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Home My WebLink AboutApplications, WC and Licenses .� ,,. ��Mec-,�.�N� �a.�s � � r TOWN OF YARMOUTH BOARD OF HEALTH (� ��.,� �j��, � � � APPLICATION FOR LICENSE/PERNIIT _+Z�Q9 � ' •..� . DE�: l 5 �0[l8 � � * Please complete form and attach all necessary documents.�y ember 5 2408. ' Failure to do so will result in the return of your ap�i�ation pac et HEI�Ld�-6 a �+EF'T. NAME OF ESTABLISHMENT: ✓ TEL. # �(� J� �-� l 4-�- LOCATION ADDRESS: , '� MAILING ADDRESS: -- l OWNER NAME: "� TAX ID FEIN or SSN : �� CORFORATION NAME (IF APPLICABLE): : MANAGER'S NAME: ' TEL. # \� �`( 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 forr.m. 1. 2. Pool operators must list a minimum of two emplayees cun ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitatian(CPR}. Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fle at your place of business. 1. 2. 3. 4. FOOD PROTECTIOl�T MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who is certified as a Faod Protection Manager, as defined in the State $anitary Cod� for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicatian. 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 establishment must have at least one Person In Chaxge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all tunes. Please list your 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 �ile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�i G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PERMIT� B&B �55 CABIN $SS _MOTEL �55 INN S5� CAMP S55 _SVi.'IMMiNGPOOL �$Oea. LODGE S55 TRAILERPARK $105 WHIRLPOOL $80ea. FOOD SERVICE: _ __ _ - __ _ — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMI?# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS S8� _CONTINENTAL S35 NON-PROFIT $30 >100 SEATS �160 _COMMON VIC. $60 _WHOLESALfi �80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SO sq.i�. S50 _>ZS,OOO sq.ft. �225 _VENDING-FOOD �25 �<25,000 sq.ft. �80 �D -O _FROZEN DESSERT �40 I TOBACCO �55 O —OZ� �a�E c��cE: �io ANIOUNT DUE = S l 35 .p0 ***w"PLEASE TUR1 OVER AlV'D CO'VIPLETE OTHER SIDE OF FORM*""*# � i f , f 1 �,. ,_ ... ADMINISTRATION � Under Chapter 152, Section 25C, Subsection G,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 5IGNED, OR ' CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES NO � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions 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 ofresidence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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. � � E i POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected t by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days pnor to opening. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been mspected and opened. E i POOL WATER TESTING: The water must be tested for pseudomonas,total cotiform and standard plate count � j by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming poml must be drained or covered within seven('7)days of closing. � i � FOOD SERVICE � � CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departrne�t by filing the required ' Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the � Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmem is prohibited. € , NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TI'Y TO RETtJRN THE CO1VL��,ETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECElV�ER 15, 2008. ':, . � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: �, � SIGNATURE: f PRINT NAME&TITLE: ��h 7' FOu�`11i _ 8X A,g��' 10'21!08 ' � , The Commonwealth of Massachusetts � Department of Industrial Accidents OfflC@of/�estf�►sdeOS 600 Washington Street Boston,Mass 0211I Workers'Compensation Insurance�davit-General Businesses Anulicant information Flease Plti'N`T"l�iblv �e: CUMBERLAND FARMS INC. ��s: 777 DEDHAM STREET city CAI+T�02� state•M� zip•02021 vhone#: (781) 828-4900 work site location full address : I azn a sole proprietor and ha�e Business Type: Retail RestaurantBar/Eating Establishment no one worldng in anycapacity. Office Sa1es(including Rea1 Estate,Autos etc.) 8 I am an employer witti:6C192employees(full&part time). ��' I am an employer providing workers'compensation for my employees working on this job. com'an name: CiJNiBERLAND FARMS 4� �, �j� address: �O 1 ` � ' � � hone#: � � ' � \ � ci : —�— � —�- insuranceco IL INOIS NATIONAL INSURANCE CO policv#•WC 19 288-6�9 .. ; . , _ : . � :-�r� ❑ I am a sole prog,rietor and have hired the independent contractors listed below who have the following workers'comnensation nolices. com an name• address• citv ohone#: -- insurance co• oolicv#• " `�� ;�.-. -. , ,, sfi,�,�s com an name• address• citv. ohone#• -_- insurance co• uolicv#• Attach,additional:sheet:ifinecessa.ry � -;.-., 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 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day agsinst me. I underst,�nd that a copy of this statement may be forwarded to the Office of Invesrigations of the DIA for coverage verification. I do hereby certify under the pa' ar p,e al' of p ju hat the information provided above is true and correct Signature. Date• �_ _ Print name: RICHARD FOURNIE Phone#: �781)828-4900 official use only do not write in this area to be completed by city or town official ' city or town• permit/license#: Building Department Licensing Board ❑check if immediate response is required Selectmen's Office Health Department 4 contact person: phone#: Other (revised Sept.2003) e • w TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-038 FEE: S80.00 In accordance w�ith regulations pronnilgated under authorit��of Chapter 94,Section 30�A and Chapter 111, Section 5 of the General Laws,a permit is hereby graiited to: Cumberland Farms Inc., 626 Route 28, West Yarmouth, MA Whose place of business is: Cumberland Farms #2268 Type af business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2009 BOARD OF HEALTH: .`�E.¢e¢tL S�Pt., J2..N., C'Racvrx►urrt ('.R�c�r.eea .�. 3G�E'iR.e�c `lliee C'R.cr.ixnurn `J�n.��nE .!. `.�l3�cc�wrz, C'�ex� tlrin C�'�ceer�ccun, J2.✓V. E��e,��• �� Jamian�8,2009 Bruce G.Murphy, ,R.S., CHO Director of Health THE COMMONWEALTH OF MASSACIiUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-027 FEE: 555.00 This is to Certifi�th�t Cumberland Farms Inc. d/b/a Cumberland Farms#2268 626 Route 2$, West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This, e it is ant di�c forn 't��«-ith Article VI of the San ta Code of The Common�sealth of�.4assachusetts,and expi�es�eceii�er�1 ..08� un�e�s sooner suspended or revo�Cz�. Januar��8.2009 BOARD OF HEALTH: ��X�¢,tt .S�tl�, �..lV., ��ttatt ��itpR,O `.�. .�i��E��, �tCC ��R.%11tJttp�t 5�a�ex� s. 53�urewt, C`�enP� a��, �..�V. Bruce . Mu p y, . ., Direetor of Health � !-� ' � �'`� 9 a G°� o �.°f=Y�'�� TOWN OF YARMOUTH BOARD OF HE '�'S �� -;_ APPLICATION FOR LICENSE/PEFt�VJ[I1��p0 .`, ,� J A N O 2 2 0 0 8 f , �►? ; �� •�..�..�a . ,� * Please complete form and attach all necessary�r�iei�w�5"y . embe H D E PT. Failure to do so will result in the return of yt�r apphcation packet. � NAME OF ESTABLISHMENT: ' � TEL. # �T�„ '" �' Z � — ., LOCATION ADDRESS: ., ` _ MAILING ADDRE : OWN�R NAM�: TAX F IN r N • $� CORPORATION NAME IF APPLICABLE : �' MANAGER'S NAME: ` TEL. # � �" 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��d.�ttach a�ppy of the certificatien to this forin. -- - 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 eertificarions to this form. T�te Health Dep�rt�ent will not use past yea�s' reeords. 'Yoa �ust 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 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 to this applieativn. �he He�tlth Department�vitl not use past years'recards. You must provide new copies and maintain a file at your establishment. 1. 2. P�RSQN IN CI3�.��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 the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of em,ployee 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. l. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE OnLY LODGING: LICENSE REQUIRED FEE PER'�tIT# LICENSE REQUIRED FEE PER'tiiIT�* LICENSE REQL'IRED FEE PERVIIT= ,BBcB S50 _CABIN S50 _MOTEL S50 _INN S50 _CA.�IP S50 _S�L'ItiIV1INGPOOLS75ea. _LODGE �50 _T'RAILERPARK S100 t�'HIRLPpOL S75ea. FOOD SERVICE: LICEI�TSE REQUIRED FEE PERMiT� LICENSE REQUIRED FEE P£R�TIT� LICENSE REQliIRED FEE PERb11T= _0-100 SEATS S75 _CONTINENTAL S30 lv'ON-PROFIT S25 _>100 SEATS S150 _C0�4fON VIC S50 WHOLESALE S75 RETAQ.SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'� LICENSE REQUIRED FEE PERtiiIT� LICENSE REQUIRED FEE PER'kIIT� _<50 sq.ft. $45 ,>25,000 sq.ft. S200 �'El�'DIIv'G-FOOD S20 �<25,000 sq.ft. 575 i3 D '� _FROZEN DESSERT S35 /TOBACCO SSO �O –(J� �r�cxa�vcE: sio AMOUNT DUE _ $ /ZS .00 "**"*pLEASE TL'R\O�'ER��D CO�iPLETE OTHER SIDE OF FOR�1***** r s c 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es a.nd liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTEL5 AND OTHER LODGING ESTABLISHMENTS TRANSIENT UCCIJPANCY: For purposes of the limita.tions of Motel or Hotel use,Transient ocrupancy 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 demonstra.te that they maintain a principal pla�ce ofresidence elsewh�e. 