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Home My WebLink AboutApplications, WC and Licenses �""',,,�. �� .`�'�� ►� TOWN OF YARMOUTH BO ��.. ` ' ' � APPLICATION FOR LICENSE ,. � ' �` FEB 7 6 200� ,� �w r,,. �� * Please complete form and attach all neces�ocuments by Dece ��6�� 'P� � Failure to do so will result in the return of your apphcanon pac et. NAME OF ESTABLISHMENT: ��kerL.. n TEL. # S�"s-��5�37 LOCATION ADDRESS: D� . � MAILING ADDRESS: .�,� �s �k�,,.e.. OWNER NAME: ha.w �`�—. TAX ID FE1N or SSN : - - / CORRORATION NAME APPLICABLE): C.�� -�s�s �,r.,� , MANAGER'S NAME: C-�� Z_ (�,.�s��,� ��c-, TEL. #�'�8�.SY37 MAILINGADDRESS: �/ L�,�� D/'_ �•-r,,�h ,�J�,,,�,�fh, �f,,4 Oz66�f ._ POOL CERTIFICATIONS: The pool supervisor must be certifed 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 emp loyees cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee cei�tifications to this farm. The Health Department �vill nat use past years' records. Yau must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Cod� for Food Service Establishments, 145 CMR 590.000. Please attach copies of certification to this application. The Health Department wilt not use past years' records. You must provide new copies and maintain a file at your establishment. 1.�, Q� � , ��-- 2. ��z�. � �..o..�s s PERSON 1N CHARGE: ___ _._ __ _ _ - — __ Each food establishment must have at least one Person In Chuge (PIC) on site during hours of operation. 1. C�..� �. �`�� .��--. 2. �\�z.�be'4-h ��ca�..� � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all tunes. Please list yow employees trained 'ui anti-choktng 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. ��r�e (2. �-��s�c�c� 3�-- - 2._E\�� l.c�'��nce.� > 3._��e\ j.l�.�rn�r�v 4. ' RESTAURANT SEATING: TOTAL# 2 Ltc�S� t�-Pss �a i � OFFICE USE ONLY LODGI�i G: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � � B&B $55 _CABIN $55 MOTEL �5� _P�TI�; S55 CANt�P �55 �WIMMWGPOOL �80ea. ! _LODGE �55 _TRAILERPARK �105 ��HIRLPOOL $80ea. FOOD SERVICE: LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UTRED FEE PERMI # Q T I 0-100 SEATS S8� ,�� —CONTINENTAL �35 NON-PROFIT �30 _>100 SEATS �160 �COMMON VIC. �60 �rs�L�S —WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN �SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.n. ��0 _>25,000 sq.ft. �225 VENDING-FOOD �25 _<25,000 sq.ft. S80 _FROZEN DESSERT �40 TOBACCO ��5 �A:�zE c��GE: 510 AMOUNT DUE _ $ /�FS,o0 ***'*PLEASE TUR\OVER AiVD CO'VIPLETE OTHER SIDE OF FORIVi**"** .-.re-� . , ADMINI5TRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED v� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy, ordinarily and custamarily associated with motel and hotel use. 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 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 ame�ded, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days pnor to opemng.PLEASE NOT'E:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt 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 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 COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T'HE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SIT PLAN. DATE: iz / SIGNATURE: �, �� PRINT NAME&TITLE: �cx��e E 1��.v Sr' ��s - io�zi!os r o • � • �11- ' �� „��ITE STATE INSURANCE COMPANY • 92252-QQOQ WC �326-74-16 --------------------------------------------- : s 1�2 '_�-l�6-O 1 Q8-00 .-•.. , . • . PENNSYLVAN I A . . LATSNAW ENTERPRI SES COPR Member Companies af 41 LOt�s po�ao DR �� American international Group S YARMOUTH, MA 02664-0000 �XECUTfVE OFFlCES: 30 PiNE STREET, NEW YORK, M.Y. 10270 SEE NAME AND ADDRESS SCHEOULE - WG990610 L�# 1 -:� ••• HUB INTERNATIONAI. NEW ENGtAND LLC WORKERS COMPEIVSATION AND EMPLOYERS 437 STAT I ON AVE �IABILITY POLICY INFORMATION PAGE SOUTH YARMOUTH, MA 02bb4-0000 INSURED IS PREVIOUS POtICY NUMBER CORPORATION RENEWAL 0088 144 OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADQRESS SCHEDULE - WC Ob10 ITEM 2 POI.ICV PERIOD 7�01 ARA.standard time at the i�ur�ecE's maiUc�g addc�ess �pM O 1/18/08 TO o t/t 8/09 er�M 3 A. Workers Compensation insurance: Part One of the poficy appfies to the Workers Compensatipn Law of the states listed here: MA B. EmpioVers Liabilitv Insurance: Part Two of the policy aqpiies to the work in