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Home My WebLink AboutApplications, WC and Licenses -� , � ^ �. C•S�1.F�►�e1h S t Y� '�r n L!'.] � � � � V � L�J ' J -�k�. TOWN OF YARMOUTH BOARD OF HEAL'T� s� � � APPLICATIUN FOR LICENSE/PERM�1'i� , 0 �" f � ' Y � . �'a �� ;� 1 2008 - * Please complete form and attach all necessa.ry do��"`t�n `� '�y . ember 1, 2(�0�. Failure to do so will result in the return o��ur apphcation packet HEAL71-� �3��T. NAME OF ESTABLISHMENT: CA �- C- S� �ti 5 TEL. # ��Z8�0' �{ I Z-S LOCATIOI'�T ADDRESS: -�— MAILING ADDRESS: G6 1 A IM-1, 02630 OWN�R NAM�: . TAX ID (FEIN or SSNI-�� CORPORATION NAME (IF APPLICABL ): MANAGER'SNAME: L�S m �'A TEL'. # �og•362 Ll�ZS MAILING ADDRESS: e,n. �.S _ls�w �3 Aa � M/, POOL CERTIFICATIQNS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi�nated 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 Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. T�te Health Dep�rtment will not use past years' reeords. Yot� ��st pr�rvide nexr copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: 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. Flease attach copies of certification to this applieation. The Health Dep�rtmekct�viH not nse past ye�rs'rec�rds. You must provide new copies and maintain a file at your establishment. 1. 2. PER�4N_1N��G�:__ _ _ _ __ ._ _ _ . __ _ Each food establishment must have at least one Person In Charge(PIC) on site durin�hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procadur�s below and attach copies of�mployee certifications to this form. The Health Department will not use past years' records. YQu must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'vUT# LICENSE REQL'IRED FEE PER'tiIII'� LICENSE REQL'IRED FEE PER'�IIT= TBBcB S50 ____CABIN SSO _MOTEL SSO _INN �50 _CA1�IP S50 �SV4'I\�L�IINGPOOL S75ea. �LODGE �SQ _TRAILERPARK S100 �Vb'HIRLPOOL S75ea. FOOD SERVICE: LICENS£ItEQUIItED FEE PERMIT� LIC£1*TSE REQL'IRED F£E P£R'�1IT� LICENSE REQUIRED FEE PER�IIT= 0-100 SEATS S75 _CONTINENTAL S30 iv'ON-PROFIT S25 ' _>100 SEATS SI50 _CO'�L'�ION VIC. S50 �VVHOLESALE S75 �C}�j� 6 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT* LICENSE REQUIRED FEE PERVII?= LICENSE REQL'IRED FEE PERbIIT r _<50 sq.ft. �45 >35,000 sq.ft. S200 _VEI�'DIlvG-FOOD S20 _<25,000 sq.R. 575 _FROZEN DESSERT S35 TOBACCO SSO NA1�IE C�VGE: s�o AMOUNT DUE _ $ �Oo `****PLEASE TL?R�OVER A_\D C0�IPLETE OTHER SIDE OF FOR�i***** , c -�-n � 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 i , Town of Yarmouth taares and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPR�PRIATELY IF PAID: � / YES `� NO MOTELS AND OTHER LODGING ESTABLISHMENTS ; TRANSIENT OCCiJPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be i limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. ` Transient occupants must have and be able to demonstrate tha.t they maintain a principal pla�ce of residence elsewh�e. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90)days within any six(6)mQnth 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. * NOTE: Enclosed Motel Census must be com,�leted and returned with this application. � POOLB 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 Depaztment to schedule the inspection five(�days � pnor to opening. ; POOL WATER TESTIlYG: The water must be tested for pseudomonas,total coliform and standard plate count ' by a State certif��ci�ab, pri<�r to oper�ng, and qua.rterly thereafter. � FOOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � ciosing. FOOD SERVICE CATERING POLICY: � Anyone who caters within the Tawn of Yarmouth must notify the Yarmouth Health DepartmeYrt hy filing the required � Temporary Food Service Application form?2 hours prior to the catered event. These forms can be obtained at the Health Department. k � FROZEN DESSERTS: i Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revoca.tion 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 ofHe.alth. OUTDOOR COOKING: ' � Dutdfle�eel�g,Pre-parat��iispl,�y o€art}��oo�prod�k�y a retail or food ser�ice establishmeat is�rehi�ited.-_ _____ ; NOTICE:Permits mn 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, 20Q7. � , ALL RENOVATI4NS TO ANY FOOD ESTABLIS��VIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEME:VT. RENOVATIONS MAY REQUIRE A SITE PLAN. , • 3' Z�-D� SIGNATURE: � � € )ATE. PRINT NAME&TITLE: �QS j-�eyv�w�i`A � (� � . j i 103pn? f t ! 1 � �'\ ?he Commonwealth of Massachusetxs Depart�rient of Industrial Accidents �ar� <� 600 R'ashingto�Street, 7`�`Floor Baston,Mass. 02111 Workers'Compeasadoa I�araaee Affidav�t:Beildieg/PlambieglEk�ctrical Coetracturs name• l.e �'1� � � address: r� Ca'�'U e/1.. �(i ` i7 2 / ci �C�Y1S�C.1�1 Q state: �R zin: ('�2��ohone# J b�. � L''� ?i� ,��s�� r�u S: 3� ,I� �� to � v�- �r�n.W.a��t�. N`� o Z� 6 y ❑ I am a homeowner perfom�ing all w�k myself. Project Type: ❑New Caa�struction�Remodel �'I am a sole proprieWr and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation far my e,mploy�wo�lcing�this job. _ _ -- -�--- -��-�-_�-� _ �,,,t _ _ _ __ — — -__ -___ — commav.