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 s�(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11�enerally be considered Transient. * NOTE: En�tos�Motel Census must be completed and returned With tnis app�icat�on. POOLS PUOL 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 ; 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 tt�ereafter. 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 Yarmauth must notify the Yarmouth Health Department by filin�the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtaineti 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 urrtil the ' above terms have been met. OUTSIDE CAFES: ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. � OUTDOOR COOKING: ' . . • aretailox'-foed ' . . . . NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN ; THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. i a 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 COMMENCEME�TT. RENOVATIONS MAY REQUIRE A SITE PLAN. ,. � � DATE: � SIGNATURE: - FRINT NAME&TITLE: Tax A�an �s� io zn n� � • .� � : , ,-��_ ¢ � �� _ �rh of 1Ylassachuseits , � - �=-__-___-. The Commanwea� �-�- --- - �� Depar•tment of�ndustriul�4ccidents " `�+ �B��Id� izf .• : __, �. � J� 600 Washington Streei � ��.,`��% Boston,lYlass. 02111 �`—" J - Workers'�Com.ensation Insurance Affidavit- General Businesses - % . - - � name: _.. _ - _ � � . . address: �`�T' �C�VLLd!`l�L�� Tax ID �� •� �-` �D i��'j r'� {0 citv �A'�.iv►�fi1n � state• 11 � zip''Qo10�� phone#1�� 1 4�� C�C7� work site location(full address): Q I am a sole propnetor and have no one Bnsiness Type: �Re�tail�Re�staurant/Bar/Eating Establishment working in any capaciTy. ❑Office Q Sa1es(including Real Estat� Autos etc.) �I am an em loyer with em.loyees(full & art time _ ❑Qther � ''�//_l/�_�%%//////%%%///�%%%%%%%///%% %%%%�////%%�/%%%///%%%//��%%//%%//�y%%///%%��/%% //////��%//// �'� I aan an employer providing work ' compensaiion for my emplovees working�n this;ob. : . , . ;:� � . com an name: ` � . . .. . . . .. .. . . . .. . _ : . _. _ C • � � . address: � � s � � �� CllY�' � . . ' U}IOII@�• l'�� "" -�1 1 L.1..�� .. �� .. . � � . . . .. . .. . . ..._. . . . ]IIS72F8r�E CO. •�OTIC. � � '� . ... � � . � � . . � � ' �. . I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensaiion polices: companv name: � address: � eitv: nlion�#' ' insurance co. � olic # ;. . . . �:::., .. ..:: . .. .. .: •: : : _ ::, .._.�. .. ..::: .... . . , . . . ...... . . .. . . .., .,.��//./%%�.1�� comAanY name:. • . • . . • .. - .. . . . address: ci�: . -- ' nh�o'ne#•� �� -.. .- insurance eo. . � ... . � olic .#: . . i . /� ' Fallure to secvre coveragE as required under Secfion ZSA of MGL 152 can lead to th�imposition of criminal penaltiea of a fine up to$1,500.00 aad/or oue yeai-s'imprisonment as well as civii penaities in the form of a STOP WORK 0�2DEJR and a 6ne of$100.00 a day against ma. I undersiand that a eopy bf this statement may be forwarded to the Office of Iave�tigatlons of the DIA for coverage ve�cation. I do hereby certify under t ains pen ' ofp jury lhat the informatian provided above is true a�td e rrert. Si,gnature ' Date ��_ � (n 1 fl�_ Riohar _ r �o�/ i Print nam.e Phone# �C X( 1 �d� �- �F-�C�1Q o�cial use only do nat wi^ite in this area to be eompleied by city or towa ot]icial city or town• � permitllicense# �Building Deparimeat ❑chack if immediate response is required �Licensing Board i ❑Selectnnen s Offica � �Healttt Deparmoetxt contact person: phone#; ❑Other (n,�a sepc zao3) , � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-044 FEE: $75.00 In accordance with re�ations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby 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 Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: ��ert S�, J2...Ar., C'f�aixnuut C!R�avc�eo :�.�f�t#�c `Uice C,'fl�ar�rr►uuz ��ct 3.J3�ca�curt, C'�exl� �'C�Ce�err�atun, Jt.,.A�. 7anuary 25.2008 B ce G.Murphy, ,R.S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF 3�ARMOUTH BOARD OF HEALTH PEi�MIT NUMBER: #08-033 �BE: $SO.Ofl This is to Certify that Cumberland Farms Inc. d/b/a Cumberland Farms#2268 626 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBIITION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This��e�nt�c�'i��Cg�or�'t�y with Article VI of the San�ar�Code of The Commonwealth of Massachusetts,and exp c r i e s sooner saspended or revo e . January 25.20Q8 BOARD OF HEALTH: .�i�¢�¢It SK.L�, �..Ar., �u� {a�ar�c�ee `.�. `.��e�(�i�r.UlG, 2Jice('�iaci�cei�att '� � J2od�act s.��u�w,ri, C� ` Clnxi C�'�eerz�aum, J`�.Jv. J. . Director of Heahry�, H, . .,_ r ` `�eIMQERCAM� FiA�?MS ��°`;'�R�.c TOWN OF YARMOUTH BOARD OF HEALTH ,�� #22 o _ y APPLICATION FOR LICENSE/PERMIT-Z00 �� J�N 0 3 '�b� F : . � . � �± ' * Please complete form and attach all necessary documents y�e�ember 31, 2006. Failure to do so will result in the return of your application packet. NAME OF ESTABLISF�VIEENT': TEL. � �� LOCATION ADDRESS: �� MAILING ADDRE� OWNER NAME: `� T � r ''� ,� CORPORATION NAME �APPLICABL : *�,,,,,.�,d �' MANAGER'S NAME: � � � ' � ` TEL. # 6�q ' MAILING ADDRESS: ._. POOL CERTIFICATIONS: The pool supervisor must be certified�s a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certific,ation to this form.- _- -,__- _ ,__,_ _____ _�_-__—__ _ l. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety, stan�lard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee � certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4, FOOD PROTECTION MANAGER.S - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 5�0.000. ' Please attach copies of certification to this application. The Healt6 Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� 1. 2. �ER�N�£��t.GE: — _ -- ---_ _.—_- __ -- ___ ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. . HEIl��IL,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcmg procedures belaw and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAtTRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# BBcB �50 CA$IN $50 MOTEL $50 INN $50 CAMP $50 SWIlVA�IING POOL$75ea. LODGE $50 TRAII�ERPARK $100 WHIRI.POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMTT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >I00 SEATS $150 COMMON VIC. S50 WHOLESALE $75 RETAQ.SERVICE: —RESID.KTfCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERIuITP# LICENSE REQUIRED FEE PERNIIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 �QS,OOOsq.ft. �75 �O 4`�8 _.FROZENDESSERT �35 �TOBACCO $50 �o�—b3� NAME CHANGE: S10 AMOITNT DUE = S �2.S.O d ' •'•"'PLEASE TURN OVER AND COMPLETE OTHER SmE 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 pennit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S CUMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ; r CERT. OF 1NSURANCE ATTACHED � OR I WORKEI�'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 t/ NO MOTELS AND OTftER LODGING ESTABLISHMENTS TRANSIENT QCCUPANCY: 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 af residence elsewhere. I Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an } aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or � dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy ; Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. I POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected j by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days � pnor to opening. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab; prior tv op�ning, and quarterly therea.fter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of ; closing. 1 6 FOOD SERVICE � CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required ! Temporary Food Service Appticatian form 72 hours prior to the catered event. These forms can be obtained at the I Health Department. FROZEN DESSERTS: f E 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 Boazd ofHeatth. OUTDUOR COOKING: ' � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETtJRN � TI-�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ; I ALL RENOVATIONS TO ANY FOOD ESTABLISHIViENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO CONIlV�NCEMENT, RENOVATIONS MAY REQUIRE A SITE PLAN. � , DATE: SIGNATURE: PRINT NAME&TI'TLE: �iaf��lyd F r �� '"�t`�t7i ��..,n�.�'�� ; 10l17/06 I C � t�%3.�i .�_� The Commonwealth of Massachusetts ��==_ - - - Department of Industrial Accidents ;� , — Olfice oflnuestigatinns � ' _ 600 Washington Street, 7�h Floor - _- �{�� Boston,Mass. 02111 Workers'Com ensation Insurance Affidavit-General Businesses , ; � E�. , , � � name• �r,(�-pd� 0 J�,�� ('��'t Mn 1� 1 ,nr� P- �� address: �' 7� ��j� � l.� citv �dl� .+V��J state: 1- 1 � zip•�[� , Phone#1 i Q i /X n!