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Home My WebLink AboutApplications, WC and Licenses __._.,.. � , TOWN OF YARMOUTS BOARD OF H�A�.T1�. . � ��o��1'`; � ,, APPLICATION FOR LICENSE/PERMIT-�010 . �, }��` � :�` JA� r, . � * Please complete form and attach a11 necessary docu�ents�iy December 1 2 L! H �sCr � . Failure to do so will result in the return of yaur application pac et. � i i NAME OF ESTA$LISHMENT: TEL. #5��j �9� ��8� �� r: LOCA�41*T AUJ?TRESS : � : ; � ` � ��°1��s. ' ��' ! �` +�►,:' �#, 7 .. , � �' ,, � , •; � OV�JNE�N'�ilvlE�:� �FE� or:, N � CORPORATION NAME (IF APPLTCABLE): n G1• MANAGER'S NAME: '�r�yK.t_ TEL. # MAILING ADDRESS: 5�,,,,..._ .�_� ...._.,.._.,,�_,�._.. POOL CERTIFICATTONS: Thc pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. i _ _ _ ; _ ._ _ 1• 2. Pool operators must list a minimwm of two employees currently certified in basic water safety,standard First Aid and Community Cardiapulmonary Resuscitarion(CPR). Please list these employees below and attac�copies of employee cerCifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at yonr place of business. l. 2. 3• 4. i � � FOOD PROTECTION�v1ANAGERS - 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 certificarion to this application. The Health Department will not use past years'records. You must provide new copies aad maintain a file at your establishment. 1. 2. j PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ; 1• 2. � HEIMLICH CERTIFICATIONS: i All food service establishments with 2S 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-chQking procedures below and attach copies of employee certifications.to this form. The Health Department will not use past years' records. I�I, You must"provide new copies and maintain a file`at your place of business. 1, �, 3. 4. RESTAURANT SEATTNG: TOTAL# �I��r- II OFF�CE US� 4NLY LODGING: LIC�IVSE REQUIRED FEE PERMIT# LICENSE REQUITtED FE$ PERMIT# LICENS�REQUIRED FEE PERMIT# �BBcB $55 _CABIN $55 iMOTEI, $55 �INN $55 _CA1�1P $55 ____SWIMMING POOI, S80ea. ____LODGE $55 _'TRAILER PARK $105 WHIR.LPOOL $80ea. FOOD SERVICE: LICENS$REQUIRED FEE PERMIT# LIC�NSE R�QUIRED k'�E PERMIT# LICENSE REQUIR�D FEE PERMIT# �0-100 SBATS $85 _CONTINENI"AI, $35 NON-PROFIT $30 >100 SF,ATS $160 �COMMON VIC. �SO �WHOLESAL� $80 RETAII.SERVICE: _ _ _ _._RESID.KITCHEN $80 _ LICENSE REQUIItED FEE PERMTf# LICENSE REQUIl2ED FEE PERMIT# I.TC�NS�REQUIRED �'EE PE1tMIT# �<50 sq.R. �50 >25,000 sq.ft. $225 VENDING-FOOD $25 „�<25,000 sq.ft. $80 a'�y S ��RpZENDESSERT $40 ' �TOBACCO $55 NAME CHANGE: $is AMOUNT DUE = S S0.O� "'"*""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"** i . . . r,y .. -?' . ADMINISTRATION Under Cha.pter 152, Section ZSC, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTAC +D STATE WORKER'S COMPENSATION YNSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF INSURANCE ATTACHED� - � OR : WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO MOTEL�AND OTHER LODGING�STABLIS$MENTS TitANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Transient occupancy sha11 be limited ta the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient accupants must have and be able to demonstrate that they mairnain a principal place ofresidence�Lsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than nin,ety(90) days within any six(6)month period. Use of a�u,est 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. a 64G or 830 CMR 64G, as amended, shall generally be considered Transi�t. ' ; POOL5 POUL OPENiNG:A11 swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Departmet�t to schedule the inspection thr�( )3 days pnor to opening.PLEA.SE N�TE:People aze NOT allowed to srt m the pool area until the pool has been inspectetl and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days af ' closing. ': FUOD SERVICE ' CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requi�red Temporary Food Service Application farm 72 hours prior to the cater�d 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 ar 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 Boazd ofHealth. � � OUTDOOR COOKING: Qu�door cQoking,�p�ration,ar�i�play of�ny food produ�t by a r�Qr foo�servic�est�lishr�nnerrt is proh�ki�__ ; NOTICE:Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBlLI1'Y TO RETLJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATTONS TO ANY FOOD ESTABLISHIVIENT, MOTEL UR POOL (i.e., PAINTING, NEW ' EQUIPMENT,ETC.),MUST BE REPORTED T4 AND APPROVED BY TI�BOARD OF HE.ALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A LAN. DATE: � d' SIGNATURE: PRINT NAME&TITLE: � d`�-- o9rzsro9 r ". ti. � The Commanwealth of Massachusetts Department of Industriat Accidents NXCON�af�s 600 Washington Street, f"'Floor Bostoa,Mass. 02�11 ' � Woricers'Compeasation Ia4oraaee Aifidav�t:B�ilding/PlambiHg/Electrical CoAtraetors ; t naine_ I" � �s: 5� 1/ � citv i [/ ��s!�C� shte- ///� zi� d�/ phone#UVD /�O �J 7 work site location(full add[essl- ❑ I am a homeowne�performing all work myself. Project Type: ❑New Constiruction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. 0 Building Addition �am an e,�npbyer.providing workers'compensation f�my employees wodcing�this job. wm oaate: , � .: , ��: q�S� 12�� Z_ p �o, ✓ lYl� ��: 5�6`39� �a�° �. �. ��r ��S �--- �� q�1 0 : , .�. : ,, , ,, .: :e r. . : _ - . . _..1.::�., »�...;�� , .�x�:t��,��.. . . h-, _ � >; � : ,.� M:..u ,. � .... ,,.�€� . , , . .�,.:, . .. _. _ _ . ❑ I am a sole proprie.�or,geaeral co�tmtor,or 6omeowner(cirde one)and have hired tbe contr�ctas listed below who have the following wo�lcers'compensation polices: co..+.��v ia�e• ' _ -- addres�- cit�- n4a�e#: �eoe-�rn. . #. � . . ._ ,:x: �;�- ��.�;; ��, c�muv�ne- _ _ _--- ad�' ,� c3ty,. uksae#_ - ---__--- - —— _ _ ___ _ _- _ _. _ -- — _ _ ..._... .. ,_ , � . . .. . . .. . . � :� ¢'= ,.�#,-�-':r ,�'ri'.� .a��.'��f.,�:`.3-�. `��:.��5.�.?�"�'ss .. - Fsihre M see�es errera�e n reqairal uder See�2SA�f MGL 13Z eu Iead t�tte irpn�r�f ai�ial qaMks�f a fe�p b f1,SM M atdltir� e�e ypn'Is�ti�a�t a�weY as dH pnaida h tbe fora��a STO!WORIC ORDER aed a Ase�[S1M.N a day spint arc.1 adaslaad tht a aypg�fii�afalm�eat�y 6e firwuded M tYe O�ee�t L�tlHs�f 1Ye DIA ter cw�ge rd�a�. /10 Jrd+eby c � rreder dYe � ofP�'.%�!'dYat dre lwjora�ratio�prodded aboae Lc brte oanbct s;� C� nm t � D . �� P�� 39'� 00� �.x.�• a..�..�iw�.��r.�r�*�� dt�,K t�w�: • pi�.,WBe'we e ['76.i�n�p'rlm�at Qllo�aqrd II ❑eteet if L�m�1e i+dpene b reqai�ed : QSdee�e�'s O�ae i a�tact pesa�: pk�e�; DOfker �t tn.6ed St�t.20Q7) . — i i , . � . o TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #10-045 FEE: �80.00 IIn accbrdance with reeulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 I,Section 5 ofthe�eneral Laws,a permit is hereby granted to: Rome Candy Co., 975 Route 28, South Yarmouth, MA Whose place of business is: Candy Co. � Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth � Permit expires: December 31. 2010 BOARD OF HEALTH: ✓��t[tYft��ltt�(►tt-Sfttf#�, C'lfav�tnuxn J 1�auuu►c�uc�t, `llr.ce Cl�aiacnuui 2U� C. Sn�+wxden Ill, f!�ex� �fi��.� `�t3c�o�� .Nt.`1?. Fehn►ary 2�.2010 ruce G.Murphy,MP , .5.,CH� Director of Heatth i _ , i 1 I 1 � � Ji I I , � : � ;r (U� �,,��,�_�,�' � TOWN OF YARMOUTH BOARD OF 1'�", ' ��'�'� N� Co. � � APPLICATION FOR LICENSE/P � 0�`,�� :,,� � `; � i ��? � DD � �.. �e t . e• � z �i,'iti ; * Please complete form and attach all necessary ��s�iy Dece er � 0 'L00$ � Failure to do so will result in the return o our applicahon pac et. ; - i NAME OF ESTABLISHMENT: � � TEL. #S�S��08� ' LOCATION ADDRESS: 1s �' Z 0 MAILING ADDRES : -G• O - < GtV u OWNER NAME: TAX ID FElN or SSN : ` CORRORATION NAME I APPLICABLE): rRorY4_ CG n�u C0. MANAGER'S NAME: �vJo,r�-�YW�' TEL. # �i D�a MAILING ADDRESS: -�y� _� d�xf�-- POOL CERTIFICATIONS: The pool supervisor must be certified as a Paol Operator,as required by State law. Please list the designated �. Pool Operator(s) and attach a copy of the certification to this form. I �� 1. 2. � Pool operators must list a minimum of two emp loyees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach capies of eYnployee certificatians 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. j 1. 