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Home My WebLink AboutApplications, WC and Licenses f .�� H ' � � C. SL}C..T G�I�-T��C.-�'-� � � TOWN OF YARMOUTH BOARD OF HEALT"H; �,�y-� ------�-��.+,��.� R ? " � �' i`; ��` � ,• j,, i � APPLICATION FOR LICENSEJP� 2 .u`�� 7 ' � e...� � ��` DD �� '�"'� � ' �� o�s�t�0� * Please complete form and attach all necessar��cur�n'�"s by Dece er Failure to do so will result in the return our application c ��!-�.+ ��.g�.,�_. NAME OF ESTABLISHMENT: C� �' �fY ' TEL. # SD� �7T�� LOCATION ADDRESS: (� MAILING ADDRESS: � OWNER NAME: T�Q�in1¢�l �U Lt.�G� TAX ID (FEIN or SSN�: � ' CORFORATION NAME (IF APPLICABLE): cc, ' �. MANAGER'S NAME: �y� ��,t,1'Y1Gr°� TEL. # MAILING ADDRESS: 4 `�� '�+�/ POOL CERTIFICATIONS: � The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees cunently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach capies of employee certificatians to this form. The Health Department fvill not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. 2. �� 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary CodE for Food Service Establishments, 105 CMR 590.000. ' Please attach copies of certification to this application. The Health Department will not use past years' records. Yau must provide new copies and maintain a �le at your establishment. ' 1. 2. PERSON IN CHARGE: --- ---- --- - - - - _ __ _ --, _ __ - _ _ __ Each food establislunent 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 Heunlich 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: TOTAL # OFFICE USE ONLY : LODGI�G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIlZED FEE PERMIT� B&B S55 CABIN $55 MOTEL �5� INTI S55 CAMP �55 SWIMMING POOL �80ea. _LODGE S55 _TRAILERPARK �105 _WHIRLPOOL $80ea. FOOD SERVICE: LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S85 _CONTINENTAL 535 NON-PROFIT �30 >100 SEATS 5160 COMMON VIC. �60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<�0 sq.ft. �50 _>25,000 sq.ft. $225 _VENDING-FOOD �25 /<Z5,000 sq.ft. S80 O�'�� _FROZEN DESSERT $40 _TOBACCO �55 NA:I�IE CHANGE: S 10 AMOUNT DUE _ $ 80.pp ****"PLEASE TURti OVER AivD CO�VIPLETE OTHER SIDE OF FORM***** r w A ADMINISTRATION ; Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any ficense 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 f WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LOI�GING ESTABLISHii��iENTS 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. � Transierrt occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. � Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an r aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as ame�ded, shall generally be considered Transient. POOLS ; POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days ; pnor to operung. 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 rnust be drained or covered within seven(7)days of � closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ' Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a rnonthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: _Outdoor cookin�,preparatio�or display of any foodproduct by a retail or food service establishment is prohibited. � N01TCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MtJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: I aa O � SIGNATURE: �l�-�� PRINT NAME&TITLE: �Y'�, �1,f�YlGjt,'� ��Cr" ioi2i�os � � VDAC � TRAV�LERSJ~ WORKERS COMPENSATION AND EMPLOYERS LIABILtTY POLICY TYPE aR INFORMATION PAGE WC o0 00 oi ( A) POLICY NUMBER: (7PJUB-7431 A07-4-08) REh�WAL OF (7PJUB-7431A07-4-07) (NSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AMERICA 1. NCCI CO CODE: i 3579 INSURED: PRODUCER: � CAPE COD SALT WATER TAFFY C0 JOHN F MARTIN INS AGCY INC f023 ROUTE 28 ' 54 LONG P01� DRIVE BOX 350 � SOUTI-I YARMOUTH MA 02664 S YARMOUTH MA 02664 (nsured is A CORPORATION Other work piaces and identificatian numbers are shawn in the schedule(s) attached. 2. The policy period is from 04-01-08 t0 04-01-09 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURQNCE: Part One of the policy applies to the Workers Campensation Law of the state(s) listed here: Ma __ �--- = B. EMPLOYERS LIABtt�TY INSURANCE: Part Two of the p�icy appiies to work in each state listed in " item 3.A. The limits af our liabitity under Part Two are: = � o� Bodily Injury by Accidern: � i 00000 Each Accident �_ Bodily injury by Disease: $ 50000o p��y Lim� _ Bodily Injury by Disease: $ 10000o Each Employee a� _ . G. OTHER STATES tNSURANCE: Part Thr�of the policy applies to the states, if any, tisted here: °°� COVERAGE REPLQCED BY E1�30RSEW�NT WC 20 03 flGA - � �� - D. This policy includes these endorsements and schedules: �� . �� SEE LISTIN6 OF Et�ORSEN�NTS - EXTENSION OF 2NFfl PAt�E � — 4. The premium for this policy will be determined by our Manua(s of Rules,Ciassifications, Rates and Rating �; Pians. Ail required information is subject to verification and change by audit to be made AN1�A1A�l.Y. ..�, .� DATE O� ISSUE: 03-17-08 WC ST ASSIGN: MA OFFICE: DIRECT ASSIC�M+�NT 701 PRODUCER: �10HN F MARTIN INS A6CY � 28LFB Q67765 TRAYELERS/�� WORKERS COMPENSATION /�ND EMPLOYERS L1/1BiUTY POLICY EXTENSION OF INFO PAC�-SCF�DULE WC 00 00 Qi ( A) POLICY NUMBER: (7P�UB-7431 A07-4-08) INSURER: TRAVELERS PROPERTY CASUALTY COI�ANY OF AMERICA 13579—MA INSURED'S NANIE : CAPE COD SALT WATER TQFFY CO I NC RATE BUREAU ID: 000157421 PREMIUM BASIS ESTIMATED RATES ESTIMATE� TOTAL ANNUAL- PER $1 t30 OF AI'�IIiAL CL,4SSIFICA'E'I(3N - CODE REMUNERATION REM�INERATIQN PREMIUM LQGATION 001 01 FEIN ENTITY CD 001 CAPE COD SALT WQTER TAFFY GO INC � 984 ROUTE 28 . SQUTH YARMOUTH, MA 02664 CONFECTION MFG. 2041 40424 2.11 853 �� STORE : RETAIL NOC 8017 32849 1 .18 3gg ' CLERICAL OFFICE EI�LOYEfS NOC 88i0 40263 .12 4g �o— �� i �� _.. _...__..... _...__.. -_.. _ __ ...._.__-_ _.._.._. _ .. . . . . �� ... . ..._ ... ...._.._ __.._ .__.... .. . - ._.-_._.. . ...___ -_._.._ . ._ @� --.._. . . _ .._ -._ _ . . � � � i n�� n= �� O� .950 MERIT RATING MODIFICATION (9885) $ 64 �"'� TOTAL ESTIMATED AI�IIJAL STAi�ARD PREMIUM i 225 �� • EXPENSE CONSTANT(09Q0) 318 �.0300 TERRORISM (9740) 34 � 5.50°I MA WC SPECZAL FU�7 AND TRUST FUf� 67 TOTAL ESTIMATED PREMIUM 1644 DEPOSIT AMOUNT DUE 1644 DATE OF iSSUE: 08-17-08 WC ST ASSIGN: MA '� SCHEDULE NO: 1 OF LAST oo��sa i ' T4WN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-045 FEE: S80.00 � In accordance��•ith regulations promuigated under authority of Chapter 94, Section 30�A and Chapter f 11 l, 5ection 5 of the General La«�s,a permit is hzreby granted to: � ; Cape Cod Taffy Co. Inc., 984 Route 28, South Yarmouth, MA � Whose place of business is: Cape Cod Salt Water Taffv � Type of business: Retail Food Service less than 25,OOQ square feet To operate a food estabiishment in_ Town of Yarmouth ; Permit expires: December 3 l. 2009 BOARD OF HEALTH: .`�Ee�Ctt S�, J2..N., �,ffavrtiuut �� ef�a�r�i .�. .9'G�ex `11 ice �`f�Cxvrrnan Jta�e�ct �.✓�3�u�cr�n, e� I �C��J2..�V. ,� lanuarr� 12.2009 Bruce G.Murphy,MPH .,CHO Director of Health � � r__ __. .C'. SAc�(,�A7P+-�AFFy i �Jti�Y�k,s TOWN OF YARMOUTH BOARD OF HEA�..T'H� �'�� f��$ APPLICATiON FOR LICENSE/P�RM�T-2�00 �� ` � C� C� L� � ML� D , * Plea,se complete form and attach all necessary daeum�nts b ec�n r 31�2�QQ7. F a�lure to do so w i ll resu lt in t he return of your application pac et. U C� 1 7 2 0 0 7 NAME OF ESTABLISHMENT: ' �Q�Q.C�..�'�"U:�/�sI-G✓�� TE . �' LOCATION ADDRESS: q$� I�L � C-�QXrvt, MAILING ADDRESS: OWN�R NAM�: �l'�,Y�12 �IA,d1nGr�'- TAX ID (FEIN or SSN1- � CORPORATION NAME (IF APPLICABLE): (A.� CD�L'Tu� �,�, �,y�L. MANAGER'S NAME: (,�j ��,�� TEL. #��34�(7j;�7 MAILING ADDRESS: _�Q,rn� ._.- POOL CERTIFICATIQNS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. i 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 ofemployee eertifications to this form. T�te �ealth Departmeat will not use past years' reeords. �'o� �t�st prQvide new ; copies and maintain a file at your place of business. � a l. 2. 3. 4, FOOD PROTECTION MANAGERS - CERTIEICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defned in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this applieation. The Health Department�viH not use past years'records. You must provide new copies and maintain a file at your establishment. I- 2. PER��I�I�N C�IA,I��E: __ __ _ ----- - - __ __ __ _�,�- �_ ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. � � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or mare must have at least one employee traine,d in the Heimlich Maneuver on the premises at all times. Please list yow employees trained in anti-chokuig procedures below and � attach copies of employee certificarions to this form. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your place of business. � 1. 2. 3. 