each state listed in item 3.A. The limits of nur liabiifty under Part Two are: godiiy injury by Accident$ 104,000 each accident Bodily injury by Disease � �i00.000 pottcy limit Bodily injury by Disease $ 100.000 eadt empioyee C. Other States Insurance: Part Threa of the palicy appiies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A rr�M a The q+�emium for this policy will be determined by our Manueis of Rules, Classifications, Rates and Rating Mans. Aii information required 6elow is subject to verification and changs by audit. Estimated Total �gtg pp,r Estimeted �' Clasaiticstions Code Number Ramunor�4ion $�00 OF Re- �mium muneration )( qnnuai 3 Year i � Annual❑3 Year � � SEE EXTENSION �F INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $29 IXPENSE CONS7ANT(IXCEPT WHERE APPLICABLE BY STASE) $ �8 MA MINIMUM PREMIUM $2I}� MA TOTAI ESiIMATED PREMlUM $$6� If indicated below, interim adjustments of premium shall be mada: � Semi-AnnuallY � Quarteriy Q Monthly DEPOSIT PREMIUM END�RSEMENTSiFORMNUMBER) SEE ATTACHEO FORM SCHEDULE - WC990612 i 03/05/08 ASSIGNED RISK bb Issue Date issufng Office Authorized Represent ive WC 00 00 Ot 39967 . � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-156 FEE: S85.00 In accordauce��ith regulations promulgated wider authorit��of Chapter 94,Section 30�A and Chapter I 11, Section 5 of the General La�vs,�permit is hereb��granted to: Latshaw Enterprises Corp., 41 Long Pond Drive, South Yarmouth, MA Whose place af business is: Bonkerz Party Zone Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2009 BOARD OF HEALTH: .i�¢�¢IL Sf�p�t, J�..JV., C.'Ptcr.ixrnan SEaTrtvG: 40 f��l�R.� .`�. .J�PQ�QJIC, �[C¢ ��►tRft ��r�✓2..N. Febn�ary?7,2009 f Bruce G.M y, P , R.S.,CHO Director of Heal � � � , _.�H_.._a � F_ �.... . ��.w�_ ._ . . , , �..,��_m.��r_.,...�y_ ,, r. _ . _ �._ _. . ._ _ � _ _ , i 1 ; THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH s i i PERMIT NUMBER: #09-099 FEE: S60.00 i This is to Certify that Latshaw Enterprises Corp. d/b/a Bonkerz Party Zone 41 Long Pond Drive, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the taws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity�vith the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �q��,�_e_-rat-S- !£t�aRt,c�fJ`��.�.A��.,��C'Rn.a'ci�cn/uut SEATIl\G: 4O �.fL�1�iC� .TG. JL�SGGiRK�i� VtC� \�N�I�;%1Yf1iQ/L Qttrt. C��teert�B�Cl�ttt, J2..lV. . ��u�' Febn�ar��?7.2009 � Bruce G. Murphy, H, .S.,CHO Director of Health • _ -� t�.,,�c� $oNk�Z � C� G�' C� OM � D ��`'Y�'k.� TOWN OF YARMOUTH BOAI��Q� � Il`��:. � C� C� o r�� ' APPLICATION FOR LICENSE/PE�YI ��2 ` � ''= � �� `� �,,` JAN 0 3 2008 * Please complete form and attach all necessar�`�ocuments by , ecembe 3 02 � Failure to do so will result in the return of your apphcation pack ��LTH D E PT. NAME OF ESTABLISHMENT: �n ker 2 PGr t�/ �Z_o n� TEL. # �8,3�g,543`7 LOCATION ADDRESS: 4) L.onQ Pnr��l �r►'ve �ou+h 11c,rrn,o��-h M/4 p2b6q MAILING ADDRESS: 4) �ona Pdnc� Dr i,�L Sou+h \Ic►rmo�+h MA d�bb 9 OWN�R NAM�:__C-��orce '' �I izra bc�h �ai�haW TAX ID(FEIN or SSNI- � CORPORATIONNAME (IFAPPLICABLE): L4tshaw Enfi��-�fiSC� C�rD. MANAGER'S NAME: �� , Lc�tShq�,v S'r, TEL. # SO$.3q8.5937 MAILING ADDRESS: 41 Lona Pnn�l f�rive �Qui'h \Ic:rrno��'h MA b��064 POOL CERTIFICATIQNS: 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 ofemployee eertifieations to this forin. The �ealth Dep$rtment will not use past yea�s' reeords. Ti'o� must provide nev�r copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food serviee 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 Establislunents, 105 CMR 590.000. Please attach copies Qf certification co this application. 'i'he Health Department wiH not use past ye�rs'records. You must provide new copies and maintain a file at your establishment. 1. �P�rae R. l.Q�haw �"r� 2. Eli�be-�h �citsha�/ PERS9I�T IN��AaR.�E: _ . _ _ _ _ __ _ -_ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. . 1. C-,�e R. La�sh a w �'r• 2. E I iz.n bic�-1'h L.a�:S�w 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 procec�ures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. You mustprovide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # �{0 OFFICE USE Ol�LY LqDGING: LICENSE REQUIRED FEE PER'�III'� LICENSE REQLjIRED FEE P£R'�fII'* LICENSE REQUIRED FEE PER.