HomeMy WebLinkAboutApplications, WC and Licenses r
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` °=YaR TOWN OF YARMOUTH BOARD OF HEALTH '
� � �� APPLICATION FUR LICENSE/PERMIT-2007 � `
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* Please complete form and attach all necessary documents by December 31, 2006. ;
Failure to do so will result in the return of your application packet. I
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NAME OF ESTABLISFIlVIENT: ��`T?LR�F�,J�N'pS Gt Gi5 TEL. # 6�8—v�9�l—O�Od ;
LOCATION ADDRESS: 8 Sa ��� ZS � S Y OZ-�6 y _____ '
MAILING ADDRESS:
OWNER NAME: F2�c.�,e.� 3Yr2N E TAX ID (FEIN or SSNI:
CORPORATION NAME(IF APPLICABLE): C.,4pE-�7L.�.DFw,nrp e �rG� lrvc .
MANAGER'S N�ME: TEL. #
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operatar(s}and at�ach a copy of the certification to this form.
1. 2. I
Pool operatars 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 ernployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your ptace of business.
l. 2.
3. 4.
FOOD PROTECTI4N 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 file at your establishmen�
l. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2•
HEIlVILICH CER'TIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-cholang procedures belaw and
attach copies of employee certifications to this form. T6e Health Department will not use past years' records.
You rnust provide new copies and maintain a fde at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY ,
LODGING:
LICENSE REQUIItfiD FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B �50 CABIN $50 _MOTEL $50
iNN $50 CAMP $50 _SWIIvIMII�TG POOL$75ea.
LODGE $SQ _TRAII,ERPAI2K $100 _WHIItLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIItED FEE PERMI'P# LTCENSE REQUIItED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE: —TtESID.KITCHEN $75
LICENSE REQUIRF.D FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIl2ED FEE PERMIT#
<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20
� �QS,OOOsq.ft. $75 #o���'j _FROZENDESSERT $35 _TOBACCO $50
j NAME CHANGE: �io AMOUNT DUE = S ?S -f � 7 S
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'*"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""""
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ADMINISTRATION '
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT 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
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (34) days, and an
aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest uflit 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.
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� POOLS
PO4L QPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ecte�i
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days
pnor to opening.
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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 sv�rimming pool Fnust be drained or covered within seven(7)days of
, closing.
FOOD SERVICE II:
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Depaztment 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. Failwe to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms ha.ve been met.
OUTSIDE CAFES: ;
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ;
OI7TDOOR COOHING:
Outdoor cooking,preparatian,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[TRN '
TI-�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 3 l, 2006. i
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ALL RENOVATIONS TO ANY k'OOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BO?�RD OF HEALTH pRIOR `'
TO COMMENCEMENT. RENOVATIDNS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PRINT NAME&TITLE:
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� The Commonwealth ofMassachusetxs y��� � � �� ���
Departwrent of Industrial Accidents �!�� Y � ��1 Cl l
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608 Washirigtoa Stree� ?"�Floor " ��� ��
Bpston,Mass. 02111
— -- – Workera'Com ' s Lsmaaee Affidavit:B�7 ' b�/Eieetricsi!Co�tnctors
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address•
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work site locati�(fitll addnssl•
❑ I am a I�omoowner performing all waaic myself. Project Type: ❑New C�a►�Reanodel
I a sole 'etor and have no one w in an ❑Bui1 ' Addition
I am an e.mployer providing workers'compensation f�my e.mployees working o�this job.
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❑ I am a sole proprietor,ge�al coatracter,or�omeowter(cn+cle ont)and have hit+ad the co�rdctats listed belovr who have
the following wotk�s'co�ensatian polices:
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sie yean'isprNy�t�s wU as dvr_pwNlRs la tM tara��ta 3T0r WOBK QR11ER ud s II�e�f t1N.N s day�ae.1 ndacs�td tbt a_
apy�f tYb st=te��y be firwardc�ts tYe Oma�t lareNipMM�s af tYc DIA tar cwerage v�a'iAa11M.
I ro beneby ce der tGe i�s 4w of perjWry tlYet tlYe iefa�aado�prodded abov�e is trxe aad oo�
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Print name Phone#
e�d�l ase e'ly de aot wrke ia this arn to 6e c�Pktcd 6Y dl'9 sr lnrn�1
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cent�ct persea: pti��; �a
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NO'TICE NOTICE
TO � f � 'TO
�� EMPLOYEES �� EMPLC�YE�S
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The Commc�nwealth_ of �assa�h�.s�tts
i���:��'���l��i�� +�� t:�i��:����`��:l���.; �:t:;t;i������:
600 Was�iington Street, Bosto�, Mass�chusetts 02111
� 617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21,22 & 30,this will give you notace
� that I (we)have provided for payment to our injured employees uxtder the above-mentioned chapter by
� insuring with:
�
{ MA Retail Me�chants WC Group Inc.
� NAME OF INSURANCE COMPANY
10 British American Blvd. Latham, NY 12110
ADDRESS OF�NSURANCE COMPANY �
014000500089107 1/O1/2007 - 1/O1/2U08
P4LICY NUMBER E�FECTNE DATES
, First Cardinal Corp. 10 British American Blvd. Latham, NY 12110-0141
� NAME�F INSURANCE AGENT ADDRESS PHONE#
�
� Cape Tradewinds Gifts Inc. 852 Main Street Route 28 South Yarmouth, MA 02664
EMPLOYER ADD.�2ESS � !
