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Home My WebLink AboutApplications, WC and Licenses w � � �. TOWN OF YARMOUTH BOARD OF HEAL'T�� E��,�� -� � v� � APPLICATION FOR LICENSE/PE �0�� , � ' t:. � : UEC 0 � 2008 e . . .�. �, . �� ` `� � W � , * P��.: . Please complete form and attach all necessary docu�:ts b��ce� 1 S 2008. Failure to do so will result in the return of your�plication pac � ��'�• NAME OF ESTABLISHMENT: �i�{-/�Cs �/�o��'/y/G�,S Ji�/E TEL. # 5�.�-77S=1f6o6 LOCATION ADDRESS: S�p- /1'J,�i,rr ST- Lcl��.txis��f- �1r4• DZ b 73 MAILING ADDRESS: OWNER NAME: 73�UL I2.c�-stF-is TAX ID (FEIN or SSNI: .� CORFORATION NAME (IF APPLICABLE): ,��r��',Q� /d��c�' MANAGER'S NAME: �C �.[ts�7►-N� TEL. # S'D�-7�4�6�ci MAILING ADDRESS: �"Ti�•/y1/�-/,U ST /� ��l/�fC.�T� 1�'l/� • C3� .�'�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operatar,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 minunum of two emp layees currently certified in basic wa r 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' recards. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is cei-tified 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 FIealth Department will nat use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. N PERSON IN CHARGE: _ -- _ _ ___ Each food establishment must have at least one Persan In Charge (PIC) on site during hours of operation. 1. oc1 /!�- 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 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 nat 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 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN $55 MOTEL �55 INN S�5 CAivIP �55 Sa'I�i�IMING PCOi S80ea. LODGE S55 TRAILERPARK �105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIR�D FEE PERMIT# LIGENSE REQUIRED FEE PERMiT# 0-100 SEATS 58� _CONTINENTAL S35 NON-PROFIT �30 _>1Q0 SEATS �160 _COMMON VIC. �60 _WHOLESALE �80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<�Osq.Yt. �50 _>25,OOOsq.B. �225 _VENDING-FOOD �25 J <25,000 sq.ft. �80 0��I _FROZEN DESSERT �40 �I'OBACCO �55 �0�-017 �a�7E cxa�cE: �io AMOUNT DUE = S j35.�D *�**'PLEASE TITRN OVER A1�D CO'VIPLETE OTHER SIDE OF FOR�'VI***** r . 4 ADIVIINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's , Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED ✓ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth 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 i 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 use. Transietrt occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(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,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days pnor to opening. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected ; and opened. '; POOL WA1'ER TESTING: The water must be tested for pseudomonas,total cotiform 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 Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepa.ration,or displaq of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETLJRN TF� COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY D�CEIV�ER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVV�ENT, 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. ' , DATE: �� SIGNATURE: --�L�-�- PRINT NAME&TITLE: l.�r,i�L� �(-S�l� — /Y/�N/�-��Z ioizuos r • • ` � � The Cominonwealth of Massachusetts Department of Indushrial Accidents N�N�I�s 600 Washington Street, 7`"'Floor Boston,Mass. 02111 Workers'Compeesation Iasarance AiSdavit:Beilding/Plambieg/Ekrtrical Contnctors _. � � �PRINT kQil�lv �: �l�P�" �2��cc/�-/F.5 �NG aa�s: ��o — / �,u .S_��` �� citv �.l� ' �/F��l lS7�Z�( state• � zip• 4�.�73 ohone# SSO S—�7�f1�cYt� work site location(fnll addressl_ 5/�JY1lf � /4�d2/LF' 0 I am a hom�wner perforn�ing all work myself. Project Type: ❑New C�structian ORemodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition [c-YI am an e�nployer providing workers'compensation for my employees worlcing on this job. __. _------ — ��c� � ,>-- �nTc��— f/C�C _ __ _____ -_— _-____ _ __ comuaev�e- address: ��''%� ��'/'/V J7 ��T.�� .�%, ��ri: �.�� . y��,�s�. �Yd � . v 2 G �3 �#. ,Sof� -77 -yGv� � �. � «= # 1.v .".. ... ..� . .,. ; ,�::, . „ ..:: ;:.:.;. ..�:... ,. r�: . .... ,.i• .� ;�, :..:r.4� a. �:� .x. :..i ,,.r,r�=rsw,�N€�«g:ro-r+ �..sa� . . t :i, ❑ I am a sole proprietor,geaeral coatraetor,or Lomeovrner(�rcle one)and have lured the cornractors listsd below who have the following workers'compensation polices: o_o�tnu�,v eamec �idress: cih+• nka,�e!!. iws to. # 4 - . -� a ..�.. � ooinmav�ame: �: citq: . uroae�- _ -- — — ---- � _ _ --- ___ ___ __.—_ _ _ __ _ - _ # _,,. .. ... . . ..;., s . ; ,: , , _ ..:' .� », ;, � •. � :" ,. :�.:. , .. .,, , Fa�a�e�seeme ewera�e n roqaired�rdv 5ectlo�24A�f MGL 152 eu lead b fYe �. .�fvi�toal�� . _ � pnaflks�f a�e qt�b t1,SN.�O aad/er �Y�'�p��s dvi peoaides h the form ot a 3TOt WORK ORDER aed�Bne e[5109.OS a day�t oe. 1 andenlaad t6zt a cepg ot tYi��areat my 6e forwaMed!e the O�ce�lwe�atloffi ef t�e DIA tar cevenge veriBeatl�s. !do hd+eby cer(ljy xxder dbe palns ar�d peealties of perJrrry diet tlYe i�fonaation provided aboae is trrte awd comct �� L�- n�� 11�ay,�� Print name_��i pU L, ��{/n Phone# �d �— / 7�Y, e�cial ose enly de aot�vrite ia thls area te 6e com�leted b9 cih'or Eswa o�cial . eity er tew�:: permiH�ense� Depart�ent ❑chcck if i�me�ale mpeme is re9�� Sdeetmea's O�ee �� °� Phone#; �Q � � . , . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT 1 PERMIT NUMBER: #09-024 FEE: 80.00 In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter � 11 l,Section 5 of the General Laws,a permit is hereby granted to: Cape Groceries Inc., 590 Route 28, West Yarmouth, MA Whose place of business is: Cape Groceries Inc. Type of business: Retail Food Service less than 25,000 square feet ' To operate a food establishment in: Town af Yarmouth Permit expires: December 31, 2009 BOARD oF HEaI,TH: .�'felen SR�a1l�, J`2..N., C'.�ra�i�rrrcarn C�arx�e �. 3�i�!'li!!►�ac `Uice C'hawrnu�tn 5�e�rt�.�B�cuiu�c, e� flnn C�'�ee�cE�a�cu►c, J2..lV. Eue�c�- .�'Eatl,eo December 16,2008 ruce G.Murphy,MP , . .,CHO Director of Health TI� COMMONWEALTH OF MA5SACHUSETTS TOWN UF YARMOUTH BOARD OF HEALTH PERMIT TtUMBER: #09-017 FEE: $55.00 This is to Certify that Cape Crroceries Inc. 590 Route 28 West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This, t is ant u� o�o with Article VI f the Sani�Code of The Commonwealth of Massachusetts,and exp�ece�iber�l.Z�03 ��ss sooner suspen�ed or revokeS. December 16_2008 BOARD OF HEALTH: ;�E¢�¢It S�� .,IV.� �tQlt C!l�cviclea .�.�'G�''lil�ex, `�1ice C'I�aar�ruxn Jt�t 3.�B�r�usrc, Ct�r� Qruc�'aCeerr�acun, JZ..IV. :P. ruce . urp y, , . Director of Health - � � t f� r �� CAPF CneOC�i�a6T r Jt�.Y�k� t, , TOWN OF YARMOUTH BOAR�;UF B�ALT� �� APPLICATION FOR LICENS�%PERN��T`-�p, � � � � � d � �° Y -�y� �'�� - * Please complete form and attach all necessa�.y'�iocuments by Decem er��LO�'7`.� 2007 Failure to do so will result in the return of your apphca,tion pa et..EALTH DEPT. H I I ��I NAME OF ESTABLISHMENT: C�41�G �✓L TEL. # .SD$-77,5-�6� s �.� ��-/c� LOCATION AI)DRESS: �"s3C�� .��i.� ST_ 1-+��7 S�i�t��,a�t11`e�1• �.� • Dz 6�3 ,� MAILING ADDRESS: _S,�ixr�- /�� ,�6�' 4WNER NAM�: �/e3?�cl L. IZ�4 5,�/� TAX ID �FEIN or �l� CORPORATION NAME (IF APPLICABLE):_.�I�p�_ �2��/Zlc�`5 f,rJG MANAGER'S NAME: UL TEL. # MAILING ADDRESS: S'�, b�-A�,�-i,U �t �5t �'t,�2uv�l• /J9i4'-o�-c; 7 i ._.__ 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. /l�' Pool operators must list a minimuxn 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. The �ealth Dep�rt�nent will not use past years' reeords. �'ot� n�ust provide new copies and maintain a fde at your place ofbusiness. L 2. � 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certificationto this applieation. 3'he iie�lth Department�viH not use p�st ye�rs'records. You must provide new copies and maintain a file at your establishment. 1. 2. PERS91�T.