2. � 3. 4. , FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tvne 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 capies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file Rt your establishment. ' l. 2. � � PERSON IN CI�AR�"iE: . __ _ _ _ _ _ _ . 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 ar more must have at least one employee trained in tlie Heunlich Maneuver on the premises at all tnnes. 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 q, { RESTAURANT SEATING: TOTAL# ! � OFFICE USE ONLY ! LODGI�iG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN $55 MOTEL S5� 1itiN S» CAMP �55 SWIMMING POOL �80ea. � _LODGE S55 �TRAILERPARK �105 _WF�IRLPOOL �80ea. � FOOD SERVICE: 1 � LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S85 _CONI'INENTAL �35 NON-PROFIZ' $30 >100 SEATS 5160 COMMON VIG. �60 WHOLESALE 580 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERMIT# _<50 sq.Yt. �50 _>25,000 sq.ft. �225 VENDING-FOOD �25 � �<25,000 sq.ft. S80 �O�'�� _FROZEN DESSERT S4Q _I'OBACCO 5» i NANIE CHA�iGE: S10 AMOUNT DUE = S 8 O .Of� *****PLEASE TURi�i OVER Ai�TD COMPLETE OTHER SIDE OF FORivI*"*** � • � 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 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 Yannouth taxes and liens must be paid rior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NYOTELS AND OTHER LQDGING ESTABLISffiV�NTS 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 of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(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 CNIR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected : by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days pnor to opening.PLEASE NOTE: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 standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtalned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,_or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQi.TIlZED 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 THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A SITE PLAN. DATE: I j� SIGNATURE: I�,� PRINT NAME&TITLE: "C�(J�f� � (�Y�•r_1 1(vY1Q,1� ioizi!os � 1 I � � �,. ; �\ The Commonwealth ofMassachusetts Department of Industria!Accidents ; N�Nir�sllfer�s � 600 Washingtoa Street, 7`"`Floor ' Boston,Mass. 02111 � Workers'Compeesation Insnrsace ABidavih Bnilding/PlambinglElectrical Co�tractors , i�f�"m�t[srt: P'l�re 1'�II�PI'le�1b1► , i name: � i address• ciri state. �p. p�� work site location(full address): ` ❑ I am a homeownet performing all work myself. Project Type: ❑New Cons(rucbion ORemodel ❑;I am a sole proprietor and have no one working in any capacity. ❑Building Addition ! [�I am an employer providing workers'compensation for my employees worlcing on this job. � com �e: � t-t7 � : ��: �S 2� Z� ; �jo. a/' o?.l��n� �#:J� � d�a j ; � �. �2 2 S � �G D : � � ��._� ,. , _�� ._ r_ ,, � I am a sole netor eneral contraetor or�omeowner czrcle one and h � .. s j��h�� > ❑ Pt'aP ' ��,8�� , om ave hired the coatracta�rs listed below who have the following workers'compemsataon polices: � _ : comoanv eaue• i � �� i ��, nhoue#• iwapraace co. : , # . ., . .. � . aonoa�v�e: a�ress• �'� ohonc#- _ _ ; _ , ,._ i�#M�' ; _ - -- ___ # . ., .�•, � s' ,. ,, ..:, �,� , �v,. � ::� -� .,_ , .., -... .. . , _. : Fa�re/o secm+e ooverage as inyair�ed�ader Secf�i 2SA e[MGL 152 eu lad h tYe io�IMr�f'cri�ioal peoaNks�f a�e�b 11,SN!0 a�dl�r one ye�n'haptbeammt as�ae dvY pea�es h tie form of a STO!WORK ORDER aad�8ne st 31A0.YS a day s�aimt me. 1 anders�d t6zt a cepg d this�tatemmt my 6e fot�vaMed b the O�oe�ltived�tls�s�f t6e DIA tat avenge veriAcatlea. /do Ner+eby c ueder Mre penelliea ojperyiury tlFat tbe iwforwadori provlded aboNe is d4r aw cornrt �� Date � d� Print na� Phone#�� 0 efficial aae�sly do set�vrite fm t�s area t�6e oemmpl�fsd Dp cih'or�wa�cial 1 cily or to�vn: I permif/�Cense N 1—LBoil.l�g�� ❑check if imme�ate rc�penx b reqnired �Sdxtmea's O�ee ceatact perwn: �y�#� ��t l��-�1�'!) I � I t � ' ' " ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #09-041 FEE: 50.00 ; � In accordance with regulations promuigated under authority of Chapter 94,Section 305A and Chapter I i l,Section 5 of the General Laws,a permit is hereby granted to: � ! Rome Candy Co., 975 Route 28, South Yarmouth, MA Whose place of business is: Candy Co. Type of business: Retail Food Service less than 25,000 square feet ' To operate a food establishment in: Town of Yarmouth � � + Pennit expires: December 31, 2009 BOARD OF HEALTH: .`�E¢L¢tt S� J2.JV., 'C.�ai�e�nuuZ � C�arxlea ,�. ��i�E`�'i�eti `l�ice C''.har�cncun J�t�.��rar�C, C!�e�k ? fln�c�!�reerclFaunc, Jt..�V. I E�� ° Januarv 9,2009 ruce G. urphy, ,R.S.,CHO Director of Heal I � a � r "•9 Jt �Y�k TOWN OF YARMOUTH BOARD OF HE�4�1�� , �' ° .�' s�. �'; � s APPLICATION FOR LICENSE/��RN��- ►�;�� j ��►�x � � , a U�C 1 7 2007 , � � � � � � �� ..,��'`� , * Please complete form and attach all necessaryw�oc��i�ar�ts'�iy Decem e A��-DEPT. Failure to do so will result in the return of your applicaxion pa . NAME OF ESTABLISHMENT: � '� TEL. #�� S�G'�"CC�%� ' , � LOCATION�DDRESS: 0 ; MAILING ADDRESS: • � OWNER NAM�: (,� �IY�-- TAX IN r N - CORPORATION NAME (IF APPLICABLE): � . ' MANAGER'S NAME: SAIYU� TEL. # MAILING ADDRESS: ,p�y�C_ _ POOL CERTIFICATIQNS: The pool supervisor must 6e certified as a Pool Operator,as required by State law. Please list the desi�nated 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 � eertifications to this form. Tt�e �ealth Dep�rtjnent wtll not use past yea�s' reeords. 3�oa ��st provide ne�� ; copies and maintain a file at your place of business. G 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 Establislunents, 105 CMR 590.000. ; Please afitach copies of certifieation to this applieation. 'i'he Health Department�viH not nse past years'recards. ! You must provide new copies and maintain a file at your establishment. ! � f 1. 2. P��S�I*T.IN_�Iit�R.��: _ __ _ __ ___ _ _ _ _ __ _ � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. �• HEIMLICH CERTIFICATIONS: : All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedur"es below and tta h co��es�o��m,��oy e,��rt„ifications to this form. The Health De�arrmeat will not use past years' records. , �� ^�.��{�'.,� '�� &Y�� y � `�+�.;��,q`.�,�`��''"i�'�� ": �' /,`� � � F� � ':..x . �1J k f N 5' d V t+ .� � t Ar`'3 ! •: b y l�" , �` ,� v t'� �,r ;�� s R x ��k y °`sa � . �',� 3 q 1 p 7 �' c 1` .n . , ��: �k . `�� 'a a � � �� ,.- �t s a+'� C � t� � x r „»� � � 4� (- a :� .�``. ,�:�, fg, s•n.�e �..r:k .,�. ��i �^-.a' ' �'�:�FY�k r`�t,fi�'�c,.,.ax�.�k', v,�'., ;a rr. . . . ' "� ��. � . . . _ 3. 4- RESTAURANT SEATING: TOTAL# OFFICE USE Ol�LY LODGING: LICENSE REQUIRED FEE PERbIIT# LICENSE REQUIRED FEE PER'�IIT�* LICENSE REQL'IRED FEE PER'�IIT= B&B 550 CABIN SSO _M07EL S50 INN S50 CA:'�IP S�0 SVVIyLv1ING POOL S75ea. LODGE SSO TRAILERPARK S100 V6T-iIRLPOOL S75ea. FOOD SERVICE: LICEI+IS£REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P£R'�<fIT� LICENSE REQti IRED FEE PER'�I1T= 0-100 SEATS �75 _CONTINENTAL S30 NON-PROFIT S25 >100 SEATS S150 CO'�L'�ION VIC S50 V4�iOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERy1IT= LICENSE REQL'IItED FEE PER�III'� _<50 sq.R. �45 >25,000 sq.2�. S200 VENDI1vG-FOOD S20 I <25,000 sq.ft. 575 ;�3 - _FROZEN DESSERT S3� _TOBACCO SSO v��c��rcE: sio AMOUNT DUE _ $ �S•o� *****PLEASE TL'R.\O�'ER A\D CO�ZPLETE OTHER SIDE OF FORJi***�� 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 ogerate 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 ta.xes and liens must be paid prior to renewal or issuance of your pernuts. PI,EASE CHECK APPROPRIATELY IF PAID: �s `/ 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 us�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence eLqewhere. Transient occupancy sha11 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 tha.t is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be consider�Transient. * NOTE: En��osed Motel Census must be completed and returned with t�is app�ication. 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 capen�g. