HomeMy WebLinkAboutApplications, WC and Licenses —�
�.-----�--, ��jc.c. CN o�o cA 77�.
.�.,. .
1d�'YA��, TQWN OF YARMOUTH BOARD OF HEAI,.�'� � �
� � APPLICATION F4R LICENSE/PER�M 2�Q _, � � � L= � M � DD
° .. �x �
. * Please complete form and attach all necessary c�o .� e c'�e be�1�� �7 z fl n 8
Failure to do so will result in the return of` ou '�' lication cket.
� Pp p HEALTH DEF�T.
NAME OF ESTABLISHMENT: �:Gt,�-2� C p �j C j�d C a/��r ��C . TEL_ #5'O 8 �7 rl,s'-�/(�,7 y
LOCATION ADDRESS:
MAILING ADDRESS:
OWN�R NAM�: D �� '✓) F IN r N :
CORPORATION NAME (ff APPLICABLE):
MANAGER'S NAME: TEL. #
MAILING ADDRESS.
POOL CERTIFICATIQNS:
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 minixnum of two erriployees curreritly certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of eniployee
eertifications to this form. T�te �ealth Dep�rtment will not use past yea�s reeords. 3�ot� t�ust pravide nev��
copies and maintain a file at your place of business.
L 2.
3. 4.
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
All food service establishmenfs 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 Establishments, 105 CMR 590.000.
Please attach copies of certificationto this applieation. Tbe Health De�artmerct wiH not�se pa�t years'recards.
You must provide new copies and maintain a file at your establishment.
l. R o�b�.��- (��r�� 2.
_ __PE�S,Qlu��'�i.A�GE�___ -- __ __ __ ,__
- - -_ _ -- ---_ _ __ —_ -_
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. »
l._ i2obe;�� C� n�`h �. C.c�w I Gwn-Ln
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-chokuig procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL # O
OFFICE USE Ol�'LY
LODGING:
LICENSE REQUIRED FEE PER'b1IT# LICENSE REQL'IRED FEE PER'4IIT�* LICENSE REQL'IRED FEE PER'�LIT=
B&B S50 CABIN S50 MOTEL S50
INN S50 CAi�IP S50 SW'IVLv1ING POOL S75ea.
LODGE �SO TRAILERPARK S100 V61-IIRLPtJOL S75ea.
FOOD SERVICE:
LIC£I*TS£REQUIRED FEE PERMIT# LIC£NSE REQLTIitED F£E P£RA41T?� LICENSE REQI;IRED FEE PERbilT=
_0-100 SEATS $75 �_CONTINENTAL S30 _NON-PROFIT S25 ,
>100 SEATS S150 CO:�ION VIC. S50 Vb�IOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S7S �_
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIItED FEE PER�rIIT-
_<50 sq.ft. �45 >35,000 sq.ft. 5200 _�'ENDING-FOOD S20
„L<25,000 sq.8. �a75 �Q�Q��D _FROZEN DESSERT S35 _TOBACCO SSO
x��c�NCE: sio AMOUl�T DUE _ $ 75•00
'�****PLEASE TL'R\OVER A`D C0�IPLETE OTHER SIDE OF FOR�Z*w***
T � ��
�
ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hoYd 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 � �
�,,�,�t i
CERT. OF 1NSURANCE ATTACHED l�"'
OR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � ;
,
f
I
Toum of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: .
�s c/ rro
MOTELS AND OTNER LODGING ESTABLISHMENTS �
�
- - -- - --- - _. _�_:_----- -- �
TRANSIENT OCCUPANCY: For purposes of the limitaxions of Motel or Hotel use,Transient occupancy shall be �
limited to the temporary and short term occupancy,ordina.rily and customarily associated with motel and hotel us�. �
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. �
,
Transient occupancy sha11 genera.11y refer to continuous occupancy of not more than thirty (30) days, and an [
aggregate of not more than ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or �
dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy �
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. !
* NOTE: Enclosed Motel Census must be completed and returned with this.application.
