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Home My WebLink AboutApplications, WC and Licenses ¢� �. ��:��^� � �� ► TOWN OF YARMOUTH BOARD OF HEALTH s � 0�'#�2Z� � i � �` APPLICATION FOR LICEN$E/PERMIT-2009 `,�� r�D��• � � 2008 �� Ow e � E * Please complete form an d attac h a ll necessary documents by Dece m ber Z S ��-�-� ��pT. Failure to do so will result in the return of your apphcat�on pac �_t. -'�� "�� i NAME OF ESTABLISHMENT: � � TEL. # ��—�� g� ' LOCATION ADDRESS: ' + � r-l- � MAILING ADD SS� — I j OWNER NAME: TAX ID FEIN or SN : � ! CORFORATION NAME (IF APP CABLE : MANAGER'S NAME: � TEL. #��,��-�L.�.�(ro�- l 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 nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIQNS: 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 wilt not use past years' records. You must provide new copies and maintain a file Rt your establishment. L � 2. �� PERSnN IN CHAR.GE: 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 tunes. Please list yaur employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4• RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# : B&B �55 _CABIN $55 _MOTEL. �55 INN S55 _CAMP �55 _SW�vIMINGPOOL �80ea. LODGE S55 _TRAILERPARK �105 WHIRLPOOL �80ea. FOOD SERVICE: _ -- -- -_ __ _ _-- _ -- - ---_ _ ----- _ LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S85 _CONTINENTAL �3� NON-PROFIT �30 >100 SEATS �160 �COMMON VIC. �60 WHOLESALE �80 RETAIL SERVICE: _ - —RESID.KITCHEN �80 'I LICENSE REQUIRED FEE PERNIIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �I <50 sq.ft. �50 _>Z5,000 sq.ft. �225 VENDING-FOOD �25 �<25,OOOsq.ft. 580 D -U�J�I, —FROZENDESSERT �40 I TOBACCO ��5 �oy-�� va:�zE cxa��cE: �io AMOITNT DUE = S 135 •00 ***"'*PLEASE TLTR�'V OVER AND COMPLETE OTHER 5IDE OF FORM*"*** 1 � , � } , ! �' a� i ,' ADMINISTRATION � Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � ' MOTELS AND OTHER LODGING ESTABLISHI��NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short terrn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy , Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. �, � I'�, i POOLS � ; POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected ' by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standaxd plate count b a State certified lab rior to o enin and uarterl thereafter. Y , , P � g q Y POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of ' closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required j Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. ; FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: ' Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN TI-� COMPLETED RENEWAL APPLICATI�N(S)AIV'D REt�UII�EI3 FEE(S)BY I3�C'�MBER 15, 2008. j ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW f EQUII'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR � TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' � DATE: � SIGNATURE: � PRINT NAME&TITLE: � g ; T�X �fanager i o�2 i,�os k The Commonwealth of Massachusetts Department of Industrial Accidents l�CBOf/RY�BdBQS 600 Washington Street Boston,Mass 021II Workers'Compensation Insurance�davit-General Businesses Applicant information• Flease PRINT''leQiblv '" name: CtJMBERLAND FARMS INC. ��.�5; 777 DEDHAM STREET citv' CAl'3�OI� state•1�' av 02021 nhone#: (781) 828-4900 . work site location full address : I am a sole proprietor and have Business Type: Retail Restaurant/BarBaring Establishment no one worldng in anycapacity. Office Sales(including Real Estate,Autos etc.) 8 I am an employer witti 6092employees(full&part time). ��' I am an employer providing workers'compensation for my employees working on this job. comnan�name CUMBERLAND FARMS �1� � �� address: �3 � , ci . hone##: � 0� � --�� ! { insurance co ILLINOIS N IONAL INSURANCE CO policv#•WC 19 288-6�� : ,. , , , ;; ,,., ..;., h ..' .+�� (� I am a sole nroQrietor and have hired the indeoendent contractors listed below who have the followin¢workers'comnensation nolices. com an name• address• citv ahone#• _ insurance co• uolicv# . � �,.�. - ; �.: aM�:,�`,�-''! com an name• address• ciri ahone#: _ insurance co• aolicv#• _ w Attach,additional::sheet.if�neCessary °°�` Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penaities in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understaad that a copy of this statement may be forwarded to the Office of Investigat�ons of the DIA for coverage verification. I do hereby certt;fy under the pa' s an e ' of p at the information provided above is true and correct Signature: Date: �� Printname: RICHARD FOURNIER Phone#: �781)828-4900 official use only do not write in this area to be completed by city or town official city or town• permitllicense#: Bnilding Department Licensing Board ❑check if immediate response is required Selectmen's Office Health Department contact person: phone#: Other (revised Sept.2003) i i � 7 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-037 FEE: S80.00 In accordance�vith regulations promulgated under authority of Chapter 94,Section 30�A and Chapter 1 I 1,Section 5 of the General Laws,a permit is herebv granted to: Cumberland Farms Inc., 1297 Route 28, South Yarmouth, MA Whose place of business is: Cumberland Farms #2262 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�ett S�, ✓`�../v., ��cti�r�tean C'%f cr�c�eo .� ��e�ili�ae `Uiee Chavrrnar�c JZv.�ct �.�l3�ruua�a, f'� Qn,r.�eert�acern, J�t..M'. Eae�n P• ��aye� lanuarY 8,2009 ce G. Murphy, ,R.S.,CH Direetor of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-026 FEE: S55.00 This is to CertifV that Cumberland Farms Inc. d/b/a Cumberland Farms#2262 1301 Route 28t South Yarmouih, IVLA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�er�it is�ant��i i��8�forn�in��vith Article VI of the San�ar��Code of The Conunonwealth of Massachusetts,and exp es ecen er � ess sooner suspended or re�•o e . January 8,?009 BOARD OF HEALTH: .`�E¢�ett S�R� �..lV., C�,ll�ctlilrtt t��pX�eO .�. ��I�PJ�G, �ICC ��InlruuL J� �.�K4[Uft� ��..�PJlI� QN,ft. (�pitllL� �..lV. � ruce . urp y, P ., Director of Health �' ` e.eM,�. �ZZ6Z r�`=Y'�k� TOWN OF YARMOUTH BOARD OF HEAL � $��;, APPLICATiON FOR LICENSE/PERMI�2 �"� � � � L I� � � � s �.,�; � � ., � ; , .��,�� f3 ;� ��u8 *Plea,se complete form and attach all necessary�c�ocuments 1� ecemb r 31 2007 Failure to do so will result in the return QfyoiYr a,��Yi"cation pac tH�A'L.i��-; v�PT. � NAME OF ESTABLISHMENT` � .- L� TEL. #_�_ � � LOCATION ADDRESS: _.. O MAILING ADDRE :" OWNER NAM�: VTAX r N � CORPORATION NAME IF APPLICABLE): '�"�' `—' MANAGER'S NAME: �, `3 TEL. # ` -, �.k_��3 _ _T. MAILING ADDRESS:`— � p :. POOL CEI�tTIFICATIONS: 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�ertification to this form. 1. : 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. T�te I�ealt� Dep�rtment will not use past years' reeords. 3�0� �n�st pravide new copies and maintain a fde at your place of business l. 2. 3. 4, ��..�,�,� FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Flease attach copies of certification co this applieation. '�he He�lth Department�viH nat nse pa�t years'records. You must provide new copies and maintain a file at your establishment. 1. �, _. P�.RSS�I�N��AR�E�__ __ –__ _ ___ __—_— _— __,__--- -- - ------------- ----- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in.tl�e Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employ�e certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'�+IIT� LICENSE REQLiIRED FEE PER'�dII'# LICENSE REQL?IRED FEE PER'�IIT� ,B&B 550 _CABIN S50 _MOTEL SSO _� �$d _CA1�IP S50 _SWIVLVIINGPOOLS75ea. _LODGE �SO _1'RAILERPARK S100 R'HIRLPOOL S75ea. FOOD SERVICE: LIC£NSE REQUIItED FE£ PERMIT# LIC£1*1SE REQLTIRED FE£ P£Rl�iIT� LIGENSE REQUIRED FEE PERIYIIT= _0-100 SEATS S75 _CONfINENTAL S30 NON-PROFIT S2� >100 SEATS S150 _C0:1rL'�ION VIC S50 Vb�IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERVIIT= LICENSE REQL'IRED FEE PER�IIT� _<50 sq.�. �45 >25,000 sq.�. S200 VE1V'DIIvG-FOOD S'0 : �<25,000sq.ft. 575 OS�Q .3 _FROZENDESSERT S35 / TOBACCO S50 ��Z NAl1�CHA\iGE: sio r AMOUNT DUE _ $ /2.5. pn *****PLEASE TL'R.\OVER A.�'D C0�IPLETE OTHER SIDE OF FOR�Z*w*«* � � � ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSIJRANCE AFFIDAVI�'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCITPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. ' Transient occupants must have and be able to demonstrate that they maintain a principal plaa,cee of residence elsewhere. � Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an � aggregate of not more tha.n ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or E dwelling unit sha11 not be considered transient. Occupancy tha.t is subject to the collection of Room Occupancy " Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with this application. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( days pnor to opening. � POOL WATER TESTII�TG: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening; and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of E closing. FOOD SERVICE i CATERING POLICY: ` Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmeirt by filing the required i Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the ` Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must ha.ve prior approval from the Board ofHealth. � OUTDOOR COOKING: ` -- __ _ �tf}8pp- ' � . . i��f�xt�tl��f>t3t�5Cft�1CC�CSt`d��tS�2t1C11t1S�1�0�i1�C�.___ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN � THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENC)VATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RE:VOVATIONS MAY REQUIRE A SITE PLAN, , • a � � � DATE: SIGNATURE: ` . Ii PRINT NAME&TITLE: �iah�rd F4 � I io;o n� : . . ' �,. .��.�..`;. .r - �=__:_� The Cammonweadth ofMassachusetts ��- �� Department of Industrinl Accidents " F• �7�J ^ O�/ � ,� � � 600 Washington Strest �� ,% Boston,Mass 021�1 , �� Workers' Com ensation Insurance AfFdavit- . % General Bnsinesses - - - - � name: .... _ - .. • address: �TT �tbX�t (.�`M.63� . � . , Tax ID �� .� �.t-` � C'C J`7�� 1fJ � � �p � �� citv A'�.�n�t,'1n � state• zin'0o th�( phone�fl 1� �1 - r " � �^f� 6� work site location(full addressl: � 0 I am a sole proprietor and have no one Business Type: �'Retail0 Restaurant/Bar/Eating Estabiishment working in any capacily. ❑Office(�Sales(inclnding Real Estate, Autos etc.) �I am an em�loyer with/�em.loyees(full & art time). ❑Qther � '�//.1/L/_///%//////////%%%%%%%%//////%�//// ///��///%/////%%%%�%%%/�//�////%//%%/////%%%///////��% %%�%%%//// �I azn an emp2oyer providing work 'compensation for my emplovees woFking tm his;ob. : , ;,, � com an name- . �^ - � . . ��rs � � � _`� c�a ,�n� � �,�' . . .. . _ eaa�ss- . � ci : , . — . . : . . : . . :, .. . _. �hone�`: l� � ^ .