�IIT� BBcB S50 CAB1N S50 MOTEL S50 ,INN �50 CA1�IP S�0 _SR'I'_bL11IN`GPOOLS75ea. LODGE SSQ TRAILERPARK S100 tL'HIRLPOOL S75ea. FOOD SERVICE: LICET*iSE REQUIRED FEE PERMIT# LICENS£REQL?IRED FEE P£R'��IT tt LICEIvSE REQL'IRED FEE PERVIIT= �0-100 SEATS $75 �/� _CONTINENTAL S30 _NON-PROFIT S2� _>IOOSEATS S150 I CONL'�IONVIC. S50 �a8-�fa- _V��-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT* LICENSE REQL?IRED FEE PERVIIT= LICENSE REQL'IRED FEE PER�IIT� _<50 sq.ft. �45 >25,000 sq.8. 5200 _VEI�'DIivG-FOOD S20 _<25,000 sq.ft. 575 _FROZEN DESSERT S35 _TOBACCO SSO NA��CHANGE: s�o AMOUNT DUE _ $ /2�.�p *****PLEASE TL'Rti OVER:�\D CO�ZPLETE OTHER SIDE OF FOR�1***** � i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or germit to operate a business if a gerson or company does not have a Certificate of Worker's Compensation Insurance. TAE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED �C OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT UCCITPANCY: 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 h�tel us�. Transient occupants must have and be able to demonstrate that they maintain a principal pla�ce ofresidence elsewhene. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more tha.n 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 amended, shall generally be considered Transient. * NOTE: En�los�Motel Census must be completed and returned wxth t�is appli�ation. POOL3 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(�days pnor to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count -by a State ceftified lab, prior to-flperrin�, and c�arterly t�ereafter. 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 Departmern 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 hy a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revoca.tion 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 COOKING: O�tdoor cookir�g,pfeparatiori,or display�f�ny food groduct by a retail or food se�'vi�gslabli�g�t is{�rehibited. 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, 2007. Ai"i• RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. REVOVATIONS MAY REQUIRE A SITE PLAN. DATE: j2��p-] SIGNATURE: �,Q�,�,Q�,.Q;� PRINT NAME&TITLE: �1►zq _-f�'1 r..q�ShGw, c�t.��r�er iu:��o� I � =. ; GRANITE STATE INSURANCE COMPANY 92252-0000 WC 885'51-4 ; 13�02 ------------------o�3-66-0107-00 ; � PENNSYLVANtA ' � LATSHAW ENTERPR I SES COPR �� Member Companies of i 41 LONG POND DR American Intemational Group ; S YARMOUTH, MA 02664-0000 EXECUTIVE OFflCES: � 7D PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 i i.D� HUB INTERNATIONAL NEW ENGLAND LLC � WORKERS COMPENSATION AND EMPLOYERS 437 STAT 1 QN AVE , LIABILITY POLICY INFQRMATION PAGE SOUTH YARMOUTH, MA U2664-0000 ! INSURED tS PREv�OUs POI�CY NUMBER CORPORATION NEW ; ER WORKPl.ACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 � 1'1EIN 2 POIiCY PERIOD t2:01 AM,atandard rime at the insured's I maUtng address pRpM ��$�O7 TO ��8��$ i � �3 A. Worlc�s Compensation tasurance: Part On�of the policy appii� to the Work�s Compensation Law of the states listed � here: ` MA � � ( B. Employers Liability I�uranCe: Part Two of the policy applies to the work in each state listed in item 3A. i The Itmits of our liability under Part Two are: Bodily Injury by Accident s 100,000 each accident � Bodily Injury by Disease S 500.000 policy limit � Bodily injury by Disease $ 100.000 each empioyee j C. Oth� Statos insurance: Part Three of the poNcy applies to the states, if any, listed he►e: � SEE ENDORSEMENT - WC200306A i ! �4 The premlum ior this policy will be determines! by our Manuais of Rules, qassifications, Rates and Ra�ng Plans. !I� All irHormation required below is subject to verification and change by audit. I Estimated Total Rate Per Estimated ! Remuneration Premium � Gassitieations Code Number mu�eration � . . � Mnuai D 3 Year X Annual 3 Ye � 1 SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $2! i i ; � o�se coNsra�rr�pcc�r vn+�aPwacaste sr sra� S 284 MA � MINIMUMPREMIUM $239 MA Tm'n�-�n�u►�u�wM $95C R ii indicated beiow,iaterim adjustmenta of premium shail bo made: � � Semi-Mnualiy � Quarterty � Moothly DEPOSIT PREMIUM � ENOORSEMENTS(FpRMNUlABER) SEE ATTACHED fORM SCHEDULE - WC990612 � i � i � , 02/09i07 ASSIGNED RtSK 66 � � issue Date Issuing Office Authorized Represent ive WC pp pp 0' j ----- i • . :� , TOWN OF YARMOUTH BOARD OF�ALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #08-147 FEE: $75.00 In accordance with re�ations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the eneral Laws,a permit is hereby granted to: Latshaw Enterprises Corp., 41 Long Pond Drive, South Yarmouth, MA Whose place of business is: Bonkerz Party Zone Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: ��P.