� `' J'h�,�`D work site location(full addressl: ❑ I am a sole proprietor and have no one Business Type: (�Retail Q Restaurant/Bar/Eating Establishment worldng in any capacity. ❑Office�]Sales(including Real Estate,Autos etc.) ,�I am an employer with ' employees(full&part time). ❑Other I am an empioyer providmg workers co ensation for my employees worldng on thisjob. .. 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COIII � �'dmC � a �'3�..""�R.."��"�' � .,�,w�` "_ .., - .. . �. ... � " x �'�xe.t`ra�; �: -' � � i � a:'w xro�.n �w�� .:_ � . �� . _� : C F z �.i N�,��.i��'�� '� p; �t�ea%� �'� ,. _P .'daf�iCSS x r " � � ��-""�'3i+�1'-!�i .� s � gr�} wz7--r� � � � .. � �''+`�a..A��.F...�.'r--S,. . . :: , . ' i -.- �c. �'S•F,�'L��.'��,�"�'�a��r ��.;g :":.., � n � �x�� ;a��s,� t�r�:}.F: . � L � $ °�•�:�+.a u� w a 'a�-yta� � ��^�..�`��-..Y� � ' �. - CI � :. ' � - !1 (-�° t" .`�""s�t +�t' .;m. 9H� .s �,� �'}�.�� "' � �4ri��d�,�t''� ... j�""-^".� .!��. �Fx y�'.�rc�-a'`'��^' ' � . ; �:_ -: .. a 4�° '�� . ; . .� �i :�,��r � � <... .... ,,.. ,�., #�, . � � ��'.:t�. insuranceco .: ' , �' .uti�...�,r �.�,-.,.� � � � � � i - � ��>�.� '" o�Y�< .._ ,'�,, � ,��^%��'aJ�T'�,�'��'r"". er«;,v<'' -- .rrr wi �,* ;� . 4 t�tau.. 4' .� .�'E�tq - � n�. �. :: ': 3�� 'i„-�f�"Y^"`� 1 �K�`�7�j"Fq,il�.�� : � � x � ukl{�;,�'�.J�� r i� �^vd.� . 1 t1 :� � �6 Y 4 G'°�4i�:N r,4'.. ' 3Rrv. F �+{ COR7�3IIV II9IDC. � 7� r �.�#'a��# Tfi� ,�",,, s:�`c �,� '�`"�.'�' �* '��'F- -�'r-�.. � ..: ii Y ��,z�aW� �� 4��(f��yr�'�r�d� � '�'�` .^rnJ '� �, � y a� i,r wcMa. -y� address. , n � �� `��,'� "�`� r. � � n�'�"�`�` ' �� n �� s u !: al �^<7!r -.��"'u.W,..� ��v_,* - .�,r. �n�Ik �s ,�y ,s�-� J r f �..i. �t ax�n- �s � �i i. �, � � �' knr �.a��'^s'��,7!� �i �'� . _ � ��4�.k� �Ih.�4 5'��{dG7 Y i �I� � � y+ �+Ft'� � t`ff"»"5 k . M1 � _i j ,� m" kk�.� � �71Nrr��el,�l0.�i��; �.e��tli� "4?�- R� �i � i w .� _ �, i �T �x w ��z+.., u'"9��, iY�S: sk° r '�rG'n 7� � T4'° �sk -�—'� � .�.Y:i CSiV:. . .: - ' I � �a� e.��' . . . �� i � .t,' il '�' t7 4''3��,.,�,3..xei Ji�s�[lFIE'� �l�k��- �b,��-r:� �,�, '��...�' �,..�i 3 . �. 4'� �zac - i� I �,�'� T� �:� },e hh Q' s-F f � fi N7�'�iso�� ' . �-_ � :,a��up�' �� '�„`;h�`�,� a��r -�` 't�''��¢� r �^ �i iy��,� . II1SU1'BIICe'C0. a�.�...�.��c.tr��'�:,�,.�a-�rfis�,.k�.,.�"��r .� �,�� :�''.�(`�j ��"��il-"4-��ie,�„�; �,''; .' _ ' . : ��s�d' � �:. �. , � : e�,�,�� :� a. �m r..��,.�� ,� ....,�.r � Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penaities of a tine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be[orwarded to the Office of I �Uons of the DIA for coverage verifica6on. I do hereby certify under the pai n en ' o at the information provided above is true and correcL Signature Date �� r� (� � 20 / `-7��r l Q q p Print nazne __Phone#L _.t 0 � / U � 0 '�_ � I � � otticial use oniy do not write in this area to be completed by city or town ofticiai city or town: permit/license# QBuilding Department OLicensing Board ❑check if immediate respouse is required ❑Selectmen's Office contact person• hone#• �Health Department (revisee Sept 2003)� p � DOther � � - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-048 FEE: 75.00 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permrt is hereby granted to: Cumberland Farms Inc., 1297 Route 28, South Yarmouth, MA Whose place of business is: Cumberiand Farms#2262 Type of business: Retail Food Service less than 25,000 square feet To operate a food estabfishment in: Town of Yarmouth Permit e�ires: December 31, 2007 BOARD OF HEALTH: B �$. ,/l+l`.b., ' ��.�s�, .�., v�e�� R�t� a�, � �� Q.�n��, R.�v. Apri13,2007 Bruce G.M hy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NITMBER: #07-034 FEE: $50.00 This is to certify that Cumberland Fa,rms Inc. d/bla Cumberland Farms#2262 1297 Route 28, �o�th Ya�rmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TQBACCO PRODUCTS AS PER TI�YARMOUTH BOARD 4F HEALTH TOBACCO REGULATION. This�en�it i�e s��t�i��o�itv with Article VI of the San��y Code of The Commonwealth of Massachusetts,and e� es e�s sooner suspended ar revoked. Apri13,2007 BOARD OF HEAI,TH: B �. �j�,/H�., e�ii�u'.,st ��r�, R.�., v�e�� Rad�t 4 L� � n��r�� 4� ��, R.N. Bruce G.Murphy,MPH,R ., Director of Health �- � C..t1M�f•R.�.�N'a �1tiS ofPaR o TOWN UF YARMOUTH BOARD OF HE�I,T� `, � _�,� , � -�� s�n��2�e�i APPLICATION FOR LICENSE/PERII�IT�-20�7�� - Y ., .;�' � ` * Please complete form and attach all necessary documents by Decernber 3 l, 2006. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHIVIENT: �, a, TEL. �O �!��5�� LOCATION ADDRESS: Co - � 3 MAILING ADDRE : OWNER NAME: �' � � � CORPORATION NAME{ APP ICABLE): '—' MANAGER'S NAME: TEL. # � MAILING ADDRESS: POOL CERTIFICATIONS: The poot supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and atta�h a copy of the certification ta this form. _ _ ____ 1. � 2. Pool operators must list a minimum of two employees cunently certified in basic water sa.fety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments a.re required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wiil not ase past years' records. You must provide new copies and maintain a fde at your establishmen� � 1. 2. . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. � HEIlVILICH 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 nat use past years' records. ' You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. ', RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B �50 CABIN �50 MOTEL $50 _INN $50 CAMP $50 SWIMIvIII1G POUL$75ea. _LODGE $SQ _TRAII,ER PARK $100 WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERNII'P# LICENSE REQUIRED FEE PERMTP# LICENSE REQUII2ED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $3Q NON-PROFTT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAQ,SERVICE: —RESID.KITCHEN �75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTf# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $24 �Q5,000 sq.ft. $75 �0�� _FROZEN DESSERT S35 �TOBACCO $50 �� ' NAME CHANGE: $10 AMOUNT DUE _ $ /2S.00 ', •'•"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""* � i . � ADMINISTRATION � i 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 INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' i � [ t CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK , APPROPRIATELY IF PAID: � YES � NO ; ; MOTELS ANp 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. Transierrt occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. � Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an ' e ate of not more than nine 90 da s within an six 6 month eriod. Use of a C � � tY� ) Y Y � ) p guest unit as a residence or ; dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy j Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha.11 generally be considered Transient. ! POOLS PO4L OPENING:A11 swimming,wadin�and whirlpools which have been closed for the seasan must be ins ected by the Health Depa.rtment prior to ogening. Contact the Health Department to schedule the inspecfiion five(5�days 4 pnor to opening. E � POpL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count __ by a State certifxedlab,prior to openingT and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(?)days of closing. FOOD SERVICE ' CATERING POLICY: E Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filin�the required 'j 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 Sta.te certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. ! OUTDUOR COOKING: O�etdoor cooki�g,�repa�ativrr,o�display of a.ny food product by a retail or food servic�estab�ishmen�is pn�e�i�i�:----- � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY �OOD ESTABLIS��VIVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMII�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I DATE: SIGNATLTRE: PRINT NAME&TITLE: fi��c I�fana ion�io6 � i �� The Cvmmonwealth o Massachusetts �-.—� .f - – � DepartmentoflndustrialAccidents ;� j — Office ofln�estigatinns � _ 600 Washington Sireet, 7rh Floor ,,.�; Boston,Mass. 02111 i . Workers'Com ensation Insurance Affidavit-General Businesses , . . ; ,� ,^ . _ �, � � � _` �t� �` name: �A�P��l-��.h�1 ('A�l L�V�l.�_�_�(�- address: � `j� �� L ciri �dl M�� state: � � zin' ��l�c�t Phone#t 1 Q\ /�G n!� � Yh 1�� work site location(full addressl: � ❑ I am a sole proprietor and have no one Business Type: �Retail❑RestaurantBar/Eating Establishment worldng in any capacity. ❑Office Sales(including Real Estate,Autos etc.) ' I am an loyer with ' em lo ees(full& art time). ❑Other I am an employer providmg workers'compensation for my employees worldng on this job. :: H� � �,Ai ,,'�a z�t � �'� ,"^rw � . 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''_ � �: ; '�r u ri�;,� ��- ��, ,� M � . � rnsnrance:co.�. ,, .,� { , ��. ��' :,.�� ,��, �"� `'• w ,,i, �_�` ��,�� r�m�M �.� � . �.. � , � n, _ o`�� _ . E � - , , -- :...�u- .. ......�;r� ..,_... ,..�n.., ,��u. „a ,�f.. , , , ._. ,-: s,:. P'��t��,�� u��u:�r��w s : � ` � . �r��-'��'� �� .�. r''"` `$�. Y �h � ��` � COQ1P$IIV IId�IDC: � ri��i �,��.