�.�. _ l� - . - , . .. . . ...._ insur•a�e co_ ` ' � � oIi .#k� • . .. �/. ❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workeis' compeusation polices: comnanv name: � � • ' address: citv: . . pIione#` insurance co. � � � � olic #. � ;. . . . �:::.� .. .... . . .. .: : . . . ..�.. .. ..;:• ,,.. : . .... .•. : . .. • . . .. . . .,. . . . . . . •. : . . ..:. ... ... �_ %%%%%%� comuanv nsni�:• . ' . � � . � ' :. - ' • � • .' .. . address- � citY: . . �— . � . � . . -.. — UI1�U0@# ' insurance co. . ... • � olic :#. ' Fallure to secvre coverage as required�mder Section 25A of MGL 152 can l�ad to the imposition of criminal penalties of a flnc up to$1,500.00 andlor// ' oae year�'imprisonment as we11 as civil p.eaalties in the fotm of a STOP WORK O;2DER and a finc of$100.00 a day against ma. I undeistand that� copy o�this statement may be forvwarded to the Office of Invntigations of fhe DIA for covetage verifieatlon I do hereby certify under t ' s a p ' of rjury lhat the informaYina provided kbove is true and c ert. Si�nature Date � �� 1 C'�� iohsr `r �t� ��e� ��°�[ ) S2 �- �-�oD o�cial use only do not wi�ite ia this area to be completed by city or town off3c1a1 city or town: � permit/licanse#f QBullding Depariment ❑check if im.medieGe response is rcquired �Llcensing Board , ❑Selec�en s 083ca OHealih Depar�ient conmct peraon: phone#; ❑Other ' (ievaed Sept 2003) . . � s TO�1�1 OF YARMOUTH ; BOARD OF HEA�.TH j PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #U8-043 FEE: $75.U0 In accordance with regu1ations promulgated uuder authoriry of Chapter 94,Secrion 305A and Chapter 111,Secrion 5 of the General Laws,a permit is hereby granted to: Cumberland Farms Inc., 1297 Route 28, South Yarmouth, MA Whose place of busiriess is: Cumberland Farms#2262 Tyge of business: Retail Food Service less than 25,U00 square feet To operate a food establishment in: Town of Yarmouth ` Permit expires: December 31,2008 BOARD oF HEALTH: �Eelen S�:acR�, J�..N., U'$aL�rn�cut C'�ee �.�CeP,ti�c `tlice C'f�ar�acn:acri �ear��.�ti�acu�n, e� Qnn(�ceert.�rxxun, S�..N. � ��. � 7anuary 25,2008 B ce G.Murphy, , .5.,CHO Director of Heaith _ ___ _ _ _ _ . _ _ -- _ THE GOMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-032 FEE: $50.00 This is to cerrify that Cumberland Farms Inc. d/bla Cumberland Farms#2262 1301 l�oute 28, South Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD flF HEALTH TOBACCO REGULATION. This�e r�it e�ant��i��8�for�'t�y with Article VI of the Sani�er�Code of The Commonwealth of Massachusetts,and exp s ec r e s s�ner suspended or revo January 25.2008 BOARD OF HEALTH: .��CIt S�, ✓`�.N.,Cl�avcnurn �R�a�ea .��'�eUi�c, `llice C!fta,ixrrucri - �s.��cauun, ('� c��., �.�v. Director o Health� ' . ., H � � a p2�f5b�3 �fr'4.� TOWN OF YARMOUTH BOARD OF�EALT � -� - � _ ''� APPLICATION FOR LICENSE/PERN� � °�;, .�_ �,� ��;-, �� JAN 0 3 2006 * Please complete form and attach all necessary i��nen�s tiy'Decem r L Failure to do so will result in the return of your application pac t�� DEPT. NAME OF ESTABLISHIVIENT: � TEL. #,�g��'�/�`'9 LOCATION ADDRESS: Q,�(� MAILING ADDRESS: U�D�/ OWNER NAlV�: T ID E or S : - CORPORATION NAME APPLICABLE): MANAGER'S NAME: . TEL. # - MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,�s required by State law. Please list the designated Pool Operator(s) anc�attach a copy of the certification to t�is form. - 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to this form. T6e 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 PR�TECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food ProtectiQn 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. _ PERSO�V-�N CI�ARGE: _ _ _ __ _ _ _ _ _ __ __ ____ __ ._ ___ _ , Each food establishment must have at least one Person In Charge(PIC} o�site during hours of operation. 1. 2. HEIlb��CH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and , attae�i-cvpies 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. RESTAITRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSB REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 iINN $50 CAMP $50 _SWIlvIRiIING POOL$75ea. _LODGE $50 _T'RAII,ER pARK $50 WHIRLPOOL $75ea. FOOD SERVICE: , LICENSE REQUIRED FEE PERMIT# LICENSE 12EQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# �0-100 SEATS $75 CONTINENTAL �30 NON-PROFIT $25 ' _>100 SEATS $150 �COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERNIIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 I QS,OOQ sq.ft. $75 O(�-0�{ _FROZEN;�ESSERT $35 �TOBAGCO $25 (Ns"O,3D NAME CHANGE: �10 = - AMOUNT DUE _ $ �a O .00 "'"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMRR!l�tR f - � � . � � z _ I i ADNIINISTRATION ; Under Cha ter 152 Section 25C Subsection 6 the Town of Yarmouth is now r uired to hold issuance or renewal � P , , , �l of any 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 WORI�ER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � 4 CERT. OF INSURANCE ATTACHED k OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES� NO , NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. ; SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO � COMIVV�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. � i i ADDITIONAL REGULATIONS POOLS ! POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. j 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 aze required to post Consumer Advisories. ' CATERING POLICY: ' Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. � FROZEN DESSERTS: _ ��oL�a�uz��ti�-�txs�-�e teste�cm�-r�en��y�asi�by a-St��e e�rt}fied-lab:--'��sult�must b��to-tl��Ie-a�tl� 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. ; i OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. DATE:1,�� SIGNATURE: J PRINT NAME&TITLE: Richard F r � 1 i � � 09/28/OS ! I � � _ :. . �`� ��_-=� The Commonwealth of Massachusetts - Departrr�erit of Indus�rial Accidents � __ - �N�I�i _ _= 6D6 Washiagton Stre� 7`"`Fl+oor _ ;,, Boston,Mas� 021I1 � Work�s'Ca��aaho�I�m�aice Affidav�t:Ba1 ' bi�lEledncxl Coatraeta�s ,_ ., v_. . _ ,.�� . �, • -�1,� name: �' � _ addccss: 0 • � �,� �398 �89 �ty san• zir►- nhone# �8-�1'Z5�'��f5� work site locati�ffull addressl: p I au►a homeO,xn�perfo�ing su Wa�C myself Pro;ecc T,rpe: ❑xew ca�cc►o�pReanaaPa I am a sole and have no�e w in an Buil ' Additi,on _I am an�np1oY�_P��B wackeis'compensatia�fa�my employees warkin��this�ob. _ ___ _ _ �r a�ae: L(��'rY1 tlJti �l /.� � l�'tf . _ _ ��o��, � � �� .C��f-� ��1 ,��: 7 g�- o��-�°x� . . , pq ❑ I am a sole proprietor,ge�a�ai costractor,or�eaw�er(circk owe)and luve hired the contractas listed below who have the following workers'compensation polices: �nr��e �. dtvt nt�arr� � � 4�f 1i�: r�� ; �Yt g�OiE�� Failarc M secQ+e a�era�e n req�+ea u�er Sa�a 2SA�f MGL 1�eu Idul b tYe hrpNitln�taiwiW pe�fNks�a II�e�p b SI,SN�M aadhr a,e yan'imptbw�mt a w�U as dv�pnaitla ia tl�bra ota 3T0!WORIC OR11ER a�d a Aae et31N.N a day�me. I aederstaud tliat a c�py dtYi�stalemest my 6e farwarded Os t0e Olpce of of f�DIA hra�a�e verlUeatlw. /ro henby cerd'jy xnder NYe prlws me tlie Mto�providad abore la lexe rtr�d onmc� �� ,alaSloS Richard Fournie� , �p—�p ��/�hT Pru►t name Phone# �J gI 'tY/10''y"'6W •ffieial ase asly d•�ot wiite ta this ar+ea te 6e c�pie�d 6Y dty.r lrwn�fficLl cilY or t*�vn: __---..__. �6oeese/ _ De�a�t ❑eheck if��ediale rdp�ti reqQed [,3etlx�n s O�oe ��• Ph�a' I-IomQ �t , � TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NUMBER: #06-043 FEE: $75.00 In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is hereby granted ta Cumberland Farms Inc., 1297 Route 28, South Yarmouth, MA Whose place of business is: Cumberland Farms#2262 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2006 BOARD oF HEAI,TH: L�er�wa.25. o�Orr,,/�l._`n., ' o�'e��lesi S�ali, �JY., 7/ice G��is Rol�zt�. Bnou�rz, � P��Al��t �!'j�.�, R.N. February3.2006 ruce G.Murphy, S.,CHO Director of Health THE COMI�ZONWEALTH OF MASSACHUSETT5 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #06-030 FEE: $25.OQ This is to certify that Cumberland Farms Inc. d/b/a Cumberland Farms#2262 1297 Route 28, South Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DIST'RIBUTION OF TOBACCO PRODUCT� AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�er�it is��t�i��gfor��with Article VI of the Sani�tarv Code of The Commonwealth of Massachusetts,and exp es s sooner suspended or revo ed February 3,2006 BOARD OF HEALTH: B �. �j�,/��., e�i�t ��s�, R�!, v�e�� Rad�t� an�,�, Gl�r� /�a�i1i�/1�a�1�t�ro� �4�!�' RJV. ru . Murphy,MP , •, Director of Health �oF•�rq� �Q�f�;,�� '4, ,�.o �" (� N � F � A. R M � U T H O - . � —y �„ -- �-„ , �, 1146 ROUTE 28 S�UTH YARMOUTH MASSACHUSETTS 026644451 MM�TTACME qs �.J Telephone (508} 398-2231,Ext. 241 — Fax (508) 760-3472 �/ �ADONA7E0�6 (O �� B O A R D O F H E A L T H � � �s (� i:� �UJ -_ � r; Ip) To: Yarmouth Boazd of Health Permit Holders ,,_.,�;� �� 5 From David D. Flaherty Jr., RS. ��r NEALTt-{ [3�PT. Health Inspector Town of Yarmouth Re: Federa.l Tax ID Number I _ �_ _ __ -__ �. Date: March 22,20Q5 ` , The Massachusetts Department af Revenue is now requiring that we fiunish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIN}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� for this purpose. If this is the case' for your establishment, be assured that we will not allow tfiis information to be public record. Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 South Yazmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to cail. The office hours are Monday to Friday, 8:30 a.m to 4:30 p.m. T'ne telephone number is(508) 398-2231,eart. 24L Establishment: �A ,�,,,�,►�Q,�,�t-=c�,��, � FEIN or SSN: � Location Address: � b 1 �� v-u; v�� (� O c�(� 6 I-t- Signature: p�t; :Rich�rd FourIIl��, Title: �� Prinked on ( Recycle � S Paper r �` '� C9c.�d1�?.b3o1 �o ('vMe�2�a-�+� �'A�R+ks ��f s R'S� TOWN OF YARMUUTH BOARD OF HEA�� , 3 APPLICATION FOR LICENSE/PEP� � � � - � -,� �; ,-�i �� * Please complete form and attach all necessary documents by December 31,��4� 5 2005 Failure to do so will result in the return of your applica.tion pack � HEALTN UEI'T. NAME OF ESTABLISHMENT: TEL. # -R � LOCATION ADDRESS: 8 'YnQ. o MAILING ADDRESS: h� o t OWNER/CORPORATION NAME: MANA ER'S NAME: R TEL. #50$-385- 39 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 emplo ees currently certified in hasic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (YCPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 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 fde at your establishment. 