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � --- �-�-State eet�ti€►ed lab;-prior to opening, and c�uarterly thereafter� - POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE i CATERING POLICI'• Anyone who caters within the Town of Yarmouth must notifiy the Yarmouth Health Deparnnerrt by filin�the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtasneti 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 i Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut uritil the above terms have been met. i OUTSIDE CAFES: ; Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeatth. ; OUTDOOR COOKING: ` __ 6ut�toor�ovi�ing;prepara 'ran,-ordisplapvFariyfoo�product by a retail vr fc>ot�servir�� ' prohibited. � I i � , NOTICE:Permits run annuall from Janu 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCJRN Y �' THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�VIVIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEME�iT. RENOVATIO�tS MAY RE IRE A SITE PLAN. DATE: � �� SIGNATURE: � �� J � PRINT NAME&TITLE: w l�l.L, 10 30 n� � The Commonwealth of Massachusetts Department of Industrial AcciJen�s � �.rrw� < 600 R'ashington Stree� 7�b Floor Boston,Mas� 02111 r Workers'Compensatioa issarance Affidavih B�ilding/PlambiagJEkctrical Coatractors �: b I,t�G r� . tyt,c.— a�_ � 4 - 30� /�,� _ city �` /a�/yl�L� state: L'/� zip• ��nl�e# �� P 5 7TJ � work site lceation fnll addttss. �� I�.�G � �• V Q� ❑ I am a homeowner performing aII wark myself. Project Type: New C�structiar�❑ emodel ❑ I am a sole proprietor and have no one working in any cap�ity. ❑Building Addition f�I am an ernployer providing workers'compensatian for my employees woiking a�n this job. _ �--l�t lY _ _ _ ____ . aom �ame: - �: ?S' L �� o� f` t�l 4?-fA� #- c�lc�'�"� �. ^ C�_ � �G � <_ . � .�,. � . � � � : . , � �_ z,.�� . , �..;� .�q� r:�� x: 0 I am a sole prapriexor,g�eral costrscMr,or Mmeowaer(crrde orre)and have lrired the co�ractors listed below who have tl�following workers'compensation polices: coona�v ame- addiress: dtv uYo�e�; � `. �;. . ,� , �.;, � �� -� � �,�.. . .�. �,<: --; �..,,:. c�o�v mee• a�: c�: o�o�e�E: # �� „�. Fsan�e d seeae cr�era�e as req�al a�3a�ZSA�f MGL 152 eai lad t�1Ye irpai�a�f cri�id pcaaltles�f a�e�p b S1,SAlM a�dl�r�' o�e years'�prh�t as wN as eivY peealtles ie thE ferm o[a 3TOr WORK ORDER a�d a 8ne�f 516�.N a day agahat ee. I ysderslud tiat a cepy�'tY� my 6e firwarded 1�the O�ce otlm�ef tlie DIA fer ewaage veri�eatl�. 1 do hereby c rnrder NYe e[hes of perjiny tAet tJit iwforu�ettoe provided above is b�te d n+ect �8�� , Date �i� ��,_ Print name Phone# �V ��O �r� e�eial a9e oaly de net w�rite ie this ar�ea to be co�pkted by city er�wn a�Ccial city or to�va: p�ioeme# ��t ❑c�eck Kimme�ale re�psnse ie reqairtd �'s O�ee ❑Heallti Dep�tf�eet eo�act penen: pho�#; �er l��p-�) . ' � TOWN OF YARMOUTH BUARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-033 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: Rome Candy Co., 975 Route 28, South Yarmouth, MA Whose place of business is: Candy Co. Type of business: Reta�Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOA1tn oF HE�,TH: .�fe�eri Sf�, J2.JV., �'f�a.vut►taa C'l�ax�ee .�.�fi�'�'i�ex `Uice C.f�av�nu�t J��ct�.StZ�cu�, C�i � C�lrut Cdx.eer�cuun, J�t..N. December 28.2Q07 Bruce G.Murphy, .S.,CHO Director of Health , � � ` �P �O`�R� TOWN OF YARMOUTH BOARD OF HEALTH �i � C� I� I1 �? i _, DD a --:o �`: .�,;� APPLICATION FOR LICENSE/PERMIT-2007 � � DEC 2 2 2006 * Please complete form and attach all necessary documents b ec� er 31 2006. Failure to do so will result in the return of mur a � " ; y pp�i�atfon pa E�LTH DEPT. i 5.. NAME OF ESTABLIS�-IlVIE : �� TEL. # LOCATION ADDRESS: 7 � MAILING ADDRESS� OWNER NAME: � r �'( CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �Cl YYt� TEL. # - MAII.,ING ADDRE5S:_ �u►�Yl� , POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. 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 j Community Cardiopulmonary Resuscitatian(CPR). Please list these employees below and attach copies of employee � certifications to this form. The Heatth Department will not use past years' records. You must provide new copies and m�intain a fde at your place of business. l. 2. i 3. 4. i i ; FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 5�0.000. Please attach copies of certification to this application. The Heatth Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� 1. 2. i ' PERS(JN IN CH�4RGE:_ ____ _ -- _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. i � HEIlVILICH CERTIFICATIONS: I 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-cholang procedures belovY and attach copies of employee certifications to this form. The Health Department will nat use past years' records. �: �o�� r��=��ri�.�°'��a�s��b��. r; :w� : �� M� F: , fi 4 .� P�§'�'�Y{�. �I +s4' �.D�� +� 1 a 1 `,.a µ ��a �:.,r� ��h":,a '�S ... �`." 5. i r "{. ��.: c� 7 �� r �y,r ti �' s�r '��t;. t�+a� � F f � ., 'tx -��r Nr�� r�tk�r�. , .-� � ;� ,� . �m. a� x�� ". 'fi- .4Pna 8> ''�a . . � a_ a ..E ii'+�r °Qa .i,,q ?." ",°'S,� �, w 1 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B �50 _CABIN $50 _MOTEL $50 i INN $50 CAMP $50 _SWIIvIlvQATG POOL$75ea. LODGE $50 _TRAII,ER PARK $100 VI��RI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LIGENSE REQUIRED FEE PERMI'P# LICENSE REQUTRED FEE PERMIT# 0-100 SEATS $75 _CONTA�ENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAQ.SERVICE: —RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# T<50 sq.ft. S45 _>25,000 sq:ft. $200 VENDING-FOOD $20 I 45,000 sq.R. $75 �� _FROZENDESSERT $35 _TOBACGO $50 NAME CHANGE: S10 AMOUNT DUE _ $ 7,�• OO •"••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•"* ��.:...,:.,:. i t ,� ADMINISTRATION Under Cha.pter 152, Section 25C, Subsection 6,the Town af 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 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 ESTABLISffiV�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Tra.nsient occupancy shall be limited to the temporary and short term occupancy, ordina.rily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use af 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, sha11 generally be considered Transient. POOLS POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected by the Health Department prior ta opening. Contact the Health Department ta schedule the inspection five(5�days pnor to opetung. POQL 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 Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE ' CATERING POLICY: Anyane who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Apptication form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Froaen desserts must be tested on a monthly basis by a Staxe 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 rnet. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter�waitress service),must have prior approval fram the Board ofHealth. OUTDOOR COOKING: . _Outdoor cookin�,prevaratior�Qr dis�lay of any food_product by a retail or food�ervic��stablishment 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. ' Ai,i, RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQIJIPMENT, ETC.),MUST BE REPORTED TQ AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMII�NCEMENT. RENOVATIONS MAY UIIZE A SITE PLAN. ' D SIGNATURE: � � ATE. a�- (�CP PRINT NAME 8c TITLE: �' ✓iS• ' 10117/06 3 �S � �. � The Com�nonwealtJ�o Massachuset�s i f � ' Depart�rient of Industrial AccidenLr � N�If�/� � b(In WashiAgt�in Stree� 7`x`Floor i Bostorr,Mass. 02111 - --- --- workers'com tioe Issm�aace.�a�vn:s�ii - bi�lEl�drual co�aaetors �. . „ � �, �„ , . �. ; name• � � address. i I Clty 318tt' ZID' i�lOIIC# i i w+ork Site locatia�(full addres3l: ❑ I am a homeowner petforming all wo�k myself. Ptoject Type: ❑New Caa�slructio��Remodel I a sole 'etor and have no a�e w in an Buil ' Addition j I am an eanployer viding workeas'compensati�for my e,mploy�s worlcing ar►this job. i �- : , . _ ___-_ _ - - - ._ _: _-_ • �,Vl . . . . �ts� ��. . a ou� �- �et- . w c. � � i o ❑ I am a sole proprietor,ge�a�al e�tracter,or�teowier(circJe oirt)and have}rited tbe c�tois listed betow who have the following wo�lcers'compensation polices: ' �'• �i�,c� ��e: �-.,�_� ....._ �• F,aa+e a seee+e orRra�e as rey.iroa.