4 RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LqDGING: LICENSE REQUIItED FEE PER'�+IIT# LICENSE REQUIRED FEE PER1dIT� LICENSE REQL'IRED FEE PER'�1IT� TB&B S50 _CABIN S50 _MOTEL S50 —�N �50 _CAiVIP S�d _SR'IVI�IfIiVGPOOLS75ea. _LODGE �50 _FRAILERPARK S100 _�'HIRLPOOL S75ea. FOOD SERVICE: LICEI+iSE REQUII2ED FEE PERMIT� LIC£1*tSE REQLTIItED FEE P£R��IT* LICENSE REQUIRED FEE PERVIIT= _0-100 SEATS �75 _CONTINENTAL S30 _NON-PROFIT S25 _>100 SEATS S150 _CO'�L1rION VIC. S50 _��IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERVIIT� LICE:v'SE REQUIRED FEE PER'�fIT= <50 sq.ft. �45 _>25,000 sq.ft. 5200 VEIVDIlvG-FOOD S20 ��25•0�sq•�t• ��5 O'�'��J� _FROZElv'DESSERT S35 _TOBACCO SSO �a��cxavcE: sio AMOUNT DUE _ $ 7�',pQ ****'PLEASE TL'R\OVER A\D CO�iPLETE OTHER SIDE OF FOR�Z*ww** r 3 ADMINISTRATION Und r Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '; of y license or permit to operate a business if a person or company does not have a Certificate of Worker's Com ensatio� Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFF AVIT MUST BE COMPLETED AND SIGNED, UR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED To of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APP OPRIATELY IF PAID: YES�_ NO MOTELS AND OTHER LODGING ESTABLISHMENTS NSIENT UCCUP'ANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limit d to the temporary and short term occupancy, ordina.rily and customarily associated with motel and hotel�s�: Tran ient occupants must have and be able to demonstrate that they maintain a principal pla,ce ofresidence elsewhere. ' Tran ient occupancy sha11 genera.11y refer to continuous occupancy of not more than thirty (30) days, and an aggr gate of not more than ninety(90) days within any six(6)mo�nth period. Use of a guest urut as a residence or dwel 'ng unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy Exci e, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * N TE: Enciosed Motel Census must be completed and returned with this appiication. POOLS PO L OPENIIVG: All swimming,wading and whirlpools which have been closed for the season must be' ected by th Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opening. PO L WATER TESTIlYG: The water must be tested for pseudomonas,total coliform and standard plate count _-.---b3�a at�certified lab, prior to opening, and c�uarterly thereafter. PO L CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closi �. FOOD SERVICE CA RING POLICY: ' Any ne who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required /' Tem orary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heal h Department. FR ZEN DESSERTS: Fro n desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Dep ment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit wrtil the abo e terms have been met. OU SIDE CAFES: Out ide cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OU DOOR COOKING: __-p� o�ng,pFep�r�tion,�'dis�l��o€�ny€ood produc�b3�a��tail or food s�rv�c�es�ablish�nt is p�ibit�. _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR � TO COMMENCEME:�tT. RE�tOVATIONS MAY REQUIRE A SITE PLAN. � � ��, � '�' I� d� SIGNATURE: g��.��%��,-� ', )ATE. PRINT NAME&TITLE: �� -� � io;o o� � ; � TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EX'tEWSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A} POUCY NUMBER: (7PJUB-7431 A07-4-07) INSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AN�RICA 13579-MA INSURED'S NAME : CAPE COD SALT WATER TAFFY CO I IVC RATE BUREAU ID: OOQ157421 PRfMIUM BASIS ESTIMATED RATES ESTIMATED TOTA� AMVIJAL PER $100 OF ANNUAL CIASSIFICATION CODE REMUNERATIO(V RER�lNERATION PREMIUM LOCATiON 001 di FEIN EN7ITY CD 001 CAPE COD SALT WATER TAFFY CO INC 984 ROUTE 28 SOUTH YARMOUTH, MA Q2664 CONFECTION MFG. 2041 36749 2.59 952 •� STORE : RETAI� N�C 80f7 29863 1 .48 442 �� CLERICAI OFFICE EMPLOYEES NOC 88i0 366Q3 .15 55 �— � �i �� !�� . r �� [r- �. L� w�r O� h�� . �1�� _�___'�_�_�__��_��_�_��.��_��_��.�_.��.�� o� .950 MERIT RATING MODIFICATION (9$85) $ 72 �� TOTAL ESTIMATED ANNUaL STAI�ARD PREMIU�1 1377 � EXPEfdSE CONSTANT(0900) ' 284 0.0300 FOREIGN .TERRORISM / TRIA (9740) 31 ,� 4.19% MA WC SPECIAL FUND A1� TRUST FUh� 58 TOTAL ESTIMA'fED PREMIUM 1750 � DEPOSIT AMOUNT DUE 1750 ; DATE OF ISSUE: 04-02-07 wC 5T ASSIGN: N!A SCHEDULE NO: 1 OF�AST 003381 � i VDA� � TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INF�RMATION PAGE WC 00 QO Ot ( A) POLfCY NUMBER: (7PJUB-7431 A07-4-07) RENEWAL OF (7PJUB-7431Ab7-4-06) INSURER: Ti2AVELERS PROP£RTY CASUALTY COMpANY OF AMERICA 1. NCCI CO CODE. 13579 , INSURED: PROQUCER: CAPE COD SALT WATER TAFFY CO JOf�qV F MARTIN INS AGCY INC 1023 ROUTE 28 50 LONG POND DRIVE BOX 350 SOUTH YARMOU7H MA 02664 S YARI�UTH MA 02664 insured is A CORPORA7ION Other work �aces and iderrtification numbers are shown in the schedule(s) attached. 2. The policy period is from 04-01-07 to 04-01-08 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATiON INSURANCE: Part One of the palicy applies to the Warkers Compensation Law of the state{s1 listed_hsre: __ . ______ _ __ _ _ _ _ __ __ =s �ra � �— � B. EMPLOYERS LlABILITY INSURANCE: Part Two of the palicy applies to work in each state Itstect in "—= 'rtem 3.A. The limits of our liabilfty under Part Two are: �.�, o= Bodiiy in)ury by Accident: $ 10000o Each Acciderrt � Bodily InJury by Disease: � 54000o paicy Limit � Bodily Injury by Disease: � i o0000 Each Employee �� C. OTHER STATES INSURANCE: Part Three of the polfcy applies ta the states, if any, listed here: �'� COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A t f--- — a� �� ..�� ,_._ D. This policy includes these endorsements and schedules: . � o� SEE lISTING OF EI�ORSEI�NTS - EXTENSION OF INFO PAG� o� � 4. The premium for this policy will be determined by our Manuais of Rules, Ctassifications, Rates and Rating a Pians. Afi required ir�formation is 5ubject to verification and change by audit to be made At�1uAL�Y. s ...� ,�. DATE OF ISSUE: oa-oa-o�r wc sT assic�v: Ma �� 7FFICE: DIRECT ASSIC�IMENT 701 I PRODUCER: JOt�V F MARTIN INS AGCY 28LFB 3103380 � _ TOWN OF YARMOUTH BQARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMIT NUMBER: #08-036 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Cape Cod Taffy Co. Inc., 984 Route 28, South Yarmouth, MA Whose place of business is: Cane Cod Salt Water Taffv Type of business: Retail Food Service less than 25 040 spuare feet To operate a food establishment in: �own of Yarmouth __ _ _ Permit expires: December 31, 2008_ BOARD oF HEALTH: 3Eele�t Sf�ac$, J�..N., C.t'ltauu►uut Cf�a.�cee� �.�'�ee�iff.e�c `�Jice C�i�Cu�cn:acnc ��3.��u�n, � ��ee�r3�, J`�..N. 7anuary 16.2008 Bruce G.Murphy, , .5.,CHO Director of Health ; i � � � • . ' � ' C�.S�T k)a't�Tqq� �°`r R�c TOWN OF YARMOUTH BOARD OF HEALTH ��'°i � ' APPLICATION FOR LICENSE/PE � � ltll�#"I'- ��47, �� '�. _ . � o = iy � � . .;? �� > � * Please complete form and attach a11 necessary docum�n�s by Decembe�31��6� 7 �� Failure to do so will result in the return of your applicatian pack�t. � w_ : . � NAME OF ESTABLISHMENT: [Q� CC�-�SCL�-�" I,c�-�f,cr 'T��. TEL. # 5�%� ��f� i LOCATION ADDRESS: ��-1 (�}� Z k ,� �`�I Cu�m c;��,-�1„ f�,� �1�f��J MAILING ADDRESS: �S c�.r'Y�� OWNER NAME: �Gt.r�� U. �u_.�rn U n-1" Tt� ID fFEIN or SSNl� CORPORATION NAME (IF APPLICABLE): ('�� [OGL 'TC�.-E-� C�• �'?C_ MANAGER'S NAME: 1,V�1 �1,�.-t�rt(�v�-k"� � TEL. # .S C.t.i'y�.�.., MAILING ADDRESS: S a rY� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Fool Operator(s}and attach a cepy of the certification to this-fornr.-- — - -- i l. 2, � Paol operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and ; Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach capies of employee � certiflcations to this form. The Health Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your est�blishmen� l. 2. _ P�RSON Il�G�A�GE: . _ _ _ _ _ _ _ , Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation. i i l. 2. HEIlVIL,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. RESTALTRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � B&B �50 CABIN �50 MOTEL $50 INN $50 CAMP $50 SWIlVIlvIING POOL$75ea. _LODGE $50 _TRAII.ERPARIC $100 WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQiJTRED FEE PERMIT# 0-100 SEATS $75 _CONTINENPAL $30 NON-PROFTT $25 _>100 SEATS $150 COMMON VIC. $50 WHOLESALE S75 RETAQ.SERVICE: —RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMiT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 �45,000 sq.ft. $75 0 —� _FROZIIV DE3SERT $35 _TOBACGO $50 NAME CHANGE: $10 AMOUNT DUE = S 7S.O0 '••'°•PLEASE TURN OVERAND COMPLETE OTHER SmE OF FORM•"""* Y � r.--.,_ .