1. 2. _ _ �RSO�-�£i�RGE:--- ----— -- _ _ _ _____ __ _ __ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIlViLICH CERTIFICATIONS: Ali food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 1Vlaneuver on the premises at all tirnes. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. ' You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE P�RMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 CABIN $50 MOTEL $SQ _INN $50 � CAMP $50 _$WIMMIl�TG POOL$75ea. LODGE $50 TRAILER PARK $50 WHIItI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED REE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTIl�iENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 ' RETAIL SERVICE: ' LICENSE REQUIRED FEE PERM[T# LICENSE REQUIItED FEE PERMI'P# LICENSE REQUII2ED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 �VENDING-FOOD $20 �45,000sq.ft. $75 'O�'�C7' �FROZEND�S�RT $35 �TOBACCO $25 �S�U NAME CHANGE: $10 AMOUNT DUE _ $ �00.00 '••""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*•*" { e g c ADMINISTRATION f C Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hpld 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 � Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE E AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ! Town of Yarmouth t�es and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �/ NO . s run annu om anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ; TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAi,ESTABLISHMENTS ARE TO CONTACT'THE HEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL REN4VATIONS 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 COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. k � � ADDITIONAL 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 closing. FOOD SERVICE CONSUMER ADVISORY: � Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporary Food Service Application form 72 hours pnor ta the catered event. Thses forms can be obtained at the Health Department. E _FROZEN DESSERTS: - — I -- ----- - _ __ __ _ _ - __ , 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. �UTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. DATE: Io SIGNATURE: I PR1NT NAME& TITLE: Ri0h8Td 1="O S� �a 10/22/04 � - 1 .�l�r r�\ . � . . - • TI/C' CO/fl/)IOII N'c�r/t/r nf:11c�ssnc•lrusctts .,; . i,., =a:i� ' :�'=:.-='=�j:� Dc�/�artmc�iN nf InrlustrialAccidc�irts � � �� - Offlce olln�esti9atfo�s .'; ` ,: � � . � ,,\_:�_1� ��;;� 60/I Nirshi�r;;1��r Strec�t ,,��, i.• , ,��,..�, '' I3ust�nr,A?uss. 02]11 .�t� ��1'orl.crs'Compcnsahon Incur uicc Affida�rt .�1'�-��C'��f lformahon .._.,'�'�--�-.�..�ry��"'�`.�`R-�I'le e rRT��Co'!1�Vmr�a�� +��a•tq*.�.s:�-..,�.r�.^' w,.�-» f11111C'\i��_(�(YJIl� 'Y�TL�� V7��' — �""w u " i��1t� � . . ' � ` �7,�3 .�$- ��18� ;t.. ,# �� _ � I am a fiomeowner performing all work myself. � I am a sole proprietor and fi�ave no one working in any capacity r.:st . . . . . . . ....,..,.,,w '..�'-��.5'!�t`..'w'}�: � L,..: . . . . .. .:, .. . . . . . . . � . � � � I am an empl��er providin��orkers' compensation for my employees working on this job.. ' comp�n��n�mc• 1..L1f1'1��I�Il Q�� JYYI�1� �'�V'�14.s � � ��17 a�n� � � � . : . �dd ress• .. sit�••�./l'��,�lY�� d�� ' �honc#•�� 0� !�`'_ • . � , �. � /� �ry ,� � . incur�ncec ��L�ltf_�I r��f�e..C:(rv`�'l�/ � � • policv# ��0�:�� . >.�. �. ��;:�ks^ . :�, . � � � ' . - :s R,,. . ,. »�' " � [� 1 am a sole proprietor,general contractor,or f►omeowner(circle o�re)and have hired the contractors listed below who have the followina workers' compensation polices: . . ,:. ,: . . . .. _. . . .. .,.::��.� �. :..: . ....: - � f... .� . . . . ..'. . . ... . . : ....� .:.. ::. �... .. . ...':.� .. : . . . . ' _ . .. . :..: .. ._ .... ..: ' " �. . ' . cori iL�m•n�mc•. . _ . , ;.... . _ _.. �dcl ress: -:.. .... _ ; ., . .,.. . . � �h•• _ phone#• ti. ' , . . ..: :; . . . insur�ncc co � ' policv# �r�,a'^i.�:�•¢±'�,�'�i'�x.�.�n`�'za�n�re`'C��n..:-,'a�,.Ttt,-$ .'r-�-sa. ..p . .. �. ' . . .,.'.•�''� . . .. . . . . ��. . sa.� . com�am'I11111C' . . ;.. . : :., :..::,. address•,, . __. ciri^ �►honc#: . : : ; ; . •. , insurance co . ,. , �... ; �: .. ,...; . olicv# ... , ; r1Af�ach.adt�ihooal's"hc�„�,,,,�iincc'"�"��""'a . � `� '�. ' ", Failurc to sccurc co��cra�c as rcyuired"under Section 25A of A1GL 152 can lead`to thc imposition otcriminal pcn�lcies of a finc up to S1,S00.11U andlur onc ycars'imprisonmcnt as��•cll as ci�•il pcnaltics in thc form oCa 3TOP\YORI:OI2DER and a fine o(5100.00 a day against mc. F undcrstaod tbat a cop�•of this statcmcnt may bc for�vardcd to tt�c Officc of Im�estigations of thc UTA for co��cragc vcriGcation. I do Ifereb��cer7ift'inrder lhe nai�ts a► �/li oj erjur}� ha �c i�rformalion provirled above is true antl correcL Si�nature Date �"� �y' a a au � - �p ,r;� Print name - Phone�� R�.� o�0'`C f� "r�ofticial usc onl}� do not�vritc in this arca to be cumplcted by city.o.r to��•n ofticial � V cih•or town: ' permit/licensc# I'IBuildin� Dcp�rtmcnt ' � pLicensing 13oard .:`•�check iCimmcdiatc responsc is rcquired � �Sclectmcn's Ufiicc '' ' �Ilc�lth Dcpartmcnt �; ' contact person: phonc#� r'IOt6cr ; . _ �rc��ised 3/9S PJA) . ... .. � . . . . � . TOWN QF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #OS-042 FEE: $75.00 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Gen�al Laws,a permit is hereby granted to: Cumberland Farms Inc., 1297 Route 28, South Yarmout MA Whose place of business is: Cumberland Farms#2262 Type of business:_ Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth^ Pernut expires: December 31, 2005 BOARD oF HEALTH: Be�r�r,u�$. �j'�a�Crg/yl._`�S. ' A��l��s�� v�l�� R�t�B� Gl� � S!� R.N. �4.r�4'�u�s��dasu�, R.N. , February 2,2005 Bruce G.Murphy, S.,CHO Director of Health _ _.. _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD QF HEALTH PERMIT NUMBER: #OS-036 FEE: $25.00 This is to Certify that Cumberland Faxms Inc. d/b/a Cumberland Farms#2262 - 1 97 RoLte�g� ��uth Y�rn,o�th MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTTON OF TOBACCO PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�c�it l�s��ted i��for�i�ty with Article VI of the S �y Code of The Commonwealth of Massachusetts,and �p 31 s sooner suspended or rev�co ed. February 2.2005 BOARD OF HEALTH: �euyrpuit�. (��,/��., ��s�xau A�� v�� Rod�t`4 B�, � �� l�k, R.N. �4�ua!�' , R.1V. Director o Health� �' H <M� � �.r 4�. '` s �txr 6�57� '1 � Cun�4�CAND �22..62. c_�!a � ,r R.�o TOWN OF YARMOUTH'BOARD �'I�E i H r o_ ' -•,� APPLICATION FOR LICF�S�IP� '�-2f��4�, �� : 'S [; `��r '� ��=' �: s ••'�' '� '' �"�� •.. ... g� �� ;.j � * Please complete form and attach all nece d�nts by Dec mb,�f�.�11,02�0�Q�J4 Failure to do so will result in the ret F�'�of your application acket. � LTH i�EPT. s �- �� - � � � � R.�. ER' AME' �FF �� 1_V�ILiNG ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. PleasP list the designated Pc�ol Operator(s)and �ttach a cc�p�c�f the cerkificati.on to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Deparlment will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. _ _ _- _ -- --- ___ , - - - _ - — - --- PERSON IN CHARGE: _ ._ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more mast 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 nof use past years' records. You must provide new copies and maintain a=file at your place of basiness. 1, 2. 3. 4. RESTAUjtANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERM(T# _B&,B $50 _CABIN $50 _MOTEL S50 _INN a50 _CAMP �50 _SWIMMING POOL$75ea. _LODGE $50 _TRA(LER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# 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 REQUIRGD EEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.R. a45 >25,000 sq.ft. a20(1 VENDING-FOOD $20 �<25,000 sc{.ft. $75 �'b _FROZEN DESSERT $35 �TOBACCO S25 -�0�� NAME CHANGE: $to AMOUNT DUE _ $ /00 .0 O *•"**P[.EASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* �,� - �� ADMINISTRA.TION ,.'` 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 Certif�cat�-=of Worker's Compensation Insura.nce. THE ATTACHED STATE WORKER'S COMPENSATION-�INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' _ CERT. OF INSURANCE ATTACHED _ � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO ` NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 � DAYS PRIOR TO OPENING FOR THE SEASQN. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e.,-PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPQRTED TO AND APPROVED BY THE B4ARD OF HEALTH FRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL FGULATION� POOLS POOL OPEI�IING: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 colifortn 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. r FOOD SERVICE CONSUMFR AI)VISORY: 4 Eaeh food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post . Consumer Advisories. CATERING POI.ICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �Tt�7��V�3�ESS�R1"�: . --__ _ __ _---- - --- — -- -- -- � � ___ -- - - rozen 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. � O�,ITSIDE C�F�S: f Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior appmval from the Board of Health. OUTDOOR COO iN : � Outdoor caoking,preparation,or display of any food product by a retail or food service establishment is prohibited. . . DATE: �� j Q I B � SIGNATU : � PRINT NAME&TITLE: � ` �c1 ��, -„` 'V' i CQ- �`K 2 S i ��'rl.'t ��'�C�0 L�-�'--'(� - 10/22/03 � � �t � ' The Coinneonwealtfi of MussQchusetrs � � Department ojlndrutrial.�ccidents ; OlIIC001/�CS��fIlllt w 600 Washington Street ,, y,,: - Boston.Mass. 02111 "' " Vh'orkers' Compensation tnsurance Affidavit . �'^' �---� m•• L�cation� l � � 1�� 9rv�_ �i � �it� �x :'v��1S � . � � ('`� r-°�� a � ohone��"�P`� i� �� '�-1-�-q C�� I am a homeow�ner pertorming all worlc my�self. � I �m a sole propriztor=-� ha�e no one��orking in am•capacin• � I am an employer pro�idin�workers' compensation for my employ�ees working on this job. SQm r a n�• n a m e• �t /w�.,.l�.�-1(��,� '�, � � J�Y vr�� v� cy. �r�l"' c�l o�� , p � �p � �.{. address: ��^—��E— �g� - v''�:�" t \f�N� � , t'�\� nZ � — �;10"'��'(�J �. �J�� "g. $ . insur�nce co. 1'h.��QJ1tiCs2l� �J�a �.