�
EMPLOYER'S �.�'ORKERS' ��MPEI�TSATION OFFICER(IF AN4'j D.4TE
ME�DICAL TREATMEN`T
The above name�i insurer is required in cases of personal injiuies a�ising out of and in the course of
employment to furnish adequate and reasoz�,a'�le hospital and rnedical sezvices in accardance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cast of the ser-
i
vices pravided by the treating physician will be paid by the insurer,if the treatment is necessary and
reasonably connected to the work related injury. In cases requi�ing hospital attention, employees are
' hereby notified that the insurer has arranged for such attention at the
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� NAME OF HOSPITAL . ADDRESS
i TO BE POSTED BY EMPLOYER
. TOW�1T OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiVI�NT
PERMIT NUMBER: #07-029 `� FEE: $75.00
In accordance with regu1aUons promulgated under authority of Chapter 94,Section 305A and Chagter
I 11,Section 5 of the General Laws,a permit is hereby granted to:
Cape Tradewinds Gifts Inc., 852 Route 28, South Yarmouth, MA
Whose place of business is: Cape Tradewinds Crifts
Type of business: Retail Fdod Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31 2007 BOARD oF HEALTH: B �. �o�or�,/�1.�., '
e�e�y���►lrc�i, .1V., �Uu;e G�ls�r��
xESTTucTTONs: Taffy and fudge only. /lo�iwht�B�u,�ry ��
n��r��
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Feb . 22,2007 Bruce G.Murphy, ,RS.,GHO
I}irector of Health
TOWN QF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUIV�ER: #06-065 FEE: $75.00
In accordance with regu1ahons promulgated under authoriry c�f Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a peimit is hereby granted ta
Cape Tradewinds Gifts Inc., 852 Route 28, South Yarmouth, MA
Whose place of business is: Cape Tradewinds Gifts
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Pernut e�ires: December 31 2005 Bo�tD OF HEAI,TH: L�e u� `.?�. o�a,�,/yl.$., '
d�e�i��'luli, �./V., ?/u;e G��i�usra+�
xEST1uc1Zolvs: Taffy and fudge only. Qtt�iPlit�. B�tiu�st, ��
�t�/�st;�/�c�PJ�r�
14�trt�'hee�t�tr�rt, /�./�
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February 22,2007 . Bru .Murphy,MP S.,CHO
Director of Health
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o� Ya��
�� .;.: . _ , o T O � � o F yA R M o U T H
�H +'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
"(�-MATTACMEES � �
�MfOqp�Aitp�6��� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472
' B OARD OF HEALTH ;� � (�: � � `�' � n
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� APR 1 9`�2005
To: Yarmouth Boazd of Health Perinit Holders .
HEALTH DEPT.
� From: David D. Flaherty Jr., RS. ��r
Health Inspector
Town of Yarmouth
Re: Federa.l Tax ID Number
Date: Mazch 22,2005
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' 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 Number(FEIN)atherwise
� known as your"T�ID Number". This is purely for administrative purposes only.
Some businesses use,the owner's Social Security Number (SSiv} for this purpose. If this is the
case fo� 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
, � 1 I46 Route 28 •
� South Yarmoutl�, MA 02664
�
;
Thank you far your anticipated compliance. If you have any questians regarding this matter,
g�ease d� nat hesitate ta call. The o�i;ee hours arz Mvn�y to Friday, 8:3� a.m. to 4:30 p.m. '�'hi e
j telephone number is(508) 398-2231,eart. 24L
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Establishment:�� •� FEIN or SSN: � / ��
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Location Address: -� � �
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Signature:
Print Title: 1����/( ��;"
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3.� r R o TOWN OF YARMOUTH BO :�, .. ALTH L� � C� � � M � DD
����� APPLICATION FOR -2005 N 0 V 2 3 2004
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* Please complete form and attach all nece ` d ' ments by Decem e ����DEPT.
Failure to do so will result in the r of your applica.tion pa .
NAME OF ESTABLIS NT: - TEL. # ' ��''
LOCATION ADDRESS: �( /
1VIAILING ADDRESS:
OWNER/CORPORATION NAME: C� �OS �-
MANAGER'S NAME: TEL. # D - �/-O��
MAILING ADDRESS: �'� d���
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. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
employee certificaxions 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 MANAGE�S -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 fde at your establishment.
1. 2-
--- _ ���5 • ----- _ _ -- ----- -- __ _ _ ;
Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation.
1. 2.
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.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE P�RMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMTP#
B&B $50 CABIN $50 ,MOTEL $50
IlVN $50 CAMP $50 _SWIlVIlvIIlJG POOL$75ea.
LODGE $50 TRAILER PARK $50 WHII2LPOOL $75ea.
FOOD SER'VICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICEN5E REQUIIZED FEE PERNIIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQiJIRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
I Q5,000 sq.ft. �75 ��S'�Z� FROZEN DESSERT $35 �TOBACCO $25
NAME CNANGE: $10 AMOIJNT DUE = S 7S�Od
;
'*""•PLEASE�TURN OVER AND COMPLETE OTHER SIDE OF FORMARRflR
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
; Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yazmouth t�es and liens must be paid prior t enewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
� NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2004. '
SEASONALESTABLISHMENTSARETOCONTACTTHEHEALTHDEPARTN�NTFORINSPECTION?-10 ''
DAYS PRIOR TO OPENING FOR THE SEASQN. '
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR P40L (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 �
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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 T'ESTING: The water must be tested for pseudomonas,total coliform and standaxd plate count E
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. �
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FOOD SERVICE
CONSUMER ADVIS�RY:
Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o 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 ca.tered event. Thses forms can be
obtained at the Health Department.
FRO��i��E�SER3'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 waiterlwaitress service),must ha�e prior approval from the Board ofHealth.
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: ��� � SIGNATURE: � „�
PRINT NAME& TITLE:�/Cf,.��G�C�f/ �� ��5,��/�
,
10/22/04
i � _ � _
I `�� The Commonwealtl�of Massachusetts
—__�
_�- - = Departme�t of Industnial Accidents
� _ - M�riMiw�
_ ��GI�
- _ _= 6(!U Washington Streeg f""Floor
--- „ Bosto�e,Mass. 02111
Workera Com hoa I�amasee A�davi�B�iid 1em lecdrical Co,traeters
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I a sole 'etor and have na a�e w in an ca Buil ' Addition
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''� I am an e.mpioyer -ding worke.cs' •a�faa�my lo worlcing on this job.
