAL AGOAEG SE 9 � �ENERnlL1A0LLiT� PRODUCTS-CO,N i0P AGO ' COMMERCIAL GENERAL UA9�LITl ' CLAIMB MADE �OCCUA PERSONAL a AOV JJUAV i ' EACN OCCURREI 2 e { .:• OWNER'S&CONTMC'rOFi'S PROT FIRE DAMAGE IUn one nnl s # MED EXP iMY o;�0 �erson) 0 i � AUTOM001LE UAlQ1TY COMHINED SWCL4��M(T • { ANY AUTO' Jf ' aLL dwNEu AUTOS BODIL�INJURV { s iPmr pereonl I I SCNEOl1LED AUTOS 3 9001LV INJURY, � f HIR�AU1'OS (pe�etadont) NON-OWNED AU"ro5 ppOpERT^!DAM4 E ' � pUTO ONIY-EH .".CIDENT b 'i:,:y;':� � 6AAA9E L�A6�lt1Y OTMERTNAN A�1 )ONLV: `:.x��'+�;r:<n��?`°�"`ia::`""::at: ._T^f'�sb.ae�� ANY AUTO f/�Cti :CCIDEN7 L <1 �REGATE 1 EACH CCCURR�N�E a nccess u�enm ,� s AQGFiEGATE uMBAEtta FOAM o OTNER THAN UMBRELLA FOiiM WC STAN• OTN•v;';�Rk t:°�r••,.y.xr•"°:>'•;`,:;,",;.` LIMf. ,:a s:...,"..,:ia::�r{:.Y•.' 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TOMS O� Ya='�Outh , StJT FA�URE TO MA1l SUCM NOTICE 6NALl NNP061; D OBUOA'rWN OR UABILRN Board OE HH81CI'1 OF ANY K1N0 UPON 7NE COMVANV,IT6 AGENTS Oi1��ENTATiVEB. 1146 Route Z 8 q�TliDRIZ�R�3�A�� ° '�`''� '�`` ��'" South YsrawuCh M71 02664 "^• ^1;�^��: �:;'`�: `�" r�_,,.,v. ' Johri 1�. " YI'r ... .....,:.�..:. ,.�,..:.,....... ......:......:•:::::..�::.:.:��: .. . . .._..:. ...... ...x,::..... . ..:•.>:•:<.�Kr.: ":'� ....... ......:......�_...... . . .>„..: .,.... . . . .. �1�.;��}ti �� .. .. . ... ., . ...... .. .. .. . .. .. ....�: . < ..... ....... ....... . . . . .<�n...<.. . ..,.�.. . , + .. ...r...... . ;�.:. y�t �y� �� .. . ...... . .. .,. ........::,...::. ..K....�::„;�:'::C :: 'Jv�y�p . ��} ....K...,....�.......:.... ..<.,,»�........... ..:. ... ... �:�.�................ .:sa , .... F..:.::.-...>.>�....>..:..>.f.�.:�.;,... . . .,. .,a.....:. ,. �GY^Q W�[nt,i.1�.F�7�v�. ... ..:..�.',.0 ..�..:•�....�.... . ......:.:.:<Y;..,�.:<.::.x.i..:� ...... UQdl► ,:,..:::.:, ...::>;:;:..: ;� . :...::: -z��".� •�. M1 . . :s;.` .��:a.:: .. ... .. . �:<... �s .., . ., ..,...:. :;.::... . • � ,.... a �, , • � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-55 FEE: $45.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: M rk F .ins in/N� h st M n g .m n , 1070 R�ute 28, 4outh Yarmouth, l��A Whose place of business is: Blockbuster�deo Type of business: Retail Food Service less than 50 square feet To operate a food establishment in:_ Town of Yarmouth Permit expires: December 31, 1999 BOARD OF HEALTH:�d�f. �et��, C'��r,�,� �oan � �u�livarc� /C.�� /ice C��irman RESTRICTIONS IF ANY: Prepackaged food items only. KoberE�}. p�rown� (�ler� a�ris6le Jahofe�e�-.lvfooPed ichae OoCou��[in '. j'1rt.�. 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