-_-, � ADMIl�TISTRATION + � � Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUS�'BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSiENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocazpancy shall be ' limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. � Transient occupants must ha.ve and be able to demonstrate that they maintain a grincipal place ofresidence elsewhere. '" Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an � aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy : Excise, as defined in M.G.L.c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wadin�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 apening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ! by a State certified lab, prior to opening, and quarterly thereafter. _ POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. E E FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmauth must notify the Yarmouth Health Department by filing the r�uired Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta.med at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a Sta.te certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdaor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDUOR COOKING: OutdoQr cookin�_pr�paration,Qr displ�y Qf any food prnduct by_a retail or_foQdservice establishmentisp�hibite� ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN TI�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY k'OOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; DATE: � (�Io SIGNATURE: l�-v�'��-l�Y�� PRINT NAME&TITLE: �-(�� „�l,t�f'Yl L i�fi (YIC.�I��-�/� 10/17l06 � ` VDAC �isr�Au� G TRAVELERS WORKERS COMPENSATION AND EMPLOYERS UABILITY POLiCY TYPE AR ItdFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: {7PJU8-7431 A07-4-06) REI�WAL OF (7PJUB-7431A07-4-05) lNSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF ANIERICA NCCI CO CODE: t 3579 1. INSURED: PRODUCER: CAPE COD SQLT WQTER TAFFY CO �10i-Rd F MARTIN INS AGCY INC f023 ROUTE 28 50 LONG POND DRIVE BOX 350 SOUTH YARMOUTH MA 0266� S YARMOUTH MA 02664 insured is A CORPORATiON Other work piaces and iderrtification numbers are shown in the sch�tule(sj attached. 2. The policy period is from 04-01-06 t0 04-01-07 �2=Q'i A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy appliss to the Workers Compensation Law of the state(s) listed here: ,� MA ..� a; = B. EMPLOYERS LIABtUTY INSURANCE: Part Two of the ic a �es to work in each state listed in �,._ p� Y PP�� item 3.A. The limits of our liab�iry under Part Two are: d� p= B�i(y injury by Accide�: � i 0000o Each Accider�t � BodNy InJury by Disease: � 50000o paicy l.imit _ �_ Bodily Injury by Disease: � 100000 Each Employee @= C. OTHER STATES INSURANCE: Part Three of the policy appiies to the states, ff any, listed here: � i � COVERAGE REPLACED BY EI�ORSEI�N'f WC 20 03 06A N- �� O� ,_ D. This policy includes these endorsemerrts and schedufes: � o,� SEE LISTING OF Et�ORSEk�N'fS - EXTENSION OF IA�O PAC� o� � 4. The premium for this policy wdi be determined by our Manuais of Ruies,Ciassfftcations, Rates and Rating � Plans. Ait r�uir� lr�formatlon i�sub]ect to verification and change by audit to be made A�1AL�Y. ,_ DATE OF ISSUE: 04-13-06 GL ST ASSIGN: MA OFFICE: DIRECT ASSI(�NT 7Qi PRODUCER: JOF9d F MARTIN INS AGCY 28LFB �azas � � , . � VDA� � �STPAUL � TRAVELERS WQRKERS COMPENSATION { AND � EMPLOYERS LIABILlTY POLICY � TYPE AR INFORMATION PAGE WC 00 08 01 ( A) I j POLICY NUMBER: (7PJUB-7431 A07-4-Q6} I CLASSIFICATION SCHEDULE: PREMIUM BASIS � ESTIMATED ��S ESTIMATED TOTAL ANNUAL PER�100 OF ANNUAL CLASSiFiCATfONS CODE NO REMUNERATION REMUNERATION pREM1UM , SEE EXTENSION OF INFORNIATION PAGE - SCHEDULE(S) SIC-CODE: 2064 -----------------------------------�__---------------------------------------- STQI�ARD TOTAL ESTIMATED A�AL STAPIDARD PREMIUM $ 1251 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTQNT 2g4 FOREIC�1 TERRORISM / TRIA 2g TOTAL ESTIMATED PREMIt�I 1563 TAXES AI� SURCHARt�S 55 DE POS I T AN�]UNT DUE 1618 A/R (WCIP) # Minimum Premium: �233 � ST QSSIGN: MA DATE�F tSSUE: 04-13-06 GL� OFFICE: DIRECT ASSI(�J�NT ?01 PRODUCER: JOHN F MARTIN INS AGCY 28LFB , . _._ _..� i � ;; �. � STPAl1L TRAVELERS WORKERS COMPENSATION i � AND I + ERAPLOYERS LlABIL1TY POLICY s i I j EXTENSION OF INFO PAGE-SCFIEDULE WC 00 00 Q1 ( A} I ' � POLICY NUMBER: (7PJUB-7431 A07-4-06) a 1 � INSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AN�RICA ! � 13579-MA INSURED'S NAf� : GAPE COD SALT WATER TAFFY CO ' I AIC RATE BUREAU ID: 000157421 � _ _ _ PREMIUM BASIS ESTINIATED RATES ESTIMIATED , . TOTAL AM�UAL PER $100 �F AN1�1AL CLASSIFICATION CODE RENKJI�RATION RENNI�RATION PREMIUM � LOCATION 001 Oi FEIN ENTITY CD 001 � CAPE COD SALT WATER TAFFY CO j INC ; , � 984 ROUTE 28 � SOUTH YARNIOUTH, MA 02664 � , i CONFECTION MFG. 2041 33408 2.59 865 _� STORE : RETAIL NQC 8017 2?148 i .48 4Q2 o� � C�ER2CAL OFFICE ENPLOYEES NOC 8810 33275 .i5 50 � ��r— �� a� ' o�- _ _ __ _ - -_ _ - ' o� . m="� � r�.� ' �� N- i �� r� Z O� �� n� ��_�'��'��...��'��"�`�'��.....�'�'��.��.�'��_��'_'��`� � � .950 NE RI T RATI NG NIODI F I CATI ON (9885) $ 66 +, TOTAL ESTIMATED AN�1AL STAI�@ARD PREMIUM 1251 ..�. EXPENSE CONSTANT(0900) 284 0.0300 FOREI(�+1 IERRORISM / TRIA (9740) 28 i � 4.40� MA WC SPECIAL FU(� AND TRUST FtJI� 55 TQTAL ESTIMATED PREMIUM 1618 i DEPOSIT ANIOUNT DUE 1618 ; ' i DATE OF ISSUE: 04-13-Ofi GL ST ASSI(�l: MA SCHEDULE NO: 1 OF LAST - ifloazro i , � STPAUL TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY i i ? EXTENSION OF INFO PAC�–SCF�DULE WC OU 00 Qi { A) � POLICY NUMBER: (7PJUB-778X441–3-06) � � j INSURER: TRAVELERS PROPERTY CASUALTY COM�ANY OF AMERICA � 13579–MA INSURED'S NAME : OUTDOOR SHDP, INC. RATE BUREAU ID: 070707 �� PREMIUM BASIS __ ESTIMATED --- BATES _ __ESTIMATEQ_ __ � TOTAL ANNUAL PER $100 OF AI�1AL CLASSIFICATION CODE REMUI�RATION REMUNERATION PREMfUM LOCATION 001 01 � FEIN EIUTITY CD 001 OUTQOOR SHOP, INC. 50 LOtVG POt� DRI VE SOUTH YARN�UTH, MA 02664 AUTON�BILE SERVICE OR REPAIR CENTER & DRIVERS 8380 30867 2.99 923 AUTON�BILE SALESPERSONS 8748 34511 .94 324 ._ „� CLERICAL OFFICE ENP��YEES NOC 88i0 IF ANY .15 �--- �� — �� r— o� o��? . . -- - - - - --- _ _ . _ ,.�.. . _ _ v� v� � _! .�. � o�� n� ��. __------�------------�----------------'---'----------_--•_--__—__---___---'-----'----�--- o� Q� .950 t+�RIT RATING I�DIFICATION (9885) $ 62 � TOTAL ESTIMATED A�AL STAt�ARD PREMIUM 1185 � EXPENSE GON.STANT(0900) 284 a� 0.0300 FOREI(�I TERRORISM / TRIA (9740) 20 �� 4.40% MA WC SPECIAL FUt� Af+D TRUST FUND 52 TOTAL ESTIMATED PREMIUM 1541 DEPqSIT ANIOUNT DUE 1541 DATE OF ISSUE: 0�-07-06 wc ST ASSIGN: MA SCHEDULE NO: 1 OF�aST oozsa� � � � vQAc '�sTPau►. TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABiLtTY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 { Q) POLICY NUMBER: (7PJUB-778X441—3-06) REt�WAL OF (7PJU6-778X441—3-05) INSURER: TEtAVELERS PROPERTY CASUALTY COMPANY OF AN�RICA NCCI CO CODE: 13579 1. INSURED: PRODUCER: OUTDOOR SNOP, INC. DICKEY INS AGCY INC 50 LONG POt� DRIVE 41 HA�L ST * SOUTH YARMOUTH MA 02664 PO BOX 39 � DEMVISPORT MA 02639 lnsured is A CORPORATION Other work piaces and iderrtification numbers are shown in the schedule(s) attached. 2. The policy periat is from o7-o3-os to 07-03-07 12:01 A.M. at the insured's ma�ing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the p�icy applies to the Workers Compensation Law o#the state(s)listed here: MA i i�s � • - B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in .= item 3.A. The limits of our tiability under Part Two are: �:r— �� o.= Bodily ln)ury by Acctdertt: � t 0000o Each Acciderrt o_ Bodify Injury by Dlsease: $ 5Q0000 paicy Limit � Bodily 1nJury by Disease: � 10000o Each Em{�oyee �= C. OTkiER STATES INSURANCE: Part Three of the policy app{ies tQ the states, if any, listed here: � COVERAC� REPLACED BY EI�ORSEN�NT WC 20 03 06A rJ'� � � O� � �._ D. This policy inciudes these endorsemerrts and schedules: �— a� SEE LISTING OF E(�ORSEN�NTS — EXTENSION OF INFO PA(� o� _ 4. The premium for this policy wlil be determined by our Manuals of Rufes, Classffications, Rates and fiating a"—` Pians. Ali required information is subject to verification and change by audit to be made ANt�IJALLY. � � DATE�F ISSUE: 07-07-06 WC ST ASSIGPI: MA OFFICE: DIRECT ASSIC�NT ?01 PRODUCER: DICKEY INS AGCY INC 29SFM aozsse . i + � - � VDAC a �STPAUL TRAVELERS WORKERS COMPENSATION j AND EMPLOYERS LIABILITY POLICY � � T1lPE AR INFORMATION PAGE WC OQ 00 01 ( A) i I f POUCY NUMBER: (7PVU6-778X441-3-06) � � i CLASSIFICATION SCHEDULE: , , PREMIttM B�►SIS ESTtMATED RATES ESTIMATED ' TOTQL ANNUAL PER$1�1 OF ANNUAL ' CLASS[FICATIONS CODE NO REMUNERATfON REMUNERATION pREMIUM ; ; � ' SEE EXTENSION OF INFORMATION PAGE - SCF�DULE(5) � SIGCODE: 7515 i ------------------------------------------------------------------------------------ I TOTAL ESTIMATED AI�JAL STAt�ARD PREMIUM $ STAt��A85 � PREMIUM DISCOUNT NOh� , 0900-20 EXPENSE CONSTANT 284 � FOREIC�N TERRORISM / TRIA 20 i TOTAL ESTIMATED PREMIUM 14$9 � TAXES Ai� 5URCHAR(�S 52 ' DEPOSIT AN�UNT DUE 1541 � � AjR (WCIP) # Minimum Premium: $267 sr asszc�: Ma DATE OF ISSUE: 07-07-t16 wC OFFICE: DIRECT ASSIt�p�NT 701 PHODUCER: DICKEY INS AGCY INC 295FM TOWN OF YARMOUTH � BOARD OF HEALTH � PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #07-040 FEE: $75.00 In accardance with regulations promulgated under authoriry af Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Cape Cod Ta Co. Inc., 984 Route 28, South Yarmouth, MA Whose place of business is: Cane Cod Salt Water Taffv Type of business: Retail Food Service less than 25,000 sauare feet i � To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2007 BOARD oF HEAI,Tx: L� :?S. �,/l+l.