�� tT�!!SY# W��J � ��0� � � I am a sole proprietor. ;enerai contractor, or homeow•ner{circle oneJ.and ha�•e hired the contractors,listed betow ��ho ha�e tht follu�.in� ��orkzr_� ;ompensation polices: com�anv namr � address• c_�i}: nhone M• insur�ncc co. olie}•# comRanv name• i�d_ress: sih'' pboee 1!: insuranee co. ��* a Failure to secure covera�e as requircd uader Secaon 2SA of MCL 1S2 n�Ind to tbe i'paiuoa of uisiW pndtla of a O�e op to 51,500.00��dlor oae rean'imprisonment as w•ell as eirii pea�IHn io the form of a SfOP WORK ORDER aad a Aee otS100.08 a dar qtiott ma t s�dtrstaad tbat: copy of tAh statement mav be fonv�rded to tbe 011ice of laveatiYatiooa of t6e 0!A tor eovera;t veriiitatia�. /do hrreby c�nif}•under the pains end prnattits ojpery'ury tbat tl�e r�jornmtion provided abovt is tnte and eorreet Signaturc Yo e�-��Ce��(/ Date 1 `� l �O ' �:� � Print name �e"� 1m c�. ��r"c�, e�n' ont�t — �� ofiicial use only do not+►�ite in this�na to be completed by ciry or town oAleial citr or tow�n: YA��IIT� _ permitAieease N nBnildioe Department � check if immediate res nse is re uired ❑L.ietasing Board � � q 261 OSeiectmen'�ORice - - _ _ _w______ _ _..-- _ '. __ _. - _�__. _ �lieslt�tlepa�;meai contact person: pfiont N•_ �508) 398-?231 ext. nOther � < < TowN oF Y�au� ' s��a�� F�R�`�"�'Q C� ,��TE�1 F��l►��TABT.ISffi�+IEN'f PF.itMIT NI3Pt��: #�t� ; �= 75.OU I�►ac��t ��1ga�d tt�c�er�uthority of Chagter 514,S�ticui 3C15A and Chapter 1 l I,�ticm 5+af1� L.�ws,a perm�t i�he�b�g,t�ted to: Cup�n�rl�d F�mt��tt�., �29?Rczut�28, 5auth�armtrttth,MA � �hose pface c�f business is: +�umberland Farms#2262 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, 2004 BOARD OF HEALTH: B.�aarrsr�$. C�'a�d�a�r,./bl.$. ' Aa�i��/l/c..`2S�irott ?/sce G�� R�t� B� � ��k, R.N. February 6.2004 ruce G.Mutphy,MPH, HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUNiBER: #04-033 FEE: $25.OQ This is to Ce�tify that Cumberland Farms Inc. d/b/a Cumberland Farms#2262 1297 Route 28 South Ya�rmouth MA IS HEREBY GRANTED A LIC`ENSE For_ SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI�YARMQUTH BOARD OF HEALTH TQBACCO REGULATION. Ttus. t is ant o �y with Article VI of the S �y Code of The Commonwealth of Massachusetts,and exp e�s�ece��er�.��u�e�s sooner suspended or revo ed. Februar�6.2004 BOARD OF HEALTH: Be�s�t�. �j�/��., e�x.�ih�t /1G�tdc�/l�fc`�3�rot�, �/ic�e�� R�� B� �k d�� l.�l.� Q�V. ruce G.M y,MPH Director of Health a `M � { ��6��(�(�fs��' �,�+e�e.cRNp �#Zz�2 ,��f;''R.�o TOWN OF YARMOUTH BOARD OF H�ALTI�I�'; � � � �.� � � � }�� APPLICATION FOR LICENSE/PERII�IIT-2(�0� � �• 3 zooz ' �� s * Please complete form and attach all necessary doct�m �t,��y ecember l, 2002 2 • Failure to do so will result in the return of�,ur application packet.;._HEALT�y DEPT. ST E . # —��`�� L — M --� � , A 'S T . # 3� � RE POOL CERTIFICATIONS: The pool supervisor must be certified as a Pooi Operator,as required by State law. Please list the designated Poo3 Operator(s} ar►d attach a copyaf tfi�-�ertif c��i��t to�his f�r�n. �---- - -- 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 wili not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOC�D PROTECTION MANAGERS - CERTIFICATIONS: All food s�rvice 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 Heaith Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. �jaC/IT�T TAT !'�TTA nc._� . _, ___ ...1-L,.3rllrv-li��--�„.7-li-i�c. „�� —_____._-�.-._.�-::— . _ . .__. -- -- .. ,�._. .._..,��- . Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All food'�service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at 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. RESTA�RANT SEATING: TOTAL# OFFICE USE ONLY LODGING: ' LICENSE REQUIRED FEE PERMIT# L(CENSE REQUfRED FEG PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN S50 _ _MOTEI, $50 _INN $50 _CAMP $50 _SWIMMING POUL$�Sca. � _LODGE $50 _TRAILER PARK $50 _WHIRLPUOL $75ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT i! LICENSE REQUIRED FEE PERM(T# 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 REQUIRCD FEE PERMIT# I <50 sq.ft. $45 _�� >25,000 sq.ft. $200 VENDING-FQOD $20 ! / <25,000 sq.ft. a75 �'Q3'6,� _�RO'LGN DESSERT $35 LTOBACCO $25 �Z NAME CHANGE: $�o AMOUNT DUE = $ /pd,�p *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i � ; r � � � � . � ADMINISTRATION r ; r 152' Section 25C Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � Under Chapte , , .__ of any lieense or permit to operate a business if a person or company does not have a Certificate of Worker's ; Compensation Insurance. THE ATTACNED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETEll AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED armouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � Town of Y , APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 3l, 2002. � SEASONAL ESTABLISHMENTS 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. i ADDITIONAL REGULATIONS POOLS POOL OPE1vING: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 5tate 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 AI)VI50RY: ' Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. C'ATERNG 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 obtamed at the Health Department. � II�; FROZEN DESSERTS• ' ' __ Fra�.en-de'�,��k�m�ast h�t�ter.�o��c�tl_�y��sis k�3��t�tg cgr:ifie� la�. T�s�r�lts-��st bP ser�t�e ihe-�eal-+�- � 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),�have prior approval from the Board of Health. ' Oi1TDOOR COOKING• � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ; , , � DATE:� ,��,�SIGNATURE: ��^^� �� Richar u @� PRINT NAME &TITLE: ; 10/18/02 • � • . � The Conrmonwealth of MassachLsetts � Department ojladustrial,-�ccidents T y � O��e OI I��,� . . 7 � ; 600 Washingto�e Street ' �� B�ston.;Mass. OZlll �'" v�y �L'orkers' Compens�tion Insurance Atfidavit n m•� —� ` - �t3 ehone tl1��2�� tic� .�� t am a homecwner pertorming all work myself. � f am a sole proprietor ��,a, ha�e no one«ori:in: in am•capacit�• 14R I am_aa�mpl6c�er pr�t�ding ��orkers' compeasatic�n for-my employees u•orkiag on tttis jeb. _ _ _ ��„�� sau _ � � comoan�• name: )t.l�n ��/� �('�/�/Yy�,� ` �L �ctdress: � "-( \ )_SL.� � �J n..�. C �/� � titv: lvD��iSyl__ � 1� � r�-� O� \ phone H� l� � 1 U�l O IT �J � �� ` ' , �`--( ' uranc R�hS.Y# � �� -C'� T � I am a sole proprietor. ;enerai contractor. or homeow�ner(circ(e onel and hace hired the contractors listed below �tiho ha�e the follu��in: ��orker� �ompensation polices: : �moanv name: addresr citv• phone#• insurancc c9. Aolic�•# comoanv name: ---- —-- _ -—------ -- _ ul.dr_e�s: titv: nhoee J�• insurance co, ��e�r* • Failure to seeure covera�e as required under Secnon 25A o(MGL 1S2 a�lad to tbe i�poridoa of eriai�l pesdtla o(a B�e op to S1�00.00 a�d/or one yean'imprisonment a�w•cll a�civil penaltla ia the form of a STOP WORK ORDER aad a tiae ofS100.00 a dsy apisst ma I a�dersta�d t6at a eopy of thy statement mav be fonwrded to the OfTice of Inve�tigadoos of tbe D[A for eovenie veri8a�. !do hrreby cerrif}�under rhe pains and ptna i� ojp ju hat the infornmtion prnvid�d abovt is true Qnd evrreet Signature � � r� '�I � a Printname R�.�hBT`d F T' ��l� onell Q C� .- o(Ticia!use onl} do not+.�ite in this area to be completed by eitv or town oQleial city or town: Y�M�IIT� _ pe�mitAicense M nBuilding Department pLiceosioe Board �cheek if immediate response i�required 261 �Seleetmen'�ORiee �Hea1tA Departmeat contace person: phoneM:_ t508� 398�?Z31 eat. nOther ... .��. � .<�il: . . i' I � s TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NLJMBER: #03-038 FEE: $75.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 345A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby granted to: Cumberland Fanns Inc., 1297 Route 28, South Yarinouth, MA Whose place of business is: Cumberland Farrns#2262 Type of business: Retail Food Service less than 25.000 sc�uare feet To operate a food establishment in: Town of Yannouth Pernut e�cpires: December 31. 2003 BOARD oF HEALTx: eiFanl�a� xilltkac, ��a� : . __ _ ____ _ _ __— - -_ _ ; . �e�fa.xt�c�. C�%dcdo�. '11K.-D.. `l/lce- • �o�aat�. !a'�, �ik �adrfek�Gtarot� s� .Si�ak. ,�.72. January 17,2003 ruce G.M hy, . .,CHO , Director of Health --- - THE COMMONWEALTH OF MASSACHUSETTS� M TO��YARMOUTH _ , . . . BOARD OF HEALTH . PEit�IT�NUMBER: #03-027 ,.� ;. FEE: $25.00 � Thi��is.�o certify that Cumberland Farms Inc. d/b/,��umberland Farms#2262, -.xa.� ,, 1297 Route 28. South Yarmou#�,1VIA ; IS HEREBY GRANTED�'�,ICENSE HY�'� , ° �;� Fbr� S�,E AND=D��TRIBUTI4I�I O�'T�B1�,�C0 P��DL�CTS - ,, , . ._ > �r�'a ��W . . . . . . . ; A�PER TI-�YARMOUTH BOARD OF HEAL�H TOBACCO REGULATION. , ,,� Tlus�er�ut�`�"�ant�i��for�it�+with Article VI o the San�tar�+Code'of The Commonwealth of Massachusetts,and �.�, exp s e er un e s sooner suspend�or revo e . _ �an�y i�.Zoo3 so�xn oF��,Tx: r �'�a��f. �ell�, �'kav�.Ka� _ � �e.,cfa.xuw D. C�a�al��c. 'lll.?�.. `rltce ��a.c. ,�o�ait�. !�'izoaoa,c, �Le� ' �a�tick'lK�or«�at� � S . .?Z, . G.M hy,MP . ., Director of Health � I " ' � C.e�nti O�c.A N D � 226 2 ; � � TOWN OF YARMOUTH BOARD OF I��I,.T.H , 08^ ----._.. �.... . �� nMf� D APPLICATION FOR LICENSE/� . y�v�`ao , �, 7 * Please complete form and attach all necessary documents by Dec � er , 2001. F ilur to �o o�tl��in the return of your application packet. ��i�,;LTH DEPT. AME O ESTABLISHMENT: TEL. # � `(�$� I D S• — MAILING AD SS� - WN C � � � E 'S N � - TEL. �b� b3� � ING AD RESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(sj�rrct-atta�h�: ' ' `--�II-��sro�m:---- _ _ _-- - — --- 1. 2. Pool operators must list a minimuxn of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• __ PERSON Tl�CI�AR��: _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of opera.tion. 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-chokuigprocedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at-your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _,MOTEL $50 _INN $50 _CAMP $50 _SWIMMING POOL$SOea LODGE $50 TRAILER PARK $50 WHIRLPOOL $25ea k'OOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SfiATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 I<25,OOOsy.ft. $75 �'6a�Z$ �TOBACCO $20 a6F'OZ-622 _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ 9 S.O Q *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****" r ` , , ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's : Compensation Insurance. THE ATTACHED STATE WORKER',S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED ' , � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � t Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISI IlVIENTS ARE TO CONTACT'TI�HEALTH DEPARTMENT FOR 1NSPECTION 7-10 � ; DAYS PRIOR TO OPENING FOR THE SEASON. � a � 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 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 drained or covered within seven(7)days of ; closing. FOOD SERVICE CONSUMER ADVISORY: Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ' ----- - _ ---- .