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❑ I am a sole praprietor,g�al co�dractor,or lameow�er(cirde on�e)and have irired the comractais listcd betow vriw have
the following wa�lcas'compengation polices:
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o�e years'ispHaomt as we�as dv�pmNia 1�t�e Lrs Ka 31'OI'WORK ORDEA a�d a Au df1M.N a day apiet�e. I udaslud t6at a
apy d Wt��eewt dy i�e_firwarded Or tAe Odtce o[l�v��f tlre D1A tet average verilialiw
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Ptim natne Phone#
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #OS-021 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 gruanted to:
\ Cape Tradewinds Crifts Inc., 852 Route 28, South Yarmou MA
l
; Whose place of business is: Cane Tradewinds Crifts
i
� 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, 2005 BOARD oF xEALTx: $. /kJ..� •
� ��iblr.� ��?/rc�G'�s��s
! �s�lttc'r�olvs: Taffy and fudge on1Y- Ro�wh�`6,�. ��ui+�t, �ehl�a
! �ele.z �4�„ R./V.
�t�C�'���, R.N.
7anuary 19_2005 ruce G.Murphy, ,RS.,CHO
Director of Heal
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� •O`;�R� TOWN OF YARMOUTH BOARD OF HEAL� � C.�. S�i 4la�n"T
��`: -;� APPLICATION F „�.0 ,�11�MT�-2005 JAN 0 3 2005
:�Y � M
..• �;=
* Please complete form and attach all necessary documents by Decembe H DEPT.
( Failure to do so will result in the return of your application packet.
I
NAME OF ESTABLIS�IlVIENT: C� 'f" 't�' ' TEL. # � -
LOCATION ADDRESS: � f� '�
MAILING ADDRESS: �SC� r'1�-�.-
OWNER/CORPORATION NAME: ' � n L
MANA ER'S NAME: Y TEL. # ^
j MAILING ADDRESS: ��IYIQ C2� ����I(_(9-� �
!
i
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. 2.
i Pool operators must list minimum of two emplo ees currently certified in basic water safety, standard First Aid
� and Community Car � pulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
� employee certificaxi s to this form. The Health Department will not use past years' records. You must
� provide new cop' and maintain a fde at your place of business.
i
I
; 1. 2.
3. 4.
�
,
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required o have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the e Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certificat o this application. The Health Department will not use past years' records.
Yoa must prnvide new ies and maintain a fde at your establishment.
l. 2.
: _
� __ -�ERS@�F�i C�IARG�: -- -- --- - --- _ _
_ --- - - _ _- ---— — --
' Each food,establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation.
� l. 2.
i
i HEIMLTCH CERTIFICATIONS: .,��-��-'--�
All food service establishmenxs�-with 25 seats or more must have at least one employee trained in the Heimlich
IManehuverlon t fe premises af�a11 times. Please list your employees trained in anti-choking procedures below and
attac cop es o employ�e certificattons to tlus form. The Health Department will not use past years records.
1 You must provide new copies and maintain a file at your place of business.
I
l. 2.
3. 4.
�'
RESTAUR,ANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMI'f#
BBcB $50 CABIN 50 MOTEL
— _ $ _ �50
INN $50 _ _CAMP $50 _SWIlVIlVIIIIG POOL$75ea.
_LODGE $50 _TRAII,ER PARK $50 WHIItLPOOL $75ea.
FOOD SERVICE:
LTCENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMTr# LICENSE REQUIIZED FEE PERMTf#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $I50 _COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMI'P# LICENSE REQUIRED FEE PERMIT#
_<50 sq.R $45 >25,000 sq.ft. $200 VENDING-FOOD $20
�45,000 sq.8. $75 (�s� 8 FROZEN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ �7 S,Q(�
'"'�"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•"•'�
i
•l,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's ,
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDA'VIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
V
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid rior to renewal or issuance of your pernuts. pLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
T'HE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAi,ESTABLISHMENT S ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR TI� SEASON.
E
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 HE.ALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of
closing.
;
FOOD SERVICE
CONSUMER ADVIS�RY:
Each food estab �shment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Toum 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.
__-�'R�}�El�-BESSE�iTS: _ _ `
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 waiterJwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
k
c� ��� �
A . �_ ���
DATE: � d' 1 SIGN TURE
i /� i
PRINT NAME& TITLE: (,,�f� L�, �.C.�YI(,.� � 'l�'L�' .C�-�- ,�" _. . I
10/22/04 :
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- �� .
�►—�''� WORKERS CO�P�NSATiQN
AND
i EMPLOYERS LIABiLlTY POLiCY
�
i
i TYPE AR INFORMATiON PAGE WC 00 0�01 ( A)
' POUCY NUMBER: (7PVUB-7431 A07-4-Q4)
REH�WAL OF (7PJU6-7431 A4T-4-03)
� _ .
i 1NSURER; TRAVELERS PROPERTY CASUALTY CDl+�ANY QF At�RICA
NCCI CO CODE: i 3579
1,
� � INSURED: PRt3DUCER:
iCAPE COD SAL.T WATER TAFFY CO clt}k�! F MARTIN INS ACaCY
INC f 023 RDU�fE 28
�50 LONG ('Ot�Hl DRI VE BOX 350
SOUTH YARNIQUTH MA 02664 5 YARMOUTH MA 02664
I .
insured is A CORP�2ATION
; Other work piaces and ide�ffication numbe�s are shawn in tne schedule(s} attached.
I 2. The pdicy pefiott is from t34-04-04 to 44-01-05 12.�� A.M. at the insured's ma�Fng address.
`3. A. WORKERS C�MPENSATlON lNSURANCE: Rart One of ihe policy applies to the Workers �
Compensation law of the state(s11is#ed here:
MA .
.�
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= B. EMRLC)YERS LtA6lLtTY INSURANCE: Part Twa of the poiicy applies to work in each state listed in
� � item 3.A. The timits ofi our liab�ity under Part Two are: .
