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Home My WebLink AboutApplications, WC and Licenses� • �°' ► TOWN OF YARMOUTH BOARD OF HE�,1'�-°� �� -��, � � ' � APPLICATION FOR LICENSE/PI��V�'I':-Z809 ._.. ° �� c�� ,` � � 2oos * Please complete form and attach all necessary�cum�nts by Dec r Failure to do so will result in the return of your application pac e . ��F�C`. NAME OF ESTABLISHMENT: �� P d �' G��. TEL. #�D�77S=UDS'� LOCATION ADDRESS: �o ` r�a�„t MAILING ADDRESS: a;h S e e-i- ,� mo eZG ,� OWNER NAME: �- : � �� (�/�/,��S �,`�'� ` TAX ID (FEIN or SSN): CORFORATION NAIVIE (IF APPLI(:AtsL�t: � MANAGER'S NAME: TEL. # ' MAILING ADDRESS: � ; POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by S#ate law. Please list the designated � Pool Operator(s} and attach a c,opy of the cei-tification to this form. � 1• � �l`t 2. Pool operators must list a mir�imum of two employees cuxrently cei-tified in basic water safety, standard First Aid and Community Caidiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must pravide new copies and maintain a file at your place of business. L 2. 3. 4. , � - FOOD PROTECTION MANAGERS - CERTIFICATIONS: I 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 Sanitaiy 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. PERSON IN CHARGE: _ _ ---- _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1• 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all tunes. Please list your employees trained in anti-chokmg procedures below and �' attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN $55 _MOTEL S55 _iivN S55 _GAMP $55 _S�INGPOOL S80ea. _LODGE S55 _TRAILERPARK �105 _WHIIZLpOOL a80ea. FOOD SERVICE: LICENSE REQiTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S85 _CONTINENTAL $3� NON-PROFI7 �30 _>100 SEATS �160 _COMMON VIC. $60 _WHOLESALE �80 RETAIL SER��ICE: _RESID.KITCHEN �80 LICENSE REQUIRED FEE PER1bIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <�0 sq.�. �50 _>25,000 sq.ft. 522� _VENDING-FOOD �25 � <25,000 sq.ft. �80 �4r7—��} _FROZEN DESSERT 540 _TOBACCO �55 ��E c��vcE: s i o AMOITNT DUE _ � S O.O O **'"**PLEASE TUR'1i OVER AND COMPLETE OTAER SIDE OF FOR1i�I**w** r � A 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 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 ESTABLISHIVV�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be . limited to the temporary and short terrn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(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 b4G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opeiung. Contact the Health De�artment to schedule the inspection five(�days pnor to opening.PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool 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 Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a 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 of Health. OUTDOOR COOHING: Outdoor cookin�,_Qr�atio_r�or display of any food product b�a retail or food service establishmem is prohibited. ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL AP1'LICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; i DATE: ��' �� '' O� SIGNATURE: —� PRINT NAME&TITLE: �t — ��'�► /-�vs�i 1'./�' r C��.�-�t� P� to'zi�os a � . � � ! �\ The Commonwealth of Massachusetxs ' Department of Industnial Accidents ' M�f If�tl�i 600 Washington Stree� 7`h Floor ' Boston,Mass. 02�11 � Woricers'Compensatioe I�araaee A�davit;Bailding/pl�mbiag/EleMriCa(Contractors j ��" p�ease PRiNT le�bl�r � natne: /"/Gt/� 7�, t"1 - VC.0 YI (�.5 tC c 1Q � ' addtess: � ��A� C' � 1/eL/ L�� Y (.