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Home My WebLink AboutApplications, WC and Licenses1 i � � �� *` ,,-� � � r�� 9 . / � r TOWN OF YARMOUTH BOARD OF HEALTH` �, � � APPLICATION FOR LICENSE/PE ��O�r" .:��QV 2 � 2008 �`,. `,;: V- ; �-� _ * P�� .::� � Please complete form and attach all necessary d�.ct�Y�ie�:�Di`ece �� Failure to do so will result in the return of�,ir apphcation pac et. � NAME OF ESTABLISHMENT: � � cAit. f- �` d�- _.L,�t c- � TEL. #37�-� -�1� LOCATION ADDRESS: �z�n l.�v' �4 � MAILING ADDRESS: ..L'�t�n� c� ��vv�-� i OWNER NAME: �Z�I,Q.<�'�`G� Ct-Y'c2� e � TAX ID (FEIN or SSN�: , � CORFORATION NAME (IF APPLICABLE): [��i�-� � � � �-� _ tl�Q--- MANAGER'S NAME: /�'l�l.� /YLQ.. G z� TEL. #S�l ��S!-f�2� MAILING ADDRESS:_�-��_ G� ��P!�-c_� POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this farm. � 1 2. _ Pool operators must list a minimum of two employees cui7 ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach capies of employee certifications to this form. The Health Department �vill not use past years' records. Yau must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishrnents are required to have at least one full-tune 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 Iiealth Department will nat use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2, PERSON IN CHARGE: _ _ . _ --- _ Eacli food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: ; All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich , Maneuver on the premises at all times. Please list yow employees trained in anti-chokmg procedures below and � attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � � l. 2. � 3. 4. � RESTAURANT SEATING: TOTAL # i OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 CABIN �55 MOTEL �55 _Rv'Iv S55 _CAMP S5� _SVJIMMINGPOOL �80ea. � _LODGE S55 ,TRAILERPARK �105 _WHIRLFOOL $80ea. __ _ _ _ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS �85 _COrfT1NENTAL �35 NON-PROFIT �30 _>1Q0 SEATS �160 iCOMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN �80 j LICENSE REQUIRED FEE PER�YIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<�0 sq.Y�. $50 _>25,000 sq.ft. $225 VENDING-FOOD �25 � �<ZS,OOOsq.ft. $80 �6�_ DZ,� _FROZENDESSERT �40 �TOBACCO �55 �b�-p/s' I `A�zE c�r��GE: �l o AMOUNT DUE _ $ /3 5. OD *****PLEASE TURi\OVER AND CO'VIPLETE OTHER SIDE OF FORM**•** e n, � � + ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Comp��sation 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 Yazrnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy sha11 be , limited to the temporary and short term occupancy, ordinarily and customarily associated with rnotel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. ; Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggre�ate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,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(5�days pnor to opening.PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool rnust be dra.ined or covered within seven(?)days of ', closing. ' - _ —_— ---- -- -__--- _: FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed 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 wa:iter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MCTST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. '; DATE: /rl� �O �SIGNATURE: � � PRINT NAME&TITLE: .t.v � l/l-��L..�, c'� T �.�I 7,e'ii� ��C��cf'" � ' �'��-�"�-� ��--__. io,�ziros ACORD DA�(M�D„-,�,,,�, --,M. CERTIFICATE OF LIABILITY INSURANCE ,,,�8 PRODUCER Ffime:(617)458-78W Fau: (61�456�St5 THI$ CERTIFICA7E IS 18$UED AS A MA7TER OF INFORMATION ' AS$OCIdT10N BENEFITS INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICA7E 529 MAIN STREET,SUITE 606 NOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND at THE SCHRAFFT CENTER BOSTON MA 02129 INSURERS AFFORDING COVERAGE Np�C# t�:nez�o� ! INSURED INSURER A: PBnn Mi11eB Mutual a CAPE WINE 8.LIQUOR,INC INSURER B: 443 STATION AVENUE INSURER C: INSURER D: SOUTH YARMOUTH MA 02664- �NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BQOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NO7VVlT1iSTpNDiNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR � MAY PERTAtN,THE�NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCLUSIONS AND CONDITtONS OF SUCH . POLICIES.AGGREGATE LIMI7S SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. titt i TYPE OF INSURANCE POLICY NUM6FR roucr�c►� roucv owus�nox uM� � 7E d� ��'��' PGC3017482-03 02/13/08 02/13/09 s 1 000 00 � �� X CAMMERCIAL(3ENERAL LIABI P��eses a�cnranw $ • $U 000 � CWMSMADE ��(jCCUR . ... . . .._.. __.. --� ---- ��---- - .