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Home My WebLink AboutApplications, WC and Licenses _ � �� ► � TOWN OF YARMOUTH BOARD OF � s �� a' � - ° �� .,,... ,��,�' � � APPLICATION FOR LICENSE/PEF�f � �,�9�': �p�g � �� u�t; � 7 � * Please complete form and attach a11 necessary docu ts� �b�r -r �,� Failure to do so will result in the return of your applicatio � . NAME OF ESTABLISHMENT: �A.deCu c� �i•,�5� Vi��'i � TEL. # �5�$ ''77l-QlD v LOCATION ADDRESS: Sl ot�ain sf" 1Z�' d� Gks�-- YarMOK�► M/�!'e.267 3 ' MAILING ADDRESS: Sa�+� OWNER NAME: TAX ID (FElN or SSN}: CORFORATION NAME (IF APPLICABLE}: MANAGER'S NAME: J o�e� �yn� TEL. #;�D g7�/-0/�6 x /8s� MAILINGADDRESS: Sld f?a;n S�- I�--1-�$ �• ��.�rHf� �� D�iG73 POOL CERTIFICATIONS: The pool supervisar must be certi�ed 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. '�6m �t.� D�i.,.�i�� 2._ Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will nat use past years' recards. You must pravide new copies and maintain a �le at your place of business. ' 1. Din 1/G�.v�S 2. (u-'��icr��G�, �' 3. 4. — FQOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is ce�-tified as a Food Protection Manager, as defined in the State Sanituy 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 pravide new copies and maintain a file Rt your establishment. l. �t)d5e✓e �-f- ��'arv`i ��i.a 2. PERSON IN CHARGE: _ _ -----___ -- ----- -- ____ -- - -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��O�c�Ve �-E �c �ri/��t 0 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures belaw and attach copies of employee certifications to this foi-m. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. � ��s � ��. 2. D�. F1 y,�� 3. `ea�c��( �' I/f CGY(/G �� 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�iG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN $55 LMOTEL �55 O�I+Q"�J -- _ 2 0 S» CAMP S 5� SWIlVINIING PO�L $80ea. – � _ _ ��f OS7o LODGE 555 TRAILERPARK �105 LWHIRLPOOL �80ea. ��S � FOOD SERVICE: LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i � �0-100 SEATS S85 _CONTINENTAL �35 NON-PROFIT �30 i �>100 SEATS S 160 o y/��f �,COMMON VIC. �60 �d�!–'�l�'" WHOLESALE �80 � RETAIL SERVICE: —RESID.KITCHEN �80 � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIKED FEE PERMIT# � _<50 sq.H. �50 _>25,000 sq.ft. $225 VENDING-FOOD �25 � T<25,000 sq.ft. S80 _FROZEN DESSERT �40 _TOBACCO �55 � �a�7E cxA�cE: sio AMOUNT DUE _ � S��S.0a ; *****PLEASE TLTR�T OVER A1�D COMPLETE OTHER SIDE OF FOR'VI'�**** ; i ' �, , �`' � � 1 I 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 COMPEN5ATION INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' � CERT. OF INSURANCE ATTACHED ✓ ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � I I � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ! APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISffiV�NTS � 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. Tra.nsient 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 unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy ` Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days ' pnor to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected � and opened. 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 CLUSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of f closing. FOOD SERVICE CATERING POLICY• Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Applica.tion form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Fa.ilure 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 Boa.rd ofHealth. OUTDOOR COOHING: f Outdoor cooking,preparation,or display of any food product by a retail or food service establishmem is prohibited. � NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETLJRN TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: t 1 I��e� SIGNATURE: PRINT NAME&TITLE: � � �� -% �'� � io�ziros � � � - ' ��fs-?9i - 3 '�F 3� ACOR'D CERTIFICATE O�F LIABILITY INSURANCE °"'�`�"'p°""'"' �► 11/18/2008 PROdUCER THIS CERTIFICAT� IS ISSUED AS A MA7TER OF INFORMATION HART INSURANCE AGENGY, INC. ONLY AND CONFERS NO RIGHTS UPON TN� CERTIFICATE HOLCtER. THIS CERTIFICA'fE DOES NaT AMEND, FXTEND OR 243 MAI N STREET ALTER THE COVERAGE AFFORDED BY THE PpLIC1ES BELOW. PO BOX 700 BUZZARDS BAY, MA O25S2-O700 INSURERS AFFORDING COVERAGE NAIC# ►nsu�o Irish Village Restaurant and Pub, InC. iNSURER A, AIG NATI NA INSURANCE CO INC 36587 , 51Z West Main Street IN5URER 8: West Yarmouth,MA �2673 �r�suRER c: � ; INSURBR 0 �nrsuRER E; ~.,._�.. COVERAGES THE POLICIES OF INSURANCE LIS7ED BELOW FiAVE BEEN 1SSUED TO THE INSURED NAMED ABOVE FOR TNE POLICY PERIOD 1NDICATED.NOTWffHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF AN`� CONTRACT OR O7MER DOCUMENT WITIi RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY P6RTAIN,THE(NSUfL0.NCE AFFORDEO BY TFIE P�LICIES DESCRI6ED HEREIN IS SUBJECT TO AlL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.AGGREGATE LIMfCS SH�WN MAY HAVE BEEN RFDUCED BY PAID CLAINlS, INSR D9_ pOLICY NUMBER p��E�� PONCY pGPIRAl10N IJMlT3 LTR GBNERAL LIABILITY EwCM OCCURR�NCE S AMA ! COMM6RCIql GENERAL UA�ILITY P i 5 CLA�MS MAGE �OCCUR N1ED EXP A� m+e tson) i PERSONAI�AOV mJURY S GENERq�qGGREGA7E s ' GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COMP/OP AGG S POLICY PRO. `� A�TD��TY COMB�NEO StNGIE LIMI7 ANY AUTO (Ea oo�idorR) '� , ALL OWNEDAIffOS BODILY IIV�URY SCH6DUL60 AUTOS (Par peeson) b _,,,,_._��. HIRED aUTOS BOORv�N�URv NON-0WNEDAU7'OS IPa�c�donl) E PROPERTv DAMA�E $ (ParacdConq Gq��vpg��y AUYO ONL7-EA ACCIDENT S � A�11�AUTO OTHER 7HAN �ACC 5 AV70 ONLy; A�G S �xc�sSruMsa�w unsn-mr EaCri oCCURRENCE a�,.,_,,w_ OCCUR �Cuo�Ms MaoE AaOREGasE a s DEDUCTiBt.E a RE'rE�ION S S A WORKERS COMPEp775AT10N AN� WC6842933 04/01/08 04/01/09 WC STA7V- on-i- EMPLOYERS'LIABdIiY E� EACM ACCIDEWT S 5OO OOO aNY PROpRiETOR/PARTNER/D(ECUTNE O��CER/ME�eER EXCtUDED7 6,L DISEASE-�EMPLOYEE S rJ`OO OOO �r yea,aeacnDe� E�L,DISEASE-POUCY uN1IT S 500 000 SPECIAL PftOVBIONS Debw 07}iER DESCF�PT�ON OF OPERaTlONS!LOCATIONS/VEHICLES/E7tCLV5pN5 AODEo BY EJ�1bORSeN1eNT/SPECIAL PROVISIONS Restaurant CERTlF1CATE HOLDER CANCELLATI�N SHOULD AN1 OF THE ABOVE DESCRIB�POLICES BE CANCELLED BEFORE THE E7(PqtA710N DATE THEREOF,'THE iSSU1NG INSURER WILL ENDEAVOR TO MAIL 3O PAYS WRiTTEN TOWN OF YARMOUTH NOTICE TG 7H�C�Ii71PICAT!FIOLDER NAMm TO THE I.FFT,6UT FAIWRE 7'0 DO SO SHALL 1146 MAIN STR�E7 IMppSE NO Og�JGA710N OR LIABILJIY OF ANY KIND UPON TNE INSURER,rT5 AGEN75 OR S YARMOUTH, MA 02673 �PR��rArn�s. AU7MORIYeD RlPR[SEItl7ATIV�`�� ACORD 25(2001108) 8 ACORD CORPORATION 1988 l 'd ll8 'ON 3�Nd��SNI l�dH Wdl� �� 8001 '8l 'AON THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARM4UTH BOARD OF HEALTH PERMIT NUMBER: #Q9-030 FEE: 555.00 This is to cenif�chat John J Hynes Jr Pres d/b/a Cape Cod Irish Village 512 Route 28 West Yarmouth, MA __ HAS BEEN GRANTED A LICENSE TO , OPERATE MOTELS This License is issued in confornury with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject ta the pro��isions of the Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such ternis and conditions,and to the rules and re�ilations in regard to said Motels so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner suspended or revoked. January 8.2009 BOARD OF HEALTH: .`��tL S�R�., �..lY., ��tQtt Cf�a�r�a .`�. `1f�iltex,� `U�[Ce C'�awrnuut +L��cS-so:sea�o�-so Jn�-,v-�-_�t �.�hutttttt, �:��/ four Cottages: Lnits—5;Bedrooms—9 l�.11l��1�Ql�A�[I�L� �.✓►'- 2a"-��.._�' ��xt�d Bruce G. urphy, , .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-124 FEE: 5160.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 ofthe General Laws,a permit is her�b�g,ranted to: John J. Hynes, Jr., Pres., 512 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Irish Villa�e Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2009 BOARD OF HEALTH: .�le�ert Sf�a�$,q J`Z�.�.I�YQ.�,��u�r�n�,,�� SEATII�G: 278 ��y,�Q� �✓�Lur[�c.� �[CE �.ruivulLt�fL (,�Jl� s �-�- �:�. �TiEcu�eo Jam►an�8.2009 B ce . Murphy,M . .,CHO Director of Health , • THE CQMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-082 FEE: 560.00 This is to Certify that John J. Hynes, Jr., Pres. d/b/a Cape Cad Irish Village ; 512 Route 28, West Yarmauth, MA IS HEREBY GRANTED A , COMMON VICTUALLER'S LICENSE In said Town of Yartnouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for vioiation of the laws of the Comrnonwealth respecting the licensing af common victuallers. This license is issued in conformiry with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta. In Testimony Whereof, the undersigned have hereunta affixed their official signatures. BOARD OF HEALTH: .�E�ert S�a.�t,t�`.lt'..JV., 'C,��uy7�m.uta SEAIIhG: 278 ��Y�d �. J�t� VIC� ��Rt�W`1ZtXtt � t.�xc�usn, C� Q.nrt��ee�c�acutt, :f2..N. �w�n..� lanuary 8,2009 gruc G.Murphy,MP , . .,CHO Director of Health TAE CQMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH . BOARD OF HEALTH PERMIT NLTMBER: #09-055 FEE: 580.00 This is to Certif�that John J Hynes Jr yPres d/b/a Cane Cod Irish Village 512 Route 28, West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Poot At Ca e Cod Irish Villa e - INDOOR POOL � 51 Route 28 West Yarrnouth, MA Ihis pennit is granted in confornuty«�ith Article VI of the Sanitan�Code of The Commom��ealth of Massachusetts,and expues December 31.2009 unless sooner suspended or revoked.� Januan�8.2009 BOARD OF HEALTH: ��¢tt S�� ..lV.� ��1�l�tfftlYtL �� . 