__ __ _ _ _ _ _ __ ; _.FRQZ�P��ESS�R`TS: - -- Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: I Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited. ' DATE: � `�� SIGNAT'URE: ~ —� —�-�--- PRINT NAME&TITLE: Tax Manager 09/11/O 1 I y � • S -\ The Commonwealth of Mossachusetts � � Department ojlndustrial.-iccidents � e OfJlceol/�estJpstliis ; 600 Washington Street ' ` Boston, Mass. 02111 �14 ��, . . . V4'orkers' Compensation Insurance Affidavit ARnlicant intormation• P'IessePR '� n�mr ��,N�P�J� � - �r�n.w� .� i� �h,� � � t.�.ro� S on: 6�3 ��1 q�_�� i�, n� tiT��-t�� '� �� I am a homeow�ner pert�rming all work myself. � I am a sole proprieror ��,', ha�e no one��orkin= in am�capacit}• �1 am an em��ecnro�i�in�w�orkers' c � for m��em�ovees u•��k;�o�t ic inh — —_-� —_-___ - - �'`�� `�� m an • n �d�iress: � '7 � �,-�1'�. ('�iw. �< ciri•• ,Cl M, .�� f� � C7�� nhone N��'� 1 � 0 r�(� ^ � � � � � � � a�- in uranc � � � I am a sole proprietor. :eneral contractor, or homeowner(circle o el and ha�•e hired the contractors listed below ��ho ha�e thz follu��in_ ��orkzr� �ompensation polices: �4moanv name: address titv: nhone It• insurancc co. �olicv# comoanv name: — ---- - _ __ -- - - - - __ _ _ _ _ __- �ddress: ____ _ �': ohoee M• insurance co. �(�nr* t Failure to seeure coverage as reqyired under Seenoo 25A o(MGL 1S2 n�lad to tAt i�po�itioa ot erisi�al pesdtla of a 6�e op to 51,500.00 a�d/or one yean'imprisonment a�w�dl aa eivil penaltie�io thc form of a STOP WORK ORDER�ad a Bae of 5100.00�day ataiost me. I r�denta�d that a topy of this satemrnt may be fonv�rded to the ORee of Invatig�tiom ott6e DU for eoven;e veriflptfal. I do hrreby cerriJj•under thr pains and pr a tie f pe jury tha t6t injornration provrdtd abovt is trtu and eoneet � Signamre • � � ic ard Fo nier Print name one M � � ^ � �� .. olTicial use onl� do not..►itr in this�rea to be completed by ciN or town o111eitl ciry or town: YA��TQ _ permitAiceaoe p n8uiidiog Departmeot pLieeasiog Boud �eheck if immediste response i�required 261 �Stlectmen'�01ftt �Healts Departmeat contact person: phonrp;_ �508� 398�2231 ext. nOther . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-028 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 pernut is hereby granted to: CLmberl�nd Fa�rms Tnc_, 1297 R�Lte 28, SoLth YarmoLth, MA Whose place of business is: Cumberland Farms#2262 Type of business: Retail Food Service less than 25,000 sc�uare feet To operate a food establishment in: Town of Yazmouth Pernut expires: December 31,2002 BOARv oF�A�.,�: �a�� z�, (�aur�uua�c i'e�ja.xia D. C�.oaalo�, '�D., ?/iee �a�irt� �natoaot, L� �a�rtek��cot� �kefe�c S�ak. ,zl. �ril 5 _2002 ruce G.Mtu-phy,MP R.S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #02-022 FEE: $20.00 This is to Certify that Cumberland Farms Inc d/b/a Cumberland Farms#2262 1297 Route 28 South Yarmouth.MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION T'his permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. A�� i i ,Zoo2 Bo�xn oF��: �4a��. �e�. �«ra.� �'�i.,c D. Cfo7do.i. 'I9�D., `ll�ec (,kaur.�caK ,go�e�rt� �Rauac, L� �a�'��xo�t �ele.t Skak .'IZ. ruce . urp , , ., Director of Health CE,t V7 �{��:�IG��`Y� �Li r��S � _# Z z %� TOWN OF YARMOUTH BOARD OF H�� ,b G3 L� � .I�'�-., � M � D � ` � APPLICATTONFORLICENSE/P�`��T `�U��go JAN 1 p 2000 ,�„A�" � A:; •n, �S�� ,s�" . �,,�h \ * Pleas� complete form and attach all necessary documents b�I��e��3�,199 . Fail r�t6�t��b1�3I£�Tult n the return of your application packet. �` � � ------------F E------------------------- ------- ---- ----- --�-,--------------------a�-------------�--#----------------��"� 1 LO AT - L D � -� � r--, i � � � � D POOL CE�TIFICATIONS: The pool supervisor must be ccrtified as a Pool Operator, as required by new State law. Please list the designated Pool Operatar(s) and attach a copy of the c�rtification to tiris 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 Heatth Dep�rtment wilt not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. H�IlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at a11 times. Please list your empioyees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. -��'�P��IRA�T��ATING:_ T4'F�,#- _ --- - — - I��F�A�-S�bI4I��T�SEATS: �A-T-�#------ -- -- ---_ t-- _________________________--------------_--------------------------------------�--_____-------------------------------___.._----------------_. (?FFICE USE ONLY �ODGING- � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 IN1�T $50 CANIl' $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWII�RVIING POOL $50ea. WHIRLPOOL $25ea. FQOD S R�: VICE; 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 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 � TOBACCO $20 y�'� I <25,000 sq.ft. $75 `�Zk•�j FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 ` AMO�JNT DUE = $ � — *""'PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM""••" V� -..�..��,. � f ADMINISTRATION � '� UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOUTH IS NOW REQ�JIRED T�O HOLD ISSUANCE'OR RENEWAL 4F ANY LICENSE OR PERMIT TO OPERATE A BUSINES5 IF A PERSORT�.OR .�OM�'ANY DOES NOT HAVE A CERTIFIGATE OF WORKER'S COMPENSATION , INSURANCE. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN l�F YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK APP PRIATELY IF PAID: � YES---� NO ' NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TQ RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY , DECEMBER 31, 1998. �, SEASONAL ESTABLISHIVVIENTS ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TQ OPENING FOR THE SEASON. '' ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M�.Y REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS PUOLS POOL OPENING: ALL SV'VIl��iMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLC?SED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND THE WATER TESTED FOR - PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A S'TATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR lN GROUND SVVINIlviIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �TERING POLICY: ANYONE WHO CATERS V�ITHIN TI-�TOWN OF YARMOUTH MUST NO'TIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO 'THE CATERED EVENT. TI-�SE FORMS CAN BE OBTAIlVED AT THE HEALTH DEPARTMENT. FR(,�Z�N,�ESSERTS: FROZENDESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTrv1ENT. FAILURE TO DO SO WILL RESULT IN TI-� SUSFENSION OR REVOCATION OF YOUR FROZEN DE5 SERT PERNIIT UNTII,TI�ABOVE TERMS HAVE BEEN MET. _ _ _ - OIJTSIDE CAFES: OLJTSIDE CAFE5(i,e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI-�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS�-�VVIEEN'T IS PROHIBITED. DATE: '. �i SIGNATURE: t PR1NT NAME 8c TITLE: Richard F ur ier. 11/12/99 �-�...�_ � _ � , ' The Conrmoawealth ojMossachusetts ,� ` � Depa�tment oJ lndustrial.-1 ccideats ' ' ; OflJceoll�s�lostliis � 600 Washington Slreet ' ` Boston, �lass. 02111 �~ v•y' W'orkers' Compensation Insurance Atfidavit /� �— nam• lucation� `"'t—C ? .J�C�rr�l`�_ �V�., . ��?�� u � � I am a homeowner perto in,all w�ork myself. � I am a sole proprieror�r.� ha�e no one �►orkin_ in am•capacin• � I am an employer pro�idino workers' compensation for mv empioyees w•orking on this job. comoan}• name• t 1��. Q pr (�/� , �. �� — lddres5� 1 � \ �� p�� ` � � � �' � 3 - `� �,Q � ��t� r�.n �r.aLu�,�r� (� � ( C � �-�-� � l-�. �a i�surance co. �.c� ,(.t ��paiicy# �'� �� I am a sole proprietor. _enerai contractor, or homeowner(cirde oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu�+in_ ��orker �ompensation polices: �omoanv name• address• ��" �hone 1!• insur�occ co. ��•� comeanY name: __ address• �'� nhoee i�• insurance co. �,� a Failure to secure coverage as�equired uoder Secnoo SSA of MGL 152 n�iad to Me iopo�idoa ot etivi�i pt�dtla of a O�e ap to 51�00.00 a�d/o� one yean'imprisonment as w•ell as eivil penaltie�io the torm of a STOP WORK ORDER aad�Bee of 5100.00 t dar Kaiott ma I a�dersta�d t5at a topy of thh statement may be forwarded to tht OlTice of Inve�tig�dom of t6t DIA for eoven;t veritiqtio�. I do hrreby cerrif}•under rhe pains and �nal�ies ojpery'u t tht injornration provedtd abovt is tr�re and eoneet , ` tt � la � Signature � Print name Riehard Fournier one N,�`� � �� c��,—�" 10 C7 .- olTicial use onl. do not..rite in this area to be completed by eiry or towa otfleial city or town: Y�M�IIT$ _ permiNieeau N nBuilding Department �Liceasiog Board �eheek if immediate response i�required 261 �Seleetmen'�OtTiee OHealth Departmeot conracc person: phone k;_ �508� 398�2Z31 eat. nOther .. < .,{: s::<:.;:.>::DATE MM DD:.;;:.>:.>:.>::i: ::;: A CORD :::::::::::::: :::.:;::::..:::::,:::;;: ::::::`::::�':::�::'': ';;:``:::':::::::: _;::.:::_.::;_::: ::::::.;;;;::..:::.:.::::...:.._;:::::::,::::: ::::::::::;::::::::.;: :::<:: :::`:':,.::::::::::::::::::::::::::;::::::::::::::::::::::::;.;.::;:: # ( / /'m ... :::;:.::::.:::...:.::..::::::::::TM ��I�� E� ��.. �?!A�`.�E:::::'F::�F:::::::::::<�:::::: 29-MAR-2000 ': ......................:..................:::..::::::.::::.:.:...:...:..::::.:.::........:.::::::::::::::.::.::::::::::::::::::::::::::::::.::::::....................................................................................:..:::.::::.::::.::::.:: PRODUCER 105579 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis of Massachusetts,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE Three Copley Place HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Suite 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston MA 02116-6501 (617)437-6900 COMPANIES AFFORDING COVERAGE �saas-000 �sosri coMPArvv National Union Fire Insurance Company of Amy R.Hegarty A pittsbur h,Pa. INSUHED COMPANY�nSU►arICC COmpany of the State of PA B P Cumberland Farms,III�. COMPANY 777 Dedham Street C Canton MA 02021 COMPANY D ::;>::;::.::.;;;:.:»<::;:::.:;<,:::»::>::>::>:«::<:>:.>:«.;::>::>::>::>::>::>::::::>::>::»:«<::<:::>::>::>::>::>::>:.>::>::»::>::»»>:;:»>::>::>:::;:::>::>::>::>::::>::>::»::>::>::>::>::>::::::»::>:::<:>:>:;<:>::»:<:::»»::<:::>:<:;::::>:::<:»::>::»::>::>:::::>:::<.>::>;::>::::::>::>::>::>:::::::::>::> . .. �::..:..::.::;:::::.-: : +�!�!ii�:;:.::;;;;»;::>::':::>:::<::<::»»::> >:�D1��iA�`a�:::::>::::>::::>::::>;;;:::»>:>':>::::>::::>[:::>::::>::::>:>:<::>::::>::::>::::>::>::>::[:>::::>::::>::::>::>::::>:<::<:<>::>::::>::::::::::><.:::>::::::>::::>::>::::>::::>::::::>::»::::>::r:;:><::>:c:c:<:>::>::.:;:>:<::::<:::::::::>::::>::>::>::::>::::>::::>::::>::>::>:<:::::<:><»::>::>::>::>:::»;::.:.