-._____ .. .9CPf/�y'-ene9erson) - .. . .e� . ' A �RsoruLL a noV I►�uURY E 1,000,000 . c�riersn�nc�Recn� S 2,000,000 GEN'L AGGRE(iATE LI aAPPUES PER: PRODUCTSCOMP/OP AGG. S 2,000,000 X POLICY LOC � AUTOMOBILE LJABILRY . COMBINED SINGLE LIMR ANY AtlTO (��) E ALL OWNED AUTOS BODILY INJURY � SCHEDULED AUTOS �� $ HIRED AUTOS BODILY INJURY NON-0WNED AUT� �p�� $ 1 aROPeRn nnaacE S (��) cnw►c�w►eam S ar�v nuro orHeRn�uw EAA s AUTO ONLY: . D(CESSlUMBRELLAW461LRY EACHOCCURRENCE f OCCUR �CLAIMS MADE AGGREGATE $ � S . DEDUCTIBLE $ REfENT10N$ YYORI�RRS COMPENSATION AND A � O7HEft EMPLOYERS'IJABILRY TORY UMITS un p�iqop�ar�cur� E.L.EACH P�CCIDENT y �IXCW�� E.L.DISEASE-EA EMPLOYEE E M ye+.desa�be w�aw ��W'��$ba1oir E.L.DISEASE-POLICY UMR $ onie�: DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EICCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PRONISIONS YARMOU7'H HEALTH DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLIGES BE CANCELLED BEFORE THE 7146 RTE 28 SOUTH YARMOUTH ��T�N DATE THEREOF,THE ISSl11NG INSURER WMl ENDEAVOR TO MAIL 10 DAYS WRfTTEN NOTICE TO THE CERTIFICATE HO�pER NAMED TO THE LEFT,BUT FAILURE TO YARMOUTH,MA 02664 �O SO SHALL�MPOSE NO OBUGqTIp►i pR L�qg��ITy�ANY qND UPON THE INSURER,ITS AC,ENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE Attention: CapeWineandLiquo�Comcastnet,pTTN;Maria Frank Venuto ACORD 25(2001/08) Certificate# 523 OO ACORD CORPORATION 1988 . . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT ; 3 ' PERMIT NLTMBER: #09-021 FEE: S80.OQ � 1 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l, Section 5 of the General Laws,a permit is hereby graiited to: jCape Wine & Liquor, Inc., 443 Station Avenue, South Yarmouth, MA I i Whose place of business is: Cane Wine & Liquor, Inc. � Type of business: Retail Food Service less than 25,000 square feet 1 ' To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .i�E¢�¢�t S�, J2..IY., C.ffa.victturn C`hEax�ea .�. 3'Ce�i�ex `t�ice C'lEavrneac�z J`2aB�rt 3. J`3�u+.cun, e� , ��'c�r�:f2..N. , December 16.2008 Bruce .Murphy, H .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #09-015 FEE: S55.00 T11is is to Certif��t11at Ca.ne Wine& Liq�,Inc 443 tation Aven�e, Soi�th Y rmoLth� 11�A IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBA O PROD TS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. Thi�s.�ern�is gr�nte�i�n��a�ornuiv��ith Article VI df�►e Sanit�rv Code of The Common��ealth of Massachusetts,and ex i es ece'hi er S unless sooner suspen e or re��o �d. December 16.2008 BOARD OF HEALTH: .`1�Ctt .5�� ✓�..lv.� �qtUlttfitlft ��4 `.�. .`�E�IIG �[CC �A6111fttllYit J�c�dE�ct s. J`3acc�w�t, C''.�e�cf� � ��, ✓2..�v. � �- ruce . Murp y, , , Director of Health I � ° ' � C.�4PE �1�N�t L/t�1uc>>2. Jt.Y�k TOWN OF YARMOUTH BOARD OF HEALTH � �� APPLICATION FOR LICENSE/PERMIT-��0�� '� �- { '�'? �� ;;�� ^��;j �. �. � ls - * Please complete form and attach atl necessary document��y December 31, 2007. Failure to do so wili result in the return of your apphcaxion packet. --� �- NAME OF ESTABLISHMENT: �`�j1e�k,e f ,Gc `�d2--- Z1? c_..• TEL. #��`�9y l/Zz 5� LOCATION ADDRESS: �4�3 J'�u.,fi�►-� ��c-.. <�. �fa�n�-�� /Zi.9 o Z(o�c,� MAILiNG ADDRESS: -S`�e �� h w-c- ' OWN�R NAM�:_ TAX ID (F�IN or SSN)- CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: �a ra f � TEL. # l� � �y�`{ MAILING ADDRESS: � ,� POOL CERTIFICATIQNS: The poot supervisor must be c ified as a Pool O tor,as required by State law. Please list the designated Pool Operator(s) and attac a c y the certifi on to this form. 1. 