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Home My WebLink AboutApplications, WC and Licensesi i � .� � < . �` ► TOWN OF YARMOUTH BOARD OF HE ��, G�'. a .� � � APPLICATION FOR LICENSE/PE �.��t19 �� .� � � 2008 �� ' * Please com lete form and attach all neces d ��wnextt's b"Dece er I S 2 � s� Failure to do so will result in the retu n of yow application pa ��° NAME OF ESTABLISHMENT: Christmas Tree Shops, Inc. TEL. # 50�-775-8151 LOCATION ADDRESS: 5i 1-525 Main srreet, Rt. 2s. we;,t varmouth. � 02673 MAILING ADDRESS: __261 White's Path, South Yarmouth, MA 02664 OWNER NAME: Charles G. Bilezikian TAX ID (FEIN or SSN): �' CORFORATION NAME (IF APPLICABLE): Christmas Tree Shops. Inc. MANAGER'S NAME: Denise Tierney TEL. # 508-775-8151 MAILING ADDRESS: same as above 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 cunently certified in basic water safety,standard First Aid and Community Cardiopulmonaiy 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 file at your place of business. i � 1 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.000. , Please attach copies of certification to this application. The Health Department will not use past years' records. � You must provide new copies and maintain a file At your establishment. � 1. 2. PERSON 1N CHARGE: __.� __��___ - �- —��____�__---— -- - _ _--- ---- - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees mained in anti-chokmg procedures below and attach copies af 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 LODGI>vG: LICENSE REQLTIRED FBE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN �55 MOTEL �5� i IiTi�' S55 GAMP S55 _SVVA'iMINGPOOL S8f3ea. _LODGE S55 _TRAILER PARK $105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT �30 _>100 SEATS S160 _COMMON VIC. $60 _WHOLESALE �8Q RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<�0 sq.ft. �,50 _>25,000 sq.ft. $225 VENDING-FOOD �25 �<25,OOOsq.ft. �80 �OR�D� _FROZENDESSERT $40 TOBACCO ��5 �a��c�vcE: �io AMOUNT DUE _ $ 8p.Gb *****PLEASE TURr OVER AiVD CO.MPLETE OTHER SIDE OF FORM***** r 3 � � � t ADMINISTRATION � � r � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renev��l 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 taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK t APPROPRIATELY IF PAID: � YES NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be � limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. ` Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. ; Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an ; aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or ; dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CNIR 64G, as ametided, shall generally be considered Transient. � POOLS � � � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days pnor to opening. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd 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 � � � � CATERING POLICY: � Anyone who caters within the Town of Yannouth must notify the Yannouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health G Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. , i 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 establishmerrt is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAlNTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �f�� SIGNATURE: r�L��G� /lU�� PRINT NAME&TITLE: Elizabeth A. Roderick, Administrative Coordinator to�2iios � ! . , . . � The Comnnonwealth of Massachusetts � Department of Industrial Accid'ents ' �� 600 Washington Stree� f"'Floor f Boston,Mass. 02111 ;i � Woricers'Compeesation Insm�anee qflidavit:gailding/p�b��Contnctors _ � �'le�rse Pl�t�'�� name: i addnss• � � i ciri �+�te- �P nh�e# work site location ffiill address). ' LJ I am a homeawner performuig all work myself. Pro�ect Type: ❑New Construction QRemodel ❑ I am a sole-proprietor and have no one working in any capacity• 0 Building Addition � ❑ I am an empbyer.�oviding w�kers'.compensation f�my employees wo�cing on this job. � COOIDfOVYB�IE' � (''F.�..is'- a� Trcn S}innc Tnr . . - - � .-. . � . . . _ . . . .._. .. .. i � . . . . . . .. . � . . . � . � �' 2 Ron P 28 city: West Yarmouth, MA 02673 ��# 508 775 8151 iu co, # .. 1;v , -:�..-. ,�A. ,..:�:.;,,1 .; ��,:,: �..��{.sP,".*, ; ❑ I am a sole proprietor,ge�era!eottraetor,or�omeowner.crrcle o1u and have hired the �:, �V: _= the followin workers'co � • � ��1��who have g mpensation polices: ' comuasv...u�• addnss: i � ��• . n�oae# { iasara�ce co. • �,_ . .:�. �� # , . .. _ . .�; ,��, , ad�4ras: e�vz ora�e�- __. _ ,... .. . . . _ . _ # — — _— - _. > ... . : . , , .,A .,�: F�'[IOlEC11�E... . . . , v.'". � ..:-.s�. �xk.z.:'%`,xr ra�:; r.x;,`' �.. s ��+dy-;,,'s ^x'f-.��'�. � • e cvverase as reyuind a�dQ Secl�2SA�f MGL 152 am Ind b I�e� _ `'i`�'r' ._. °�Y�'�pHeoemmt aa w+e�as dvil pemlUn ia t6e fita�ota STO!WORK ORDER�Bne�t�00 P��'a Soe ap b i1,SM.ls a�d/er eepg of thh�fa etemeat may 6e fonvarded eo the O�ce ef lsra�st fhe DU fw�aw�n�age veripatles. Y�me. I mAerslard t6at a I do h�eby cerlijy uw tlYe paGes ewd pene/Nes ofPe+j tllret tbe i� S18natuce ��,�`��/�d�/� �°riaallo�provided aboae is dzre ahd�r►r�c� n�te ��"aL/O� Printname Elizabeth A. Roderick pbane� 508-394-1206 •fficial ase only do aet write�thh area to 6e cempleted DY�Y�'��offichl , city or to�ru• • ' p+ernstr/�cenx� f'1� �i„_Deparfinent ' ❑ehai�Kimae�aie r+espeex is nequired �Beacd Os�'s oea« �m�oo�' P�e�; �Q °�"�e"c . TOWN OF YARMOUTH a BOARD OF HEALTH ; PERMIT TO OPERATE A FOOD ESTABLISHMENT i � PERMIT NUMBER: #09-020 FEE: S80.00 � In accordance with re�ulations promuIgated under authority of Chapter 94,Section 30�A and Chapter ; 11 l,Section 5 ofthe General Laws,a permit is hereby granted to: __ Christmas Tree Shops, Inc., 511-525 Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops, Inc. Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 l. 2009 BOARD OF HEALTH: .`;E¢�¢It S�K�, J�.JV., C'f�a,vcr►tan �Itc+�c�e�s ,�. a'G�'Qi�ex 21ice Cl�awrrna�t ./2c�B�e�rct �. J3�cacurc, e� Ur:n �'ree��uum, J2..�V. Eae�ri J• .1�arJ.ea December 16.2008 Bruce G.Murphy,MPH . .,CHO � Director of Health � � r ' Cily¢tSTYNF�S TKE� � J`'Y"k�. TOWN OF YARMOUTH BOARD OF HEALTH (w y� � � `' APPLICATION FOR LICENSE/PERM�'i' �408 ' r��i a �, �s �;; Z�tii � ` "� ;��t�� ,� � *Please complete form and attach all necessary docuriients'�by�December 31, 2007. Failure to do sa will result in the return of you�=Application packet. �� NAME OF ESTABLISHMENT:_rh,.;�fi,„a� TrAe Sh�,�s, Inc. TEL. # 508-775-8151 LOCATION ADDRESS: 511-525 Main Street, Rt. 28, West Yarmouth, MA 02673 MAILING ADDRESS: ��i wh;tP's Path. SoLth Yarmouth. MA 02664 OWN�R NAME: Charles G. Bilezikian TAX ID�FEIN"or SSNI' CORPORATION NAME (IF APPLICABLE): Christmas Tree Shops, Inc. MANAGER'S NAME: p�t Kelly TEL. # 508-775-8151 MAILING ADDRESS: same as above .�� .�� 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 certificanon to this form. 1. 2. Pool operators must list a minimum of two emp loyees currently certified in basic water safety,standard First Aid and Communiry Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. The �ealth Departtnent wtll not use past years' reeords. 3�0� �t�s�pravide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attaeh copies of certification to this application. The He�tlth Departme�at�viH not nse pa�t years'recards. You must provide new copies and maintain a file at your establishment. 1. 2. P��9I*T IN_��I�:�E: -.__ _ — _ _ Each food establishment must have at least one Person In Charge(PIC) or�site during hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trainec� in �he Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LQDGING: LICENSE REQUIItED FEE PER'VIIT# LICENSE REQL?iRED FEE PER'1rIlI'� LICENSE REQLTIRED FEE PER'�fIT� B&B S50 CABIN SSO MOTEL S50 INN S50 CAi�IP S�0 SVVIv1:V1ING POOL S75ea. LODGE 550 TRAILERPARK S100 Vl'HIRLPOOL S75ea. FOOD SERVICE: LIGEI+T5E REQUI#tED FEE PERMIT� LIC£NSE REQLTIRED FEE P£R1�iIT tt LICENSE REQUIR£D FEE PER'�IIT= _0-100 SEATS S75 _CONTINENTAL S30 lv'ON-PROFIT S25 >100 SEATS 5150 CO;�L'�ION VIC S50 V41-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERVIIT� LICENSE REQL'IRED FEE PER�IIT� _<50 sq.R. �45 >25,000 sq.ft. S200 _VEI�'DI1vG-FOOD S20 I <25,OOOsq.2t. S75 �OS-�� _FROZENDESSERT S35 _TOBACCO SSO NA11�CHANGE: sio AMOUNT DUE _ $ 7�',Oa *"***PLEASE TL'R\OVER a\D CO�tPLETE OTHER SIDE OF FOR�Z**"�** I r Y � R �. � ADMINISTRATION y Under Chapter 152, Section 25C, Subsection b,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 1NSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPR4PRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS ; TRANSIENT 4CCUPANCY: For purposes of the limitations of Motel orHotel use,Transient occupancy shall be � limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. f Transient occupants must have and be able to demonstra.te that they maintain a principal