' �� Bod�y injury by Accidern: $ i 0000v Each Accider�t
�,� Bodily Injury by Disease: � St�bOtu) Policy Limit
� B�od�y injury by Disease: � �000t� Each Employee
�'—' C. t3THER STATES INSURANCE: Rart Three of the poficy appiies to the statss, i�any, listed here:
�
. `�� SEE E�ORSEN�f�iTT WC 2� fl3 46
�
�
��
��
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_
�� D. This
� policy indudes these endorsemeMs and sch�tuies:
� SEE LISTING QF EADEtRSEN�I'rt'fS - EXTENSION E}F iP�O PAt�
o� ,
� 4. The premium for this�icy u+ili be deLermined by�ur Manuals of R�les, Classifications, Rates and Rating
u.--- Plans. Alt requireci information is subject to verificatian and change by audit to be rrzade AtdI�1A�4Y, .
�
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_�
DATE OF 1SSlIE: 04-02-04 WC ST ASSIc��i: MA
OFFfCE: DIRECT AS�iC�NT 701
PR�DUCEF�: J�i F trfARTIi3 iNS A�Cv L�iLttS
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' � �. VDAC
; _ �
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�� WORKERS CLIMRENSATiaW
AND
EMPL�YERS LIABILiTY POLICY
� �
TYPE aa INFORMATiON PAGE WC o0 0o a1 ( A)
P0�1CY NUMBER: t7P�uB-��st ao7-4-oa)
CLASSIFiCATiON SCHEDULE:
� � FFiEM1UM BASIS �
ESTlMATED RATES ESTIMATED
TC)TAL ANNUAL PER$100 OF ANNUAL •
� CIASSiFiCAT10NS CODE NQ REIIAUNERATION REMUNERATiON PREMIUM
1 �
� SEE EXTENSION OF INFORNIATION PAE�E - SCFEDEJLE(S}
i
i
�
SIC-CODE. 2064 MA BUREAU FILE t�:
: -------------------------------------------------------------------------------------
STAi�ARD
TOTAL ESTIMATED A[�lllAL STAt�1ARD PREMIl1M $ 1130
PREMIUM DISCOUNT P�
i C1900-20 EXPENSE CQNSTANT 264
� TERRdRISiN RTSK INS ACT 20Q2 23 _ __
TQ'Y�L t�TiI�TEi3 ��EMIi1M 14i 7
TAXES AI� SURCHARC-�S 42 '
DE POSI T AMOtMiT DUE #459
i
�
A/R (WCIP} �
Minimtsm Premium: $239 �
. �.
DATE OF ISSUE: 04-02-04 WC ST' ASSIC,'t�t: NiA
OFFICE: DIRECT A55IC�M�N'f TOi
PRZ}i1UGER: J� � MARTZPI I!� AGCY 28LFB
,
� �-
� -
� WORKERS Ct3MPENSATiUN
AND
EMpLpYERS UABiLiT1'POLICY
EXTEIdSIDN O�' INFO PA{�E-SCF�DULE WC 00 d0 01 ( A 3
POLlCYNUMBER: (7P��-743iA07-4-04)
� INSURER: TRAVEL�RS PROPEI2TY CASUAL.TY COA�AN'Y OF AMlERICA i 3579-FAA .
� ��UR�p�S NANtE : CAPE COD SQLT WATER TAFFY CO
, INC RA� gt1REAU I4: 040157421
� Ah�iIVERSARY RATING DATE : 43-05-05
PREMZUM BASIS
ESTIMATED RATES ESTIl�{ATED
� Ti7?AL A�1A� PER �100 OF ANI�,IAL
CLASSiFICATION CODE RENN1h�RATIQN REI�1t�RATION PREMIUM
� LQCATION 461 D1
� FEIN ENTiTY CD O{�1
GAPE COD SALT 4tATER TAfFY C�
,.
� INC
� 984 ROUTE 28 ..
j _ ��T�fi 1fiA�}+AOt1�H, MA 02664 __ _ - --- _ �____ ----- _
� 2041 276i0 3.0? $48
� _� CQNFECTION MFG.
I ""'� STORE : RETAIL i�C
g0#� 22436 1 .31 294
i ="-� .1'7 47
� '� CLERICAL OFFICE Ei�L0YEE5 F�C 88�a 2�540
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b,�..
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a�
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I e+�
o� ----"-------"--_"�-----'------_"`-----"'----",----'—"----�-------"^------�.�.._.�.r.....��—^---
�� .950 I+�RIT RATING NIODIFICATTON {9885) $ 5g
�,.� TOTAL ES7IMATEa !lt�YVL1AL S7�AR0 i'REMiUhi 1130
u,,,�.� E XPE NSE CONSTANT(0900} 264 .
s� TERRORTSM RISK INS ACT 2002 (8740) 23
3.7Q% MA WC SPECIAL FUP� ANQ TRiJST FUt� 42
Tt3TAL ESTIMATED PREMIUM 1459
t3EPOSIT Af►�UM' BUE 1459
DATE OF iSSUE: 04-02-04 WC 5T a55It3N: i�iA SCHEDU�.E RO: 1 QFLAST
i - ` � '
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHIVV�NT
� PERMIT NLJMBER: #OS-048 FEE: $75.00
i
�
I In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a peimit is hereby gcanted to:
Donald Dumont/Cape Cod Salt Water T , Inc, 984 Route 28, South Yarmouth, MA
Whose place of business is: Cane Cod Saltwater Taffy
� Type of business: Retail Food Service less than 25.000 square feet
; To operate a food establishment in: Town of Ya�rn,outh
� Pernut e�ires: Decem�i�r 31, 2005 Bo�oF��,�: Ber�,rs�`h. �'v�iLl.$,
p��r��, v�ei��
! R�t�B�, G'l�k
��'l� R.N.
�!�l����+�� R.N.
i
� February 3,2005 ruce G.Murphy,MP .,CHO
� Director of Health
i
; + _ :_ G�II�`� �2�
L� CC� C� � ML� D
i f_ A
i �° ; R� TOWN OF YARMOUTH BOARD �.�i�.TH NOV�g 202oa�w�
� -'` APPLICATION FOR LICENS �T`-2004 3
' Y:•.. ..�'? -* � �',, . F HEALTH DEPT.
* Please complete form and attach all neces � o��i'nts by December , .