��J�Jj �7l.�.� ( ��—� i- j citv Cc'n.-��>��•� sfate• ! �!7 zip• dr�7�� oh�e# �7� 02�'}��—(�„� work site location ffull addressl: ld / / a/"/(�A ��1Q u✓ yL�lE'�YJ . /7 / /!7 d�lv �� ; ❑ I am a hom�w�r perFornung all work myself. Projec �ype: ❑New Consttvcbion QR�nodel j ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition � �I am an employer providing workers'compensation for my e,mployees wo�cing on this job. j oomoanv�a: ��•�:: d c�/cY P . L��oJ /`I A�, C�� j aa � u;., � , ; �_ �/- �-/'a,� .�du�� , 1�'I� �:�� #- -�n� - �7� o�'.y ; ' � � # � :�:, ... ...� �. :,< <�.>,.: �. ;, .� : ;��„ . ;.�r . , . ..-' .: �._.;:�t. .. . ,:_. ..e a-a' .. ;'...s '� ..; .. .�7�'vr�: qfiauA..k,z'',�a4,».i''. ❑ I am a sote proprietor,geaerat coetraetor,or 6omeowser(cerc%one)and have lrired the contractors�listed below who have the following workers'compensation polices: couwiav�c: � add�ess. � cit9, ��• i�m�atce eo. # k � . . ._ .. .. . . . _ .. .. - -' � �. . �xi.. .'..��:�:•,: i �V�ffi!' j �!'�' 1 �� DbO�!*` _ _ _ _ — — _ — fA. � __ _ I ..�. ' . .. �.�... ..:.. :'. ,�. .'� .: � ..� �.�.�. , ? .�� fifil;'�•, .:�IST �,v�_�. �di'," .. F1�IY�7lCOl'C�t��$�{9l ZSl,��'�.�ti��!��Of Ct'��(1lfi�lf Of S QO!1p b;lr'�,�� . . �Y�'�p�t as we0 aa dvi pemWes ta t6e form ota 31iUP WORK ORDER ud a 8ne etS180.is a day ag�toat de. 1 aedvshnd that a c�py�f fhld stzMae�my 6e for�rarded 1a Ne O1Hce ef Lave�atlsna�Y tlie DIA ter ew+�erage vea'ipatloa. /�o JYereby cerBfy�tnder Mre prrfns e�d penelties ofPer�urp tl�at tlie Fxfor�ra[Joe prov�ded abov�e fs true awd oomct signature-- .�/ �y f��i��+�-�/f Uate /2. // Q'� Print name �'rrh� tr.crl��S.G/�f� Phone# �Ut�'��7�" d Uc��C e�cial ase snly do not�vtite f�this area te 6e cempleted by dty or 6swe-a�chi . citq or tewu: �# ��nt ❑cLeck if imme�ah napeme is reqaired 0��Boat+d �Sdec�en's O�oe ce�act �Hakk Dqnrfseat cmo�a s�C�mm°' p�ene#' ��+' � � 12>11/2008 15: 15 Benson Young & Downs Insurance Kathy Jones�TOwN OF YARMOUTH 1/2 i ACORD DATE(MM/DD/YYY� � TM. CERTIFICATE OF LIABILITY INSURANCE 12l11/2008 � PRODUCER Phone: (508)432-1256 Fax: (508)430-1532 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION � BENSON YOUNG 8�DOWNS INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 565A ROUTE 28 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR � P O BOX 158 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. HARWICH PORT MA 02646 j INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Norfolk 8�Dedham Mutual 23965 CAPE CODDER SEAFOOD MARKET LLC INSURER e: 679 MAIN STREET INSURER C: WEST YARMOUTH MA 02673 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED,NOi1MTHSTANDING ANY REOUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TMpE OF INSURANCE POLICY NUMBER POIJCV EFFECTIVE POLICY E%PIRATION� LIMITS 'I LTR INSRD DATE MNVDO/YY DATE MMND/YY IGENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY �nMacE 7o RENiED $ PREMISES(Ea occurence � CLAIMS MADE � OCCUR MED.EXP(Arry one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SIN�LE LIMIT ANY AUTO (Ea accident) $ A�L OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NOf�OWNED AUTOS (Per acddenq $ PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND wc SraTu- orHER EMPLOYERS'LIABILf1Y WE080904A 01/11/OS 01/11/09 TORYLIMITS E.L.EACH ACCIDENT $ 1 OO OOO A ANY PROPRIETOR/PARTNER/EXECUTIVE r oFFicewmeMBER exc�uoEo? E.L.DISEASE-EA EMPLOYEE $ 1 OO,OOO If yes,tlescribe unAer