place of residence elsewhere. � Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an � aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or � dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy y Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as aznended, shall generally be consider�Transient. j � i * NOTE: Enclosed Motel Census must be completed and returned with this application. POOLB � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' � by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( days pnor 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 c�uarterly thereafter. - POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7)days of � closing. i � FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health DepartmeYrt 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 Pennit 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 of Heatth. OUTDUOR COOKING: 9utctovr eoaking,PI'ePara�ia�,ar drs�laY�€a�'€oe�Pf�y�retail or-€o�se�viceestab�ishmeat is prehi�. -- _ i E NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � THE COMPLETED AP'PLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. � ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUg'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � . DATE: II' ��•D� SIGNATURE: ,� �rr '��(►� ' PRINT NAME&TITLE:Elizabeth A. Roderick, Administrative Coordinator ' io?o o� � •- s � The Commonwealth of Massachusetts ' Department of Industrial Accidents � > �f�� 600 Washington Street, f�`Floor Boston,Mass. D2111 Workers'Compeesatioe Imaraace AtS�vih Baildieg/Ptembieg/Electrical Co.tnetors .__u":�r...,:��.,._�_ ��s�i'��► �. --- natne: 1 address: " i � state• � zio• nhone# ; i k WOI�C S1tC IOC3110ll��I'�CSS)• . � . i ❑ I am a homeowner performing all work myself. Project Type: ❑New Construc�ari�Remalel � ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition � pI��,�y��,g W��'compensati�for my employees worlcing on this job. 4 --- -- _ ; __ _ ________ , Gl�ri-s-�aa$s �ree �i�rogs,-_�nc. __ __ _ _ --_ , com" _ —tifine: I �- 529 Route 28 a� West Yarmouth, MA 02673 ukme#• 508-775-8151 � 11WC14934100 , . • ,�.:; ��-��.�,�� „.- � ❑ I am a sole Praprietor,getera�cottraetor,or�omeoweer(arcle ouej and have lrit+ed tbe co�ctois listed below who have ` the following wo�cers'compensation polices: ; citv a6a�e!�• : to- # . - x ..;; sd�e+�s' u�o�e�� _ _— _----- --- -- _— - � ' FaB�u�e b stcu�e eu�verase��ii'ed u�er See�2SA ef MGL 1S2 cu kad b tYe h�p�Wa�f eri�ial pefaNia�f a�ae�p b:1�N-M a�l�'" i oae yean'ImprNo�ant as weY as dvi pesaitla is t6e 6sr�ot�3T0!WORK ORDER a�d a��t S16l.M a day a�,aimt ne. 1�dvs�ud tLat a 1 c�pY ef tYis�taleseit my be firwardcd 1s tie OlBce�lrtv�om of tlu DIA fir arcrase verMatl�s. � t!o be►+eby certijy nn e patns and pene/tiea of perjrrry at tbe i�for�u�uto�provdded abor�e is trxs awd c»nrc� �� i� ��i � � ` nete �/•��• �� p�� Elizabeth A. Roderick Phone# 5Q8-394-1206 e�cial ax ealy do net write it thfa am to be ce�pkt�d 6y eHy er Inva�chl � eity or tewn: � P�°�� ❑c�eck if immdlia�e resps�e is reqffidi �'s O�oe �HaN6 De�r�t 3 ��; ph�e#> �a' I t+�� i i f + TOW�1 OF YARMOUTH $OA�2D OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHII�NT : PERMIT NUMBER: #08-021 FEE: $75.00 In accordance with re�tions promulgated under authority of Ghapter 94,Section 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby granted ta Christ�nas Tree Shops, Inc., 511-525.Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops, Inc. Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Per�mit expires: December 3l, 2008 BOARD OF HEALTH: �E�¢It S��, JZ..N., C'�ai�ecm.art �'R�anlee �. 27ice C!f�aci�cman C�C�ceen��i�,� J2...lV. December 3_2007 B ce G.Murphy,MP , .5.,CHO . _ ..._-- . . , .. Director of Health , .. . ' , f,��jbbb�t (� rS7'r1a5 'rR� L� C� C��II� �-wY� 2�`:''R,yo TOWN OF YARMOUTH BOARD OF k�,E�.T� 1 I' o: -�y APPLICATION FOR LICENSE/PE��'�200? N O V 3 O 2 O O 6 ' � � . ,,a - ,, � .�, ,, �,a, . * Plea.se complete form and attach all nec�ssar�d�ments by D ,_2006�r Failure to do so will result in the r�urn of your applicatio . NAME OF ESTABLIS�-IlV�NT: Christmas Tree Shops, Inc. TEL. #508�775-8151 LOCATION ADDRESS:511-525 Main Street, Rt. 28, West Yarmouth, MA 02673 MAII.�CT�D�SS: �(jl b�hita�c Path� Srnith Yarmrnith� MA 0�664 OWNER NAME: Charles G. Bileziikian TAX ID CFEIN oi SSN�: CORPORATION NAME(IF APPLICABLE): �hr�stmas Tree Sho�s. Inc. MANAGER'S NAME: Bob Tullis TEL. # 508-775-8151 MAII.ING ADDRESS: same as above POOL CERTIFI�ATIONS: The poal 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 cei#ification ta this form. l. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitatian(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Heaith 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 PROTECTI4N MANAGERS -CERTIFICATIONS: All food service establishments a.re required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment 1. 2. I�I PERSON�1V CH�RGE: - __ _ -- ----- _ _ _ _ - _ _--- --- --- _ � �ach food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH 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-chokm� procedures below and attach co�Sies of employee certifications to this form. The Health Department will not use past years' records. You must provide aew copies and maintain a fde at your place of business. 1. 2• , 3. 4. RESTALJRANT SEATING: TOTAL# - OFFICE USE ONLY "LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMTI'# ' • B&B $50 CABIN $50 _MOTEL� �50 INN $50 CAMP $50 _SWIIvIMING POUL$75ea. LODGE $50 TRAII,ERPARIC $100 _�LPOOL $75ea. FOOD 5ERVICE: - LICENSE REQUIRED FEE PERMfr# LICENSE REQUIRED FEE PERMfi'# LICENSE REQUIItED FEE PERMI'T# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 � >100 SEATS $150 COMMON VIC. $50 WHOLESALE $'75 RETAD.SERVICE: _—RESID.KTTCHEN $75 LICENSE REQUIItELI FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T,<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 L45,000 sq.ft. $75 �d7�O�7 _FROZENDESSERT $35 _TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE _ $ 75-0� i *••"•PLEASE TUBN OVER AND COMPLETE OTHER SmE OF FORM•""•* � , , , > ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of a,ny license or pernvt 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 I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LUDGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be j limited to the tempora.ry 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 af residence elsewhere, Transient occupancy sha11 generally refer to continuous accupancy of nat more than thirty (30) days, and an ! aggregate of not more than ninety(90) days within any six(6)month geriod. Use af a guest unit as a residence or � dwelling uzut 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 Tra.nsient. � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ecte�l by the Health Depaztment prior to opetvng. Contact the Health Department to schedule the inspection five(S�days � pnor 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 xnust be drained or covered within seven(7}days of closing. � � FOUD SERVICE ' � CATERING POLICY• � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required ; Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ' Health Department. I 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. ' OIITSIDE CAFE5: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOI�TG: . . OntdQor co�kino�a�atiens�r�.isplay of any food product by a retail or food�erv�ce gstablish�nt�s prshi�iited. � � � � I i NOTICE:Permits run annually from January 1 to December 31. IT IS YQUR RESPONSIBII.ITY TO RETLTRN i 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 EQUIPMENT,ETC.),MUST BE REPORTED TQ AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' n � DATE: �I• .?8-d� SIGNATLTRE: C�j�, �?��/� � G�� PRINTNAME&TITLE: Elizabeth A: Roderick Administrative Coordinator � � r � 10/17/06 � � � 1 t x �'°'� TJee Comnanwealth of Massachusetts DepaRene�t of Indus[�nial Accidents > N�w/ii�MM� 6U6 Woshington Strec� 7`�'Floor Bo�,Mass. 02111 — --- Work�s'Com _ tio'Lama�ce A�davih B�ii ._ ' leetrical Co�haet�rs name: eddiess' �• zin• nhane# - I work site 1 '�► full address: � ❑ I am a homoownea perfoimin8 all wark myself. Project Type: ❑New Ca�ucti�OReanodel I am a sole ' and have no a�e w ' in an ' . ❑Buil ' Addition ❑ I am an employer providing worke�s'compensation foc my employees working at this job. . _ ___ _ - �' ('hri armac Traa Sh(]�],�C�Ty�(" , 529 Route 28;� . > : _; "_ . _. U; '. ,� ` West Yarmouth, MA 02673 ��. 508�775-$151 _ Fidelit & Guarant Insurance Co. DQOlW00355 ❑ I am a sole proprietor,gaeral tu�tractor,or 1►o�meaw�er(cirde out)a�have hinad the coa�ractars listed below who have the following wot�ecs'compensation polices: ; � �� #� I ; � �� I _ _.. _--- � FaNmY�a se�+e er�er�e as rey.irea uder Sedi.t 2SA.r 1►!eL iSz e..le.a a ue inp.itM..rc�wiid pe�al�s.