�ertt S�cl��i,c�p`J�Z�.�J�V., C'f��attwer,nta�Qtt_,-��_ SEATII+tG: 40 � �✓1.��X( /��_�V�Q�/CE �r(kivu/tQfL �J_—I— r a/U (��Gr�J�UL (�{[!� {� � aJ�..,lV. �al�lL J.��d i � '' Januar,�28.2008 . ruce G.Murphy, ,RS.,CHO Director of Health � _ _ . _ , ___ _ , ; � THE COMMOI�TWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH i � � PERMIT NUMBER: #08-092 FEE: $50.00 ; . � This is to Certify that Latshaw Enterprises Corp d1b/a Bonkerz Partv Zone � 41 Long Pond Drive,South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the , licensing of common victuallers. Tl�is license is issued in conformity with the autl�ority granted to the licensmg authoriries by General Laws, Chapter 140, and amendments thereto. � In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures. i BOARD OF HEALTH: �Eeeert Sffac�t, J�.JV., C'Iplta'ixnuat SEATING: 40 �� v��«�L � Sh.v��u.S..�i��YQ�W/L� ��YJ[l� Q�rui C�'ceer�accm, J`�..Ar. �ue�rt J. ,�'f�cc�..ets 7anuary 28,2008 Bruce G.Murphy,MPH,R.S.,CHO Director o�Health ��.� 3` _�; 's� __ 1'oIJKER'L �°f:aR o TOWN OF YARMOUTH BOARD OF��+.�L'I'H ' � 3 -�� APPLICATI4N FOR LICENSE/PERNi�'I'-'�00 G3 L C� � � M I� (� � �;- ,,�i �, - * Please complete form and attach all necessary doc�ments by Decemb r 3 M,�C�.2 2007 Failure to do so will result in the return of your application pac et. H NAME OF ESTABLISFIlVIENT: ��c\, �s- � TEL. #� -�R�-S4�7 LOCATION ADDRESS: ` MAILING ADDRESS: OWNER NAME: � . l.� `�� T IN r '-� CORPORATION NAME APPLICABLE : ��,� �_��. C�� , MANAGER'S NAME: . (.�. T'EL. #�.�FS_S43`7 MAILING ADDRESS: I POOL CERTIFICATIONS: The pool supervisor must be cerlified as a Pool Operator,as required by State law. Please list the designated Poql Qperat�r(s)and a�ittach 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 Resuscitatian(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. L 2. 3. 4. FOOD PROTECTI4N MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protectian Manager, as defined in the State Sanitary Cade for Food Service Establishments, 1Q5 CMR 5�0.000. Plea.se 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. ��rca� �<�`��,9-� �'�r- . 2. ��.z��, 1...��crce� P��f�-- _ _ _ __ --— ___ __— _ - - ___ __. _ -- . _:--. _ -- _ _ —_ Each food establishment must have at least one Person In Charge(PIC) on site dwing hours of operation. 1. ��_ �, t-�`�t�s�s�c-�,�� r-, 2._�!�hc.�l� � �`��4 � 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 fde at your place of business. 1. � � �r-- 2. �\i:�c.�o�-� `.cc'��c ,`, 3. 4. RESTAUR.ANT SEATING: TOTAL# �Z OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PfiRMIT# LICENSE REQUIRED FEE PERMIT# _BBcB �50 _CABIN $50 _MOTEL �50 INN $50 CAMP $50 _SWIMIv1IIdGPOOL$75ea. _LODGE $50 _TRAII,ERPARK $100 WHiRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQiJIRED FEE PERMI'P# LICENSE REQUIItED FEE PERMIT# �0-100 SEATS $75 'I(,� _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 / COMMON VIC. $50 �CCXS _WHOLESALE �75 RETAII.SERVICE: --RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTT# LICENSE REQUIRED FEE PERMTT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _45,000 sq.ft. $75 _FROZENDESSERT $35 _TOBACCO $50 NAME CHANGE: $10 . AMOUNT DUE _ $ �ZS.OO •••""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••""* i t"'.: o ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renew�.l 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 not more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POQLS POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Degartment ta schedule the inspection five(5�days pnor to opening. POpL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ' by a State certified tab; �riort�opeiung, and quarterlytirereai�er. ; POOL CLOSING: Every outdoor in ground swirnming pool Fnust be drained or covered within seven(7)days af ' closing. FOOD SERVICE CATERING P4LICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKIl�TG: _--9�tdear-cesl�g,-prepai'atio�e►��iisplaY 8f an��ci�.oduct-hy a�etail or foodseruice Esta.blishment is_prohibited. 