$., ' d�e��i�i, ��,►./Y, ?!i�G�ls�� Ro�e�t�B�i, �le� A�� l.u�f�'�r�.�, R./V. March 28_2007 Bruce G.Murphy, S.,CHO Director of Health 1 � `: ,� � I.?i3 ?�a'°,ic.c.SA�r W�a�rc.?a�, � ,;R�. TOWN OF YAR1Vi0UTH BO • F�.��AI. � �� . .,c - f G3GC� C� � `�' � D APPLICATION FOR LICENSE � +�20 °_ ,.,s �� . �� 2006 * Please complete form and attach a11 nec�ssa�y" ocuments by Dec er 3T,�80�. Failure to do so will result in the return of yow application pa k��ALTH UEI'T. NAME OF ESTABLISHIVIENT: C O(� �0.L"I'" (�a-'�' �Q + �L. # 5bk 3qy �SS� LOCATION ADDRESS: q Y,� . Q.,ViM �,t�� MAILING ADDRESS: �Sa,VY1;2, OWNER NAME:__�• J 1A,hnr�n�1' TAX ID(FEIN or SSNI: CORPORATION NAME (IF APPLIC.ABLE): �Sq.,m� MANAGER'S NAME: I.OY� �t,�MC�n�- TEL. # MAILING ADDRESS:_<S Q,m c� i POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list th�designated P�ol�perator(s}a,nd attach a sopy nf the eer-�if�ati�n to�his fcnm. ; 1. '`�J�C�--� 2. iPool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new � copies and maintain a file at your place of business. { 1. 2. � 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of 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. i � 1. �-� , 2. �F�SQ1�T IN CH�RGE: --__ _ _ _- - _ _ _ _ Each faod establishment must have at least one Person In Charge(PIC) on site during hours of operation. i 1. 2. j HEIlb�T�H CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attae�i eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. I �--� 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERNII'P# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 �' "� _INN $50 _CAMP $SD _SWIIvBvIING POOL$'75ea. TLODGE $SQ _TRAILER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LIC S EN E REQUIRED FEE PERMIT# LICENSE REQtJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 _�100 SEATS $150 �COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERNIIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 I 45,�OOsq.ft. $75 �'0�� _FRQZENDESSERT $35 �TOBACCO $25 NAME CHANGE: �10 AMOUNT DUE _ $ �S-O O il R R R RpLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM***"• :,, . ADNIINISTRATTON Under Chapter 152, Sectian 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 COMPEN5ATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� ' OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits: PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN TI� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. i ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. ` ADDITIONAL REGULATIONS �; � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed€ar the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. . POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. � FROZEN DESSERTS: y , y . � Department�Failure to d so willresult m thesu pensson or re oca ion of our�Frozenu es�ert�Pe�rm��u�ntil�thhe r '' above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. DATE: �� OS SIGNATURE: �� '�-�"-'� � � PR1NT NAME&TITLE: ��l, �l.(.V11C.�'�� — f�l'1R�� 09/28lOS i t� � -_--� ?Tie Com�nomvealth of Massachusetts � _�� Departntent of Indrtstrial Acculents -_- - -— N�wM � - - - 6//b Washiagton Stree� 7`�`Floor _�,J Boston,Mass. 0211I _ � wurlcers com tioa i�va�ce nffiaa.�B� i�aeal cu■araetors . �� . .. .: , � �, � �.�� :;_ � ��.. � � ��, . � e>E ya.�'� � �� .:,r. - .3 �_ s t�a�e� TQ �S- �l .. �ly+ l J• �(/l�l !' \ ��/�-� g181g' \ Y ) Z1D' V��J ( 1�10IIC# l�✓U V! l. �✓J � WOI�C S1tC IOCStI��2�fESS): ❑ I am a homeowner performing all wark myself. Project Type: ❑New Ctmstructioo�Rsnnodel I am a sole �etor and have no�e w in an Addition I am an employer p�oviding workers'compensati�f�my employees working aa►this job. c�r�►e: �: �r: ��, , ❑ I am a sole praprietor,geaeral ca�tractor,or komee�►ter(cirde owt)and have}rited tbe co�actors listed below wlw have the following worke,�s'compensation polices: \ ��;r�,��: "��t}e�xs• r;l c� J�°�r,n !'1�,+'� .� �o �� 3�o ,�; S.�r,r�m r,w1-h ��: � ��; �: �: ��e: Paihme a xc.re ervera�e,.rey.ireA.�der seew.2SA.t MGI.LS2 e..la�a a lYe hrp�iWa.r�p�ltla.ta�se.p a sI,SN.e�aaat.r eae yan'impt�usnt as wer as cM pmitla ia tie 6r�ata 3T0!WORK ORDER a�d a Aae dS1AO.N a day ataimt�e. I�dastud tiat a apy af tYis�Ie��y 6e firwarded 1s I�e 018oe o[Iav�Mm of f6e DIA hr avrra=e veeiAnliw. ��y c ' �rnder�e patws 4wd pe�rsl�,ojper,�Wry tAret t1Ye iwjona�+toa prov�ded��la�ixe�d oa�c� � ;1 � Print name ( .��(1 ��.LYYI CXl� Phone# �� -T `� �J,\ / efficia/ase osly do Dot wtite k tWs area te be os�pl�d bY cNy er�e�l city ar ts�vn: p�ifl6oeese# QBeidt�Depardmmt ❑cAaic if�Ie rapseae b reqei�evl �Bsard ❑Sdxt�a's O�ee �D�ar�t ceatiet Pcr'son: �e#, �Otl�' (aviecd 5c�f.2003) - � � VDAC - �STPAilL TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY PO�[CY TYPE AR INFORMATION PAGE WC 00 00 01 ( Aj POLICY NUMBER: (7PJUB-7431 A07-4-05) REf�WAL OF (7PJU6-7431 A07-4-04) INSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AMERICA �. NCCI CO CODE: 13579 INSURED: PRODUCER: CAPE COD SALT WATER TAFFY CO JOHN F MARTIN INS AGCY INC 1023 ROUTE 28 50 lON6 PO1� DRIVE BOX 350 SOUTH YARMOUTH MA 02664 S YARMOUTH MA 02664 lnsured is A CORPORATION Other work places and iderrtification numbers are shown in the schedule(s) attached. 2. The policy period is from o4-oi-05 to 04-01-Q6 '12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) tisted here: , �� MA m— �� ,— �_ B. EMPLOYERS LIAB{LITY tNSURANCE: Part Two o#the policy applies to work in each state listed in _ item 3.A. The fimits of our{iabiifty under Part Two are: �� o.— Bodify tnjury by Accident: � 10000o Each Accident o_ Bodity Injury by Disease: $ 50000o paicy Limit o_ Bodily InJury by Disease: � 100000 Each Empioyee �= C. OTHER STATES INSURANCE: Part Three of the policy appiies to the states, if any, listed here: � SEE ENDORSENE NT WC 2Q 03 06 m-- �� o� �� D. This policy inciudes these endorsements and schedules o� SEE IISTING OF EI�ORSEMENTS - EXTENSION OF INFO PAC�E � _ 4. The premium for this policy will be determined by our Manuals of Rules, Ciassifications, Rates and Rating � Pians. Ali required information is subject to verffication and change by audit to be made aNnlua��v. ..= DATE OF(SSUE: 04-01-05 TR ST ASSIGN: MA OFFICE: DIRECT ASSIGI�AENT 701 FRQDUCER: JOt�I F MARTIN INS AGCY 28LFB oo»sa � STPAtlL TRAVELERS WORKERS COMPEPISATION AND EMPLOYERS LIABILITY POLtCY EXTENSION OF INFO PAGE—SCHEDULE WC 00 00 Q1 ( A) � P4LICY NUMBER: (7PJUB-7431 A07-4—Q5) INSURER: TRQVELERS PROPERTY CASUALTY GOMPANY OF AMERICQ 13579—MA INSURED'S NAME : CAPE COD SALT WATER TAFFY CO INC RATE BUREAU ID: 00015742i PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANI�.lAL PE R $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 Of FEIN ENTITY CD 001 CAPE COD SALT WATER TAFFY CO INC 984 ROUTE 28 SOUTH YARMOUTH, MA 02664 �� CONFECTION MFG. 2041 30371 3.07 932 _ a� STORE ; RETAIL NOC 8017 24680 1 .31 323 e; �� CIERICAL OFFICE EMPLOYEES NOC 88i 0 3025Q .i 7 51 �� o� '� o� o�"'�^� �� m� �� i � � n� Q� ��.��r��.��.^��.�� — .950 MERIT RATIN6 MODIFICATION (9885) 65 � TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1241 `� f XPENSE CONSTANT(0900) 264 _�" TERRORISM RISK INS ACT 2002 (9740) 26 4.90% MA WC SPECIAL FUND AND TRUST FUND 61 TOTAL ESTIMATED PREMIUM 1592 DEPOSIT AMOUNT DUE 1592 DATE OF ISSUE: Q4-01-05 TR ST A55IGN: MA SCHEDULE NO: � OF LAST oo��ss � � VDAC � � �STPAUL TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLtCY ' TYPE AR lNFORMATION PAGE WC 40 00 01 { A) ' POLICY NUMBER: (7PJUB-7431 A07-4-05) ClASSiFICATION SCHEDULE: PREMIUM BASIS ESTIMATED � RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERAT{ON PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(5) SIC-CODE: 2064 MA BUREAU FILE NO: ------------------------------------------------------------------------------------ TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ STAND24D PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 264 TERRORISM RISK INS ACT 20Q2 26 - T07AL ESTIMATED PREMIUM 1531 TAXES AND SURCHARGES 61 DEPOSIT AMOUNT DUE 1592 A/R (WCIP) # Minimum Premium: $239 ST ASSIGN: MA DATE OF ISSUE: 04-01-05 TR OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: �1oFNv F MARTIN INS AGCY 28LFB , . . „ TOWN 4F YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-041 FEE: $75.00 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Donald Dumont, 984 Route 28, South Yarmouth, MA I ; Whose place of business is: Cape Cod Sa1t Water Taffv;Inc. ; ' Type of business: Retail Food Service less than 25,000 square feet � , To operate a food establishment in: Town of Yarmouth � F B `?