�,�3�'�-,� �i��, �.� ..�, '�� 2 a ��g`„�5'��u� ��'�� . P:_. . , • "fh4. k �,�} q . Jf i . -� � k ��4..�.'7:+_ C�� .�k'S� �� 1� �'.� IM�1-Y M�a4 �y vr - address� .. ' : �� I1 k kY'�-.�� rt�� 3 `a�b� 'R �: � �:t r �:g��r��X�S� j fI . . �..I�7 x s w �,�, Y'"^�'�I.��h�.�h�hl � .r � ,�ir <a"�r�"�``i1�`;s+i S,�.U�'��3'�y ow '�'r`. ..�; .. .: : - 1 w :�x a� y r I ro t�mr su r��,s � �� ..., . : .. . � = lo � h�'�{'� S r . �� P'��i i �i ' ."+� � ��"�, ✓��:�.�fi'#�4? `.�.�,� � � �dk . Cl.. : ;.. . . �� h��i,, �A„��"g'�,�.� :a..��T��:��a�•urA!�.''7� �� F � �f��a.,��"�r��'�`iW,s-'� " r'H`. . � :�, "�f �N a u u�'dv (�1II a'.�"Ju.-i-� a r i ��""#x�: tl` � �d r. ; �s � r v �� ;� �a��"4 �� '�' i�;�:"°�a,�',��Ce�" +�� Ih"�` `L�.'�H a `' 7 �' � � � 'i�'�� d�,�f ir ��'fi�.�j`'C��1� �'�.,`��s� ^ �✓'ti�E7� �, �. � �fx'�s �,k lIISlll'flIICC C0. � � ,�„,. �� "`�. �u. -�` a �' � �_i . .� , tx,,x�..efan�u:3..1*iw,!. O�1C. . �`�'+� �';��a'.�,<.�:�9.a fi�",m!I�,k,. . . . -� ...; > .. .:' .. , � .�....�, ' . -. , , � , - ;� :.. .-��.. " �" -....� - . 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 SI,500.00 and/or one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Oftice of I 'gations ot the DIA for coverage verification. I do hereby certify under the p ' d a of ju at the infvrmation provided above is true and correct Signature Date 30 8 � _PPhone#L ! Q � / U C�-(l'�_ � I � D Print name otiicial use only do not write in this area to be completed by city or town official rity or town: permitllicense# ❑Building Department ❑check if immediate response is required OLicensing Board ', OSelectmeu's Office ❑Health Department co�St person• phone#; ❑Other ( m�zoo3) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-049 FEE: $75.00 In accordance with regulations gromulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Cumberland Farms Inc., 626 Route 28, West Yarmouth, MA Whose place of business is: Cumberland Farms#2268 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yazrnouth Pemut e��res: December 31 2007 BOARD OF HEALTH: � �xis,c$. , /dl.$., ' ay� ��i, �sce eliar�inr�,rs R�t�B�, �k n��r�� 4,��.�, R.N. Apri13,2007 Bruce G.Murp H,R.S.,CHO Dire�tor of Hea1 THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF�EALTH PERMIT NUMBER: #07-035 FEE: $50.00 This is to Certify that Cumberland Farms Inc. dJb/a Cumberland Farms#2268 62b Route 28, West YarmoutlL MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTI4N OF TOBACCO PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�er�it i�s�ant�i�i�for�it�with Article VI of the Sani�{tan�Code of The Commonwealth of Massachusetts,and e� es er e s sooner suspeuded or revo ed A��3,Zoa� Bo�oF��.Tx: B �S. �'ond,o.t, Arl.�., G'�r� ��r� R.N., v�e�� R�4 B�, �l� Pa�isc�a/l�c_`?Se�ruitt �4�l�' , R.N. Bruce G.Murph ,MP , , Director of Heatth �' . p � c.��62�f SZ�3 � �°D Zua .�f;�R.� TOWN OF YARMOUTH BOARD OF HE � � �� -'� APPLICATION FOR LICENSE/PE � 6� ��' �;, .;? �„�� ,,� �� J A N 0 3 2006 * Plea.se complete form and attach all nece�s� �;�n �y Dec ��-�C��pT, Failure to do so will result in the returr�,of our application . NAME OF ESTABLIS��VIEENT:�Q�m.�� rno ��l�S �L. #.��-��i� LOCATION ADDRESS:lvo�6 Zc� MAILING ADDRE : C��,�-/ OWNER NAME: T ID E or S : CORPORATION NAME IF APPLICABLE): tr,� MANAGER'S NAME: TEL. #��id8-��S.�� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pot��l�Op�ratz�r(s) and attach a cz�py-af the certificati�n to tlus forin: 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR)_ Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applica.tion. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. _ _ PE�S�1�iIN GH1�RC��:-- -_ _ _ -_ _ _ __ _ __ ____ _ -- _ _ _. Each food establishment must have at lea.st one Person In Charge(PIC) on 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-choking procedures below and at�ae�i�,-opies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUII2ED FEE PF.R.MTP# B&B �50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIlvIlvIINGPOOL$75ea. LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _<50 sq.ft. $45 >25,0�3 sq.ft. $200 _VENDING-FOOD $20 �QS,OOQ sq.ft. $75 �� _FROZENDESSERT $35 / TOBACCO $25 ��U,3 NAME cHnNGE: $io ` `�' `` AMOUNT DUE _ $ la0.00 """""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"*" , � : � ; ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ' Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAY�T Mi�ST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � ; Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: / , YES �� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.TTY TO RETLTRN TI-�E COMPLETED APPLICATION(S}AND REQLIIKED FEE(S)BY DECEMBER 31, 2005. i SEASONAL ESTABLISHIVIENTS ARE TO CONTACT T`HE HEALTH DEPARTMENT FOR INSPECTION 7- I i0 DAYS PRIOR TO OPENING FOR THE SEASON. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO C4MIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I ADDITIONAL REGiTLATIONS � r POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected ' by the Health Department prior to opemng. � I POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to apening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. � _ i I 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: - F��r IIzs3�is==�u��.,teste�-e��-men�l�y-basis�y-� Stat�c�r�ifi�d lab.-��st r$s�lts rna�t-be sent-ta-tl��ealth ___ i Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the , above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishment is prohibited. � � � r, I DATE: j� ��r� SIGNATURE: ! � Riahard Fou A � PR1NT NAME&TITLE: . 09l28/OS � � . . � ' ---� The Commoxwealth of Massachusetxs �_ f - . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIVV�NT PERNIIT NUMBER: #06-Q44 FEE: $75.00 In accordance with re�ations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the neral Laws,a pernut is hereby granted to: Cumberland Fanns Inc., 626 Route 28, West Yarmouth, MA Whose place of business is: Cumberland Farms#22b8 � Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 200b BOARD oF HEAI.TH: �e `21. �au�cr�,A9.`�., ' �y�sl�k, .N., ?ld�G�� Rodent�. Bnau�n, G`l�(a P��l��tt � �4�f�'�u.,�, R.1Y. February 3.2006 Bruce G_Murphy RS.,CHO Director of Health THE COMIIZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-031 FEE: $25.00 This is to certiffy that Cumberland Farms Inc. d!b/a Cumberland Farms#2268 626 Route 28,West Yarmouth,..MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCT� AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�e�it i�t�i��om�'ry with Article VI of the San��Code of The Commonwealth of Massachusetts,and e� es s i ess sooner suspended or revo February 3,2006 BOARD OF HEALTH: � �. �j�/��., e�t�h�u�s ��r�, R�!, v�e�� R�t�. e�, er� �� r , a.�v. . ce _Murp y,MPH, Director of Health I I F�Y.q� l�ixa.�� - ,�� ,�o ~T' � N F XA �ZMOUTH � � �"3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACHE 9s� '� Telephone (508} 398-2231,Ext. 241 — F� (508) 760-3472 � ��R�OFATE��65 � . �C7 [�� B O A R D O F H E A L T H To: Yarmouth Boazd of Health Permit Holders From: David D. Fiaherty Jr., RS. ;��r � (� ;� ;.� ;; �,��;; ;� Health Inspector �J -' ' � '��; Town of Yarrnot�th � �� ,� Re: Federal Taar ID Number ��'��'� '� �'��'T• _ _ __ _�-�#e.:. __ ,�._ -�s,��,-�QOS The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIN)othervvise known as your"Tax ID Number". This is purely for administrative purposes only. So� businesses use the owner's Social Security Number (SSlv} for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to � Yarmouth Health Department 1146 Route 28 South Yarmouth,MA 02664 Tha.nk you for your anticipated complianee. If you have any questions regarding this matter, please do not hesitate to cail. The office hours are Monday to Friday, 830 a.m. to 4:30 gEm. The telephone number is(508)398-2231,eart.241. Establishment:�i��. �,D��M,�,�N.�.�L �0 6$ FEIN or SSN: ? �, Location Address: ��, 11 (,��,,,, � (� (�� g � � �� ., Pt d� � a ��t 3 � signature:_ �R#a3� l�aurn�i�� . n�3, �4 Print: '� �; �� Title: � �� V,~ ted on ecycled Paper � � , ;- c,��4-�,z�263c�f �?90`� �°`;'`R�o TOWN OF YARMOUTH BO _ `T�- ; C.�+��r��M1hS � -�� APPLICATION FOR LICEN E - ' 0� � �� -�� °:: ,/s n * Please complete form and attach all necessary documents by December 3 , 2g� p 5 2005 Fa.ilure to do so will result in the return of your application packet. _ T. NAME OF ESTABLISHIVIENT: TEL. -77 � LOCATION ADDRESS: O ' MAILING ADDRESS: ( a0a-i OWNERICORPORATIO N MANA ER'S NANIE: 'TEL. # - - 3 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. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 prnvide new copies and maintain a fde at your establishment. 1. 2. PEKSON��H�RG�: _ _ _ -- ---- _ __--- - ----- —---- - --_ = Each food esta.blishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one 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. l. 2. 3. 