3�e� v� �►� ��t s. ✓�3�vuuc, U� Qnn 'C�nee�r�accrn, J2..N. � �'. � Bruce . Murp y, H, . � Director of Health i a , f THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-025 FEE: 580.OQ This is to Certifi•that John J. Hynes. Jr.. Pres. d/b/a Cape Cod Irish Village 512 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in confonnih ��ith the authority granted to the Board of Health,bv Chapter 14Q,Sections 51,of the General La�r�s,and amendments thereto,and is subject to the provisions ofthe Laws ofthe Commonu�ealth ofMassachusetts relating thereto, and upon siich ternis and conditions,and to the niles and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 3 l,2009 unless sooner re�•oked. January 8,2009 BOARD OF HEALTH: ��E�¢IL S�C�, �..lY., ��A,�U,tflt�tL �1�t�0 .`�. ��O�I�X,� ��tCt', ��tYlXlttlift .I�.QB��. ��tL, �:C(Xft Q/ttt �t�lrt.tftt, J�..lv. G:Murphy,MP' , . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-056 FEE: 580.00 rhis is to cerc�f��that John J: Hynes, Jr.. Pres. d!b/a Cape Cod Irish Village 512 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Pubtic Swimming or Wading Pool At Cape Cod Irish Villa�e - OUTDOOR POOL 512 Route 28 West Yarmouth, MA This pemiit is granted in conforniit�•�cith Article VI of the Sanitarv Code of The Conmion�i-ealth of Massachusetts, and expires DecemUer 31 2009 uniess sooner suspended or revoked.� Jamiara�8,?Q09 BOARD OF HEALTH: .1�¢It 5�� ..lV.� ��l�GtttlY.tt C!�%�rrc�e� ,�. �Cet�iR�e�e 2Jiee C�avu�tan J`�a�ea�tt .``t. J`3aco.u,.�c, e�rl� t� ��, �..N. Bruce . y, P , , Director of Health �� , o�y��.�.1,�,sH I/�u.��E °�=Y�k� , TOWN OF YARMOUTH BOARD OF HF,�LT��'�"•�a�,� r s '' ' APP L I CA T I O N F O R L I C E N S E l P � - �ry Q �.� L�� -��`s E�� ;�� 7 ��f ; :, �i.�, - •�,.�.., • * Please complete form and attach all necessary d cur`�e�it�by D mber�-Y;2007. i Failure to do so will result in the return o�your application packet. NAME OF ESTABLISHMEIVT: ��e Cec� -L r��5"� Vi C�q e TEL. #�Q� 77/—+O�o 0 LOCATION ADDRESS: Sl d2 /'1'it%� S f- R�zg L�r-�-�- .sir•or,c�'1. MAILING ADDRESS: 52ht � OWN�R NAM�: _ T X ID(FEIN or SSNI- CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: �01�� S TEL. # MAILING ADDRESS: .S/d. f��:�► <<'if'. R�.Zg �cl��- Y•�•o�/2 ti�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 of the certification to this form. i 1. �t�lnG S �, t/i� 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 eertificatictns to this form. T�te �ealth Dep�rtment will not use past years' reeords. 'Yo� �►ust provide nev�F copies and maintain a file at your place of business. �> 1. / D!'►� /,L U i,.S 2. ��c,`�' �n/:.ri4ll,�" 3. 4. —_,—�� FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Flease�ttach copies of certificationto this application. The Health Departme�t witl not nse past ye�rs'rPcords. You must provide new copies and maintain a file at your establishment. 1. �oaS��l f D� C�rv.� '�o 2. P��9I�T 1N�I�A,R�►E: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. l�doSC'�e l� Oe C�,v�l�t.o 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and i attach copies of employee certifications to this form. The l�ealth Department will not use past years' records. � You must provide new copies and maintain a file at your place of business. � �. C1��; S L.yr�,G� 2. � Fl��K. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE O1�LY LODGING: LICENSE REQUIRED FEE PERWiIT# LICENSE REQL'IRED FEE PER'bIIT* LICENSE REQLTIRED FEE PERVfIT= _B&B S50 _CAB1N SSO �MOTEL S50 �08-Oflo �o8-03a �INN S50 _CA1�TP S�0 Z S�'ItiLVIING`POOL S75ea. _�o�3-C73/ �LODGE �50 _TRAILERPARK S100 �R'HIRLPQOL S75ea. �/08�� FOOD SERVICE: - _ --- - — _ - - -- _ _ - __ _ _, LICENSE 1tEQUlItED FEE PERMIT# LIC£NSE AEQUIItED F£E P£R�iIT�. LICENSE REQti IRED FEE PERViIT= 0-100 SEATS 575 _CONTiNENTAL S30 Iv'ON-PROFIT S25 �>100 SEATS S150 �C�$-USZI �CO�L�rION VIC S50 �O p � _V4�IOLESALE S75 t RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERVIIT� LICENSE REQL'IRED FEE PER'�IIT= _<50 sq.ft. �45 _>25,000 sq.ft. S200 VEI�'DING-FOOD S30 _<25,000 sq.ft. 575 _FROZEN DESSERT S35 TOBACCO S50 :va��cxa�vcE: sio AMOUNTDUE _ $ �75-00 ***•*PLEASE TL'R.\OVER��D CO�IPLETE OTAER SIDE OF FORJZ**w** . . , ADNIINISTRATION 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 �nsurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. 4F INSURANCE ATTACHED --' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Ya.rmouth t�es 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 OCCUPANCY: For purposes of the limita.tions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�. Transient accupants must have and be able to demonstrate thax they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or dwellin� unit sha11 not be considered transient. Occupancy tha.t is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with this application. POOL3 PUOL 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(�days pnor to opening. POOL WATER TES'I'ING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and c�uarterly therea.fter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernrit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. _ __� _w_---w_____._ _ _ __ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPUNSIBII.ITY TO RET[JRN THE COMPLETED APPLICATIQN(S)AND REQUtRED FEE(S)BY DECEMBER� 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISH1VlENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCEME�TT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: /�l' ��-D 7 SIGNATURE: ''^ ��Lo, PRINT NAME&TITLE: ��►� � 'r�� - 10300'' r NOV. 13. 2001 3: 51PM HART INSURANCE N0. 826 P. 3 on�l��crrrr� AC4RD�, CE�iTIFtCATE OF LIABILITY INSURANCE ��3rzoo7 PRooucfx THIS C�RT[FlCAT� IS ISSUED AS A MA'RER O� INFORMATION HART INSURANCE AGENCY, INC. ONI.Y AND CONFERS NO RIGHTS UPON TH� CERTIFICATE HOLpER. YHIS CER7�FIGATE DOF-S NOT A�END, EXTEND aR 243 MAW$TREET a�TER T�t� COVeRaGE AFFo�ED �r�rNE Po�aFs B�OW. PO BOX 700 BUZZARDS BAY, MA 02532-0700 {NSURERS AFFORDING COVERAC�E t�u►►c# ��'�D irish Vitiage Restaurgnt and Pub,Inc. ��s�ER�; GRANITE STATE INSURANCE 2�� 592 West Main Sheet wsuReR e; West Yarmouth.MA 02673 ��R� • INSUR6R D; ; iwsuRER E: COVERAQES TttE POLICIES OF INSURANCE LISTED BEIOW IiAVE BEEN ISSUED TO TWE INSURED NAMEO A801/�FOR THE POLICY PERIOD INDtCAT�O.NOTUVITMSTANDING ANY REQUIREMENY,TERM OR CONDITION OF AN7 CONTRA+r"C QR C'T'HER DOCUMENT 1M'fH RESPEC7 TO 1NH�CN THIS CER71FlCATE MAY BE ISSUED C1R : MAY PERTAIN,THE MSURAt�iCE A�FORDED 6Y 7HE POL1GlES DESGRIB�D HBREW 18 SUBJECT 70 ALL THE 7ERMS,EXCLUS�ONS AND CONDITIONS OF SUCH POUG�S-AGGREGA7E LIMITS SHOWN NIAY HAVE BEEN REDUCEO BY PA1D CLAIMS- INSR D' POLtGV NUM9ER POIICY EFFECTNE POLTCY E%PIRATION LiMTrS ep,t�10CCURRENCE S 6FtVEitA1.eJA9R1T1t CAMMERC�AL 6ENERAL L�ABWTY- PREMI$� €a�� S . . CLAIMS MADE a OCCUR AdED EXP A �e Pe+so S PERSONAL�ADV IPIJURY S GENERALAGGREGATE S GEN'L AGGREGATE UMIY APPLIES PER; PRpDUCTs-GOMPl�P ACi6 5 POUCY p� LOC q�OM0011 P Uqg�� CqM61NED SINGLE LIMIT S tEa 7�enU ANY AU7'O A6L01M1MEDAUTOS �BpL��URY g SCMEWLEDAUTOS HIREO AUTOS ��"'"��'� a (Peracddanp NON-OWNED�oS PROPERTY�A�GE S - (PersceWend GARAGE LWB1LiTy AUTO ONLY-EA I�Cr�DEKf S ANY AU70 OTM�R 7HAN �FJ1 ACC 5 qIJTp ONLY: AGG S E7LCESSNMBf3ELlR WiB�RY EACH OCGIIRREIZCE s occuR �Cwa�S naD6 AOOREGA'� s S . s i)EDunne�E S RETENTION S WC STATU. OYI+ A WpRKERS COIAPENSAliON ANG V1106832452 04I01/07 04/0'I/08 � OAPWYERS'ilA91L3TY E.L�6ACN ACCIDEPfT s OOO M1Y PROPRIEi'O�PqRTN�/E��1NE OFFICERlME►A6ERE7CC�.UDED7 E.LpI$EA3E.FAEMP�QYEE S OOOOO Ifyee,CeSCIA661�tlOr E�G W$EASE.POLI�UMIT s 000 SPECIAL PROv15�0 hebw OTNQt DE�N OF�FJtAT10r+5 f LpCAT10N3 f VEHICLES/EXCLUSIONS ADDE�B1'�NIDORSEMEN7!SpEG1AL PROV�STGNB Motel CERTIFICA7E HOLDER CANC�LLATION SHOULO AnY OF TMB A00VE 4�CWBED POLICIES 6E CJwCELLED BEFORE THE�'JfPIRAf10M pp7�'(}��tEOF,SXE ISSUINO WSU�M�1L1-EI�DEAYOR T6 MAfL �O DAYS WRRiEN T01NN OF YARMOUTH Np�•(p�{E CERnFl�qT�µ�,p�Np�Ep 7p 7HE LLPT,BUT FNWRE m DO SO SHALL 1146 RT 28 oarose No oe�cw►rioH oR uneiurr o��wv Kwo vroN r+E iNsu�a,rrs nc+En�rs oR S YARMOUTH, MA 02644 �,��A,.�, qIJTk10R�D REPRES�TAi1VE � . I ' .,. .. ... �p�CORD CORPORATION 1968 ACORp 25(aooi�o8) I i I Mni'l� � ' TIIE COMMONV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH : PERMIT NUMBER: #08-016 FEE: $50.00 This is to Cenify that John J. Hynes. Jr.. Pres. d/b/a Cape Cod Irish Villa�;e 512 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Tlus License is issued in conformity with the authority granted to.the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulatians in regard to said Motels sa licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. December 6.2007 BOARD OF HEALTH: `.�¢Q¢tt S/fAtf�� ..lV.� ��t1ut C!f�ac�ceea ,�.�e�i�e�c `�7iee �.(fai�cnu�er� *u�u-80;s��-so J2cr.�'�e�ct s.J�3�t, C'��xrP� Four Cottages: Units—5;Bedrornns—9 � � �-✓�'- Bruce G.Mutphy, , . .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-054 FEE: $150.00 In accordance with�ations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby granted to: John J_ Hynes�.Jr�Pres., 512 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Irish Village Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 3l, 2008 BOARD OF HEALTH: ��t SRtaf�, rJZ..N., C'f�ai�rtttan SEAruv�: 278 ��,`�.�t�� `vtCe��uut ;��c�'t . Q.tttt , . December 6,2007 � Bruce G.Murp , H,R.S.,CHO Director of He th • ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-041 FEE: $50.00 This is to Certify that John J. Hynes, Jr., Pres. dlb/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMI�ZON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 20Q8 unless ; sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the hcensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .��t Sf�a�i, J�..N�., C,f1�aUunart SEAruvG: 278 �J� ��ff�G(,� `UICe C'�acvc�fta�t :C.exr� . c��, .