�f:�e�p a s1,sN�N adhr � ose yeus'1e�►rb�esmt as wU as dv�pmdtles h tbe 6ra ata 3T0!WORK ORDER aad a 8ee ef 5190.M s day��e. 1�sdnshad tlut a crpy�[thb efaleteat�sy 6e firwarded M He d�ee�t I�vatiptlw�f tMe DIA far tevera�e vermeatlw r do J�ekby c der Nis prt�s«wapen.r�of M�t�Ys ixf�e�dnw provtaed arLwae la bxe R»a c�sn+�c� i �� '�1� �� -a�� Prurt na� ��L�� . Phone# ��7` ��b affi�iat ex only do not wrke i�t�s area b be c�spleted DY cit�'e�lrwn�Cial �Y��°= � Qlio�Beard �ekeelc if i�1e�+�s�e is re4� ��s� �� ce�act peneac ��' � tn'^��-�� . .. �. � � 1UL-19-06 ~ �8:52AM FROM-BED BATH BEYOND RISK MANAGEMENT 908-688-3169 T-122 P.002/0�4 F-iTl Item 1 Extension Schedule , r, • Schedule of Named Insureds , NAMED INSUREDS: BED HA��'1; & BEYOND INC. �CIN 1i: � � , � � :�, I � � ,� � ,, �i I �,' � ' ,� � , :, '' f ,i .i� ` � .� 1 � � .j� � ' ! 1 ' . insured: BED HATH & BEYOND ].:x�C. , Policy Number: D001,W00355 � Effectivo Date: 03--01-06 WC 08 00 01 A �Fl�GINn� qAA �Rf� Z1�q PAGE.G�2 �� .n �.nnr e n.ve' , ' JUL=16-06 '� �19:3TAM EROM-BED BATH BEYONO RISK MANAGEMENT 908-688-3109 T-1Z3 P.001/001 F-1T3 i • � • ' � ' � ' ` Policy Manual = ,._ _ • ..�_� 03/01/06 fo 03/1lO7 Covern�e: WOR�CE1•t:i' COMPL-NSATION �c EMPLOYERS LI.A.BII.ITY(AOS) Carrier: Fideliry aayl Gua�nry Insurance Company Puticy Number• D601W0��:�55 poticy Term: March 1, Z'�006 to March 1,2007 Scates included: AllOthe-States Covorage �s provided in the followino rnoaopoliscic states directly through srdte agencies: ND,OH.'i]JA,W'V,WY i Covera ��B- BI by Accident- $ 1,000,000 Each Acci�ent BI by Disease - � 1,000,000 PoIicy Liuiit BI by Disease - $1,000,000 Each Emptoyee Deductible: S1,OOO,C�pO including allacated expenses Audit: '�u� , • ^lerrftory: All Stau:s 1 Covcrages: • Other S�u�tes Insurance • Siop G,►��Coverage • Foreigil�overage • Waiver��f Subrogarion • Longs2:.c�.remrn's aAd Harbor Workers Coverage � • Maririrn�.Covarage • 90 Da�s Nocice of Cancallation . Volun��ry Compensation • Torror��.Itisk Insurance i t..' �HRH. ' ��1� �o=�l 6 �IIsLDs JUL 19 2006 11�20 908 668 3169 PAGE.01 � ' . i TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-017 FEE: $75.00 In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�reneral Laws,a pernut is hereby granted to: _ Christmas Tree Shops, Inc., 511-525 Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops, Inc. Type of business: Retail Food Service less than 25,000 square feet To oper�te a food establishment in: Town of Yannouth Permit expires: December 31, 2007 BOAUD OF��.�: Berr�c.�r,rsa `11. 4'�d,oa, A�$., ' � d�el�.s �, R./1!, ?!�G'l�� RodP�tt�B�u,.�rs, G� P��c�(a/l�c_`1Se�ix� �(�'�.td� R.N. � y 7anuary 25.2007 ruce G.Murphy, s.,exo Director of Health � I ; � ' _ :�_-. ��,.,��t i �.�..NRI03 30��S?I�H.LO�.L�'IdI�iO�Q1�iV?I�AO I�RIt1.L�SV�'Id..... oc•SL $ _ �l1Q ZN110N� ot� ��[�u��w�u � sz$ o�adgoi� s£$ s��ssaQxazox�— /£0—�� SL$ 'g'bs000`saT ' OZ$ Q00.3-�JI�IIQ1�ISt1 OOZ$ '$'bs ppp`SZ< St,$ 'g�bs ps> #J1Y1R13d ��3 Q�2IIf1a�2I�Sl�I��I`I #.LII�1RI�d �3 Q�2II11a�2i�S1�L��I'I #.tII�I2I�d �'33 Q�I[la�2I�S1�I��PI ' �a�tnx�s�u�z�x ' SL$ �'I�'S�'IOHhA OS� '�IA NOI�IO� OSI$ �� SZ$ .LI302Id-NO1�I 0£$ `1H,LN�II.LNO� SL$ SZ�''3S OOI-0 #.LIY�I2I�d ��3 Q�2IIIla�i�SI�L��I'I #.LII�RI�d �� Q�2IIf1��S1�L��I'I #.LIYII2I�d ��3 Q�[fla��SI�L��I'I ��IA��S QOO,d , '�SL$ 'IOOd'RII�-IM OS$ �I2Idd 2T3'IIN2I.L OS$ �JQO'I •8='SG$'IOOd tJ11II'tiY�IIMS OS$ dL�I�� - OS$ N1�I[ ' OS$ 'I�.LOY�I OS$ 1�IIHN� OS$ $� #.LII�I2T3d ��3 Q�Ifla��SI�I��I'I #.LII��d ��3 Q�2IIfla��SN��I'I #.LIt�t2I�d �33 Q�HIfla�?I�S1�I��PI � =9I�IIJQO'I ��uo �sn ��o I #�ios ��t�us�as s�n�is� � �� .£ •Z .i •ssau�snq�o aag�d ano�f�s ai��u��u��w pus saidoa n�au ap�noad;snui no� •sp.ioaa.� �s.�Ba�f�sud asn�ou j�n��uaai�gdaQ q;�Bag aqZ �uuo�sn��o�suoil�e�gi�za�aa�olduia�o sardoa.i{a�� pue n�ojaq sa.�npa�oid�u�ou�-i�u�ui pau�.z�. saa�ojduxa mo�f �stj as�aid •saiui� i� ��e sasnuald au� uo lannau�y� u��ag au� ui paurei� aa�oidLua auo �s�ai �� an�er� �snuz a�ouz io s�Eas SZ u�inn s�uaun{s�q��sa a�in.�as poo� � ' �S1�IOI.LV�I�,L2i��H3�'�Ii�-I Z 'i �uo��iado�o smoq�uunp a�Ts uo(�I�}a�req�uI uos.zad auo�ai�an��.snui�cuusi�4�e�.sa poo�u�Bg _- _ —_ _ - _ -__--- _ ____ - _ _ _�:=�3?1�H�"�1'�it3��c� �Z 'I •;uacaqsi�qB�sa.�no��e ap,�B u�g�u�gw pag saidoa�au apino.�d;sncu no� •sp.ioaaa �s.i�a��sud asn�ou mb;uaiu�aBdaQ y�ivag aq,L �uoi��Tjdd�sn��o�uot�t��a��o saido�u��e as�eald '000'06S 2IL1I� SOI `s�uaun�siiq��s�a�uuas poo3 io� apo� ��tu�es a��s a�ui�paugap s� `ia��uey�uoiaaa�old poo� � s� pagi�a� si oqnn aa�ioidcua aun�-� auo �aj ��e an�u o� pa.nnbas a.r� s�uau�sijc��sa a�rn.zas poo� �� ; �Sl�IOI.L��I�,L2I�� - S2I�1J`v'1�L1I NOI.L��,L02Id Q003 �' '£ .Z �I •ssau�snq�o a�gid.cno��s ai�B u�r,�aisw pu� saidoa �au apino.�d �smm �o� •sp.ioaaa �saga�C�stcd asn �ou m,+�► �aam�BdaQ q��ag aq,L •uuo� sn{� o�suor��gr�a� aa�Coiduia�o saidoo u��pus nciojaq saadoidwa asaq�}sij as�a�d -(gd�)uoi��i�snsag�uoutlndoip.t��iunuiuto� p�p�r�sn,�p.repu��s `�a�s ia�Enn�ts�eq ui pa�i�a��i�ua.un�saa�ojduia onn��o umutiuiw��sii�sriui sio��aado iood � z 'I I � �uuo�sn{�o�uoi��g�a�aq��o�do� e q�ii�puB(s)io�siad��ood pa��isap aq��s�as�ald •n�►s�a��s�q pa.�inba.�sB�ao�eaadp�ood B sB pag��aa aq�sna.�osin.�adns�ood aqZ �SNOIZ��I�,LZI��'IOOd anoqB s8 am�es :SS�2IQQ�'�NT'TI�J�1i TSi8-5LL-805 # �"I�L silTns qog :��'1�I S��I��l�NI •�uI �sdoug aa.zs s�em�si.zu� :(g'Ig�''�I'Idd�� l�'1�I1�IOI,L�2IOd2I0� LOZT-L+�Z-�i0 � so � ,L . . aT. 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I�IHII.L�2t O,L�.LI'IIgIS1�iOdS�2III0�SI ZI 'I£jaquza�Q o�I�.renuer uzo.r��i�nuue uru s�tuuad:��I.LOI�i pN x S� �QI�d,�1�'I�.L�'I�d02IdcI�' �I��-I��5��'Id 's�iuuad mo��o a�uenssi io�nnauai o�ioud pr�d aq�snuz sua�pere sa��q�nouu��o unnoZ Q�I��Z,L�' QI�IV Q�I�IrJIS ZIA`d�33� 'dNiO� S�2I�O�c1 ` ?IO Q�-I��'Z,L�1��N�d�C1S1�II 30 '.L2I�� 2I0`Q�I�i�IS Ql�i�'Q�,L�'IdL1i0� �g 1.SRiAi��33� � ��l�i�'?II1Sl�II I�IOI,L�SI�I�dNiO� S�lI��I2IOAc1 �.L�ZS Q�H��Z.L� �H,L 'a��nsuI uoi��esuaduxo� s�iaxiom�o a��giva� �e an�eq �ou saop �uedu�o� .�o uosiad ��i ssauisnq � a��iado o� }iuuad .�o asua�Tj �u��o II �nnauai io a�uenssi pjou o�pannbai nnou si u�nowre��o un�oZ au�`9 uoi�aasqns `�SZ��i�S `ZS I ja�d�u��apun � j l�iOI.L�2I1.SIl�IIL1I([H ; i , z i " � � The Commonwealth of Massachusetts . � - Department of Ind�sirial Accidents ' Office of Invesiigations . . � 600 Washington SYreet Sostor�MA 02111 .. . www mas�gov/dia Workers' Compensatioa Insurance Affidavit: General Busiaesses� Aunlicant Information Please Print Le�iblv , Business/OrganizatianName: Christmas Tree Shops, Inc. - West Yarmouth, MA store Address: 261 White's Path • City/State/Zip• South Yarmouth, MA �02664 phone#: 508-394-1206 Are you an employerT Check the a�propriate boz: Basiness Type(required): 1.(� I am a employer with�employees(full and/ 5. (�RetA.il .. or pa�t-time)* 6. ❑Restaurant/Bar/Eating EslabbsbmCnt � 2.❑ I�am a sole proprietor or parhn�ersl�ip and ba.ve no �. 0 Office and/or Sales(incL real estate,aarto,etc.) tmPloyees warl�ng for me m aay capacity. [No warkers' co�p,insuraace requu�ed] 8• ❑Non�rofit 3.❑ We ar�a corpo�a.tion and its officers have exercised 9. ❑F�e�cnt • . their right of exe,mption per c.152,§1(4),and we have 10.�Man� no employees.[No woikeas' comg.insurauce reqaired]s 4.❑ We are a nan profit organization,staffed by vol�mxeers, 11.0 Hea1�Care . . with no em�loyees.[No workers'comp.insurance req.] 12.� Oflier � . •Aay applicant that ehecrs boic!�1 must also fili mrt the sec•xion below showing thdrworloets'o�P�h�P��Y iofo��ation. � **If tlu coxporate offiaers have ezempted t}�emselvea,but ti�e co�oiaoion Las adur miploYees,a worlcecs'compea�tioa Po1icY is reqaired and such an ocganiutioa should check box#1. ' . • . „ . I am an employer that�s prov�3ng worka•s'compensation insra�a�ecx for my tmployt�s. Btlow 1s the pol'icy�nforn�crt�on. Ins�ce CompanyName: Fidelity &_ Guaranty Insur,ance Com�anv . 385 Washington Street, St. Paul, MN 55102 (or) Ins�uer'sAddress: elo Hi1b R�,gal . & HohhG� �n0 FirGt Stamfc�rcl P1aeP ��5��: Stamford, CT 06902 • Policy#ar Self-ins.Lic.# DOO1W00320 ExpuationDate: 3-1-06 Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure cove�age as rEquued unde�Sectia�25A of MGL c.