2. Pool operators m st li ' ' of two employees currently certified in basic water safety,standard First Aid and Community Car opu onary esuscitation(CPR). Please list these employees below and attach copies ofemployee eertifications to 's form. T e �ealth Departtnent will not use past yea�s' reeords. Yoa mt�s� provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one fiill-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 certification to this application. Tt�e Health Departme�t wiH not nse past years'records. You must provide new copies and maintain a file at your establishment. I. 2. _PERS9N_IN��E:_ � . __ _ -- _ _ -_ _ __ - _ _ _-- --- -_ Each food establishme t st at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIMLICH CERTIFIC TIONS: 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�mployee certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE Ol�LY LQDGING: LICENSE REQUIRED FEE PER'bilT# LICENSE REQUIRED FEE PER'4IIT* LICENSE REQL'IRED FEE PER'�IIT� BBcB S50 CABIN S50 MOTEL S50 INN S50 CA141P S50 SV�'IVLViING POOL S75ea. LODGE $SO 7'RAILERPARK S100 V4�IIRLPOOL S75ea. FOOD 5ERVICE: LICET*iSE 1tEQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PER'�41T tt LICENSE REQtiIR£D FEE PERViIT= _0-100 SEATS S75 lCONTINENTAL S30 NON-PROFIT S35 >100 SEATS S150 CO�rIl410N VIC S50 w�-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER�IIT� LICE:�'SE REQL'IRED FEE PER'4fIT� _<50 sq.ft. �45 T>35,000 sq.n. 5200 _VENDIlvG-FOOD S20 / <25,000 sq.ft. 575 �� 6 _FROZEN DESSERT S3� /TOBACCO S50 0�—QQy NA��CHANGE: sio AMOUNT DUE _ $ �2-'`"v-00 *****PLEASE TL'R\O�'ER A\D C0�IPLETE OTIiER SIDE OF FOR�Z****�* � ` , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPRQPRIATELY 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 us�: Transient accupants must have and be able to demonstrate that they maintain a principal pla,ce ofresidence elsewhene. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)manth 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:AII swimming,wading and whirlpools which have been closed for the season must be ins ed by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys ' pnor to operung. POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarter�y thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health DepartmeYrt by filin�the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed 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 urrtil 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 ofH�. OUTDOOR COOKING: __flutdoareoaking;prepaz�tio8,-ortlisplay-of a�y faod�rvdus��y a retai�flr food sefvic�es�ablis�ment i�pre6ibited. _ NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RE�VOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: ' io:u o� i � : , , . , ; � � �he Commonwealth of Massachusetts ' Departneent of Industrial Accidents ; MAfri�f�w�1M�s � 60D R'ashington Street, 7`�'Floor � Boston,Mass. 02111 � Workers'Compesaatioa I�m�aoee Affidavit:B�ilding/Pl�mbieg/EIeM�rical Coetractors � • l�Sre PRIIVT le�d�lr r �• (',/�-I�� lit/��t/� S �.��J d T�� aadress_ �`�'2 S�'n 0 iV �' ! � �' "L1�2 �/l�l te_ - : O�� `� -Q� � � work site location(full addressl: ' � ❑ I am a homeowner performing all work myself. Project Type: ❑New Caristructian�Remodei � ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition �I am an employer pmvidu►g w�kers'compensation far my employces worlcing on this job. � wmwav�e:---��C.� �f t�� - "� �-.�F-��t�E}�"_-�/-�-C_ �__ _ __� __--- -- -- ----- aaaress- 7 �� _�/I�"�1'�N ..�1/�.� / ; �: � � �l A-rc,.vr.t Gr.c �-vt. r/Lt y�- ��: �'c� �-� y �--aaJ-� � � ° d� . �3� 1: �� 0 c�v� .rv 3� 7 s��-io � � ; r- � ;�� ; ;�: ,�.: � �� - .�, �.��r�.rt.� ., F. j �❑ I am a sole pro�ri ��r,g eoatnctor,or �� waer(� owe and have hired the cornractors listed below who bave� � t]�following workers'compensation polices: I , � ��m.�...x- .aaress: : c[tv o�otC#- co. # _ ., . - •> °< _�� _�. � �t+�e: �: � sitp: o�a�c�- ----- ---- --_ _-- --— -- _. _ _._ _ —--- ----—__ _ # s � � � ` �Sll�llwlwuill!� ; � � � � _ ,..� ,' � .. �,-_ „ :; Faitre os aecm+e erven�e a�reqi�+ed�ader Sectloa ZSA�f MGL 1S2 aa Ind b tYe irp�a e[cri�ial pe�aNies�f a�se�b t1,SN.Nyaad/or; one ynn'impti�ment as we8 as dv�pealtles in t!e forat ot a 3T01'WORK ORDER aad a Ane sf s199.YA�1 day a�ainst me. 1 a�dershud tlut a cepy ef tY��a�my 6e finvardcd to tee ORke ef lw�of t�e DIA for eavenge veHAntlee. I � /do hti+eby ce►�fjy xnder tbe polre.v and pena of per,�ury tbef d6e infor�waAto�provldad aboae is b�re Rwd oarv+ccG � s�� c � n l`—/.