POOL3 ,
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected ;
by the Health Department prior to openuig. Contact the Health Department to schedule the inspection five(�days !
pnor to opening. �
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a S�ate certifled 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
closing.
_ _a __ FO(�D gER�ICE __ __ ___ _ __ -_ _ - �
_ _ �
t
�
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmetrt by filing the required �
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta.ineci at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pennit urrtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth:
OUTDOOR COOKING:
O��door eflal�ing,preparation,or displ�y of any food product by a retai�o�food s�rvice estab�shm�is prohibited. _
I
NUTICE:Pernuts 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, 2007.
;
,
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW I
EQUIl'MENT, ETC.),MUST BE REPORTED�'O AND APPROVED BY THE BOARD OF HEAL'I'� PRI4� �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
;
j
DATE: / 0 �' SIGNA?URE: ��� ���_ �
I
PRINT NAME&TITLE: f� LU i�,h G� CL�D / �� �'1<h '
io;��o�
�
�A CNA Plaza
Ghicago,Illinois60685 STANDARD WORKERS COMPENSATION
. � AND EMPLOYERS LIABILITY POLICY
INFORNIATION PAGE - NEW POLICY
p :s�>:<:>::�>::;::::[:;:<;:<:;::;<.:::<;:;�::::»::::;r:,;:>:::;:;::;>:;::>;>«r:.:::;,:,_•:>;::>+>�<.:•.:;:�:.r.,..�.;:::fi;:
::::�;i{`::'::'::::[::.>:::::;.>:::t.:>:.:i>:::;.:'i::::::::::.�..+::;.:•::::::t::`:t::.>.:::t.>::::.:ty':�.:y:::j�.::.;;:;:;i.:;:;
:.>;>:s::.:>::t:>:::::l:i::i::;'i:.::'>:f.:::i::i'.:::`:::i[":;.:::ii':>:»:,.>t%C°[;[(('::`i':[i�t;'+.i'�'.
.. i:. i.:;;;:i::i::i:;[::i:%::P�'d�[i:.::::;'... . .:: . 'P ..� ... .. . {�: . �..�{,'t:ii:i."i::;�'.i:.:;:�>•.i'�':iii.i:i:i i::::;i;'<?;it;ci;i:2::i . .::::i:i:;�::;.:.i,;'.:..i:`.
F7�N:.. ::�::::::::::::::..:::::::::..�::.�.::........ .:i.!?�l;RVYi..�:::::::.._:::..:::::.�:::.�:::::.:::::.:.��>5�-.�:::::::,,:::..�tlF::::::.�::::::::::::,:::.::::::..::::;:.�::::::::::.�_.::.:..:...._..._....
.::.:..�..................................................��........:................................................................ .
WC 2 97546119 03/01/a7 o3/01f08 TRANSPORTATioN INSURANCE ca. 003863120
>::<:>::>:;::>:::><::»::>�::::;:>:<:>::><:::;:<.:>;<.:.:,:.:y::,;:.>:.>:.;:.:�:�::,,..,..,.>:;:..;...;:::.::.:::::::.::.»»::>:<;;:>:><:;;>:»::::>:�>:.::.;:<.;:.:;::.;::.;:;.;:.;:.:;;:.>�.;:.::.;_:.;:.:<.;>:.;:.;;:.;:<..:.;:.;;:.;;;;;:<.;:.;:.;:;.;;::;;;::................::::.:::::;.;:.;:.;:.:.;;;:_:<.;:;;.:.;:;.;::.;:.;:;:.;;;;;;:;.;:::.;:.;:.;;;;;:
<:>::>::>::::>::>:�>::>:<:»:::s:::;»>>::> :. :. ;. . :.;;;;:.;;:.;:.;:;.;:.;:<;::<.::.::<:>::<:>::>::>::<:>::»::::>::>s:::>;:>.:::>::>:;:>::>::>::::>:::::>:z:»>:<:<>::»>::>::>:�::>;:
i::::>:::<>::A :�.�.:;>::;'::::::�::>::<:::>::::><:;<::;::::<:>:<`::::::;:;':»>:<:<:::«::>::<::::::>:<::__::::::::
. '.. .. . 4�#: . . ... :.. . ......:>:.»>:;.;;:.:::;�.:::.:::.;:.>:.>:.;:.>::.>;:::.:t.>:::.>:.:::.;:�::c;:>:.>::::::.::.:::::::::.:::i:::::::;:::;i5;:;;:;:<:;;:i............. ...... ..............._..............:::..-:::::.::::::::::.�::::....