sPEcuLLpROVISIONsbelow E.L.DISEASE-POLICYLIMff $ SOO�OOO OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION License De t. Restaurants DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO p � � THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO 'I'I4O RtB ZS OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE , � V`� Attention: Katherine L. Jones � � 12/11/2008 15: 15 Benson Young & Downs Insurance Kathy Jones-�TOWN OF YARMOUTH 2/2 � I � � � j IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, e�end or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2001/OS) Certificate#9065 � ' ' • i � TOWN OF YARMOUTH i � BOARD OF HEALTH ? PERMIT TO OPERATE A FOOD ESTABLISHMENT ; j PERMIT NUMBER: #09-Q32 FEE: S80.00 I ; In accordance«�ith regulations promulgated under authorin•of Chapter 94,Section 30�A and Chapter � 111,Section 5 of the Ge�leral La«•s,a permit is herebv grantzd to: � Mark Van Buskirk, 679 Route 28, West Yarmouth MA Whose place of business is: Cape Codder Seafood Market Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .`ifE¢P.ett SR�, �JZ.JV., C'f�a�ixrttan �l�C! `.�. J`�l�X, �lCe ��.IJYtttCCtt Ji.c�e�ct 3. ✓`3�cucc:ra, �'ee� Qnrc C�'�ceerc8aum, J`�..N. Eue�rt J'- ,i�ae�eO December 31.?008 Bruce .Murp y, . ., Director of Health � i , ,; � Jt'Y''�k TOWN OF YARMOUTH BOARD �: �� '�� L � � � d � D . � � ! � � � APPLICATION FOR LICENSE/PE � �8 r'�� ,`'�� L 0 Cl$ .,. � - *Please complete form and attach all necessary documents hy ecember 1 �� p�- f . Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: ��/,I c� �o��/„ �t�� /T TEL. #S'^�g' � 7 7 S'-ooS'f'c LOCATION ADDRESS: G'7 9'�.�,%� s-T �'/ . �r�o�-T! `i/!� � MAILING ADDRESS: G� `7 ,� rT h/ - y�, ,.� G` 7`� �f , _ � �WN�R NAM�:_��r-.� l/-�� /�s�i;- � � - '�:� �� ` °" , CfJRPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /��/r �jt., ��s�,�,/r TEI.. #,�'G8' - Sczo-os-�� MAILING ADDRESS:_�-�. SG 3 ..S-��'h.�c� �� , 0 2 s"!.� POOL CERTIFICATIQNS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. Tfte �ealth Dep�rtFnent will not use past yea�s' reeords. 'Yot� mus�prQvide new copies and maintain a file at your place of business. 1. 2. 3- 4. �_� „�� FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food serviee establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. i Please attach copies of certification to this applieation. Tt�e Health Department witl not use pa�t years'recards. You must provide new copies and maintain a file at your establishment. 1. �•r r/I� (/�h �c. � .t�i�!r— 2. �l 7 o�i- C�+� �-s r �(� P��t�9N.IN��'iE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �•-� ��! �Ls �i�i� � 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-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE Ol�LY LqDGING: LICENSE REQUIRED FEE PER'�IIT� LICENSE REQLjIRED FEE PER'4fIT�* LICENSE REQL'IRED FEE PER'tiIIT� TBBcB SSO _CABIN SSO _MOTEL S50 �INN S50 _CA11TP S�0 �SV4'I'�L1�IPVGPOOLS75ea. _LODGE S50 _TRAILERPARK S100 R'HIRLPOOL S75ea. FOOD SERVICE: LICEI*iSE REQUIRED FEE PERMIT# LICENSE I�EQL?IRED F£E PERA-IIT� LICENSE REQliIRED FEE PER'411T= _0-100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25 >I00 SEATS 5150 _CO:�L'�ION VIC S50 V41-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIltED FEE PERMIT� LICENSE REQUtRED FEE PERVIIT� LICENSE REQtiIRED FEE PER'�IIT� _<50 sq.ft. S45 T>35,000 sq.tt. S200 VE;`'DIIv'G-FOOD S20 �<25,000 sq.ft. S75 � �OJ _FROZEN DESSERT S3� _TOBACCO S50 NAiVIE CHANGE: sio AMOUNT DUE _ $ r7S�� *****PLEASE TL'R\OVER:�\D CO�ZPLETE OTHER SIDE OF FOR�i***** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or germit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR �, WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �' NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with this appiication. POOL3 '' POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days ' prior to opsning. 