�der sec�.2SA.t MGI.lst e..le�a a ue i.p..Mi�..r�pdal0a.ca aae.p�.s1,sN�M a�d/�r o.e�•�rt»..m��we�,.d.r��.ere�n..t.smr wox�c oxnx�a.a a sne.rsieo.M�aay�,�. i ma�.a mc a apy�f tYie Maleaieat dy 6e firwarded M Ne dmce e[lm��t�D1A toresverase v�ettlw /do lYeneby ' rndere t�e s a d pt�of ptrjxry tNat t1Ye iwfonri�proddel aboNe ls�rrte ae I oernc� �B� L— � Date _ �' �o Print name � Phoae#�Iu�,L19 "/�� effie�l ase enly d�aot wrke i thia am ta be c�plaed bY dty or Mw,�al cit�'or tewn: � De�utoeet ❑eYeck K�1e reapes�e is reqei�d �Sd�'s O�ct �� ee�act Person: P4�ne#; Dp� tn.�d sq�c wo3) � � � , - , . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUNIBER: #(}7-039 FEE: 5.00 In accordance with re�ulations promulgated under authority of Chapter 94,Se�tion 305A and Chapter 111,Section 5 of the�'ieneral Laws,a permit is hereby�granted to: I Howard Rome, 975 Route 28, South Yasmouth, MA I � Whose place of business is: Rome Candv Co. , Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth , Pernut e�ires: December 31, 2007 B�ARD oF HEAI,TH: B `n. , /�`�., ' ; dle��5'lr�lz, �sce G��S�vt.,r�.z ; R�t�B�«�, G'l� � n�� 4.� � Q./V. March 27-2007 Bruce G.M H,RS.,CHO 13irector of H , i �� '" � �l( {O Ro�eE�4y ��AR TOWN OF YARMOUTH BOA O ��' o 32 •� '�. '�' G� � C� �� ] C� D o �''� APPLICATION FOR LICEN��lP . ��86 � � � � � �� * Please complete form and attach all necess�y d6Ci�inent by Dece er�1 Zpp��z005 Failure to do so will result in the return ofyour application pa k�.Eq�T�-! E:?EPT. NAME OF ESTABLISHIVIENT: TEL. #�,�(��D LOCATION ADDRESS: r 2 � MAII,ING ADDRESS: ` -o • ✓ �� ic� . I OWNER NAME: TAX ID IN r S � � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: I The pool supervisor must be certified as a Po�l Operator,as required by State taw. Please list th�designated � �'oui-Operator fs)�nd-attaci�-a�opy of the certification to this forrt�. � � 1. 2. I i Paol operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and � Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee j certifications to this form. The Health Department will not use past years' records. You must provide new � copies and maintain a file at your place of business. � � 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: A11 food service establishments axe 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 certifica,tion to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. _ g�SOAT IN��ARGE:- _ - ._ __ ,__ _ __ -- , - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i l. 2. ; 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 all times. Please list your employees trained in anti-choking procedures below and � att��i-cc�pies of employee certifications ta this form. The Health Department witl not use past years' records. � You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN �50 _MOTEL $50 i]NN $50 CAMP $50 _SWIIvIIvIB1G POOL$75ea. — _LODGE $50 _TRAII.ER PARK $50 _WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIl2ED FEE PERM[T# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 NON-PROFTT $25 _>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: � s �j �;..A � q� ��.'� •�,+� � '� � ��w 4- ��'"��. � �_..'��3 a'� �r��'f' '�. '$ ,y ��..�„�' � t y r p,�' r;i � .,�,j- �t.t � -. � ,,� �.. a y � .�yR�a �� 5 t s,��s H �*�,.a, ��' �_ �' �'Yq+R ,x ,� 4-�h�.r j a"` �`:, Y` ,: ,� ,�,,. � � � '� �� . � . .�s� � '�3�4�r a = �.,i Xt��-: ��.s ��.y 3r� �<n.�ww-,�F �:t n y, i p� �� (�"�'� �'te� �� a r�":$'E*°Y'�� _� �+, x. `�.�.3'w.p �r".^s� 'a„w��ku �.'bM�..� x"...r _4��'� .q*,, r"'e�,,^.,;? �% ^?�c ._v.7. <�`vfir�'�"dt;,.��.��M �QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ ?$'•00 A R R R ApLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*""" « ; AD1ViINISTRATION ; Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ; of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO ' NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RET[TRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2Q05. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPE1vING FOR THE SEASON. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMN�NCEMENT. RENOVATIONS MAY REQUIlZE 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 opemng. 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 wluch 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 hows prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Fro�en dessefts m�st be tested n��ont�basisby�S�ate eertified l�tb. Test res�ts�ust be�e��-tt3�I�ealth , 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,preparatioq or display of any food product by a retail or food service establishment is prohibited. � DATE: SIGNATURE: II' PRINT NAME&TITLE: 09/28/05 � � `�� The Cominonweahh o Massachusetxs ��_-_-_� f - Department of Indastrial Accidents � __ = N�'1�irl�li� � - _ _ -= 6(IB Washington Stree� 7`�`Floor � _-l„ � Boston,Mass. 02111 ��Wori�era'Com�aahoe I�s�a�oe Affidav�B�ildiog/Pl�mb�glEleedncal Ce�tnetars �..<< ..,.. M�. . , ,. ,�� , „ ..� . ,_:. ��y d ,. ,.. .�v� di. tnik. 5 A� ,''." �'�`Y '�,�..��F.�.s^' `�r'.M-y'S � q . sa a r name: q a�: �b �vC,�� k �. city ��L �}l I 1�, state:L 11� zin: �� ohme#�� / /0 "l�C7J / work site 1 'at fnll address: J � c�D e D ��.(p W ❑ I am a itameowner performing all wark myself. Ptoject Type: New C�ructiaa� odel I am a sole 'etor and have no one wo ' in any capacit� Buil Addition ,. _, .. ,.. , _ � ,.,,.` ` ..�� ,.�a �� ,� - � .�"°��'��,.. �� . � : � I am an e�nployer providing wotkers'compensati�f�my employees wo�cing�this job. _ - - -- g�i y�e 4 Lk:1,M;U�i � �� f�-1 � ' ao M� �2 �o #-�� r a�� -r� �ee.r S� G � 11�C. o ❑ I am a sole proprietor,geseral co,tractor,or bomeowa�(circle oAe)and have lured the contractors listed below who have the following workets'compensation polices: �: div nia�e A�: . # ��,�.x,�.�,�,hP'f� �w tar:_.. .-o'"� ,,,�.w- =;sra`� r'- �� -h`�"�'a � _,x�.. ',� c .�,.� , ., �`a., � _..., ..,., _. . , m, ..„_.. . .. _. �ffiY L�l: �' ciN" Dliai!#• +, c�3,,. Mxs �' "v�:`"�a K��3,'s��' .,aui`." a��'��,'��'i�»��e:'"r�. `Y`u�� Faiive�s seearc orrerase a�req�ed��dv Sec1Ma 2SA ef MGL 152 aa Ind a tYe irpaiWa�f cc�ial pe�alMa�f a�ose�a t1�M.M aad/�r oae yan'imprboament a�wr8 as dv�pe�altles in the brs ot a STOI'WORK ORDER aad a Sne et 5169.M a day�t me. 1 ae�s�d t6at a cepy et tria�fa�e�eat my be ferwarded/o tee Oeke of l�tleffi Af the D1A for cevera�e vea'iAntle�. I do ke►+eby ce ' ueder tli r penelties of perjrRy tNet tlYe infoe�adon provide�i aboae is tr�e awd Qomct Si Date �L/Z�/0 S'� Print name '— Phone# ��7��"C�'�� et6cial ase only do not�vrite�this area to be comp�eted by cHy or tswn o�i city or tewn• permiHliceme# �Baidfmg Depariment �l.keefia8 Boud ❑c�cch if immedjabe nypeme is req�red �'s O�ce QHaNY De�at�egt centaM peraon: phone#; � (,�,�a s�c Zoo3� � ; � . a T4WN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A F�OD ESTABLISHMENT PERMIT NUMBER: #06-040 FEE: $45.0� In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby'granted to: Howard Rome, 975 Route 28, South Yarmouth, MA Whose place of business is: Rome Candy Co. � Type of business: Retail Food Service less than 25,000 square feet � � To operate a food establishment in: Town of Yarmouth � Permit expires: December 31, 2006 BOARD OF HEALTH: B �ust$. �ond.ors,�_`n., ' i d�� s!�lz, .N., ?/�G'l�vw,�.� ': �� 4� , R February 2,2006 Bruce G.Murp , RS.,CHO Director of H th i I i r ; p= '- ��3a8b�t o�',R • .-�� TOWN OF YARMOUTH BOARD OF HFA,L1`H�`�-� � � �, �� °' � a ;o .� - � ��` APPLICATION FOR LICE � 2 �5 �: .�? N�� ; � .� JAN 1 4 2005 , ,�X;:� _ g��. �: * Please complete form and attach a11 necessary{ �um December 1 ; Failwe to do so will result in the return o��ur apphcaxion packet. '��•LT H D E i�T. i � NAME F ESTABLIS�-�1ENT: - TEL. # - - �D j LOCATION ADDRESS: �S Z r p � � � MAILING ADDRESS: � i OWNER/CORPORATION NAME: o� - " �. MANA ER'S NAME: fYl,c.- T�,. MAILING ADDRESS: � � -z � PQOL CERTIFICATIONS: The poo!supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. � 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. T6e Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: ! All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. Yoa must provide new copies and maintain a fde at your establishment. ; 1• 2. F�RSON IAi�HAREC�: -_____ __ ____ _ _ _ __ _ _ Each food esta.blishment must have at least one Person In Charge(PIC) on site during hours of operation. 