� .......................................:.:::: ..............................................:::..:::::::::::::::::::::::::::::::::::::::::::::::::::::::::..................................................................................................:::.::•::::::: .....l....,....-:.::::::::::::.:.......................... ............................................................................................:.:.:::::::.:::::.:.�:::::::::::.�.::::::.�:.�::::::.::::::::.::::::::.:::::::::::::::::.::::::::::::::::::::........:.:::.�.:::::::•::::;:::::::.:::::::::;;:>;;;;;;;;;:.;:.;:.;;;;>;;;:.; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT FO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TypE OF INSURANCE POUCY NUMBER POUCY EFFECTIVE POLICY EXPIRATION �� DATE(MM/DD/YY) DATE(MM/DD� LIMITS A GENERAL W181LITY RMGL6123386 01-APR-2000 01-APR-2001 GENERALAOGRE6ATE $ 1 O,OOO.OOO x COMMERCIAL GENERAL UABILITY PRODUCTS-COMP/OP AC�a $ 1,$O O,O O O CLAIMSMADE � OCCUR PERSONALBADVINJURY $ S.SOO,OOO OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,5O O,OOO X �rJ00,000 Self-Insured FIRE DAMAGE An onefire $ 1,50�,��0 Retention MED EXP An one erson A AUTOMOBILE LIABILITI/ RMCA5347766 01-APR-2000 01-APR-2001 COMBINEDSINGIEUMIT $ 2.000,000 X ANY AliTO ALLOWNED AUTQS B�ILY INJURY SCHEDULEDAUTOS (Perperson) $ X HIRED AUT0.S BODILY INJURY X Per accident) $ NON-0WNED AUTQS � PROPERTYDAMAGE $ GAHAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE EXCESSLIABILITY EACHOCCURFIENCE $ UMBFELLAFORM A06REC�ATE $ OTHER THAN UMBFE�LA FORM B WORKERSCOMPENSATION AND MW��J27�Z�7 . _�'(-AP�-�6Od. �T AFsF-Z�IO� STATU= DTH- _ _ - TORY LIMITS R ' ' ' EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 1,OOO,OOO THE PfiOPRIETOR/ INCL EL DISEASE-POLICY UMIT $ 1,O O O,O O O PARTNEFS/EXECUTIVE OFFICERS ARE: EXCL ELDISEASE-EAEMPLOYEE S,OOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS�VEHICLES/SPECIAL ITEMS I ii:;.�F''`::.;>;;s;>:.:,:;:.;::;::.?::�.::.:i�:>:;;.�>:.>;;>:;.:;:::?iEi;ii;EEiEiE:i;i:;'::iii::':::?iiEE:iiiiiiii;iii�i`EiiEEi:EiEEiiii::i:iiiiEEiiiiEii;iiiiii;;iiEiiiiEi;?i::i:::''i:::;ii:�::;:i::?::;::ii:?EEEEEEEE:::::;::::i:;;::.::_:::?:.;;s;s:..'::'.::'..';"'.`:�`�"iEiii�EEEE:iEEiEEEi::::::::::;?:?:;i:i::::::i:i;i;i;iii:iiiiiEi:ii:i::::::;?:;`:iEi;:Ei`�`;i:ii;;:�:ii::i:i::;:;:i:�:;iii;EEiEiiEiE:ii::iiii::i;iEiii;ii::;iiiii::ii:i�;i:;i;iEEE: .:...,�''��:��'..:..:::::::::.:...........::..�:::::::::::.�:::.:.:::::::::::::.�:::.:::::.:;�:::. .::::::::::.::.:: �::::::::::s::::::::::.:::.�:.�::::: ...................................................................:.....:.�:::::�A1��i.#,1t'1'[CiN::::::::::::::::::::::::.;:.;;:;.;::.:::::::.;:.;:.;:.;:.><::::;::>:>::>::::»::;:.;;:;.>:.;:.:;.;:.;:.;:<.;::-;:.;:.;:.;;:.;:.;;;:.;>:;:.:;.:.:.:.;:.;: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, TNE ISSUINQ COMPANY WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TOWN OF YARMOUTH BUT FAILyRE TO MAIL SUCH.NQ71C£'SHALL��POSE Nb OBLIGATION OR LIABILITY BOARD OF HEALTH OF ANY KI � UPON THE COMPANY' ITS GE OR REPRESENTATIVES. S.YARMOUTH MA 02664 AUTHORIZED REPRES IYE v� a :::>:.::.::.::.::::.:.::::::�.::.:.::.::::.:::.::.:>:::.::.:::.::.:::.::.:::::::::::: .:.:.::::::::::::::.:::::::::::::::.:.::::.::�:::::::::..................................$...�........ ..:...... . . . ...... ........................ ............ ................................................. .......................... ..:::: :::::.:. .:.:::::::.:.:.:�._:::::.�:.�::::::::::::.:_:. ::s�t�p::Z��:;S�.'# ..S�:<:::?:::::':::;:<:«::::>::>:::<:>::;::::::>::::::::::>::>:::<::::>:::::>::::::>::::::>::;[::<z:;�:L�tL�fF�s»::>::::::>:<?:[::::;:>::::::::;:»;>:::::<:::::»:<:>::>�:»::>::>::::>::>:::::>'::::;;:::<:F:>:>:::::::::::;::::::<::»:::::::::::::::«?;»::>::::::>::;: •::: :::::: ::::::::..:::.::::::.�.::.:::::::::::::::::. .................................................................::.::::::::::::::.:.::.:::::::.:::::.:.::::::::::.::..::. .::.::<.;:.;:.;:.;:.;;:.;;:.;:.;:.;:.:.:;.;;::;.;:.;:.;:....::. .. ::L�QRPS�1��1'#7fl1�::'1:�:<::::::: TOWN OF YARMOUTH . BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-54 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: (' �mberland Farms inc_, 1297 RoLte 28, S�uth Yarm�uth_ MA Whose place of business is: Cumberland Farms#2262 Type of business: Retail Food Service less than 25.000 sauaze feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �gt��, C'��,�n �oan� �u[livan, �//., Vice ��irma �o�ert� �rown, C�lerh a�rielle�ako(�ky-J�oo�ve� ///ic� oCo hLin "`d 7anua�y28 ,2000 Bruce G. Murphy, MPH .S., O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-43 FEE: $20.00 This is to Certify that Cumberland Farms Inc. d/b/a Cumberland Farms#2262 1297 Route 28, South Yaxmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PROD CT _ AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO FGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. Januarv 28 ,2000 BOARD OF HEALTH: �i`� �e�e�, C�iairman �oan� �ullivan� K.//.s Vice l��irmarc Kobert.}. �rowa� l..�rk �adrielle�a�o(.��y-.1�ooPe� [ � o h[ia . I11Ce . UI'p y, , •� Director of Health _ ,: , �umi�;rtand �u Y rns �. � X a � c� r� ad_� o , , :, TOWN OF YARMOUTH Bf`)AI�D Q�'H�A1�«�H JAN - 8 1999 - : APPLICATION FOR LICENSE/PERMIT- 1��b .�o��i * Please complete form and attach all necessary documents by December 3l, 1998. Fai ure EA TH D in the return of your application packet. -------------------T�-I------------------------ ---- ------ --- ------------------------- ------------�---------�_"--I � O ATI N RA N ' ��.�.. R' N L. # ^ �, 6�1 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. -- _ _ -- -- -_--___ - - -- - - ---- - 1. 2. ___ Pool operators must list a minimum of two employees currerrtly certified in basic water safety, standard First Aid and Commwuty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below 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 file at your place of business. 1. 2. 3. 4• �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 a11 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 frle at your place of business. 1. 2. _ 3. 4. _ RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ------------- ------- ------ ------- ------- ----------------- ----- - --_ _ _ _ _ ____ - OFFi��USE-QNL�-- -- _- - -- --- -- LODGING: LICENSE REQUIRED FEE FERMiT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SV'VIlVIlVIlNG POOL $SOea. WHIlt�LPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 N�N-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 � RETAII.SE�tVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 �TOBACCO $20 �� I <25,000 sq.ft. $75 Q�►�q FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ �� " *""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM��R f�R � � w � r ADMINISTRATION � , 4 U1�DER Ci3AETER 152, SECTION 25C, SUBSECTION 6,'THE TOWN OF YARMOUTH IS NOW REQUIRED TO HQLI1 ISSUAI�TCE 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 STA�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT i MUST BE COMPLETED AND SIGNED,OR. ' CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � k TOWN OF YARMOUTH TAXES AND L S MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK AP OPRiATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEiVIBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY � DECEM$ER 31, 1998. , � i SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPAR'TMENT FOR INSPECTION " 7-10 DAYS PRIOR TO OPENING FOR TI-� SEASON. � i ALL RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COA�IlVtENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DDITIONAL REGULAT�ONS POOLS POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR 'THE SEASON NNST BE INSPECTED BY TI�HEALTH DEPAR'TMENT,AND THE�VATER TE5TED FOR ' PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIl�IlVBNG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. i f I FOOD SERVICE � CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH ' HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION ' FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FRO�EN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST , RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII.,URE TO DO SO WII,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERNIIT UNTIL TI-�AB�VE TERMS HAVE BEEIVMET:_ - ___- -- --- --- --- -- - — - --- OUTSIDE CAFES: OLTTSIDE CAFES(i.e.,OLJTDOOR SEATING WITH WAITERlWAITRESS SERVICE), 1VILTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL�R FOOD SERVICE ESTABLISf�VViEENT IS PROHIBITED. , DATE: SIGNATURE: Rz�h�,rd � rnier � PRINT NAME& TITLE: Ta,x Nlana � , i � �►' � _ The Commonweolth of Mossachusetts • ` : � Department ojlndustrial,-lccidents T o Olflce ol/eres�l�sdiis � 600 Washington S�reet •` Bnston,Mass. 02111 '�~ ��v` W'orkers' Compensation Insurance Affidavit Aoolicant informallon: PleesePR�'TTe�"i,i'ia \ � namr: �-� �vu� `�G$i`^�� '(�l�w,.. ,� � M �' — �—_� locati�n: ."'�7�1 � f>��(�iv„� �,�, �it� � �ffi r\� � c�� c� \ phone_fA�1 � � o�� Q 0"C7 � 1 am a homeowner pertorming al work myself. � f am a sole propriecor��,� ha�e no one ��orkine in am•capacity �am an employer pro�i3ine worl:ers' compensation for my employees workine on this job. _ _ _ --- -- - _ _ , - ___ - - - comnam• name: ��,�n n�.,�� h,/� � _�� 1ddreSS' l� �ln �� c� C1 ^ _ � � ��ahone q: \ 1(�� P� rl ---� ��- � � � - `�surance co . � a li # � � I am a sole proprietor. :eneral contracror, or homeowner(circ e onel and ha�•e hired the contractors listed beloµ «ho ha�e the follo«in� ��orker�� ompensation polices: companv name• address: c�y: phone#: insurance ca �olicy# t4m a�ny name: ___ -- --- -- _ _ _ _ _ ------ -- -- _ _ _ ____ _ _----.__ address: - - slty: ohone 11• insurance co. pysy N Failure to secure coverage as�equired under Sectioo 25A o(MGL 1S2 eaa Iqd to t0e iopoeitioa of erisf�al pe�alda of a 6�e op to S1,S00.00 a�d/or oae yean'imprisonment a�w•ell aa eivil penaltles io the fo�m of�STOP WORK OItDER and a 8oe of 5100.00 a day apinst sa I a�dersta�d that a copy of thN statement may be fonvarded to the Ofiiee of Ime�tigation�of the DIA for eovenge veri8atb�. /do hrreby cerrij}•under rhe pains ai pena/tti s ojpery'r fy th�[ttie rnjornmhion provided abovt Is true and eonect � Signaturc � ` ' _r, �tiehard Four r Print name Phone�l ��"Z' 2� � 1 ?�c��,.