�2..n�. December 6.2007 Bruce G.Murphy, ,RS.,CHO Director of Health THE COMIIZONWEALTH OF MASSACHUSETTS TflWN OF 3�ARMOUTH $OARD OF HEALTH PERMIT NLTMBER: #08-030 FEE: $75.00 This is to Certify that John J Hynes Jr Pres dlbla Cape Cod Irish Villa�e 512 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERNIIT To Operate a�ublic, Semi-PubGc Swimming or Wading Pool At Cape Cod Irish Villa�e - INDOOR POOL 512 Route 28 West Yarmout , MA ____ This permit is granted in conformity with Article VI of the Sanitary Code of Tlie Commonwealth of Massaehusetts,and expires December 3 i,2008 unless sooner suspended or revoked. December 6,2007 BOARD OF HEALIT-I: ��¢�¢tt S�� ..lV.� ��l�itttt�t C'�icvc�eo .� 3'�if�eac `Uice C'Pcacycnuun - �JZ�iF,e�ct s.J�.�ca.cua,C'�eack Qnn ,�2.,Ar. Director of H lth� � � � � • ` THE COMMQNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NI7MBER: #08-011 FEE: $75.00 This is to Cenify that John J H�nes,7r, Pres d!b/a Cape Cod Irish Village 512 Route 28 West Yarmouth; MA HAS BEEN GRANTED A LICENSE T� ENGAGE IN THE BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS This License is issued in conformiry with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of ihe Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms acid condirions,and to the rules and regularions in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner revoked. December 6 2007 BOARD OF HEALTH: ��¢�fL S�� ..iv.��uiltt C'f�acac�eo .�.9�i:P�i�r.eac `1Jice C�wunurn . ��.��,� : , Bruce G.Murphy,MP , . .,CHO Director of Health . ' � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH j PERMIT NUMBER: #08-031 FEE: $75.00 �rhis is to cenify that John J Hynes Jr Pres d7bla Cane Cod Irish Villa�e ' S12 Route 28 West Yarmouth,MA f IS I�EREBY GRANTED A PERNIIT To Operate�Public, Semi-Public Swimming or Wading Pool At Cape Cod Irish Villa�e - OUTDOOR POOL 512 Route 28 West Yarmout , MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2008 unless sooner suspended or revoked. December 6,2007 BOARD OF HEALTH: ��R.tt 5�� ..iV., ��ZQIrt ('.�c�vc�ea .� `.IGeP�i.Rr.e�c `Uice ('f�aci�ittut fi,a�eacE�.J�3.�cocan, C'� . Q�n , J�,..Ar. Bruce .Murp y, , •, Director of Health � , � i ,,.a� �. C,�i��1365 �7��' C.C, l�2rSH V c.c1lGE ; �°f P R�o TOWN OF YARMOUTH BOARD O��.,1,� b'?7b�' ' o "�� APPLICATION FOR LICENSE/PERMIT-2tl07 . �� c _;��.�;i��. ; �:; ,�i , . __ * Please complete form and attach all necessary documents by December;31,��6� � 2006 � Failure to do so will result in the return of your application packe�. I NAME OF ESTABLISHMENT:�ao�Co� .�rE`��. i/l�j�y P TEL. #i_d8 7 71-0/a 0 ! LOCATIONADDRESS: �S/al /1��n �^�. �Q-F,z� l�J�sf �oc /^�wwµ�• �1� Q.2(s7.? MAILING ADDRESS: � OWNER NAME: .��'L 1�- Ul �i�z a [ �.,� Tt�X i�fFEIN or SSNI CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �I6�ti �,�c es TEL. # MAILINGADDRESS: �l�t �(os. �t �F �K GJ. ��,an�C GG� �•z6�3 POOL CERTIFICATIONS: The pool supervisor must be ceriified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a capy of the certification to this form. 1- '��/�S A.�/%5 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 capies of employee certifications to this form. The Heatth Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. 1. � c� ti�s 2. h� Qavi 3. �i, EK�i 4. �G,^y 6na�c , k �_ FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food I 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 Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your est�blishmen� ; 1. �.a6SC�/e G f' ��r r/��.a 2. PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �.__�tte l� d��r�a�� 2. HEIMLICH CERT'IFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1.- �1G��ts/r.� 2. % qui` 3. Cor��; � c�e�l� 4. �r; �z,c a� RESTAURANT SEATING: TOTAL# � , O�FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIf2�D FEE PERMIT# B&B S50 CA$IN $50 r MOTEL $50 �7—CJ0.6 _INN $50 CAMP $50 Z SWIlVIMING POOL$75ea. ��O?-Q!/3 ' _LODGE $50 _TRAII,ER PARK $100 I WHIIZLPOOL $75ea. �Q�—pd 3 --_ _ FOOD SERVICE: _ _ - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTT# _0-100 SEATS $75 _CONTIlVEIVTAL $30 NON-PROFIT $25 �>ioo s�Ts �iso �� / COMMON VIC. $50 �Q-�-p ib _v�o�s� a�s RETAII,SERVICE: —RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIItED FEE PERMPT# ; T<50 sq.ft. $45 _>25,000 sq.ft. �200 VENDING-FOOD $20 _45,000 sq.ft. $'75 _,.FROZEN DESSERT S35 TOBACGO $50 E NAME CHANGE: $10 AMOUNT DUE _ $ �7 5,0 0 I •••*•PLEASE TURN OVEB AND COMPLETE OTHER SmE OF FORM*•""• � , q 4 ` . �i � � k ADMINISTRATION � � � Under Chapter 152, Section 25C, Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal ; of any license or pertnit to operate a husiness if a person or company does not have a Certificate of Worker's Compensation Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUS�'BE COMPLETED AND SIGNED, OR ` CERT. OF INSURANCE ATTACHED � ; OR � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taares and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO _____---_ - ___- - - _ _ _ _ _ � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSYENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transierrt occupants must ha.ve and be able to dernonstrate that they maintain a principal place af residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not rnore than thirty (30) days, and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amendeci, sha11 generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected � by the Health Dega.rtment prior to opening. Contact the Health Department to schedule the inspection five(5�days G pnor to opening. ; 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 xnust be drained or cavered within seven(7)days af e�osing __ _ _ _ _ - _ a FOOD SERVICE 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 obtamed at the Health Department. FROZEN DESSERTS: � Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. , OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. � OT7TDQOR COOKING: ; Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited. E E i - - _ __ ---_ -_ __ ._ � NOTICE:Pertnits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETtTRN TI�COMPLETED APPLICATION(S)ANI}REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , � DATE: �—��—D f� SIGNATURE: i � PRINT NAME&TITLE: �..�1�� t`�y,++��- P� �i I 10/17/06 � I � i _ - _ -" ( ! � \ •.�,.� A—�-aTM C�RTI�ICAT� U� LIABILiYY INSURAN �� ,� CE i�i�� oos HART tNSURANCE AGENCY, INC. ONL C�ONF RS�Nq RIC��H g�U pwR�� 243 MAlN STREET H4LDER 7HIS C&RTiFICATE DOES NpT AMENb, FFXl'ENQ OR p0 BOX 7'00 u.t� THE co RAGL AF1=< ED 81f 7H POI.ICI�& �ELOW. BUZZARDS BAY, MA 02532-0700 µ��o INSUREt4,S AFPORDiNa COVERAC�E �� Irish Vilfage Rest-aurant and I�ub.Inc. , uReR,,: q�� N SiZ West Main Straet � �N� 98 Z We�t YaRnouth.MA 02673 �r►su�R� INSI1RHp G ir�surteh o: COVERAGES �N �R E: rHE POuciES 0�INSUR�wcE us7eo BELOw HAVE eEHN ISsuEG 70 n��INSUREp huMED A�ovE FOR THE POUCY PEsbA INDIc!►TED,NQ7W17F18TANDING ANY REQUIRFAAENT,TERNI OR CONDmpN OF ANY CONTRAC7 OR 07NER DOCUMENT wrrH R�Sp��T Yp yyy�H TM�C�nF�Car�p�Y e�iSSuEp pR MAY PERTAIN,THE INSURANCB AFFORDED eY 7HE POLICIES DESCRI6ED HEREIN 1S SUBJECY Tp ALL TH�TEWw6,EXGLUSICN$RNp C�NnIT1pNS OF SUCH Pdl.1CIE3.nGGREGATE CIMIYs&HOVVN MAY IiAve BEEN aEouCEn aY Pala CLAlI1Ns. �� POLICY NYNBEJt P4L1{.'Y PR�A7101f �t�RAL Lln9�Ty LIMlTS EnCH pCCURR6NCE i CAMMERqqL GEMEF=q{,LIABIIn'`/ CWM6MADB �CICCUN �� ' � _ MED,EXp qt� � _ �� PffR BADVINJURY = OEN'�,q([�REC�I�TE WMIT A LIE8 PEiC �►�RAL Al3GR�Gp7E i �4 a POIICY P�' �� PR UCTS.C4MplOP/1GG � AUTo�rOBq.ENABa,►Tp ,_ . , . JINYAUI'0 ��M��INGl.E tJNIT S ALI.owNQOAUTos SCFEDUREO AU70$ 80011LY INdURY i (P�r panen� HIREDAUY06 . NON�pVyp@D AUTQ$ �� S � ��MAfE ; WpAOE unel{.ITy AUTOCNLV-EAACCID@Nr .i ANY AI,I70 ,.. bni@R ThIAM �A ACC, t AUTo ONLY; A06 3 ExCE$SA��16RE11A Lu�Y EACH C RRENCE y oC�UR �CLA�M9 MAD� � � i ' DEDUCt'18LE _ �1'EM10N j `:S . A �ns�uwa°YPEN�`it'non�wo UVMZ80Q4199072005 t}4101108 E14/01/07 w�csr� u. o H. � � ANY PROPRIQ'Yp(�p�TMEWEi�CIJTIVE ,E.L EACM ACClCJEM ; Q- OFFICERMqy@ER EXCL►Ipppp if Y6e,dawbY UMr E.L DI $E-EA�AAPLOYEE i ...:. eJ 0� SPEiMuL PROVI$IW�$ mfi6R . S.Lq E::POURYli1MR i � OO, DESCRIPYION OF OPFAATIONO f LOG110t15 J VENICLE6!BXCI-USI6Ni ADOm 6Y�NDOR3BYENT fl�ECJAL PR011L71GMf Motei CEIirIFiCATE HOI.pER -_ CJ1Nc noN iHOUIb MNY OR TX!AYOYE DEiGR1�FA WLIWli BE CANClV,�g�ORE 7NE EXPIFU1170N TOWN OF YAf�MQUTH ��r�e++��n��suu�o mww�R wul.�+n�wae ro Ma�. 30 DAYS WRITiEN 1146 RT 2$ �T��t��cn�No�wwEn ro ine�r,�aei Far-u��ro oo so s�+Au, S YARMt]UTH, M/4►Q2�Q4 M�N��LIWYIQN OR WBILJiY OP�qy K�ryp UPON 7ilE N$(�p�,�7�$/u�NTS OR TATN�, �uTMoa4l��xEserr'r�yii ACOiiD x5(20011a8) // ' �ACORG C�R��ATION 1988 ! I � , , THE COMMONWEALTH OF MASSACHUSET'I'S TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #0'7-QQ6 FEE: $50.00 {� This is to CerWy that Irish V'illage Haldings d/bla Cape Cod Irish Villa�e 512 Route 2$West YarmoutH, MA HAS BEEN GRANTED A LICENSE TO OPERATE M�TELS This License is issued in conformity with the authority granted to ihe Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the pmvisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and expires D�cember 31,2007 unless sooner suspendecl or revoked. Januar,y 19.2007 BOARU OF HEALTH: B t�tt$. o�oit,/��5., ' ��s�, k��!, v�e�� Rad�t�. B� � p��N��,ft r�l�Cj�e.idr.s�,�, R./Y. �� . Bruce G. Mwphy, S.,CHO Director of Hea1th TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-025 FEE: 150.00 In accordance with regulations promulgated tmder authority of Chapter 94,Section 305A and Ghapter 111,Secfion 5 of the�'ieneral Laws,a permit is hereby ganted to: Irish Villag�Holdings, 512 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Irish�illa�e Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires:_December 31, 2007 BOARD oF HEAI,TH: L3 `�. ,/j��,, • SEaT1xG: 278 o�ee�,��t�>'�i�i, �ic�e��t�swt . R�t 4 B� Gl� 1�u��l�.r�ott �J.t.z� , R.N. Janua�19.2007 Bruce G.Murphy, H,RS.,CHO Director of Health i � y THE COMMQNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-016 FEE: $SQ.00 � This is to Certify that Irish Village Holdings d1b/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respeeting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunta affixed their official signatures. BOARD OF HEALTH: 8e ��i�/s$�. (�'and,ois, /`l._`7�., ' SEATING: 27$ e�re� d/l�f�� IlJV., vice elt�i�s�r�c Ra�t� B�, �k � A��l��tt �t.