1• 2. HEIlVILICH 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. Plea.se 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. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $50 IIVN $50 _ �CAMP $50 �SWA�IlVIIl�iG POOL$75eR. _LODGE $50 _TRAII,ER PARK $50 WFIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMI'P# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERNIIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VTCT. $50 WHOLESALE $75 ' ftETAIL SERVECE: �., ��.. � . . � . . .: . .,., �, < : � .. : - „ � _ �,. 4 LIC�NSE REQUIR�'�f,=,FEE ,P��rIlT.i� �..:, �,IC�1+F'��REQ�,JII�ED. b".EE � FE�T'# ; .� LIC�fSE REQiJllZEF3 FEE ;,,,�ERMIT# , ' _<50 sq.ft. $45 >25,000 sq.ft. 5200 - vVENDING-FOOD $2fl . _.., _ �Q5,000 sq.ft. $75 �6 � FROZEN DESSERT $35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 7�'..Od '""'•PLEASE TURN OVER AND COMPLETE OTHER 3IDE OF FORM"""*' f ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 INSiJRANCE 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: J YES �J NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T�-�E COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT TF��ALTH DEPARTM�NT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEAS4N. ALL RENQVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR i TO COMI��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 outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CQNSUMER ADVISORY: Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY• Anyone who caters within the Town of Yarmouth must notify the Ya.rmouth 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. FROZ�N DE3SER`FS:_ _____ _ __ _ . ' 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 you�-Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdo�r seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i DATE: SIGNATURE: � PRINT NAME& TITLE: 10/22/04 � - - t i <�°. �-�--� The Commoawealth o Massachusetts - ==_- .f _- - - = Department of Industrial Accidents � _- = N�'f/fi�/MMR _ --= 600 Washirigto�e Stree� f""Floor --- Bos�on,Mass. �211I �• Workers Com hos I�maate Affidavit:B'il ' bi�lE _,, . .� � �� ,. � � , °r .._ IeetricAl Coatractors � U, ;. �� ;,��,: .: r A �•�� ` ��,. , ,� r._ � name- ad�s: � �S I� e• $ � T -a- � Z�p � �o� r � p _ wo�x�� -� r,�uu�s• Z �. 1'T�lo y ❑ I am a homeawner performing all wark myself. Project Type: ❑New Ca�ara��Remodel I am a sole 'etor and have no ane w ' in an ca ' . ❑Buil ' Addition ❑ I am an e�ployer pso iding work�s'compensatio�far my employees worlcing aa►this job. `� t �. �o• ,�n �, „��- v`�-3��-�.� �e� �S � C�. o ❑ I am a sole praprietor,gc�eral co�tracMr,or homeo�rter(�arde oae)and have hired the contractors listed below who have the following wotkers'compensafion polices: �: �: _ c�ls: _P�.�F.i.. #� �a�: �: e�itr; ��. � FaOm�c a sec�e ew�era�e a..eqdnd.�dv sedi.i ZSa.rMGL 1S2 ea.ieaa a u�e ierpMitlH.fcrt.ial pe.aNia.t'a fe.p a t1,sM.N a.dl.r s■e years'ieq�riw�ant as well n dv�penitla ia tre 6�e�ota STO!WORK ORDBR aad a Ane e[S1M M a day agaidt ae.I mderslud tht a c�py�f tiis stalea�t my be f�rwardcd 1s He Oeioe a[I�af�e[tlk DIA fir averase veri�eatlw. I�o lkeneby e �ra�der dYs p d p�neltt�s o +.�EI� P a f ptry�wry thtt dYe isforaxrAion provtded abo�e is s aa onmrt Sig"a�°�e ,,,.� nan �/7`�j Prim name �- Phone# � -(�I�� effixial ase asly de aat w3ite h�t�s ura ta be e�pteted 6Y e1lY ar lwvn s�cLl city ar tswn: �* ��a�t ❑ebtd�if imma6ale respeme is reqeed �� QSdxde�'s O�et eentact persoa, �De�r��e.t c�.�a s�c 2om� Phese#; J� . . TOWN OF YARiViOUTH BOARD OF HEALTg PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-054 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: Howard Rome/Rome Cand Co. Inc. 975 Route 28 South Yarmout MA Whose place of business is: Rome Candy Co. � Type of business: Retail Food Service less than 25 000 ua.re feet To operate a food establishment in: Town of Yarmouth , Pernut expires: December 31 2005 BOARD OF HEALTH: Be�r,;��y, (�y��j,f�y. P��la��tt, ?��G��;� Rod�t�B�o�,, �, ��s!� R.N. �� R.N. � � February 3 2�5 Bruce G.Murphy,MP .,CHO � Director of Health ; i , � i , I , � � ; i � ; - - � ; � .:- �,�� •O`r R�r TOWN OF YAItMOUTH BOARD OF HE �� Q �1� � � b C� DD a ; �: � ;`;� APPLICATION FOR LICENSE/PF�VI � O+f�'4 '� { ..•• .� �` � � �r FEB 0 6 2004 ; * Please complete form and attach all necessar�d�aeumentsby Decembe 3��1-I DEPT. ; Failure to do so will result in the return�fyour application pack . I I ; { � � o a � N A ER' NAME• T MAILING ADDRESS: Srirry�2_ POOL CERTIFICATIONS• The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Po�� Operatc,�s)and ati�ch a copy of t�e cer�ifiiation i� this form. 1. 2. � i Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid iand Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. i � ( FOOD PROTECTION MANAGERS - CERTIFICATIONS• ; All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. i 1. 2. --- _ -- -- --_ __ _---- _ __ -- ---��ar�nv-ci��: -__ __ _ _ ; Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I 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 all times. Please list your employees trained in anti-choking procedures below and attach copies Qf 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 busiaess. ' � . . . . . . . .. . � � . . . . . . �' x. .a^ `,�» � ,ti.' � 1• �. 3., .. _ _ 4, ,.: RESTAURANT SEATING: TOTAL# Q�FICE USE ONLY �ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FGE PERMIT# L(CENSE REQUIRED FEE PERMIT# _B&B �St� _CASIIV $50 _MOTEL $50 _INN $50 _CAMP SSU _SWIMMING POOL$75ea _LODGE $50 _TRAILER PARK $SO WHIRLPOOL �75ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS S75 _CONTINENTAL $30 _NON-PROFIT S25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SO sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 �<25,000 sq.ft. ��5 �`-��(� _,PR07.EN DESSER'f S35 _TOBACCO S25 LVAME CHANGE: - -� AMOUNT DUE _ $_ 15�Oo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***�" . . '.�� v. f ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ; � CERT. OF INSURANCE ATTACHED � 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 RESPONSIBILITY TO RETLJRN : THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2003. � � SEASONAL ESTABLISHMENTS A.RE 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 REQUIRE A SITE PLAN. AI�DITIONAL RFGULATIONS i 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. P�OL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � closing. ' FOOD SERVICE CON.SUMER ADVISORY: Each food esta.blishment wluch 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. F�O��?��E-��.__ _ _ -- _ -- -- _ _ 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 resuJt 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),mt sti have prior approval from the Board of Health. QU'TDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. : ; DATE: SIGNATURE: . PRINT NAME& TITLE: 10/22/03 � Gfk p, �C I .�w , I . C' I � The Coinmoawealth of Massachusetts � � Department ojlndustrial.-�ccidents � o OfAceoller�s�lostliis ' � 600 Washington Street ' ,•` Bnston,Mass. 02111 � " �� V4'orkers' Compensation Insurance Affidavit n m. (,v on: �J ��d • �� a �j �Z� � I am a homecw�ner pertormin;all w�ork myself. � f am a sole proprieror �r.� ha�e no one��orkin_ in am•capaciry �] I am_an_empio�er pro�idino w�orkers' compensa_tion_for my e_mp_ioyees w•orking_on this job. m an • n . �� : address: "1 7� �'e- � �'�• ��1� �tli .. �o, � , �, � _ � �,` i ur�nc � � � p ��, C � I am a sole proprietor. Qeneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ ��orker�� :ompensation polices: zomoanv name• a�dress• citti: nhone M• insurancc co. FQJi�y# comoanv name• ad d ress• �'� nhoee iE• insurance co. ��eY* t Failure to secure covera;e as requ�red uoder Secdoo 2SA of MGL 1S2 ea�!nd to the iopo�idoa o(erisi�tl ptadtla of a O�e op to SI¢00.00 a�d/or one years'imprisonment as w•efl a�eiril penaiNe�in the form of a STOP WORK ORDER aad a tise of SI00.00 a day apin�t me. i a�dersa.d mae a topy of thh statement may be for.varded to tht OlTice of Inve�ti�auoos of tAt DIA for tovenae veritiudoa /do hrreby cen }•under thrPa�nd penalties ojperjury that 1ht injorneation provrdtd abovt is true conect ��._ Signamre ! � � � Print name � V one�f �(�/�� .. olTicial use onl� do not w�ite in this area to be completed by eih or town oflttia) ciry or town: Y�� _ permiNieeau N nBuilding Departmeet �Liceosing Boa�d ❑check if immediate response is required 261 �Seiectmen'e Ofiict ()HealtE Depanment contact person: phone N:_ �508� 398�?231 eat. nOther ,....