��I�A.R�E: _---__ ^____ -- -- --- ---- -- - - — -- __ _ __ Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. R1 2. �tJ 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 yow employees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The I�ealth Departmeat 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 LQDGING: r\ LICENSE REQUIRED FEE PER'vUT# LICENSE REQL'IRED FEE PER'tiilT� LICENSE REQUIRED FEE PERVfIT= B&B S50 CABIN S50 MOTEL S50 INN S50 CAiVIP S�0 SV4'I'_bL'1rIING POOL 575ea. LOUCrE $50 �IRAILERPARK S100 V�7-IIRLPOOL S75ea. FOOD SERVICE: LICENS£1tEQUIRED FEE PERMIT� LICENSE REQLTIRED FEE PEI2i'�41T* LICENSE REQliIRED FE£ PERVi1T= 0-100 SEATS 575 _CONTINENTAL S30 NON-PROFIT S3� >100 SEATS S150 CO�L'�ION VIC S50 �VHOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S7� 'I LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERyfIT= LICENSE REQL'IItED FEE PER'�fIT� _<50 sq.ft. �45 >35,000 sq.ft. 5200 VENDING-FOOD S20 �<25,000 sq.8. a75 �03�3l7 _FROZElvT DESSERT S35 /TOBACCO S50 U S�O � �� va��cxa�cE: sio AMOUNT DUE _ $ /2�i_00 '�"***PLEASE TL'R\OVER�`D C0�IPLETE OTHER SIDE OF FOR�Z**"** , a . Y ' AD�vmv�s��oN Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now reqtured 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, 4R ' CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1� Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � / : YES V NO MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUP'ANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term accupancy, ordinarily and customarily associated with m�tel and hotel us�. Transient occupants must have and be able to demonstrate that they maintain a principal pla,ce 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 s'vc(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, sha11 generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with this application POOLS POOL OPENING: All swimming,wading and whirlgools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days ` pnor to open�ng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ---b�a-State certified lab, prior to opening, and quarterly the�eafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. � FOOD SERVICE CATERING POLICY• Anyone who caters within the Tawn of Yarmouth must notify the Yarmouth Health DepartmeYrt by filing the required Temporary Food Service Application form?2 hours prior to the catered event. These forms ca.n be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Ot�d�eeaking,-P��P � � � P�Y of a�}��ooc��-by��ai�ar-€oa�-sefvieeesl;�bkshment is prahibite�. _ NUTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTrY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT', MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME=VCEME�tT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: f Z. !, Q SIGNATURE: �— PRINT NAME&TITLE:��-5l¢7/)=/'�S f�e t � ��d-.�,E-St�� io�o o? � . , _ � ' � ti . . � �\ The Commonwealth of Massachusetts � Departnient of IndustriaY Accidents M�fri�i�li� 600 Washington Street, f"'Floor Boston,Mass. 02111 Workers'Compe�aatioa Iaseragee Affidavir Boilding/Plembi�g/Ekrtrical Coetractors , name: G address: ��gD"�/�'//1� �7/ //�� r�U citv �.[�L��.-�T 7/6�Ll9L T�} state• /,�'� �n• oL�O� oho�e# ��-77�- ��o� ��«�s�: i 61�,�� .�� • �n.� a�.�� ,s-�or �.��r,�'��fi ❑ I am a hom�wner performmg all w�k myself. Project Type: ❑New Constructi��Remodel ❑ I am a sole pmprietor and have no one working in aay capacity. ❑Building Addition [�I am an employer providing workers'compensation far m ployees working on this job. ___ __ .__ ___. ________- -= - ---- -— -- �-�_ com �me: G�" E� ` /t�`G �aa�• ;_55�� — 1'I'I�E-!iV �l //1r �.� � � t� #: 8'- "�l , � �. ��' �G � �� c�' g 7� ti�..�}� ,....;: [,] I am a sole proprietor,ge'eral co�traetor,or�omeowa�(cirde one)and have hired tbe contractors listsd below who have the following workers'compensation polices: ad ci�*• �#. to. � . � �: nl�e�t• - ---- # - —----___ �� Falhme a secure orrera�e aa neqair+ed��ler Seelfe�2SA�f MGL iS2 cu k�d a tte hlp�itMa�f cririal peaNia�f a 8me q�a t1,SN.�9:a�dl�r o�e yean'isptbeammt an weA as dvi pe�alqa ia tbe for�ata 3TOr WORK ORDER aed a Hne otfla9.M a day�t ase. 1�dezshcd tLat a cspy of fl�a�a��y 6e fir�vaMed ro the Oleee et lave�m of t�e DIA tor teverage veriACatiea. !ro Nd+eby ceKrfy xnder Nire peins aad pe�alties ojperfxry tliat tJbe iwforatiado�pro�ded eboae ts dare�d co� Signah�re�_ f I_—�/' Date � �T�! 0 7 �— i�:S/s�2� � Print name�� Phone# �� g� 77�„_,y��d efficial nse only do not�vrih�this area to be ce�pleted by dty er Mwn e�i city ar ts�vn: p�e g �Baidi��rtment ❑e�eck if immedia6e r+espeax is reqa�+ed �+s p�� liealtk 1�part�t centad P�� pksae#; �� lTMvi�d 4p-2003) � � `4 . ; _ > . � TOWN OF YARMOUTH BOARD OF HEAL'�'H � PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-032 FEE: $75.00 � In accordance with regularions promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby gcanted to: ; ! Cape Groceries Inc., 590 Route�28, West Yarmouth, MA Whose place of business is: Cape Groceries Inc. Type of business: Retail Food Service less than 25,400 square feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 i, 2008 BOARD oF HE.4I,TH: .�eeert SRtal�, �JZ..IV., C'R�a.iacrttan e'�artt.@eo �.�,�ifl�e�c `Uice C,f�ar�cnuYn 5�c►.�irt 3.�t3�cun, C'�e�cP� Clurt�'neerr�a�urri, ✓2..N. December 20.2007 Bruce G.Murphy,MP R .,CHO Director of Health THE CONIlVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOTITH BOARD OF HEALTH PERMIT NUMBER: #OS-024 FEE: $50.00 This is to Certify that Cape Groceries Inc. 590 Route 28, West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION exsi�es�ece�ei 31�L��gorm�'�with Article VI�f�e Sanitarti Code of The Commonwealth of Massachusetts,and p ss sooner suspen e or revoketl. December 20_2007 BOARD OF HEALTH: ��C�Cft$f�/�� J�,.JY.� (�r6ttqlt C'ffaxl'ee �. 3�i�if�ex, `?Jice C!fEavurtar� � J�3.J��cvtutt, �� Qtttt , J`�.,1v , Bruce .Murphy, H . ., Director of Health , ~ C14iF Git4GE1?J ScS oF=aR - ,. � TOWN OF YARMOUTH BOARD OF HEALTJ�.,>--��(�3� �2`. � APPLICATION FOR LICENSE/PER1V�' 2�f 0'7s� � �a� JAN 0 2 2Uo7 ': * Please complete form and attach all necessary docume�ts��ec�ber.31, 2006. ` Failure to do so will result in the return of y�ur"apphcation p�ck�t. .,. .- .�- -` NAME OF ESTABLIS�IlVIEEIVT:�pCr' �,t2�C�/r.�� /lJZ TEL. # ,��8�-77�y�d� LOCATION ADDRESS: ��b /�,.�i�� S?" Lv� �,�i��svvT'/`l /17i'q D� vr >.� MAILING ADDRESS: ��-�►� ,j�s OWNER NAME: f�-.�h�JL �/tS.�/�� T�X ID(FEIN or SSNI: CORPORATION NAME(IF APPLICABLE): �/{�� S �/��" MANAGER'S NAME: �/jjj'(�� ,,�._�n TEL. # �'v8--77.S-L1�6 �,rlvG aDD�ss: - �r r.� 6 POOL CERTIFICATIONS: A_ The poot supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Uperator(s) and attach a copy of the certification to this farnn. _ _ l. /V � 2. %��/�--.0 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 certifications to this form. The Health Department will not use past years' records. You mast prnvide new copies and maintain a file at your place of business. l. 2. �, � 3. �� • 4. �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, lU5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmen� l. 2. �" / � !� �" - - PERSOI�FRT CHARGE: . _ - _ __ - __ _ . _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. ,�/ �`� 2. '� . HEIlVILICH CER'I'IFICATIONS: 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-cholang 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. G. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � , LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUII2ED FEE PERNIIT# B&B �50 CABIN $50 _MOTEL $50 1NN $50 CAMP $50 SWIIvII��IING POOL$75ea. LODGE $50 TRAII,ERPARK $100 WHIIZLPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# LICENSE REQUTftED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >I00 SEATS $I50 COMMON VIC. $50 WHOLESALE $75 RETAll.5ERVICE: �RESID.KTTCHEN $75 LICENSE REQUII2ED FEE PERMfr# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 �<25,OOOsq.ft. $75 �O�I�b�� _FR9ZENDESSERT $35 �TOBACGO $50 �Z NAME CHANGE: ��0 k';, AMOUNT DUE = S l2 S.00 �•"•"PLEASE TURN OVERAND COMPLETE OTHER SIDE OF FORMRR�1kf� . � Y ADMINIST'RATION 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 i 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must ha.ve 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 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 CNiR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected ` by the Health DepaRment prior to opening. Contact the Health Department to schedule the inspection flve(5�days I pnor to opening. { � POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool�nust be drained or covered within seven(7)days af 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?2 hours prior to the catered event. These forms can be obtazned 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. Failwe to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,pre�aration,or display of any foQd produ�t by a retail or footi serc�ce�stablish��is prehibited: ; __ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN TI-�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY k'OOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII�MENT, ETC.),MUST BE REPORTED TQ AND APPROVED BY'TI�BOARD OF HEALTH PRIOR ! TO COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: �Z. � SIGNATURE: _,�� _� PRINT NAME&TITLE: / P/! �j'' ; ioii�io6 I � � � . � � The Commomvea&h of Massachusetts Departnent of Industrial Accidentc NI�riN�w�1M�i 61i11 WashiAgtow Stree� 7`�'Floor Bos�o�i,Ma.ss. �2111 - Workera Com tws I�aaraaee Affi�vt�B�il ' bi��/Eleetiricat Co�tractors � - ---- �aa � � .... , , _. .,..�-.. .. � � �,;, . , , ... � .. , �: C'�� G�� c�.r�/� �.v c �: s��,��/�z�- ��` ��y ��_��lc�l�/1sv7�1 �: y�fl� rip:4Zf1Z�,�# S`�8-77.5=�c�o� work Site locaa�rrnuu�Ssr. � I am a 6omeowner perfonning all wak myseif. Projed Type: ❑New Ca�u�Mion ORemodel 1 aQt a sole 'etar and have no a�ne w in an Buil ' Addition _ [�I am an eanpioyer providing wa�keis'compensation far my e.mploy�s warlcing o�n this job. __ - _ - _ �._- _----- I __ � —.__._:- �� ,�}0 �i�lN ,�7` .��".,,�� 7 � '' - - �- ❑ I am a sole pmprietor,g�ral ca�tractor,or homee7raer(iircle owe)and have hired the con�actars listed below who have the following wodce.as'compensation polices: # cr�r.v� — —— --- --- _ � Fai1Qe b see�cwera�e as req�al oder Seel�2SA�C MGL 152 ea�lad b lie hrp�ilMa�f ai�ial pn�iKes�f a�e�p q=1,3M.N a�dhr eee yan'6p►riaeae�t as we�as dv/p�ia tie fsr�eta STO!WORK ORDER aed a Aue oif166.N�day a�aint�e. 1 ader�ud tY�t a apy�t f��ety be fitwarded 1s Ife Omcs a[I�Was of tlte DIA tar averaae ver�ieafiw. I do Are�+eby cerdjy xnder dYe paies end P�'ofP�+�1'�Yet t,l6e iwfor�r�ton pro�ded ebont+e is bue�d oam� Signature L_G-�' I�te �i� —/��-- l�C� Print name �,�f�.[, /�_ �/��Q Phone# �O � -'7��d�(J o�d�l ase oely de sat wrke L tE�s uea to 6e oe�plaed bY tit7 er Mwn e�ial c�p ar ts�vn: pe�if/�oe�se# f�IBnidia�Depare�at ❑eLecic if imme�iabe napsaae is reqmed �Sdeelmea O�oe 's �M6 De�arbemt c�ct Pcrsa�: Phwe S, � l��-�� { . j . . � . TOWN OF YARMUUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #07-046 FEE: $75.00 In accordance with regulations promulgat�under authority of Chapter 94,Section 305A and Chapter ; 111,Section 5 of the General Laws,a permit is hereby granted to: �� Cape Groceries Inc., 590 Route 28, West Yarmouth, MA '� Whose place of business is: Cape Crroceries Inc. Type of business: Retail Foad Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31,2007 BOARD oF HEAI,TH: B us�S. a�r�,/�1.`75., ' ��s�, �t.�, v�e��-� R�t�. a�, et� P�� 4.�.��d�.�, R.A! Apri12.2007 Bruce G. urphy, ,RS.,CHO Director of Health THE,COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #07-032 FEE: $50.00 7'his is to Certify that Cape Groce�ies Inc. 590 Route 28 West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUT�i BOARD OF HEALTH TOBACCO REGULATION. ��eerngt is�rb�te3dlit��or�t�y�Articls��f�h�Sre o�a�ry Code of The Commonwealth of Massachusetts,and Apri12,2007 BOARD OF HEALTH: B �. �'o�.�,�N�5., . i . ��s�, Rrv., v�e�� Rad�t�. e� � A�A�Ic��r� �4.�!�' , R.JV. �� .Nt,.� , ., I}irector of Health < .:, • 4 G�2,�°6D��pfl C,aoFGRnc.�t� .o�;qR.y TOWN OF YARMOUTH BOARD OF HEt�,�,TR' � o� ''� APPLICATION FOR LICEI�T��P�$�VI ,2006'; ;�'� L 1 Z005 �r , �? � r�ti�� * Plea.se com lete form and attach all ne�ess t� � �tsb �becember 31, 2005. � � Failure to do so will result in the`t�urn�#'y�our�application packet. NAME OF ESTABLIS�IlVfENT: C��C� �..P/�D�,FZ/F,5 /VL TEL. #_,�D S 77S�/�C� LOCATION ADDRESS: ��p -- �,�//lJ,s�'� �/'v�� MAII.,ING ADDRESS: �S�iZ[� , '� ��T.2� OWNER NAME: L l T ID E r —/ - �.� CORPORATION NAME(IF APPLICABLE): G� � cGs �l/�- MANAGER'S NAIV�: TEL. # ;�'"r�S� 77�� MAILING ADDRESS: S�-t1�1� �-s �'l�[lCs POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list th�designated PoQI_Qper�r(s) and attach a.r,apy of t1�c�rtif��t�l�i�s�a�. __ _- ._ _ _ _ _ 1. ,eC� //� 2. /�' Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. � � 3. 4. ,�/'/� 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. � PERSON IN_CHAR�E: __ _ _ _ - -- _ _ _ _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �//�- 2. � HEllt�I�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 at�a�i 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 PERMTP# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B �50 CABIN $50 MOT'EL $50 �INN $50 _CAMP $50 _SWIIvIlvIII1GPOOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHTRLpOOL $75ea. FOUD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# �0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 3EATS $150 _COMMON VIC. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# IdCENSE REQUIl2ED FEE PERNIlT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 I QS,OOQsq.ft. $75 O�/'OZ� _FROZENDESSERT $35 I TOBACCO $25 �'O6"��7 NAME CHANGE: $10 AMOUNT DUE _ $ �0 O.O O "••*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"" ADMINISTRATION 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 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: j YES� NO ; NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-�E COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 3l, 2005. „ SEASONAL ESTABLIS��VIENTS ARE TO CONTACT'TI�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; t ADDITIONAL REGULATIONS G [ POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected ' by the Health Departrnent prior to opening. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count f by a State certified lab, prior to opening, and quarterly thereafter. r POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i closing. ' i F FOOD SERVICE ' CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post ` Consumer Advisories. CATERING 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: ! �rozen�esserts must b��ste$e��:monthly�asis by a�tate c�tified iab. Testresaits-must be sent t�the�h f 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 waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. I { DATE: � SIGNATLTRE: � � PRINT NAME&TITLE:�i/�!>�� ,�� ! /��i�l'�'f�/ll�.� ��—�I�� r-- i j 09128lOS I I � I _ _�� The Comneonwealth of Massachusetts ,�--_-_� ==- - = Depart�nent oflndrtslnialAccidents -- �If - _-= 608 Washington Stree� �""Floor _,,,3 Bos�on,Mass. 02�11 � Work�a'Com�aho�I�a�a�ee Affidavi►:Bait leetrical Co'traetors ��. �� ,.. . ..� _ ��. , � - - ,_ _ : _. . ,_-n. a. _ _ �.. .. _ _ � � �� ,�� _ . . � � . �w� ,� .�.�< � ,�� - C'i4 I�� !��F.�1� �.r�� s� ��cc5� -- 1'1'l.a�,v ��T v� g �� Lo�- ��-lt f�62�Ti�{ �� !/� � �ip��c�� n�# �'d •y�77� �6 a�" work site locati�rfnu addressl- ❑ I am a homeowne�r perFarming all wark myself. Ptoject Type: ❑New Ca�struclio�QRernodel I am a sole 'exor and have no�e w in aa B ' ' Addition �'I am an eanployer providing workeas'compensation f�my empioy�s warking an this job. _ _ _ _. - -- - _-- -.. - - - - ------ - - �: C'i4-D� �olv��yL1 z��S G�c _ �: S�c� • �/I,��v � /'��.�.rg �►: t�� - ��tc��z�� c� g . -�,S^� y�6 LJc- � . wc"crG /77 ❑ I am a sole proprietor,gaeral co�tracter,or kameo�er(crrde owe)and have hic�ed the co�ctors listed below who have the following wa�c�s'compensation polices: �E�e• �t• � FaiM+e i�sxe�e erv�e a�req�teed�r Seetln 2SA�f MGL 1S2 na lad b IYe hrp��!'