4. RESTAUR��NT SEATING: TOTAL# OFFICE USE ONLY LODGING- LICENSE REQUIIZED FEE P�RMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 INN $50 _CAMP $50 _3WIlvIlvIIl1G POOL$75ea. LODGE $50 _TRAII,ER PARK $50 �VHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQIJIRED FEE PERMTr# LICENSE REQUIItED FEE PERMI'P# LICENSE REQUIRED FEE PERNIIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VTCT. $50 WHOLESALE $75 RETAd SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIltED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. 5200 �VENDING-FOOD �20 �Q5,000sq.ft. $75 0 s � �FROZ�T'DES�ERT $35 �TOBACCO $25 �0S-�3S� ,e.f NAME CHANGE: $10 AMOUNT DUE _ $ I�O.00 •""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•" � 1 : i � ADMINISTRATION ; � Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or campany does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. i ; SEASONAi,ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTHDEPART'MENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR'THE SEASON. i ALL REN�VATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR i TO COMI��NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. � i ADDITIONAL REGULATIONS ! POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opetung. 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. I POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i closing. � I , FOOD SERVICE CONSUMER ADVISORY: Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY: 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 t4 the catered event. Thses forms can be obtained at the Health Department. �'RQ��N DESS�itTS: — — _ --- - _ __ ___ __ _ _ _ � 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.,outdot�r 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 establishment is prohibited. L DATE: �0`1.�_ ,Q,��+�- SIGNATLTRE: PRINT NAME& TITLE: 1�ittb$3'd F Managef 10/22/04 ' �I i � �"'"�, TGe C��mnlon►retrltlt ��f:'17assnchusetts . i ._, �� :i, , =a:i• - .,i71 _1.� De/�nrt�tu�nr�flnr/ustrialAccidents ;: � t �}� � :K , ' '�'�, O/f%CBOI//IYeS!%yalf0/JS � . ��.� � -'`\ , �� , :� �(1/1 Niisl�i�r�;lu�r Strc�c�f �.._ 4W+ , �'i ,�,�,�,r � ' I3ostar,A�uss. (12111 t�� `-' VVorl.�rs' Compens�hon lncur�ncc Aftida�it . � .......-ay»�--c- � --....,.k r--�--`t-'M�'t�na^�.n�rs� re�.�r _ .. ^sw4aag'a^'"-T"T7-d•r�pNr�st'Tfin*+"�,'Y-S�- '� .^-;."'^s"' . -""�- - �ant�nfo�niahon � Please PRINT 1ea>>l�_ : �_....,._..._. �.__F._. ....._.._..... _._._W.w..___..__...____.._____ ..�.___._.______.__,w...�......___--..__.____ .�._... .., .._.. .,. n�me•l .111'Yl�.�ll�,�111l��fZn/171L) �020�0� � a'�w o . �O'� 1 ti .�J$- -9r189 ;t�� ,� •# �� - � I am a homeowner performing all work myself. � I am a sole proprietor and have no one working in any capaciry _..� �...,�,:�„ ��:��-'..:� �.,. � I am an employer providing workers' compensation for my employees workin�,on this job; camp�n}�n�mc• L,CIlYV(�l p11 ov unGL `�L11�'?'Y�� U'�1L� � rddress• "1" 1 1 ��'� �1�I _ ' _ � �it��f/�,��'�Q �� hone#•I � �� `0-"t'�(�� - m�ur�ncec Y�L.hL1J��a��W,��(�'nn � ' �olicy# � �•:�� z€'^�=�•" . �g:9:...., x, , �� '�` �2��' �..r,��;�� : . . . , �: ... .. , . ,��. � I am a sole proprietor,general contractor,or homeowner(cirele o�te)and have hired the contractors listed below wl�o have the following workers' compensation polices: . ;:.: ;.; , .. _ , _ _. . _ . _.. ,.. : ,: . { .. . comP�m•n�me• _,: : , , „ • - _ . . _ . address: <.; <. . , . _ _ ,,, cih^ - - phone#: —- �ncur�ncc co ' - policv# �g �r�* `� �.�?^Ff:"��'"`.5'!a�?P7�3�'e'tAn3S�i�...x..rs�`��u�u�i.ti..Y's�tiec-K�`is,i�'t x"�sSe:^� :q`S +'F+' ^�'��3�sd�`�s�+'ifi' e�PF'".�"� ``��"� �. x , — 'N•'. . .aX�` .s��:�� .. compam�nnmc• � — _ _. :.. _..,.. _ _.. _. address• . , : _... �h.. : _ phone#• - ,_: : olicv# ; :; .:. _,:. _ _ , . . . insurance co ' P .__... �,,.:� . , . �Attncfi ad�ihooai sheefil`n'ecc ex� x. �'., ' : "' .....�..K�'X..��.:•: ,. Failurc to sccurc covcra�c as rcyuired under Section 2iA of�1GL 152 can Icad to ihc impositiun of criminxl pcnaltics of a finc up to S1,i0U.00 and/or onc ycars'imprisonment as�vcll as ci�•il pcnalties in thc form ota STOP�YORI{OI2DER and a fine of S100.00 a day against me. I undcrstand that a eop}�of this stsitemcnt may be fonvarded to the Office of lm�csti�ations ol'thc DIA for co��crage vcrification. I do hereb��cerlifi•under lhe pains m �ghi nj erjur}� ha ie injormnlion provided above is true and correcL Si�nature Date --�� a a ou - ,t� f'rim name Phone�.�`�� '7 1� °`�ofticial nse only do not�vritc in this arca to bc completed by cit}�.or to�vn ofticial � � cih•or town: ' permit/licensc# nBuilding Dcp:rrtmcnt � • . �Liccnsin�13oard •p check if immediatc response is rcquired �Scicchnen's Office : �licalth I3cp:�rtmcnt = contact person: phone#; � nOtlicr (recised 3/9:P1A) � � . .. _... . . . ` . . � . ,. �- .. - . ... .. . � � . . . r � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-041 FEE: $75.00 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�'reneral Laws,a permit is hereby granted ta 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 aperate a food establishment in: Town of Yarmouth Permit e�ires: December 3l, 2005 BOARD oF HEALTH: Berry�sr�.`2S. C�''o�ra,JyI..`?S. ' ��, v�e�� s�R�v� ��,�, R.�v. Februaiy 2.2005 Bruce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-035 FEE: $25.00 This is to ce�tify tt�at Cumberland Farms Inc. d/b/a Cumberland Farms#2268 62b Ro�te 28, West Yarmo�tl�, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBi7TION OF TOBACCO PRODUCTS AS PER TI-�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. Tlus��er�it�ant�i�confor�'t�with Article VI of the Sani�ta�Code of The Commonwealth of Massachusetts,and e� 005 e sooner suspended or revo . February 2,2005 BOARD OF HEALTH: Be��t$. �'o+u�,o�t,/H�5., �s�at��rt � /��/Llc$�rirctt, ?Ju;e G�lr�i�iyu�rs Ro�i`t� l�nocwz, Gl� � s1� R.N. ��, R./V. Bruce G. urphY,MP •, Director f Health i �'1� __ , ��6a5'� `!� c,�n,e�� #�zzbs �`� .� TOWN OF YARMOUTH BOARD OF>HEAL r � . _.�._�.--�___..... o� -'�� . � � �C �� j, � � _ _ APPLICATION FOR LICENSE/P��R1VI��`��0 G� �, � , Y ' .:•'.°S. �y,Y,' .. .. - ,, * Please complete form and attach all necess ." doeu e�by Dece bet��ly 2?UQ.i�.�1�`� '` Failure to do so will result in the return�f�o application p cket. �� i��PT. � - ^��-�f-- T DD S • oZ I �j . r--- r--� �2�. ER'S N � u �D - �� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s}�d a2zach.�.�apy of the�ertification to th�s f�rn�. __ __ _ . 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 Heatth 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. �OOD 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. _ _ __ � - - _ _ - - _ - --_ _ � P�R�aN IN�FIAIt�E: ----___ __ _ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. ' 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee 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. . RE$TAURANT SEATING: TOTAL# OFFICE USE ONLY �,ODGING: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN S50 _,MO�'EL $50 � _INN $50 �CAMP S50 _,SWIMMING POOL$75ea. � _LODGE $50 _TRAILER PARK S50 WHIRLPOOL $75ea ;; FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# [.ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL S30 _NON-PROFIT S25 , >100 SEATS 5150 CQMMON VICT. $SO _WHOLESALE $75 � RETAIL SERV�CE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICGNSE RGQl11RED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. 5200 _VrNDING-�OOD $20 �<25,000 sq.ft. S75 �b�,�'6� _FROZEN DESS[:RT S35 �TOBACCO �25 0�� NAME CHANGE: $10 AMOUNT DUE _ $ �00. �Q � **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* 1 � r � ADMINISTRATION �\ � � � �_ Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required.�o 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 ! Compensafion Insurance. THE ATTACHED STATE WORKER'S COMPENSATI¢�"IAISURANCE f AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSURANCE ATTACHED Q$ i 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 RESPONSIBII.ITY TO RETUItN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. ' 4 � 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 I EQUIPMENT, ETC,),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � f ADDITIONAL RFGULATIONS ' ; 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 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 CQNSUMER ADVISORY: Each 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. ____F n7.F.N 11F.CCFRTC� _ _ ` _ - -- - f Fmzen 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 tetms have been met. OU�'��F��: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. i i OUTDOOR COO�jNG: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. �I DATE:�`�,I�O r0�j SIGNATURE: �? .-� `,, ' PRINT NAME&TITLE:��V � .ry� c5�,h y� ��. • ' 10/22I03 v�C�- �Y Q S t c�`2�v�� Ca,,�.�iC� L.�.�C � The Comnronwealth of Massachrtsetts : � Departrr�ent of Indrutrial.-�ccidents a O/1lCeoll�s�lOstl�i�s � � 600 Washington Slrett : Boston.Mass 02111 ' "` �•v Workecs' Compensation tasurance Affidavit . � r� n m•� Ltication• \ —( �� h `tivL_ �i � �it� Ll'�A .