�. � A�l.`n. { Permrt e�ires. December 31, 2006 BOARD o HEAI.'rH. , , ��`s�, .�, v�e�� aaa�t�. B�, er� �� , R.lv. I Febn�ary 3.2006 ruce G.Mutphy, , S.,CHO i Dire�tor of Health , 1 � ` ' � o�,yq Iw'��"'� to� j �" .a . ��o T4WN OF YARMOUTH � O _ y H 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 " MATTACNE 9s�/��'�] Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 � � ��A�ORAIf��b� .1�' C- B OARD OF HEALTH �' � � ^�' �'� n_� __� �,�-, �� . Y� � _ To: Yarmouth Board of Health Permit Holders J� `� ±� j�'�'�� HEALYH C�Ei�T. From: David D. Fiaherty Jr.,RS. ;��r � Health Inspector � Town of Yarmouth i Re: Federal T�ID Number Date: Mazch 22,20�5 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishme�t's Federa.l Employer ldentification Number(FEIN)otherwise � known as your"Tax ID Number". This is purely for administrative purposes only. I So� businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. ` Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to call. The of�ice hours are Monday to �ricfia.y, 8:30 a.m to 4:30 p.m. The telephone number is(508) 398 2231,ext.241. � Establishment: ��Q�; �(,�-� l'�:�� E SSN: ��,��;��, ( Location Address: _� �� -tt Z�' • S � L�G�(_.ti r'Yl C�,t,�-�� Signature: �-..-- �I,C.G��r'yL.� Pnnt. �V� ��V�GYI� Title. �b'i.T �3 n� ,:,,A �� Printe ��3 Pe � ` .- ` . t.P2�1�-F36 �76 j �°`;''R� TOWN OF YARMOUTH BOARD OF H ��'° � � � � � � � ° � � APPLICATION FOR LICENSE/P I 04, ' �:;, ,,;�s NOV 1 0 2003 .. ; * Please complete form and attach all necessary` � �'�y$December 31f,��3-�-H DEPT. Failure to do so will result in the return o �ur pplication packe . T �. C� S'a,� I,� � , -�s � LOCATION ADDRE • � �I 12� 7� t�'b � �'�Yl�c,c, (�y(p(�� I,I�IG ADDRESS: �Sa-rY`-�— OWNER/CORPORATION NAME� �.S��C...- MANAGER'S NAME: L,C�1�� t�r"��'f— TE # SGt�I'Y�v � M�ILING ADDRESS: SC�m� � �OOL CERTIFICATIONS: T6e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pov��perator(-�j a�atta�lr�-ct�py af�e certifieation tc�thrs €orm. i 1. 2. I ' 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 ernployees below and attach copies of employee certifications to this form. The Health Department will not use past years' reeords. You must i provide new copies and maintain a file at your place of business. � 1. 2. i 3. 4 FOOD PROTECT�ON 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, l05 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 -- - --- - - _ �IN�iARGE: _ _ 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 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. �STAU�ZANT SEATING: TOTAL# OFFICE USE ONLY _LODGING: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _B&B $50 _CABIN $5� _MOTEL $50 _INN $50 _CAMP S50 _SWIMMING POOL$75ea. _LODGE $SO _TRAILER PARK $50 WHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS a75 _CONTINENTAL S30 _NON-PROFIT $25 >100 SEATS 5150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE RF.QUIRGD FEE PERMIT# L(CENSE REQIJIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 �<25,000 sq.ft. S75 �� _PR07.,F,N DL'SSGRf S35 �TOBACCO �25 NAME CHANGE: $10 AMOUNT DUE _ $ �15•OO *'"�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* r ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance ar renewal �� of any license or permit to operate a business if a person or company does rtot 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: I'ES_� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003. ; ; SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPAR'TMENT 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 BOAR.D OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITL PLAN. DITIONAL F.CULATION ` POOLS POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. '; � r POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count s 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. p FOOD SERVICE CONSUMER ADVISORY: Each food esta.blishment 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 �2 hours prior to the catered event. Thses forms can be obtained at the Health Department. ; FR�ZEN H�5�1"S:- _— - _ __ - --- - i 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. t (.�UTDOOR COOKING: ` Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � � DATE: ( D� SIGNATURE: � �� I PRINT NAME&TITLE: �ib Y�i � �G�1�'l G�t� C�/1Cc '� 10J22/03 , ' , ` � The Conrmonwealth ojMossachusetts � � Department ojlndustrial.-�ccidents � ; Ofllceol/eres�l�stfiis 600 Washington Slreet � •� Boston.Mass. 02111 ,: � " �� W'orkers' Compensation insurance Att�davit Aonlicant intorm�tion� Pfess�pRinlTTe�.'W� ' �,m� C'cz r�e- C� S�Q.,�-t �a,-� 1�-� lucation� �� l � I � C--15 �ic. ��- ��L-vt+ {�C��' 1 � �� IU �� ohone a J(J� ��/`1 �5�� I am a homecwner pert�rmin,all w�ork myself. � I am a sole proprieror �r.� ha�e no one ��orkine in am•capaciri� _�I am an empio�.e_r pro��ino wori:ers' compensation for m��emplo��ees w�orkine on this job. _ comnanr name: ��(Q,l}-P,�.P,I�C_ ,�"1/_'U!VYII(1 I�_ �� . � I �-- �ddress: ( O �� cih•: �J� ��d 1�l�- � C�tS d 2 nhone a: Y�(�(� ' S��Z "��iS t� insurance co. Qolit,y# �� Q� � �� I am a sole proprietor. _enerai contractor, or homeow�ner(circle onel and ha��e hired the contracton listed belo� ��ho ha�e the folluc�in_ ��'orkzr�� ompensation polices: sompanv name• address• �ty: nhone t!• insurance co. Aolicy!! company name• addresr e�: ohoee 11• insuranee co. �y N � Failure to seeure coveraet as required under Secnoo 25A o(MGL IS2 a�lad to tAe iepaifioa o(erisi�i pndtles of a 6�e op to Sl¢00.00 a�d/or one yean'imprisonment as w•ell a�eivil penaltie�io the lorm of a STOP WORK ORDER aad a fiee otS100.00 a day a�aiett ma I s�denta�d that a copy of thi�statement mav be fonvarded to the Ot'(iee of Inveatiguion�of the DU tor eoven�e verifiatio�. I da hrreby cerrifj�under th�parns and penalti�s ojperjury that t6r i�fornration providtd obovt is tnte oad eorred Signature � "�-'� ��Y�---7� Date 1� ��„�(�3 Print name �� r' ��Y�.�l�l� Phone N �� / 't 7�� .. o(Ticial use only do not Mrite in this area to be completed by city or town otfleial eiry or town: YA�� _ permitAiceau M n8uildiog Department �Lieeasioe Board �cheek if immediate responst i�required 261 QSelectmen'�OlTiee �Hnitb Departmeat contacc person: phone N;_ �508� 398--2231 ext. nOther .. ._� .< �„. � � . � � � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT ; PERIVIIT NUMBER: #04-009 FEE: 75.00 , , � In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,S�tion 5 of the al Laws,a permit is hereby granted to: Cape Cod Salt Water Taffy, 984 Route 28, South Yarmouth, MA Whose place of business is: Cape Cod Saltwater Taffy Type of business: Retail Food Service less than 25.000 sauare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD oF HEALTH: Be�i� `.�. go�us, A9.`,�5. ' ��, v�e�� Ro�t�. 8.�, � _ _. _ _ _ _�Sl�, R./V. November 19.2003 BruCe G.M ,MP R.S. O Director of Health � � .� - i. c.c. s�.T c��.�A�y OF-YqR TOWN OF YARMOUTH BOARD OF•�ALTH a �� r =�� APPLICATION FOR LICENSE/P 2003 f ' '. � ��' � v,;� �-� o.t -, ��,��,.��So� [_-. � u � D ,� ; .�;r � . , � �� * Please complete form and attach all necessary,�� 's`by Decem�er�l��0�2� �QQz Failure to do so will result in the retur�r� - �� plication pa et.� � ��' F-�i-t��_�._n c N IS T: � � . # •s's L I • 9 7' 8' S'o `, o+�o � r�AiLING ADDRESS• -s'�4M � C TI N • -s MANAGER'S NAME� " Bn � TEL. # '3 9�/�-3�(�T MAILING ADDRESS• -s�i.k i� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required 6y State law. Piease list the designated -- �€�e�ertif�ea�io�to this form. - - 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION 1VLANAGERS - CERTIFICATIONS• All food service establishments 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 Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must rovide new co ies and maintain a file at our establishment. P P Y l. 2. _ �'ERS9�--I�i CH�La�r—_ _ _-____ ___ _ _ ___ . ___ _ __ _ __-- Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2• ; HEI LICH 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-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. l. 2• � 3. 4. RESTAURANT SE�ITING: 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 $SO _TRAILER PARK $50 _WHIRLPOOL $25ea �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TO-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 i _>100 SEATS $150 _COMMON VICT. S50 _WHOLESALE $75 R�TAIL S RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,_TOBACCO $20 I CL5,000 sq.ft. $75 ,�'a��b _TOBACCO $20 ' <50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ �l5•00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ' 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 Yarmauth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLIS�-�fENTS ARE TO CONTACT TI�HEALTH DEPARTMENTFOR INSPECTION 7-10 ' DAYS PRIOR TO OPENING FdR THE SEA50N. 