»:.:::.::.s»:>;:;ii>;:.::::n::t:t;�:::::::�s1�:��.::::::::::::::::::::::::::.�::::::::..::.:�:::::::::::.:.:.:.�:::.:...::...:... . -�............................. ... . . .....
..........................................
ITEM CAPE COD CHOCOLA.TIER, INC. OGERS & GRAY INS. AGCY. , INC
1. PO BOX 687 434 ROUTE 134
SRNDWICH, MA P 0 BOX 16Q1
OUTH DENNIS MA 0266Q
Q2563
FEIN NUMBER: NCCI CARRIER CODE N0: 12408
OTHER WORK PLACES NQT SHOWN A30V�c SEE ATiACiiEI3 SCHEDLTIsE(S)
YOU ARE A - CORPORATION/S�
2. POLICY PERIOD- 03/01/07 TO 03/01/08 12 :01 AM STANDARD TIME AT THE
INSUREDS MAILING ADDRESS.
3A. PART QNE OF THIS PQLICY APPLIES TO THE WORKERS COMPENSATION LAW AND ANY
OCCUPATIONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE:
MP..
3B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS LIABTLSTY INSURANCE FOR WORK
IN EACH STATE LISTED IN ITEM 3A: THE LIMITS OF LIABILITY ARE:
BODILY IIVJURY BX ACCTDENT $500,000 EACA ACCIDENT
BODILY INJURY BY DISEASE $5Q0,040 POLICY LIMIT
BODILY INJIIRY BY DISEASE $500,OOQ EACH F�lPLOYEE
3C. PART THREE OF THIS FOLICY APPLIES TO OTHER STATES, IF ANY, LISTED HERE:
ALL STATES EXCEPT AR, ND, OH, WA, WV AND STATES DESIGNATED IN
ITEM 3A OF THE INFORM�ITION PAGE. �
3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCAEDULES:' SEE ATTACHED SCHEDULES
---------------------------------------------------------------------------------
� 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMP,TION REQUIRED BELOW IS
�g SUBJECT '�'O VERIFICATION AND CHANGE BY AUDIT.
� ADJITSTMENT OF PREMIUM SHALL BE MADE: AT POLICY EXPIRATION
CLASSIFICATION OF' OPERATZONS EST ANNUAL
PREMIUM
SEE ATTACHED $645
PREMIUM DISCOIJNT 0
EXPENSE. CONSTANT 284
FOREIGN TEk2RORISM PREMIUM 11
� MINIMUM PREMIUM $283 TOTAL ESTIMATED ANNf7AL PREMIIIM $940
� TOTAL STATE TAXES/ASSESSMENTS/SURCHARGES $27
� TOTAL ESTIMATED COST $967
� DEPOSIT PREMIUM $940
a
��
� Roger&&Gray Insurance Agency,6�C.
� ACCOUNT NUMBER: 3009618472 :
� DATE OF ISSIIE: Q4/26/Q7
� POLICY ISSUING OFFIC }�EW ENGLAND By:
� COUNTERS.IGNED �`��`�f�r� BY �
� DATE �1UTHORIZED AGENT
� WC000001 P-33398-E (ED. 6l87)
�
�
� 1� �„N�..,w,.f"
o' s.�w„�
v "cn+n.n we.eo.a�
TOWN OF YARMOUTH
BOARD OF�IEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT :
PERMIT NLTMBER: #08-046 FEE: $75.00
In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter
111,Secrion 5 of the General Laws,a permit is hereby granted to:
Robert Cronin, 44 Route 28, West Yarmouth, MA __ _
Whose place of business is: Cape Cod Chocolarier Inc.