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, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR ' TO COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: z 3i c SIGNATURE: � PRINT NAME&TITLE:�� '�� c<< ��-. �r�5��n�— io�i7ro6 + • � �'i�l.� GRANITE STATE INSURANCE COMPANY 92252-0040 WC 885-5�-�+�+ 13 l 02 --------------------------------------------- o�3-6b-oto7-oo . -.- . . . PENNSYLVAN I A . LATSHAW ENTERPRI Sf5 COPR �� Member Companies of 41 LONG POND DR American international Group S YARMOUTH, MA 02664-0000 EXECUTIVE OFFICES: 70 PIME STREET, NEW YORK, N.Y_ 70270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# MA f : HUB INTERNATIONAL NEW ENGLAND LLC WORKERS COMPENSATION AND EMPLOYERS 437 STATION RVE LIABIIiTY POLICY INFORMQTION PAGE SOUTN YARMOUTH, MA 02664-0000 INSURED IS PREViOUS POUCY NUMBER CORPORATION N�W OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 REM 2 POUCY PERIOD 12:01 AM.standard time at the insured's mailing address FROM O 1/18/07 TO 0��8�08 t['Eh►a p, Workers Compensation Insurance: Part Qne of the poliCy appiies to the Workers Compensation Law of the siates listed here: MA B. Employers Liability insurance: Part Two of the policy applies to the work in each state iisted in item 3.A. The limits of our liability untier P8rt Two are: godi�� njury bV Accident $ 1 QO,000 each accident Bodi(y Injury by Disease $ 5{)0.000 policy limit Bodily injury by Disease $ 100,000 each employee C. Other States insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A (iEM A 7he premium for this poiicy wiii be determined by our Manuats ot Rules. Ctassifications, Rates and Rating Pians. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration 5100 OF Re- Premium � Annual❑3 Yea� muneration �qnrtuai �3 Year SEE EXTENSION OF INFORMATlON PAGE - WC7754 TAXESIASSESSMENTS/SURCHARGES $28 D(PENSE CONSTANT(DCCEPT WHERE APPUCABLE BY STATE) �S Z O jF MA MINIMUM PREMIUM $239 MA TOTAL ESTIMATED PREMIUM $9�Q � If indicated baiow, interim adjusiments of pramium sball be made: � Semi-Annualiy � Quarterly � Monthly DEPOSIT PREMIUM ENDORSEMENTSiFORMNUMBER) SEE ATTACHED FORM SCHEDULE - WC990b12 � � ; 02J09/07 ASSIGNED RISK 66 'r Issue Date Issuing Office Authorized Represent ive WC 00 00 O7 1 � .,,.,.�� _ _ _�� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-100 FEE: $50.00 This is to Certify that Latshaw Enterprises Corp. dlb/a Bonkerz Party Zone 41 Long Pond Drive, South Yarmouth, MA IS HEREBY GRANI'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and ex ires December thirty-first 2007 unless A sooner suspended or revoked for violation of the laws o the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority ganted to the licensing authorities by General La.ws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned ha.ve hereunto a.ffixed their official signatures. BOARD OF HEALTH: B sa�. �� , /61.`n., . SEATING: 4O e�� CJI.� (�fC6�G�dINlG�IL - Rod�t� B�ux�, � A�al�� l.�.t��, R./V. A�ril 4,2007 Bruce G.Murphy, S.,CHO Director of Health TOWN OF YARMQUTH � BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT � � PERMIT NUMBER: #07-165 FEE: 75.00 � , ` In accordance with regu1ations promtzlgated under authority of Chapter 94,Section 305A and Chapter ' I i l,Section 5 of the General Laws,a permit is hereby granted to: Latshaw Enterprises Corp., 41 Long Pond Drive, South Yarmouth, MA ; Whose place of business is: Bonkerz Party Zone ; Type of business: Food Service ; j To operate a foad establishment in: Town of Yarmouth ; ' Pernut expires: December 3 l, 2007 BOARD oF HE�.TH: B�/ ��p�� `?/S. �on�uC,�61.`b., ' SEATING: 4O df&e4I�6/L e7�fGit, �!, v�e��.� ;' R�t� a�, e�,� � P�M�� ; � t4.z.z�j��, R.N. , ; i Apri14.2007 II�� Director.oM�hty�,MPH, HO � ` ' �:E�133� � �,._R�o TOWN OF YARMOUTH BOARI�,..