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 OPEIVING;All swimming,wading and whirlpools which have been closed for the season rnust 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 CONSUlV�ER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temparary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. : FROZEN DESSERTS: -Frozen�Tesserts musf�e tes�ed ori a mon�i y basis by a S'�ate certifie��a�_ "I1est iesui�s mus��e-sen�to�he�-Iealt�i 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 Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepara.tion,or display of any food product by a retail or food service establishment is prohibited. i DATE: � /-( �-'� �-- SIGNATURE: �'h /� � PRINT NAME &TITLE: J� �rtf j� C(�.,U/a/-y-' �,�£��', 10/18/02 r UAIE(MNVDU/YY) � AC_O._R_D_,M CERTIFICATE OF LIABILITY INSURANCE 11 /1 8/02 Pnooucen THIS CERTIFICATE(S ISSUEO AS A MATTER OF INFOIIMATION John F. Martin Insurance Agency, IriC. ONLY ANO CONFERS NO RIGIiTS UPONTNE CERTiFICATE 1 0 2 3 ROute 2 8� BOX 3 5 O 110LDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND Oli South Yarmouth, MA. 02664 ALTERTHE COVEfiAGE AFFORDED BY7IIE POLICIES eELOW. 508-398-2277/FAX: 508-398-2239 INSURERSAFFORDINGCOVERAGE ' _ __._.. ._....___ -------- ' iNIIED —---------- --..__ ___...._. ... �ape Cod Salt Water Taffy Co. , Inc. �Nsu�ER�._ Legion_Insurance Company 984 Route 28 iNsunene: ----------- - - South Yaxmouth, MA. 02664 ir,sur�enc: _ INSURER D: INSUHER E: COVERAGES ' 1 t IF POLICIES OF INSURANCE USTED[�ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE fUR THE POIICY PERIOD INDICAI ED.NOI WI I I IS IANDING ANY REC1UIfiEMEN f,1 ERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICN 1HIS CERTIFICAf F MAY BE ISSUEU U11 MAY PEFiTA1NL711E INSURANCE AFFOROED BY TIi�POUGI�S DESCRIBED HEREIN LS$UBJEGT TQAt.I_.tl�E 7EAMS,EXCLUSIONS ANJl C[�Nl�p IONS��F SUCI# POLICIES.AGGREGAiE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAiMS. ' _ �---. ..-------- __ __ _ IWSR iYPE OF INSURANCE ` POUCY NUMBER POLICY EFFECTIVE POIICY EItPIRATION LIMIIS GENERAL LIABILITY EACII OCCUIIIIENCE S CUMMERCI�L GENERAL LIA8IU�Y FIt1E bAMAGE(Mry one li�e) S ICI AIMS MADE I___I OCCUR MEU EXP(Airy one peison) S PEfiSONAl8l1UVINJUf1Y S � GENERA�A(;Gfl[(3NG t � GENL Al3GREl3A�E tJMlf AP!'LIES PER: .. Pf1UDUCIS•COMP/UP A(i(+ f � � , _-- __. I'UUCY �,�� LOC .. . AUTOMOBILE LIABILITY COMEfINFD S�N(➢LE LIMII a � ANY M110 �En acr.kleol) ,. ALL(.WYNEU AUIOS DODILY INJURY SCIIEDULED AUtOS (her peison) f 111f IED AtIIOS � � tS0OILY INJURY f � NON-OWNEb AUIOS (f'er aCcidenQ , _ _ _ . .---.------_- PFlCN'EfItY l)AMAGE ' � (Per accklenl) _ �� QAqAOE LIABIL�fY ` AU�OONLY-EA ACCIVENI Z ANY AUlO O111E11711AN _EA ACC f AUlO OIJLY: �� _ E%CESS LIABILITY EA(:11 OCCUI1fiENCE S ._ ..- --- -_..... ._... _..)(KCUR I_ I CLA�MS MAUE . AOUPEGAfE _- ___ .. . S_ .. S bEUUC1IBLE i f1ElEN11(NJ S f lVOifKEtiS COMPENSFIWN AND . �NC S1AfU- Olfl � __ IUI]Y I.IMIIS E(1 EMPLOYERS'UABILITV E.L EACI I ACCIbEN f E � O O� O O O. A WC7 0926702 3/05/02 3/05/03 - - E.L.tHSEASE-EA EMPLUYEE f S O O� O O O. E.L.OISEASE•PUUCY LIMIt S � O O 0 OTHER "� UESCRIPTION OF OPENATIONS/LOCAt10NSNEHICLESIEXCLUS10N3 ADDED BY ENDORBEMENi1SPECIAL PROVISIONS CERTIFICATE FIOLDER ADDIiIONAL INSURED•INSURER LETtER: CANCELLATION SHOULD ANY OF iHE ABOVE DESCRIBED POLICIES BE CANCEIIEU BEfOfiE 111E E%PIRAt1UN Town Of Y3Y'IROUtYl OATEIHEREOF,THEISSUIN61NSUpERWILLENDEAVORTOMAIL � � OAYS W111tfEN 1 1 4 6 Route 2 H N0110E T0111E CERTIFICAiE HOLDER NAMED TOTf1E LEFT,BU(FAILURE 70 UO SO S►IALL I .SOLlth Yarmouth, M�. 0 2 6 6 4 IMPOSE NO OBLIQAiION OR LIABil1TY OF ANY KINU UPUNT{IE IHSUtiER,ItS AC3ENfS OR REP ESENTAi1VES. ; A I D REP ESEN iIYE � � l� ,G�.; ` � j ACORD 25-S(7l97) m ACORD CORPOf1ATION 1988 i � � ' " � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT j PERMIT NUMBER: #03-016 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: Cape Cod Salt Water Taffy Co. Inc., 984 Route 28, South Yarmouth, MA Whose pla.ce of business is: Cape Cod Saltwater Taffy Co Inc 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. 2003 Bo�oF��.�: eka��ea# �eUlkaa, L��xa.c _ _ b�e�t.�D. C��mralo�._71L.?�.,_�/iee_ _. __ �o�att�. �iocoac, L� �a�rte�79�Dar.xot� ',�efe�,c.Slr�k, �?Z. , December 10 ,2002 ruce G.Murphy,MP ,CHO Directar of Health , 1 1 , I 1 I � i I 1 i � I I , C.c. SA c.T WA�rt—e.TA FFy F � TO �� RD OF HEALTH APPLI -f`-'TI l�i': �} SE/PERMIT -2002 . ,:_ //o�� '°7`3"• !r� * Please complete form and attach all necessar�documents by December 31, 2001. Failure to do so will result in the refurn of.your application packet. NAME OF ESTABLISHMENT• TEL # �� y��S r n�ATION ADDRESS• o;�gg� ��e�. . MAILING ADDRESS: 9s4 RnuTE 2s WN O I HRe,flc''JTH, M 26 -^� r ° N TEL. # � � �38/� ING A D SS: I POOL CERTIF CATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated II Pool Operatorjs)and attach�co�y of the certification to this form. � _ -- --- __ _ . _ _ 1. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must rovide new co ies and maintain a fde at our lace of business. � P P Y P ! 1, 2. i 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. 1. 2. I , --PERS�N IlV�HARGE:___ _-- -- _____— _- --- _ . _ _- ------- Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and � attach copies of employee certifications to this form. The Health Department will not use past years' records. ` You must provide new copies and maintain a file at�your place of business. 1. 2. 3. 4• RESTAURANT SEATING: TOTAL# i O�'FICE USE ONLY ; LODGING: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 � _INN $50 _CAMP $50 _SWIMMING POOL$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 5EATS $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 � _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 � NAME CHANGE: $10 AMOUNT DUE _ $ 7 5.�Q 1 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � _ . ,� .........e � 1 ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuanc�e 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,�11�TD 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 1/1 NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLIS��NTS ARE TO CONTACT TI-�E 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 OPElvING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _-- --- -_ -_ _ _ _ __ _ __ _ _ _ - ___ _ _ --------- -- __ FROZEN DESSERTS: 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.,ou�door seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: f" ��6 C SIGNATURE: �C7 h�� ,U � PRINT NAME&TITLE: `� D /�/� �� t� � T �.�1�� 09/11/O1 , UA F (MM/ U/YV) AC�RD_,M CERTIFICATE OF LIABILITY INSURANCE ��Zo1'o� �__- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFUI1MA�ilON John F. Martin Insurance Ayency, Inc. ONLYANDCONFERSNORIGHTSUPONTHECERTIFICl11E 10 2 3 Route 2 8 , . Box 3 5 0 HOLDER.THIS CERTIFICATE DOES NOT nMEND,Ex7ENU On South Yarmouth, MA. 02664 ALTER7HE COVERAGE AFFORUEU BYT�IE POLICIES BELOW. _ 508-398-2277/FAX: 508-398-2239 INSURERSAFFORDINGCOVERAUE INSURED __ __ _- --- -— -- ------ ---- -- --_ — . _ Cape Cod Salt Water Taffy Co. , Inc. �NsuneRn 984 Route 28 INSUF1Et18: South Yarmouth, MA. 02664 INSUHERC _ .._ _. . INSUREf1D Le�ion Insurance Company INSU(tER E: COVERAGES TNE POLICIES OF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POUCY PERIOU INOICAI ED.NO f WI t I iS I�NUING ANY RECIUTAEMENT,1 ERM OR CONDITION OF ANY CONTR/1CT OR OTHER DOCUMENT yVITH RESPEC�TO WHICH 7HIS CEFli1RCAf F MAY BL ISSUI_U Ufl MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEFiEIN IS SUBJECT TO ALl THE TERMS,EXCLUSIONS AND CONDI I ION;OF SUG1 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS. ----------------------- ------------ --- ------- - -- __ - - -- - _ INS11 TYPE OF INSUAANCE POLICY NUMBER POLICY EFFECTIVE POIICY F%PlfiAllON � LIMIIS GENERAL LIABIL�iV EACH OCCURHENCE $ COMMEFlCIAL GENERAI UABIUTY -P FlRE DAMAGE(Any one fir�) $ _ CLAIMS MADE (__._.l OCCUH MEU[XP(Any one peison) $ PEf1SONAL&AUV INJUfI'�' $ GC_NER�LAUG(IEGAtG $ GEN'L AGGREGAiE UMI!APPUES PER: . PRUDUCi S-COI�1P/OI'AGc; $ f'OLICY -_ PRO- — LOC AUTOMOBILE 11ABIL1?Y � — COMHIIJF_D SINGLE LIMI f R • ANV AU�(O (En acr,iden�) ALL OWNED AUTOS fiOUILV IIJJURY $ SCIIEUULED AU70S . (Per peison� -� .__._ _. _. I IIREO AU 1 OS NON-OWNED AUTOS '30UILV IN,IU'HV $ Per accidonl _. .-..