Type of business: Retail Food Service less than 25 000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31�2048 Bot�RD oF HE�.TH: ��t SR�af�, J2..N., C'�iali�crrtan
� �'�a�s �.-�e�IP.i�e� `�7ice C!R�avr�u�rt �
J�e�ct s.�3�wuuri, C'�
llnn f�'acee�`�iauni, J�..N-
� ��ue�J-:i�rxrl�°
7anuar�25,2008 ruce G.Murphy, H, .5.,CHO
Director of Health
. � c rtocacanEn..
_. ��:C.
°`;AR� TOWN OF YARMOUTH BOARD=O�'�AIyT$' �3
a _.,o
F: . _;,� APPLICATION FOR LICENSE/PE�IT-'�0�,3���,`�� JAN 0 2 2007
•-.. .....
, C�" �
* Please complete form and attach all necessary documents by Decembet 3��,2U05. -
Failure to do so will result in the return of your application packet.
NAME OF ESTABLISF�VVIEENT': CC� e Co� G�'10(,,a���('-� TEL. #�5 b S�r17S-�(0'7�
LOCATION ADDRESS: �-{� f2�k.. 2$ W P S+ v �rM a�a� t Mr� d Z�'7�
MAII.ING ADDRESS:
�WNER NAME: �o b�,r--}- C�ro ri�✓1 T� ID(�EIN or S SN�� ��-
CORPORATION NAME(IF APPLICABLE): C�1 �d G h a�a la'�i�cr� 'Ti�,C .
MANAGER'S NAME: TEL. #
MAII.,ING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by St�te law. Pleas�list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach capies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and m�intain a file at your place of business.
l. 2.
3. 4.
FOOD PROTECTI4N MANAGERS - CERTIFICATIONS:
All food service establishments a.re required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishmen�
1. _ Q e�ie� ��� 2.
_PEF��ON�T C��FrE: . _ --- - - -- --- _
Each food establishment must have at lea.st one Person In Charge (PIC) on site during hours of operation. ,
l. I��he.r-�' �w h;v� 2.
I�IlVILICH CER'I�ICATIONS: '
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business. '
1. 2.
3. 4.
RESTAUR.ANT SEATING: TOTAL# �
OFI+'ICE USE ONLY '
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIR�D FEE PERM[T#
BBcB �50 CA$IN �50 MOTEL $50
INN $50 CAMP $50 SWIlVII��IING POOL$75ea.
LODGE $50 TRAILERPAI2K $100 WF�RLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PER.MIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUTRED FEE PERMIT#
0-100 SEATS $75 _CONTIIVEIVTAL $30 NON-PROFIT $25
>100 SEATS $I50 COMMON VIC. $50 WHOLESALE $75
RETAQ.SERVICE: —RESID.KITCIiEN $75 :
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
�45,�0 sq.ft. $75 �j,�p�j _FROZENDESSERT $35 _TOBACCO $50
NAME CHANGE: $10 AMOUNT DUE _ $ 7 S.00
•"""•PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FO1tM*"�"'•
. 1 r� [
ADMINISTRATION
Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarmouth is novrr 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 COMPENSATION INSURA.NCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT, OF INSURANCE ATTACHED
OR /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEb ��
;
�
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRTATELY IF PAID:
YES NO !
MUTELS AND OTHER LQDGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Transient occupancy shall be
limited to the temporazy 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 princigal place afresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an I
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. �
f
POOLS °
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days
pnor to opetung.
�
PO4L 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 tnust be drained or covered within seven(7)days of
closing.