�152 can lead to fl�e�position of criminat penatties of a fine up to$1,500.00 aud/�a�-year imq�riso�at,as well as cavl peaaltiss m the faim of a STOP WORK ORDER and a Sne of up to 5250.00 a day against the violator. Be advised flzat a c�opy of 9�is st�ement may be f�warded to the Office of InXestigations of�e DIA far insurauce covaage verifi,caxian. � I do heFeLy e the of fhax the lnformatlon provided above��s lrut aud correc� i/��alties` v� � . d � � �: /a � Phone#: 5os-�94-1 2nC, � Of�ctal use only. Do not write in this�to be completed by crity or tanm o,Q`'rc3itL � City or Town• � Permit/I�cense# Issuing Anthorfty(drele one): 1.Board of Heaith 2.Bnild'u►g Department 3.City/Town Clerk- 4.Iacensing Board 5.Selectmen's Office 6.Other � Contact Person: Phone#: www.mass.gov/d'ia � OCT=20-05 S O4:42PM FROM-BED BATH BEYOND RISK MANAGE�ENT 908-688-3169 T-009 P.0�2/003 F-548 _ ' 1 Bed Bafh & Beyond Policy Manual 03I09/05 to 03/�/Ofi /Coverage: VJOIt10ERS' CONA'ENSA?ION&BMPLOYE�tS LIABII.ITY(AOS) � Carrier: Fideliry and Guaranty Insurance Company PoUcy Number: DOO1W00320 poiicy Term: March 1,2005 to March 1,2006 States Included; A11 Qther gtatey Goverege is provided in tl�e following monopolisUc states direetly through stace agencies: ND,OH,WA,W'V,'WY Covera e B- bl by Accident- $1,000,000�ach Accidant BI by Disease - $ 1,000,000 Policy Limft BI by Diseasd - � 1,000,00�Eacdi Employee Deductible: $1,000,000 u3cluding allocacad expenses AudiC: ,4nnugl Territory �it g��es Ceverages; � • Othac States I�isurance � 1 � Stop Gap Coverage • Foreign Covorage • Waiver of Subrogation • Longshoremen's end Harbor Workers Coverage � Maritime Coverage • 90 Days Notice of Cancellation � Voluntary Compensatiun • Terrorism Risk Insurance � ✓ I OCT 20 2005 19:G1� Q�+a �s�a z��Q p°rF A� OCT-20-05 '04:43PN FROM-BED BATH BEYOND R1SK MANAGEI�NT 908-688-3169 T-009 P.003/003 F-548 � Item 1 Extension Schedule Schedule ot Named Insureds NAMED INSUREDS: BE;D BATH & BEYOND INC. FEIN #: �� I � i „ -- �nsuced: BED SATH AND BEYOND INC. Policy Number: DO O 1TA0 0 32 0 Effective Date: 0 3-0�-0 5 WC 00 00 01 A ORK�INAL --- --- -•-- .,...,� .,� - ; , . ti TOWN OF YARMOUTH B�ARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISffiVIENT PERNIIT NUMBER: #06-031 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 pernut is hereby granted to: Christmas Tree Shops, Inc., 511-525 Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops, Inc. Type of business: Retail Food Service less than 25 000 sauare feet To operate a food establishment in: Toum of Yarmouth Permit e�ires: December 31, 2006 BOARD OF HEALTH: B s,�r�_`?S. ��,os�, /Ll.-`n•, ' �� s�, �v, v�e�� a�t�. �� e� �� 1� ��, R .�v � January 31,2006 ruce G.Murphy, S.,CHO H th Director of eal , j oF•Yq� G3 C� r. �� j`�. -� �� - ,�"o TOWN OF � .f� RM � UTHAPR9� �- r��5 o � - - `" —y EALT�.�. C ��.,�.:.�..• �, :- �, 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664 � MATTACMEES Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472 V � N��ApORAlEO 6�9 /� • . � 1 (�v � B O A R D O F H E A L T H To: Yannouth Boazd af Health Permit Holders '�' � . : :� . From: David D. FLiherty Jr., RS. ;�D r $ �� p� Health Inspector ✓ `' - 6 ' '�; � Town of Yarmouth ; , � , ..__ " Re: Federal Tax ID Number . _._ I � Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we fi�rnish 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 estabiishment's Federal Employer ldentifieation Number(FEIN}otherwise ; known as your"Tax ID Number". This is purely for administrative purposes only. � Some businesses use the owner s Social Secur' Number SS for this � rtl' ( 1� purpose. If this is the case''for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Health Department � 1146 Route 28 South Yarmouth, MA 02664 � T'hank you for your anticipated compliance. If you have any questions regarding this matter, ; p�ease do na#hesitate to-eail. The office ho�.u�s are Monclay to Friciay, 8:30 a.m to 4:30 p.m. The � telephone number is(50$)398-2231,ext.241. , , � Establishment: r � �G FEIN or SSN: ' Say �ak a�'' i � Location Address: ��Sf�/�Q?,yl�i+�1�'l, �!GO�'1 C� � Signaiure: /�G� ��`'��'+"/ /`� �UC�/l�C� �/!I�/klTi� � p�t= Title: c�1�� /c�i �G GOO ��, �� Printed on ( Re cycled , � .,]i Paper i 3 � � � �� '. pr/_'{�� I � � �R o TOWN OF YARMOUTH BQARU OF A o � W y , � - � G � � � �,: ,,s APPLICATION FOR I,IC,�P�S�� -2 5 ��,�� DEC 0 6 Z004 * Please complete form and attach a11�ee�ess�q aocuments by D ember 31 200g _ _ Failure to do so will result in th"�i-eturn of your apphcatio �Ll'H DE�-'�i . NAME OF ESTABLISHMENT TiG� �C • TEL. # - S�/.�/ LOCATION ADDRESS:S//-5dS' �' T. i. a /Lna/ G ? MAILING ADDRESS:o? / ,G/J►%�' � � OWNER/CORPORATION NAME: `i?� �i1e�S y1� . � MANAGER'S NAME: �i 5 TEL #5�� 77S I3/ MAILING ADDRESS: ,�,qrn 2s (�6vV��, 1 �----- --- ' POOL CERTIFICATIONS� � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated , Pool Operator(s)an��ttac�a copy of tire certification to this form. - L 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 certifications to this form. The Healt6 Department will not use past years' records. You must # provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CER'TIFICATIONS: 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 o£certification to this application. The Health Department will not use past years'records. � Yoa must provide new copies and maintain a fde at your establishment. 1. 2. __ _ __F�R�O�T-�N E�ij4Rf�:--- -- - -._ ___ _--- ------_ _----- _ _ _-- _ -- --- Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation. ; 1. 2 HEIlVILICH CERTIFICATIONS� ' All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich Maneuver on the premises at a11 times. Plea.se list your employees trained in anti-choking procedures below and attach copies of employee certifications to this fonn. The Health Department will not use past years' records. You must provide new copies and maintain �file at your place of business. 1. 2. 3• 4. RESTAURANT SEATING: TOTAL# � Loncnvc: ��CE USE ONLY LICENSE REQUII2ED FEE p�RMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRgD FEE pERMIT# —B� $50 _CABIN $50 MOTEL S50 —.� �50 _CAMP $50 _SWIlvIlVIING POOL$75ea. _LODGE �50 _TRAII,ER PARK $50 WHII2LPOOL $75ea. FOOD SERVICE: ' LICENSE REQUIRED FEE pERMIT# LICENSE REQUIRgD FEE PERMPf# LICENSE REQUIIZED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS �150 COMMON VICT. $50 — _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIltED FEE PfiRMIT# LICENSE REQUIRF,D FEE PFR11qT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 I QS'000 39'ft'. ��5 #Q�6�Y _FROZEN DESSERT $35 TOBACCO ____ $25 NAME CHqNGE: $10 AMOITNT DUE _ $ ')6� ""'"'PL$ASE TURN OVER AND COMpLETE OTHER SIDE OF FORM wRwre• 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 permit to operate a business if a person or company does not have a Certificate of Worker's � Co�pensation Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVTT MUST BE+COMPLETED AND 5IGNED,OR , � CERT. �7F INSURANC�ATTACHED ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEA5E CHECK APPROPRIATEL�IF PAID: yES � NO i NOTICE:Permits run annually from January 1 to December 31. IT IS Y4UR RESPONSIBII.ITY TO RETURN � TI-�COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2004. � i SEASONAL ESTABLIS��NTS ARE TO CONTACT THE HEALTHDEPART�NT FORINSPECTION 7-10 � k DAYS PRIOR TO QPENING FOR THE SEASON. E ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO CONA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ; � i ; ADDTTIONAL REGULATIONS POOLS POQL 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 i closing.� � � ; FOOD SERVICE CONSUMER ADVIS�RY: Each food estab ishment 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 Yannouth must notify the Yannouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtamed at the Health Department. _ _FRB�E��E�SERT�: -- - — _ _ - --- ___ __ Frozen esserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. QUTDOOR COOKING: Outdoor cookmg,preparation,or display of any food product by a retail or food service establishment is prnhibited. . /� '1 �//d� ` DATE: �o? �'�� SIGNATLTRE: �c. � PRiNT NAME& TITLE: �iZ�E�I A �l�Pi1iC�� /��•'��'✓� �o.P��a2 10/22/04 t , . . ti ! L � The Comnionwealth o Massachuset�s �_ =-= .f = Dcpartment of Indastria!Accidents ' -- I�a.�►rww� � =--- - � _ _< _ - =- 608 R'ashuzgton Stree� f"'Floor —,,,,� Bosto�e,Mas� 02111 � Workera'Com�raatioe Lsaaace At6davi�B'il �kdrical Co�tnet�ers �.�.,. .. �.a � � ' ' �-.r � �..;;�� ,...� name: address- �iN ar„rP' zin' R�ae# � work site locati�ffnll addressl• o ��a��„�,,��w�m,,�: Project TYPe: ❑New Co�ructio�o�� I a sole 'etor and have no a�w ' in an ' . Buil ' Addition I am an e,mP�.f lP�V1�S W'��an fac mY emPbY�W�8�this job. �.�: �e�:s�n� /�:[,�S1r��s `✓n ��i�-.�a.� ��,�.�- �--��' . � � � �: . ��' ��" � ��el� �� -/�s', �- l 1�iJooa�.' , ❑ I am a sole proprietor,geaeral co�tracter,or�omeow�er(circl�au�)a�have hic+ed the co�ctors listed belovr who have the following worlcers'compensation polices: i��urre: .+.�..`�.. � �,�. �T 1�e_ �� , CI�Y' B�i!�' � --- —-- — -- — Failvc a aeeae aMe�e�nqi��ed odv Saliu 2SA�f MGL L�cn led n tYe��[ct�id��f a�e tp a=1,SM,M a�dhr �Ya�'�p�aeM�n wd as cM pwdtles 6 tie fsr��f a 3TOt WORK ORDSR a�d a Sae af t1N.N a day a�t ie.I adastatd fi�a c�py�f t��teae�t my be f�rwarded�o the Odloe o[Im�aqys KtYe DIA t�ravrraae v�ermcatly. ��'�y� ��f��/e��L�°�tAret dYe nr�fonaafio�pro�ded aboae fs�rxe au�l onnbct S;gnature t.�r � J..1��G �� CXI LI P�� 7Z��.,�1 ,��%� ' ,E , _ r/IiC Phone# .