�e: �a"Cc.in S '�1 � � r��'� - �- �I�Sg' � � .��VV��;. �A�� . �U'� � � . -�� A �a• �o B'. 2�0, t,� 12.5 ��- ��.rnou M. �. # . . � � �� ..��..�.„�� , . ❑ I am a sole proprietor,ge�eral co�tractor,or�eo�(r�rde one)and have lrirad the co�actors lisrted below who have� the following workers'compensation polices: con�v�- addtess• cifi• o�owc#: # � ,�_.,.t; �._ <- � �, , r, . a�. �,.� �t��ame• �: �9: o�o�ue�: --- ------- - ---- ---- — -- - --- — —-- _ # - _ __ _.___ -��rr� _. ,, _�.,,.; Fa�mt�s seem cevera�e as neqdned��der Seetle'2SA�f MGL 1SZ aa Ind b tte hrp�tl�a�f c�fi�ial pe�altla�f a�se�p b t1,SN,M udla� one ye�n'imprbeaneat as wsB as dvi pe�aWa ia tbe 6srat af a 3TOt WORK ORDER aed a Sne dS1i0.M a day a�aiist ne. 1 a�dnsland Unt a c�py�f tYb�tt/e�t my ba forwardtd lo tee Omce�lave�gatless sf the DIA hr a�verage veri�tatMe. I�o henby ce�fjy x e paixs anr o tNat tbe�fonn�lo�provlded aboae is trrre awd cornct Signature Date J� G Q�6 � Ptint name Le S �y�Yv1 w1�' �4 Phone#,S,Q.Q� J 6 Z'LJ �� •�cw ax oaiy ao noc.vrite m chis ara to ne comqetca ey dly or tewa efficbl city er tewn: �# �� Board ❑c�t if immediabe respe�e is tYqaired OSdcct�ea's Office �� ceetact pesson: Pti�e#; �er c�s�a-�) � . � . - i � TOWN OF YARMOUTH BOARD OF HEALTH ' PERNIIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #08-169 FEE: $75.00 In accordance with regularions promulgated under authority of Ghapter 94,Section 305A and Chapter ! 111,Secrion 5 of the General Laws,a permit is hereby granted to: Les Hemmila, 37 Huntington Avenue, South Yarmouth, MA � Whose place of business is: Ca�e Cod Seafarms � Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31�2008 BOARD OF HEALTH: :�� Sf1�a�,J2..N., �,acvuma�t C'�eo .�. �'CeP�ifl�ex ?Iice C'�avrr►iacn Jiar�ext.�.J`3.�uecc�n, C'� t��,�, �2..�v. �,�,z�. .�,� March 24.2008 ruce . urp y, , • •, Director of Health .� C.C.S�4FtMMs 2°`:"R o TOWN OF YARMOUTH BOARD OF HEALT'H �`�' o�. "�y APPLICATION FOR LICENSE/PERMIT-20��c�3 � �� b !� �� ., .,s * Please complete form and attach all necessary documents by Dece�mbe 31,��6� 7 2Q07 Fallure to do so will result in the return of your application pack � HEA H �P NAME OF BSTABLIS�-IMENT: � S P�� n., S TEL. #�g��.`�D�-4 I Z�� LOCATION ADDRESS: „n � 1vtAII,nvG A�DREss: ,�t,n � A �Z 6 d � OWNER NAME: ��S T r � � CORPORATION NAME (IF APPLIC LE�: ' MANAGER'S NAME: L� -I�r+�, , A TEL. #��,��`5'0��l�ZS' MAII..ING ADDRESS: C-n o R� s R e. A a POOL CERTIFICATIONS: 1'he pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and atta.ch a copy of the-certif�cation to this form. - --- - - --- - 1- 2. Pool operators must list a minimum of two employees cunently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitatian{CPR). Plea.se list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. _ �__ FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 1Q5 CMR 590.000. Plea.se attach copies of certification to this application. The Health Department will not use p�st years'records. You must provide new copies and maintain a file at your establishmen� l. — 2- PERS4N fl�F�H�R.��: __ . _ _ - _ _--__ __ ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CER'TIFICATIONS: 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 fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# _BBcB a50 CA$IN $50 MOTEL $50 _1NN $50 CAMP $50 _SWIl��IING POOL$75ea. _LODGE $50 _TRAII,ER PARK $100 WHIRI,POOL $75ea. FOOD SERVICE: � I LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMI'P# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >I00 SEATS $150 COMMON VIC. $50 �WHOLESALE $75 �J(o� RETAIL SERVICE: rRESID.KTTCHF,N $75 LICENSE REQUIRED FEE PERNIIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# ` T<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.B. $75 _FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE = S 7$,00 ••"'"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'•*"• i � � i_ 'J ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af 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 � f OR ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ,<< YES ✓ NO MOTELS AND OTHER LQDGING ESTABLISHMENTS �i '� 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. Transieut occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty {30) days, and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest urrit as a residence or dwelling unit sha11 nat 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,wadin�and whirlpools which have been closed for the se�son must be ins ected i by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days ! pnor to opening. ; POQL 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 Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failwe 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 COOKING: __Qutdoer r.