�ial paaaNies�f a�oe�p b SI,SN�M aadl�r oae ynra'iuprir�seat as weY as dv�paaltla ta tl�e bra�ota 31'Ot WOR1C ORDER a�d a Aoe dS1a0.N�day a�aimt me. I aederslaad tbt a c�pq�f frb sta�'fy be fenarded 10 the Omce�Im�iptlys af tYe DIA hravrrage vafAaliw I�fo ber+�by c�rdfy�rnder NYe pa�fi�s end penallka of ps�jray tbat Mbe I�rfor�w4Qo�provided aboae ia d�re asd oamrt �� ' I�te 1� �� g1�� Prim naroe �l�/'��'�� Phone# �C��^77�y� � efficial ase eHly do gat wrih fa this ara ta be cyPletcd bY dly er Irwn offichl city or te�vn: # ❑ckedc if jmme�aie reapasae b reqdred � ��t �Sde�n s�ee ceatact peissn: p��. ��t�t cTM'vmcd St�l.2oa0) , J TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT ; + PERMIT NUMBER: #Ob-021 FEE: $75.00 I In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter , 111,Section 5 of the General I.aws,a pennit is hereby granted to: i Cape Groceries Inc., 590 Route�28, West�armouth, MA � Whose place of business is: Cape Groceries Inc_ � Type of business: _ Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth � Permit expires: December 31 2006 BOARD OF HEALTH: Bei ��l. anaf.as� /19$., ' � , e�l�i, ./Il., 'Ur'ce G'lsr�� Ro�ht�B�u.ist, � /��/�c�e�iut� �4sui('j�ee�r�, R./Y. January 23,2006 ruce G. hy, , S.,CHO Director of Health �co�olvwE�.�oF�ssAeausE�rs TO�VN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #06-017 FEE: $25.00 This is to Certify that Cane Groceries Inc. _ 590 Route 28 West Yarmouth. MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION �s�t is��t 3d in��or�tv with Article VI�f jhe Sanitazv Code of The Commonwealth of Massachusetts,and e es �ss sooner suspen ea or revokeS January 23,2(�6 BOARD OF HEALTH: B �. (��,/y�., . d��5'lu�i, R.N., ?/ice G�ls�r.,r�rs Rol,�t� B�awu.z, G�l� �� _ �lsuz Cf , Q./V. G. Murphy, ., H Director of Health , � +��,°Y�� D 1,�E'�/ /t,tJl l'o�i�f � �� .� .�o �' � l�T OF YAlZM � UTH O - - —y �, �_ - �, ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 �MATTACMEES� Telephone (508} 398-2231, Ext. 241 — F� (508) 760-3472 4��4�OqATt��6j9 B OARD OF I� EALTH i ; To: Yarmouth Boazd of Health Permit Hoiders [� � � r- � �, � �. From: David D. Flaherty 3r., RS. ;��r '�� `� � Z��5 � � Health Inspector �� Town ofYarmouth H�� ' N �EPT Re: Federal Tax ID Number a � � - Date: March 22, 2005 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 establishment's Federal Employer ldentification Nnmber(FEIN}otherwise known as your"Ta�c ID Number". This is pureiy for administrative purposes only. Sa� businesses use the owner's Social Security Number (SSN} for this purpose. If this is th� 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 Heatth Department 1146 Rotrte 28 South Yazmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do noi hesitate to caL'. The office hours are Monday to Friday, 8:34 a.m to 4:30 p,m, Tlae telephone number is(508)398-2231,ext.241. Establishment: ��p� �j�CL--/1/��S' l�i/c FEIN or SSN: Location Address: �1�• !'��JN ST/�j�� L�C��ST y/f�'�y16vT'd�• ��-�26 73 Signature: ��,�� Print: �-/�//�U�. ��,� Titie: �2�10�iv�' /��,r� �/� �� .�t� �� Printe � � Re P i � , ,�. . ; Ck.�'t(?ob �Wa'�� 32°`�R o � ,- TC��V1Q"�F YARMOUTH BOARD QT . C{�PE Cs72oc�/E5 �: . �� . � , APPLICATION FOR LICENSE/PE �-2�0 � � � � ,� �,� � (� ..••' P��` � * Please complete�orm and attach a11 necessary da3��ts by Dece ber��2Q0�. 2004 � Failwe to do so will result in the retumrof ur application p ket. �_,:.., NA1V� OF ESTABLISHMENT: C�#pcs' �'�CGsJ2l�5 /� TEL. # S�f�77S 4boG LOCATIONADDRESS� f�d�- ilil�iv �"T c.��sr�i��vT� �s� a ��.�73 MAILING ADDRESS: �°�a1� � 1�-Ba�ts" OWNER/CORPORATION NAME: CO4-1�Ls �,i�,��-/r/FS /�/G MANAG�R'S NAME: /�3�v�- lz�5 tF//,' �,. # �-o�zz,s y6�G �. MAILING ADDRESS: �; go- l�d��tJ sr- ��.sr y.��r� •r�,a -o� ��3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. y,��- 2. � / , Pool operators must list a minimum of two emplo ees currently certified in hasic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). 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�le at your place of business. 1. lT�,�_ 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 Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. /V /� PERSOAT IN GHARFE: _ _ . - - _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. N a. !ti�/�- HEIlVILTCH 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 fde at your place of business. 1. 2. �/fl- 3. 4. RESTAURt�NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PBRM[T# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEB PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _ _CAMP $50 _SWIlvIlvID1G POOL$75ea. LODGE $50 TRAII.ER PARK $50 WHIItLPOOL $75ea. FOOD SER'VICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERM[T# 0-100 SEATS �75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VTGT. $50 _WHOLESALE $?5 RETAIT,SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERNII"P# I.TCENSE REQUII2ED FEE PERMIT# _<50 sq.ft $45 >25,000 sq.ft. �200 �VENDING-FOOD $20 Ij- �Q5,000 sq.ft. $75 6`S� _,_,FROZEN DESSERT $35 �TOBACCO $25 �'7 NAME CHANGE: $10 AMOUNT DUE _ $ �00•bd '""""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•"`•" f _ i , , - �, ' � ADMINISTRATION ' , " - Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or re�ewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ` AFFIDAViT MUST BE COMPLETED AND SIGNED, OR `` � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � - Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annuatly from January 1 to December 31. IT IS YOUR ItESPONSIBILITY TO RETURN � TI�C4MPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. � ; SEASONALESTABLISHII�IENTSARETOCONTACTTI-�HEALTHDEPARTMENTFORINSPECTION7-10 ` DAYS PRIOR TO OPENING FOR TI� SEASON. � � ALL REN4VATIONS TO ANY FOOD ESTABLISHMENT, 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 I , POOLS POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depaztment 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. j � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i closing. C i FOOD SERVICE CONSUMER ADVISQRY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required ta post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the ca.tered event. Thses forms can be obtained at the Heatth Department. _ �R6�EN DE�SS�R'�S: . _ _ _ _ - — Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. yf OUTDOOR C40I�NNG: ` Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. f I � � DATE: f/� ��,� o/.( SIGNATURE: � ` � PRINT NAME& TITLE:_�!�/,G.-- ,� �z�19/� Y �1�.��r�, 10/22/04 f � .__�� -`�� The Com�aoa►vealtl�of Massachusetts �� --_-� � == Depart�nent of Indus�rial Accidents =- - . N�ri�iiwW�fMMi "' - _= 600 WashiRgton Stree� 7"`Floor -� Boston,Mas� U2111 - v. ; .�.:� wo.��c��ao.i��.�a�a.�c:s�a• ��co�� ... .. . � ,. - . . _ _.. , . _� ,,� , ,� f w , �� :�.�,��.�. s .� �� ,�p� �� r�12�� l�sr9L , �_ .S-Qi'D-- l/!��-//� �T �,�� ,�� - ��ri �.vG�Sr �i�e2�avr� ��- !dl� an� �z,67��# S vs-77s-�6a6' work site locatia�(fnll addressl: ❑ I am a homeow�r petfoaning all work my�lf. Praject Type: ❑New Ca�structi��Rexnodel I am a sole 'etor and have no one w in an Buil ' Additian :,. _ [,�I am an employer�xoviding w�kecs'compensatian fac my�npioyee,s working an this job. . ��,�� ,��L� �� 1 S �G , �� .��v-- liJ7�--i.� _�/11r� �1�1.��.L��t�r"�f ��C2�� 12��-77�"--��' � �c L�e �g177 ❑ I am a sole proprietor,ge�ral co'tractor,or lam��rar�(cirde oue)and have hired tbe co�ractars listed below who have the following worlcers'compensation polices: ��: �s c�T: �r�: � 4�t�ez �; 4'�Y: �� FaYa�e L seeee orvera�e as req�ed uikr Seci�a 2SA�f MGL 152 cn Id�d b lie irp�itlK�f cri�id pe�fNia�f a 8�e�p b t1,3M.M aadl�r oie yan'Imptie�a�eat as we8 as cM pwHks ia t6e fer�of a SSTOI'WORK ORDER a�d a Are e[31�.N a day ataMt�e. 1 ndershtd fiat a apy of tY�ata�my be forwa�+dcd 1s tf�011ice oE I�af tl�e DIA fer eav�erage verqlatlw. !ro bentby cerdfy xwder NYe pai�u m�peualdea ofPrrji�'tAiat tlie hrfor�r�lo�prov�ded aboae ia d�rs axd uomct SiBna�u'e �[-�.-. Date /��-'Zz� d T Pritic na��L7l,C 1x-.�6,/�/.Q Phone# J�D�-7�,��-�iv6�I�' effic�l sx oely as aot wrke in t�s area ce ne m�pleted bp cNy er en.s�ial �°r�' P�� Depatt�ent ❑c�edc if lemmatlah reapesx is teqared �Sdect�'s O�oe ❑link6 De�t�mt e�at'd per''°°' P4�e�k; �omer c�sqw-�+) 1 � ! . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT , PERNIIT NLJMBER: #OS-011 FEE: $15.00 In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Cape Groceries Inc., 590 Route 28, West Yarmouth, MA Whose place of business is: Cape Groceries Inc. Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth � Pernut expires:_December 31, 2005 BOARD oF HEALTH: B��$. (�'��y, , P�� v�e�� R� �� R.N. _ December 28.2004 i`uce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #OS-007 FEE: $25.00 � This is to Ce�tify that Cane Groceries Inc. _ 590 Route 28 West Yarmou MA � IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER T'HE YARMOUTH BOARD OF HEALTH TOBAC O REGULATION �s�er��antg�d in2�form�'tv with Article VI pf Yhe Sanitarv Code of The Commonwealth of Massachusetts,and e s er 1 �ss sooner suspenuen or revoke� �t�2g.Zoa4 Bo�oF��,Tx: 6�-�$. �'o�d,o�,119.25., A��, v�e�� R�t� e�, e�,� �s�, Rrv � r , R.�v. � _ Director of H�ealh3'> > •� Q a _ � � - . �f��3�v ��. _ ��,�� ,��c�z.� OF-Y'9R 32 ,r-�.c TOWN OF YARMOUTH BOA ALTH Q � � � � � � D o z _ �., APPLICATION FOR LI A , IT-2004 '` �•.. ..••��? � �'�` NnV 2 2003 * Please complete form and attach all necess�documents by Decembe 31, Z00� Failure to do so will result in the return of your application pack • HEALTH DEPT. P2s c i� .v� � -17 _ d L T N s • �-m �—�r w�- o �VIAILING ADDRESS: ��//�� -s /-�/�r1� WN R/ T C' l�G �213 C�i2. L �IfC M.ANAGER'S NAME: �. �3 t�i�� f i2�-StL!/� TEL. # v""r�$--7�,�= � MAIL�IVG ADDRESS: �'qC3— i1��-�n1��RY'� NJ�-��Zt��?'Y� �1�4-a:1 G?� POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s)and attach a capY of the certi�fication ta thas form. 1. /"/� 2. /1.l ' Pool operators must list a minimum of two employees currentiy 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 Heaith Departraent wilt not use past years' records. You must provide new copies and maintain a file at your place of business. l. r"//-� 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 Heatth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. � 2. ��'"' PER�11V CHARGE: -------- - --- -- _--- --- -_ __ _ _ -- ---- _ Each food establishment must have at least one Person In Chazge (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-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. N��- ,�� 2. 3. 4. R_FSTAU�AI�1T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# B&B S50 CABIN S50 _MOTEL $50 INN S50 CAMP S50 _SWIMMING POOL$75ea. _LODGE $50 _TRAILER PAItK SSO _WHIRLPOOL $75ea FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0.100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25 >100 SEATS �150 _COMMON VICT. SSO _WHOLESALE S75 RETAIL SERVICE: LtCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. �45 >25,000 sq.ft. $200 _VGNDING-FOOD S20 !<25,000 sq.ft. S75 ��6(g _FR07_EN DL'SSf;RT S35 �TOL3ACC0 �25 �0 �� NAME CHANGE: $to AMOUNT DUE _ $ !00•00 ****'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****" r r „ ' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO ��.__ �_�_._ __---_ .. _ _._ _ _ N4TICE: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, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTML'1�1"f 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 �r:i1i ATrn�vc POOLS POOL OPEI�IING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: 1'he 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 CONS MF. �VI ORY: Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are requiretl to post Consumer Advisories. CATEIZiNG 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 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 tertns have been met. OUTSII�E C�F��• Outside cafes(i.e.,outdoor seating with waiter/waitress service},�have ptior approval from the Board of Health. OUTDOOR GOOKIN • Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: j/—D��L7 � , SIGNATURE: � � � PRINT NAME&TITLE: ��j� �,Q-, �� jy��r��p, � 10/22/Q3 � �• • � � � The Conrmonwealth ojMassachusetts � - � � Department ojlndustrial.-�ccidents � :; Olflceo/%s�los�iis ` 600 Washington S�reet ' = Bosron,Mass. 02111 �'~ ��~ W'orkers' Compensation Insurance Atfidavit A,Rnlicant informallon: P►essePRil'P�`Te�.'Wa mm r• /'��L� ��'C��/� /!fJ L location: �!b '' �%1-/.v �7� /��` .� � c�t� W �J�r /�I�l,`l� �- �r`7' � U � O / � ehone� ��`� —�7.>"��C7 � I am a homecw�ner pert�rming all w�ork my�seff. � ( am a sole proprieror �r.� ha�e no one��orkine in am•capacitv � I am an empioyer pro�idins workers' compensation for m��.employees w•orkine on this job. _ �- t�maam• name• �� f�� /(,� � a��ss: �`i ��S — /l�l�t-�/ � � / ,2�" � �' siit• �1��l�.,�J'T:'�L� —(7�/'��.� nhonetl• ��'77Jr�6O�j insurance co. 111Qrf,fG_1_L�2iJiY� ��TU lN��E-'�RolicY� L�G lSfl9/77O�Z � I am a sole proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the conaactors listed below ��ho ha�e the follu�+in� ��orker� :ompensation polices: s4mpanv name• address: citt�• phone q• insur�ncc co. oolicv!! �maany name• ---- —�- i�dress. cit�+: �hone M• insuraessso. �liev�f � Failure to secure covenee as required under Secnoo ISA o[MGI,l52 a�Ind to t6e iepai4o�of erisi�fl peedtles of a A�e ap to Si¢00.00 a�d/or oae yean'imprisonmeat a�w•ell a�civil penalde�io the form of a STOP WORK ORDER aed a fiat of 5100.00 a day q�in�t ma I ndersta�d t6at a eopy of thy satemenc may be fonv�rded to the O�iiee of iave�tig�tiom of t6e DU for eoverate veri8ado�. !do hrreby cenif}�under thr pains and pena![i�s ojp�ry'ury that tht iaformation provid�d abovt is true�td contct Signaturc �s+T i/JL�-� Date f�—d C� ""�3 Print name - �/�� , /C}f5�� PhoneN c�D t� `-�7S'Y6C�p9 .. olTiciat use only do not r►�ite in this area to be completed by eiry or town oAleial city or town: Y�M�IIT� _ permiNieeau k nBuildiog Department �Licensioe Board �eheek if immediate responst i�required 261 OSeiectmen's 0f1iu �Healte Depanmeat contacc person: pAoneN;_ (508) 398�?231 eat. nOther .. :<�„, � � TOWN OF YARMOUTH BOARD OF HEALTH ; PERMIT TO OPERATE A FOOD ESTABLISHMENT � - � PERMIT NUMBER: #04-018 FEE: 75.00 1 � In accordance with reRulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a pernut is hereby granted to: Cape Groceries Inc., 590 Route 28, West Yarmouth, MA Whose place of business is: Cape Groceries Inc. Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2004 BOARD oF HEALTH: �e�rs�.h. l�i��tdo�I�l.$. ' I�af�ic��l�Ic.?S` e�rxo�`, ?/ics��rra� _df�.� S!�l,y�RJY� � � � , _ December a.2003 ruce G.M ,MP S O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERIVIIT NUMBER: #04-014 FEE: $25.00 This is to certify that Cape Groceries Inc. 590 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRiBL7TI4N OF TOBACCO PRODUCTS AS PER'TI-�YARMOUTH BO�RT�OF HEALTH TOBACCO RFCxLlTJATT_�N. - -- _ _ - --- -- �s��er�t i�s��iny��form�'t��cle VI f ��u�Code of The Commonwealth of Massachusetts,and December 4.2003 BOEIRD OF HEALTH: B�t�aytirs.h. (�dtc�xt, /��5., ��, v�et�� a�t� B�, e� � .�t�. �� . � , ,R. Director of Health � ',, . �-lk�O�3 �cao�°'' ' - Cs�PE G�oc�u� uf YqR � L� L�J � � � � � .�o TOWN OF YARMOUTH $�Al� �F AL Y . - .,'� APPLICATION F ��TCENS�E��t;�r�'-�o pEC 3 1 2002 -......- � * Please complete form and attach all '' ess�ry documents by Dec mber 31 20p2 Failure to do so will result in the return of your application acl�iEtAl'TN D�PT. NAME OF ESTABLISHMENT: C'.Q-.nc�' �Gc�i�lE3 �tJG TEL. # 508-775 � LOCATION AI)DRESS: S�o� �J.N��r/,�1r�S cv+�sT �.�l�f�! �1.4 • d 2 6 7 3 MAILING ADDRESS: .�.�i� ,� ��3arr�6s' O WNER/CORPORATION NAME: C�� ..�«.�/� lv� MANAGER'S NAME: A-L3/.w�- �A-S�jh TEL. # 3"D S-7 7S�6o� � MAILING ADDRESS: S 90� /�it�/iiJ $T /Lc�E'd7 `7'�R�1'l6U7�'f/ 11'!/� 6�. 6 73 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certif catiun to this form. 1. ��i4 2. /(f /�- Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. N �' 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1, N//� 2. N /� _ -- ��ai�fi�e�-iARGE: _ __ __. _ _ - _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2• HEIMLICH CER'�IFICATIONS: 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 �le at your place of business. 1. �1//r�- 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S50 CABlN �Sfl _MOTE�� $SQ INN S50 CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 _TRA[LER PARK $50 _WH(RLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L(CENSE REQtJ1RED FEE PERMIT# LICENSE REQUIRED FE6 PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 ,NON-PROFIT $25 _>100 SEATS $150 _COMMON V[CT. $50 _WHOLESALE $75 RETAIL SERVICE• • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 �<25,000 sq.ft. $75 Q3—(� _FROZF,N nF.SSERT S35 �TOf3ACC0 $25 �0 3-0.