��J��' I��'�o a�elal nse enly de aot wlite is this am a be a�pleted M9 eitY+r lswa�1 dly ar to�rn. pe�g B°'ia�� ❑eLed�if 1m�a1e r�e�na��ed � O�oe . n.eoa s�yc�� P��e S, �� Mrdeat � I f . � TOWN OF YARMOIIT'g BOARD OF HEALTg PERMIT TO OPERATE A FQOD ESTABLISHMEI�T7' ; PEItMIT NUMBER: #OS-024 FEE: $75.00 � ; In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ` 111,Section 5 of the General Laws,a pennit is hereby granted to: i � j Christmas Tree Shops, Inc., 511-525 Route 28, West Yannouth, MA V�hose place of business is: Christmas_Tree Shops, Inc. Type of business: Retail Food Service less than 25 000 uare feet � To operate a food establishment in: Town of�armouth f Pernut e�ires: December 31 2005 BOARD oF HEALTH: Besr�,�$, (�'°,�j,�/fi�$. ��g�e�e�a ��a�st �Sl� R.N. �� R.N. , 7anuarv 20.2005 ruce G.Murphy, S.,CHO Director of Health � � � i4 V t �. � �� t38�� . � ` � s :: C ct2csrM�s�?c�wy �°`:aR� TOWN OF YARMOUTH BOARD F � �� - ��O � !� C � �� M �`� � o_. .-,y APPLICATION FOR LICEN � ' '�? DEC Y 2 2003 ; � * Please complete form and attach all necessa c s by Decembe 31 2003. Failure to do so will result in the return our application packe �--�EAL1"H DEPT. a � r s r� %— ' ��$!S!� � A RES //- �'" � � j wN T ON N ' A ER' NAME• .��s� 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 at#ach a copy of the certificat�on to this form. i 1• 2. � a 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 forrn. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. l. 2. ! 3• 4. FOOD PROTECTION A AGER - C RTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. a 1. 2. _ PER��N IN�A� ----- - — Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. � � 1' 2• l � HEIMLICH CERTLFICATIONS• 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, F TA RANT SEATIN : TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERM[T# _B&B $5U _CABIN SSG _MOTEL $SQ _II�1r1 $50 _CAMP $50 _SWIMMING POOL S75ea. _LODGE $50 `TRAILER PARK S50 _WHIRLPOOL $75ea. FOOD SERVIGE• ' LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT S25 >100 SEATS $150 _COMMON VICT. a50 WHOLESALE S75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq:ft. $45 _>25,000 sq.ft. �20Q _VENDING-FOOD $20 �<25,000 sq•8• �75 O��,j'� _FR07.F,N DESSfRT �35 _TOBACCO a25 NAME cH"xc�• $�o AMOUNT DUE _ $ ?5.o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•�� - { � r F . � i ADMINISTRATION = � �f 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 � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMP'L�`'TED AND SIGNED,OR � � CERT. OF 1NSUR.ANCE ATTACHED �/ � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK � M APPROPRIATELY IF PAID: ' YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 { DAYS PRIOR TO OPENING FOR THE SEASON. � ; ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i f ADDITIONAL REGULATIONS � � i POOLS POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. 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 dra.ined or covered within seven(7)days of ' closing. � ; i FOOD SERVICE I CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATE iN POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporaty Food Service Application form 72 hours prior to the catered event. Thses forms can be obtamed at the Health Department. FR(17.FN DT.CC�u�tr�. ----_ _ _ _ _ _ - _ �__ --- - - - --- - - _ _ 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 seaiing with waiter/waitress service),must have prior approval from the Boazd of Health. �UTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE: � G� �O �3 SIGNATURE: `��/�� ' ; � � _ �!-- , I�' PRINT NAME& TITLE: �77C' 19. ��' �� 0�" � � 10/22/03 , + � � � The Conrmonwealth of Massachusetts ' � � Department ojlndustrial.-�ccidents � ^ J . O Of/ICOOII�reSlJ�s�liis ' : 600 Waskington S/reet '- ,>•` Boston.�lass. 02111 ~ �• W'orkers' Compensation Insurance Att�davit Anniicant information• p��s�pR��,-},� namr � location: i � ' ttt� ohone q ' � I am a homec�ner pertorming all work myself. � f am a sole proprieror �r.� h��e no one ��orkine in am•capacin• (� I am an empio�er pro�iding workers',compensa[ion for mr�employees w•orking on this job. ,�,,,.r.^ __ m a n • n : " � ic-.c�O S�`P�.S � �/UL - address• ✓1 /• � � %tJ T Y�-IZMf?�f.�.."�� i m}�" �� .. sih•: 'j��-��— �� nhone i! i anc � # � -��.J��1) '� � I am a sole proprietor. generai contractor. or homeowner(ci�cle onel and ha�•e hired the contractors listed below ��ho ha�e the follu�+in: �.orl:er�� ompensation polices: comnanv �ame• address cin': ehons# insurancc co. �olie�•# comoanv nams• address• ciiY: nboee� insurance co. �,* t — Failure to seeure cove�a;e as requ�red under Secnoa 25A of MGL IS2 ea�lad to tbe iepo�ilioe o(erisi�fl pesdtles of�O�e op to 51�00.00 t�d/or one yean'imprisonment a�w•efl a�eivil peaalde�io the lorm of a STOP WORK ORDER asd a liee ot3100.00 a dar a��iort ma I a�derita�d thst a eopy of tAh statement may be for.vuded to the 011ice of tnve�tig�dom of the DU tor eovenge veritit�do�, 1 do hrreby cerr' der rhe pains and penalties ojp ury that 1hc injorniotion providtd obove is trut a�d corr�ct Si nature ��.riU� Ll /L�' g �✓ ,L� Ib z �0� Print name G=�/,TC��r� �. /CG��P I�G'� P'fione 1l �d '�7/• �0�0�� _ .. otTicial use only do not w�ite in this area to be completed by eiry or towa oflltial ciry or towe: Y�M�DT$ r�niNieense a - P� nBuiiding Department cheek if immediate res ❑Lieeasiog Board ❑ ponse i�required 261 �Seleetmen'�ORice (508) 398�2231 eat, �Hnit6 Departmeat contact person: phone p;_ __ _ nOther j ... .� � ��,; ( , � ,r, , �. TowN oF Y�ou� ' BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-035 FEE: 75.00 i � In accorclance with re�ulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of tbe General Laws,a pennit is hereby granted to: __ Christmas Tree Shops, Inc., 511-525 Route 28, West Yarmout MA � � Whose place of business is: Christmas Tree Shops, Inc. ; � Type of business: Retail Food Service less than 25 000 square feet � � To operate a food establishmem in: Town of Yarmouth Pernut expires: December 31, 2004 Bo�tD oF HEALTH: ,Be�r�-.�rsu.�f. �j'�, �f.$, • /��/c`.��of#, ?/ice G'��xa� Rodeq��B� G�l�r�fs � �1�, R.�V. � January 29.2004 ruce G.Murph3',MP , .,CHO � Dire.ctor of Health � � � �, �� HEALTH �S�s T�- (w y> .��;s'?.� TOWN OF YARMOUT�i,B(��,R3�(�F •o ' �{ '�y APPLICATION`�� f�l��'E�L�►�IIT-20 � I�, (�` i�� (� `jf � [� Y '•.. r.•'�S ��t.tl��_�� c � � a E• * Please complete form and attacl�l ne ` s�ary documents by Dec m��I,�CI07�� Failure to do so will result in the return of your application acket. � ' �-1 F�� _.� _ N r . # -51� A I / - T : S• {��- T ' . # - �775. D SS• ' POOL CERTIFICATIONS: The pool supervisar must be certified as a Pool Operator,as required by State law. Please list the designated Poa�f3peratarEsj-ane�atfiaeh-�ea��ef the certification to t�is form. L 2. Poal opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGER� - C�RTIFICATIONS: All food service establishments are required to have at least one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service 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 eew copies and maintain a file at your establishment. 1. 2. ' —_.PRR C(1N iN C`NA R(`YF., _ . _ _ _ i - �— � —_ _ � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEI LICH CERTIFI�ATIONS: ' 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. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# _B&B $50 _CABIN $50 _MOT'EL $50 _INN $50 _CAMP $50 _SWIIvIIvIING POOL$SOea LODGE $50 TRAILER PARK $50 WHIRLPOOL S25ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _TOB�CCO $20 L <25,000 sq.ft. $75 �O( �TOBACCO $20 � _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ ?5.00 *****PLEASE TURN OVER AND CUMPLETE OTHER SIDE OF FORM**'** � _ � ��.. , � � $ ADMINISTRATION , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Co�np�nsation Insurance. THE ATTACHED STATE� WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST B� COMPLETEI�AND SIGNED, OR ` � , �CERT. OF INSUIZANGE ATTACHEL� � � , . . . �R , , � � WORKER'S COMP. AFFIDAUIT SICJNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: t 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. f SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FbR THE SEASON. ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW j EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I � ; , 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 openmg. POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � closing. � FOOD SERVICE � i CONSUMER ADVISORY: � Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post r Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: + Frozen�sserts musfbe�ested on a monthly�asis�iy a�ate certi�Iab� '�`es�resu�s must�e sen�o�e�ealth � Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the i above terms have been met. ; ; OUTSIDE CAFES: , Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ; � OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: `/`�` !