�� r ' roduct h �etai�o��ood serviceestahlis�xie�t is ibited. _ xig�� d�s�p�:�y-ofanY--fogd P Y � � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPUNSIBILITY TO RETLTRN TI-�COMPLETED APPLIGATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY �OOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT',ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PL il i � DATE: /� ��- D� SIGNATURE: � I, i ' � PRINT NAME&TITLE: L.�s _f�lev�, r� I,�O � �2 � � I ion�io6 I ; ` . � The Commonwe�rlth o Massachusetts f Depart�nent of Induslrial Accidents �� 6(IB R'oshiugto»Stree� 7`�"Floor Boston,Mass. 02111 —____------ Workaa'Com tios I�smuce Affi�vi�B'il ' tectrlcsd Coatraetors �..� ._. . �_ ; � .� . �� _..-„- , _ , . �, _. .. - - � , nawe: ��,f' ��2 yY� 1'y�1 � � � address: � � ��en.,r a�,f �('J � ' �� _. �aa-v�,s��i��- ��: M� rin_D263� �# �a8�Z�G- �l ZS^ work site 1o�aam►rr,ili�dress)- ❑ I am a homeowner perfo�nning all w�lc myself. Projed Type: ❑New C�ao�Remodel am a sok 'etor aud have no o�e w in an ❑Buil ' Addition ❑ I am an e�nployer pmriding workecs'compensati�fa�my e�ngloyees wcnicing aai this job. ' ❑ I am a sole pmprietor,g�ai co'h�actor,or�omm�vaer(circk o�)a�have hirad ti�e c�ctots listed below who bave the following worlcers'compensati�n Pofices: , . � i � FaY�rce r.aec�e er.erase as req�ree nder satloa 2'�A.tMGI.ls2 ea.laa a dre hrpaNb..ceri�iW pnaltla.[a�e�p a t1,sM.M a�v.r o'e yws'ispriee�seat as wes as ciH pealqes h tie�'sr�ota STO!WORIC ORDER aad a�re e[f1i0.M s day�re.I ndera�d tiat a apy�tib afaleseat my be firwarded 1a Ne Omce oElm�ioaa of 1Ye D1A far av�rage veri�atlH. I do hd+eby cer�ify xw dis p�nbes aw ofP�i�'tlYat tlbt urfonw�lo�provided abov�e ia btire awd oa�ck Sigoatare L Date /� �"6 � P�t� L�s ��rv,rn r `� pbo,�# S�� Z�o• L1 l 2 � . effieial�e onip de a.t wrke i�t6ia arn te be ce�pkted 6Y dty er Mwn�cial dty or tewn' p�cc�se# `i—_-�D�eat . Qlioee�Bs�nd ❑ekee![if imae�ate rapeme i�req�ed �Sdec�m's O�oe �� P� ��; � t�:�a sy�-zars) I TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #07-160 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 peimit is hereby granted ta Les Hemmila/Wayne Hayes, 37 Huntington Avenue, South Yarmouth, MA Whose place of business is: Cape Cod Seafarms Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth Permit e ires: December 31 2007 BOARD OF HEALTH: B ��. �1.`h. • xP � e�sles� Slsals, �./V., ?/:c�l��i�ursa�s Ro�t�.B�ou�, G'1�6a P��t�la��t � y4.�.�� R.M. Apri14,2007 ruce . y, ., Director of Health .. y , �(0��'j� G3 C� C�L�.O S �`;AR.� TOWN OF YARMOUTH BOARD OI�BEAL� � � `� APPLICATION FOR LICENSE/P'ERMIT-2006 D E C 0 8 2005 3 - c / °:; .;? * Please complete form and attach all neces�a.r�do�u�nts by Dece .EPT. Failure to do so will result in the ret�t'n of your applicaxion packet. NAME OF ESTABLISHIVIENT: C e ��- � pR,y TEL. #_�nQ• ��,�-�1 l Z� LOCATION ADDRESS: �I J� MAII.ING ADDREss: � o �, b OWNER NAME: �. J�I Q T E r � _ CORPORATION NAlV�(IF APPLICABLE):� MANAGER'S NAME: Le.c I`Ieyv� ►'n � A TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The poal supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Po�l Operator(s}and attach a capy of�he cer�ifi+cation to this form. 1. 2. Pool operators must list a ' oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmon uscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. e H lth Department will not use past years' records. You must provide new copies and maintain a f e 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. PERSON�V GHAR�E: - -- - _ __ - --__ , _ ___— — - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlb�I�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 a11 times. Please list your employees trained in anti-chokmg procedwes below and at�ae�i ec�pies 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 REQIJIRED FEE PERMTI'# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 _INN $50 _CAMP $50 _SWIlvIlvIII1G POOL$�Sea. _LODGE $50 _TRAILER PARK $50 _WHIIZLPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# , �0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VIC. $50 / WHOLESALE $75 �"�O RETAIL SERVICE: LICENSE REQUIRED F�E PERMTT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUll2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 7 5.OO "•""*PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM"""�" i � - S. sc ' .. f i � AD1ViINISTRATION k i Under Chaptier 152, �ection 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 ` Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ; � 1 CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Ya.rmouth 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 T'HE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL REN4VATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO M COl��IlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � � � ADDITIONAL REGULATIONS � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab, prior to opening, and quarterly thereafter. � POOL CLOSING: Every outdoor in graund swimming pool must be drained or covered within seven(7)days of � elosing. � FOOD SERVICE CONSUMER ADVISORY: �; Each food establishment wluch serves or sells ready-to-eat,raw or undercooked animal products are required to post f 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: ��_ .... ��w� T�zen�e�s�rts�riust�tested on a matrt�rly basis-by a State e�tified-l�r.