�—C� �' � Print name ��/i�� lJ hone# ��( ! d O'�`� I , � o�cial ase enFy do not�vr#e is this arei to 6e eompkted 6Y dty er Es�rn afficial i � city or tgwa: � � P�/�oe�e# �B�idinE�P�g� Beard I ❑egeck if i�me�a�e rc�peme is ral� �Sdeetmen's�ffice I costact Person: phese#; �Haltk DeparUveet i,�a sw�moa� �� I � � � � ,I i � � I - � • t CERTIFICATE OF LIABILITY INSURANCE �`��i�� Producer THiS GERTIFICATE IS ISSUED AS A MATTER OF As�ocfatlon Benefks Ins/Agcy Inc INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE i 529 Main St Ste 806 CERTIFICATE HOLOER. THIS CERTIFICATE DOES NOT � Boston,MA 02129-1121 AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY � THE POLICIES BELQW. ' M18URER$AFFORDING COVERAGE NAIC# � ; Insured INSURER A: MA Retail MerchaMs WC Group Inc. � Cape Wine 8 l.iquor,Inc. INSURER B: � 443 Station Ave South Yarmouth,MA 02684 INSURER C: i INSURER D: � � INSURER E: a COVERAQES � 1HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 7b 7HE INSURED NAMED ABOA/E FOR TF�POLJCY pERIOD INDICATED,NClTVNTHSTANDING ANY f�QUIREMENT TEi�1A OR C�ONa710N�ANY CON7RACT OR Orl'FIER DOCUMENT VNTH I�SPECT TO WHICH THIS CERTIRCATE MAY BE ISSUED�R MAY PERT/11N 7HE INSUR/1NCE AFFORDED BY TFIE POUpES DESCRIBEDHEI�iN IS SI�JECTTO ALL lHE TERMS,EXCLUSIONSAND C01�1710NS OF SUCH POLICIES. ACifil�CiATE UMITS SH�N�MAYHAVE BEEN REDUCED BY PAIDCL�. POUCY ADD'L �FECTIVE Q4TE POUCY D�IRATION � rc+sR LiR wsnD TYPE OF INSURANCE POLICY NINiqBHt DATE M! ��'� 6BiHtAL UABIUTY EACH O� s � COMM62qAL 6BJHtAI UABIUTY � FRE�AMAGE(My ane�re) a iCLAIMS MADE O OCCUR M�D D�(MY one Dereon) a �tsoww�..s nav w.arrr g GBJ9tAL f�G(iRECiATE s fi9J'LAfiORE6ATELIMITAPPLIE3PBt PRQDUI.'rS-COMP/OPACiG � PRO- POUCY J�.T LOC AUTOM06q.E WBILITI' COR7&P�31NGLE LIMR ANY MJTO �� s ALL ONM�AUTOS 80qLY INJURY �HEDUL�AllTOS (�P�) S . kMIiED AUTOS BODILY IN,NRY NON-0VNJ�AUfOS (��) s - - PROP�TY DAAAI�E ... - . : . . (aera�idaml � oeut�use w►e�itr auro or�r-en ncaoair a rru�nn nuro orr�x nuw �+� 3 ,�o�Y ,� s , ��.�„� �A� s ; «� ❑ «�� a I a i �� a jREre�rioN s s � a�r�.or�a unaurr X r�oer�uM�rs � ' AOFF�ICBt/MEM�t EXCU�ID�'t�'� EL EACH ACqOBJT $ 7�.� �� o�� N� 014005030752108 1l01/OS 1l01/09 EL.pSEPSE-EA B�LOY� a 100,000 i ELqSEASE-POUCYLIMR a 5�,� OTiER � DES(X2IPTION OF OP9tAT10W3!LOCATtOWB/VB�NCL�!E]�LU810N6 ADO�8Y BJDOR�lT f SPEqAL PROVISIONS CERTIFICATE HOLDER ,�na�iNs�:�r�a�ex��: C CELLATI�1 SHOULD ANY OF TF�ABOVE�S(XiIBED PaIC1E5 BE CANCELLED BEFORE Yartnouth Healtli Departrnerrt nie�xa�RanoNoare n��aF,T1iE ISSIANG INStAiERVNLL E(�EAVOR TO 1146 ROUtB 28 MAiI 35 DAYS WRIT7EN N0710E T�7HE CERTIRCATE HO�DER NAMED SOUth Yem10U1h,MA 02664 TO TF�LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLK�/►710N OR UABILITYOF ANY KII�I�ON THE INRlBtER,ITS ACiEN7S OR REPRESENTATNES. AUTHORIZED REPt�SENTATNE �� - a , � . a i TOWN OF YARMOUTH BOARD OF HEALTH j PERMIT TO.OPERATE A FOOD ESTABLISHMENT I PERMIT NUMBER: #08-005 FEE: $75.00 In accordance with reguiarions promulgated under authority of Chapter 94,Sectian 305A and Chapter 111,Secrion S of the General Laws,a permit is hereby granted to: Cape Wine&Liquor, Inc., 443 Station Avenue, South Yarmouth, MA Whose place af business is: Cape Wine&Liquor, 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, 2008 Bo.vt�oF HE.�LTH: .�eeen SPtaRc, J`�..N., C�avrmara C'�ar�cl'ea .fi�.�'�eP�iRr.e�c `llice C!R�awrtreac�a J`2a1,°r�3.J3�uruvz, C'�eacf� Clrui.C�xeerc�aurn, `J�..IV. November 20_2007 c .Mutphy,MP , .,CHO Director of Health . __ _ . . _ _ _ _ _ _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-004 FEE: $50.00 This is to Certify that Cane Wine&Li�uor,Inc_ 443 Starion Avenue, South Yarr�r outh, ll�L� IS HERESY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This, e t is ted cO�o��y with Article VI o e Sani�r Code of The Commonwealth of Massachusetts,and exp�es�ece�er 3�2008 unl�ss sooner suspen��or revokcd. November 20_2007 BOARD OF HEALTH: .�E�Rtt S�R�� ✓2..1V.� �Yift(Xtt ��d .`�. `.��QlG �CC6 ��,�lll�1[ttL�CtL �r�ct 3.J`3�au�it,�'�ea�P� � Bruce G.Murp y,MP , ., H Director of Health . , :; ��- < _ �,"".