�a' SIGNATURE: �G �k'�i �/�/0 PRINT NAME& TITLE: ��Zd -✓)oC/P�l�� / { I 10/18/02 ' r • � � � � The Commoawealth of Massachusetts � � � Department ojlndustrial.-�ccidents ': � ; OI1Jceo1/�es�lostl�is 600 Washington Street ' „-` Bosron, Mass. 02111 �'" �� Workers' Compensation lnsurance Atfidavit Agolicant informallon: PlessePR�'T'ie¢._'� namr location� �t� o�ne� � I am a homecµner pertorming all work myseif. � I am a sole propri�ror�r.� ha�e no one «orking in am•capaciry �j i ��*+_ an__�m__Tt��e�_pr�n�idin�w•ori�ers' compensarion for mr�empioyees w•orking on this job. m an • n 1 S ddress• `� i ur�nc OVL(Z• � � � I am a sole proprietor. general contractor, or homeowner(circ/e onel and ha�•e hired the contractors listed below ��ho ha�e ' the follu�.in� ��orker �ompensation polices: sQm�anv name• address• citv• phone f!• insur�ncc co. ooli �•# comeanv name• ' ---- - ---— —.___ —� -- ----- --—- — __--- _ � ad d ress. siiv: phcn��. insurance co. �gn,* t Faiiure to secure coven;e as required uader Seenon 25A of MGL lS2 n�Ind to the iopo�idoa o(tAsl�l pe�dtla of a d�e ap to 51,�00.00 a�d/or oae years'imprisonment as w•ell a�eivii peadNa io the form ot a STOP WORK ORDER asd a iise of SI00.00 a dar a�aio�t ma I r�denn�d tti�t a topy of thy statement mav be forwarded to the Of'(ice of lave�tig�tion�of tbe DIA tor eoven=t veriAqtio�, ; !do hrreby c ' •und r the ai nd rnalti�s j trjury that tht injonnation provided abovt is true and eorred . Y Signaturc � � /1��07 o�Q�'�' � Printname /�r��7,/ ��/CG l� Phonell ��7' �� (J i .- oRcial use only do not Mrite in this area to be completed by tity or town oQieial ciry or town: Y�M�DT$ _ permitAieenu M nBuiiding Department pLiceosio�Board �check if immediate respoese i�required 261 �Selectmen's Otfiu QHealtb Department contact person: - pfi��p�_ (508� 398�?231 eat. nOther � .. .� <�,., � , . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-014 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Christmas Tree Shops, Inc., 511-525 Main Street/Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops. Inc. Type of business:. Retail Food Service less than 25,000 sc�uare feet To operate a food establishment in: Town of Yarmouth � Permit e�cpires: December 31, 2003 Bo�n oF�A�,�: �l�a.;{� �cfUkac, ��ria� __ _ _ �e�fa+xt.�?3. C��. 7�D., 2/�e;e ,�o�art�. �zoa�c. � �a�� ele�c Skak. ,�.'�Z December 5 ,2002 ruce G.Murphy ,RS.,CHO Director of Heal � i i � I , � -.r " ,e ��'�f.�. G+fLt 5'�'�nFF 5 T7LEE �W�f> •� �... . � �:: R r - �'j �� F YARMOUTH BOARD OF HEALTH �� `� �� ~�k ATION FOR LICENSE/PERMIT-2002 �� ' �9/a'��S' �''�/.�Z_o�'� ��'"�'� � � �� ; * p ary y , o so will result:in Please com lete form and attach all necess documents b December 31 2001. Fail e to d the return of your application packet. � ` �_ � k ' NAME OF ESTABLISHMENT• �� s n,��—T�� 5 n,o. ,�... TEL #S�S•'17�-8tS! i.nC:ATION ADDRESS: S�l- a?S f'Yl�a�., S-!^. R-�. �$ ��[��p r,.+p�..�.� MAILING ADDRESS: 0'1/ 1 •)I,�-F�_n��- s , �l/.+rw.or_-�-� . 7'h� • oz,Ll.0 QWNER/CORPORATION NAME: [1�m,�y T.« ��,os, �'nc. MANAGER'S NE�M�: r�,a.�l �3 n � r��s�� TEL. # 7�k- 1-�S 1 t MAILING ADDRESS• �� ,.,, �� . 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. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. P�RS��ARG�:___ -----. _ ------__---- -- -- -- __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificatians 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: �'�'�)TAL# ^°�;. OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICEN�,REQUIRED FEE PERMIT# LICENS�REQUIRED FEE PERMIT# _B&B $50 _CABIN�`:;,, $50 _MOTEL $50 INN $50 CAMP ��'� $50 _SWIMMING POOL$SOea LODGE $50 TRAILER PARI� $50 WHIRLPOOL $25ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE ;�ERMIT# LICENSE REQUIRED FEE PERMIT# ; _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 COMMON VICT, $50 WHOLESALE $75 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 �<25,000 sq.ft. $75 �-OZC1 _TOBACCO $20 _<50 sq.ft. $45 >25,000 sq.$. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ 7S•O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � f > �_, . ADMINISTRATION i Under Cha.pter 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'$ COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGI�IED, OR, C�RT. OF.INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIG�IED AND ATTACHED Town of Yarmouth ta��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN j THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY 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 products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth 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. ' - - �_ _ _- --- - - -__ _ _ _ - __ _ _-—--- — - --- -- _ � FRn7.F.N 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. : I OUTDOOR COOKING: ; Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � � DATE: �I�O�D I SIGNATURE: �, �2e'G� /i�� PRINT NAME&TITLE: �'7 Z�,�j 2i� l�� I�aC�'�P/>>U� ( 09/11/01 � � i ; ,: , � - ' � The Coinmonwealth of Massachusetts � � Department ojlndustrial.-lccidents ; Ofllce o/Iar�s�loslliis : 600 Washington Slreet ' •' Bnston.Mass. 02111 ' �'~ �•y W'orkers' Compensation Insurance Affidavit ARolicant intormallon: P►essePRINT'Te�r+'iJic �� namr� ' location: �� nhone� � I am a homeowner pert�rmin,all w�ork myself. � I am a sole proprieror�r.,', ha�e no one��orkin_ in am•capacit}� � I am an employer pro�idino workers' compensation for my empio��ees w•orking on this job. comnanv name• rl �Y1�� P JF1ts►�S� r��• ddres : � ' � �, tiri•• _phone t1• �� insurance co. �1-�lIOU e2 L u Su rw n��. Ao�y a !,v I�r� ti( �'�f S �� 8S � I am a sole proprieror. ;enerai contracror. or homeowner(circle onu and ha�•e hired the contractors listed belo� �tiho ha�e the follo��in_ �sorkzr_ ;ompensation polices: comnanv n�me• address• citti�• phone M• insurancc co. ooli �•# �m�anv name• __ --- --- _ — —, __ ,___ _ _- _ _ —_ - -- - , a�dresr titv: nhoee At• insurance co�_ �p(�nr� t Failu�e to secure covenge as requ�red uoder Secnoo 25A of MGL IS2 ta�iud to tht iopaifioa otuisi�al ptaaltlef o(a 6�e op to 51,500.00 a�d/o� I� one ynn'imprisonment a�w•dl a�eivil penalHa io the iorm of a STOP WORK ORDER aod a(ise of 5100.00 a dar a�aiost ma [��dena.d mae a � eopy of th'n statemen[may be fonvarded to the OtTiee of Invati��tiom ott6e DIA for eoven`e verititatio�. ' /do hrreby ce }•under the P rns end p�n ltia ojper' that the injormation providtd above is tnte wed eonect Signature �2/ �/'/�/ � `j a�'D� Print name ��z��7 � /IliNP/1o�C. Phone J! `�� J`1��o�p � .. olTicial use onh do not+.rite in this�rea ro be completed by ciry or fown o111tia1 ciry or town: Y�M�IIT$ _ perrnitAicense M n8uildiog Departmeet , �Lieeasiog Board �check if immediate response i�required 261 OSdeetmen'e OlTice ' �Healtb DeQ�rtmeot contact person: ph�M;, (508� 398t?231 ext. �Other � I ♦ r TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-020 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: C' rittmac Tree 4h�, Inc_„�.11-525 Main Street/Route 28, West Yarmouth, MA Whose place of business is: Christmas Tree Shops Inc Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31,2002 BOARD OF HEALTH: ��?� �e�llikat ��%a�ca.� ��D�.�C�oadavc�D.. `U�ee �athick?�eDarnra�t S ,� March 29 ,2002 Bruce G.Murphy, .5.,CHO Director of Health �' . q � ";_��' � "`� N�rs trnRs 77Qa`5 N� cc1 y� � .- , }� �� r Q � � � � d � � � f„ TOWN OF YARMOUTH ; `f F :�TH p E� � g 2000 APPLICATION FOR LIC IT -200��t�t c��` HEALTH DEPT. * Please complete form and attach all necessary documents by December 31, 2000. F e o o so wi result in the return of your application packet. -------------------------------------------------------------------------------------------------------------------------------------------- NA1V(� (�F F�TAAi T�HMFNT• �'hri�s�-mas T�c� �Shop,s zi-�c• '�E�,, # S�S-?7l- 8/5� i.nC'ATION ADD,�,�S�• .�IJ-S'25 Ma�n �S+ �Zf a8 wes+ �a�mo�rH ��AiI 1NG ADDRESS• a�� ,�h� t�s PAr�+ a Sv� YAR.nnocrrH� mA ,d�by OWNER/CORPORATION ME� hr+s-IrnaS T'r�� Shops Znc . �VIANAC7RR'S N�VIE� Ai me� �Na TEL.# 568-771-4151 �,Cx A�t ,DRFSS• �ame as �t,h�re POOL CER',�'IFICA�ONS: The poal $upervisor must be certified as a Pool Oper�tor, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. l. 2. Pool opera.tors must list a minimum of two emplayees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. �INLi.ICH CERTIFICATIQNS: 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 maintaiu a fde at your pla�e of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SM4KING SEATS: TOTAL# ; �._WM.'