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' ��' °' � TOWN OF YARMOUTH BOARD OF HEALTH �
� APPLICATION FOR LICENSE/PERMIT-2011 � ` `�'=�
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* Pleas � A
e complete form and attach all necessary d"o�umer�ts ' Dec mb �5 A ;�
Failure to do so will result in the return of your application acket.
��t3�:
ESTABLISHMENT NAME: �,u;y,��c�-,� Y�z�-rns ���� TAX ID• �
LOCATION ADDRESS: i� � , � TEL.#: - � y
MAILING ADDRESS:% � � �o
OWNER NAME: Qri.r,� �.,� ,
CORPORATION NAME (ff APPLICABLEj:
MANAGER'S NAME: �P C�,- rar-; TEL #•�d j 77/-l0�$'�
MAILING ADDRESS: ��. �-,� �,�,��,.�
POOL CERTIFICATIONS:
The poal supervisor must be certified as a Pool�perator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2 ,
Pool operators must list a minimum of two employees cun ently certified in basic water safety,sta�idard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these em�loyees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide ne�v
copies and maintain a file at your place of business.
1. 2
3. 4
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents are required to have at least one full-time employee who is cert�ed as a Food
Protection Manager, as defined 'ui the State Salutary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1- 2.
PERSON IN CHARGE:
Each food es�a�i1`isiuneritinustiiave atTeast one Person In �Iiarge�PIC`j on site duruig hours of operatioii. ;
l. 2
HEIMLICH CERTIFICATIONS:
All food seivice establishments with ZS seats or more must l�ave at least one employee trained in the Heimlich
Maneuver on the premises at all tuiies. Please list your em�loyees trauied in anti-chokuig procedures below and
attach copies of employee certifications to this foi�nl. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your plRce of business.
1. 2
3. 4.
RESTAURANT SEATING: TOTAL # ''
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERVII7" LICENSE REQUIItED FEE PEIL'VIIT�
_B&B S�5 _CAB1N S�5 _MOTEL S»
—�N SSS _C1�viP J:,:J _S�'�L�'liVf1IVGFl.'1C7L JEOe'a.
_LODGE S5� `TRAILERPARK S105 ���'HIRLPOOL S80ea. �
FOOD SERVICE: j
i
LICENSE REQL�IRED FEE PERI�IT� LICENSE RE UIRED FEE PERVIIT� r {
Q LICENSE REQLIRED FEE PERiVIIT� f
=0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 �
>100 SEATS S160 _COMNION VIC. S60 _W�IOLESALE S80
RET:�IL SER�'ICE: —RESID.KIICHEN S80 !
LICENSE REQUIRED FEE PERVIIT# LICENSE REQUIRED FEE PERI�IT~ LICENSE REQUIRED FEE PER�'�II7� I
<50 sq.ft. S50 >� �
_ 5,000 sq.8. S225 VENDING-FOOD S�5 i
�<25,000 sq.ft. S80 ��� —FROZEN DESSERT S40 f
�TOBACCO S» -�611--�1� j
\A�'tE CHA\GE: S15 AMOUNT DUE _ $ 13S•O� �
***"*PLEASE I'tiR`OVER A\D CO�IPLETE OTHER SIDE OF FOR�i
**,.**
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ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i
,
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 E
AFFIDAVIT MUST BE COMPLETED AND SIGNEI), OR ;
�
CERT. OF 1NSURANCE ATTACHED �
i
OR i
WORKER'S COMI'. AFFIDAVI SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS _
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refe� to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. �
POOLS �
�
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected �
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection three(3)days ':
pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected
and opened. �
i
POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standard plate count �
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ;
thereafter.
PUOI.CLC3SIlVG: Every outdoor in ground swimming pool must be drained or covered within seven(7j days of �
closing. '
I
FOOD SERVICE '
SEASONAL FOOD SERVICE OPENING: � '�,
All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening.
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,or from the Town's website at www.varmouth.ma.us under Health Department,Downloadable
Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocahon of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
i Outside cafes(i.e.,outdoor seating with waiter/waitress service),must_have prior approval from the Board ofHealth.
,_ _______ _ _
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN .
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN
DATE:J�t�//� C� SIGNATURE:
��
PRINT NANIE&TITLE: ichard Fournier
ax anager
10'06 10
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� � �
The Commonwealth ofMassachusetts
Department of Industrial Accidents
N�I N�I�
600 Washingt�in Street, f"'Floor '
Boston,Mass. 02111
Workers'Compensalloa Imarance AHidavit:BaildioglPlnmbiag/Ekctrical Contractors
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name: v'Vl pi� ! !'✓I'� S �
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wnrk site location(full address)•
U I am a homeowner performmg all work myself. Pro�ect Type: �New Constrvction QRemodel
❑ I am a sole proprietor and have no one woc�cing in any capacity, ❑Building Addition
�I am an employer providing workecs'compensation for my employees working on t6is job.
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❑ I am a sole proprietor,geaerai coetractor,or homeowner(circl�on�)and 6ave hired the contractors listed below who have
the following workers'compensation polices:
comnauv oamr
address-
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ose n•� �daieia�Pe�aNks�t a Aae�b f1.3N�0�a�d/�r
Ya mpt6ae�nt a�weY as cM pe■aitln la t6e[orr�o(a 3TOt WORK ORUBIt aed�ene d SIA�.O�a day ag�Imt se. 1 aeden�d t6at a
c�py�[tib�taoeme�may be forwarded os tee O�ke e[I�vptlgW�d�t f6e DIA for arerase verlAnMs�.