-3'est r��3��,.�ser�t�e- 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 waiterlwaitress service),must have prior approval from the Board of Health. OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service ablishment is prohibited. � , DATE: � Z'" �—d J SIGNATURE: , � PRINT NAME&TITLE: Le s �� .�'�Vv�w,� I/� '— �( �i � , i { 09/28lQS I I � I � � ! I �. �, The Com�nonweatth of Massachusetxs �_-� -_ Depart�r�ent of Industrial Accidents � -_ - -' M�I/f�� - =_= < 60o w�h��►,�sr.,� �F�oT --,,,J Boston,Mas� 021I1 Worlcera'Com�sahos I�svasee Affidavi�Bn1 bi�/EleetncAl Costractors �.� r . �f. . � ��. .,, � � . � ., � : >� ,-:,F � _. ,. ,.� ., �- i �s 1-� �,�,,�, A _ �: pe� i(3 o x � Zl C� , � A 2 �2- l z work site locatio�rfnll 1- ❑ I am a homoowner petfomning all wark myseif. Ptoject Type: ❑New Ca�ruction�Remodel am a sole 'etor and have no a�e w in an Buil ' Additian ❑ I am an e�npbyer pmviding warkeis'�mpensati�far my employees wadcing an this job. ❑ I am a sole proprietor,ge�eral ce,trutor,or�omeow��(cirde owe)and have hiced the contractars listeti below who have the foilowing wo�cers'compensation Polices: � �: ��• � __—___-- _ _ — __._ _ _-_ # Fai�re�s aeene cNera�e as reqi�+ed tida Sa1i�2SA�f MGL 1S2 m Id�d b fie brp�itlK�!'�al pnaMks�f a�e�p b t1,3M.M aad✓� eae yan'fe�pttNeaveat m weY as dN paakfa ia tbe firie•ta STO!WORIC ORDER aad a Au et 3190.N a day s�ut voe. !nderstud tht a c�py�[trb afales�my be f�rwarded M tYe .f Im�atl�e at tYe DIA L�r pv�erage vd�Catlw. I do ba+eby certljy e mid f parjt�y Niet tbe b�forurel/oe providad ebov�e is bxe aud onn+�ct 3igo�nre � p� � Z- S �� P��_L,�es � /�,�w► ,�,� � p��# Sog�3 62�► ►z� •fficial ese only ao aot.viite r.chis uea co ee m�plaed br eily er inr�s�Cchl �P�t�= pvmifl�e# ❑e�ic if�►media�e respsa�e b reqirod 0�Bea[d �Sdec�'s O�oe � �ne�r�..�.t c�� #; i , i TOWN UF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHII�NT PERNIIT NUMBER: #06-106 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Les Hemmila, 37 Huntington Avenue, South Yarmouth, MA Whose place of business is: Ca�e Cod Seafarms Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31 2006 BOARD oF HEALTH: � r�r sss_`h. a�r� /j9.$., ' � a��te� �'�ir�li, �./V., 7%io�G��viKr�ss R�� now�, Gle�k P��N�� 1�(�'�isesa6�, R.N. January 27,2006 � rttCe . �M �� Dire�tor of Health ? , W��•Yq �° �� : ��o T C) N O F Y A �Z 1�I O U T H � O - � --y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 � MM`TACME qs" 'x Telephone (508) 398-2231,Ext. 241 — Fax (508) 760-3472 �, �R�ONAIE��b � �Ci C� B O A R D O F H E A L T H To: Yarmouth Board of Health Permit Holders � � '� '� �' � From: David D. Fiaherty Jr., R S. ;�� 3�� `�� Health Inspector ✓ HEALTH C��cp`�', Town of Yannouth Re: Federal Tax ID Number Date: March 22,2005 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}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSN} 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 Departnient 1146 Route 28 South Yannouth, MA 02664 "Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to cail. The office hours are Monday to�riday, 8:30 a.m. to 4:30 p.m. The telepho�number is(508) 398-2231,ext. 241. Estabfishment:�' A e �a� ��A 1 A�.w.s FEIN or SSN: � Location Address:��•�,�� c�� -e Signature: Print: ��-'.f <�(e y►.,rr►��/� Title: �!Y�C�� Printed on [ Recycled L 3 Paper � � . _ - Y � � �� 2 0;d R� TOWN OF YARMOUTH BO -�HEA��TH t2� -S '� '- 3 =c APPLICATION FOR LICE ` �OQS °: ,,� :� f� � �:� D E C 1 6 2004 ..•• :r� ��:.;,; �,.; . * Please complete form and attach all necessary `cuments by December 1,��T H D E I�T. Failure to do so will result iri the return of yow application packet. NAME OF ESTABLISHMENT: �a e- �o SP,�-�'�lL.rn S TEL. # bo$- �2- y� zS� LOCATION ADDRES S: �`�- ��+,r.o-t'a.� (1 v� MAILING ADDRESS: o�G�- � O`L OWNER/CORPORATION NAME: L� (� MANA ER'S NAME: e /-► TEI.. # ' . 1 Z S' MAILING ADDRESS: I�o f3c�,t �Z 1 G��„�.,N.�a, r�� MA 0-z � �� 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. 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). Plea.se 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 applica.tion. T6e Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. FERSO�Il�£HARGE: -_ ___ _ - _ _ _ ___ _ -- __ _ - - ____ , Each food establishment must have at least one Person In Chaxge(PIC) on site during hours of operation. 1. 