� }��C�� ., oRcial use onl� do not w rite in this area to be completed by ciry or town otfleial ciry or town: Y�M�IIT� _ permitAicenu M nBuildiog Department pLiceasiog Board �check if immediate response is required 261 QSelectmen's ORiee (508) 398-�2231 eat. �Health Department contact person: phone It;_ __ _ nOther Ire��ised 3;95 PJA1 -� ��. �'>::::::::;°:.:.;;DATE MM DD:.;;:.;;:.>:.;,.:. t ::.;:�<::;::::<�..;::::>:::.>.>:�: I I ( / /m ::: '::; A RD :::. :. : ..:. :: .:: :::�:::::::::::�::�::::':::'�:::��':::�:::��::::::::::��::::��'�::::�::>:::..:..::..:::::::;:::'" �'��:::`:::�::::: :::::::� ::��_�':° :� � :��:::':'::��::� ::'��:��':��:�;::`:::::�:::';':::::`:��_��:''�::::::��::::;:`��::::::::::�:>::: �::.�TM v:�.��.�.R��::.��-::.FW�.��.�.��.�..::�.�..��i,,.�:��:..,.,_�i„�..,.�r.?>:.: .: .::. .......�i1�!G�<:::>:>;. .;:>:�»�:::> 27—MAR-1999 :::> ,.. :.:::::::::::.::::::::::::::::::.:::::::::::::::::::::::::.::::::::::.::::::::::::::::::::..::::::::::::::::::::::.;;:.::;::.;::.::.:::::::::::.::.:::::::._.::.:�:.........................'�.��............ ;:.;:.;:.;:.;:.;:.;:.::.;::::.::.::.::.:.::.:;;:.;:.;:.:;.;;;:.:�;:.;:.;:.;:•;;:.:;.;:.;:.;:.;:.;:.;:.;:.;:.;:.;:.;;:.;:.;;:.;:.;:.;:.;:•;::;•;>:•;;;;::�;:;.;::;:.;:.;:.:.;:.;:.:;.;:.;:.;:.;:.:.;:.;;:.;:.;:.;::::::::::::::...:............................................................................................. PHODUCER 87533 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis Corroon Corporation of Massachusetts ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Three Copley Place HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Suite 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston MA 02 7 1 6-6501 COMPANIES AFFORDING COVERAGE (617)437-6900 coMPnNv�nsurance Company of the State of PA Gayle M.Daly A INSURED COMPANY�IIIIlO1S NHt10�18I(I1SU�8IICC CORIPB�Iy B COMPANY D Cumberland Farms Inc. C 777 Dedham St. Canton MA 02021 COMPANY ' D :::i:ii:i'ii:i'iiiii%ii:iiiiiiii:i:::�:Ji::::•::i:•:::ii::'i:iii::i::ii::::•i::i:•::ii::•:iii:'i:•ii:::'iiiii:.:.i::i::iii::i::ii::i::i::i::i::i::i::i::i::ii::i::ii::i:::•:::•:::•:iiiiiii:4ii:i::4iii::i::i::i::i::i::i::i::ii::i:�::::::::::::::.�......:••:...•:: �!F�yy� ��W��{ y� ?:i::::i4::i:::::::::::::::::::i::::i::::i::::iii:::i::i:::�:i:i:::::::::::::::iii ......: . .. .. . ..............................I�1T��::�. :: ...�: . '. ?::iFL:Y��Mu�Al::i:ijii:::::::::::!::•::i>:::i::::•:::•':::::•:i:::::::•,::::ii:::•:::::•::i:::•::::i::::::::::ii::::i::::i:::i:::::::::i::::i::::i:::::::::::::i::i:::i:i::s>::i:::::i::::•:::L::::C:::�::�:�!:�:�':�':�":�':�':�':�':�':�:':�:�::........................... '.. .. .......:..::.::..iii?iiiiiiii?iii?i:4i:i.i:i:'iiii:�:::::•:•:•:ii w:::::::::::::::::::::::::::.�::::::::::::::v::::•::v::::::::::::::•:::::::::.�:::::.�::::::::::::::::::::::::::::::::::::::::.�:::::::::::::::.�::::::::::.�:::::::.�.�:::::::::::::::::::::::::::...:n....................................................�:::::::::::::::::::::::::::::::::::::::: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEIAW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WNICFi TNIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFFECTIVE POLICY EXPIRATION L,� TYPE OF INSURANCE _ POLICY NUMBER — DATE�FiM/DD� DATE(MM/DDJYY) �� A GENERALLIABILITY RMGL6122670 01—APR-7999 01-APR-2000 GENERALAGGREGATE a lO,OOO.00O X COMMERCIALGENERALUABILITY PRODUCTS�OMP/OPAGG $ 1.500,000 CLAIMS MADE � OCCUR PERSOtVAL 8 ADV INJURY $ 1,5 O O,O O O OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $ 1,5 O O,O O O $5��,000 Self Insured FIRE DAMAOE An onefire $ 1,50 0,0�0 RCt617t10I1 MED EXP An one rson B AUTOMOBILE LIABILITY RMAL3209860 01-APR-1999 01-APR-2000 X ANY AUTO COMBINED SINGLE LIMIT $ 2.O O O,O O O ALL OWNED AUTQS BODILY INJURY $ SCHEDULED AUT0.S (Per person) X HIRED AUTOS BODILY INJURY a X NON�WNED AUTOS (Per accident) PROPERTY DAMACiE $ CiARAGELIABILITY AUTOONLY-EAACCIDEP7r $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLAFORM AGGREGATE $ OTHER THAN UMBRELLA FORM B WORKERSCOMPENSATIONAND RMWC3473432 01-APR-1999_ _07-APR-2000 W�Y�T�� _ °TH' �=< ' EfdPLOYER3'LIABtGfTY I,O O O,O O O EL EACH ACCIDENT $ THE PROPRIETOR/ X INCL ELDISEASE-POLJCYLIMIT $ 1,OOO,OOO PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE 1,O O O,O O O OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS ::::.:...:.:.:.�,::.;:.;:.;:.;:.;:.:.;:.;:;::.>:.>:.;:.;::.::.;:.;::..:�:.:.::.<:.;:i;i�;::;:::'::;::;:::::i::::::::::::::i::i::;::;;::;;::;:.;::;;:,;:.;::;:::�:`�:�::;:::::;::i::i::i::i:::::::;:::::::.;:;:...:::>:»:.;:.;:.::�>:.>:.;:.>:.;:.;:.;:. :::::::::::::::::: .::::::::::::::::::::::::::: � ................. . ::. . .. . : ::: : :::. fiAi1+t�F..f:�T#�N '::>::>::>::>:::::::::<:>::>::>:::::<:>::::>:<::<:::>::::>::::>:::::::::::::: >. ?E.H�I.,I�:::<:::><:>:<:;::<::<::::«::::::<:�::::<`':s>:>«:::>::>::>::::>::::>::>::::>::»>::::>::::>:<::::?;:::::::::>::::;�:;:>::::>::::>::::>::::::::::»::::>::.. �F.�'1'#f�Y�...........................:.......................................................................................................................................................:..:.::::.......:.:::::::.;:.;;:.;:.;:.;:.;:.;:.;:.;::.:.;:.;;:.;:.;:.;:.:;.;:.;:.:;.;:.;:.:.;:.........�:::::::::::: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TOWN OF YARMOUTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY BOARD OF HEALTH OF ANY KIND N THE COMPANY ITS AGENTS OR REPRESENTATIVES. S.YARMOUTH MA 02664 Au oRIZE REP Es� � ...................................................................................:.......::::..�::::::::::::::::::::::::::::.::_:::::::::::::::::.�:::::::::::::.�:::::::...:::::::.:::::::::::::::::::::::::::::::::::::::.::::::::::::::. >:::>::>:::>::>::>:::>::::>::: ::.:.::::>::>::>::>::;;::;::•;::.:.;:.;:.;:.;:.;:.;:.;;;.::;>::>::>::>::»::>::>:;:::>;::::;:.>:::;.:: :::,.::::.::.::::::::::.:.::::..::.::.::.:::.:::..:::::::::.. ...:::::::::::::...::.::..:.:..::::..:::: ::::_::::::�:::;:.,.:.,:::::.::::.;::,::,;:::::,:.,:,.;.:::::,:::::.::;;::::: :.; . : :.:.: :�;:.>::>::»::>::>::>:>:s.•:::::;:;;::::>::>::>::>::>::>:<�:<>::::;;:;:>;::::>::::>::Q.1:�0.Li�5f�:::>:::::�:°:':::::>:::s;::::>::::>::::>::>:::<r:;`.'.;;>::::::>::>::::::::'::>:'<:::::::::>:<:::;:>::;::>::::<':::::':::'.:'°::::::::::;;[:[........:.:.::::...:.A�i3�kGC�RPf7k�4'�'Ifil'�.'1�.... ;�.t'f3RF�:2�.:�.3.�5::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::..................................................... ................................... .. � ' WILLIS CORROON Mazch 27, 1999 Willis Corroon Corporation of Massachusetts Insurance TOWN OF YARMOUTH BOARD OF HEALTH Seroices S. YARMOUTH, MA 0 2 6 6 4 Three Copley Place Suite 300 Boston,MA 02116-6501 Phone: 617-437-6900 Fax: 617-247-1211 Dear Certificate Holder : Enclosed is the Certificate of Insurance issued on behalf of Cumberland Fazms Inc. Should you have any questions please feel free to call. Sincerely you=s, Willis Corroon Corpoiation of Massachusetts Enclosu=e cc: Cumberland Farms Inc. Insuiance Company of the State of PA Illinois National Insu=ance Company ' r ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-39 FEE: $20.00 This is to Certify that Cumberland Farms Inc d/b/a Cumberland Farms#2268 _ 626 Route 28, South YarmoutlL MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBITTION OF TOBACCO PRODUCTS AS PER TI-� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31. 1999 unless sooner suspended or revoked. FebntatYl l , 19 99 BOARD OF HEALTH: �c`� �}af�fe�, ��iairman �oaic� �ullivar�, K.�, Vice lrhairman Kob¢rE J. 4�rowit� l.[erh �adrie��al�afe�Z�oopes ' �i,ae[O� hlin Director of Health � •, � � � " TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLI5HN�NT PERMIT NUMBER: 99-49 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of We General Laws,a permit is hereby granted to: _ Cumberl nd F rmc in . , 626 R�t�te 2R� S� � h Y rmo� h,R�A � Whose place of business is: Cumberland F�� #2268 Type of business:_ Retail Food Service lec than 25,000 s�ua�re fec�t To operate a food establishment in: Town of Yazmouth Permit expires: December 31, 1999 BOARD OF HEALTH:�d�f. �at��, C'��,� . � �oan� �ullivaa,K.i/•� �ice C.�irman , Ko�art�.}. /�rouia� l,[erk . ! a�irie[[e�a�ol��ooPa� '//ic�6 ooCou �li� � Februat,�Z 11 , 19 99 Bruce G.Murphy,MPH,R ., O Director o�Health i �- � •' Cu�t►k�r lu.vjd �-arvnS � � ��3,�� zcez I TOWN OF YARMOUTH BQARD OF HEALTH (,�!� ' • APPLICATION FOR LICENSEIPER�T"� 1�99j ` �'`' � � � � � � � � ' ' ` JAN 0 $ 1999 * Please complete form and attach a11 necessary documents by December 31,�19�8. Failu to do so will result' the return of your application packet. HEAl7H DEPT. -------------------T�-------------------;---------- ------------ ------------------------------------------------------��z�q ATI D - � M - o � C N N '' � �e ` R' N � 6�� II�T POOL CERTIFICATI�NS: The pool supervisor must be certitied as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. _ _ - ; 1 _ 2 Pool operators must list a minimum of two employees curreritly certified in basic water safety, standard First Aid and Community Cardio�ulmonary Resuscitation(CPR). Please list these employees below 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• HEIlVILICH CER'�IFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. ' 1. 2. 3. 4• � RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# j ------------------------------------------_---_--------------------------------------------------------------------------------------- j - - — - - --—---------- � _ _ —_______ t3�FICE�SE 6��Y_ ___ _. --- __ LODGING: LICENSE REQiJIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i B&B $50 �CABIN $50 ' INN $50 _CAMP $50 LODGE $50 TRAII,ER PARK $50 ' MOTEL $50 _SVVIlVIlVBNG POOL $SOea. WHIR�I.POOL $25ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 5EATS $75 CONTINENTAL $30 >lU0 SEATS $150 N('1N-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SE�iVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 �TOBACCO $20 �Q-'3 I <25,000 sq.ft. $75 �� FROZEN DESSERT $25 >25,000 sq.ft. $200 �TAME CI3ANGE: $10 AMOUNT DUE _ $ q� � "*"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""`"" I � � � , ' ADMINISTRATION . UNDER C��PTER 152, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOLJTH IS NOW REQUIRED ; TO HOLD ISSUANG� OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A i �ERS.