/do heraby cerGijy rrader Nie peJws and penelda of perjpry tlY�t yre lajorwratJon provfded oboae fs dTte rwd co ,
Signaturt
Date _ � /� j
P,;,,t„� Richard Fournier
Phone#
af8eial ux oety : _. I
do not wrke le thb area to 6e rnvpkted by dty or�wo o@kW ;
ciry or town: '
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' � The Commonwealth ofMassachusetts
( Department of Industrial Accidents
' Of,ficP of InvestibQations
� �
600 Washin,gton Street .
Boston,MA 021II
www mass gov/dia
� . Workers' Gt�mpensaiaon Insurance Affida:vit: Geaeral Businesses
Applicant Informa#ion Please Print Le�ibiv
$usiness/Organi�ation Name: ��E�� FARMS , INC. .
Address: 100 CROSSING BOULEVARD
City/Sta.te/Zip: FRAMINGIiAM , MA 01702 Phone #: (508)270-1400
Are you an empioyer?Check the appropriate bog: Business Type(reqnired):
1.� I am a employer with 6�09 2 employees(full and/ 5• �Re�ail
or part-time).* 6., ❑RestauraatBar/Eating Establishment
-;
2.❑ I am a sole proprietor or pariaership and have no �, � Office and/or Sales(incL real es�ate, a�,etc.)
employees worldng for me in any capacity. .
[No workers' comp.insuranca required] $• ❑Non-grofit
3.❑ We are a corporation and its officers have exercised 9. ❑E�ertainment '
their right of exemption per c. 152, §1(4),and we have 10.�Manu�acfi�g
no employees. [No workers' comp,inenranpg re�e�* i l.�Health Care
4.❑ We are a noa-profit organization,staffed by voltmteers,
with no employees. [No workers' comp.�surance req.] 12.❑ Other
*Any appIicant that checks box#1 must also fill out the section below showing thcir workers'compcnsati�policy informatioa
**If the carporate officets have exempted thcroselves,but the corpora�on has other employees,a wor3ceis'campensati�poIicy is roquired and such�
organizatian should c3uck box#1. •
I am an employer that ic providing workers'compensatian insurance for my employees. BeIow is the policy information.
Insurance Company Name: ILLINOI5 NATIONAL INSURANCE COMPANY
Insurer's Address: 50 KENNEDX PLAZA / lOth FLOOR
City/State/Zip: PROVIDENCE , RI 02903—Z393
Poficy#orSelf-ins.Lic..# WCO20342628 ExpirationDate: 04/O1/2011
Attach a copy of t6e workers'compensation policy deciaration gage(showing the policy number and ezpiration date).
Failure to secure coveiage as re4uired under Section 25A oi MGL c. 152 can lead to the imposition of eriminal penalries of a
fine up to$1,500.00 and/or one-yeaz imprisonme�t,as well as civil penalties m the form of a STOP WORK ORDER and a fne
of up to$250.00 a da.y�against the violator. Be advised that a copy of this stateme�t may be forwazded to the O�ce of �
Investigations of the DIA for insurance coverage verification.
I do hereby certi,fy,under the pains p ' of rjury that the information provided a�ove ' true and cnrred
o�-' ' -
Si ature: > /
Date: CO
Phone#: 508 270-1400 � �AGER
Official use only. Do not write in this areq to be cn»tpleteu'fiy ci�y"'�r�'own o,;�"�iaL •
City or TowQ: Permit/License#
Issning Authority(cirele one): �
1. Board of Health 2.Building Depariment 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Uther
Contact Persoa: Phone#:
www.mass.gwlciia
TOWN OF YARMaUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #11-029 FEE: 8U.00
In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A and Chapter
111, Section 5 of the Generai Laws,a permit is hereb�granted to:
Cumberland Farms Inc., 626 Route 28, West Yarmouth, MA
Whose place of business is: Cumberland Farms#2268
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yartnauth
Permit expires: December 31. 2011 BOARD OF HEALTH: ��tlutt��Ltt�Q�tt-SHl�, �.awwnan
J y 1�I�r�►cr�, `Ui.ce Cf�a�i�rrnarc
2t1p��ia�m C Snau,.ct�n Ill, C'�ex�
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d�a�e���� ✓1�.1�3.
December 7 2410
' ru e G. urphy ,R.S.,CHO
Director of Heal
TAE COMMONWEALTH OF MASSACHUSETTS
TbWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #11-019 FEE: �55.00
This is to Certify that Cumberland Farms Inc. d/b/a Cumberland Farms #2268
626 Ro�te 28, West ��rrn�»th MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBA CO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATI4N.
This permit is granted in confornury�vith Article VI of the Sanitarv Code of The Common�vealth of Massachusetts,and
expires December 31 2011 untess sooner suspended or re��oked.�
December 7.?O10 BOARD OF HEALTH: ��L� txotf,..s�ft�(#,(�, (�yttttqh
J 1`}�Qt, `Uiee C'�awrncan
2Ui��un C'. Sau�uden Ill, �Qex�
�. ,�fcul,eo
�, .it�t.�
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Director of Healt' ' �