�y' , R.N. January 19.2007 / `� Bruce G. urphy, H,RS.,CHO Director of Health _ __ , _ THE COMIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-011 FEE: $75.00 This is to cenify that Irish V'illag;e Holding;s dlbla Cape Cod Irish V'illa�e 512 Route 28, West Yarmouth,MA IS HEREBY GI7tANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Cod Irish Villa�e -INDOOR POOL 512 Route 28 West Yarmouth,MA This permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachnsetts,and e�ires December 31_2007 unless sooner suspended or revoked. _January 19_2007 BOARD OF HEALTH: B ��5. �ondo�,il�l.�., • d��Slr�li, ./V., ?Ju�G'l�vta�.i Rod�t� Bnou��, G'le�r�(a A��ok�Yl��t �t�� , R./V. � B�u� . Director of Healtyh� ., � ' � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-012 FEE: $75.00 � This is to Certify that_ Irish Villa�e Holding;s d/bla Cape Cod Irish Village 512 Route 28�West Yarmouth. MA IS HEREBY GRANTED A PERMI'I' To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Cod Irish Villa�e - OUTDOOR POOL 512 Route 28 West Yarmouth, MA This permit isgranted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and ' eapires December 31_2007 unless sooner suspended or revoked. January 19_2007 BOARD OF HEALTH: B yc�� t�s�. f}a�,/�.�1., ' o��leic S�i,IzJV., ?/sce�ir�i�uiu�ss Rod�t� B� Gl� !�c#�s�d�lo��o#�` �t�(�' , R.N. ,,,. Bruce G.M y, ., Dir�tor of Health . _ . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-003 FEE: $75.00 This is to ce�tify tt�at Irish V'illage Holdings d/b/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO EN�AGE IN TI�BUSINESS OR PRACTICE OF -GNING OF YAPOR BATHS Ttus License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections S 1,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the niles and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and exgires December 3 i,2007 unless sooner revoked. 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SES�AIs�1'7�V CF OPERATd7id$J lpCAT10N9!VEMIGLL�S!E%CWSIDNS A6D�D 6Y ENDORiEY�qT f bPEGAL PRpMIS1pNB _ _.. c:.�, `�� ._. . -_ 1 ��nF,�ca�Ho�e�a c�wce noN t SMQ114.0 AHY OF 71iE NBOYE DESGRIP�D POLICIE'�P!OANCELlED BEP°ORE TMS�1C?IRAYtOI�I �TC�Y�tI��YARMCIUTI"� ��THEREOF.7HE 166YW�IN�@R W�J.ENPJI:ItYOR TO tlA1L 30 �AYS !NRlTtEt! `�,��.+�.��$ NOTICL=TO TUE CFA'nFICATE NOI.f�R NNAED TO 1'HR{.ERT.QU7 FARVRE Td W 80 5N3d:. 1 ;$Y�RMOU7H, M�6►02�44 �x�ao oeu�r►noN on u�earrv o�rwr�ro uaow n+�wsu�t,ms�wn;ar� RE9ENTN71vpb. . � A{ITNOR{YEC REPfiESBN7A t i ' S J��x .i`c�39�`o�3G I, A�O�25(��1/U8} 8 ACORD CORPO�tTl�i�198FI Zg ��yd l�9G 3�NdafiSNI l�IdH 99EL65L805 90�5t 500Z/80/T.t THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOiTTH BOARD OF HEALTH PERMIT NUMBER: #06-006 FEE: $50.00 This is to c�tify that 7ohn J Hynes d/b/a Cape Cod Irish Village 512 Route 28 West Yannouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in confomury with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the pmvisions of the Laws of the Commonwealth of Massachusetts relafiing thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adapted by the Board of Health,and expires December 31,2006 unless sooner suspended or revoked. December 5.2005 BOARD OF HEALTH: Be�tf��ist�. �j�,/��• � /��/1�1�?S` �rctt, ?liae G��s�v'uxwwz �s�R� � ,Q�C�'��, R./V. Bruce G.Murp H,RS.,CHO Director of H th TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT, PERMIT NUMBER: #Ob-032 FEE: 150.00 In accordance with regulahons pmmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a penrut is hereby granted to: John J Hynes, 512 Route 28, West Yarmouth,MA _ Whose place of business is: Cape Cod Irish V'illage Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 200b BOARD OF HEALTH: Be��ns�ss -`?1• ��e��s SEA'r�xG: 278 p�sc�1�c�e�t� Rad�t�. B�«�, G�le�a e�� , R./V. �/��' , R December 5.2005 ,RS.,CHO ruce G. urphy Director of Heal II . � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARM�UTH PERMIT NUMBER: #06-027 FEE: $50.00 This is to Certify that John J. Hynes dlb/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General I,aws, Cha.pter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Besr��,r�c�S. 4'did,wc,/�.`h,.� � . SEA'rnvcr. 278 /��ck J1�lC`��, ?/u�e C:�u'�rrtytc,�st RoG�t�Bn«�, G'l�ila � �k, R.N. �4��j�-�, R.N. December 5 2005 ruce G.Murphy, .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NCTMBER: #06-011 FEE: $75.00 This is to Certify that 7obn J Hynes dlbla Cape Cod Irish Villa�e - 512 Route 28 West Yarmouth�MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming ar Wading Pool At Cape Cod Irish Villa�e -INDOO&.POOL 512 Route 28 West Yarmout MA This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachuseits,and expires December 31.2006 unless sooner suspended or revoked. December 5_2005 BOARD OF HEALTH: Beitfr�tist�S. �'Jo+�or�,/�$• ��, v�e�� R�t�. e� e�,� , � �!� R.N. �4��j , R.IV. � ruce . urPhY, �R -� Director of Health { , � � I THE COMMONWEALTH OF MASSACHUSETTS ; TOWN QF YARMOUTH i BOARD OF HEALTH PERMIT NUMBER: #06�Q12 FEE: $75.00 This is to cerri�y that John J Hynes dJb/a Cape Cod Irish Village 512 Route 28 West Yarmouth„MA '' IS HEREBY GRANT'ED A PERMIT � To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Cod Irish Villa�e - OLTTDOOR POOL 512 Route 28 West Yarmouth, MA IThis permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires Deceinber 31.2006 unless sooner suspended or revoked. D�,�s,Zoos so�oF�ai.Tx: BB��`?�. �o�di+�,�l�l.`n. ' ��, v�e�� a�t�.a�, er� � � �1�, R.N. �4��j , R./V ruce G. urphY, , -, Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-005 FEE: $75.00 'rhis is to certify that John J Hynes d/b/a Ca�e Cod Irish Village 512 Route 28 West Yarmouth, N1A HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,az�d to the rules and regulations in regazd to the cartying on of the occupation so licensed as adopted by the Board of Health,and expires Dec;ember 31,2006 unless sooner revoked. Decetnber 5_2005 BOARD OF HEALTH: B �. ��i ��v � p t�il��s�tt, v�e�.v�.z Rod�`� Bnou�, C� �s�, R.n�. �v�r��, a.� ruce G. urphy, , S.,CHO Director of Heal � - �.� �1 �� 'YAe �� C.C. /2tSH ViukCst� 3� ,:: _�c TOWN OF YARMOUTH BOARD OF�EAL'�`H�r �,� o._. ;y APPLICATION FOR LICENS��I'E =��05 `` `••.. ...;s � , G� � �'G-, c `�, `� * Please complete form and attach a11 necessary do� M�� '7`' ts by Decem er��0�44 2004 Failure to do so will result in the retum Qf y ur application pa et. . ; . NAME OF ESTABLISHMENT: d ' ! 6 7 ; o� LOCATION ADDRESS: S� GJ� -I- a,• oK MAILING ADDRESS: S�-.e OWNER/CORPORATION NAME: MANAGER'S NAME: J ol�� l-k-�H�S TEL. # __ MAII,nvG AnDRESS: .S/2 /"la.ti S'�- GJ c�t �/.,.w.�w� /�r� aa G 73 POOL CERTIFICATIONS: �The pool supervisor must be certified as a Pool Operator,as required 6y State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. �4W/t iC S�Gc!�l.r.r� � 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 file at your ptace of business. i. �,-t a. P�.� �k,;��-� 3. �.r !- G 4. JatlL l�c,�,�_C 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 o£certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a fde at your establisbment. 1. I�aoSeve �, ve C�rvc� ��.p 2. FERSCQAi Ilv e�i�G�: - - _ _ __ __ _ __ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �. I�oo 5 c ve �� De Ca:�va l�0 2. J�6C. ��,es � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list yow 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. v � t � 2. 4 �h�% � 3. � 4. li z L �e RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B $50 CABIN $50 1 MOTEL $50 �8 S��lI _INN $50 � _CAMP $50 a SWIlvtIvIING POOL$75ea. �e� LODGE $50 _TRAII,ER PARK $50 1 WHIRLPOOL $75ea. ,�aS-007 FOOD SERVICE: , LICENSE REQUIRED FEE PERMTP# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERIWIIT# 0-100 SEATS $75 CONTINENTAI, $30 NON-PROFIT $25 �>100 SEATS $1S0 �€0 S�3( �COMMON VICT. $50 �62� _WHOLESAI,E $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I.TCENSE REQiJIRF,D FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT $35 � ` NAME CHANGE: $10 AMOIJNT DUE _ ��- '*""'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•••• �Z�-✓6� � � E a ADMIlVISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hpld issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE t AFFIDAViT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED ! f 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 31. IT IS YOUR RESPONSIBILITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPAR'TMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.},MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMl��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � ADDITIONAL REGULATIONS i I POOLS POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. � i POOL WAT'ER 1'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ; closing. k i I V FOOD SERVICE � I CONSUMER ADVISORY: Each food establishment 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 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. _ FRBZEl��S�R`I'�:---- ---_ _ _ _ __ --- -- _ _ __ - _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• � Outside cafes(i.e.,outdot�r seating with waiterJwaitress service),must have prior approval from the Board ofHealth. ' OUTDOOR COOI�NG: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' DATE: �/ I$ 4 � SIGNATURE: i PItINT NAME& TITLE: �o�h '.l. �U`��'S D k�rt �P�r'' 10/22/04 i I i � � � � �� -_� The Comnanwealtb of�liassachusetxs =_-- - - Deparhnent of Industria!Accidents = M�N��IM� __- � 600 Washiagtoa Stree� 7`�'Floor - - r =,,,, Bostoa,Masc. 02111 , wurkera'com�aha�Lsora.ce Afli�vIt: ' z« ..