2. HEIlVILTCH 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 yaw employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4- RESTAURt�NT SEATING: TOTAL# OFFICE USE ONLY LODGIlYG: LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEB PERMIT# BBcB $50 CABIN $50 MOTEL $50 iNN $50 _CAMP $50 ,SWIMMIAiG POOL$75ea. LODGE $50 TRAILER PARK $50 WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTr# LICENSE REQUIRED FEE PERNIIT# 0-100 SEATS �75 _CONTINENTAL $30 NON-PROFTT $25 >100 SEATS $iS0 _COMMON VTCT. $50 I WHOLESALE $?5 �O b� RETAQ.SERVICE: LICENSE REQUIRED FEE PBRMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERNIIT# <50 sq.ft. $45 _>25,000 sq.ft. 5200 �VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ ?S�� '••""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM"••*" ( : � ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is naw 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 Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED i 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 C(?MPLETED APPLICATtON(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. . SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTN�NTFORINSPECTION 7-10 ` DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOT'EL 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. F 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 opemng. � POOL WATER 1'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count I 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. � , � � I FOOD SERVICE ; � CONSUMER ADVISORY: � Each foad estab ishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLYCY• Anyone w o caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the reqi.ured Temporary Food Service Application form 72 hours prior t4 the catered event. Thses forms can be ' obtained at the Health Department. �RUZEN��LRTS: _ _- - - _ � 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. i � OUTDOOR COQKING: � Outdoor cooking,prepazation,or display of any food product by a retail or food 'ce establishment is prnhibited. f ` i DATE: � Z � 3� � SIGNATURE: : PRINT NAlV�& TITLE: LE.S /,I�ew� w.� �/� — L►� � � i 10/22/04 , 1 ` _ . �� -_--� The Com�nomvealth of Massachr�setxs = DtpartMeRt oflndustrial Accidenfs � --_ - -— N�flfrlrli� � = 600 R'ashiRgtoa Stree� 7"�`Floor . � _�, Boston,Mas� �Zlll workera'Com��rYN�t�■I�saraace Affi�vi�B�il • kelrical Coitractors ,��,. � ....-w : .f. ... ! .'�� .. 4� < . ..., . ..,.... .,.,. _ > � -.., v .'� " r. . ' '' . X .� i . .... ._� . �: �-�s 1-��,�►-> >-n�/J �s: pO �o yc �Zl citv��tit .�,.o/J o .J � O� s�te: / "t�` zip:dZ j Z� nhone# ��`h) 6 Z" � � �� -- /� v wrork site loc.atia�[fnll s): ��,��'l�a rs� /� e `��,1^^� ❑ I a hameowner performing all wak myself. Projed Type: ❑New Caa�c.rti��odel am a sole and have no�e w in an ca Buil ' Addition ❑ I am an employer pcoviding wa�kers'compensation fas my employces wo�cing ar�this job. ao�aonv a�: _ _ _ _ #d�e�s; � ��•� . � , ❑ I am a sole proprietor,ge�ai co��tractor,or Lomeo�er(e�d�o�)and have Itinad the ca�actors listed below who have the following wotkas'compensation polices: ...+ �; �''� _8�.�� ass�v me: ild�: �: ��s - - — _ _ _ _----- ---- --__ _ __ - -- --- -- --- _ — __ ___ __ _. � Fa�u�c b see�e ervera�e a�reqei�ed uder See�a 2SA d MGL 152 cn lad b tl�e��f cr4�id pesfWa�f a 8�e�p b SI,3M.N aadl�r e'e�rs'imptia�mt as we�as dv�pwltla i�tie firrt ota 3T0!WORK OBDEB a�d t A�e�tf1A0.N a day ataimt ee. !udeis�d tiat a d�ry�f Wt sta�acat�y be t�rwarded os tee of Ir�a��t IYe DIA ter avara�e ve�iatl�r. /ro ha,eby cerajy rarder e pdwa ¢ of perJiay dYat tlYe arfor��lo�provdded aboae!s texe aed onrnct Signatare Date �Z— � �('i �-,I ,e S .-�- P�� . /,�ew� w►<�� Pt��# SO�S'- �j,?_-�J Z� offidal ase oaly do aet wrke I�tYa am b 6e cyplded Dy d/y er�aws e�l c�y ar ta�v°' �q ��t ❑cheek if immeUiale �Bsatd r�peme b t�eqorod OSdeet�m's O�oe �� ceatict Pa'rs: Pk�e#; QO� t,�.�e ssmc�oac+� i , _ a � � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-095 FEE; 75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Les HemmilalWayne Hayes, 37 Huntington Avenue, South Yazmouth, MA Whose place of business is: Cape Cod Seafarms Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31, 2005 BOARD oF HEAI,Tx: l3esrya�rui�`?!. �''°nd°�rrti/l�.h. ' p�� v�e��.� R�`� B�, � �s!� R.N. �I.�l�'��, R.N. January 27,2005 rttCe . iuP , , •� Director of Health � ,: � �t� _.. �'� � � � � � i� c-c. s�,��s O f.Y'qR . . t',c'� f: . �� -: �c TOWN OF YARMOUTH BO Yy� F HEALTH Y: + �i•,,� APPLICATION FOR LICENS ^�� j I�:�3004 _ G3 (� C� C OMCD * Please complete form and attach all necessary documents by Dece ber��QO�. 2004 Failure to do so will result in the return of your application pa ket � Co � R/ L c.S � e ,q R' N E: L.