�°� r f�Ya ��:R�o TOWN OF YARMOUTH BOARD OF HF�TH /i✓� � F: _;;� APPLICATION FOR LICENSE/PERMIT�2007 �bq` G3 [� c� o � ` -� � * Plea.se complete form and attach all necessary documents by ecember 1, �.Q 1 20 6 ; Failure to do so will result in the return of your application packet NAME OF ESTABLISFIlViENT: �fla'E lrI`,v� � ,�,/�e/L _ TEL. #S�F-�yJ�D 2 2-y LOCATION ADDRESS:____'��3 .S��"« yv `�r MAILING ADDRESS� J'�-�r� A� A�'s✓�' _ � OWNER NAME: ��—��%N� �P�d ! /N�• TAX ID fFEIN or SSN}: CORPORATION NAME (IF APPLICABLE):_C�?'� �iN�� ! L/QudR, /IU`L'- MANAGER'S NAME: /�7AM/a- /1�tf�IZ��4J��°� ' TEL. # 57� � f�ULu/ MAILING ADDRESS: �� .f' v�/ '� �li (./�u2��Fl �t � � r POOL CERTIFICATIONS: The poot supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operatar(s)and attach a copy of_the certification to this form. _ _ l. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitatian(CPR). Please list these employees below and attach copies of employee certifica,tions to this form. The Heatth Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will aot use past years' records. � You must provide new copies and maintain a file at your establishment. , l. 2. ' PE��F-H'�C�ARG�:- --- --_-- ---.—�_� ----_ ---^ _ _�------ ---- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. i { HEIlVII,ICH 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 all times. Please list your employees trained in anti-choking procedures below and ; attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � L 2. 3. 4. RESTAURANT SEATING: TOTAL# 4�FICE USE ONLY LODGING: j LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMI'T# 1 ' B&B $50 CABIN $50 MOT'EL $50 INN $50 CAMP $50 SWIIvIMING POOL$75ea. j - - - LODGE $50 TRAII,ERPARK $100 WHII2LPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTIl�TENTAL $30 NON-PROFIT $25 ' >100 SEATS $I50 COMMON VIC. $50 WHOLESALE S75 RETAQ,5ERVICE: —RESID.KTTCHEN S75 LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � T<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 ? �Q5,000 sq.ft. $75 �7�6( _FROZEN DESSERT $35 � TOBACCO $50 �U 7-0(� NAME CHANGE: $10 AMOUNT DUE _ $ �ZS.O O '*•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•""" R , , ADIVIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth 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 taa�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT QCCUPANCY: For purposes of the limitaxions of Motei or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordina.rily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere. � Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an aggregate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. POOLS POOL OPENING:All swimming,wadin�and whirlpoals which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days pnor to opening. POpL 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 swirnming pool�nust be drained or covered within seven{7}days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOI�NG: � Outdoor_coo_kin�,preparatior�or di�pl��_�f�food pros�u�t by a retail or food senrice_Establishment�prohibitgd.- - ' NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQIJIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: j� ' U � SIGNATURE: � G�v ��(it._ ' PRINT NAME&TITLE: �" /�-�'. 10i17/06 11`fZ8l2Q46 03:19:3�t t�rt �nerz-� L. lUlll.'�VLl—t�Giay = --�-� ----_------- - - - - - py,-�{�apmr? k GER�'IFlCATE C3F LiABtLlTY INSURANCE �l/zsro6 _ � -- — THIS GER7tFICA"fE iS tSSUED AS A MATTER OF Producer k��q-np{t{ph{��(pNQ CON�ERS NO RtG}iTS UPOId THE Associatia�Benefits ins Aycy i� CERTtFiCP+TE NflLi?FR. TNfS CERTlF�C.4TE DC�S t�T � 529 Main St Ste 6os AMEi�ID,EXTEND OR ALTER TNE COVERAGE AFFORDED BY ? Boston,Ma o212s-1121 THE PUL�lES BELOW_ _ �1.4URERS AF�ORDfNG COVERAGE NAlC# �nsurea iNSijRER JL ��UAerc�ards WC G�oup Ir�. Cape Wine&l.�quor,t�. iF{5t1RER B: , -- 443 8tatinn Ave iNSURER C. South Yarmavth,MA 02864 {NSUt2ER D- � 1NSt1R�R E: � C�VERAGES r iHE POLICIES OF tliSURANCE LISiEa SEIOW HAtfE BEEN ISSUED i0 TT�INSt1(�B NM91ED ABOY�K7R THE POL.ICY PEfilC�INCNCAiEO�NOTdYITHSTAFlOING � ANY ftECkJf REMENT TERM Oif CON[M110N t�ANY�ITRACT D0��CT iiD AU.TtiE TERMS,EXCLUStONS RNt3��T10NLS OF`SUCN POLtC'1 ES. } iPER?3liN lNE IFiSURAMCE AFFOROED SY'PF£POLiC1ES DESGRBE .._—....._� � AGGREGATE�TSShKNM'lMAYHAVE�ENREDUGEOBTPAlO{xJV�. � - __._� � Ef�Ti'1t�d7A7E r�QfSGY EW5R1173UN U6qTS . A00'L ii7L3GY� W_TE�Rf--.__. IFLSR L7H PBk� TVP'E C7F Ii�tSiStAtSE FAC1�i CCLIRfi£P10E —J ... ___.