�
�
FOOD SERVICE �
f
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 pnor to the catered event. These farnns can be ob#amed 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 waxter/waitress service),must have prior approval from the Boazd ofHealth. :
Ot7TDUOR COOKING:
Qutdoo�cooking,preparation,or_tiisplay Qf ar�y��d product-b3�-a-r�t�-sr fo�s�uirye establisl�m�n�-�s prehi�itgd. _
i
�
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETC7RN
'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR '
TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: !� �2��e�i SIGNATURE: � _ '
�
PRINT NAME&TITLE: RO b er � G'ra 'r���n Q d,c�h.e.}— �
i
ion�io6 !
t
j
.: :
�
The Comnionwealth o Massachusetts
f
Departrnrext of Indrts�rial Acci�lents
I�fa�rwA�
608 washi�tgton sr.,ee� f'�'Froor
Boston,Mass. 02111
-- ---- wor��s'com Uue Lsaraace Affi��n:Bn7 leetrkal coiaxee�rs
-
�« �.. . . .. - A �.�� .., s
r �..� � ��._.._ ,�, , .�
name:
address:
S�y state- zio• ohoae#
work site locatia�(fnll addc�essY.
❑ I am a homoowner perfom�ing all wark myself. Ptoje�t Type: ❑New C�s�tian�odel
I am a sole 'etar and have no a�e w in an Buil ' Additioa
I am an e.mF�Y�Pt'QYidinB wa�lc�s'oonnpeasation for my�ployee.s w�king c�.this job.
" — — -- _ _
�_��2, C_�� ,[`,Gl DC.b�Q{,�� _
�: ��' �'�- Z�
s�- , M� 0 3 �: a 8 'l'7���l(�`�
`1"rv� -�rs � . Ku 13 �3 A- -G� '
❑ I am a sole propri�or,ge�eral co�tractor,or�omeow�r(circle oirt)a�l have hinad the contr�ctors listed betow who bave
the following watkers'compensation polioes:
�_�
��
�' _��'a ��,....
�
�Y�l:
.�......��.
A�"!�:
�
FaiM+e M secn+e ea�era�e as req��ed udQ 3ee1�23A�f MGL 152 en le�b tl�e brp��[er�id pe�aNb�f a�e�p q sI,SM.N aaiWr
•re yan'I�tiNn�mt as r�e!as dvr pw�ia tre fir�eta STO!'WORK ORDER s�d a A�e�f S1M.N a day��e. 1 oder�ud tYat a
apy�t tYb wleae�t my be firwarded/s Hc Omce�tlm��f tl�e DIA ter av�erage ver�ettlN.
!�o be►+�by csrdfy�nedee NYe prina sw�f pe�rlliea of pe�jrry tll�t tbe iwforu�d�nw provlded arbovie Ls trrre and oarnrR
Sig�u�e Qv'�.fn�'� '1�c�► � nen �Z'�2 g � ts7o
Print name �i o�1,�—"�" ��i'o ni Yl Phom#�� 7�$—'�'y ts 7 y
�
e�al ase esiy as aet.v�ite io chia am te ne or�pided by dty er erwe�1
d!y or tswne permitlBo�se� Q�Ya�.�t
❑r�ed�if imme�a�e napede b req�ed � d��oe
cenfiet persoo: �#�
� �
(,�,�o�a sar-mnc{)
I
I{
I
i � �
TOWN OF YARMQUfiH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
PERNIIT NIJMBER: #07-041 FEE: 75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted ta
Robert Cronin, 44 Route 28,West Yarmouth, MA
Whose place of business is: Cape Cod Chocolatier
Type of business: Retail Food Service less than 25,000 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 3 l, 2007 BOARD oF HE�I.TH: Be��s��. ,/N$., '
o��[ess ��i, �i�e�ar�-.�a
/l�� Bnou� �
/��thfe+�s//�c`��
� f4stsc�j'�cdas�ruy /�.1�.
March 30,2007 ruce;G.Murphy, ,R S.,CH4
Director of Health
. c��-l�fz7 �`� a � c� � od � �
�f�YqR A�R 0 7 2006
TOWN OF YARMOUTH BOARD OF 1�$
o�� � �y APPLICATION FOR LICENSE/PE , � �,0�16 :'
� ' .,�r �,'� , � " - H L E PT.
* Please complete form and attach all necessar`�-do��n�nts by Dece , .
Failure to do so will result in the returrr�of your application packet.