-c s 1-� ► a 6 Z- j� MA S • O `Z C � /� , POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool �peraior(s)and aitach a copy of the certiiication 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 MA1�tAGERS - 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 Depariment will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2, _._ _ _ _ __ _ _ __ _ . _ __ _ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. �IMLICH 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-chok�ng procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 4FFICE USE ONLY LUDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# L[CENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $5(� _MOTEL $50 _INN $50 _CAMP $50 _SWIMMiNG POOL$75ea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea �OOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS a75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS �150 _COMMON VICT. SSO �WHOLESALE $75�0�� t,ETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR6D FEE PERMIT�! L[CGNSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VGNDING-FOOD $20 _<25,000 sq.ft. S75 ,_FR07_EN nL'SSI3RT $35 _TOBACCO S25 dAME CHANGE: $]0 AMOUNT DUE _ $ �`J•OO , *"""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"" `l �, � i ADMINISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yatmouth 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 f t CERT. OF INSURANCE ATTACHED Q$ 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 RETtJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. �; r ; SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTIVIENT FOR 1NSPECTION 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 � � � f POOLS ' POOL OPENING:All swimming,wading and whirlpools which have been closed for the sea.son 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 � closing. i FOOD SERVICE CONSUMER ADVj,,�O.$Y: , Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLIC'Y: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the ' required Temporaty Food Service Application form 72 hours pnor to the catered event. Thses forms can be � obtained at the Health Department. FR(17F,N nFCCFRTC•---- _ _ _ _— --- - ___ � Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuits 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. OUT,IDE C��_ � Outside cafes(i.e.,outdoor seating with waiter/waitress service),n�ust have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail food service establishment is prohibited. DATE: / Z� 2-�`" � 3 SIGNATURE: � PRINT NAME& TITLE: es � � (V� � 10/22/03 � � . ,A � The Commonwealth of Mossachusetts � � Departme»1 ojlndustrial.-iccidents 0 ofllceoll�s�losdiis � 600 Washington Street ' �= Bnston.Mass. 02111 ~ �� W'orkers' Compensation Insu�ance Affidavit An�licant information: PlessePR�'1'Te�.'� namr� / 2-.S N2.1')') Vn, 'A . location� �� ehone� � I am a homecwner pertorming all work myself. �m a sole proprizcor�:-� ha�e no one ��orking in anv capaciry � I am an empio�er pro��in� w�orkers' compensation for my employees workine on this job. _ _ _ an • n � GQ � dress• [� d � '�. titv: L ��nn�J�l4 nhone 11• �,,,�� Z� � � 2 � insurance co. policy tt � I am a sole proprietor. generai contractor. or homeowner(ci�cle onel and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ �corker�� .ompensation polices: companv namr address• ci�}: nhone q• insurance co. Rolic}•# s�mRny name• , add ress: ciri• nhoee A�• insurance co. �y N � Failure to sccure coverage as required unde�Seenos 25A of MGL 152 a�iad to tde iepaitios o(erimi�l pt�dtln of a O�e op to SI,S00.00 a�d/o� one vean'imprisonment a�w•ell i�civil penaitia io tfie form of�STOY WOWC ORDER aad a tiae�SIOOAO a dar ataiost ma I a�dersta�d t6at a eopy of thy statemrnt may be(onvarded to the ORce ot Inveati��tiom of t6e DU for eoven;e verifieatb�. I do hrreby certif}•u der rhe in nd penalti�s ojperjury that tht injornration provid�d above is nue and evntd Signature �Z— Z�—� � Print name �� /��Y1'�YY)t �� P1�one�l J d�• .,3� Z' L� 1 2� .. otTicial use onl� do not M�ite in this ares to be completed by eiN or town ol'llti�l city or town: y�M��TQ _ permitAieense t1 nBuildieg Depaetmmt �Lieeasiog Board Q cheek if immediate response i�required 261 QSeiettmtn's Ofiict (508� 398�?231 p�t, OHeaItA Department • contact person: phone N;_ _,_ _ nOther ,.. .-C .t �I�', ��. i i TOWN OF YARMOUTH BUARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-142 FEE: $75.00 In accordance with regu1at�ons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Les Hemmila, 37 Huntington Avenue, South Yarmouth, MA ' Whose place of business is: Cane Cod Seafarms Type of business: Wholesa_le Food Service To operate a food establishment in: Tovcm of Yarmouth Permit expires: December 31. 2044 BOARD oF HEALTH: Ber�yc.� _`?�. � /�l._`Yl. ' A��, v��,.� R�t�. e� et� � Sl�k, R.N. February 10,2004 �u� . y , •, Director of Heal .. _ TOWN OF YARMOUTH BOARD OF H [� [ (�' [� p iU! � [�p . APPLICATION FOR LICENSE/PE "' fl� S t� � 3 �4G2 * Please complete form and attach all necessary documents by Decem�?er�_�:��- O r. F il e o 'll r lt ' the return of your application packet. rt-'$� �� H��L�H�EF�� .�;, . AM T I H T: e A �2 S # � •Z 6� �Z� � �n�'i� U� A 't A S: � C � � i " A . # Sa�v�e �t 2 S A � �OL CERTIFICATIONS: The pool supervisor must be certified as�Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees 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 PROTF,�TION�NAGERS - CERTIFICATIONS: All food service esta.blishments 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 atta.ch 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 establis6ment. 1. 