��lS �tL . � � C'`� r�f� �, ohoneM�c l� (� 2��'��}-�C�� 1 am a homeou�er pertorming all worfc m}�self. � ( �m a sole proprittor�r.,�, ha�e no one��orkin_ in an.•capacit�• � f am an empio�er pro��ins worl:ers' cornpensation for my employ�ees w•orking on this job. eomnanr n�me• \11_1w�,� 1,-�dt 1i � �E�Y vv�'q ,� t� �. `c7�"' c�.� b� 1cldrrs5: l(��,g t�-t l.J v^LtL?-• E \f�JV� � . �Q. r� � . ,.: , o ��6�3 �. '�a� �'"�$� 8 insur�ncc co �'�IJIQlv�CQ_� �1 l�1Fi �� Qolicy� W FJ �, ��0� � � I 1m a sole proprietor. :enerai contractor. or homeowner{circle oneJ.and ha�•e hired ttu contractors listed betow ��ho ha�e the foliu��in_��orkzr_� ,ompensation polices: ;,�mnanv name• � a�dresr �y,�• nhone#- insur�nte co polic}# _ companv name• z�d res�• tjly: ,phoee M. incuran��n. � 1 Failure to secure covera�e as required uader Seenoa 25A af MGL IS2 na ind to tYe ioporidoe olerisi�fl pe�alfta of a S�e op to S1,500.00 aad/or oae ve�n'imprisonuunt as w-dl as eivil peaalda io tbe form at a STOP WORK ORDER atd a Ms o�3100.09 a dar qtY�t s� t��dersta�d t6at a rnpy of tAi�siatemcat mar be fonva�ded to the 011ice oi Inve�ti;atiom ot tht DU tor eoven;e veriAatie�. I do hrreby c�rrij}•under tbe poins aad peaelti�s ojpery'�ry rhm tlrr injornm�tion provided abo+�e is tstte aAd eorr�d Signature � � , Date \ � \ �O � o � Printname �Q"� 1� ��"`�`�' a�" P'honeN ' �� c ofTicial use onl. do not r►ryte in this ana to be rnmpleted by eiry or t��wa oAleia! SL£��601�`90b 'iza 006�-LZL {Lt9) �#�aaoqd ' _. . . ._. ..__. ... ___ ,�. � ; i � I THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-034 FEE: $25.00 'rhis is to cerafy that Cumberland Farms Inc. cUb/a Cumberland Farms#2268 626 Route 28,West Yarmoutt�, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION 4F TOBACCU PRODUCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBAGCO REGIJLATION. �s_i� it is�ant�i��fo�it�y��clsue�o�f�e S�ani�tar�Code of The Commonwealth of Massaahusetts,and February 6.2(�04 BOARD OF HEALTH: 1Qestfayai��. ��'v�ly$., e�i�tnu-.�rt �� v�e�.� R�t� g�, � � �r� �.�v. Dir�tor�of H ltli ' �' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO UPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-050 FEE; 75.00 In ac.cordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 211,Section 5 of the General Laws,a permit is hereby granted to: Cumberland Farms Inc., 62b 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 Yarmouth Pernut expires: December 31, 2004 BOARD oF HE�+►►LTH: Be�r�.�uc`Zf. C1''a+�d°�r,, /�l.$. ' p��a�� v� e�,�.� �s�h R.N� February 6,2004 ruce G. Murphy,MP O , Director of Health � `-�v ' � . �,��t��f�l�a" CuMB�'��AND #?-?�B ' ��F;;�R.y TOWN OF YARMOUTH BOAR�F HEAL'[�H o � " � =`c APPLICATION FOR LIC ��y �I'ERMIT -2003 Q C-��, .C�4�' r.s. � M i� rJ � �� ,S *l 4`+H . . . :.,: •.. .,.,. .� .W�.� ��o� 3 2002 * Please complete form and attach all necessa�ocuments by Decemb r 31`; - Failure to do so will resuit in the return of your application pack t.',.�EALTH DEPT. S S '- S�1�F-�f- D M Z � � WN �� ' E � L 0 � � DRE S• POOL CERTIF'ICATIONS: The pool supervisor must be certified as a Pooi Operator,as required by_State law. Please list the designated ___ - --_ _----- Foo1�pera�or(s�and a�ach a copy of the cet�ification 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. 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. l. 2. -_ PE;F�S�N Tt��-IAFt��—--- ------- -- -___-- ------- — __— _ � _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIML.ICH 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 attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2• 3. 4• RFSTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: • LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRGD FI:G PERMIT# LICENSE REQUIRF,D FEE PERMIT� B&B $50 _CABIN $50 _,1LiOTEL $50 _ INN $50 CAMP $50 _SWIMMING POOL$75ea _LODGE S50 _TRAILER I'ARK $50 _WHIRLPOOL $75ea ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $'75 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200- _VENDING-FOOD $20 �<25,000 sq.ft. $75 6 -0" ��ROZGN DESSF,RT S35 LTOBACCO $25 ��-(S�$ NAMECHANGE: $�o AMOUNT DUE _ $ /OO,DO *****PLEASE TURN OVER AND COMPLIETE OTHER SIDE OF FORM***** �� F"' .. � � � ADMINISTRATION � , � Under Chapter 152, Sgction 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance ot�renewal •of any license or permit to operate a business if a person or company does not have a Certificate of'VVorker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF INSURANCE ATTACHED ; OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK 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 ESTABLISHMENT5 ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 '. DAYS PRIOR TO OPENING FOR THE SEASON. 4 � E 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 f 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: T'he water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of t closing. � FOOD SERVICE CUNSi1M�R AI�VISORY: 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. --��Q��F-B�SSE��'�:----_- ___ _ _ -_ __ _ _ __ � _ _._ _ _ - ---__— _- ----- Frozen desserts must be tested on a monthly�asis by a State c�:rtif�d lah. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTDOOR COOKING� � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' � � �. DATE: SIGNATURE: PR1NT NAME &TITLE: Richa o�rniet� " � Ta� �lan e r � � 10/18/02 i E ! F ty � _ � The Commonweollh of Massachusetts � � Departrnent ojlndustrial.-lcridents � ; Ofllcevl/�s�lOtdliu . A 600 Washington S�reet ' : ,;,� Bosron.Mass. 02111 � ~ � VI-'orkers' Campens�tion Insurance Affidavit m• ` . (' �- `t �� tt` one q1�r,�T � I am a homecw�ner pertortning all work m}�self. � I am a sole proprietor_:;� ha�e no one�►�orkins in am•capacity 14f11 am an emplo}�er pro�i,�inQ w�orkers' compensation for mr•empto�•ees working on this job. `I�� : _ _ _ -- /-' ,.----. ___ --- ---_ comnam• name; 4 1�,..� �/�� . �(�/�/1rvl.� � �!L _ addre�s• �� '( ,�,)�.L��c1 AM � �/�; citv: l�,Q�1m,. iy�� 1'� C� �-.L7 a ` nhone M• \� ! 1 U� O -- /'T`1 V � �� ---� , � � u . � � - �a a. . I �' I.am'a sole proprietor. �enerai contractor.'or homeow•ner(circ%onel and hace hired the'contractors listed below� ��ho ha�e thz follo��in: �.orkzr_' �ompensationpolices. , : s�mRanv n�me: address• cin• nhone H• , . ...:, � , . i��rancc eo. , ooliev l! ` .. . tQmoanv name• id�rsss: �= , oboee I�h insurance c� �� Failure to seeurc covenee as required under Seeeos 2SA o[MCL lS2 ca�Mad to trei�pe�ilio�oteri�ia�i ptultin ot a O�e op to 51,500.00 a�d/o� ✓ ooe years'imprisonaient a�wdl a�eivil penaltla ia the[orm of�STOP WORK ORDER a�d a A�t�S100.6��daJr Kaiast m� I ndenta�d that a eopy of th'n statement mar be fonvarded to the ORce of lavntig�dow of t6e DU(or eorera=e rtriQptie�, ._ I do hrreby crrrij�•under rhe pains und peno ie ojp 'u hat tht injor►nal3on providtd abovs is ddt�tnd corrtct 5ignaturc � � 1 ��.I 0 �U� .. � Printname ��•��iSi'd � �' ��lr; one� � (7 .r olTicial use onl�• do not w�ite in this area to be tompleted by tity or town oAlcial citv or town: y�M�DT� _ permir/lieenu N n8uiidiag Department �Liceasio;Board ❑cheek if immediate response ie required 261 �Seleetmen'e ORite OHea1tA Departmeat • comact ptrson: phone N:_ �508� 398�2231 ext. nOther a F TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD E5TABLISHMENT PERMIT NLTMBER: #03-039 FEE: $75.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter i l l,Section 5 af the neral Laws,a permit is hereby granted to: Cumberland Farms Inc., 626 Route 28, South Yarmouth, MA Whose place of business is: Cu.mberland Farms#2268 Type of business: Retail Food Service less than 25.000 square feet To operate a food establishment in: Town of Yarmouth Perrnit e�ires: December 31. 2003 Bo�oF HE�.'t�: �uvrlca�lF, i�il�kai, eka�r�raac ------ ---__ _ _ _ _-- --_ __ �u�ri�c D. �mide.i. �D.. `l/ice • . ,�o�it�, b�aoar�c, �aik . �a.�riek�'JlcDar.xatt �ele� S . ,��l. 7anuaay 17.2003 ruce G.Mutp y, .5.,CHO ° Director of Health THE CQMMONWEALTH OF 1t�I�iSSACHUSE,TTS,, � _ ,... _, TOWI+�0�`YARM4UTH . . � � �� BOARD OF HEALTH � . � _ . R . PERMIT NUMBER: #03-028 '_. :FEE: $25.00 This is to certify that Gumberland Fatms Inc: d/b/a Cumberland Farms#��68 ; 626 Route 28 South Yarmouth MA IS HEREBY GRANTED A LICENSE '•q < : For SALE-AND:DIS`T'RtBUTION�E TOQ�ACC4 PRODiIG'�'�S ' ' •F �; �= �. w , . AS PER'THE YARMOUTH BOARD OF HEALTH TOBACCQ RE�LJLATION This. e t is d �y with Article VI of the S Code of The Commonwealtlr.ofMassachusetts,and exp�es�ece�enr�1.�0(��e§s soo�ner suspended or revo e . Januarr+1'7.2003 BOARD OF HEALTH: �ca�rfed�r�, i��i. (��c �'e.a fa�riu,c D. Gioarde�c, 'I�dG.?�.. �/iee �o�t�. �aoa�c. eP.ack �atctek�JlcDac.xoz� � S . �?Z. .Murphy . .,C Director of Heal i i , � � � �;;. s M(�E�CAN D 1#�2 . . TOWN OF YARMOUTH BOARD OF HEAI��I 4g_ �� " ,� G C� !� � a � D ` A P P L I C A T I O N F O R L I C E N S E/P E � `_� ��ti3 W>��A� s� � ZO�1't' � tr * Please complete form and attach all necessary documents by Decembe��3'�, 2 �l. Failure t d��oAv�i.