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. j � FUOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notifiy the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut utrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS Y4UR RESPONSIBIIIITY TO RETCJRN � THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEME�TT. RENOVATIONS MAY REQUIRE A SITE PLAN. j I , DATE: ,� � �� SIGNATURE: �`�=-`-�/ ��""' / i PRINT NAME&?ITLE: /'��r .� v�'? ��'s��r� ;� ��''_`�c �` !, to;u o� f • � �'he Commonwealth ofMassachusetts Deprcrtment of Industrial Accidents �N�/1f�s 600 Washingtoa Street, 7rh Floor Boston,Mas� 02111 Workers'Compensatiou Insarance AffidaviE:Building/Plambing/Electrical Co�tractors .�u►lie�t�f.�rt�.w; l�ease P1tINT le�Mr name: G1/J P Cc u��t`1` J r{�c ,� i!��'Y � address• L� � � �-i s i 7 s% L✓.. �/'�^�z o� Yi citv 6✓ /� state• �� yip 02G73 phone# �G � � �7.� OG �SG work site location ffnll address): ❑ I am a homeoWmer perfornung all work myself. Pro�ect Type: ❑New Construction[]Remodel ❑ I am a sole proptietor and have no one working in anY caPacih+• �Building Addition � I am an employer providing workers'compensation far my employees woflcing on this job. comoaav eame• �ddress: citv: �� m�aaae ea /��r-��/� c�v�Li t # ..�✓�4 8 O 9 � � .SI ... � ,;_ . .. . . .: s .::4d::i�+� r. ❑ I am a sole Proprietor,gea�ai coetractor,or Lomeo�rner(czrcle one)and have hirad the contractots listed below who have the following workets'compensarion polices: �omouv bama- ad�ess: dtv- n�ont# i�snrsnce co. # t�mmav�ame• addresa. citw oboae�Ih eo. #-:: . . . .. .�: . , ,.,, ;: : Fa�m e�s xeare ea►erage u reqaind'adv Seetloa 2SA ef MGL 1S2 aa lad b tYe�of crlsioal pmal�n af a 8�e�p b S1,SM.0��aad/er �e Yb*s'ie�Pr6o�est as wdl as dvY peeaitks tA the ferm ota STOI'WORK ORDER aed a 8ne otS109.OS a day�t me. 1 oederelaad that a eepy attlds pa1e�eny 6e forwarded ro fbe O�ee otlnveWgatla�of the D!A tsr ceverage veri8eatlea. I do bereby cemjy meder N(re pains and perre/�ies of perjxry tlset tlye ixfonwo(toe provided above is dzre and carn�cG Signature (/� Date �/� a � Print name i�' / l/--� i�E?— /� Phone�Y'' �7,$� � 06 S � _ , official ase only do aet wrke�this sra to 6e compieted by cilY or town e�cial eity or tewn: Pern�itlBceffie# �BaHdlnE Depat�ent ❑eheek if�media�e respeme is required 0�°�8��rd �en's of6ce rnntact peiaon: ph�ne#; �Hesith Dqnr�ent c�a s�w.mm� ppth� � � 1 . , 1 ` ' , � TOWI�T OF YARMOUTH j BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT ! PERMIT'NUMBER: #08-052 FEE: $75.00 ; � In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter � 111,Section 5 of the General Laws,a permit is hereby granted to: � Mark Van Buskirk, 679 Route 28, West Yarmouth, MA Whose p�ace of business is: Cape Codder Seafaod Market 1 Type of business: Retail Food Service less than 25,000 square feet To op+erate a food establishment in: Tovvn of Yarmouth Permit expires: December 31, 200$ BOA�2D OF HEALTH: ��¢�t S��, �..N., C�avr�na�t Cfta�ee �JCe�if�e�c,`t�ue C/l�cwufu�z �ta��ct�.��, CCe� Uiui(�;�cee�c�a.cun, J`�..�V. F�t�'-�� May 13,2008 ce . urp y, ,R. ., Direetor of Heal