�3 NAME CHANGE: $10 AMOUNT DUE _ $ /oO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**** _ �` A � { ADMINISTRATION 2 ' ; � Un�er Cl��at�r 1�2�,.Se�io�25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ; of any Iicerise'or p�rnn��b 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 `'� 2R 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 '; r APPROPRIATELY IF PAID: ' YES � NO NOTICE: Permits run annually from January 1 to December 3 l. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 3l, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT 1�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 OPEl�1ING: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: T'he 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 S�RVICE �ONSUMER ADyISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. C'AT�Ri_NG POI,ICY• 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. _ �itO7EN�ESSEB�-_ __ __ __---- - _ _ __---- -_______ ' - -- -- ------ --- � _ Frozen desserts must be tested on a monthly basis by a State certitied 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),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. f DATE:� I�Z SIGNATURE: � : � PR1NT NAME& TITLE: � > � 10/18/02 , � � � �; . � ,. The Conr►rionwealth of Massachusetts � � Department ojlndustrial.-�ccidents � a OJJlceol/�s�l�sdiis 600 Washington Street ' •` Boston,Mass. 02111 ,�� .� W'orkers' Compensation Insurance Atfidavit A,Rnlicant informallon: plessepRiNTTe�r,-i.iir _ �, �mc� �-2 C�i�j�P/�fL�Lc`5 !i�/ C- lucation: ,� �� — �i�//+� JT/�/� �� it� 1��'Sr �/�/ZJ��Ln'l'� '^ ��} �Z G �� phone q �i�� 7.�y�b � f am a homecwner pzrt�rmin,all work myself. � I am a sole proprieror�:-� ha�e no one��orkin� in anv capacin� _ � I am an_employer pro�i�in�µ�orkers'_compensation for my emplo��ee�w•orkine on this job. comnanv name: �/�i�Ce�" �� L address: �/ 0 `- �/�-/J� � ��r �� tiri•• l.!/�cST �7��'1�7 �- ////7' • 0 Z, CJ� nhone il .�� "77l -L1E?O�j insur�ace co. !'.�/� e7�/1111C,t�/�/UTU/� /�f/ .� policy# (�tJ� � �/ 7 7 � I am a sole proprietor. _eneral contracror. or homeow�ner(circle oneJ and ha��e hired the contractors listed below �tiho ha�e the follu��in_ ��arker� �ompensation polices: �omoanv n�me• addresr ��n'� ohone#• insurancc co. polic}•# comoanv name: — ___ — _— _— --- __ ___ —_ _----------- -------- address: — -- ------------- �': nhoee N• insurance co. ��eY* t Failure to secure coveraee as required under Secnoo 2SA of MGL 152 ea�lead to t6e iopaidoe ot erisi�fl pesdtla o(a O�e op to 51,500.00 a�d/or oae vean'imprisonment a�w•ell as eivil penaltie�io the form ot a STOP WORK ORDER aed a liae otS100.00�dar qaiott ma I s■dersa.d ma�a topy of thy satement may be fonvarded to the Ot'Ifee of inve�tigadom of t6t DIA for eovera`e veri8eatio�. /do hrreby cenif}•under tbe poins und prnalties ojp�ry'ury that tl�e injormation providtd abovt is tnte and corred Signature � � �Z —3� —Q� Printname ��L� �/�'��,� PhoneM ��75-��`� .- olTicial use only do not w rite in this�rea to be completed by citr or town oAleial ciry or town: Y�M�IIT� _ permitAieense N nBuildiog Departmeot check if immediate res nse i�re uired ❑Lieeosiog Board � � Q 261 OSdectmen'e Otrce �Health Depanmeat contact person: phont M;_ �508� 398�2231 eat. nOther ,.. ._� ,.�,.: , �• . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERIVIIT NLTMBER: #03-047 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 Groceries Inc., 590 Route 28, West Yarmouth, MA Whose place of business is: Cape Groceries Inc. Type of business: Retail Food Service less than 25,000 syuare feet � To operate a food establishment in: Town of Yarmouth Pernut�ires: December 31, 2003 soAltn oF xE,�,1�: �rlca;� ��, �a� ____ __ __-- _ _ --- _____ _--- __ _--- _ -- --- - _ _-- �ja.r�i.r�C�ro ic�c�,��,tiiese �a�ek 711C'Doz.�t _ ?fele�Se�C, ��'l. , Januarv 24.zoo3 �u�G.M�ny, .,cxo � >. " Director of Health ' THE�OMMONWEA��'H OF MASSACHi�SET`�S � _ � TOWl'�T f�`Y�"YARMOUTH ; :M .. . � � } �. K'ii'pK 1r .. t BOARD'OF HEALTH - . PERMIT NUMBER: #03-033 , . FEE: $25.00 'rhis is to Certify that Ca�e Groceries Inc. 590 Route 28, West Y�rmouth,MA . , : . IS HEREBY GRANTED A LICENSE ` For SALE AND DISTRIBUTION OF TOB�CCO PRO�DL�ETS� . h . �.,: � � . . � - : ; . . , . �.�a AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This. t is anted' form'ty with Article VI f e San' Code of The Commonwealth of Massachusetts,and . exp�es�ece�iber 31�2�0� un��ss sooner suspenc��or revo�. , " "�� January 24.2003 BOARD OF HEALTH: �led`�f. i�ell's�raa. (�cr� �'esc fiaoxt.��. Ciaxala�c, 'I�D., `�/ie;e �oB�it�. b'aecwc, L�le�rk �a�ilc�'11�cDar�cott ��s�. �� ruce G. Y, •, Director of He,alth f ; ; C_A-Pe C�c,t.'�¢,t ES � � TOWN OF YARMOUTH BOARD OF HEALTH [ ��r�� ' �'s,. . �, �l r �� 1 f�. S/ ,. i . APPLICATION FOR LICENSE/PERMIT -2002 Q �' ��- � '' �� u `" ��. �� * P l e as e c o p e t e f o r m an d a tt a c h a l l n e c e s s a ry d o c u m en t s b y December 31, 2001. Fail e t��'o so�v�nl result i the ret�s yo��applicatign9��ck� �..��AL�� C}EPT• 7 � �re;;,;� �1F FCTART TC�TT��TFATT• �"'/4D� G.�r�-rLi�s /�c� TEL. # S"D 8'77.�5"5/Ge� LOCATION ADDRESS• 5��.5 /1�.aa.�ST—�ret8 �✓�ST �/ � -�a• e�6 ?� MAILING ADDRESS- S'�F ,L.�-� k�m/� OWNER/CORPORATION NAME• �fF�l'G�' �ieo��2��s /ivG MANAGER'S NAME• ,�-B Ov� �2.o-S�t� TEL. # .�'0 3'��s-y�►6 MAILING AT�DRESS• S�v -/J��r�r a fs G.,�r,5;�siav�-��t • a.z6�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. N�� 2. N/� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �/� 2. � � , 3. 4. 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 tlus application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. N 2. N'/i� PER�aN IN Cf-TAI�GE: _ __ - _ _ . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2 HEIMLICH CERTIFICATIONS• All food service 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. 1. oV 2. ��' 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 INN ` ` $50 _CAMP $50 _SWIMMING POOL$SOea LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE• LICENSE REQUIRED FEE F'�IQ�,tT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 �:; COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# U�CENSE REQUIRED FEE PERMIT# - LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 I <25,000 sq.ft. $75 �Oa" �TOBACCO $20 �'6 -O lS _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DTTE _ $ �S•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** c � r � ADMINISTRATION � ,� ' � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACAED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � /� YES �t/ 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, 200L SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRTOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS _ . POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a Sta.te certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CQNSUMER ADVISORY: Each food 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 DESSERTSi^ _ - --- -- ---- - _ _ ___ _--- - - ---- -- - : Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE: (II 3�� r SIGNATURE: � PRINT NAME&TITLE: ��bl�L--- /c A�S��D � /✓l,Q-iV/a--�'i�h-�/�i��lb�;v� 09/11/O1 ', _. - � . I . �� , The Conrmoawealth ojMossachusetts � � Department ojlndustrial.-�ccidents � o OJIIce ol/eres�l0stliis ; 600 Washington Street ' •` Boston.Mass. 02111 w,, �,�' W'orkers' Compensation insurance Affidavit ARnlicant informallon• PleasePR '� nam�� ( I�-p� �-1/�.�lL�� //!�G location: �/� —IJ7.dr�itJ �T /�T r�(7 �tt� �i IGsST 7'iE�1_��1c52�Tdf /t'I/.J-_��d �-3 Qhone� �0�7 ��7 o f am a homeowner pert�rming all work myself. y�� I am a sole proprieror�� ha�e no one ��orkin_ in anv capacit�� I am an emplo�er>pro��dino workers' compensation for my employees w•orking on this job. ' sQmoan�• name• � � ,�oC'l.��-fi� �il/�l �ddress• j��D /LI.f��t/ e��/�T� dZ g sitv: (N�.�T //�2/Y1l�I�� ` /�/y" ��0`2(.