Failure to do so will result in the retu '� your application packet.
� I a � �
I T N �
� _ f�
? N ,� � � �S ./ �'�
i
" A ER' NAM • T -�
AD S • -Z- �. i
' POOL CERTIFICATION •
� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
� Poot Qper�r(s�ac�d�t'��'n a�op�T of�he;eertificat�on �o tt��s fcrnt. - --
j 1• 2.
' Pool operators must list a minimum of two em lo ees currentl certified in basic water safe
p Y Y ty, 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.
1. 2,
' 3• 4.
i
�
i
IFOOD PROTECTION MANA R - 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, 1 OS 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.
l. 2.
_—-_PE�S�7N IN"i;FiAl��'rE:— -- - - --- - - _ —_ --- __ _ __---_
Each food establishment must have at least one Person In Charge (PIC)on site during hours of aperation.
l. 2,
�
, HEIMLICH CERTIFICATION •
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1• 2.
3. 4,
RFSTAURAstT SEATIN T: TOTAL#
�.ODGING:
OFFICE US� ONLY
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _C;�iN $SC ,_M(3�'EL $50
_I1�11�1 $50 _CAMP $50 _SWIMMING POOL$75ea.
_LODGE $50 _TRAILER PARK a50 _WHIRLPOOL a75ea
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE RE(�UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT S25
>100 SEATS �150 _COMMON VICT. $50 _WHOLESALE S'75
RFTAIL.SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU►RED FEE PERMIT#
,_<50 sq.ft. S45 __ _>25,000 sq.ft. $200 _VENDING-FOOD $20
�<25,000 sq.ft. S75 _��—� _„FROTEN DGSSE;RT S35 VTOBACGO �25
IYAME CHAN F• $io AMOUNT DUE _ $ ?5•00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*•*
ADMINISTRATION .
Under Chapter 152, Section 25C, Subsection 6,the Tovm 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 Insuranee. THE ATTACHED STATE WORKER'S COMPENSATI(�N INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
QB
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
�
Town of Yarmouth ta�ces and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK ;
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-]0 '
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 TE5TING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening,and quarterly thereafter. �
i
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of t
closing. �
�
�
FOOD SERVICE
CONSUMER AI)VISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING P(?�,,ICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
requxred Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be
obta.med at the Health Department.
�
FR(JZ�IY_DF.S�F�'�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 CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
O�j'�DOOR �OOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited.
;, �
DATE: �� � SIGNATU .
PRINT NAME& TIT �: / � ^
10/22/03
= _ �
The Conrmonwealth of Massachusetts
� � Department ojlndustrial.-1 ccidents
� a Of11C0o1/atestlOfllils
= ; 600 Washington Slreet.
' ` $�ston,Mass. �02111
_' ,, ;,.` _.
V1�'orkers' Compensation tnsurance Affidavit -
A,Rnlicant information: ples�epRIRTTi•er,"�
nam�/"/�,������fifXJf�.f/��/��f y//l/�/�
_ �
Ls�cati�n: 'l% ,i��./��`�� �'� �
! , � �I �
� I am a homecw�ner pertorming all w�ork my eif.
� I m a sole proprieror�r.,a, h��e no one��orkin_ in am•capacin•
� I am an em�lo�Terpro��din�w�Qrkers' compensation for mti��mplo���es w•orking an this jsab. _
s�snnam• name• /.� /�/7 3 ✓` �°/`C�l�a''.1����[�'�(',�.�' .� / ��lj��� �6sd�`� (�!r(F�'4,�U
ddress: � � �'
M.
insur�nce co. �C�,�/%����� �!!Sv#
� I am a sole proprieror, general contractor, or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the foll�t�in� ��orkzr� ,ompensation potic�s:
comoanv n�me•
address•
citv• ehone k•
insurancc co. nolic�•!!
t4mnanv namr
id.dresl:
SLtY: nboec N•
insurance co. ��ex*
t
Faiture to seeure coven;e as required uoder Secnon 25A of MGL 1S2 ea�kad to tAe ioporidoa oterivi�al peaaltlp of a 6�e op to 51,500.00 a�d/o�
one yean'imprisonment is w•ell a�eiril pendNe�io tAe form of a STOP WORK ORDER aad a Bse of SI00.00 a day apio�t ma I a�denla�d that a
copy ot thi�statement mav be forwarded to tfie Ofliee of Inve�tig�tioo�of the DU tor eoven;e veritiado�.
I do hrreby cenify�un he poins and p�na 'es ojperjury that the injornwtion proveded above is trtrt and orrtet
�''
Signature ate , �
1
Print name � � 9 one� ` ` � `'
.- olTicial use only do not M rite in this area to be completed by eiry or town oAieial
city or town: Y��IIT$ _ permitAicenu a nBuiidiog Department
�Lieeosioe Board
❑cheek i�immediate respoest i�required 261 �Seiectmen'e Otliee
�Heaith Depanment
contact person: phoneM;_ �508� 398�?231 ext. nOthcr
,.. .�. �.,,;
1
G • 1�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-020 FEE: ?5.00
�
� In accordance with re sUons promulgated under suthority of Chapter 94,Section 305A and Chapter
! 111,Section 5 of the a1 Laws,a peimit is hereby granted to:
i
j Cape Tradewinds Gifts Inc., 852 Route 28, South Yarmouth, MA
i
� Whose place of business is: Cape Tradewinds Gifts
� Type of business: Retail Food Service less than 25,000 square feet
; To operate a food establishment in: Town of Yarmouth
e
i Pernut e�ires: December 31,2004 Bo,4xD oF HEAI.TH: Bs.r�xi�a$. C''°'rdorr� �l.$. '
� A�/1�1c.b` e�iro�, '�/Ice G��r.�c
1 xEs�ucTToxs: Ta�'y and fudge only. Ro�� B�iocwi, �
, _ _ _-- __ . ��Sl� R.N. __---
__ -- . _
k
i
December 5.2003 ruce G.Murphy,MPH, .,C
Director of Health
�
�
� ,
� � . � Q , ��R j��
a�'!�,� TOWN OF YARMOUTH BOARD�F���ALT'�I �' � � �
j � z., .