____._----------------- Pf101'ER(V UAMAGF R . �P�r accidonl) OARAGE LIABtIITY AU(O ONLY-EA ACCWEf�t S ANY AU70 _, _ _ _ . OI I IFII I I IAN EA ACC $ AU100WLY: �Uv $ E%CESS LIABIUTY � EAGH OCCUIIRENCF $ ,OCCUR �J ClAIMS MADE AGGFIEGAIE $ S . DEUUCT IBLE $ . f1ElENT10N $ � WORKERS COMPENSATION AND WC S1AI U GI I I D EMPIOYERS'LIABILITY WC O 9 2 F)7 O 2 3��5��1 3�O 5�O 2 1URY IIMI I S EI I � E.L[ACH ACCWEN t �10 0 ,0 0 0 . _.__ __ _ _ E.L.UISEASE�EA[MI'IOYEE 5 S O O �O O O . � 'E.L I)ISIASE-POLIGY Uldl I $ O O - OTHER DESCRIPiION OF OPERAiIONS/LOCATIONSNEHIClE3/EXCLUSIONS ADOED BY ENDORSEMENTlSPECIAL PROVISIONS CERTIFiCATE HOLDER AODI110NAL INSURED�INSURER IETTER: CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLEU BEFORE THE ERPIRAfION I DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR 10 MAIL 1� _ UAvS Wflil fEf� Town of Yarmouth - - � 114 6 Rout e 2� NOTICE TO THE CERTIFICA7E HOLDER NAMED TO THE LEFT,6UT FAILURE t0 00 SO SIIALL � IMPOSE NO OBUOATtON OR LIABIL�TY OF ANV KiND UPUN THE INSURER,If S AGEM-S OR ' South Yaz'mouth, MA. 02664 REPRES 7ATVES. i AUT ZE RESE TATIV �%�/�C_ ACORD 25-S(7/97) �ACORD CORPORATION 1908 T � � . r i � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT ; PERMIT NUMBER: #02-013 FEE: $75.00 i � 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: � Whose place of business is: Ca�e Cod Saltwater Taffy Co. Inc. Type of business: Retail Food Service less than 25 000 square feet To operate a food esta.blishment in: Town of Yarmouth Pernut expires: December 3 l. 2002 BOARD OF HEALTH: �s�, i��fli�i ��D. �mrd.�c. .D.. `l/�ce �a�att� �, L� �a�uk?1l�Da�o� ! � �yl. March 15 ,2002 ruce G.Murph}+ , .S.,CHO Director of Heal i I � i � � i T ,' Cc� Cczl Sc�l`t I�a.�t-er 7��'y Cc-� ; � '� "�"'� TOWN OF YARMOUTH BUARI)OF HEALTH � � � � � d � � ; t�iPPLICATION FOR LICEN�/PERMIT-��0�� D E C 0 8 1999 � � - �"� `, � * �lease complete form and attach all necessary documents by De�ember�31�, 1999. Fail �lt the return of your application packet. � ----------------------------------------------------------------�-------�------------------- ----- , NAME OF ESTABLISHIVIENT: �'_C'--- S'�.c.� �Sk --------- -�------�-------------------_. ' LOCATION ADDRESS• � Sf y /c�,��" S'n, ��„ �, . �y # � yy�7•��7 � � s � L I7 S �- a � ' # l0 3 S�� a D �7`' s. o � �r-' POOTr�RTIFiCATIONS- ' -- -------------------------------------------------_-----------------------___--------____. T6e 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 tlus form. ' 1• 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I � L 2. � 3• 4. � HEIl1�iLICT-�CFRTIFICATIONS• All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at all times. Please list yc�ur employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain �tile at your place of business. 1• 2. 3• 4. RESTAUR�IT S�A�TING: '�'�TAb#--_ _ AKJA�-S�IF3I�A�SEt�'£�: TO'£A�#---- - — - - -------------------------------------------------------------------------------*---------------------------------------------------------------• �FFICE U,�E ONLY LODGING• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 `CABIN $50 � �INN . $50 _CANIl' $50 LODGE $50 �TRAILER PARK $50 MOTEL $50 �SVVIMMING POOL $SOea. WHIR.LPOOL $25ea. FOOD SERVICF� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# 0-100 SEATS $75 �CONTINENTAL $30 >100 SEATS $150 __ _ _ � _ __A�UN-PR(}F�T _._ $��-- - -. _._ _ _ .. �. �COMMON VICT. $50 � WHOLESALE $75 RET ERVI F• ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 ,TOBACCO $20 ' I <25,000 sq.ft. $?5 I�C-� FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME C A E• $10 AMO�JNT DUE = $ �Cj� """"PLEASE TORN OVER AND COMPI,ETE OTHER SIDE OF FORMx„rt R R � � _ ._ �._. + 4 . ...__. ....._....... ... ..... .. .._. _ . � , ADMINISTRATION '� -.�` '_ UNDEI�C�I�4P',TE�152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED '�O HOLD ISSIJANC OR RENEWAL OF ANY LICENSE QR PERMIT TO OPERATE A BUSIN.�SS IF A REI3.1�01'��-t?A.-'.�MP� DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATIUN ; INSUR�NCE. 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 QF 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 JANtJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FE�(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�IENTS ARE TO CONTACT TI�HEALTH DEFART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. � , ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW ` EQUIl'MENT,ETC.),MUST BE ItEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO ; COMN�NCEMENT. RENOVATIONS MA.Y REQUIRE A SITE PLAN. ` DITIONAL REGULATIONS � POOLS � POOL OPENING: ALL SVVIlVIlVIlNG, WADING AND WHIRLPOOLS W�-IICH HAVE BEEN CLOSED FOR ; THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TQTAL CULIFORM AND STANDARD PLATE C�UNT BY A S'�A'�E CERT�F�D LAB, PRIOR TO OPENII�TG, AND QUARTERLY TI�REAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD 5ERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TF�YARMOUTH HEALTH � DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 ! HOURS PRIOR TO TI-� CATERED EVENT. T`HESE FORMS CAN BE OBTAINED AT TF-� HEALTH ! DEPARTMENT. FRQZEN�ESSERTS� FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII..L RESULT IN THE SUSFENSION OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. . _ ` Ot,]TS�E CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), ML7ST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. C)IJTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHIVIENT IS PR4HIBITED. _ DATE: � I �� 7 --��/ � SIGNATURE: � ��_ PR1NT NAME& TITLE: %`� /) /!/ I.� �� o �v? I� /� %= S 11/12/99 � — � CERTIFICATE OF INSCIRANCE ISSUEDATE(MM/DD,�) � ZL/1�/99 .. . . _. � PRODUCER ° THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO j John F. Martin Insurance Agency � RIEND OR AL�ER THE COVERAGE AF�FORDED BY THE PIO ICIES gOLSO`NOT AMEND, EX- j 1023 Rc,ut� 28 , box 350 ,e�.... _.., me ._.��.... . �. _._.�. evaem� .... : �ee � w .. re e°e e .. .� South Yarmouth, MA. 02664 COMPANIESAFFORDINGCOVERAGE � °v...,. esAmeve� .� .... ..e� e ... �_ ._eee �..... .e � ..� . �� ... _.,� .. m e� � 508-398-2277/fAX: 508-398-2239 = COMPANY ` LETfER A � CODE SUB-CODE �v �em ..,,...m. e°e� .�� ....�„ �eee ... , R e��e ...�. ., ,�e .... �.eve, ...� _ ._ ra , _,.. ' COMPANY . . ___ .. ,� . _._... . ...� . .___._.� ; LETTER B � INSURED , - .e.� .W.......�..... ��... „ w ... ,.A� m .N_. .. ae..,� . .,.. .aa.�.e ..._. .. � Cape Cod Salt Water Taffy Co. Inc � E�ER"Y C 984 Route 28 x e.. �_. �m . � . �. _ . � . . . m. . .. .._..� � South Yarmouth , MA. 02664 �� coMPnNv�� ETTER D L�egion Insurance Company � °� _______ . �. ._.. __._ . ___. . - COMPANY .. ` ._ . _.. �_ _. . . __._ __ LETTER E ° vi C01/ERAG�S a ,; � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIST�D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN- o DICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER- a TIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLU- � SIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS a � ,� e � .... eeee , � . _ e� _. . .� esae� _ ....� � Aa�emd � .. .� v=� ,r� _. �e . ..,�. em ,.,.. . eee� . . . �e,e.. ..,< . ees e_ .., . �e CO ° POLICY EFFECTIVE 'POLICY EXPIRATION ;, � � iTR TYPE OF INSURANCE POLICY NUMBER ALL LIMITS IN THOUSANDS • DATE(MM/DD/YY) j DATE(MM/DD/YY) � � ., ,M .�� Ne. H_ ee��.e_.... ._ e.� �.�,_._.. _ ..,.� mee.�..�... . . .� ...,...,a.. .meee�a ... ee.ae ._. . J .M, .�ed ,.........� ..a . . ,.e.em ._,.......-a J 'GENERAL LIABILITY a GENERAL AGGREGATE a x ` COMMERCIAL GENERAL LIABILITY ' °PRODUCTS-COMP/OPS AGGREGATE ~ 3 'CLAIMS MADE • ; OCCUR. ' PERSONAL&ADVERTISING INJURY � ..., .a ee m �'�� OWNER'S 8 CONTRACTOR'S PROT. ; ;EACH OCCURRENCE Q ' a FIRE DAMAGE(Any one fire) � : p � .. . .... . .�. e . _ � � � MED.EXPENSE(Any one person) � .. _ �a� ..._, . eve. �...,. _e ... . � esevee._�... _ � v�,._.,.,. s�.._..�, w�.,. ..,., � P. .., ee em ,,. « e .�.. AUTOMOBILELIABILITY �� =COMBINED �� '�. ANYAUTO :'�.SWGLE � I LIMIT � ¢ ALL OWNED AUTOS �BODILY � ; SCHEDULED AUTOS ��INJURY �� - (Perperson) F HIRED AUTOS ., :BODILY � � INJURY Z NON-OWNED AUTOS ' z ' GARAGELIABILITY (Peraccident) , Q PROPERTY � € ; DAMAGE � � __ . � __ .. _. . ... .� . __._ .._. .. . __ _� �._ .. .... � _ ...•� . . .�._ .�� ,. .mm,e.., , ��. .._._ ::.� p EXCESS LIABILITY � EACH � AGGREGATE ° "" ' � " OCCURRENCE w � i, ;� = ; � ��_,_ _ _ _._ ¢ - -` _ OTHER THAN UMBRE�L2tFQF3�A - �- --— — — - ` -� a a� � .; .<_ e �. ° = _ . �, „�. . .ee,e � . .. �mwem _m w. .._ .,e �. �� e .�, „ e , . b e „. �bme.,R STATUTORY Z r - WORKER'S COMPENSATION ` ; ; �e . d � ,_, � m , .. ... � 1 O O � O O O . (EACH ACCIDEN� � D' AN� WCq'-09267�2 3 3/05/99 " 3/05/00 ; 500 � 0�0, (DISEASE—POLICYLIMIT) ? �� EMPLOYER'S LIABILITY �_ �.. _. .._. �_� _... 1 O O �O O O. (DISEASE—EACH EMPLOYEE) � OTHER __ .__ . ._ .e.._.. .�_ _.__. .,_ � m �._.. ..� _.. ... . _... ... .,.. _ � � O LL . � Q � U ' Q . .,—.- .. .e,ee ... . ..�.e �e. .� r�,.._«.. �� a....