�H , .: F� � � � � � � `Ya RI �� _ 3� � � o z �y APPLICATION FOR LICENSE/PE � ' ��+, 0 ,� � Y ,,, .,,,�. ' D E C 3 0 2005 * Please complete form and attach all necessary documents by �cembe 3 e�H DEPT. Faulure to do so will result in the return of your application pack . � NAME OF ESTABLISHIVIENT: (3a n ke rZ �a r�V Zo h� TEL. # �,08-.3�i 8-59 37 LOCATION ADDRES S: 4 I Lo rl � t� � Ur vC r rn�o -t 02 6 4 MAII,ING ADDRESS: L.o ri v� rmorrfh OWNER NAME: �--�c�rae g �1� bc°th La-F�5 h Q w TAX ID(FFIN or S SNl� � CORPORATION NAME (IF APPLICABLE): ►�q w r r i S Co r MANAGER'S NAME: �-�eo rc� �_ L.a-F�ha v�e J r. T L. # r-,�Q$-3�i 8-�S2b MAILING ADDRESS: q I Lo r�a �or�G� T7►-i v� �outF� �l a r rnov-Fh M� 0 26�c�4 , �_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ope�ra�a�(s)-��ttae�i a copy of the cer�ifi�a�ion to-this forn�. 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 employe� certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � l. 2_ ! 3� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sasutary 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 fde at your establishment. 1. C-�c�or�e �?. La+�haw� Jr. 2._Eliz�b��h L�+sh�w , � PER.SON IN CHARGE: _ . __ ---- - _ ' Each food establishment must have at least one Person In Chaxge(PIC) on site during hours of operation. �� . C-��e'' �lizabc-t'h Lutsl�w 2. C�n�he_�-ir�c� �+�G fi�ar� � HEIlb�I�CH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and i 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. a ; � 1. C-,eora� �R. La��hG w �r• 2. �I i''i.a�-I-F� LatS Ft�w � 3. ,A�rnei Mur�hv 4. � � j RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERNII'P# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMTI'# B&B $50 CABIN $50 _MOTEL $50 �INN $50 _CE1MP $50 _SWIlVIlVIIIQG POOL$75ea. �LODGE $50 _TRAILER PARK $50 WH�LpppL $�Sea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERNIIT# �0-100 SEATS $75 � CONTINENTAL $30 �NON-PROFTT $25 _>100 SEATS $150 I COMMON VIC. $50 ��68� _WHOLESALE $75 RETAII,SERVICE: LICENSE REQUIKED FEE PERMTI'# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _<50 sq.ft. $45 _s25,000 sq.ft. $200 _VENDIl•iG-FOOD $20 _Q5,000 sq.ft. $75 _FRQZENDESSERT $35 _TOBACCO $25 NAME CHANGE: �10 AMOUNT DUE _ $ �ZS•00 A R R 6 RpLEASE TiJRN OVER AND COMPLETE OTHER SmE OF FORM•**"" . .. d � 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 STATE WORI�ER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, 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 X NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- ' 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspecteti 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 haurs prior to the catered event. These forms can be obtained at the Health Department. FROZEN DES5ERTS: Frozen ziesserts�m�r�tbe teste��n a moriH�iq basis�y a�tate eertif ed�ab:- Test�esu�ts mt�s�be sent��e�ea��l� Department. Failure ta 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 waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: 1�I 3...�O S SIGNATURE: �a�-�'�euw� , PRINTNAME&TITLE: EI►Zalr�e�h L��S�w IoW�'le� 09l28/OS � � � � —=_—� T/ie Com�nonweahh of Massachusetts �`�_ __ �� =� _ Dtpart�nent oflndus�trial Accidenls __ — N�'1M�Mi� � _ -= 600 WashittgtoR S'tree� 7`�`Floor - � —�„ Bo�ox,Mas� 021�1 ' " Workera'Com�eaaatios I�saraaee Affidavit:Beil ' �,, ,.n. ., .__ . ._, . � , . kctrical Co'traetors �� ,: . �. ., .,�:.<, � �. x. , .. � _ � . �: f3on kr rz �ar-{•, Zon�. / Gr ra� f �I;�b th Lats ha w �S:4 I Lo r�a Po r�cl �rivL j s�ty Sou� l��rmouth � MA -„ �2bb9 �.�# 50$ 3a8 �4 7 i � � work site locati�(fall addressl• ; ❑ I am a homeow�r performing all waalc myself. Pmjed Type: ❑New Canstn�ction�ReJnodel j1 am a sole 'etor and have no a�w ' in an ca ' . Buil ' Additian iI am an empioyer pzoviding wa�iceas'compensatian f�my emgloyces warking�this job. _ _ __.___ , - _�: f�r,ke rz PC►--Fv Zon - _ _ _ �: `T� Lnv�n �c�YIG� drl rf'e _..___^ - -- �: .�,u�-h �Iarrn��l'h ,��- 5oF5-.�q8� 5937 'i ran►�c S��e Sns�rancc . wC 7 2 - 54 - 7 3 ; ❑ I am a sole�oprietor,ge�eral costractor,or�omeawoer(circk oAe)and have ltired the cw�ractas listed below who have j the following woskers'compensation polices: �mu�: �s �'• nit�e�- ' � s�Y�� i �. i � �Y: ��. --- __ ------- __ __ - - -- - -- � . __ _ _ ___ Fa�ne�.aeeve orNera�e as nqirod.�der Satl..2SA.f MGL 152 aa ind a/ie irp.itl�t.