NAME OF ESTABLISHMENT: ��,p e Cr0 G/� 0 C o I Ct� e-�" TEL. # Sa� 7'7S��fO�7�
LOCATION ADDRESS: �f �,� Z�( iNtS� �1�rh M o c�(f'L�
MAILING ADDRESS:
OWNER NAME: G'Gr�'u I �t.r�G� /�he�-� �Yo�t�Y� TAX ID(FEIN or S SI�:
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 th�designated
Pool Operator(s)and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
F�OD 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�ood Service Establishments, 105 CMR 590.000.
Please attach copies of certifica,tion 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. ��ber-� �v�t►rl 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. �0���`-�" l�w�1 t�1 2. C(Jl 1� � �i���l i�
HEIll�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-chokmg procedures below and
at�aeli copies of employee certifications to this form. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 CABIN $50 _MOTEL $50
IlVN $50 _CAMP $50 _SWIIVIlVIIl�TG POOL$75ea.
LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
0-100 SEATS $?5 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIKED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTI'#
_<50 sq.ft. $45 >25,000 sq.ft. $200 VF,NDING-FOOD $20
�QS,OO�sq.ft. $75 ,�() ^O _FROZENDESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $�J '�j •�a
"*""*PLEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM•""•
b T t
�
AD1ViINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal :�
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's �
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �;
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ;
CERT. OF INSURANCE ATTACHED
OR '�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 3 L IT I5 YOUR RESPONSIBII.TTY TO RETLJRN '
THE COMPLETED APPLICATION(S}AND REQUIIZED FEE(S)BY DECEMBER 31, 2005. '
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMIVIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected �
by the Health Department prior to opening. !
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the r�uired
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiterJwaitress service),must have prior approval from the Board ofHealth. !
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishme�t is prohibited.
DATE: �p f� I �, Z 6� �Q SIGNATURE: �Q��n�� �
PRINT NAME&TITLE: Lil�o � (�vb v�►r� U (,tt 1`.Q.�l- I,
09/28105
�
' � The Cominonwealth o Massachusetts
�
Department of Industrial Accidents
> N�ea�i�lM,�i
600 Washington Stree� f�'Floor
Boston,Mass. OZlll
Workers'CompeeaAtioe Ieseraace Affidavih Baitdiag/Plambieg/Electricxl Coetracbrs
#r�ie�r�tir� �'1ea�ie PR�I�IT Iteiblr. .
name_ _�Gl 1rD ' ��i i�l
addcess:
city state• zin• nhone#
work_site location(full addressl:
�I am a homcowner performing all w�k myseif. Project Type: ❑New Constructiom QRemodel
❑ I am a sole pmp�ietor and have no one working in any capacity. ❑Building Addition
�I am an employer provi,ding worlceis'compensatio�for my employees worlcing o�this job.
�n�o��- c�e C.� d C_..%oc� l a-[�e,r^
��- ►-1-� �-k 2�
�: uJ�S� y a..,�r ���'hti. r.�t r4 ��• ��S �'1�-�(�?�
Tru� e � KU �3 '7 4�1 ozlo �
� 13lIISSO1C...�-�. �,._.. �,.. , ;r. � ��;� ;:�. .:,;:,� ;: >:> ......< . : . �;;.. ..�` :'' d ar�.T :a�,.N+ti.p ...... _,�,.
0 proprietor,ge'erat costractor,or�omeowzer(cirdt o�e)and have hirsd thc cantr�ct�s listsd below who have
tbe following workers'compensation polices:
�r�w�v�ams:
addras:
dt�+• o�awe#:
#
_ _ �
�mme:
�-
�►" oYo�c M-
�
,,. , �. �.�.,. ,...
FaOrre tr xeQe e�e af reqaiied oder Satl�a 2SA�f MGL 1S2 m Ind b 1�isp�itl�i�f'M�I�aI pefaltla da gae tp b=1,SM.N aidla�
ene years'Isptieen�mt as weB as dvi pe�altka ia tYe fir�.t a 3TOt WORK OBDER aed a Ane a[f1N.M a day�t se. 1 oedersbrd t6at a
apy af His�atr�t may be forRarded to tee Omce etlmdlptlw of tre DIA tar�ovsrase v�erbiatl�.