>..��ee,.__.. ...�... m.e...... ...e.eeem..._. �...save._....._em„..> .._d e,.., e�ae ,_.., esa.a. ., _ee eg...... eve.._.�y _e�e. .....� LL DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS � T O z 0 � a ¢ a > a � � GERTIFICATE HOLDER CANCELLATIQN � ' Town Of YdY'IIlOUtYl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE � ' �, 1146 Route 28 °� ' EXPIRATIONfL DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO � � SOUtYl Yarmouth� MA, O 2 6 6 4 MAIL 1�DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE � �, LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR o N LIABILIT OF ANY KIND UPON THE COMPANY, IT AGENTS OR REPRESENTATIVES. a ¢ , � AUT 12 E E A E � � � ❑ � ¢ � `�� O ' � V Q .. .. .... .. .... ..... . .. ... ... ... .. .. . . . . " � � i i TOWN OF YARMOUTH ., BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-19 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: 1)�n num�nt, 9R4 R�nt R},,4�uth Yarmo � h, MA Whose place of business is: Cane Cod Saltwater Tai�y Co. Type of business: Retail Food Service less than 25,000 s�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�% ��t��, C'�t�►,�� oan� �ullivan, ��, Vice �hai�ma o�ert,}. p,rown, C,[e�h a�rie��e�a�o[��c�-�oope� ��10�0�,.��K December 17 , 19 99 Bruce G.Murphy,MPH, .5., Director of Health �. __ � a�Sct.l+u�'i.}e�r`ro� CJo � �� ' � � � � D � ` TOWN OF YARMOUTH BOARD OF-$E�L• �� APPLICATION FOR LICENSE/PERMIT- 1999 d�(; � 9 �99$ I � �� i `�` Please complete form and attach all n�ecessary documents by December 31, 1998. Fail 1'd��aqnit ' ; the return of your application packet. �� SA�.� WATER TAFFY c'�O� �Nfi;. 984 ROUTE 28 -------------------TABLI-------—N----------------80�Ei'17fi"P7CAIii1�UTN;"IiAA-D268�"------------------------ -��----------3 -� # � AI D S: �` � _ _ T � ' MAI�TAGER'S NAME� � �c�,,.�,� -�-- TEL. # � �� 3 � �o MAII,ING ADDRES S� ----------------------------------------------------------------------------------------------------------------------------------------- POOL �ERTIFICATIONS: 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 tlus form. 1. 2. Pool operators must list a minimum of two employees currently ceitified in basic water safety, standa.rd First Aid and Commumty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus 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. i � HE��,V[,�H CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yau must provide new copies and maintain a file at your place of business. 1. 2. i 3. 4. � RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ------ ------------- ----- ------------_-------------- --- - � _ - -____ _ __ __ . _ _ _ --- - 4�ICE-�SE O�TLY - _ _ _ _ _ _ LOD�NG; LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 � INN $50 CAMP $50 , LODGE $50 TRAII,ER PARK $50 � MOTEL $50 �SWINA�ING PQOL $SOea. WHIIt�I,POOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 I >100 SEATS $150 NC)N-PROFIT $25 � — — � COMMON VICT. $50 WHOLESALE $75 RETAIL SE�VICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _<50 sq.ft. $45 TOBACCO $20 �<25,000 sq.ft. $75 �� FROZEN DESSERT $25 >25,000 sq.ft. $200 NAME CHANGE: $10 �. AMOUNT DUE _ $ � ��' """"*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""*" i / � 1 � ' � ADMINI5TRATION '` UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOLJTH IS NOW REQUIR�� O �IOLD ISSUAl�TCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF � , PERSON OR COMPANY DOES NO'T'XHA�"� "CE�TIFIC�I�E OF WORKER'S COMPENSATION INSURANCE. THE ATTACHEI�.��NOR��L'5,,,,CQJ•.1�PEN5ATION INSURANCE AFFIDAVIT MU5T BE COMPLETED AND SIGNE ' -� � �� ' � � � CERT. OF IIv�� ' � � -, � � � , _ . - �� Y� - WORI�ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK OPRIATELY IF PAID: YES NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS��NTS ARE TO CONTACT 'THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE 5EASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlI�IEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIMMING, WADING AND WHIRI.POOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTN�NT,AND THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIF�RIt�t AND�TANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR T4 OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERIl�TG POI,ICY: ANYONE WHO CATERS WITHIlV TI-� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TE5TED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SE1�TT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI-3_E SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS -- ----- .--- - _ _____ __ --- . HAVE BEEN MET. - -- - - _ OUTSIDE CAFES: OITTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT$Y A RETAII.OR FOOD SERVICE ESTABLISHIVIENT IS PROHIBTTED. DATE: / �— �—�1 � SIGNATURE: ��Y�-��`-'L�i�-�Y`-�� ""' J / PRINT NAME& TITLE: � E.S , � C� /U � l� � O �'' 1 a � �ERTIFICATE OF INSURANCE '��E°"TE'M�,°°,�, • _i2�o�/�s .�.� r-� � a PRODUCEI7 � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO J��ITl F'. Martin Insurance Agency, �T�NTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EX- 10 2 3 Route 2 S � BOX 3 S O TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW South Yarmnuth , MA. 02664 � _, .�. __._._ _.. ___ � _ , m.__. ___ COMPANIES AFFORDING COVERAGE 508-398-2277/FAX: 508-398-2239 ; . : _ . _ _ _ ; COMPANY i LETTER A CODE SUB-CODE � �__.. .. �. ... _. __ _ _ .._ __ _-�-- % COMPANY _ _._ � LETTER B INSURED { � � � _ _- �__ _.._. .. � _. (,'ap}�,e COC� S31t Water Taffy CO. t COMPANY �+ �. 'laffy I�ane & Route ZS LETfER V South Yarmouth; MA. 02664 `. ..__ _.._.__.__. .__ . . ___ _ _ _,�___ .._�.__. _, ______. � E°RER"'" D Granite State Insurance � 4 _ ._. . . ..___. ___. __ .. __ _.�, ___ __. _. = COMPANY � LETTER E . ,.. _ f� t vi �. . ,.. „, .. . _ � ' COVERAGES ¢ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN- ¢ DICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER- a TIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLU- � SIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � _.._. . _.�. _.� w_. _..,y._ _ . �,_� �.. . _ .�_ �._r.__�. .� �._�.._m,�A�. CO TypE OF INSURANCE POLICY NUMBER �LICY EFFECTIVE 'POLICY EXPIRA710N ' ALL LIMITS IN THOUSANDS y LTR DATE(MM/DD/YY) � DATE(MM/DD/YY) : ... .. .. ........ .._. __..__ _.._..< ........ ......._,..,.._ ......_....�._ .._..........._ . __._7 ...... ., ........._......_.... ....u._.,.,_._...,..«....J.«....,....�., J GENERAL LIABILITY ` GENERAL AGGREGATE a x � COMMERCtAI GENERAL LIABILITY 'PRODUCTS-COMP/OPS AGGREGATE 3 CLAIMS MADE OCCUR. :PERSONAL&ADVERTISING INJURY m OWNER'S&CONTRACTOR'S PROL '.EACH OCCURRENCE a 'FIRE DAMAGE(Any one tire) � U � MED.EXPENSE(Any one perwn) p __ _ ,. . . . _ ..__....... AUTOMOBILE LIABILITY � � � # �� ' � COMBINED Z � � SINGLE - ANY AUTO LIMIT � O ALL OWNED AUTOS 'BODILY � � LL ' INJURY � SCHEDULED AUTOS ; ;(Per person) � � HIRED AUTOS � � "�.80DILY � � Z . .. NON-OWNED AUTOS . ;(Per�accidenQ a GARAGE LIABILITY . , '�.PROPERTY 3 DAMAGE � _ _ ' _ _ _ -. .__:._.:.e.:..._ EXCESS LIABILRY ` OCCURRENCE AGGREGATE, W � ¢ x � OTHFR THAN UMBRELLA FORM. ' � a .. ... .. ._ ;. .e., ..,.. ..... ... .. .. ....� .. ., .._.. ...�.�_ «.._.....,.,,... C7 .. . .. . . . . _ . . , ._ ,.. . Z ---- - — __ _--- —- ______ ; STATUTORY w ------- -- -----_ ___ -- --- - � --��.- n WORKER'S COMPENSATION 1 O O �O O O. (EACH ACCIDENn N � AND W(,'3 rj t�7 1 8 Q : C)�O 1.�9 S ; E�1.O�9 9 , C�� Q� . (DISEASE—POLICY LIMIT) � ¢ EMPLOYER'S LIABILITY � �:- 1 O O �O O O . ( N DISEA$E—EACH EMPLOYEE) N `, _ _. ....___ � OTHER � LL � � � U Q LL . . .... ... .,.. ... ....„ . ......... . .�.. . .... ... .......... .. .._.. .. ..... .. ......... ........ , ..,.,,....__.,.._. O DESCHIPTION OF OPERATIONSlLOCATIONS/VEHIC�ES/SPECIAL ITEMS z O � Candy Stand a � a > < � � CERTIFICATE HOLDER CANCELLATION � Town Of YaZ'ItlOUtYl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE m � 114 6 Route 2 H EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Z � SOL1tY1 Yarmouth y MA. 02664 MAIL 20DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NA.MED TO THE � > LEFT, BUT FAILURE TO MAII SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR o N LIABI Y OF ANY KIND UPON THE COMPANY, ITS ENTS OR REPRESENTATIVES. ¢ 0 r� A OR REPRE NTAT v � ¢ � �U � Q �� O Q I 1 1 1 ; " TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-16 ' FEE: $75.00 � In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: C'ane Cod Saltwater Taffy('o , tnc-, 984 Route 2$, S�uth Yarmo �th, MA Whose place of business is: Cape Cod Saltwater Taffy Co., Inc. 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, 1999 BOARD OF HEALTH:�d�/. ��t��, C'�tr,�� oan � �alfivarc, K.//., �ice l��irman obert� �rouin� C.ler� ! a�rielle�a�of�h�.�-.l�tooPe6 '//ichae� dou hlin. � December 17 , 19 98 ruce G. Murphy,MPH, .,C Director of Health � . i i