=�� APPLICATION FOR LICEN I��003 �Q �}
Y • „� `� �J�� �.(QSb iti�� L .�r f i E' ?.
r •. ��.., . �45.�,e_ s
* Please complete form and attach all necess "` -cu�nts by�Dec� ��1���2, ,.�,--�-
$ Failure to do so will result in the return o our application pa . ---�--
{
NAME OF EST,A�LISHMENT: C:qPE ?12A��FWiN►�S C�n� �N C. TEL. # �S-39Y Q300
LOCATION ADDRFSS: 3�2 2r� Zs� , S Y o'L66�1
MAILING ADDRESS: �
OWNE CORPOR.ATION NAME:
MANAGER'S NAME: TEL. #
MAILING ADDRESS:
POOL CERT�'ICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
___F�ool(3perator�s�an��ac a copy ��ertificaCion ta this form. _ _ -- -- _ .
; 1. 2.
I
i Poal 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 m�intain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to ha.ve at least one full-time em�loyee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
�
1. 2.
_ PFRS(11�T i1�T-G���= _ _
Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation.
i 1. 2.
i
�i�IMLICH 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 anri-chokuig procedures below and
attach copies of employee certifications to this form. The He�lth 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 SE,.�TING: 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 $SO _SWIl��MING POOL$SOea.
_LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL $30 TNON-PROFIT $25
>100 SEATS $I50 _COMMON VICT. $50 _WHOLESALE $75
RETALi S�, VR ICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMJT#
,_TOBACCO $20 �CL5,000 sq.ft. $75 � ��7 �TOBACCO $20
<50 sq.ft. $45 , _>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $10 AMOiJNT DUE _ � 'T5.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION j
4
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ;
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces 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
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002.
SEASONAL ESTABLIS��IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter. '
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal pxoducts are required to post
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS: �
F�rozen dessert�e tested on a montTiIy basis by a�tate certified Iab.-e resu ts must be sent to�e Healt�h `
Department. Failure to do so will result in the suspension or revocation of your Frozen D�ssert 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.
/ i
DATE: �/ _ SIGNATURE: / , , ' ��"
PR1NT NAME&TITLE: �
10/18/02
r
.. ' . • � . - ..
The Conrmonwealth of Massac/rusetts
� � Department ojlndustrial.-�ccidents
� ; Omceoll�st/�s�liis
; 600 Washington Streel
�, �,: Boston.Mass. 02111 '
" '"� W'orkers' Compensation Insurance Affidavit '
ARnlicant intormation: PleasePR[1�TTe�'I�tc
� � �
m• �' -�
�on: ��� c.�
r �� � � � y!�/ i
� I am a homecwner pert�rmin�all wo myseif.
� I am a sole proprizror �r.� ha�e no one��orkine in anv capacin�
_ �-an�r�n . _ . • eompertsatiorr for m��empi�yees w-orking ocrthis job. _ _ _
company name• //��� .��1'�///,N/ �/�����// / � !�/'-� �./
ddres : �
� �, - �
i ranc � � � i # (� J
l�/ Ci
� I am a sole pro ri to�gene�i n adtdr.�homeowner(circle one) and hace hired the contractors listed below �tiho ha�e
the follut�in� ��orker_ �ompensation polices:
sompanv name•
�ddress• --
��" nhone q•
insur�ncc co policy#
somg�nv name•
-- _— -- ------ — -- _ _ ---
:�drc«•
sjri. ohoee M•
insur�ase o ootiev�t
_ .
Failure to secure coverage as required under Secnoo 2SA of MCL 1S2 es�iad to tbe i�paidoa o(eriviad pe�aitle�of a O�e op to 51�00.00 a�d/o�
ooe yean'imprisonment a�w•ell as eiril penaldee io the[orm ot a STOP WORK ORDER aad a liae o�S100.00 a day apinst me. I a�denta�d t6at a
copy of thh statement mav bc fonvarded to the ORce of inve�tig�dom of t6e DIA for eoven`e veriftado�.
I do hrreby cerrij}•u er the pains n tna!lits ojptrjury that tht injorntatioa provided abovt Ls dtte d co d
Signaturc � ��
Print name � one 1� / ��/�� � ,
., oRcial use anlv do not..rite in this area to be completed by eiry or town olfleial
citv or town• YA��IIT� _ permitAieenu N I�Buildiog Departmeot
• — �Lieeasiog Board
�cheek if immediate response is required 261 QSelectmen's Offiee
�Health Department
contact person: phone M;_ �508� 398�2231 e7[t. nOther
.. . -< ,,,.
_�
i i
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
9 PERNIIT NUMBER: #03-017 FEE: $75.00
� �
� In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter
3 I 11,Section 5 of the�'ieneral Laws,a permit is hereby granted to:
�
i Cape Tradewinds Gifts Inc., 852 Route 28, South Yazmouth, MA
Whose pla.ce of business is: Cape Tradewinds Gifts Inc.
Type of business: Retail Food Service less than 25 000 s,�uare feet �
To operate a food establishment in: Town of Yarnaouth
� Permit expires: December 31, 2003 Bo�xD oF xE.4L,Tx: ��� �ilP�tk�, �a�,ra�ca�c
� --------- -_ _
� D:- - �1L:D.. `f/ice .
e��a"rt�c -
� RESTRICTIONS IF ANY: Taflj+and fudge only. ° �a�0'd j1• $��toa�c, �
� �a�rle,�?1le'Dos.xott
� '��c Skak. �?Z.
�
December 17 ,2002 ce G.Murp y,MP , .,CHO
Director of Health
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� The Commoawealth of Mossachusetts
� � Department ojlndustrial.-lccidents
" o Of1ICQ01/OYCSII�f�I/f
: 600 Washington Street
' ` Boston.Mass. 02111
w,, ,�.�'
W'orkers'tompensation Insurance Affidavit
n m• � � �
a o :
� # �C���
_ � I a o eow er e �u ing al wor mys If.