� ,. � ,�� _ kcdrical Co�tractors , -. F.� ,_ _ . ,.._ „; � �, � v� ,�, �. name- address- citv cratr• zip• n�irnc# work site locati�ffnll addressL• ❑ I am a homoowncx performing alI work myself. Project Type: ❑New Ca�ructia��Rennodel I am a sole 'etor and have no a�e w in an ca Buil ' Addition �v�'`I am an e.mployer�ovid'mg w�s'co��fos my employees woiking�this job. �R C'a-�o e ��d �r,_,5�,, U�`C�� /ol /t'I� i dt ��•: �,��.1.�1�f YN�n�.��,-�GL,. /yi4 0.�6 7 � �� 7 7/-0/4 d ss �u�� '� �s rl� � �1h oo ��' o aoo � � ❑ I sui a sole praprietor,ge�at co'tractor,or homeew�er(cirdt ow�)and have hic+ed the contrnctors listed below who have the following worlcas'compensation polices: �: �: s,�s: �� o su�e; �: �ts: �. . � Fai�te�.�am a�a.req.4ed.�der sawa 2SA�1►lG1.152 en kaa a lie hrp.itl�a.tai�t.al poaNks.ta�oe�p a tI,sKM aadhr ose yean'i�eptbo�mmt a�wra as cM pmltles h t6e fars K a 31'O!WORIC ORDER a�d a me�if160.N a day ata6st�e. 1 nderslaad t6at a e�py at Irb�t my 6e t�rwaMe�b Ne 01ltee�l�af fYe DIA Lor ave�rage ve�'IAatly. /do benrby ce�eify und Nie padns swr paudl�ea of pe�ary tAret dYe h�foriaadon provPded ebov�e is dr�re m�d oemrR �� n� l.�/�o � Prim name `I � Phone# �7�� 7 7�"OI Q� affidal ese o,ly ds eot�eerlte i�t�is arn to be e�plded 6Y eftY a'�rwa s�dal cilp ar te�vn: �# ��t ❑ched[if�a�iah rppeme i�req�ed �� a ��n' �#' �� t � f + � + _ - - - r--�---�-__ . __ i CE��Ii'��T■"• �1' ,I��I��L'/ ISSUE DATE(MM/DD/YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TffiS CERTIFTCATE � Hart Insurance Agency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY TI�E PO BOX 7OO POLICIES BELOW. Buzzards Bay, MA 02532 COMPA1vIES AFFORDING COVERAGE INSURED � John J. Hynes coMPnrrY � LETTER A A.I.M. Mutual Insurance Co_ � dba Cape Cod Irish Village _ _ _ . ` 512 Main Street _ _ W. Yarmouth, MA 02673 COVERAGES � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIItEMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CpNDITInNS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � CO � Typg OF INSURANCE POLICY NUMBER �LICY EFFECTIVE POLICY EXPIRATIO LIl1�ffITS L DATE(MM/DD/Yl� DATE(MM/DD/Yl� GENERAL LIABII.ITY , . GENERAL AGGREGATE $ � COMMERCIAL GENERAL LIABILITY - PRODUCI'S-COMP/OP AGG. $ LAIMS MADE�DCCUR PERSONAL&ADV.INJURY S OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ �� . FIRE DAMAGE(Arry one fire) S � - � � �� MED.EXPENSE(A�ry ore person) S . �AUTOMOBII,E.LIABII,ITY � � � � � �� ' � COMBINED SINGLE $ ANY AUTO LIMIT � ALL OWNED AUTOS � . . BODILY INJURY SCHEDULED AUTOS (Per person) a HIRED AUTOS BODILY IN7URY NONAWNED AUTOS (Per accidenq $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABII,ITY EACH OCCURRENCE $ MBRELLA FORM AGGREGATE $ THER THAN UMBRELLA FORM � -- - �:�.�w A � eY .....�THE � OItKEIYSCOMYEN5A7'Y(3NAN�. ._..—..— --__.-------- . . ,: ------� --.._ ... ._._-- -- .. - �--� LIMIT�� - `- ' .�. MPLOYERS'LIABII,ITY EL EACH ACCIDENT S � SOO,OOO � 8004199012004 04/Oi/2004 04/O1/2005 A HE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ ARTNERSBXECUTIVE SOO OOO FFICERS ARE: X EXCL EL DISEASE-EACH EMPLOYEE $ SOO OOO OTHER ESCRIPTfON OF OPERATIONS/LOCATIONS/VEffiCLES/SPECIAL Pl'EMS Fax to 508-398-2231 and mail CER�ICATE HOLDER ` CANCEI.T.ATit)N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWIl Of YaTIllOU�l '' EXPIIiATION DATE THEREOF, THE ISSUING COMPANY WII,L ENDEAVOR TO MAIL 10 DAYS WRITT'EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 1146 rt. 2g ' LEFT,BUT FAII.URE TO MAIL SUCH NOTICE SHALL IIvIPOSE NO OBLIGATION OR _ LIABILITY OF ANY KIND UPON THE COMPANY, Tl'S AGENTS OR REPRESENTATIVES. ' AUTHORIZED REPRESENTATIVE South Yarmouth, Ma 02664 THE COMMQNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-011 FEE: $50.00 Tbis is to certify that John 7. Hynes dlb/a Cape Cod Irish Villa�e 512 Route 28, West Yarmouth,MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adapted by the Board of Health,and e�ires Deceivber 31,2005 unless sooner suspended or revoked. J�,�y�,Zoos Bo�oF�t.�: B�ya.,u��l. �'o�o.�iL1.�. . _ A��, v�e�� aad�t� e�, G� �s'� R.N. r4.z.t f�'��.�d�, R.N. ; Bruce G.Murphy,MP , .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERNIlT TO OPERATE A FOOD ESTABLISffiV�NT PERMIT NLTMBER: #OS-031 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: _ John 7. Hynes, 512 Route 28, West Yarmouth,MA Whose place of business is: Cape Cod Irish Villa�e Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2005 BOARD oF HEALTH: Betic�ari�$, l�'u�c�/��, • SEATING: 278 �� v��.� �S�R� Q � , R.N. J��y�,Zoos - ruce G.Murphy,MP ,R .,CHO Director of Health � . . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH , PERMIT NUMBER: #OS-024 FEE: $50.00 � iThis is to Certify that John J. Hynes d/b/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-first 2005 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensing authoriries by General Laws, Cha.pter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a.ffixed their official signatures. BOARD OF HEALTH: Be,ryw• ,rts�c`h. (�''o�id�t,tyl.`?S. SEA'rn•tG: 278 ` �c�i�/yJ�` e�rr�olt, ?/r�C��avx�iswt R�t�. B� Gl� �f� �, R.N. r4�!�' , R.N. JaIIuvy 7.2005 s Bruce G.Murphy,MPH S O Dir�tQr of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-017 FEE: $75.00 This is to cerafy tt�at Jahn J. Hvnes d/b/a Cape Cod Irish Villa�e 512 Route 28 West Yarmoutl�MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Cod Irish Villa�e - OUTDOOR POOL 512 Route 28 West Yarmouth, MA This permit isgr�ted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachuset�s,and expires_December 31.2005 unless sooner suspended or revoked. J�,�y�_Zoos Boau�oF�.�: B��. �'�de,�,�19.�. • �� v�e�� R�t�a� et� ��, R.N. �4� R,A+. H,R . Director of He�alth� I � O THE COMMONWEALTH OF MASSACHUSETTS j TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUIVIBER: #OS-016 FEE: $75.00 This is to Ce�tify that_ John J Hvnes dlb/a Cape Cod Irish Village 512 Route 28 West Yarmouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-PubGc Swimming or Wading Pool � Cape Cod Irish Villa�e -INDOOR POOL 512 Route 28 West Yazmout MA ! This pemut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31_2005 unless sooner suspended or revoked. January 7.2005 BOARD OF HEALTH: Best�tslt�S. (�o+�oa,/M.�1. ' � pr�ic�a//y�` y� � v�e�• R�t�s� e� �s�, a.�v. � , R�v Director of Health� � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-007 FEE: $75_00 This is to cerafy that _ John J. Hvnes d/b/a Cane Cod Irish V'illage 512 Route 28 West Yarmout MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN TI�BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS This License is issued in confomuty with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the pmvisions of the Laws of the Commonwealth ofMassachusetts relating thereto,and upon such tem�s and conditions,and to the rules and regulations in regard to the canying on of the occupation so licensed as adopted by the Board of Health,and�pires December 31,2005 unless sooner revoked. January 7_2005 BOARD OF HEALTH: B �. (��/��j., . /��/Llc$e�rr�, ?/�ce G��n��sc R�rt�B� � ��'l� R R.N. , Director olf H�eal�tli�MPH, O � " ' ` v'0�� C.c. l2cSM Viu.,4� � *.; , �F;r R.y TOWN OF YARMOUTH B ARD Q ��6�I:T'H � ''� APPLICATION FOR LICENSE -2004 �"�' }� � r�,."�"�"'~�- �� •;'x ,�, � � (� �� •.. ...., � � �, * Please complete form and attach all necess�y docuix�nts by Dece be�� (�3.�� Failure to do so will result in the return o�our application p c�c,e�A t�i N�ME OF ESTABLISHMENT: C�� c� '_�-�- v�`1R.�� G TEL. # ��& �� LOCATION ADDRESS: 5�2 M��,u S�+-- � •��-�J� r`'�t9-o�-� �3 '' �ILING ADDRESS: �WNER/CORPORATION NAME: ��- �.`u�-g� ,�.(� c�.,�..a�,,- MA�TAGER'S NAME: �� S TEL. # M 4�LING ADDRESS: 5�-�G POOL CERTIFI�ATIONS: The pool supervisor m�est be certified as a Pool Operator,as required by State law. Please list the designated ' �o� pera or s an�ffacti a cop�of the certif ca�iori to this form. l. ��w� S �i..,r-�-��v"J��-� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid ' and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Heatth Department witl not use past years' records. You must ; provide new copies and maintain a file at your place of business. 1. �� 1 2. ��2►�. ' 3. ��' ^��p-- 4. t FOOD PROTECT�ON MANAGERS - C�RTIFICATIONS: 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' reeords. '� You must provide new copies and maintain a file at your establishment. I 1. ,�o u,s�irt,v�lil v"� .�- Q2 v� G-�-Ga 2. ��cil,z.c�/ G�,:�,�- I _ ___ _ - -_ _ _ -_ __ ----- _- _ _ __ ___ i - _ PERSON IN CHARGE: _ _ _ Each food establishment must have at least one Person In Charge (P1C)on site during hours of operation. '' �. �v�1 y,� ,�'d �. ��--�s H�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-chokmg proeedures 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'i �e� c� 2. �� n� ��' 3. —�_ 4. , F TA �LANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L(CENSE REQU(RED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# B&B �50 CABIN S50 'MOTEL $�0 O �Ot INN $50 CAMP $50 2-SWIMMING POOL$75ea.�Y�� ' — — — � LODGE $50 TRAILER PARK $50 �WHIRLPOOL S75ea.