I do be►+eby certrfy xeder dYe pe�s and penaldes of perjury tlYet NYe i�for�wabion provdded ebone Is t�re med�
s�� _�,/� c�.� � na� _�0l� � 7, Z07)�
P�� C a►-a 1 C�v n i v� Pbo�# Sa k ?7S-�l� ?�
.�a��y a.H�.�d�'��ee��a nr a�r��.�
ary or ts�vn: per�l�Cs�e il OBaiWt�Depar�eat
❑chcd�if imme�ia�e re.�sax is re9�'� QS❑de�'s Of�ee
�1t6 Deparde�t
t��a• phoae#' ��
�
TOWN OF YARMOUTH
BQARD 4F HEALTH
PERNIIT TO OPERATE A FOOD ESTABLIS�NT
PERMIT NUMBER: #06-058 FEE: $?5.00
' In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the eral Laws,a permit is hereby granted to:
Robert& Carol Cronin, 44 Route 28, West Yannouth, MA
Whose place of business is: Cane Cod Chocolatier
Type of business:_ Retail Food Service less than 25.000 sauaxe feet
To operate a food establishment in: Town of Yarmouth
Permit e�ires:_December 31, 2006 BOARD oF HEALTH: B `h. �o�ic�o�c,/ll.�., '
��"�s�, .�, v�e�►��
a�t� a�, et�
�����
�I.���.�",�, R.�v.
Apri17_2006 ruce G. urp , S.,CHO
Director of Health
�- s �.���s ���
� 55� t svfs c:a�Na�i
��f::R�r� TOWN OF YARMOUTH B F HEALTH
3 , : ,
-�C APPLICATION FOR LIC �' , �D06 -
... : _
° !? .� , � � Cr �� � M � �
.. � C ��
�� � ,3 --
* Please complete form and attach all necessary docurnents bytllecember 1, ZQ�. � � 20��
Fa.ilure to do so will result in the return of your application packet. �
NAME OF ESTABLISHMENT: fo dco '@ I- TEL. 7Cf
LOCATION ADDRESS:
MAILING ADDRESS: �5 f �/a ri'1�i o GC� M� D Z!o 7 3
.
OWNER/CORPORATION NAME: cCro I ra/�:
MANAGER'S NAME: TEL. ,T��' 8'�8�i'''do�-'f`'
MAILING ADDRESS: /o� GcJGS�G��t.f ��'. �• Sr''�1�Cc1�Gr�r�� ti1l4 aaS 3 7
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 af the certification to this form.
l. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must '
provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
--�'EP�'s9P�T�-E�ir93�GE:— ____`_ _� _ __ - _ —_ _— - --—- - ._ __- - - ;
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
A11 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records. '
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURA�NT SEATIlVG: TOTAL# 0
OFFICE USE ONLY
LODGING-
LICENSE REQUII2ED FEE P�RMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 CABIN $50 MOTEL $50
_INN $50 _ _CAMP $50 _SWIIvIlviIl1G POOL�75ea.
LODGE $50 _TRAII,ER PARK $50 WHIRI�POOL $75ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERh+IIT#
0-100 SEATS �75 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $ISO COMMON VICT. �50 WHOLESALE $?5
RETAIL SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMI'P# LTCENSE REQUIItED FEE PERMIT#
, �
_<50 sq.ft. S45 =>25,000 sq.ft. �200 �VENDING-FOOD S20
I QS,OOO sq.ft. $75 S�O�� �FROZEI+TI`1E55�RT $35 �TOBACCO $25
NAME CHANGE: $io' ' � � AMOUNT DUE = S 75.00
'••""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"••
a •. 3 ' r
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth is now required to hold issuance or renewal i
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's �
Compensa.tior� Insurance. THE ATTACHED STATE WORKER'S COMPENSATION TNSURANCE
AFFIDA�IT MUST BE COMPLET'�D AND SIGNED, OR
� � .CERT. OF INSURANCE ATTAEHED
' � ' 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 V NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S)AND REQLJIKED FEE(S)BY DECEMBER 31, 2004. �
SEASONALESTABLISHMENTS ARE TO CONTACT THE�ALTHDEPARTMENTFORINSPECTION7-10 `'
DAYS PRIOR TO OPENING FOR THE SEAS4N. '
r
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.},MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
6
�
�
r
�
i
ADDITIONAL REGULATIONS
�
POOLS
;
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Depa.rtment prior to opeiung.