(�N O�t C€��ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STAfiE WORKER'S COMPENSATION INSURANCE AFFIDAVTT � MU5T BE COMPLETED AND SIGNED, OR ' ': CERT. OF INSURANCE ATTACHED I � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I � TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF � ''I YOUR PERMITS. PLEASE CHECK AP OPRIATELY IF PAID: i � YES-- '� NO j ; y---- N9�E:-PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEN�BER 31. IT IS YOUR RESPONSIBII.ITY TO RETiJRN 'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. ' SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATTONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SVV:N�VIVIMING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR TI-�SEASON MUST BE INSPECTED BY TI�HEALTH DEPART'MENT,AND THE WATER TESTED FOR ' PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, [ PRIOR TO OPErtING, AND QUARTERLY THEREAFTER. � � POOL CLOSING: EVERY OUTDOOR IN GROUND SVV:[NIlVBNG POOL MUST BE DRAINED OR COVERED � WITHIN SEVEN(7)DAYS OF CLOSING. ; ; ; FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FII,ING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. �ROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESLTLT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSER.T PERMIT UNTII,TF�ABOVE TERMS G ----- -- -- ------ ---- __ _ _ - -- – _ __ --_ --- __ —_ . _ HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM TI-�BOARD OF HE.ALTH. 4UTDOOR COOKiNG: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD ; SERVICE ESTABLIS��vVIEEN'T IS PROHIBITED. i i DATE: � ' "� � SIGNATURE: � E , ; PRINT NAME& TITLE: Ricria d Fourn' � Tax �anager � : . , � �\ �� _ The Commonwealth ojMossachusetts � � W Departmenl ojlndusfria/.accidents T ; O/flce o1/eres�l�sd�is � 600 Washington Street �,� �.� Boston,Mass. 02111 °�� Workers' Compensation Insurance Atfidavit At�olicant information: P(easePRI1�T'�'}�c _ � ,, � .--� f�-> nam�• �.�� .�y�p�^. (,Z�v. ��,eM�+o�T�,=\��— location'. � �`�C � I � � `(�C�n�n_ � cit�. l. ,�l.v._�� . T'� � � c�� phone#\� � \ 1��-- '-tl� � � I am a homeowner perto ing all work myself. � f am a sole proprietor�:;� ha�e no one ��orkine in am•capacin� �m an employer Pro�idins workers' compensation for my employees workine on this job. _ _- _ .., - �' -- _ ( � _ gompan� name: �/vv�.K�rP�� (�/Ln..n /� .� �' 1�� _ _ S addre�s• �� \2 �� i � �• '`�O� � Q � insur�nce ca � � � � I' # L'. � I am a sole proprieror. general contractor, or homeowner(circle onel and have hired the contractors listed below� ��ho ha�e the follo�cin� ��orker,� ;ompensation polices: �om�v name• address• �• phone�• insur�nce co �olic,�# com�nv namr -- — ----- _-- ------- a�d r __------------- ----_ �e• -- --__- ----_ - tjty• nhoee M• incnr�nww en �p�� - Failure to secure coverage as required under Secdoo 25A of MGL 1S2 ea�lad to t6e iepai0os of trisi�al pe�dtla of a 8�e op to 51,500.00 a�d/or one years•imprisonment a�w•ell a�civil penalda in tAe form of a STOP WORK ORDER aed a tiee of S100A0 a day apiost ma I r�derst��d tlat a eopy of tha statement may be fonvarded to the Oliice of Investigatioo�ott6e DU tor eovenge verilieatio�. /do hrreby cerrij}�under the poins and pena!ies perjury ot e injornwtion provided above is true and eorreet Signature � ��.�� 9 Richard Four e Print name Phone N�� 'Q l� � R '�'�-�c�� .. oRcial use onl�• do not Mrite in this area to be completed by city or town oAltial city ar town• Y�M�� _ permitAieenu N nBuildiog Dcpartmeot pLiceosiog Bo�rd �cheek if immediate response is required 261 QSdectmen's Otiiee �Health Departmeot contact person: phone q;_ �508� 398�2231 egt. nOther �re�-ued i�a5 P1A1 � , � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-48 FEE: $75.00 In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Cumberland Farms Tn ., 1297 RoLte 28, S�Lth YarmoLth, MA Whose place of business is: Cumberland Fa.rms#2262 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:��/. �et��, C'�tr�z ', �oan� �udlivara� K.i/•, �icg C��irmarc KoberE J. �i�ouin� l.[er� abvieLle�ahol��t�-.J�too�vee icha Odou��lin Februa,rY 11 , 19 99 Bruce G. Murphy,MPH S., HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-3 8 FEE: $20.00 � This is to certify that Cumberland Farms Inc. d/b/a Cumberland Farms#2262 1297 Route 28, South YarmQuth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBiJTION OF TOBACCO PRODUCTS AS PER'THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. I � This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and 'i expires December 31. 1999 unless sooner suspended or revoked. I c7 ; February 11 , 19 99 BOARD OF HEALTH: �c`� ._te#ee, ��iair.riarc . �oan(�. Ju[[ivaic� /C.//.� Vlca l.�irman � Ko�ert J. /�rown, l,[er� �abrie[le�a�of�l�rf-�/�ooPee �0' o��.�. n�ce - u�P Y, Director of Health /� ;.:.:::.:<�:�>.::.;:�>DAT�>.::<.>:;::;.:<......... ( E MM DD �i' ��::A CORD ::':::::::,::;::::. .::::::::`::,`.:::::-'':::. :::__:__:::.:::�::::>:::,::,:.::::::��`::::::;.:::::::::.,:::..::._:_::::::``::::"`�'»::>::::::::`.:..`::::`:::;'.::,::.'.;::.,'::<°:.:::;:.'::::`:::�'::::::::::::��:::':::::::::::::::::.#�:::::;:::::::::::::::::.:: � / � .. :'::'... TM '�I�� ::::��::::�:�.��:��::.... ��!±' �%�� .... :::::::.�� .................... . .VR�.>:.:.:k>:. ' ..::::::::::::';:i: ' :::.:.::::.:�:::::::::::::.>:.s:.>:.>:.>:.:.::.>:::::.:�:::.:�:::::::::::::;;::.>:.s:.;:.;:.:::.;:.>:.;:.s:.s:.s::.:.::.:.>:.>::.:;.�::.�:.�::::::::::::::::::::::::::.;:.>:.:;.::.;:.::.>:.::.:.::.>::.>::.:>;;:.::.::.::.>:.>:.>:.>::::._.�:::::::::::::::: .......�... . .............................................................:..::::.::::.:::::.:�::::::.::::::::::::.�....................................:::::.::::::::::::.:::::..�::::::�1:._:::::::::::�.:.:::::::: 1 APR-1998 :::: PRODUCER 72760 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis Corroon Corporation of Massachusetts ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Three Copley Place HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR Suite 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston MA 0211 t'r6501 (617)437-6900 COMPANIES AFFORDING COVERAGE connPnrvv National Union Fire Insurance Company of Gayle M.Daly A Pittsburgh,PA INSURED Insuranc COMPANY � � A B Cumberland Farms Inc. ��PANY APR 0 6 1998 777 Dedham Street C Canton MA 02021 COMPANY HEALTN DEPT, D ��'`�'.:�A�'::::.:::;,>:::::::>::::::>::::>::;:>:<::::::>:::::::::::�:>:'::i�':::>:::::��:�:::>:::::':::::::::::::::>::::�::::�:��:::><::>::>::><::>::>::>'::>::::>::;::::>::>;»::::>::::::>::::::::::::::>:::;'�:>::>::::::::::::>:':'::>:<:::>:<:>::>:::;::::::::::>::::::>::::>:::::::;::::»::>::::::>:::::::<::<:::::>::>::>::::>::::::>:<:::>::::::»::::>::::::::::::::::»'::::::::::::>::>::::::::>::::::>::;:::»»::»::>::»::»::>::::>::::>:::::>:;:>::>::>:: ,.,.::. � �� .:::.:.::::::::::::::.......:::::::::......:.::::::::::::::.;;;:.:.;;:.::.:::::::::::::._::::::.�::.:.;:.;:;;.;;:.;;:.;:.;:.;:.;:.;:.;:.»>::.;:.;:.;:.;:.;:.;:.;:.;:.::>:.::>::»:•»::>::>::>::»::>::>;<::«:>;::>::>::>::>::>::>:<:;:::::>::>::>::>::>::>::»>::»:::::>::>::»>::>;::>:<:::>:::<:>:::::::::<:::::::;;;;:::;::::::::::>::::::::>::::>::<:>:<:>:::::::::::::::::«::::»:<:>::::>::::»:<::::» THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELAW HAVE BEEN ISSUED TO TME INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TypE OP INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIpATION uM� LTR DATE(MM/DD/YY) . DATE(MM/DD/YY) _ —_- -- a► GeNeRn�uasi�m RMGL1735841 01-APR-7998 01-APR-1999 pENERALAGOREGATE a 10,000.000 X COMMERCIAL GENERAL LIABILITY PRODUCTSCOMP OP AGC3 $ 1,�5 O,O O O CLAIMS MADE � OCCUR PERSONAL&ADV INJURY $ 1,7 5 O,O O O OWNEF'S&CONTFACTOR'S PROT EACH OCCURRENCE $ 1,7 5 O,O O O X $500,000 SCIf-IIISU�efI FlRE DAMAGE An onefire $ 1.�5�,0�0 Retention MED EXP An one rson A AUTOMOBILE LIABILITY RMCA3208701 01-APR-1998 01-APR-1999 COMBINEDSINGLE�IMIT $ 2.000,000 X ANY AUTO ALLOWNED AUTOS BODILY INJURY SCHEDULEDAUT0.S (Perperson) $ X HIRED AUTOS BODILY INJURY $ X NON-0WNED AUTQS (Per accideM) PROPERTYDAMAGE $ QARAGELIABILITY AUTOONLY-EAACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ Af3�REGATE EXCESSLIABILITY EACHOCCURRENCE $ UMBRELLA FORM AGGRECiATE $ OTHER THAN UMBRELLA FORM B WORKERSCOMPENSATIONAND RMWC1165770 01-APR-1998 01-APR-1999 W�YLIMITS �H i._......... :::. :::: :: EMPLOYERS'LIABILITY .. ......_.....::.:: -- . _-- e��nc►�ncs�c�►�r ; 1.0 Q 0,0 Q(1 _ ; THE PROPRIETOR/ F PARTNEAS/EXECUTIVE X INCL ELDISEASE-POLICYLIMIT $ 1,OOO.OOO OFFICERS ARE: EXCL ELDISEASE-EAEMPLOYEE 1,OOO,OOO OTHEH DESCRIPTION OF OPEHATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS ,;�Ll::1yR7y:!t.�::;:;:;;::�:�.yy:�:.;::.>::;�:..::{�.�.�;..:�i:::r'�'�'�:::::'�::;::::::;::'�:;ii:::::�::::::::::;:::`::::::::::::;::::'�':'�::::::::::5�::::::::::::::::::::::::::::::::;:::::::::::i::::::::::::::::;:i::;':?;:�:;:.;:.::.:�:;.:.;:.:;:>::::.�.::.;:.:<'::;;;:::::i:::;:::::::::::::::::::;::::;:::::::::�r::::i::i::::;::::;::::i:::i:::;:::i::i::>::;:::i:::::i:::>::;::i:::�::::::i:::�;;:y:.>:.»;:.::.>:.;:.:.::;.::.:.:; � ..................4Y��.i1kP::i�/GRl .:::::;:::..............:......:: .......................................:::::::::::::::::::::::::::::::�;:.:�::::�::.:;;::�>:�>:�:;a;;:•::�>:�:;�:;;:::�:� ..:�: •:� � :•>:�::�;:�::>::::�i:�i::�:•::•>:�>:�>:.>:.;::�::�::�:::::�;:•>:�:;o:::�::�:�i::s::•::�>:�>:�::;:::n:�>:�;:::•>:�>:�::.::i:�;ii:•;::�;>:�::�:�>:•:::�;:�:>: ...........................................��.�:.�::::::::::::::t•>:•>:�:>:>:•>::�>:�::�::::•::�s:�>:�»::•::�::�:»::<:�i::�i::::::�::�::�:�'::i:�>:�::::?:�:�::::;�:::�:::�:�:i:S:S::�>:�:::%;:� ...................... SHOULD ANY OF TNE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CEHi1FICATE HOLDER NAMED TO THE LEFT, TOWN OF YARMOUTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGA710N OR LIABILITY BOARD OF HEALTH OF ANY KIND N THE COMPANY ITS AOENTS OR REPpESENTATNES. S.YARMOUTH MA 02664 Au ORRE REP Es� �.................. ;�i�#I.�p�..t.:...;:.a;::.:.;;.�:;,;;�:.;C:.:<�..:><:::::::`::»?;�':»>:::'�>::::>:::::[:<::>;':>:'::::::::::::::::�?::::::'<<>::>::::::::?�;:.>y;.:;;::.L;:.}°y<�.:>��>f<,«::«:::::::::::::::::::::<::::::::::::<:>:::::::::::<'::..:�::>:::«:;::>:::::::>:::::::>:!::::»:«;::::>::::»:<:>::::>::>::::::::::::>::i><:::>::::::>::::::»::>::::>:::>��I y•�i�:>:>:>::>::»::;>::»>;>::::::::».::»»:;>;>;:,;;>;;;;:.::,>;:.;;:;:.>:�:� f:[�'.�..�.x�:�XM .........:�:...::.:�:::.: .........::::::a;r.:.:.;Y:�i:X7'Y.:::::::::::::::: �s �ptyy p]�.�iy{��7�i{;(�� ........ ...............::::::::::':i::i::>::}:i:::r::iY}::i::r::j:::::::ji::i:::J:::::::r::J::?>:Lv::v:Y:::::::ji::J::::>::::::i::::i::::$:::J?.R:} . .. . :..:�.!'/:' . ...... ......�;........::::: ..........................��.Mli.1�'r.'.��.Rin��1.1►.1�::•:1'T/.f[�f::::::ii