�. � .<��4; ' . � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-060 FEE: $45•00 In accordance with regulations promulgated under authQrity of Chapter 94,Section 3ASA aud Chapter 11 I,Section 5 of the General Laws,a peimrt is hereby granted to: , Rome Candy Co.,975 Route 28, South Yarmout _ MA Whose place of business is: Candy Ca Type of business: Retail Food Service tess than 25,000 square feet To operate a food establishmc,mt in: Town of Yarmouth Fe�mit expires: December 31 2004 BOARD oF HEALTH: B�ei�_`?!. (�'a�Bars, �`.b. • �/l�l�t+�, ?lics G�i�rai�ea�,a�ra � �f�.�. Sl�. R.%Ye� � R.N. � , ; ; March l0_2004 � Bruce G. urphy ,RS.,CHO I Director of Heal 1 I i � � r i i I <,�C.�ui3� ��' c��'�" G3 C ��j�,� ' ' �r R.� TOWN OF YARMO �ARD OF HEALT o�� APPLICATION F NSE/PERMIT-20 3 FE B 0 5 2003 � .;? �.� , ;� , .� PT. * Please complete form and attach all�cessary documents by De T Failure to do so will result in the return of your application packet. N T T• # 0 - -�'D L A I 1� � - I'I'VLva D 1�i -`(}. � �� i TI ' . # � ��I � D S ..(�- ,� POOL CERTLFICATIONS: ; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated PQoI 4perator{s)and atta�h a�opy of the�ertification io thisform. � 1. 2. ; Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid i and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this forrn. 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. I 3. 4. I , � FOOD PROTECTI0�11VLANAGERS - 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 Department will not use past years' records. You must provide new copies and maint�in a file at your establishment. 1• 2. I ( pE-�cn=�I IN C'�R��r_ ____-- ------ __ - _ _ . _—__ _ , _ - - �_ ; Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. i. 1• 2. HEIlY1LICH CERTIFICATinN�• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and atta.ch 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. RFSTAURA�IT SEATIN : TOTAL# o IN : OFFICE i1�F ONLY , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B �50 _CABIN $50 _MOT'EL $50 _II�1N $50 _CAMP $50 _SWIMMING POOL$SOea. _LODGE $SO �TRAILER PARK �5o _WHIRLpOOL a25ea FOOD SERVI E• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 �NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 � .... ..,. .., � � � , . ._. .. - -- ,. .�. , $�T�e.�',R�CE:� ._ � ., . ,_ i . .,_ , I 4' LICENS�2tEQUIItED ;FEE ��R�1.['�"# , LICEIVSE REQiJI�tED PLE ;PERMIT# ,�.I�E�SE R�.QIJIR�D;FE�" PEI2MIT# ' i ,_TOBACCO $20 �<25,000 sc�.ft. $75 O.3� �TOBACCO � $20 � _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 f NAMEC ANGE• $10 AMOUNT DUE _ $_ 15.p0 � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i r j ADMINISTRATION �� .• f j��P�.� e i��-, � , Urtd�er`�li�p�`er 15�, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO 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 ESTABLIS��VtENTS 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 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. C'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 DESSER�____ — - –- ` ---- -- _ _ --Frozen 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. OUTSID►E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any foo roduct by a retail or food service establishment is prohibited. . '. DATE: SIGNATURE: ' PR1NT NAME&TITLE: \ �-• i 10/18/02 ♦ - � a� � . ' . . . � � The Coinmonwealth of Massachusetts � � Department ojlndustrial.-1 ccidents ; Of11C001/OYCSl10��lI/t 600 Washington Slreet ` Baston, lKass. 02111 �, ' " �• W'orkers' Compensation (nsurance Affidavit n m.. �U. a �� , �- o Z (� # � f am a homecµner pertorming all w�ork myself. � f am a sole proprieror �r.� ha�e no one��orkin_ in am�capacitti• � I am an emplo�er pro�idins w�orkers' compensation for my�empio��ees w•flrking on this job_ • na _ � ddress• �-o ' � ` - � Y � . So� 3 k -�� i ra n c �� '�'S� Y(,Lti q �,fl� Z, � I am a sole proprietor. generai contractor. or homeow�ner(cire e oneJ and ha�•e hired the contractors listed below �tiho ha�e thz follu��in: �corker�� ompensation polices: s4moanv name• address• titv: ohone 1f• insura�cc co. �olic}'# comoanv name• - --- - —___ _ - -____------- __ -------- iddress• sity: ohone[�. insurance co. �Y� t Failure to secure coverage as requi�ed under Seenoo 25A of MGL 1S2 n�iead to the iopo�iooa ot erisi�fl peadtle�of�O�e op to 51,500.00 a�d/or oae yean'imprisonment�s w•cll a�eivil pendtie�io the form of a STOP WORK ORDER aed a liee otS100.00�dar apintt ma [a�dersta�d t5tt a copy of tha statement may be fonvarded to the ORice of Invadg�tiom of the DIA for eoven�t veritiatf� I do_hrreby nif}•u th�pains and prnallia ojperjury thar 1lre infornration proved�d above is true wrd corrtet Signature a' �I�3 . Print name � �e K��- ��k`�� .. o(Ticiat use onh do not write in this area ro be completed by eiry or town oAleial eiry or town: Y�M��TR _ permitAieense p nBuilding DcQartmeot �Lieeesiog Board �eAeek if immediate nsponse i�required 261 �Seieetmen's Otliee �Health DeQartmeot , contact person: Pnop�p�_ (SOB� 398�2231 ext. nOther .....�. � .< ".��,.� . � � � ' TOWN OF YARMOUTH B4ARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-059 FEE: $75.00 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter i 11,Section 5 ofthe General Laws,a permit is hereby granted to: Rome Candy Co., 9'75 Route 28, South Yarinouth, MA � Whose place of business is: Candy Co. Type of business: Retail Food Service less than 25,000 syuare feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 l, 2003 BOAx�oF xE�,TH: eifa�rPea.�. �e!llkac, L�aar�rcaa b'e.,c�a�i D. C%mra�o�c. 711.D.. `!c/icce ,�ad�ct�, b�Zoaa�c, (� �a�tck�cDarixat� ��s�. �� , ' February 11,2003 ruce G.Murphy R.S.,CHO Director of Heal i i - 4 � � � ��: L s��; ;�'��'�� _,, TOWN OF YARMOUTH BOARD OF HEAL � �,; � �� '� � ro•. tlyFfa,i�j APPLICATION FOR LICENSE/PERMIT 0 k N �ti,a,5 �� Q `J t��: � f j � �� :,- � * Please complete form and attach all necessary documents by Dece , . F ilure to o��sfix�t iri'� the return of your application packet. `�.';. .��.LL�� AME OF ESTABLISHMENT: TEL. - d� �l�S TZ L .�8 rV►'l. 0 MAI G ADDRESS: 2(n 1� E: MANAGER'S NAME• TEL. # ; MAILING ADDRESS• �'GIIYI.e.� i � � i POOL CERTIFICATIONS: I 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 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. i ; 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 maintain a file at your establishment. 1. 2. _ ��RSO�fi II�C��fi�---- - _ _ -----_ � _ _ _ 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 all times. Please list your employees trained in anti-choking procedures below and atta.ch copies of employee certifications to this form. The Health Department will not use past years' records. n maintain a file at� our lace of business. You must rovide new co ies a d ,.,� .. P P , _ �.. .�� , , , q ,k�, � �p �., �'. . . � � �n � ... ... ..,. .,. . . . , . , , , °� . .' �, , .. . . , ��.�., � . . . . .�� , . . . �� . . . . . . � „ . , . �� 4 RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL $50 INN $50 _CAMP $50 _SWIMMING POOL$SOea _LODGE $50 _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 � <25,000 sq.ft. $75 O -'bII _TOBACCO $20 _<50 sq.ft. $45 >25,000 sq.8. $200 FROZEN DESSERT$35 NAME CHANGE: $10 AM�UNT DUE _ $ ?S.OU *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � 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 RESPONSIBILITY TO RET'LTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS��NTS ARE TO CONTACT TF-�HEALTH DEPARTMENT FOR INSPECTION 7-10 : DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , ADDITIONAL REGULATIONS ' _ _ POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE C'ONSUMER 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: 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 COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: � 0 Z SIGNATURE PRINT NAME&TITLE:�y�L(��N� �- �(��S � 09/11/Ol r ti � The Commonwealth ojMassuchusetts � � : Department ojlndustriaJ.