___-._ _ � �c�AtI.IAB�Uiv .._ . . _ . . .- - .._._. �ai�0A3.1AGE{Anv«ietxe) S �� CAMMERLIALGEMB2A�Lt1Al8ilf7Y -- _.._�. � h3EISF]W(MYmnPersw�; _$ _.�.._ � � ctA�4vts raAQE (_I ��`� pE�R�w1.a A[At Rta��r $ j � � QcNk3tA1�l(iGRE6RTE s . � € I PR�TS-COMPI4PAGG _ Y ..__— � � �AGCsi�v'ATELIta9TRPPit�S�[t YA�- -. .� PtTLaC! S£Ci .l3G COMBIIfcD SII�LE LIti�T § �;� AUTOff,a&itEllAS"iLiTY..-- C6sec6denB � ��,A.*2Y id.T;`s � 0C`sF�Y FPdJtRt!' � ..:. . � �G!�AL'CCS (�P�t .. �5�:�1.c"}AtFDS f �,'`p�Y!lvJURY $ � - .. :3�A�TLlu (Per�anq - .�3fJ.�Ya�'EG w.tios PftOPERSY UA.4iAGC .. �y�a�1 $ � ....:: - �- % : � AUTO 9t�LY.-EA AGr10FdiT $ ._......---...__ � [ �Ge�.RiiGE 41A8tLtT1� y QTH6tTHAt+I EA A� $ � ANY isi.RO Nl�O QA1.Y A3G $ � EAR+OCGtY3F=._NGE S � � i EXCE5S LfABFIITY . /tGGREGATE $ � � �,� D �a�s� �_. ; $ � ��cn�.c � 3 aEreHrusH s X wc sraru- ont- � etamsens ca�as�r�sanoN a� so[n uwres �_ F�e�Orats CWBaItTr EL EALt!ACGDEt�tT s 100A04 AWY PR6PRScTERl�RTtJERFE��TNE � � il�yesGdescime86ZEfCW6E0? � p1 40 0 50 3 07 52�07 tf4tlft7 1lQtf08 Et. 1�-E!EwRov� .� t00.04� F SF'ECfRLflfiOV15013S6ebw F Eza��-s�o<<cv�i�wr S 500.000 � � �� ' . _-�--- CESCR1PTfON Or flP62AT103�tCCAT1CPt`Y�lCiE'.+1'ElQ-lSS3�5 AU�b SY£NflDRSE1EF-�`li t�Al�tOV79C3l6 � . f � � � � � �! � wa,a�a tEnc� CANCELLATION --) GERTIFICATE HOLDER l�i3�'�� S�{p(�„Q qMl OF Tt�A90VE�SCR�BED POUCIES BE CANCELIED BEWRE � ` YarmouthHe�thDepartment THEEXPIRAi10NUkTETHEREoF.TrfElSSUP1GINSURERWIlLE1�EAY�t74 XP MAE! � DAYS WRITTEN N0�10E TO Tt�CER71FtCATE HOL.dER NAMED � t1�6Ra�te'ZS TO�tEFT.6uTFMlUREle?DUSOS1i�4u-TS��NTS�L��TiONOR : Sat�i11 Yarmouth,MA 02864 t.1A8�l3'il'OF RNrr lat�tlPON tHE 1NSURER. REPRESENTA7!\IE$. i ,�{,lnipRIZEBREPRESENTAtTfHE i � �� y t � II I t ___. F � � 3 � CERTIFICATE OF LIABILITY INSURANCE �A11/07/06 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF Association Benefits Ins Agcy Inc INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 529 Main St Ste 606 r� p CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT Boston,MA 02129-1121 rL3 C�s C� � C M '� � AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NOV O � '�ZOO6 INSURERS AFFORDING COVERAGE NAIC# Insured HEALTH [�Ei'T• INSURER A: MA Retail Merchants WC Group Inc. Cape Wine&Liquor,Inc. INSURER B: d!b/a Cape Wine&Liquor,Ina � 443 Station Ave INSURER C: South Yarmouth,MA 02664 INSURER D: INSURER E: COVERAGES THE PQLIGIE�DF tNS��RONrF LISTED_��OW_HAVE BEEN IS5UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,N0TIMTHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH�FiIS CEF271FIZ`AYE MAYBE iSSUED OR NIAY PERTAIN THE INSURANCEAFFORDED BY THE POLICIES DESCRIBEDHEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY noo'L EFFECTIVEDATE POLICYEXPIRATION INSH LTR iNSRD TYPE OF INSURANCE POLICY NUMBER MM/DD DATE MM/DDM/ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERA�LIABILITY FIRE DAMAGE(Any one fire) $ ' CLAIMS MADE O OCCUR MED DCP(Any one person) $ PERSONAL&ADV INJURY $ i GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS—COMPlOP AGG $ PRO- � POLICY JECT LOC AUTOMOBILE LIABILITY COMBINm SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNm AUTOS BODILY INJURY $ �HmULm AUTOS (Per person) � HIREDAUTOS BODILYINJURY $ NON-OVJNm AIITOS (Per accident) PROPERTY DAMAGE $ (Per accident) i GARAGE LIABILITY AUTO ONLY—EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS LIABIUTY EAGH OGGURRENCE $ OCCUR ❑ GWMSMADE AGGREGATE $ $ DEDUCTIBLE $ RETENiION $ � $ � WORKERS COMPENSATION AND X WC STATU• OTH- QAPtOYERS LfA9FLtTY __ _ TO&KLIA417S _ ,_ER_- _ _ __ ANY PROPRIE�'ER/PARTNER/IXECUTIVE EL.EACH ACCIDENT $ 1 OO,OOO A OFFICER/MEMBER IXCLUDED'? If yes,describe under ND 014005030752107 1/01/07 1/01108 EL.DISEASE—EA EMPLOYEE $ 100,000 SPEGAL PROVISIONS below E.L.DISEASE—POLICYLIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS�LOCATIONS/VEHICLES!IXCLUSYONS ADDED BY ENDORSEMENT/SPEpAL PROVISIONS � 3 CERTIFICATE HOLDER ADpTIONAL INSURED:INSU292 LEfTER: CANCELLATION � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE � Yarmouth Health Department TFiE EXPIRATIONDATE THEREOF,THE ISSUINGINSURERWILL ENDEAVORTO 1146 RoUte 28 MAIL 35 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED South Yarmouth,MA 02664 TO THE LEFT,BUT FAILURETO DO SOSHALLIMPOSE NO OBLIGAT1oN OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR � REPRESENTATNES. � AUTHORIZED REPRESENTATIVE � i : - ' TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT T4 OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #07-019 FEE: $75.00 In accordance with regulations gromulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby granted ta Cape Wine&Liquor, Inc., 443 Station Avenue, South Yarmouth, MA Whose place of business is: Cape Wine&Liquor Type of business: Reta.il Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l, 2007 BOARD oF HEALTH: B �uc`�. /�$., ' �� s�, .�, v�e�� t� a�, �►� �� ,��r��, R.�v. Januaiy 30.2007 ruce G.Murphy,lvtP .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NITMBER: #07-015 FEE: $50.00 This is to Certify that Cane Wine&Liquor, Inc. d/b!a Cane Wine&Liauor 443 Station Avenue, South Yarmouth, MA IS HEREBY GRANTED A LICENSE For _ SALE AND DISTRIBITTION OF TQBACCO PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. : This�sr��n�te��n2�omu�with Article VI oaf t�ie Sanit�Code of The Commonwealth of Massachusetts,and e� s ss sooner suspen or revo Januazy 30,2007 BOARD OF HEALTH: �eh��c;�i� �u:e��i�uitc�rt Ro��. Bdo[ua, �� l��,�til�� l.ua C�'�ee.r��, R.N. c.x,.t - Bruce G. wP Y> > • •� Director of Health i • o f�qR �.�f r�� ,r _o TOWN OF YARMOUTH BOARD OF HEAL'� ��'��, �`,�Ap j o�� -,y APPLICATION FOR LICENSEfP , I��O� �. � ,� � - - - __-- r ., ;�?' �`�� w ,� * Plea.se complete form and attach all necessary document�`by�ecembe 31,��Sp 6 2006 Failure to do so will result in the return of�our application pack t. -,� � NAME OF ESTABLIS�IlViENT:��P6 Lt)INc-� �iq�v�-.Inie- cL/bla �Jl.�(LTiN'S 1JUA�t�.r'�`I'EL. # �v�-3��-c��a� LOCATIONADDRESS: �43 SrtrkrtoN /kv�'�tvE � sJ :��;°�,� MAILING ADDRESS: s� on1 /�../� �� v > n� OWNER NAME: I�/l/�(Z► /� ►►�/-�R-�s c� T ID IFEIN or SSI�� CORPORATION NAME (IF APPLICABLE): CA-p� 1�t,1 i t,�. � ��t�v�,�. l �V c_.. - MANAGER'S NAME: V I/l/�L.t /t Vl.°l�k?2--� s c_ .� � � TEL. #��=�v � -c) � MAII.,ING ADDRESS: �4-3 S 7�'t.��u ft,�� S v: u R�.a�v�...�,-u _ 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 employees currently certified in basic water safety, standazd 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 must provide new copies and maintain a tile 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 fde at your establishment. 1. Z. PERSON IN CHARGE: ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ; p � � 1. /v�l��1�,�G1 �Gt�LD�id �? 2. � �-�l'�/�uLCiJ HEIlb�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 a11 times. Please list your employees trained in anti-choking procedures below and at�at�i�opies 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 REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 _INN $50 CAMP $50 _SWIlVIlvIDJG POOL$75ea. _LODGE $50 _T'Rf1II,ER PARK $50 VVHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE ItEQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# �0-100 SEATS $75 CONTINENTAL $30 �NON-PROFTT' $25 >100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIItED FEE PERMIT'# �<50 sq.ft. $45 >25,000 sq.ft. $200 V�,"NDING-FOOD $ZO �QS,OOQsq.ft. $75 (��0��+ _FROZENDESSERT $35 �TOBACCO $25 �Ob"03,3 NAME CHANGE: $10 AMOUNT DUE _ $ /lQ�� , , ""*""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM��#h k 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ��/„� YES NO i � N�TICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQiTIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of , closing. ; FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form?2 hours prior to the catered event. 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 ta 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 establishment is prohibited. i DATE: D SIGNATURE: < �'� �l,G� , PRINT NAME&TITLE: ��/�/fi -�� , ��'-�'��' 09/28J05 � � , i j CERTIFICATE OF LIABILITY INSURANCE DATEZ�O6�O6 j Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF � INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE � Association Benefits Ins Agcy Inc i CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT � � 529 Main St Ste 606 � Boston,MA 02129-1121 AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY i � � � � ;� � � D THE POLICIES BELOW. � INSURERS AFFORDING COVERAGE NAIC # Insured , •. INSURER A: MA Retail Merchants WC Group Inc. � Cape Wine &Liquor,Ina INSURERB: --- ---_- __ _____ �la hAar#ir':,'Al��aheuse Li t -- - - _ _ _ ___ �_ h€H�i� �Ef�1`. 