� ' FOOD SERYICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEB PERMIT# LICENSE REQUIRED FEE PERMIT# ; 0-100 SEATS $75 _CONTINENTAL S30 NON-PROFIT S25 : I >100 SEATS $150 �6�(-O`�4 �COMMON V(GT. S50 �-0�'�3� _WHOLESALE $?S RETAIL SERVICE• LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEG PERMIT# LICGNSE REQIJIRED FEE PERMIT# _; <50 sq.ft. $45 _>25.000 sq.ft. $200 _VENDING-FOOD �20 _<25,000 sq.ft. S75 _FROZEN DESSGR'f �35 �TOBACCO S25 NAMECHANGE: a�o AMOUNT DUE = S 500.0� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � _ 1 _ � . �y -� I� 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 erson or com an does not have a Certificat ' P p y e of Worker s Com ensation Insur � p ance. THE ATTACHED STATE WORKER S COMPENSATI ON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � I � �'� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO ' NOTICE:Permits run annually from January 1 to December 31. IT IS Y�UR RESPONSIBILITY TO RETURN I THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. �, SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 I DAYS PRIOR TO OPENING FOR THE SEASON. II ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW 'I EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; ; ( ADDITIONAL�(*ULATIONS � ; POOLS ; POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing. FOOD SERVICE ' CONSU F.R VI ORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consutner Advisories. CATERNG PO,�It CY� 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 prior to the catered event. Thses forms can be ' obtained at the Health Department. � i FRtI�TN��Ce�u�e._ ._ j -- - - — - ---- - - -- � 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 C FF;S• i Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTDOOR COOKI� } Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � i � DATE:�,uY �' _SIGNATURE: �. PRINT NAME&TITLE: D �� • � �j �`�-e-�. i 10/22/03 � � i ��. OATE(YNfDdYYYI� AG4RD.� �Ei�TIFICATE �F LIAB�LITY INSURANCE 11/25/2003 PiaoouCFae THIS CERTIFICATE IS f3SUED A,:i A MATTER OF IN�Ot7NU1710N HART INSURANCE AGENCY, ING. �NLY aNa CONF�R$ Na R�c�,�Ts UPON Trf� c�rtr�FicA� 240 MAW STREET AL�R TFIE COV�RAG��T��RbED BY THE POLiCIE.X�8�B�1.QW PC1 �OX 700 BU7�ARDS BAY, MA U2532,07Q4 INSURERS AFFaRDING CQVERI�GIE _ � NU11C# �"�'�D Irish Village Rest�urant snd Pub,Inc:Restaur�nt INSURER A; AIM iN w4taCE COMPP,NY 18929 512 West Main Stnet iNsu�R e: _ west Yarmoud�,nna o2s�3 ��su�R G _ INSURER a IN6URER E: ' cav�►�es - THE POLICI�S OF INSURANCE LIS7ED BELOW HAVE BEEN ISSU�D TO THE INSURED NAMED ABOVE FOR 7HE POLICY PEI2IOD INDICATED.NaTwIYM37ANDING ANY I#�QUIREMENT,7EIZM OR CONDfflOt+1 OF ANY CON7'RACT OR OTHER D4CUMENT 1MTH RESPECT TO YIMICM TF11S CERYIFICATE flA�Y BE 1SSLJED OR Mqy p�(tfA1N,THE INSURANCE�►FFORDE�BY TNE POLICIE$DESCRIBED WEREIH IS SUBJECT TO ALL THE TERMS,E7(CLUSIONS AWD CGNPPI7�NS OF SUCH VOLICI�S.AGGR�C.+ATE LIMI75 SMOWN MAY HAVE BEEN R�DUCEO SY PAID CLAIMS. _ W� PQG.IGY NIli18ER p0��ECSIVE POLICY ExPIRA y U� GENERALYA81L11'Y EACH��7�C�CU�� S COMMERCUILGENERALLLABILITY `�i' O0°1O^CO 8 CWM6 MAOE �OCCIIR M86 E)�' aw �rsan' S __ , PER60Nn�.aA6VINJURY S f3ENERALAGGREGA76 S GEKLAGORE6ATEUMRAPPLIESPER, PROQlCT5-COMPR7PAGG S P011CY P� �� — p�7tp��uqplGlTY COMBUVIcD SINGLE LIMIT s ANY AUTO (Ea aceldontl ALLOWNED/VUTO6 90DIL1'INJl1RY � (PBf�'fB.V'JII) � . SCHEDUIED AUYOS — NIREDAl1T0$ BOD1L1'INJURY s (Pe1'eo�lelYl) NpN•QWNE�AUY06 — PROPE�Frr D�4a�arE y (fwrwale�? �JIRAOEWBIYTY AIJ�O��i�ILY-EAACC�DENT = ANY AUTO OTHEF'.'HAN �'� s AU70qIJ�Y: p�G S ��TM � 6ACIi q�;CURRENCE t bCCUR �CIAIMSMAL�E AG�Ee(iATE S S DEouCriBLE �-- _ R�ENnON 5 s A y�pRKEp,qC,QpIpENSATidNAND 1NMZ80b38900120�3 04l01/03 04/01l04 ��=grnru- ot►+- E�a►�rts'�we�urr E.L,��t++ncc��n+T 5 _r 5�O OOO nNv PkOPRIETORIPartTNER/ExECUTIVE OCF10ERfMEM9EN�X�lLLfG2�4 E.L DI51:ASE-EA F.�IQLOYEE 5 SOO OOQ Uyf�e Qeaalbeunder ELO15iEASE-P9lI�YLJMiT S 5�� SPECIAL PROVI810N$MYow OTFIER pESGRIpTIOW OF OPEpAYI�I LOCA710N5 f VEHIdFS J F10CLU9fON5 A0�0 BY EAIDOR9EMENT/Sl°EGN1L p�11�S10NS W CERI7FICA7�HOLDER CANCELLATION _ SHOULO ANY QF TXE ABOVE OE5Cq19�D P461G�S BE CAHCELLED 8��4RE THB FXP�R�noM DATE YNEIiL4F,7ME ISSLW6 INS!lRER YYILL EP1DEpY0R TO MAIL � DA75 WR�'« T4WN O�YARMOUTM uoncE ra n��ec�nPicnre Noinr�re na�e,c ro tr�e�r,sur Faw��o 0o so se�►u. 71 A6 RT 28 �NppgE Np paWGpriON OR L1A�WTr oF IuiY uiNo LIvON'fHE INSURER,ITs AOENTS OR S YARMOUTH, MA 02844508-398�0836 REPRESENTATIVES. p RPSENT 's ACORD 75(2009f08) �ACORD CORPORATION11988 Z9 39dd 1�9ti 3�NtJaf1SNI 12lGH 99El65L895 9b�5Z E98Z/9Z/ZT , � ��R�� CERTI�ICATE OF LIABILITY �I�SU�ANCE � °"�,"""'°'Y"�' 7112�/2003 • p�� 7HI5 CERTI�ICAIE IS ISSUED%5 A MA't'T�R OF INFORMATIONf MART INSURANCE AGEtdCY, fNC- ONLY AND CONFERS NO RI:GHYS UPON THE CER11FlCATE 240 MAIN STREET HOLD�R. THIS CER7IFICAT� DQES NOT ANIEND, ExTEND oR ALl'�Kt 7H� COVERAGE AFFO1iD�b �Y THE POL.ICI�S SELOW. PO B�X 70D BUZZARDS BAY, MA 02532-07n0 IliSURERS AFFORDING GOVERAta� NAIC i� INSURED �ri3h Village Restaurant and Pub,Inc:Mate! INSURERA7 AlM(NSURANCE COMI?ANY 98929 512 West Main Str+eet , �NsuRERa WPrSt Y�1f1T101F�1,MA 02673 IMSURER C: • • INSURER D: -Y`� INSURER E: 4 �. CO �� Y � 7HE POLtCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED'Ib THE INSUItED NAM�D ABOH�FOR THE POUCY PI_lilpD INQICA'1'E0,N07W17MSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE$PECT 70 WHICFi TYiIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE�FORDED BY THE PORIC��S DESCRIBEQ NEREIM 13 SU6J�CT TO ALL TNE TERMS,ExcwSipNS aND CONDIIIGMS OF SUCM ' POLICI�S.AGGitEGA7E LIMI'f3 SHOWN MPIY HAVE�EEN REDUC�D 8Y PAID CLAIMS. MISR L PQIJCY NUIN�HR AQ41CY Fi+ E PGIJC �ICPIRA710N LIYIIT$ GENERAL iJAWLfiY EAChI C�CCURRENCE � COMMEIiCULLGENEFIAI.LIAdILn'Y PREM�FS Eeomaenae S CWAASMADE �OCCUR MEOE�P pntr rap� # _ PER&�W4L X AGV INJURY S G�1VEkqLqppqEpqTE 5 GFJJLAGGREGATELI1AtTAPPIJE3PER: PROOUC7S-I�IPpPn� S POLtCY P � LOC AUTOYDBILE W4&LrtY COMEIt1E081NGLE IIMR ANYALfYO (Eaaoqyent) S ��A�T� eoa�v inuuar SCN�OULEDALI708 (parpuwr� S HIRED AUrOS BODILY INJIIRY NON-0WNEDAUTO6 (Peraxmenq $ �oPs:rY ouuu+�e � (Prr wxldunt) OAFL4GE W191LJ'TY AUTO C NLY�FA ACCld�ptT S ANYAU7'Q OTHE�TFVW ��C $ nuro cr��r� AGG s aYrEgBruMertEttA W1BIurr �CH CCCURRENCE S OCCUR �CWw13NA0E AGGREa4TE 8 _ 5 DEOl1CTI8LE _�^�,�,�,,,., S RE7ENIlON S � A �yp�J�$CQYPENSA'IIONANU yV1Nz8Qp4199012003 03l31/03 Q4J01/04 ��CS7ATU- OTM. EMVLOYERS'LIABILT' ANYPROPRIE�D��raK�vFxECUYIVfl EL.E��I:MAC�IOENT S SQ��OO OFFlCEWME#�19Ep EXCLUDB64 EL.D SFA4E•EA EMPLOVEE S SOO OOO s�� Rp��,�pe� E.L.D SEASE.aoucv uMrr s 500 000 ornFx ORS��dN DF CPERA710N5 f I.00ATIONS!VEHIGI,E$J EXCWSIONS ADDED HY F?IOORSENENTJ 9PECIAL PROY1610N6 CERT�FICATE HOLD�R CANCELUI'170N � SNOULD ANY OF TXE ABOVE OESCRIBED POLl�dEB BE GNCELLED BFFORE iNE OLPIRA710N T4WN OF YARMOUTH �TE TXERDOF,iHE tSSUIN6 INSURER WIL6 ENflEAVOR TO MAIL �O__._pAYS WWTIEN 7146 RT 28 ��T�T�E CER71FiCATE MOLGEIt NAlAE:C TO TXE LEFT,Bt1T FAIWRE TO DO SO SNALL S YARMQUTM, MA 0284�F508-398-083fi ��e NO 091.IGMTqN QR W�9MJ1Y 4P IUIY KIND UPON Tl1�IN$URFJ�ITS AGENTS OR �PR4$p-�'►TAfNF$ AU�X9�,Oj�PRE�TN L fi' / ��i �. ACORD 26(2004J06) �1 ACORD GORPQRATION 9988 E9 3�Jdd 1,Jt1 3�Nd�f1SNI l�IbH 99EL65L869 9b�9Z E00Z/5Z/ZT THE COMMONWEALTH OF MAS5ACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-012 FEE: $50.00 This is to certify that Irish Villa�e Holdin�s dlbia Cape Cod Irish Villa�e 512 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A;32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adoptad by the Board of Health,and expires December 31,2004 unless sooner suspended or revoked. December 2_2003 BOARD OF HEALT'H: B�t�st�u�tt�. ��t,/��. ' �M��, v� e�.� �� _ � � ruce G.Murp ,MP , .,CHO Director of Health � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-040 FEE: 150.00 In accordance with regulabons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Irish Village Holdings, 512 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Irish Village Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2004 BOARD oF�.�,TH: B�y�ir��S. (�onda�,M.`h. ' SEATING: 278 ��n/�v_'�e�� Q�� .� �� December 2.2003 � �' , �`y` Bruce G.Murp " H,RS.,CHO Director of He T'HE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-030 FEE: 50.00 This is to Certify that Irish Village Holdin�s d/b/a Cape Cod Irish Village 512 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town af Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Bn�_�,-'in:7t. �tdau�,J/��$. ' 3EATING: 278 I��i �/�'��'n R�t�. B� Gl� � � � R.N. � , ..�..t �- - . � Deceinber 2_2003 `_`�4_ f' .�. Bn�e G. Mwrphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-009 FEE: $25.00 This is to Certify that Irish Villa�e Hol ' s d/b/a Ca,�e Cod Irish V'llage 512 Route 28 West Yarmouth. MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBITTION OF TOBACCO PRODUCTS AS PER TI��ARMOUTH BOARD OF HEALTH TOBACCO REGULATION. �s�t is ant�in2�'arm�'��A�cls��f�.l��T o�Code of The Commonwealth of Massachusetts,and n��2.aoo3 soaxD oF��,�rx: B `n. � M.�., ' /��eic�Mc�b�, ?/u�G�r�raau Rodwit�. B�«w�, � � Sl�., R.N. , � ; ��.-�r�, �+.� � Duector of H al� � i i i . . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-022 FEE: $75_00 This is to cerrify t1�c Irish V'illa�e Holdin��s d/b/a Cape Cod Irish Villag�e 512 Route 28, West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Ca e Cod Irish V'ill e -INDOOR POOL 51 Route 28 West Yarniout MA This permit isgranted in conformity with Article VI of the Sanitary Ca1e of The Carnmonwealth of Massachusetts,and e�cpires December 31.2004 unless sooner suspended or revoked. ��2.Zoo3 soaxD oF��,�: B�.r�.$. Qmrd�M.�. • Ao�/l�o_`?1e�r�o�, vsc�G�ars Ru�d e�tt�. Barouai, Gl�e �� S!