�l�re�l��. the return of your application packet. �--- AME ESTABLISHMENT: TEL. # u �- �1.�1�- I D ILIN ADDRE S:� � � � E 'S N : TE . -�6�q �yMAI IN D SS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Qp�rator(s) and attach a copy_o_f the certification to this form. l. 2. Pool opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. 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. _ _ 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 a11 times. Please list your employees trained in anti-choking procedures below and atta.ch 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# LTCENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 iNN $50 CAMP $50 _SWIMMING POOL$SOea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _TOBACCO $20 I <25,000 sq.ft. $75 -��q �TOBACCO $20 �oa-r�3 _<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $io AMOUNT DUE _ $ QS.00 ' � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , i s w , . y � . 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 Work�r's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � VrJORKER'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 RETLTRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT'TI�HEALTH DEPART`1VIENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ; EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. : � � ; � ADDITIONAL REGULATIONS i POOLS � � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of k closing. � , f FOOD SERVICE CONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. r.ATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _— ----- - — ---- � _ --_ __—____ - , FROZEN DESSERTS: - --_ _ _ __ _-___ Frozen 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),mus have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. t DATE: '� ' SIGNATURE: �ii h rd ourniBT `PRINT NAME&TITLE: 09/11/O1 � . . . � _ Th e Conrmon wealtk oj Massach r�setts � � Depar�ment ojlndustrial.-�ccidents � J Omceo�Ier�stl�stJfrn a ; 600 Washington Slreet ',.= Boston,Mass. 02111 � "' ��y Vb'orkers' Compensation (nsurance Affidavit Aoniicant informallon: Plesseplt11�7'Tiyh'�t n�mr� ��,Nv�� „�. �� `D lt � [�c� � r� �b$ rS . ° �� 6�( r'S� g�-gz�� cit� . ohone tA `�,�c►T-(�S - 'S �1.��,�r- � t am a homeowner p�rt�rmin�all work m}�self � 1 am a sole proprietor_r..�. ha�e no one ��orkin_ in am•capaein• �I am an employer pro��din�workers� c mpensation for my empioy�ees working on this job. i�' `--� n ad�lress: � "7 '"� /�;�� (�rv,�. � , Si[)" Cl-Al�, . � \ T 1 � 6Y—�."�� Dhone �� U t�� 1� � . .-� ^ i urTnc p �} pL�- � t am a sole proprieror. :eneral eontractor, or homeowner(ci�cle o e) and ha�•e hired the contractors listed below �►ho ha�e the folla��in_ �corkers� :ornpensation potices: S�R�Rv name• address• cin•• phone q• insurance co. �olic�•# tomnanv name• ' addresr tiri: DbOee 1!• insurance co. ��* a Fsilure to seeure covenet�s r�qyired ndder 5ecnoa 2SA of MGL iS2 ea�ie�d to t`e i�paioo�o(trisi�i peuitfe�ota 6te�p to 51.500.00 a�d/or oae yran'imprison�nent as�c11�eirii peeattie�io the forn�of a STOP WORK ORDER aed s Aae of S10A.00 a dar asiost sa t a�dersta�d tlat a copy of thy stattmcnt m�r be(orrvtrded to tAt Oi'Iice of lovatituion�ot tAe D[A tor eorera�s veritipdo�. I do hrreby crnij}•r��rder rlre�airts and pr v 1ie jpe 'ary�hat l6t infornmtion provided obove is ttie and coirect � Signaturc � � ,� c �rd Fo nier l, Print name .> one�t�`(� 1 ��oZ� d`��Q '� .. otTrrial use onir da aot writr irt tbis area to be completed by citv or town uAkial citv ar town: �� _ pennitAieenee M nBuiidiog Departmcnt �Lieeasioe Board jp eheek ilimmrdiatt rrsp�snsr is required 261 �Seleetmen'�Oftiee EartE�t�c�e�s��. ,, pHe.��e o�p.nm�ot phoneN:_ �508) 398�?231 eat. nOther THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLJMBER: #02-023 FEE: $20.00 'rhis is to Certify that Cumberland Farms Inc. d/b/a Cumberland Farms#2268 626 Route 28, South YarmouttL MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE 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 31.2002 unless sooner suspended or revoked. Anril 17 ,2002 BOARD OF HEALTH: �anled� i��, (�aw �c�D. �%a�, 7K.D.. 2/�ee ,�ode�ct? �raao�a, �k �a�c�� Skak Director of Health � TOWN OF YARMOUTH � BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�IlVIENT PERMIT NUMBER: #02-029 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: (:LmUerland Farms inc_,_�26 Rotte 28, �oL h Y rmo� h,MA Whose place of business is: Cumberland Fazms#2268 Type of business: Retail Food Service less than 25.000 square feet To opera.te a food establishment in: Town of Yarmouth Pernut expires: December 31.2002 BOARD OF HEALTH: ekanle�.� �e�ez, ekal,uxa� � '�� D. C�ard�c. 111.D.. ?/iee a�ao� �, L� �aarlck 7�er�xott S .?Z. April 17 ,2002 ruce G.Murphy, .,CHO Director of Health � ` � _ _ � ' C,vn�e�ecAnta Fi�eMs�#2Z68 �� _— TOWN OF YARMOUTH BOARD OF HE �Y ''` �� d � � . APPLICATION FOR LICENSE/PERM�- ``�►'��' ,)Q� 2 9 ZOO� ��- * Please complete form and attach all necessary documents by Decem�ie��l, 2�0. Failur 1[�"sRf�'in the return of your application packet. �►�' ----------------------------------------- ---- ------ ----- - --_�_-----��-� --------------------------- ------ -------------- T l�. �' a -5' - l�t-� • �--' � -t � ' ' , � �� 63`� POOL CERTIFICATIONS: The poal supervisar 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 emplayees currently certified in basic water safety, standard First Aid and Community Cardiopulraonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Heslth Department will not use past years' records. You must provide new copies and maitttain a file at your place of busineas. 1. 2. 3. 4. 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 yesrs' records. You must provide new copies and maintain a file at your place of business. l. 2• 3. 4. RESTAURA1dT SEATING: TOTAL# NON-SMOKINCir SEATS: TOTAL# _ ,� - --,�s_-�------z-------z-------------------------------- -----�------------------------- -----------_ - - - — - -— — _ _ __ _ __: _ _� ___ �_ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 LODGE $50 _TRAILER PARK $50 MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD S�RVICE: � NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Estabtishments,the effective date for food protecnon manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAI., $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 / TOBACCO $20 �L� �<25,000 sq.ft. $75 �O(- 0 TFROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CH[.A►�iG_]_�: $10 - AMOUNT DUE _ $ 9 S'.0 D ***k*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � i f- . _._W....:... ._....,,... .........._..�_._.....i . ' � i ADMINISTRATION ; � � Under Chapter 152, S ction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ,of�ny Iic�ns�{ti�#�n�iit to operate a business if a person or company does not have a Certificate of Worker's . . �Campensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �`" NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEAS4NAL ESTABLISHIVIENTS ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIN'G FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPR4VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �p�TIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a Sta.te certified lab,prior to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE ��,�.'�ATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 200L As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection manager. Tlus provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effect'rve date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establishments which sell or serve ready-to•eat,raw or undercooked animal products are required to have consurner advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the requu�ed Temporary Food Service Applicat�on form 72 hours prior to the catered event. Thses 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 Heatth ' Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDF CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor+cooking,prepara.tion,or display of any food product by a retail or food service establishment is prohibited. DATE:�;�,�l�\ SIGNATURE: PRINT NAME& TITLE: Tax �lanager 11/16/00 , o _ _ i - - � _- — r � . � The Commonwealth of MassQchr�setts � r Department ojlndustriQl riccidents � ; Ol!lCs01/eves�l�s�liis � 600 Washington Street .•` Boston,Mass OZ!I1 W'orkers' Compensation lnsurance Affidavit �j��licant information: P`IessePRIlQ'1"�"bTioc , ( � n�mc• `�Mv�.�/��nn,.,./1 "��eL� '— a o� e� Iocation:��P� `� -c�• ub/�.hn.c�l,�. ,��,. 01661�1- ( �o�fa .�{�,i:,.S�•��.a$.� �•�.1oti=--r,.,_ �t��(�73 cit� --- #�-�..��(S -�� [ am a homeowner pertormin�all work myself. � I am a sole proprieror�rd ha�e no one�rorking in am•capaciry (� I am an emplo��er pro�idins workers' compensation for mv employees working on this job. �� v�. � ^ �Omi2�4�' name• � .. � (�Annti.1� ��y C �rirlrrcc• 1 '� � � J-C��(J��1rv� �� - �iri•• �inn.,�,_ �tS�. � Y'\'f1 � c�.