� I am a sole proprieror �-� ha�e no one��orkin_ in an��capacit�•
�am an emplo�er pro��din�w�orke s' compensation for my empio��ees w•orking on this job.
-
a � n a : �� � __ --__ . _ _ !/��� T � LC i'
ddress• J � ���/'
��
t�• �
in�urance ca oolicy# � D �! a'—�� ��
� I am a sole proprietor. :eneral contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
thz follur�in_ ��orkzr_ �ompensation polices:
s4m�anv name•
address•
cttv• phons M.
insurancc co. Rolicy#
s4mnanv name•
- -- _ _ __—_ —__ ---- -
--- - ___ _ _
addrcss•_
sitV: t�oes�•
insurance co. ���*
a
Failure to secure covenge as requ�red uoder Secnoo 25A of MGL 152 ta�Iqd to the fopaidoa oterisi�d pesdtlaaf a dae'op to 51.500.00 a�d/or
one years'imprisonment a�w�ell a�civil penalties io the form of a STOP WORK ORDER aod a liee of 5100.00 a dar a��iost ma I a�dersn�d tbat a
copy of thH statement mav be fonv�rded to the OlTice of(nvatiguiom of the DIA for eoven`e verifiatio�.
1 do hrreby cenif}• d �poi ond pe �' jperjury that�l�t injoinration providtd obovt is tttte ond e ned
Signaturc � /` �
Print name � one ll � -
.- o(Ticial use only do not M�ite in this area ro be completedby eiry or towa oflleial
city or town: YARM�IITQ _ permitAieenae p nBuilding Departmeot
�Lieeasiog Board
0 check if immediate response i�required 261 �Selectmen'�Otiice
�Health Departmeet
con�ace person: phone K:_ �508) 398--2231 eat. nOther
�
' � -
I "
TOWN OF YARMOUTH
� BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
� PERMIT NUMBER: #02-018 FEE: $75.00
i
� In accordance with regulationspromulgated under authority of Chapter 94,Section 305A and
� Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
� C:aY,r�e Trar_lewinds, 852 Main Street��Lte 28, 40 � h Y rmo� h, MA
� -
� Whose place of business is: Cape Tradewinds
Type of business: Retail Food Service less than 25 000 sc�are feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31,2002 BOARD OF HEALTH: ���f. ZePki&�. (�s�ca�c
�.,cla�ci.a D. G��mtdou, �?�.. `Uice
�STx�C'rtolvs 1F.�wY: Taffy and fudge only. ,�o�ie7t� b�'aouaic, �,lerk
�a�tiek�e�cat�
`s�e�c$kak, ,�:.72.
Mazch 22 _2002 Bruce G.Murphy, .S.,CHO
Cc�� -7r�levv i ra�L�, �
. , G3CC.� �� � � �� D �
� 'ry TOWN OF YARMOUTH BOARI�flF�EALTH �, j
,; APPLICATION FOR LIC�I����Itl1(I�T'-200 ��/ D E C 2 3 1999 �
�� t ,FA ��1. PT �
* Pl�ase complete form and attach all necessary documents by December 31, 1999. Failure to•t�o��- !
the return of your application packet. i
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�'OOL CERTIFICATIONS� '
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the j
designated Pool Operator(s) and attach a copy of the certification to tlus form. j
1. 2. '
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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. l'he Heatth Department will not use past years' records. You must provide
new copies and maintain a file at your place of business.
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3. 4. �
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HFIlViLICT-�GERTIFICATI�NS.
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 your place of business.
1. 2•
3. 4•
RESTAUItANT SEATIl�IG:—TOTAL#-- -___ N4N-SA�I4KIATG SEATS: TO'��.# - — - ;
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�?FFICE iJSE ONL.Y
i OD ING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT #
B&B $50 _CABiN $50
� �50 _CAMP $50
LODGE $50 �TRAILER PARK $50
MOTEL $50 _SVV:[QVIMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FBE PERMIT#
; �0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
�
COMMON VICT. $50 __ WHOLESALE $75
�tFTAIL SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� <50 sq.ft. $45 _TOBACCO $20
1 <25,000 sq.ft. $75 'yZrC' FROZEN DESSERT $35
>25,000 sq.ft. $240
� �[AME CHANGE• $10 �
AMOUNT DUE = S ��—'
PLEASE TiJRN dVER AND COMPLETE OTAER SIDE OF FORM'""`"`
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ADMINISTRATION
YJNDER CHAPTER 152, SECTION 25C, SUBSECTTON 6, T'HE TOWN OF YARMOUTH IS NOW R�QUIRED
TO,HOLD IS$LIANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
`PERSUl�T OR COMPANY DOES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSA'�ION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTAC�D
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WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUA.RY 1 TO DECEMBER 31. IT IS YOUR
' RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASO1�tAL ESTABLISHMEN'TS ARE TO CONTACT THE HEALTI3 DEFARTIVGENT FOR INSPECTION 7-10
DAYS PRIOR TQ OPENING FOR THE SEASON.
' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR FOOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE ttEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH pRIOR TO
CONIl��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL FG ATIONS
PUOLS
POOL OPENING: ALL SV'VIlVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSFECTED BY TI-�HEALTH DEPARTMENT, AND THE WATER TESTED FOR
PSEUDOMONAS, TO�'AL C�LIFORM AND-STANDARD PLATE COUNT BY A STATE�::ERTIFIED LAB,
PRIOR TO OPENII�tG, AND QUARTERLY TI-�REAFTER.
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POOL CLOSING: EVERY OUTD�OR IN GRUUND SVVIlVINmVG POOL MUST BE DRAINED OR COVERED '
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE '
�ATE TN('7 POT i('y•
ANYONE WHO CATERS WITHIN TF-iE TOWN OF YARMOLJTH MUST NO'TIF'Y TI�YARMOUTH HEAL,TH
DEPARTMENT BY FILING THE REQUIRED 'T'EMpORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT THE HEALTH
DEPARTMENT.