�73 nhone M• �0 g— 7��' �v`�j insurance co. l �13L1 C c5Ls2 rL� �/sT(•�i4-��/US• C�O policy# LC)� l3Z� �� 770� � I am a sole proprietor. :enerai contractor, or homeowner(clrc/e onel and ha��e hired the contractors listed below ��ho ha�e the follu�cin: ��orkzr� ;ompensation polices: �omoanv name• address• citti•• �hons t�• insur�ncc co. Qolicg# �omoanv name• --- -- --------— -- _ --- — -- __ - — addresr ___ —_____ sitr: phoae_+�. insurance co. �,� t Failure to secure coverage as requ�red unde�Secnoo 25A of MGL 152 es�!ad to tbe iepo�itioa o(erioiad peealtles o(a 6�e ap to 51,500.00 a�d/or one years'imprisonment r�w•ell a�civil peaalNe�io the form of a STOP WORK ORDER aad a fise of 5109.00 a day apio�t ma I a�denta�d tfiat a copy of thh statement may be forwarded to tht Of'rice of Inveatig�tiom of t6e DIA for eovera�e veri8pdo�. I do hr�eby cenif}•under rh�parns end penal�ies ojperjury�hat t6t rnjornratrion providtd abovt is tnte and corrtd � Signature C� p� 1�- �a� p/ Print name /�t��UL �/!s�l,�-j� Phone Il ✓�v�^ 77,��-�/6�� .. otTicial use only do not write in this area to be completed by eiry or towa oAltial ciry or town: YA��DTQ _ pertnitAieense N nBuildiog Department pLieensiog Board �check if immediate response i�required 261 �Selectmen'e ORce OHta1tA Department cont�ct person: Pfio�p._ (508� 398�2231 ezt. nOtAer I � � . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #02-019 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: Ca�e('rroc.�ries inc_, 590 Main Stree /RoLte 8, Wett YarmoLth,MA Whose place of business is: Cape Groceries Inc. 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. 2002 BOARD OF HEAL,TH: �aa�� d�, C�� fa�s D. C'oxdawc, 71t D.. �l/�ee ,�od�rt� �, �rk ��«�ott �� s ��t March 22 ,2002 Bruce G.Murphy, , . .,CHO THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-015 FEE: $20.00 'rhis is to Certify that Ca�e Groceries Inc. 590 Main Street/Route 28, West Yazmouth_MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PR4DUCTS AS PER'THE YARMOUTH BOARD OF HEALTH TOBACCO REGULAT`ION T'his permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: �led�f, i�elli�, ��a�c ��. c��. ��., v� �� . G'r� �aa��tt � s . ��t ru�e . urp y . ., Director of Heal C��C,r ce �4-'i c� . '' • Q � �N [�� (� 11% i,r; !L� = TOWN OF YARMOUTH BOARD OF HEALTH qD APPLICATION FOR LICENSE/PERMIT-2000 ,j�� °,/ �AN 1 3 2000 S' Cp'�� HEALTH DEPT. * Please complete form and attach all necessary documents by December 31, 1999. Failure to o so wi resu t m the return of your application packet. ----------------------------------------------------�--------------------------------------------------------�---------------------------_. NAME OF ESTABL�S�pV��TT• G%�G �i2�aCcs/LtG� �i7r°C TEL. # ,5�8-77S-y'6o�! L��ATION ADD,�ES S�,S�o �� S T ��Y,.�2�,>'r�•�i�- c�� .7 3 MAILING ADDRE S S: .5r�-t�1� ,,�5 ,�m/� ��L�CORPORATION NAME: e'�PL-�' ��,�,�,�I� /�c MA�IAG�'S N�ME: f��-.��✓/S TEL. # �r,s�-77S S�G�6 MAII.,ING ADDRESS: ��3� --i�J,�¢/.v �'T_ ��r�r,_,.,�.�t�„r,��'�� . �,�t � �_ G 7^� �'OOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. __ 1. N�/� 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 wiil not use past years' records. You must provide new copies and maintain a file at your ptace of business. �. �/� 2. �;�� 3. 4. HEIMLICH��RTIFICATIONS: 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 yaur 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 yaur place of business. 1. N//� , , 2. /�t�/,�f-� 3. 4. RESTALJRANT SEATING: TQTAL# _ : _I�TQl�I�MOKI1�I��EATSt-�DTAL_# ------ -- __ _ ---------------------------------------------------------------------------�--___----------------•-------------------------------------___ OFFICE USE Q�L I,,ODGING: LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $SO `INN $50 _CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 _SVVIMMING POOL $SOea. WHIRLPOOL $25ea.. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 N4N-PROFIT $25 _COMMON VICT. $50 � WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 � TOBACCO $2Q �� <25,000 sq.ft. $75 C'�j(o FROZEN DESSERT $35 � >25,000 sq.ft. $200 NAME CHANGE: $10 AMO�TNT DUE _ $ �Cj— ""`""PLEASE TURN OVER AND COMPLETE OTf�R SIDE OF FORM�„�RR � ; � , ADMINISTRATION ` UNDER CHAP'TE�152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED TO HOZD ISS�J�ANCE OR RENEWAL QF ANY LICENSE C1R PERNIIT TO OPERATE A BUSINESS IF A Y �; 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 `' , .Q'$ '' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES_,� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFaVIEENT'S ARE T�CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR T4 OPENI1�tG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLTIPM'�NT,ETC.),MUST BE REPORTED TO IAND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. AI�DITIONAL REGULATIONS PUOLS POOL OPENING: ALL SVVIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS,TQTAL GOLIF(�RM AND STANDARD PLATE COiJ1�iT BY A STATEGERTIFIED LAB, PRIOR TO OPENII�TC, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlI�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO T'HE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZ��ESSERTS: FROZEN DESSERTS MUST BE TESTED 4N 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 TI-� SUSPENSION ORREVOCATION OF Yt�URFROZEN DESSERT PERMIT UNTII.THE ABOVE T'ERMS HAVE — - — ---_ __ _ _ __ _ ___ _ BEEN MET. _ ___ _ ___ _ OiTTSIDE CAFES: OiJTSIDE CAF�S(i.e., OUTDOOR SEATING WITH WAITERiWAITRESS SERVICE), MU5T HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. QUTDOOR COOI{1NG: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII., OR FOOD SERVICE ESTABLIS��VVIENT IS PROHIBITED. DATE: �—l� — ��XU SIGNATURE: � PRINT NAME& TITLE: jyJ + ��>�� 11/12/99 ' ., � . The Conrmonwealth of Massachusetts � � Depa�tment ojlndustrial,-�ccidents - " ; Of1IC00110YCS��f�Ilf ` 600 Washington Slreet ' �' Boston. Mass. 02111 ' " '��y W'orkers' Compensation Insurance Affidavit ARnlicant information: PleasePR�7"Ted.'Wir n�m� �i�I�L' .-��/7��'L��l� /� lucati�n: , 7r�D — ,��/,�G� ,�r � �` �.�'' 4!S? li(/ r r ��L2�1d1�� D 2-[�� phone q ;��r� 77S-��O� � I am a homeowne�r pert�rming all w�ork myself. � 1 an� a sole propriz[or�:-,a, hs�e no one «orkin� in am•capacin� � I am an emplo}er pro��dins w�orkers' compensation for my�employ�ees w•orking on this job. __ _ ___ _ _ _ _ __ _ _ __ _ compan�• name• � G� �jD�p/c�'�� s/��'` a�ldress: o�, G`� -' �/�lf� c�T� //1� �� , 51��.. ��r //�lL�i�f��l�< �-�/� ' O� ��.� ehone�1 insurance co. �!' /C � �2i/fC�-r l�I��"kL.. /V,5" �/��1V, ool'�y# �� -`�'�sj6�— �� I am a sole proprietor. :eneral contractor, or homeow�ner(circle one/ and ha�•e hired the contractors listed below �tiho ha�e the follu��in_ ��orken� :ompensation polices: somnanv name• address• cin�: ehone M• iosurancc co. �olicv# �2moanv name: idd.c��s�_ �'� �hoee 1{• insurance co. �e�eY* s Failure to secure covera;t as requircd uoder Secnoo 2SA of MGL 152 n�ind to tbe iopo�idos o!eriei�fi pt�dtles of a ti�e op to 51�00.00 a�d/or one years'imprisonment a�w•ell»civil penaltle�io the form of a STOP WORK ORDER aad a Aae of 5100.00 t dar ttaiost ma I asdersta�d t�at a copy of thy statemene may be for.v�rded to the Ofiice of Investig�don�of tbe DIA tor eovenge veriliqtio�. /do hrreby cerrif}•under�he parns and penalties ojperjyry thal the injornia�ion provided obovt is trtr[and eor►tet Signature '� l `� Date �� l Print name � 7�C_ _/��fi,tH� Phonell .�15c�"�77� — �/�^� .- olTicial use onl. do not��ite in this�ra to be completed by ciry or town oAfeiil ciry or town: Y��T� _ permitAleeeu k nBuildiog Departmeot �Licensing Boa�d �cheek if immediate response ie required 261 �Seleetmen'e OlTice �Heait�Departmeat contact person: pAont M;_ �508) 398--2231 eat. nOther .. . _ <,�,: TOWN OF YARMOUTH - BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-56 FEE: $75.00 [n accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l, Section 5 of the General Laws,a permit is hereby granted to: C'ane('Troceries Tnc_, 590 Main Street/Route 2R, West Y�rmouth, MA Whose place of business is: Cape Groceries Inc. 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. 2000 BOARD OF HEALTH:�d�/. �et��, C'��.,�� oan� �ulLivan, K.I'/., Vice l,�irma Kobert,}. 4�rown� (��r� ,a�riel�e�a�to(,��Zy-JdooPe� ///ic�el oCo hlin lanuary 28 ,2000 Bruce G.Murphy,MPH, R.S,C Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-45 FEE: $20.00 This is to Certify that Cape Groceries Inc. 590 Main Street/Route 28. West Yarmouth.MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of 1'he Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. Januar�28 ,2000 BOARD OF HEALTH: �i`///. .