_.._---�--�--�------------------------- ----------------------- -- -- _ _ _ _ _ ___ _ _ . __. _ ___ __ OFFICE USE ONLY . .. ._ . LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 �SWIMMING POOL $SOea. �WHIRLPOOL $25ea. FOOD S�RVICE: NOTE: Per the new 105 CMR 590.00(1 State Sanitary Code for Food Establishments,the eff'ective date for food protection manager certificallon is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 TCONTINENTAI, $30 >100 SEATS $150 NON-PROFIT $2S COMMON VICT. $50 WHOLESALE $75 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.R. $45 _TOBACCO $20 �<25,000 sq.ft. $75 0I-OZ TFROZEN DESSERT $35 , _>25,000 sq.ft. $200 � �1AME CHANGE: $10 � AMOUNT DUE _ $ 7S, 0 a *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r � _.. �. � �— . ��; � � �' f �, . �� " i �� :,_: ADMINISTRATION , f Und�r C`�� ,,�e�� '25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of an�y`�icense or`"�"-m��'t�o erate a business if a erson or com an does not have a Certificate of Worker's Pe P P P Y Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF iNSURANCE ATTACHED - : � , WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V 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:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHI��NTS 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. �DITIONAL REGUL T,�IONS POOLS POOL OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establishnnents which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CAT�RING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporazy Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �'ItOZEN 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. QUTSID " ' ' Outside ca es(�tdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE• '/ ' I NA �� G �� . lo� 3 G� s G �ruxE: �-2� � PRINT NAME&TITLE:� '{�i �. �o�'�C,� ', 11/16/00 �Q(,Y� i�1 , Coord�na.-f�r� ' ; � ; r ,- z � The Commoawealth of Massuchusetts M W Department of Industrial.-1 ccidents � ; OIIICQ 0//OYeSd�l�//t � � 600 Washington Street , �.� Boston, Mass. 02!11 "� W'orkers' Compensation Insurance Affidavit A,00licant informatiom P`Ieas�PRi1QTTe�ii� mm�� location• cit� p_h_one# � I am a homeowner pertorming all work myself. ' � I am a sole proprietor�r,� ha�e no one ��orhing in am•capacity (� I am an employer pro�iding wor__kers'tompensation for my employees working on this job. com�an�• name• �I^I ��S ��Q-- ��l�S , �L • �ddress• �f !�� iC� • YQ./'�'1 42J'�l� ��{ �y.. nhone t!• insur�nce co 7l��i� �-1�/►J�UI'�Q..l�)C� Aolicy��M��4� � I o 5 � I am a sole proprietor. _eneral contractor, or homeowner(circle anel and ha�•e hired the contractors listed below� «ho ha�e the follu«in��orker� �ompensation polices: nv n addresr � Ahone l�• - i�sur�nce co Ro��}'# an addr sa• -- ' �,. nhone#• _ insurance co R�Y� Failure to sccure coverage as required under Secdon 25A of MGL 1S2 a�lad to t6e ioposidoe oterisi�l pe0altla of a 6�e op to S1,500.09 a�d/or one years'imprisonment as w•elt as civil penalties io the form of a STOP WORK ORDER aod a fioe of 5100.00 a day at�in�t ma I e�denta�d tbat a eopy o(thy statement may be forwarded to the ORee of Investigatiom ottht DIA[or eovengt veri6tatiw. /do hrreby ce�'}� der�he pai s a e lties ojper' tha>>he injormotion providtd abovt is hue and eorrtet Signature �� ` � I �— � `� -�� ( Print name ' ( Phone# ��g "�Gl`t � �Zb� .• o(Ticial use onl�• do not M rite in this are'to be completed by ciN or town otfieial � ciry or town. YARMOIIT$ _ permit/lieenu p nBuildiog Dcpartmeot ' �Liceasing Board �eheck if immediate response is required 261 QSdectmen's Offiee ', OHralth Department contact person: phonc q;_ �508� 398=2231 egt. nOther Irevned 3;95 P1A1 �....��. r � : .� � ^CJ �C�• � � Q� r�i � � z w ° �� o �A " >;� . � `"�" � ��O \ �� ' � �x � � °� � � � ° � � � o x � �� `� � t� t� - °' °' H x � w a, �; �_ G�A � [-� W °� � O � A .o� � � WO �� x �" " � ' N �„� � O � d � � � W � F 'b � � 3 � Q � � � � p�Q C p.1 p,� � „ •� � E� 0 � � O � � , � � i"' N �o�n ,� G�'' .� '��" ~ � � � � ,�.� v� a 3� •� r� .� � W c°'i� � � ,b o � �� 4r � 0 N � o� � •� � � ^ �� A. M I—�� S U f.s� ,� � � � � o ^ � � � o � � a � � H a `� _ �l�r'�S�i �x�S I r��Shc�, f n _ ,� 1 r�C� TOWN OF YARMOUTH BUARD OF HEALTH �'�" ' -., r�: n rJi f��, D APPLICATION FOR LICENSE/PERMIT-2000 � � � ~�" �� s� �'��c� �� Q��.� '� 0 1999 * Please complete form and attach all necessary documents by December�,;3�; 1999. �ailu to do sQ wi�l��t i ,the return of your application packet. � 4``�'�-` `` ' ------------�E------------------------- ��--�-- -------- -- -- ------�----------------------�--��]71'---�---• � L A I //:S� �3i�'I . : . L D �' ' � ; � , # , ! � f POOL CERTIFICATIONS: T6e poot supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the f designafed Pool Operator(s) and attach a copy of the certification to tlus form. 1. 2. ' Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of : employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. �[�[,��CH�ERTIFI�ATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich , Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. I�STA�:1�T�EA'�Il�:`'FOT�i,# : �I�k-�Mfl��:-TQ��# —.- ___— _ _ � ------______�____--------------------------------------------------------�---------------------------_--_---_--__-----____--- ------------• OFFICE U5E O�Y � LODGING• ' ; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CAB1N $50 ' INN $50 CAMP $50 ' LODGE $50 TRAILER PARK $50 MOTEL $50 SVVIl�IlVIIlVG POOL $SOea. WHIltLPOOL $25ea.. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 I <25,000 sq.ft. $75 y��l�L FROZEN DESSERT $35 >25,000 sq.ft. $200 ', NAME CHANGE: $10 � AMOUNT DUE = $ �,7" *•""•PLEA5E TURI�i OVER AND COMPI.ETE OTHER SIDE OF FORM""'" � � � � - .� - ADMINISTRATION UNDER CHAPTER 15�, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED ' TO HOLD ISSUANC� OR RENEWAL OF ANY LICEN5E OR PERMIT TO OPERATE A BUSINESS TF � � �PERSON OR COMPANY DOES N4T HAVE A CERTIFICATE OF WORKER'S COMPENSATION { ITV�I7R�i�iCE. THE'ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT � MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACi�D _ � ` A � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ TOWN OF YARMOUTH TAXES AND LIE MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR.PERMITS. PLEASE CHECK OPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR � RESPONSIBILTTY TQ RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS�-IlVIENTS ARE TO CONTACT'THE HE.ALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR T4 OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POO�, (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE�EPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO I COMMENCEM�NT. RENOVATIONS MAY REQUIRE A SITE PLAN. t AI?DITIONAL REGULATIONS I PUOLS POOL OPENIlVG: ALL SV�G, WADING A1VD WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND THE WATER TESTED FOR � PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDUOR IN GROUND SVVIM1VIITiG POOL MUST BE DRAINED OR COVERED ' WITHIN SEVEN(7)DAYS OF CLOSING. k FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TF�TOWN OF YARMOUTH MUST NOTTFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 � HOURS PRIOR TQ T'HE CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT THE HEALTH ' DEPARTMENT. � LQ EN nEp S�Elll S. � FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI-�E HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI-� � SUSFENSION OR REVOCATION OF Yt�UR FROZEN DES SERT PERMIT UNTIL T�-�ABOVE TERMS HAVE __ _ ___ _ _ _ _ - - - - -- _ _ � BEEN MET. -- - _ QUTSIDE CAFES: OUTSIDE CAFES(i.e., O[TTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR CO,QKING: g OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT B A RETAII,OR FOOD SERVICE ESTABLISHIVIENT IS PR4HIBITED. DATE: �a•�'�/ SIGNATURE: !/.��'! C �/ w � 7Z � n i PR1NT NAME& TITLE.L�'" C'�i+�-� �lc=�J l��, �I�'1!� �� , 11/12/99 � ! � � f �� The Conimonwealth of Massachusetts � � Department ojlndustrial.-�ccidents " T � Offlceol/eves�lOs�liis 0 600 Washington Street ' ` Bnston.Mass 02111 , , �% " �� w'orkers' Compensation insurance Affidavit �R[�licant information: PlessePR�7'Ti�.'hi�r namr� location: : �tt� nhone# � I am a homeow�ner perturmin;all w�ork myself. � f am a sole proprieror �� ha�e no one ��orkin� in am•capacin� /��I am an emplover pro�iding w�orkers' compensation for my employees w•orking on this job. l.�'"�.�— ---- — ` �� , m n • n �,. dres : J / t citv: nhone t1• iosur�nce co C7LCJ' I � � ��y� �� 1�� I �m a sole proprietor. generai contractor. or homeow�er(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in� �.orker� �ompensation polices: comoanv name• address• citv: phone q• , insur�ncc co. �olicvll comoanv name• address• T �ri: phoee M• insurance co. po�nr* t Failure to seeure coveragt as�equired uoder Secnoo 25A of MGL 152 n�iad to t6e iopaitioa oteri�iafl peaaltle�of a 6�e op to 51�00.00 a�d/or one years'imprisonment as w�ell as eivil pcnalda in the fo�m of�STOP WORK ORDER aed a Ase of 5100.00 a day apinst ma t s�dersta�d t6at a copy of thh statement mav be forw�arded to tht Oflice of leve�tigatiom of tht DU tor toven;e verifiutia. /do hrreby ce '}•under the parns prn r� oj�erj that�ht injormation providtd obov�t is trrre and eor►td Si naturc �C'' `��w�� 8 Print name � �. � / one�Y �d� �97'�� ' .