FROZEN�E SERT�•
FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEpp�RTMENT_ FAIL,URE TO Dp SO WII,L RESULT IN TI-�
_ SUSPENSIONORREVOCATIONOFYOURFROZENDESSERTPERMITUNTIL'THEAgpVETEg1VISHA�E
---____ __ _
BEEN MBT. -- _ _ ---- - _ _—------- --
4�JJT.�E �F".��
OiJTSIDE CAFES(i,e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE pRIOR
APPROVAL FROM TI-�BOARD OF HEALTH.
OUTDOOR COO�Cs�
OLTTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLIS��VIVIENT IS PROHIBITED.
DATE: SIGNATURE:
PRINT NAME& TITLE:
11/12/99
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� � " ' The Co�nmonweolth of Massachusetts '
� � Depa�tment of Industrial.-�ccidents
�
� ; 01flCe01/eveS�loftlals '
' ' 600 Washington Slreet
� ,.` Boston, Mass. 02111
�'" "• W'orkers' Compensation Insurance Atfidavit .
gRnlicant informallon: P►easeYRil'�TTe�+'iJtc
n;mr�
-��li� � ��/,d�dt�0-s ���-S �,�� '
n� F� V I
� � � e a - � i� vV '
� f am a h meoµ�ner pert�rmin;all w�or myself. '
� I am a sole proprieror �r.,'. ha�e no one ��orkin= in am•capaciry
�am an emplo�er pro��din� w�orkers' compensation for my employees w•orking on this job.
comP�n_}� name' b"'^�LL�������Vll�fl!/.J ,���� / �(/ ��' �
ddress• � v�
� s � _ � �Gi�� � � �L/ C�J
iosur�nce co �olicy t�
� I am a sole proprietor. generai contractor, or homeowner(circle onel and ha��e hired the contractors listed beloH ��ho ha�e
the follu��in_ ��orker.� .ompensation polices:
vn
�ddress
� Rhone M• -
insur�ncc co polic�# -
m n m : ____
�a�res•-
� � � ���
e
Failure to secure coverage as required under Sec�ou ZSA o(MGL 1S2 ea�Ind to tbe iepaidoa ot erioiad peeaitles of a O�e op to Sl¢00.00 a�d/o�
one yean'imprisonment as w•ell a�eivil penaltie�in thc form oi a STOP WORK ORDER aad�tiae of 5100.00 t d�r K�iost sa I a�denta�d tbat a
copy of thh statement m�v be fonwrded to the ORce of lnvcstig�tiom of t6e DIA tor eovera`e veritiqtio�.
1 do hrreby cerrij}• er rh pains a lties ojpery'ury that/ht injorneation provid�d abovt is tnie aitd correct
�" � /
Signaturc �
Print name�i��c.r��� � ���� Phone N �.�,�� �����
., o(Ticial use only do not w�ite in this area to be compieted by ciry or towa olfieial
j city or town: y�MOIITQ _ permitAiceou N n8uildiog Dcpartment
� — �Lieeasiog Board
� �cheek if immediate response i�rcquired 261 ❑Sdectmen'�Otiice
� QHeaItA DepaRment
hone�;_ �508) 398-2231 eat. nOeher
contact person: P -- —
. .. .�. < ,�„
TOWN OF YARMOUTH
� BOARD OF HEALTH
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PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-36 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
I 11,Section 5 of the General Laws,a permit is hereby granted to:
Cane Tradewinds ("rifts inc_, 852 Main Street, South Yarm�uth, MA
Whose place of business is: Ca�e Tradewinds Gifts
Type of business: Retail Food Service less than 25,000 s�uare feet '
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:��f. �el��, C'�irman
�oan� �ulliva�, �//., Vice t�hairma
RESTRICT[otvs �F,�NY: Taffy and fudge only. /�o�art� �rocury C�er�
a�rielle�a�oG�h�-.J�oo�ve�
' ��O�o��
lanua,�r� 14 ,2000 Bruce G.Murphy, , R.S., CHO
Director of Health
�•�� �.•v�.��•�. �� ���"�« �� ��� ������ ��ua�. pannersn�p, association, corporation or other legal entiry, or any two or more c
tl�e fore�,�oin_ en�_a`_ed in a joint enterprise, and includin�the legal representatives of a deceased employer, or the
recei�er or trustee of an indi�idual . partnership, association or other legal entiry, employing emplo��ees. Ho��ever the
u��ner of a d��ellin�= liouse ha�in� not more than three apartments and who resides therein, or the occupant of the
d��ell;n� house �f anotl�er�t�ho emplo��s persons to do maintenance , construction or repair woric on such dwellin¢ hous�
.�r ��n chz �_r��un�i; �r buildin�_ appurtznant thereto shall not because uf such emplo}�ment be deemed to be an emplo�er.
`1Gi_ �lia�ter I�= ;ecti��n :� als�� states tliat e��en� state or local licensing agene�• shall ��ithhold the issuance or
rene���al of a license or permit to operate a business or to construct buiidings in the commonN•ealth for am•
:�i��licant «�ho has not �roduced acceptabie e�•idence of compiiance with the insurance coverage required.
.�ddi�i��nall�, neither the common��ealth nor an�• of its political subdivisions shall enter into am•contract for the
performance of public ��ork until acceptable evidence ofcompliance �vith the insurance requirements ofthis chapter ha�
hren presented to the contractin_ �uthorit�.
.�ppii�..nts
Please fill in the workers' compensation affida�•it completely, by checking the box that applies to}•our situation and
suppi�in�_ compan} names. address and phone numbers as ail affidavits ma�• be submitted to the Department of
Industrial Accidents for contirmation uf insurance coverage. Also be sure to sign and date t6e aftida�i� The
aftida�it sl�ould be returned to the cit�• or town that the application for the permit or license is being rcquested.
not the Department of lndustrial .�ccidents. Should vou ha�•e am•questions regardin¢the "1aw"or if you are requi�•ed
to obtain a ��orkers' compensation polic��, please call the Department at the number iisted btlow.
City or Towas � -
Please be sure that the affidavit is compiete and printed legibly. The Department has provided a space at the bottom of
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