[cr4�id pe�.Nies.f a 4�e�p a Si,SN�N aidl.r ese years'�ptieaawmt a�we8 as dMl pn�ltla ia t6e 6sra�af a STO!WORK ORDER aad a A�e�[5161�.N a day asaiet�c. 1 odeistud dut a apy�t t�b slateae�t my be firwaMed�s tlr O�oe�f lm��He D1A tar e�vaage v�ieatly. /�o A�ereby cerlfjy xeder NYs prins sw��aurTt�a of pery�rrry tlYet dYe befonNr�tow pro�ded abov�e is te�ts wtd c»m� �'� �� Da�e �Z,►3,�o S Print name E�1'ZA�"H'1 Lats haw Phone# �d$-39 8- 5�137 •�clal ese only do sot�rrke 1�t�a am te be oampleted by dtp or�wra affiehl dlp ar tewn: P�� De�ment ❑ekak if�edi�le rdpsase is reqecd �Sdxt�ea s O�ee �r�t Pe�a: pgeae#, ❑��t�e■t c�.m s.�.mm� � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUNIBER: #06-143 FEE: $75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the(ieneral Laws,a pernut is hereby granted to: _ Latshaw Enterprises Corp., 41 Long Pond Drive, South Yarmouth� MA Whose place of business is: . Bonkerz Party Zone Type of business: Food Service To aperate a food establis�unent in: Town of Yarmouth Permit expires: December 31 2006 BOt�RD OF HEALTH: B�e/�r� ' `�, �jo��` crs /19./`��5., • SEATING_ 4O � sf6�� KJI.� �[tt7�G�f�it R�t� B�, G'l� P�t�k iLl��t ' �4��d�s.�, R.N. i ; � Februarv 3,2006 i" ruce G. urphy, .5.,CHO Director of Health � i ; J � 3 i 1 j THE,COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #06-087 FEE: $50.00 This is to Certify that Latshaw Enterprises Corp. d/b/a Bonkerz Partv Zone 41 Lon�Pond Drive, South�armouth, MA IS HEREBY GRt�NTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless , sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornu with the authorit anted to the licensm authorities b General Laws C r tY Y�' g y , ha.pte 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a.ff�ed their official signatures. BOARD OF HEALTH: B�/ �`?/S. ,/N`�., . SEATING: 4O oY¢��l�fL ��yy, �iv.v�e�� R�t�B�, Gl� n�� , R.�v. February 3,2006 � ruce G.Murphy, S.,CHO Director of Health i . ' �;-� �~' �:� � 2i5a Y2��`:aR o TOWN OF YARMOUTH BQA��E� -A�.� ��2 C� C�' C� Ll M � Do �� APPLICATION FOR LICEI�.SE/�EI�[��J�� t�p ��-'� ` .. APR 1 4 2005 �,� �� * Please complete form and attach all necessary documents by December 3 , ��LTH DEPT. Failure to do so will result in the return of your application packet. _ NAME OF ESTABLISHMENT: Zcx�e_.. TEL #�08=737-��v'7 LOCATION ADDRESS: I MAILING ADDRE S S� g ��(�. Pd `(c�-r��-4r, M l� c�6��-! OWNER/CORPORATION NAME� 1.A �.� ��.,�-c��`�ses Cc�r-fl MANAGER'S NAME: � r— TEL. # - - - 7 MAa,II�tG ADvxxEss� g� !� -- �� d. �� , Y Y-�, �s,, ll�l A a�6b�-{ 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 basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee cerhfications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3• 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code 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 m�intain a fde at your establishment. 1. �--,�c��P �, l.Q`��t cx� J r 2. ��Q� Lc��'s�� PERSON IN CHARGE: Each food estabhshment must have at lea.st one Person In Charge(PIC) on site during hours o£operation. 1 � 1. �e�crnQ_�. �`�.� �� `Sr-: 2. �\c�.� �s � � i v ; ; HEIMLICH CERTIFICATIONS: j All food service sstablishments 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. l. �va�_�.�'�s��-. 2. E��T s�P�-�1 � o � 3.—� 4. , RESTAURANT SEATING: TOTAL# s� (� __ OFFICE USE ONLY _ LODGING: LICENSE REQUIItED FEE PERM[T# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 iINN $50 _ _CAMP $50 _SWIlvIlvIIl�TG POOL$75ea. _LODGE $50 _TRAII,ER PARK $50 WHIlZLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE �PE # / LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# �6 _0-1�SEATS $75 __�� _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VTCT. $50 ��j�� _WgOLESALE $75 RETAIL SERVICE: LICENSE REQUIlZED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQiJIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.8. 5200 �VENDING-FOOD $20 _Q5,000 sq.ft. $75 �FROZEN DESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �Z,S.