-�ccidents ; � o OfJlce o1/eves�lostliis 600 Washington Slreet ' �` Boston. Mass. 02111 ' �,ti �.., ! V4'orkers' Compensation Insurance Affidavit ! ��(Ill�, � � n m (� � location� t�� 11�Q- � f/ � �t� ��- �Q� �� Z�U �7 rzhone� Q I am a homeowner pert�rming all w�ork myself. � I am a sole proprieror ��,', h��e no one ��orkin_ in an�•capacin• [�I am an emplo�er pro��dins w�orkers' compensation for my empio��ees w�orking ort this job. . 1�tJ _ _ m a n • n � �Q, : ddress: �-� - � r � a �b d �� insu��nceco �m�Q..(�1� v��,(�� Ao�Y� l��L.1�tJ� �Z�(1"7Z'' � I am a sole pr�prietor. ;enerai contractor. or homeowner(circle oneJ and ha��e hired the contractors listed below �tiho ha�e the follu��in_ �+orkzrs .ompensation polices: s4m�anv name• ad d ress• citti�• phone t!• insurancc co. Rolic}•# comoanv nams: _ _ - —- — —--- --- ----. . ■aa��ss• - --- — eiev: R��. . insurancsso. ��* t Failu�e to secure covera;e as required under Secdoo 25A o(MGL 1S2 ta�lad to the iopoeidoa of trisi�al pesdtles of a O�e op to 51.500.00 a�d/or one years'imprisonment a�w�ell a�eivil pendtla io the form of a STOP WORK ORDER aod a liae otS100.00 a dar q�iost ma I a�dersta�d that a copy of thy statement mav be fonv�rded to the Ofiiee of Iove�tig�tiom of t6e DIA for eovera`e veritieatio�. /do hrreby c 'f}•under the pni d penal�ies ojperjury that tht injormation provid�d abovt is true nd cn ct Signature � � �� Print name�lr�� I�IYlQ - Phone�l �� t��'� .. olTicial use only do not..�ite in this�rea to be completed by city or town otfieial city or towo: YA��DT� _ pe�mit/lieense q nBuilding Department �Licensiog Board �check if immediate response i�required 261 �Sdectmenb Oliitt pHealtA Departmeot contacc person: phone q;_ �508) 398�?231 ext. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-011 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and ; Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: How�rd Rome, 9�5 Route 28, South Yarmouth, MA Whose place of business is: Rome Candy Co. Type of business: Retail Food Service less than 25,000 s�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEALTH: ��s{� ��, Lka�iuxaac �eacfa.xi�c D. G�w7d�one, 71L.D., 2/�ce � ,�o�t� �, �k � �a�ctck 711�De�at�C I � March 13 ,2002 ruce G.Murphy, H, .,CHO Director of Health I I I � � � ; i ; � '�+....�. ' t � � f�j ,� _ �,,, (r�i � i!-�� N �� iti ��.�r = TOWN OF YARMOUTH BOARD OF HEALTH � F�t°� � � ��OO , APPLICATION FOR LICENSE/PERMIT- 2000,�,c��'�r1 , ��,, � �ti^� HE�!1�;�! �?�PT. * Please complete form and attaeh all necessary documents by Dec�n�er 31, 1999. Failure to do so will result in the return of your application packet. -� �, -----------------------------------------�--------- ---- -----------------------------------------------------#-------��-------• FE N L ATI D .�. Z N MANAG R'S NAME- I (�S�_ # k�l sb'�Z� MAIi,ING ADDRESS� �n uw� POOL CERTIFICATIONS: , The pool sa�ervisor must be certified as a Paol Operator, as rec�uired by new State law. Please list the '; designated Poo�l �perator(s�-snd attach a cc�py o�he c�rtificatian to ttus-fbnn. " - -"" - " E 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 certifications to this form. 'Ifie Health Department will not use past years' records. You must provide new capies and maintain a fde at your place of business. 1. 2. '; �: �� 4 ,. r: �' N�TMi TC`H CERT�'ICATIONS: .�I 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 y�ur employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. -- 1��TAI3R�AIT-SEAT�NG: TU'�A�;��-- ---. _ . _ S�KT�i uT� _. __ — -- -------------------------------------------------------------------------------�--------------------------------------------------------_----- OFFICE IJS,� Ol�LY LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 _CABIN $50 INN $50 CANIl' $50 LODGE $50 �TRAII,ER PARK $50 MOTEL $50 _SVVIlVIMIIVG POOL $SOea. WHIRLPOQL $25ea.. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 ____CONTTNENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RFTAiL SERVICE• LICENSE REQUIRED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $24 � <25,000 sq.ft. $75 y ZK.'� FROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CHANGE• $10 � AMOUNT DUE = $ �� 3 _'*•*PLEASE TURN bVER AND COMPLETE OTHER SIDE OF FORM"`*"" � �...... .............. ... . .....a .. �............. ` C � � ADMINISTRATION w } UNDER CHAPTER�152, SECTION 25C, SUBSECTTON 6, THE TOWN OF YARMOUTH IS NOW REQUIRED '. 'I'O HOLD ISSIJAI�TCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINES5 IF A � PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION 1NSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. 4F INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN t�F YARMOUTH TAXES AND LIENS MUST BE PAID FRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMI'LETED APPLICATION(S) AA1D REQUIltED FE�(S) BY DECEMBER 31, 1998. SEASOIVAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEFARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEM�NT. RENOVATIONS Mt�Y REQUIRE A SITE PLAN. ADDITIONAL REGL�,ATTONS POOLS POOL OPENIlVG: ALL SVVIlVA�IlNG, WADING AND WHIl2LPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLiFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPElVING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVINIlVIING POOL MUST BE DRAINNED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERIlVG POI T Y_ ANYONE WHO CATERS WIT:EIIN TI�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII.ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FRQZEN�E� SERTS� FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPAR'TMENT. FAILURE TO DO SO WII,L RESULT IN TI� SUSPENSIQN OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTIL THE AgpyE TERMS HAVE _ --- __-_ _------_ ----- - _ _----- BEEN MET. _ _ _ _ _ _ _ __----- -- OUTSmF CAFES� OUTSIDE CAFES(i.e., OIJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLIST HAVE pRIOR A,PPROVAL FROM TI�BOARD OF HEALTH. �'I700R COO�.iNG. OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS�-IlVIENT IS PROHIBI DATE: � � t a � SIGNA � PRINT NAME& TITLE: , — ��,�� 11/12/99 r � ; � The Commonwealth ojMassachusetts � � Department ojlndustrial.-1 ccidents ' � ; Ofllce oller�s�lpsdiis ; 600 Washington Street � �.� Boston, Mass. 02111 " "' v• W'orkers' Compensation lnsurance Atfidavit ' Aoolicant informallon: PleaseYR�7�iic n m•� � ' '', , � R�� a-�� ,�, S • • . _ �( 6L C a � t am a homeow�ner pertorming all w�ork myself. � ( am a sole proprieror �r.,'. ha�e no one ��orkin� in am•capacit�• �I am an emplo�er pr�o��din�w�orkers' compensation for my empioy�ees w•orking on this job. compan�• name• `�-�� a-� t�t,�l�� _ �dciress• � .�-.^ li• in uranc � � � � ��' � � I am a sole proprietor. _enerai contractor, or homeowner(eircle oneJ and ha�•e hired the contractors listed beloµ ��ho ha�e the follu��in� ��orkzr� �ompensation polices: companv name• ddress• cin•• ohone f!• — insur�ncc co �olic}•# �moanv name• addr ss• �y• ohoee M• insurance co 1l�Y� z Failure to seeure coverage as required under Seetioo 25A of MGL 1S2 a�Ind to tbt iopaidoe o(erisi�fi pesdtla of a O�e op to 51,500.00 a�d/or one yean'imprisoement a�w•ell a�eivil penaltia io the form of a STOP WORK ORDER aed a liae otS100.00 a d�r a��imt ma t a�dersta�d tbat a copy of thi�statement mav be fonv�rded to the ORce of Inveetig�tiom of tAt D1A tor eoven�e verifieatio�. /do hrreby cerrij��under the parns and penal�i�s ojperjyry that tbe infor►notion providtd above is trtte and corrtct Signaturc _ � ��t � Print name Phone It ,��1L%��"� .. ofTicia! use only do not w�ite in this area to be compieted by citr or towa oAleial citv or town: Y�M�IITQ _ permitAicense k n8uilding Departmeot ' — �Liceasiog Boa�d �eheek if immediate response is required 261 QSeleetmen'�OtTice �HealtA Department contacc person: ��p;_ (508) 398�?231 e][t. nOther � . . �,,. . TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-57 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: _ Rom Cand��n , 975 RnntP�R, Snuth Y rmo� h, 1`�� Whose place of business is: Rome Candv Co. Type of business:_Retail Food Service less ha�n 25 000 square feet To operate a food esta.blishment in: _ Town of Yarmouth Permit expires: December 31„ 2000 BOARD OF HEALTH:�l�/. �Bt��, C'�t,,,�,� �oan� �u�[ivaa, ��, V�e (��irma ,�o66,E� �,�w,�, c�.