� R.N. � _ � �..,, ,� : � n;��tor ofx�ty' '� ' �' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NiJMBER: #04-011 FEE: $75.00 'rhis is to C�y that Irish Village Holdin�s d/b/a Cape Cod Irish V'illa.se 512 Route 28, West Yarnnouth, MA HAS BEEN GP:ANTED A LICENSE TO ENGAGE IN'TI�BUSINESS OR PRACTICE OF -GIVING OF VAPOR BATHS Ttris License is issued in conformity with the authority granted to the Bo�d of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the pmvisions�f the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires De�ember 31,2004 unless sooner revoked. December 2.2003 BOARD OF HEALTH: � �. �j�/��., ' p i�ir�a��, v� e�� R�t�. e�, et� �� S!� R.N. 1 � � T I - �%i '-y /� nice G.Murphy,, , S.,CHO Director of Health , � R � THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH I BOARD OF HEALTH PERMIT NUMBER: #04-023 FEE: $75.00 This is to ce,-tify tt�at Irish Villa,�,e Holdings dlb/a Cape Cod Irish Viliage 512 Route 28, West Yarmouth, MA � IS HEREBY GRANTED A PERMI'T To Oper�te a Public, Semi-Public Swimming or Wading Pool At Caue Cod Irish Villa:�e - OUTDOOR POOL 512 Route 28 West Yarmout MA This permit is granted in�nfoimity with Article VI of the Sanitary Code of The Co�tunonwealth of Massachusetts,and e�cpires December 31.2004 unless soonea suspended ar revoked. December 2.2003 BOARD OF HEALTH: Be�t�ts�t$. �'o�a�,/H$. p��f�:��tt ��G�� , Rad�rt�. 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I do hrreby cenifj�under►he parns and p�nalti�s ojp�rjury thet the injornration provided abovt is tr�e and coned Signature � ��,�/L�� Print name one 1! .. o(Ticial usc onl� do not..rite in this area to be completed by eih or toan oAlcisl eitv or town: YA��IIT$ _ permiNieense M nBuildiog Departmen[ ' — �Lieeasio6 Board �cheek it immediate response i�required 261 QSdeetmen'�OlTiee � �Healt6 Dcpartment contact person: phoee M;_ �508) 398�2231 eat. nOther � i .. ._� < �,,. G�F�ATE �F 1�ISt�RA►N�CE ��-� �� 7H1S'E'€RTIRCAI��'rR�"EFlJ4SAIfMf►Ti@lQ��[7�T10�1tI1iY14i�iC4�SNEiNIGtfi�if�d!'f1fEt.'�flf[GAi� }�10�. lt��ZE ll[��S 1�1TfV�Q,EXiE�qtl6t.�ER,7lE A� � I�iYl�AlilE��RDiNG fi.l��I�lES� t�'ii�� 24��t�T,Pi1�[T011 �' w ��Y,l�.� �, � s Mi�LfG�M!/t�L GA�E R�i 1�iH wr■��1'At, C0�l1llWY '.�'�Z�S'�T C ��4R1!!��w. q�li�3 � i � aCOA��& Ttr5151t}{�€IFII Tki11�TTf�P6]!!�€.fi OF�tk►'I�B�t.�il!ttA4tE�i R�D7'�Ci R��FiA�D �18fY11��Y��'�t10D�D�Jl��TYWIi?i�Tl�fGl1l�D1!'� ��t'�IR�i fIIF 11AYl1f C�Mt'�t OR�1tER DOt�IARi}d�ECT 70'fNM�Cli TR�S t��1�1G4E MAY 8E ^�+�R�Ylil1�P�tTAi�,l�E ��ID BY Tt�P��i iS:,�YE'tECT'ft3 ALI_t�ptQ�A�}t�!- Tid71�5�F StICi#P�_ ti�'S S'�IOIM�B l�AY�i14VE�N BY PA�.i t�.�l� � d� Mbics►� �'id�e �+qWi�Eiea: i.�� Goee�r�i 6�erat ii�w�e $ � �� d�a��adR � Pa�J��r!+� �'. �QCa..�e x 6iaa aa....o. ;c -Q�s i Gu�ac�s �ar O�e � lMoi�Ciier i�iiea�� S Auborwa6�a I.Ia6� �o�ed iiwgle S ' '��p � -�f��/fri�slf ie��1�Y► � -��bos �tie'lws�w� �� Y S ��r f�� t�� S � �� ;� �� r �►�e s�oor+a�o �� ao�,o�o � �R�dc�t �P'i#ON OF L�PF3�TK�;A O(�A fl�l,�'� �IQTl� �7C�TE.i�lO6� CAIM�l/!`lfOlt ' AMlY�IETf�Rt1t�VE � 8'E��E 7�E�7��'!StlITMIN�4��,'�E '��Y� �["s t'd�11NY�.1L F.#�DEA11�It 7!t3#iA�.30 DAYS� i�3T�E'i�TtE�•`ICA7E tiOiL:CiE�t�i�f3 Tii��'i:�iF �l4M�if�T+CB�..�I�C8i1�E S�ll1l.L�NO tAB�LlGi4R714�q�R: �.1l1El�.ItX t!�/M�IY Nt/�tUF(3iF1 „11�51�fS t7tt �'R�i�111[�Y�:. � � � I1R�2�&(7-�Q� �•s� �S T�it� �tl �tl �'�ti THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-029 FEE: $50.00 This is to Certify that Irish Villa.�e Hol ' s d/b/a Ca.pe Cod Irish Village 512 Route 28 West Yarmouth, MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This Lice,nse is issued in conformity with the authority ganted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as am�ded,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked. Januar�l7.2003 _.__ _ BOARD OF HEALTH: (�� Zefl�ez, (�a�c __ __ _ _ __ - --------_ . $e�cfa.acc�c D. _ __ . `l/iec • ,�o6er��. �reaac. L�lark �a�te��D�ott �ele�c S�, ,�..?Z. ruce G.M hy, .S.,CHO : .�� Director of Heal , � . .TOWN OT-YARMOUTH — ' , , . � . �'� � �BOARD"�F�EALT$� � �� t , i PERMIT TO OPERATE A FOOD ESTABLISHMENT° - PERMIT NLTMBER: #03-103 ` `' �EE: $150.00 � . . , , In accordance with regulations promulgated under authority of Chapter 94,Section�D�SA�nd:Chapter ' 111,Section 5 of the General Laws,a permit is hereby granted to: .-:�r ' ` ,,f- _ ; � } Irish Village Holdings, 512 Route 28, West Yarmuuth,�1!IA; �. ° ,- , ,., , ,. . , � , , ;, , .r . � ,. . � � . Whose place of busiriess is:`" Cape Cod Trish V.ill_age , ° ` , _ .: ype o usmess: oo ervice ,�- ` To opera.te a food establishment in: Town of Yarmouth �� Permit e�ires: December 31,2003 Bo�oF�.�.'rx: �ilea�. �dllkar. ��a.� s��rnvc: 27s biu�D. C�acdaec. �K.D.. `l/iee ,�o�art�. �no�w�, � �a�1ck�Kc�Dar.� �elur S �.'�l. January 17.2003 G.Murphy, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' PERMIT NUMBER: #03-067 FEE: $50.00 'This is to Certify that Irish Villa.,ge Hol i s d/b/a Ca�e Cod Irish Villa�e 512 Route 28, West Yazmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2003 unless sooner suspended or revok�l for violation of the laws of the Comm�onwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affi�ced their offcial signatures. _ __ _ _ _ --- __ — - - �OARD-OF HEALTH: �antea�-Zu�a�.- aac«ra�-- ------- _ _--- SEATING: 278 �C�G � �. ��, �D.. �1� : j`0��. �7,OAWI6, J�KI� �a�uu�flleDac�cott �el�c S�ak, ��l. January 17.2003 � • tnP Y, . Director of Health �� THE COMMONWEALTH OF MASSACHUSETTS - ' ; ` � ' �T�WN��YARMOUTH . . �� } 4 � ,� < w.. � - BOARD OF HEALTH ; PERMIT NtTMBER: #03-053 ° ..�{ � FEE; $75.00 ` ' _ ._ _., � This�s to�,Certif�that Irish V' e Holdin�s d/b/a Ca�Cvd Iris�Villa�e _ ' S12 Route 28 West Yarmouth:lVlA ` '' IS HEREBY GRANTED A PERMIT �� `� To Operate a Public, Semi-PubGc S�vimming�or W�diag Pool �> = � � � . : At : Cape Cod Irish VilL�e -INDOOR POOL - , -�?��at�2� West Yarmautb, MA This pemut is granted in conformity with Article VI of the Sanitary C�e of T�►e Commonwealth of Massachusetts,and „ e�ires December 31.2003 unless sooner suspended or revoked. January 1Z�2003 BOARD OF HEALTH: ,_ �anled�, i�af�, �iavc�ea�c _ b�e�cfanri�D. G�iond,o�, 111.?�., ?lic� ,�o��, t�oao�c. (,,�laak �aDrEe�7ll�Dai�rott � Slak, �72. • Y,MP . Director of Health _ • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-054 FEE: $75.00 � ; This is to Certifythat Irish V' e Holdings d/b/a Ca�e Cod Irish Village 512 Route 28 West Yarmouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Ca Cod Irish V' e - OUTDOOR POOL 5 Y Route 28 West Yarmouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2003 unless sooner suspended or revoked. __ _ — - January 17.2003 __ __ BOARD OF HEALTH: _(�'�.-�if�Oz,�itLt�ca�__ _ _ �'e��ii 9. C�.azdo�c. '�9., `lliee °' ,��e�tt�. �'aaoaoac. � �a�a�sk�D�r.�o�t '� SaFak �?Z. � ruce G.Murp y,MP • -, , ;.. . ; , Director of Health ` � i a. , _.., . ; �:; = THE COMMONWEALTH-OF MASSACHUSETTS z:,, . TOWN OF YARMOUTH . f . . _ BOARD OF HEALTH ' . _ PERMIT NUMBER: #03-018' , FE�; $75.00 _ � �'his is to ceraiy that Irish Villag��-Ioldin�s d/b/a Cape Cod Irish Villa�e 512 Rout�28 West Yarmouth�MA < . ; :F I,� � ; � ., � �H��E�N��(�RANTE��A�LICENSE TO 4.,- . , ,> _ � - , �. .�r , r ' : ENGAG�IN THE BUSINES5 OR PRACTIC�O� .� T; . � :`:� , .-. � _ �_ _ - GIViNG OF VAPOR BATHS This License is issued in conformity with the authonty grante to e oar o y ap er . , , General Laws,and amendme�rts lhereto,and is subject to the provisions of the Laws of the Commom�vealth of Massachusetts � relating thereto,and upon such terms and conditi�ns,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board af Health,and expires December 31,2003 unless sooner revoked. Januarv 17.2003 BOARD OF HEALTH: �aalP,o�� i�il�i��, �ravr�ra�c ' �e�c1 D. �aralo�c. 'IK.D.. ?/t�e ��1fe �. `�'rearMc, (,��ar� �a��araro�t `s'�F .$ .� ruce G.Murp y, .,CHO Director of Health 1 � 9 � , • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH I BOARD OF HEALTH PERMIT NLTMBER: #03-025 FEE: $25.00 { 'this is to certi£y tt►at Irish V' e Hol ' s d/b/a Ca�e Cod Irish Villa.�e 512 Route 28. West Yarmouth.MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�er�is�nte��n2c$$�ormi�with Article VI o�t�e Sanit�Code ofThe Commonwealth ofMassachusetts,and exp es ece er s sooner suspen e or revo ----- _ __ January 17.2003 -----_ BOARD OF HEALTH._ �rc�tled�_ i��e�, ��a�c_ _ __ --- _- b'e�cfaMct�c'�. �jiardo�c. 'I1�C.?�.. `l/iee ' ; ,�o8�rt� ��seaooac,'_. �. .� . , �atrick�eD�ratt � S ��l. G. y, ., � _ , Director of Health �� ; ;� � . . , ;; ' . 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Mass. 02111 �" "• Workers' Compensation (nsurance Atfidavit Aoolicant information: P►esscPRD'�T'�.'Wir ' nam� �—�fL.S LC V.��4�i1 �d l-�/ locatian: �! Z �-��n.� .S� • . � � � � . g /Ls�w L�7�Lt- l'`�'�' 1��7� �� I am a homeown pert�rming all w�ork myself. � I am a sole proprietor �:-,a, ha�e no one��orkin_ in am•capacit�• -__�a�an_emploler-.-pra��in�-u��Qrl�ers' compensation for'my emplay�ees u�orking on thi��oh. m an � n rJ address• ciit�: �one q• insurance co. �icv# t.�.