(� '••""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R R fe R i 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 pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED t/ Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEA5E CHECK APPROPRIATELY IF PAID: YES�� NO : NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN T'HE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPE1�11NG FOR TI� SEASQN. ALL RENQVATIONS TO ANY FOOD ESTABLIS�IMEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COr�IlVIEENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. : ADDITIONAL REGULATIONS '. POOLS POQL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depariment prior to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLYCY• _ ___p�yo�Q ' �' 3�arinet��s� �oti€y the Yarmout�-Heal��-Bepa�tmen�-by ��t�zg t�ie-- - 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. OUTSIDE CAFES: Outside cafes(i.e.,outdot�r seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOI�TG: Uutdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. � DATE: �z� � SIGNATURE: /� / � �,C PR1NT NAME& TITLE:��e 6G r L�� /'- �h`s��I/ 10/22/04 . � ' � � � -� Tlse Comrnonwealtb of Massachuset�s �---__=� _= DcpartMent of Induslria!Accidents — — �,1/M�111� - _ == 608 Washington Stree� 7�""Floor , Boston,Mass. 02111 ��'Work�a'Com�e�sahae La�a�oe Affidavit:B�il ' iectrical Costnetors .�,,,. �.�. , e -..� 4.. z., � "��r«, � ��-�-�. t, .�� name• ��2 SZ Qca�-T�.� L� � r D��P c �TD \ ackiress: { i � citv ewt�• aD• p�ha�e# work site locatim►ffull addt+essl: ❑ I aar a homoowner performing all wa�k myself: Project Type: ❑New Co�structi��]Reanodel I am a sole 'etor and have na one w in an ca Buil ' Additian I am an employer providing wackeas'oompensatiar fa�r my employees wa�lcing a►this job. aara�v�• �: j � � ! { ❑ I am a sole proprietor,geaeral co�tracter,or komeo�vaer(cirdt oAe)and have hiied the co�ractars listed belovr who have the following woti�e�rs'compensation polices: , �E�: �: c,�: �� T�tez � �• �tY: ��- Failare�secm�e a�era�e a�req��ed uder 3eetl�a 2SA�MGL 1S2 en k�d b I�e��f a�ial pnailics�f a�e�p b S1,3M,N a�df�r �e years'ie�rbeammt as wd as dW pebltles h tie firn ef a 3T0!WORK ORDEA a�d a M�e�[5199.N a day�ie. [a�der�ud that a copy ef fYb stahme�t may 6e forwarded lo-tee O�ce etlave�m at 1�DIA ta�eaverase v�'�tls'. I do benby ceKify mede e pat»s r pe��d�of pe�rrey tNet dYe nrfor�rallo�provPded abov�e is lrxe mid r t Signartoie Date 2v � P,�� '�� ""Cr-t Pbo,�# ��—.3Q�-SY37 .�dal ase o�ry• a.Ho�.rrke i�t�.area�e ne ce�plefea nr a�y er Iawn e�i.t dly ar town: pe�e# �� ❑cied[if�sediale reapsese is neqa�ed �Sdxt�ea's(l�ot � D�rmt ��P�*'�= �e�e�; 1 ; • � ; . ` � ; , � ; Interno a . HUB International New England, LLC 437 Station Avenue A World of Protection Right Nexf Door - So.Yarmouth,MA 02664 Office 508/394-0946 Office MA 800/649-0946 www.hubinternational.com Fax 508/760-1407 March 29, 2005 Latshaw Enterprises Corp d/b/a Lakefield Road 83 Lakefield Road South Yannouth, MA 02664 � Re: Policy Number: WC 8725473 � Coverage: Worker's Comp Assigned Risk Term: 03/09/OS to 03/09/06 � Dear Rick: � Enclosed please find your Worker's Compensation Policy written with the Granite State Ins. Company. Employer's Liability is included with this policy at the following limits, Bodily Injury by Accident $100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 each employee ! Please review the policy and payroll levels to be sure that they reflect accurate projections of what you expect for the upcoming year. Thank you for allowing our agency the opportunity to service your insurance needs. Should you have any questions or if I may be of any assistance,please do not hesitate to call me at this ; office. ' Sincerely, ,��' ; '� Maurabeth Chilson, CIC • � Account Manager ' I i � , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NIJMBER: #OS-107 FEE: 50.00 This is to Certify that Latshaw Enterprises Corp. d/b/a Bonkerz Party Zone 902 Route 28, South Yarmouth, MA IS HEREBY GRANTED A � COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned ha.ve hereunto affixed their official signatures. ', BOARD OF HEALTH: Besry�rx�f,�.`�hS. C�''u�,/I�`�n.f ' SEATIIVG: 4O p�/Y/0.!lphyl�� v!�i.KG�hKt�t Rod�1�.Bnorwt, G�le�a ��l�k, R.N. �4��j�� R.N. � � A.pri121,2005 ' ruce G.Murphy,MPH, HO Director of Health f .. . ... . . . � . . .. .. . .._ . . . . .._ .. .. .. ... . .. .. . . . . . . .. .. . .... . . . . I TOWN UF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERNIIT NLTMBER: #OS-175 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Latshaw Enterprises Corp., 41 Long Pond Drive, South Yarmouth, MA Whose place of business is: Bonkerz Party Zone Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31, 2005 BOARD oF HEALTx: Qe�,is�$. !�'c�P,�„/�`7�,.f � • sEa'rtrrc: 40 n�isc�a/�+le�e�itr�, 7/�ce��r��t Rod�t� Bnou�, G� �� , R.N. �!��, R.N. a��Zi_Zoos Bruce G.Murphy, . .,CHO Director of Health