- oRcial use only do not w�ite in this ara to be tompieted by cih or town oAftial ciry or tow•n: Y�M�IITR _ permitAicease p nBuildiog Department pLieensing Board �cheek if immediate responst is required 261 OSelectmen'e ORce �HeaitA Department contace per�on: phone 1t;_ (508) 398—�Z31 e�t. nOther , .. ._� .,,, ! TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: Y2K-41 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: C:hristma�Tree �h��, inc., 511-52 M in Str !R� � R, West Yarmo � h,1��A Whose place of business is: Christmas Tree Shons Type of business: Retail Food Service less than 25 000 saua�r�feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d �f. �gf��, C'�irman �oan� �u[Livan, K.I'/., Vice C,hai��na Ko�ert,}. a,rown, C,ler� abrielCe�a�ZoG�t�iy-../�tooped ///ichael aCo hlin � Janu ,arv 24 ,2000 Bruce G. Murphy,MPH, R. ., C Director of Health Mas�achusctts G�neral La��s c apter i�.. se�uu�� _., �..y...•----- -- _,___, _ _ e111p1��ees. .�s auoied from the "1a��'�. an en:plot•ee is defined as e�•ery person in the service of another unac� a��; contract of hire. express or implied. oral or wntten. �r !u�•er is defined as an indi�idual. partnership, association. corporation or othfa'deceasetd emplove o�hemore of �n e► p . thr fore�_oin� en�,�a�_ed in a joinc enterpnse. and includin�the legal representatrves o 'o �nQ em io��ees. Ho«ever che recei�er or trustee of an indi�idu31 . partnership• is�ee�at rtmentshand who rets des here n,or the occupant of the o��ner of a d�tiellin�= l�ouse ha�in� not more than h p air woric on such dwelling house d��eil;n� house �f anotlier�tiho emplo��s persons to do maintenance , construction or rcp , ��n chz �_r��u��Js �r buildin�� apPurtenant tflereto shall nuc because uf such emplo��ment be deemed to be an emplo�zC. �r _ `iGi_ �I�a�cer i`= �ecci�`" '-` a�� tates that e��er�� state oio cunstruct bu Idings inhhe'commoin tealth for an or renc��al oi a license or permit to operate a bus�ness or ;i licant ��ho h�s not produced acceptabie e��idence otcompliance�'�nh shall entec�into an�onvact�forrth rr� .�ddicionall�. neither the common��ealth nor am• of its polincal sub iv�s�o ' rmance of ublic ��ork until acceptabie evidence of compliance with the insurance requirements of this chapter ha� perto P b�en prese»ted tu the c��ntractin^_ �uthor�t�. �ppiic.:nts ' ' the �yorkers' compensation affidavit completelv,by checking the box that aQpl�es to}�our situation and Please t�il in .' ,* com am names. address and phone numbers as all affidavits ma�� be subaDd date t6e�aftida i�t The suppl. �n� p . lndustriai �+ccidents for contir h21O i°or touvn that he application for the permigor license +s being requested. aftida�it should be returned to , uired not the Department of Industrial .accidents. Should vou ha��e an�q teat the number 1 sted belowor if you are req to ohtain a ��orkers' compensat�on p o l i c��. p l e a s e c a l l t h e D e p a rt m e n r a � .� Cl�ris�mus�rc��'"' -x-�, ,� � �� ,._,� '1rJ`� ^��, � � TowN oF YA�ouTg so��►��' 9�E�L� ;� Q C� C� C� � M C� D APPLICATION FOR LICEN��/P �# «�19�9�°' �3� �' DEC 1 0 1�q8 * Please complete form and attach all necessary documents by December 31, 1998. Fail re to d0 o 11 ult n the return of your application packet. HEAL�H�3E�'�. ---------------------�------------------ ------ ------�------J�-� ----- -----.�-�-----------L:-#------�l�/3- A I D :�' -3 � � Ta � r>i M •a l.v � .S h� � YI� RA N N 2!S � : N.�ANAGER'S NAME� Ai�-e� ��Tl O TEL. #�Y 7`7/ /5"/ MAILING ADDRESS� cSHm� �S � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the . designated Pool Operator(s) and attach a copy of the certification to tlus form. _ - _ _ i 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardio�ulmonary Resuscitation(CPR). Please list these employees belaw and attach copies of employee certifications to tlus 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. ' HE�, ,ICH CERTIFICA I'� ONS: 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-cholcing 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 frle at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---------------------------___--- --- _ _ ---- _ —— O�L�-_ __ __ _ _ _ ,_ _ �, ! LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 C.ABIN $50 ' INN $50 CAMP $50 ' LODGE $50 TRAII.ER PARK $50 MOTEL $50 SWIMIVIIlVG POOL $SOea. WHIItLPOpL $25ea. �OOD SERVICE: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 N(�1N-PROFIT $25 — — _ - - - _ ._ ._------�__ i COMMON VICT. $50 WHOLESALE $75 j �7r�u.s��vr�F: i � LICENSE REQUIRED FEE �ERMIT# LICENSE REQUIRED FEE PERMIT# `'; _<50 sq.ft. $45 TOBACCO $20 ' �<25,000 sq.ft. $75 �� FROZEN DESSERT $25 _>25,000 sq.ft. $200 , �1AME CHANGE: $10 � AMOUNT DUE = $ � S�" "*"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*R R�Y R k � F � ADMINISTRATION UNDER CHAPTER 152; SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOLJTH IS NOW REQUIRED TO HOLD ISSUANCE;OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COlVIPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STA�E WORKER'S COMPENSATION INSURANCE AFFIDAVTT , MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORI�ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' TOWN OF YARMOUTH TAXES AND LIE S 1VIiJST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK AP OPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULAT�ONS ; ` POOLS � POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR t TI-� SEASON NIUST BE INSPECTED BY TI�HEALTH DEPARTNIENT,AND TI�WATER TESTED FOR ' PSEUDOMONUS,TOTAL CpLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVV[M1VIII�TG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. k FOOD SERVICE � CATERING POLICY: ; ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH 4 HEALTH DEPARTMENT BY FILING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT- I �ROZEN DESSERTS: ' FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERNIIT UNTIL THE ABOVE TERMS ___ _ HAVE BEEN MET. � OUTSIDE CAFES: .. ,�.� OLTTSIDE CAFES(i.e.,OiJTDOOR SEATING WITH WAITER/WAI , APPROVAL FROM THE BOARD OF HEALTH. OiTTDOOR COOI�ING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�VIENT IS PROHIBTTED. � �,I . v� � I DATE: I a`3 SIGNATURE. �� " � PRINT NAME& TITLE:��7d�c��'/ � �►`U C_��1 i G� i �OdL��n�� I � i ♦ J �� _ The Conimoawealth of Massachusetts ��'! w W Department ojlndustrial.-�ccidents ' ; 01I/ceo/%s�lost/iis 600 Washington Street •� Boston, Mass. 02111 ' '� ��y W'orkers' Compensation Insurance Affidavit Aoolicant informallon: p`►easeP�tIl�7"Teaii,Tv: . . � namr: location: �it� �hone k � 1 am a homeowner pertorming all work myself. � f am a sole proprietor�:;� ha�e no one��orking in am•capaciry � I am an emplo er pro�idin� worl�ers' compensation for my emptoyees working on this job. _ i __ __ _ - - ,^---� -- _ - /� - _ m a n • n . /G� � - .�.00..� �ddress: li� '�. ' O[ � //lJ Ps5 ��I7I C� , �� ciri•• nhone f1• insur�nce co. ��UZ/L-•�` ! o,,�� v ��$�y�� I am a sole proprietor. aeneral contractor, or homeowner(circle oneJ and have hired the contractors listed below� ��ho ha�e ' the follo��in� ��orker� �ompensation polices: , sompanv name• address• ci�y: ohone 1�• i � insurance co. policv# com a�ny name: - ---- - _ --- - ,aa��ss: — ---- _ ____. . � c�y: nhone 1!• insurance co. ,��f ', Failure to secure coverage as required under Sectioo 25A of MGL 1S2 ea�lud to tbe iopaitioe of erisl�al pe�dde�of a 6�e op to Sl*500.00 a�d/or one yean'imprisonment as w�ell as civil penaltie�io tAe form o[a STOP WORK OItDER aed a lise of 5100.00 a day apiost ma t a�dersta�d trat a ; copy of thu satement may be forwarded to tbe Of�ee of Inve�tig�tiooa of tbe DIA tor eoven`e ve�iliutiw. � /do hrreby ce ' •under�lre pains and ena 'es ojperju hat 1tit injormation provided above is tntt and eontet � Si narurc l�. �".�l� ��Y�� /O�'3' �� - i f � � { Print name �"�'��T'� �• ��G�'�� PhoneN ��/�� i i ., otiicial use only do not w rite in this ares to be completed by ciry or town oflleial � city or town: Y�M��T� _ permiNicen�e N nBuildiog Department i �Liceasiog Board �check if immediate response is required 261 OSdectmen's OtTiee I (508} 398�2231 eat. OHealth Departmeot f contact person: phone p;_ __ _ nOther ! � � Ire�-ised J;Oc P1A1 . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-18 � FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ('hri�tmac Tree Shonc�, Tnc , Sl 1-525 Main Street/R�Lte 28� West Yarm� � h, MA Whose place of business is: Christmas Tree Sho�s 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, 1999 BOARD OF HEALTH:�d�/. �et��, C�ar.�►� �oan� �ullwar�,KD.//.s �ice C..hairman. Ko�art.J. 9�rouin� l,lar� a�rielle�akoG��-J�tooped ic�el � oa��fin. v�b�i� . 19 98 ruce G.Murphy,�x,x.s., o Director of Health i i i , i � � � i i