443 Station Ave INSURER C: South Yarmouth,MA 02664 INSURER D: INSURER E: � COVERA�ES I THE POUCIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY'PERIOD INDICATED,N0TIMTHSTANDING � ANY REQUIREMENT TERM OR CONDIIIQN OF ANY CON7RACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY � PERTAIN 7HE INSURANCEAFFORDED BY THE POUCIES DESCRIBEDHEREINIS SUBJECTTO ALL THE TERMS,EXCLUSIONSAND CONDIl10NS OF SUCH POLICIES. AOGREGATE LIMITSSHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ... . .:. . POLICY � � noo'� � �� -�� - �� EFFECTIVEDATE � POLICYEXPIRATION � � � � . �.� �� .. �. wsa�Ta � iNsao _„ TYPE OF INSURANCE POLICY NUMBER MM/DD DATE MM/DDlYY � � �� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCfAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ CLAIMS MADE O OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ , � - GENERAL AGGREGATE � $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ � PRO- � �'-�=" JE;.T ; I L�aC � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ � ANY AUTO � (Ea accident) ALL OWNED AUTOS BODILY INJURY , SCHEDULED AU70S (Perperson) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) . PROPERTY DAMAGE $ -� �- �� . � . (Peraccident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ � : � � �-ANV AUTO �. .. .. . � ., . . . . . .. .. . . .. . . .-0THER.THAN EA ACC $ ��. ... , AUTO ONLY AGG $ � EXCESS LIABIUTY EAGH OCCURRENCE $ ' � OGCUR ❑ CLAIMSMADE AGGREGATE. $ � � . . .. . . . . . ...$ . DEDUCTIBLE � $ � � REfENTION $ $ . WORKERS COMPENSATION AND WC 5fATU- OTH- EMPLQYERS�IABILtTY � X TORYLIMITS ER ANY PROPRIETEWPARTNER/EXECUTIVE E.L EACH ACCIDENT A OFFICER/MEMBER IXCLUDED? NO $ _ 1 OO,OOO Ifyes,describe under 014005030752106 2/15/06 1/01/07 E.L.DISEASE-EA EMPLOYEE $ 100,000 SPEqAL PROVISIONS below � i E.L.DISEASE-POUCYLIMIT $ 500,000 I _ ,. .,�e _ __ . _ __ .- —-------_ _ _ - - —_ ' RFFERENCE: ' DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPEqAL PROVISIONS Workers'compensatbn coverage is provided by coMract to all empbyses of Martin's Warehouse Liquors Coverage does not appy to any empbyess not approved and assigned by Martin's Warehouse Liquors effective 02/15/2006 CERTIFICATE HOLDER ADDITIONALINSURED:INSURERLETTER: CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yarmouth Health Department THE EXPIRATIONDATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO 1146 Route 28 MAII 35 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED South Yarmouth,MA 02664 TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGAT1oN OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �� L r ' TOWN OF YARMOUTH BOARD OF HEALTH j PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #Ob-046 FEE: $75.00 3 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ; I 11,Section 5 of the General Laws,a pemut is hereby granted to: ' _ Cape Wine&Liquor, Inc., 443 Station Avenue, South Yarmouth, MA i i Whose place of business is: Martin's Warehouse Liauors a 3 j Type of business: Retail Food Service less than 25,000 square feet , ; To operate a food establishment in: Town of Ya.rmouth ' Permit e�ires: December 31, 2006 BOARD OF HEALTH: Q ,�`h, o�,��,, a�� i�s�i, �./V., ?litt�C�u�r�i�c�s a Rod�rt� B�ou�, C'l�k ' P��` ' �4�uC f�'�ue��r��, R./Y. � i � February 9.20(?6 ruce G. Murphy, S.,CHO Director of Health , THE COMMONWEALTH OF MASSACHUSETTS TQWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-033 FEE: $25.00 This is to Certify that Cane W�ne T i��,r Inc �1�hfa Ma�rti ' Warehou e T i�uors 443 ta�ion Avenue,�»th y�rmo�th, MA IS HEREBY GRANTED A LIeENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI-�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. �s�em�is�r�nte�i�n2cg�om�with Article VI o�tjie Sanitaxv_Code of The Commonwealth of Massachusetts,and e es er s ss sooner suspenaen or revok�d _ February 9 2006 BOARD OF HEALTH: B �tt��, ,/dif,�,� ' �� st�, ��e�� R�t� B�, et�,� P��Lla�� lsus�j'�eess�u�, R.N. � Director of Health� � . ., H : �