2. PERSON .�HARGE: Each food establishment must have at least one Person In Charge (PIC)on site duri�rg hours of operation. 1. 2. HELMLICH CERTIFIC T� IONS: . All food service establishments with 25 seats or mare 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. 1�S,TAURA.NT SEATING: TOTAL# OFFICE.�,TSE O j Y ��pSiil�G� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIMMING POOL$SOea LODGE $SO TRAILER PA12K $SO Wf�RLPOOL $25ea FOO,�S�1�VICE: 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. SSO ✓WHOLESALE $75 �� RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 �<50 sq.ft. $45 >25,000 sq.ft. $200 _FROZEN DESSERT�35 / NAME CHANGE: $10 AMOUNT DUE _ $ ^7� . *****PLEASE TURN OVER ANA COMPLETE OTHER SIDE OF FORM***** . r ; „ , _.. _._. . , a . . � . � � . - n�:w,�:,� .�;�;a� �r _ ` t . ADMINISTRATION � , Unde�'�Yi�pter 1 S2; ��n 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 COMPL�TED AND SIGNED,OR CERT. OF 1NSURANCE ATTACHED � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: , / YES V NO NOTICE:Permits run annually from January 1 to December 3 L IT TS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTME�1'T FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � i f � � ADDITIONAL REGULATIONS j POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department pr�or 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 closing. FOOD SERVICE CONSC�F1_?ApVISORY: � I Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post , Consumer Advisories. CAT.�I�iN�PUi I�Y:. . ' Anyone who caters wrthm 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.ROZFN DE SERTS: � 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 unril the above terms have been met. � ; QUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter%v�aitress service),must have prior approval from the Board of Health. �UTDOOR COQI�NGi Outdoor cooking,preparation,or display of any food product by a retail or food servi establishment is prohibited. DATE: SIGNATURE: � PRINT NAME&TITLE: L.eS �� A `— � (2 09/11/O1 j _ _ _�:; �� . • � The Co�rrinonwea/th of 11�assacbtrsetts _ '� = Depar�ment ojlndusttial.-lccidenls _ > �11llcsol/era�los� ,� 6b0 Washington Slreet ,' Boston.Mass 02111 W'orkers' Compens9tion lasurance Aff�davit Aonlicant tnformation: PlessepRllQT'T�r�.l't namc: �.Ca'�� COp• ��A�(�1GLYVI,S L [, C l� t-+ U 2- cit�- �AR..YnOu�� ehonet�B'2..� • �1Z.�� I am a homeowner penortning all wutk myself. �"i am a sole proprirtor_r.� ha�z no one�ti•orkine in am•capacin� � 1 am an employer pro�iding worlcers' compensacion for my emplo�ees working on this job. comnanv namt; 'cf�'P�.� ��.-�'��'Y`��t-�` . address• • � � s , eit�: ehene Ih. insur�nce co. olicy p � I am a sole proprietor. generai contractor,or homeowner(circle onel and hace hircd the coneractors listed below• Nho ha�� thz follua�ing�sorker' �ompensation polices: comp��nv eame• address• . , cip+: � ehone i!• insurance co. �eliev!f t�moany name• zddress: ..:. �� ,y: eboee M: .., i r �.n � , ,.' ' Faiture to�eeure core�a�e as required Yode�Satios,2SA of MGL 1S2 ta�le�d to�e i�o�oteri�ini pwltks of a A�e,�p to s1�90A0 a�d/or .. eoe year:''impriiesme�t a�w�ll ai eivil pesdtla i�tbe fors of a SI'OT�VORK�tDER aM a A�e eES10�.0i s d�l'apiat s� I�d trat a � �copy of thb sateaient miv be forwardcd to tAe Otlicc of lavesNpliom o�lre DL►tor em�era�e veeiQeNiM. . /do-hrreby crnifj�un r poi»s a�d pea fies o �rjyry thm tae iNforn�lion proridtd above is�e ond eoritet _ � � Z Signaturc _e 6 l 2� • Print name L�S �'1�`' I�?'! 1'1't i �A P1�ene�! �D�f' �--�� l �7�� _ _ . _ __ _ olTicial use oely do not w►ite in�his are�ro 6e eompieted by eit�or low�oAkial eity or tara: Y��T$ _ � • persilAieeax N nBuildla;Department �Ueeesia�Bo�rd �eheck if immediste respoose is nquired 261 �Seleetmen'�Ofliee �Hea1tA Oep��7ment contact pcnon: ��M;_ (508� 398-2231 eat. np�tier�_ ue.nea;oc PlA� - � . .. � . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-189 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: (:a�e Cod Seafarms I,L.C, '7 H n ington AvenLe, SoL h Y rmo � h, MA Whose place of business is:�a�e Cod Seafarms LLC Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31,2002 BOARD oF HEAI,�: ekanlea� Ze�tkez. Lka.lu�,ca�c �'�r�D, C�ard,o.t. l�L.D., 2/� ,�a8r�rt� �. � �a�ek�D� �� s , �n �f s�t�,nb�i� ,aooa �°` Bruce G.Murphy� H, .,CHO Director of Heal r.� �s� e �. s�►�ns of;;a?� TOWN OF YARMOUTH BOARI��Ql�`EAL � � / 32 � it �lh lc' jt \�il t`=' 'i� ; `V�1�1� ='� APPLICATION FOR �lP�I;11�TT-2 � � � �: .? :�� ' ` " 3 � Z�OZ � �p° •., ..