� �� honp�e q• �� \ !1 r�l�— �-�-�� C� - . r--, in u nc ` � � I am a sole proprietor. general contractor,or homeowner(circle onel and ha�•e hired the contractors listed below� «ho ha�e the follu��in��orkzr�,ompensation polices: s�g,panv name• ^ddress ' �:r.�• Fhone�• insur�nce co oolicy# S9laR�Y name• _ �adress• - �:+•�• ohoee 1{• ine��rsnww rn ��* failure to secure coverage as�equired uoder Seeaoa 25A of MGL iS2 ae lad to t6e iepaiooa oteriai�l pe�aitla of a d�e�p to 51,500.00 a�d/o� one vears'imprisonment u w•eli a�eivil penaldes io the fo�m of a STOP WORK ORDER asd a tiK of 5100.00 s day apiast ma I e�dersta�d th�t a eopy of thy statement may be fonvarded to tbe OlTiee of Investigation�of t6e DU for eoven`e veriQatio�. !do•hrreby cetiifj�under the pains ond penalli�s of per' �hat tbe injormotion p�ovidtd abovt is tnre and corrtd Signaturc au _�a�� Kichard F u nier Print name Phone i� . olTicial use onh• do not r►rite in this arca to be compieted by cify or town oflitiai ' ciry or town: y�M�IITQ _ permit/lieense N nBuildiog Deparnoeot pLicensiog Board �theck if immediate response i�required 261 ❑Selectmen's Otiiee ' (508� 398--�2231 �t, �Hralth Departmeat contact person: phone M:_ _ _ nOtder Irt��sed 3,9t PJAI TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-052 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: __ Cnmherl nd F rm�in , 6 6 Ro � . R, �oLth Y rmo� h, I��A 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 Yarmouth Permit expires: December 31 2001 BOARD OF HEALTH: �d� �et�, �iavr�ua�c el�an�ed�f. �e��. `l/�ce ��a;v�oxa�c ,�a�t�. ��, C� �� . c�°�°�. ��. March 8 ,2001 Bruce G.Murphy,MPH,R.S., CHO ' Director of Health ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiJMBER: #O 1-040 FEE: $20.00 This is to certify that Cumberland Farms Inc. d1b/a Cumberland Farms#2268 626 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. This permit is granted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and e�cpires December 31.2001 unless sooner suspended or revoked. March 8 ,2001 BOARD OF HEALTH: �� e�ed, �xQ�i (�,�,ca�ed�f. �a�. ?/�ce �?�ca�vr�ca.o� �a�t� �'�. �?� �ewc�a.rc� �. C%ardo�c, �l.�. Director of H alth� � � 1 j ��v��Y��k�r��i �Fz�r v n5 �Z� > ,.. � (� f� C� .�'� aMf� UD TOWN 4F YARMOUTH BOARD OF HEAL�H ,,�� ' � � APPLICATION FOR LICENSE/PERMI�"-2000 �°�� J A N 1 0 2000 �r �° �' � '� �� EALT�. DEPT. * Please`complete form and attach all necessary documents by Dec�nber 3 T�� 1999. Failure � the return of your application packet. I --------------E-----------------------�-------------- --- -- --------------- ------------------------#----- ---------��--• ATI �4 . L � � ' c # � �� D D POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator, as required by new State law, Please list the designated Pool Operator(s) and attach a copy of tfie certification to this fofm. - 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. The Health Department will not use past years' records. You must provide new capies and maintain a file at your place of business. L 2. 3. 4. �Il1rILICH 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 yc�ur employees trained in anti-cholcmg 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�.1��' SE��i�IG: Tfl�AL# �tOI�T-S�40KFNG-�E��:-'F4T�#_--- -_- —- --------_�_--�--------------------------------------------------------------------.._---------________----------��_.._----------- OFFICE U�E O_�Y i.OD�ING• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _INN $50 _CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMIVIIIVG POOL $SOea. WI-�tLP�OL $25ea. FOOD SERVICE: LICENSE REQLTIRED 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 PERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 L TOBACCO $20 Y��_4� �<25,000 sq.ft. $?5 �•55 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 . .,,,, ;, .. AMOUNT DUE = $ ��^ . ""••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•" C�, r � . _ _. _� ,, : = ADMINISTRATION \�� ; UNDER CHAPTER i 52, SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOUTH IS OW REQtJIltED • ` � TO H,QLD IS,SUt�N�CE OR RENEWAL OF ANY LICENSE 4R PERNIIT TO OPERATE A INES5 IF A '-PERSQI�1� O� Cb1V1PANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMP ATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATIUN INSURANCE A VIT � MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � ' � VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK APP PRIATELY IF PAID: ' YES---�,� NO NOTICE: PERNIITS RUN ANNUALLY FR4M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII.ITY TO RETURN 'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY ' DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE T4 C�NTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 ' DAYS PRIOR TO OPENII�TG FOR THE SEASON. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ; EQUIPMENT,ETC.),MUST BE ttEPORTED T4 AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEIV�NT. RENOVATIONS NtAY REQUIRE A SITE PLAN. ADDITIONAL REGULATI� � POOLS � POOL OPENIlVG: ALL SVVIlVIl��IING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR � THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR . PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFI�D LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlVINIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLIC�: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NO'TIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO 'TI-� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH ' DEPARTMENT. FROZ�N,�►E, S� FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII..L RESULT IN TI-� SUSPENSION ORREVOCATION OF Yt�URFROZENDESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE - �EEi�fi ME� __ -- _ ---- _---- _ _ _ __ --- - _ _-- _-- _ _ , OIJTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), M[7ST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. �UTDOOR COOI�ING: OUTDOOR COOKLNG,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLIS�-IlVIENT IS PROHIBITED. DATE:,� � SIGNATURE: Richard �" ur ier PR1NT NAME& TITLE: T�,. u�,.,,,,�e„ 11/12/99 � ,, � � � The Co�rrmonwealth ojMassachusetts - ' � � Department ojlndustria/,-iccidents � �" 011lce oll�sll�sll�is ,, o ; 600 Washington Street ' ` Bnston,Mass. 02111 �y V�V' W'orkers' Compensation insurance Affidavit Aoolicant intormation• p►e�sepRi�7"T�,-hTir nam� �,c J[�...1M�� - �'�L L�cation� �� SJ �� tit� � Xl n�. �6� .� \i'� � c�C� �.. ` phon_ e�� c�� O l7 � I am a homeow�ner perturming alllwork mysetf. � I am a sole proprieror�r.,a, h��e no one ��orkins in am•capacin• (�►, I am an emplo�er pro�idins workers' compensation for my empioyees w•orking on this job. _ _ _ -- - n � _ --— - _ __ _ __ -- — _ _ ( i�,c ,� - _ . comnan�• name: _ : Q . �,� -,��'�� .�ddress: �6��Q �� . ` � #' / `�c 'T' i u ra n c � � � "3 t-�. 3 � I am a sole proprietor. :eneral contractor, or homeow�er(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follo��in_ ��orker �ompensation polices: sQmoanv name• �sld ress• ��h� nhone#• insur�ncc co. Rolic�•!1 s2mnanv name• - - - - _ __ _ _ -- _ _ -- ---__— ress _� - �� nboee It• insurance co. �� t Failure to secure covera�e as required unde�Secnoo 2SA of MGL!S2 ea�iad to tbe i�paitjoa oterisivl peadtles of a O�e op to SI�00.00 a�d/or one yean'imprisonment as w•ell a�eivil penaltia io the form ot a STOP WORK ORDER aad a liae of 5100.00 a dsr Kaiost me. I s�deRn.d ms�a copy of thy statement mav be fonvarded to the OfBce of Inve�tiguiom of t6e DIA for eoven`e veritiutfa. I do hrreby cerrif}•under rhe parns and rnal�ies oj erj th t6t injoinwtion providtd abovt is lrue and eoneet Signaturc !�' � �O � —� Print name R Ch3I'd O r � OY' .-r� t � one M �� O ��— r-�-�d l'� , .- oRcial use only do not w�ite in this trea to be completed by eity or fown oflitial city or town: Y�M�IIT� _ permitAieenx N nBuildiog Departmeot pLieeasin6 Board ❑eheek if immediate response is required 261 �Seieetmen'�ORee (508 3 QHeaItA Depanmeet contact person: phone M;_ _ � 98�2231 egt. nOther i � .. _� < ,,., i - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-55 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: (:umherland Farms in _,�6 Ro � 8, So � h Y rmo �th, MA Whose place of business is: Cumberland Farms#2268 Type of business: Retail Food Service less than 25 00�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2000 BOARD OF HEALTH:�d�f. ,�et�a, C'�irman �oan G. �ullivan, ��, Vice ��irrna Kobert,}. p.)rowa, �fer� a6rielle�a�ol��it�-,�tooP�d �� o�� ' January 28 ,2000 Bruce G. Murphy, MPH, R.S.,C Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-44 FEE: $20.00 This is to Certify that Cumberland Farms Inc d/b/a Cumberland Farms#2268 626 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. 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: �c�� .telte�� C`iairman �oan.� Ju6lwan, K.//., Vice C,�irman �o�art� �rowre, C,lerh �abrieLle�a�o(�ky-�ooPed l Q� �lin ruce . urp y, , , Director of Health