� a��ie[��a�io[��ie�-�ooPe� ��10�o��n Februarv 1 .2000 Bruce G.Mtrrp�i�,11MPH, R.S.,CHO � I�irector of Health Information and Instructions �-- --. I�i;�s�acliu•,ctt; General La��s chapter I�� section '_5 requires all employers to pro��ide workers' compensation for their ��p��'�«'� .as au��t�d trom the "la��, an emnlot�ee is defined as e�•ery person in the sen�•ice of another under an� ��iicract ��f hire, express or implied, oral or written. � ,�►n en1p��rer is defined as an indi� idual. partnership, association. corporation o�other legal entity, or any tv��o or more of tl�� (ore��ii�� en�_a�=ed in a joint enterprise. and including the legai representatives of a deceased employer, or the r��ei�zr ��r tnistee of an indi�idu�l . partnership. association or other legal entity, employine empio�•ees. Ho�tiever the ��ner oi,i �«ellin�= I�ouse ha�in� not more than three apartments and who resides therein, o�the occupant af the c1��= lie�use �f anotl�er��ho emplo��s persons to do maintenance , construction or repair work on such dweiling house .►r �� r ��r��u��i; �r buildin`� appurt�nant thereco shall not because uf such empio��ment be deemed to be an emplo�er. ��- ��I��r I�= ;ecti��n =� als�� states that e�•en• state or local licensing agenc�•shail��ithhold the issuance or rene�.�al ��f a license �r permit to operate a business or to construct buiidings in t6e commonw•ealth for an�• i��licant �� has not �roduced acceptabie e�•idence of compiiance v�ith the insurance roverage required. .��d��'��. neither the common��ealth nor am• of its political subdivisions shall enter into an}•contract for the pr�tormaiice of public ��ork until acceptable evidence of compliance with che insurance requirements of this chapter ha�e h��n prea�i�tzd to the �untractin= authorit�. ,.�ppli�..nts F�lease tili in the �rorkers' compensation affidavit compietely, by checking the box that applies to}•our situation and ti��PP�`��'_� ��mpan} na�Ties. addre�s and phone numbers as all affidavits ma�• be submitted to the Deparcment of L.,��ctri�i � _-'-,--" c'.._ ,..._a:__....,._ —�--------- - -. . . .. . ■. �_ . . . . . _. � . .. � � � ,. .. ,� 1�(� .�,,,j7_,�,. i��`("��;-.. yi� _' � , .,_-..� ... . ,, TOWN OF YARMOUTH BOARD OF HEALTH , � APPLICATION FOR LICENSE/PERMIT- 1999 ; I�� 1 � �� ' ; � , _ ; _ * Please complete form and attach all necessary documents by D� . e�"�, �` �e�o�o sci will resuit in the return of your application packet. � '' � � � � y� .a � ------------------------------------------- - --- ---- --- --- -- �-.�--- . .s��- -- ------------ - - --------- �-- -- -- -- - --- - - - � E TAB I # `�� O A I N S: � f �l S- ( �- T N N C� - R' N L # - -� MAILING ADDRESS: SQV�3L ----------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new 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 currently certifiied in basic water safety, standard First Aid and Community Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus 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. � HEIlVII,ICH 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. l. 2. 3. 4. RESTAURANT SEATING: T4TAL# NON-SMOKING SEATS: TOTAL# -- ----------_--_--_------ ------- ---- ----------------------------------- — _ - _. -- - _ D�FICE U�`Et�fiLI�-_ _ �ODGING: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _INN $50 _CAMP $50 '; LODGE $50 TRAII.,ER PARK $50 MOTEL $50 SV'Vl�IM1NG POOL $SOea. WHIIt.LPOOL $25ea. �'OOD SERVICE: — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# 0-100 SEATS $75 CONTINENTAL $30 _>100 SEATS $150 NC)N-PROFIT $25 _CONIMON VICT. $50 WHOLESALE $75 RETAII.SE�tVICE: ; , � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# i _<50 sq.ft. $45 TOBACC4 $20 � �,,. � � <25;�Q.sq.ft..: . . $75 � � .�.��RC�ZEN DESSERT. . .. $25,i , , � �� _ � ., .-� , . s . . � , _ ., r ; � >25;040 sq:ft. � = $2Uf1 •' , ___ , � NAME CHANGE: $10 � AMOUNT DUE _ $ �� "*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"""* � ADMINISTRATION " UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMP.ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STA'�E WORKER'S COMPENSATION 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 RE5PONSIBII.ITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 3 i, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COr�IlVtENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDiTIONAL REGULATIONS POOLS POOL OPENIlVG: ALL SWIlVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR ' TI-� SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT,AND'TI�WATER TESTED FOR PSEUDOMONUS,TOTAL CQLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIF��7�B, --� PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. ; i k POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMIVIING 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 FII,ING TI-� 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. FAII,URE TO DO SO WII.,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS _ _- — _ _ __ --_ _ _ _ — _ _ _---- - - �AV��EE�M�fi. OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OLTTUOOR SEATING WITH WAITER/WAITRESS SERVICE), MIJST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS�IMENT IS PROHIBIT DATE: � I SIGNATURE: PR1NT NAME& TITLE: � ��C.- � ; � .., , � � � , � ^ The Commonwealth of Massachusetts � W Department ojlndustria/,accidents ' � W O/1/ce ot/eres�l�s�is a � _ a � 600 Washington Street •` Bnston,Mass. 02111 � V�y W'orkers' Compensation Insurance Affidavit Aoolicant information• p►�sepg -y�. n m•: � �C. - - . � � � � �' f� '� V _`� # �O V�'�'`� � I am a homeowner pertorming all work myself. � I am a sole proprieror�r,� ha�e no one��orking in am•capacity �am an employer pro�idino w�orkers' compensation for my employ�ees working on this job. � __ _ - - __ ____ __. ^ __ __ _ _ _ _ _ _ __ __ _-- m a n � n (� �ddress• �J � Z-b � J�� ; S� �}- 0� „. o-�t�c� insur�nce co `�.��I��. �Jt �� .�� poli�y# �J ��/o�� 1 fl � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below� ��ho ha�e the follo��in� ��orker� �ompensation polices: som�anv name• address• citv• ohone q• insurancc co. policy# �omnanv name• -- -- - — -- ---------- ---- �ddress: _ - --- _ . s�ri� Fhoee#• insurance co. ��y* Failure to secure coverage as required under Secdon 25A of MGL 152 aa lad to t6e iopwidoo o(erisinl peaaltla of a A�e op to 51�00.00 a�d/o� one yean'imprisonment a�w•ell as eivil peoalHes io the form of a STOP WORK OEtDER aed a line otS100.00 a day a�ainst ma I a�denta�d tlst a eopy of thy st mrnt may be forw�rded to tht Otlice of Invatigatioa�of t6e DU for eovengt veriflta�w. /do hrreby c un er , pains and pena/ries ojperjury thw�he injor►nation providtd ebovt is nue nd eorrtet Signaturc ( � ate Print name Phone N ��0 ��t} .- ofTicial use only do not..rite in this area to be completed by city or fown ollitial city or town: Y�MO� _ permit/license q nBuilding Deqrtmeut QLictesiog Boa�d �eheck if immediate response is required �Selectmen'�Ottiee 261 �Health Departmeet contact person: phone q;_ �508} 398�2231 egt. �Other Ire.ised i;95 P1A1 . . i I , . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-62 FEE: �75.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the Geueral Laws,a permit is hereby granted to: H�w rd R�m /Rom C' ndy('�, 97 R� � 8, So �th �' rmo � h, 11�A Whose place of business is: Candv Ca Type of business: Retail Food Service less than 25,000 satare feet To operate a food establishment in: Town of Y t-rnouth Pernut expires: December 31_ 1999 BOARD OF HEALTH:�d�/. �et��, C'�airman �oaz G. �ul�ivam,K.//•, Vice l.hairman �obevE J. 4.Jrown, (�farh � ad�i�[��a�ofa�y-�l�ooPes 'ifichael oCou hlin � j Mav 20 , 19 99 Bruce G.Murphy,MPH,R S., H � Director of Health � , I I � i � � � � � - � � I ( �