• �. D _ � * P1ease complete form and attach all ne��"' s :��iments by De embE C31, 2002. � ' Failure to do so will result in the �� of our a licatio Y PP P�LT;-i C��F'T. NAME OF EST,A�LISHMENT: �A ae A��an m S C TEL. # � __ ' �� L A I N � A x� � �30 3Z e 1� o i TI N ' , # ��Z SS• Z C�u �a V1 ' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated i _. __Pool O�r�tor(s� and attach�cogy 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 Cardiopulmonary Resuscitation (CPR). Please list these empioyees 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 - C�RTIFICATIONS: All food service establishnnents are required to have at least one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. _ ____ uFucnAr rt�t ue,u�T • _ _ _ - ---- —____ __ _ __ ___ _- --- -- Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIMLICH CE�TIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# LoncING: QFFICE USE ONLY : LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _MOT'EL $50 _INN $50 _CAMP $50 _SWIbIIviING POOL$SOea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea F(�OD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TO-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 I WHOLESALE $75 �03��j �TAIL 5 RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ^TOBACCO $20 _<25�00 scZ.ft. $75 �TOBACCO $20 _<50 sq.ft. $45 �>25,000 sq.ft. �200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ �IS•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�*** a , �..� .., . -r r i f i ADMINISTRATION Under Chapier 152,, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license ar 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 i CERT. OF INSURANCE ATTACHEL OR ! / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: � YES 1� NO ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'LTRN E THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002. ' { SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-�HEALTH DEPARTIVIENT FOR INSPECTION 7-10 � DAYS PRIOR TO OPENING FbR THE SEASON. � � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � I , k ADDITIONAL REGULATIONS � POOLS _ _v __ POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openmg. POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count by a Sta.te 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 C closing. FOOD SERVICE F � 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 Yannouth 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. I FROZEN DESSERTS: Frozen desserts must be teste�on a mont�Y.ily basis by a�tate certified lab. Test results must be sent to the�aith - Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the , above terms have been met. i OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mu t have prior approval from the Board of Health. QUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food ervice establishment is prohibited. DATE: ��"� -- � SIGNATURE: � � PRINT NAME & TITLE: �e S N�e y�_�� A �Y1 C��L � �, ' 10/18/02 ' i � I , i 1� t � The Conrmonwealth ojMossachusetts � � Department ojlndustrial.-�ccidents " a Of11Ce0/I�S�l�stli/s � ; 600 Washington Street ' ,•` Bnston.�lass. 02111 ' " �� V4'orkers' Compensation Insurance Atfidavit m.. �„Q S �� e /i 1 •� �j{1.-_.` . � � � � iJun �h ,� ttt� \/.�2Yv�cu�)�L. ohone� �� " b �� ?� �.�� I am a homecµner pertorming all w�ork my�self. �am a sole proprieror �r.� ha�e no one��orkine in am•capacin• _Q I_am an emplo�er ro��din� w�orkers'_compensation for my empio��ees w•orkine on this job: m n • n � G o� c�CA`� e: dress• �� Y1. a Q._ .. �{ m�`�` �4 O z� 6 ' L I Z� in�urance co. policy# � I am a sole proprieror. :enerai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below «ho ha�e the follo��in_ ��orker�� .ompensation polices: comQanv n�me• address• cin•: nhone M• insura�cc ca �olicy# comnanv namr address• tiri: Fboee M• insurance co�_ �Y* i Failu�e to secure cover�;e as required under Secnoo 25A of MGL 152 n�iad to tre ioporitioa ot erisi�fl pesdtle�of�O�e op to 51,500.00 a�d/o� one years'imprisonment a�w•ell a�civil penaltle�io the form of a STOP WORK ORDER aed a Aae otS100.00 a dar apiost ma [a�denla�d thit a eopy of thH statement may be fonvarded to the Olrce of tnve�tigatioo�of tAe DIA tor eoven=e veriBado�. /do hrreby cenij}�u er rhe ain nd penal�ies ojperjury that tht information providtd obove is tt�e and contct Signature _ /�2'"��` d Z Print namt Le S �7e YYt vYl� �C+'4 P1�one N .S 6.{� ��i yc..` L�� .. olTicial use onl� do not Mrite in this area to be completed by eiry or town oAlcial city or town: Y�M�IIT� _ permitAieeau a nBuildiog Department OLieeasing Board �eheck if immediate response i�required 261 �Selectmen'�0f6ce �Health Departmeat contace person: - phone a;_ f 508} 398�?231 eat. nOther ,.. .Y. .<��{: � . - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #03-133 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: Cape Cod Seafarms LLC, 37 Huntington Avenue, South Yazmouth, MA Whose place of business is: Cape Cod Seafarms LLC i � • Type of business: Wholesale Food Service To operate a food establishment in: Town of Yarmouth —__- _Pernut ex�es: December 3 l. 2003 Bo�oF��.Tx: �a�cllea r� zell�ai, (,�ka�aoxa.� -- _ __ _ _— _ - ---- _ - - _ __ - --- , � ,�o�tt� �aaar�c, � +� ' � �'�� a�uck'�ar.�cott , �f�e�c S�c. ,�.'�Z. January 24,2003 ruce G.Murphy, .,CHO Director of Health : -, : =. : . � , � . .. r . 3 f:n� : � � - . �_ ".�.i�" . '.. •