}ef.�e�, ��iairmarc �oan� �ul�ivan, K.//., Vice ��irman Kobert� �rown� l.[erh �a�rieile�a�ol.��c�-✓�tooPes ?'�I��10�ouy��n ruce . urp y, , . ., Director of Health r � . .,� � �'Groc�rie� w TOWN OF YARMOUTH BOARD OF HEALTH ��q� � .,�� ,r APPLICATION FOR LICENSE/PERMIT- 1999 � � �" �� APR 2 2 1999 � * Please complete form and attach all necessary documents by Dece��+� 1 9 .� lur to o so will r I �:,� �' ._� �� .�� q►�T��. , I t he re turn o f your app lication pac ket. _ _,,,, ---------------------------------------------------------------------------------- -------------------------------�------------------ � NAME OF ESTABLISI-�MFNT� �PE �,20«/1/� /�JC T i # So8-77S-y�v6 I �,OCATION A.DDRESS: S9D- /�.k.�/ Sr- �,�/�T y,q,�,y��r� ,iyl,4-o�G73 MAILING ADDRESS� 5�-�l� /1s �4 �� a�CORPORATION N MF• C,4pc�Rec,�a/�'S !� MA�NAGER'S NAME: �1'l3TluL �2l�sk!-�� TE # So877r 4iGv6 �1�IAI�ING ADDRESS• .r�o-vr-,�N ST-r��sr y.�,y��rsr • �,a • o�G�3 � -------------------------------------------------------------- _____------------------------------------------------------------ , POOL CERTIFICATIONS: The pool supervisor must be certiGed as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. , . ' I 1. h//-� 2. /��Q I Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and � Community Cardio�ultnonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' recorda. You must provide new � copies and maintain a fle at your place of business. ; 1._ �//�- 2. N� � 3. q. � i � 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 Heatth Department will not use past years' records. You must provide new copies and maintain a file at your piace of business. l. /� �4 2. �/�/�- . 3. 4. RESTAURANT SEATING: TOTAL # NON-SMOKING SEATS: TOTAL# � ------------------ -- --------------------------------------------------------------------------------------------------------- ---- � OFFICE USE ON Y ' � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# � _B&B $50 CABIN $50 _INr1 $50 _CAMP $50 _LODUE $50 _TRAILER PARK $50 � I _MOTEL $50 _SWIMIVIING POOL $SOea. i WHIRLPOOL $25ea. � FOOD SERVICE• — LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# _0-100 SEATS $75 CONTINENTAL � , $30 � _>100 SEATS $150 NON-PROFIT $2g ' _CONIMON VICT. $50 � WHOLESALE $75 I�TAII,SE VI .F- 1�' � i LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $45 lTOBACCO $20 ,, � I �<25,000 sy.ft. $75 � � FROZEN DESSERT $25 ( _>25,000 sq.ft. $200 1�1AME C AN �E• $10 AMOUNT DUE _ $�— """""pLEASE TURN OVER AND COMpLETE OTHER SIDE OF FORM •/1Af111 / , , , . � : ,, ADMINISTRATION :INDER CHAPTER 152, SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOLITH IS NOW REQUIREI� CO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A ' 'ERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION :NSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT VIUST BE COMPLETED AND SIGNED, OR. CERT. OF INSURANCE ATTACHED .� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED COWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF �OUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: YES '✓� NO JOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR 2ESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(Sj AND REQUIRED FEE(S) BY )ECEMBER 31, 1998. >EASONAL ESTABLIS�IlViEEN'TS ARE TO CONTACT TI-�HEAL'�H DEPARTMENT FOR INSPECTION �-10 DAYS PRIOR TO OPENING FOR THE SEASON. �i,L RENOVATIONS TO ANY FOOD ESTABLIS�3MENT, MOTEL OR POOL (i.e., PAINTING, NEW 'sQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i O COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONA_i_.RFGULATIONS POOLS 'OOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR 'HE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND TI-iE WATER TESTED FOR � 'SEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, � 'RIOR TO OPENING, AND QUARTERLY THEREAFTER. j � � 'OOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMMING POOL MUST BE DRAINED OR COVERED ± VITHIN SEVEN (7) DAY5 OF CLOSING. j f FOOD SERVICE 'ATERINS�POLICY: � , ►NYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI-iE YARMOUTH ; [EALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION ` 'ORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE IEALTH DEPARTMENT. ROZEN DESSERTS: ROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST .ESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN T3E SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERMIT UNTIL THE AgpVE TERM$ i [AVE BEEN MET. �JTSIDE CAFES: �LTTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE I ),�T HAVE PRIOR ,PPROVAL FROM THE BOARD OF HEALTH. i �vT�ooR cop�nvc� . , �UTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD � . � ERVICE ESTABLISfIMENT IS PROHIBITED. ' I ATE: Z `� � SIGNATURE: (�- .. PRINT�NAI�E& TITLE:_ �jJU� D�/�'S t�'I L� — p12�'S f 1JC-�iU r � v _ � � � The Commonwealth of MassQchusetts � W Departmenl ojlndustrial.-iccidents � o Olflceol/evesl/osdiis � 600 Washington Sheet ' ,,•` Boston, Mass OZlll �~ �• W'orkers' Compensation Insurance Affiidavit A,Rnlicant information: PlessePRilQTTe�t.'riTa - _ --- � namr: � 14�C �/2d CGs/ZlC3 �NC location: ��D-' 1YIA-l/Il �7" /.,�T „1 g' �it� (.tf�"�S%�i�-R/�2�r"6�f - /Yla - v 2 l�7 3 phone� ,��-7 7.r-��s� � I am a homeowner pertormin�ali work my�self. � I am a sole proprie[or�^� ha�e no one ��orkine in am•capacity � I am an employer pro�idins workers' compensation for my employ�ees working on this job. comnanv name: �/4P� �12bCGs'/1fc�`S �/I/C address: �9fj-- f'n�!/1/ �Y'/f.�j�� s��,�: wc��r y��T� - m� � o z G 7� nhone#• S�g-��-_ �Go 6 �sur�nce co �t��Li e J�/1✓1CL= �UTU<FC- INS� CD/11P/��oficy# d d��3 or�r�l�� I am a sole proprietor. aeneral contractor, or homeowner(circle onel and ha�•e hired the conttactors listed below �tiho ha�e ' the follu��in� ��orker;� �ompensation polices: � i sompanv name: asidress: citv• phone q• insurancc co. policy# comqan,y_n�me• address• [lLy� nhoee#• insurance co� ��sy�_ � Failure to secure covenge as required under Seedoo 25A o[MGL 1S2 ea�lad to t6e iopaidoa of erisl�al peul8a of a A�e op to 51,500.00 a�d/or ' one yean'imprisonment a�w•ell as civil peaatNa io the(orm of a STOP WORK ORDER aed a liee of 5100.00 a day a��iost ma I a�dersta�d tlat a copy of thy statement may be fonvarded to the Ofiice of Invatigadon�of t6e DU for eovenge verifltatio�. /do hrreby cenij}•under�b�parns and penalties ojperjury thw�h�injormation providtd abovt is true and eon�et Signaturc __��/� �` p� �{f2(� �9 Printname �e,�L�L— Ril��'1�i1� Phone# SD$� 7�.3= ytSa6 .. olTicial use only •do not..rite in this ara to be completed 6y ciN or town ofllcial city or town: Y��T4 _ permitAicense M nBuildiog Dcpartment pLiceasiog Boud �check if immediate response i�required 261 �Sdectmen's Ofliee OHealth Departmeet cont9ct person: phone q;_ �508� 398--2231 egt. nOther Irecised i;v5 P1A1 � TOWN OF YARMOUTH . BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-61 FEE: �75.00 In accordance wi�th regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of We General Laws,a permit is hereby granted to: C'ane ('7roceries Tn ,�90 A�ain 4tre !R� �tP �R� �x�e�t Yarm� � h, ll�A Whose place of business is: Cane Groceries Lnc Type of business: Retail Food Service less than 25,000 sa�ase feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 1999 BOARD OF HEALTH:�'d�f. �ef.��, C'��,� �oan C�. �uLlivaic, �i/•� �ice (�iusirman KaberE J. 4,rouin� l�ler� � a�rlel[e�a�ol��r�-.�tooPe� 'i/ic�e ooCou �fisa � � Apri126 . 19 99 Bruce G.Murphy,MPH, .,C Director of Health THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: 99-48 FEE: $20.00 This is to Cer6fy that Cane Groceries Inc. 590 Main Street/Route 28, Wect Ya�nnoutl� 1VLA IS HEREBY GRANTED A LICENSE For SALE AND DIS'TI�iIiUTION OF TOBAC O PRO U T AS PER THE YARMnT BOARD OF HEALTH TOBAC O REG TT ATION This permit is granted in conformity with Article VT of the Sanitary Code of The Cammonwealth of Massachusetts,and 4 expires December 31_ 1999 unless sooner sUspended or revoked. Apri126 ,-19 99 BOARD OF HEALTH: �c`� �}ef,le�, C.�ai.rman �oan � �u[[wan�K.i/•� Vice C.hairmaic . Ko�ert J. �i»wn� (�le�� a�rie�le�a�of�l�rf-_J�tooPea • B�0' ��.�,� Director of H alth �