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 f
closing.
FOOD SERVICE
CON5UMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
reqwred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FRO��l�fi HE�3SE�S: - h
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 �
f
OUTDOOR COOI�NNG•
�utdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
i
DATE: /a�0� SIGNATiJRE: C�2.G� �. �.�.� . �
PRINT NAME& TITLE: C��'"°� C-�n�✓� p c�r�..e� F
Ro bc�� c7: ��h�r� a ul.�crt
10/22/04
I
-� r
_�
_- =_= The Com�nonwealth of Massachusetts
� �' _ Deparhnent of Induslrial Accidents
_= - --= �'1Ni1��
� J - 6(K1 R'ashiagto�SYree� f"'Floor
�
-,,, Bostox,Mass. �2111
� Workers'Com�eaa�hoa Ls�a�oe Affid�vi�B�ii bi�/Eleebrical Coshaeters
r r�.,... � . � r,;.-, .�F �
,�,� ��-�. ,�._�r. _._ . .. . -- TM,
,..��.�. ,
.�.v r
�
�: c�� �a d ch a�o/a-��.---
�: �� ,�,�- z�
��� WcSf ya.�-�r��. �. �.t� ap.G�673 �#���) 77S-y���
work site tocati�rrutl a�d�e,ssl-
❑ I am a homeowner perfoaning all wo�k myself. Project Type: ❑New C�ructia��Re,model
I am a sole 'etar and have no a�w in am Addition
I am an eanPbY�'��S wa�kecs'�on faa�my employ�s working ari this job.
��� �abe Cod Gh a co >a7S'�r'"
�: -� L�a x, (n ' r7
,�:- S�un`c� M� oa 5� 3 �� (��,� ��3-z�t3
r v UL�73L. �lr� o��a _
❑ I am a sole praprietor,geaa�al co�tracMr,or komeaw�er(cindt ow�t)and have hiied the co�actars listed below who have
the following workers'compen�ation polices:
�t�:
_�.. �,.
�:
e�: olra�r�-
�
�;
- -- dtw ��.
Failme Ir aec�e or►era�e as nqdeed odcr 3ecWa 2SA�f MGL 1S2 en Iq�d q tre��!'�ial pauNin�a�e�p b=1,SN�M a�d/ir
ose yan'impti�a�ent ae ws9 as civ�pe�in the�ota STOI'WORIC ORDSR ud a 9oe e[S1M N a day apiet�e.I ndas�d tht a
apy�f Wa�a�my be fonvarded 1s Nc Omee�tliva�ef tre DlA t�r avr�e vei'I�atlei.
I�o beq+eby cer�ify xwder dYe aw� of perjruy dYet tlYe i»fon�miow pnnvlded ebove is trne awd onmct
�� • �n �a/3/,f�y
Print name C.,�l'D� (�o/1�� ��G/"� i7'• Ct0/7�/? Phone# .�� 77•�`�lo?�
.
e�cial oae only da get�vrke�t�a am ta be os�plaed 6Y dlY er fswn e�eLl
city ar tawsr #
❑ekeck if tmme�Eiale rppsme h[eq�ired �+s pffia
� �� D�mt
l��� �'
:.�-
. '
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHIV�NT
PERMIT NUMBER: #OS-047 FEE: $75.00
In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pemut is hereby granted to:
Robert& Carol eronin, 44 Route 28, West Yarmouth, MA
VVhose place of business is: Cane Cod Chocolatier
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, 2005 BOARD oF HEALTH: Besryw,r��S. �j''a�,o,a,/19..25. '
A��a�s� v�e���
Ro�d�t`� Bnou�, G''�k
��� R.N.
�I.rn('�e��r�.n, RJV.
February 3.2005 ruce G.Murphy, ,RS.,CHO
Director of Health