> G �'( ��P S! a � I am a sole proprieror. :enerai contractor. or homeowner(circle one/ and ha�•e hired the contractors listed below ��ho ha�e thz follo��in_��orker �ompensation polices: com{�any name• address• -- citti�• nhone M• insur�nce co oolicv# — comg�nv namr - addre�•• eitv• oi�one M• insurance co 1l�C,X� � Failure to secure coverage�s�equ�red under Secnoo 2SA of MGL!S2 n�Ind to tbe iopailios o(erioi�fl pesdtles of a O�e op to 51�00.00 a�d/or one yean'imprisonment a�w�ell a�eivil penalde�io the form ot a STOP WORK ORDER asd a liae of SI00.00 a day Kain�t ma I a�dersta�d that a copy of thh statement may be fonvarded to the OfTiee of Inveatig�tions of tbe D[A for eovenge veri0atio�. /do hrreby cenif}• r rh ains and tnal�ies ojperjury thm tht injoinmtion providtd abovt it utte and cor►eex Signature = �: ��"�`"_f Print name __ Phone M ., o(Ticial use only do not+.rite in this area to be completed by city or tmve oAlcisl ! city or tow�n: Y�M�IIT� _ permiNicense q nBuilding Department � — �Lieeasing Board � �check if immediate rcsponst ie required 261 QSdectmen'�Otlice , �Healt6 Departmeet � contact person: �q��p;_ (508� 398�2231 eat. nOther i f s CERTIFICATE OF INSURANCE ISSUEDATE: 11/09/01 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTICATE- HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BELOW. PRODUCER COMPANIES AFFORDING COVERAGE: HART INSURANCE AGENCY INC 240 MAIN ST, PO BOX 700 COMPANY A EASTERN CASUALTY INSURANCE COMPANY BUZZARDS BAY, MA. 02532 COMPANY B INSURED: IRISH VILLAGE RESTAURANT AND COMPANY PUB, INC.DBA IRISH VILLAGE C RESTAURANT AND PUB COMPANY 512 WEST MAIN STREET � WEST YARMOUTH,MA.02664 COVERAGES: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ' ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY � CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE MAY BE ISSUED OR MAY PERTAIN,THE , INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS EXCLUSIONS AND CONDI- ' TIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ' Co Type of Insurance Policy # Effectivs Expiration LIMITS Commercial General Gen Aggregate $ Liability Products/Comp Op S -Claims Made Personal 8 Adv Inj s ' -Occurrence X Each Occurrence $ -Owners 8 Contractors Fire Damage S - Protective MediCal Expense S Automobile Liability Combined Single S -Any Auto Limit -All Owned Autos X ' Bodily injury S -Hired Autos`� (Per Person) ' -Non-owned Autos Bodily Injury S ' -Garage Liability (Per Accident) ' Property Damage � ' Excess Liability Each Occurrence $ -Umbrella Form X -Other Than Umbrella Aggregate S Form A Workers Compensation WC 08/01/01 08/01/02 Statutory Limits �d 9494510 Each Accident S 500,000 Employers Liability Policy Limit $ 500,000 __ Each Employee S 500,000 Property DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS: OPERATIONS AS PERFORMED BY THE TERMS OF THE POLICY CERTIFICATE HOLDER: CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN TOWN OF YARMOUTH NOTICE TO THE CERTIFICATE HOLDERNAMED?O THE LEFf,BUT LICENSE 8 PERMITS DEPT FAlLURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. F/U(.a�5Q8-39&2365 " _.. _ _ . _ ::__ . _ ACCORD 25S(7-90) '-^�'.� - �`'� , i f. " f � �M1��J .�,� j }s��"�+...,� �"`�.✓'A � � � i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-015 FEE: $50.00 This is to Certify that Caue Cod Irish Village 512 Main Street/Route 28 West YarmouthYMA HAS BEEN GR.ANTED A LICENSE TO OPERATE MOTELS 'This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachuse�ts relating thereto,and upon such tem�s and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and�pires December 31,20b2 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: ��D G�, �2/lee ,�oliezt� �cowc, elo'rk �a�rsek�oz.xott � s n ruce G.Murphy .5.,CHO Director of Heal TOWN OF YARMOUTH BOARD OF HEALTH pERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-092 FEE: $150.00 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= Ca�ne Coa r�sh vi►��e �12 l��ain Street/RoLt�_2A, W �t Yarmnnth�MA Whose place of business is: Cane Cod Irish Village - Type of business: Food Se i e To opera.te a food establishment in: T wn of Yannouth Permit expires: December 31. 2002 BOARD OF HEAt.TH: �a�rlea�• xdli�. �"'a1°` ��C�a�cd�c�D., ?J�ce SEATING: 27g �Q�1CC� //GGvdlIK4t� f� .S . �� March 22 ,2002 Bruce G.Murphy, , .,CHO Director of Health i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-062 FEE: $50.00 • T'his is to Certify that Cape Cod Irish Villa�e 512 Main �treet/Route 2R We�t YarmoLth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �a�ed�. ��. C�a.a sEa�rnvG: a78 �ea�a�c D, y.mrd.a�, 7�D.. ?/�ee �ode�rt� �, (�lar� �a��ck�kD� �f S�. ��l. March 22 ,2002 ruce G. M rphy, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF AEALTH PERNIIT NLIMBER: #02-014 FEE: $20.00 This is to cenify that � Ca�e Cod Irish Village 512 Main Street/Route 28 West Yarmouth MA IS HEREBY GRANTED A LICENSE Far SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: �e(cetnlea� i��, (�xa� b�eet�atl��, y[°'�c�. ��.. �/lCe ,�o�t jl �toraora, �ez� �a�rfck�er�cot� �f .SIFak ,'f2. ruce Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-026 FEE: $50.00 This is to Certify that Cane Cod Irish Villa�e 512 Main Street/Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cod Iri h Vill e - DOOR PO L 51 Main Street West Yarmouth, MA This permit is granted in confornuiy with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: �ranled'�f. i�ePlilez, (�uac ��D��.�Giardo.a�D.. ?/iee p��tt �� s�. .�t ruce . u , , , Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #02-027 FEE: $50.00 This is to certify that � Ca�e Cod Irish Villa�e 512 Main Street/Route 28 West Yarmouth_ MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Pu61ic Swimming or Wading Pool At od Iri h Vill e - UTDOOR POOL 51 Main Street West Yarmoutl�MA This permit is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: �anfed'r�, i�ef$i�re't, �avr�ra�c S�ija�D. C%�ndo.i. 'I11.D., ?/ice �o6e�ct� ��, L� �� S .72 ruce . urp , . Director of Health 1 � � � • • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-011 FEE: $25.00 'rhis is to Certify that C�e Cod Irish Village 512 Main Street/Route 28,West Yarmouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws, and amenclments thereto, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 3 l,2002 unless soonerrevoked. March 22 ,2002 BOARD OF HEAL1`H: `�. �e�'raa, ��D. ym�d.�, .D., �J� ��rt� �aaoevx, L?f�r�k �a�iek 7KcDe�uxat� �f .S .�l. ruce G.Murphy,MP R.S O ' Director of Health �s� f '. „ (/'�� `t �� o . ��:=� G3 C' ; � : � C� [� OM (� � TOWN OF YARMOUTH BO��R��'H Q�C 2 1 ZOOO APPLICATION FOR LICENS�JI', 2001 �� HEALTH DEPT. * Please cornplete form and attach all necessary documents by December 31, 2000. Failure to o so vv� in the return of your application packet. ---------------------------------------------------------------------------------------------�---------------------------------------------- c e � ►� v �� e. i -o�a� a � N �1 �vIANAGER'S NAME• �TQh_� HuneS ____ _T��,:# 7 �U►Oc� MAit.T1VGADDRESS+--5�2_ r+ila� ----�-�rPe---,--t i_e-�,�.P� rM0[_}rWl- , YV14� naU+�7--------------- pOOL CERTIFICA,��ONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. ��►c� S � 2. Pool operators must list a minimum of two emplayees currently certified in basic water safety, standard First Aid , and Community Cazdiopulmonary Resuscita.tion(CPR). Please list these employees below and atta.ch copies of employee eertifications to this form. The Health Department will not use past years' records. You must provide new copies �nd maintain a file at your place of business. 1. Y Y� � 2. M 1� ��S 3. 4. � HEIML.ICH CERTIFICATIONS All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificadans to this form. T6e Health Department will not use past years' record�. You must provide new copies and maintain a fde at your place of business. 1. � 2. , 3. 4. RESTAURAIVT SEATiNG: TOTAL#� NON-S1�VI�KING SEATS: TOTAL#_�� ---------------------------------------------------------------------- - O�'FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 iLODGE $50 TRAILER PARK $50 Co �I�� MOTEL $50 �41 ��Z� 'y SWIMMING POOL $SOea. y � ( WHIRLPOOL $25ea. �)=0 — FOOD SERVICE: � N4TE: Per the new 105 CMR 590.000 State Sanitary Code for Food Eatablishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _,CONTINENTAI., $30 �>100 SEATS $150 01—08(� NON-PROFIT $25 �COMMON VICT. $50 � Ol`D,�� ,WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<Sp Sq,ft. $45 �TOBACCO $20 ��J l-1�30 <25,000 sq.ft. $75 TFROZEN DESSERT $35 >25,000 sq.ft. $200 NAM�CHANC�Fs $10 AMOUNT DUE _ $ 3`I S.00 *****PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM***** ___ _ , . . . r-. ._,..._ y � T.��..,,� . .....�.. .._ _ �� . { . .. . . . ... . � s . � ��,. ,. � , Y ADMINISTRATION i , s � �� : � ; i U�der�1�er,t5?�R S�tic�n 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of�q�cense'or permit to operate a business if a person or company does not have a Certificate of Worker's . , Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of�annouth 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 I5 YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEA�SONAL ESTABLISHN�'NTS ARE TO CONTACT T�-�HEALTH DEPARTMENT 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. i T N TI ADDI IO AL REGULA ONS POOLS � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State cerhfied lab,prior to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. ; FOOD SERVICE NE��TATE SANI�Y CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR Sg0.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection ' manager. This provision is effective one yeaz from the date of promulgat�on of 105 CMR 590.000. � The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell or serve ready-to-eat,ra.w or undercooked animal products aze required to have consumer advisories. C�TERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FRQZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. ' OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/wa.itress service),must have prior approval from the Board of Health. ' ; OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment is prohibited. ' DATE: �� I � SIGNATURE: PR1NT NAME& TITLE: �kv �: l�,1,e,,,�,._ �� g� 11/16/00 i' _ . � � The Commonwealth ojMassuchusetts � W Department ojlndustria/.-�ccidents � ; O/flce o/%resl/ostliis � 600 Washington Street ,� Boston, Mass. 02!11 ��'"' "•v` Workers' Compensation Insurance Atfidavit Anniicant informatiom ��s��T�+'�T n�m�. ��'i �� U lf�{�C_C�� l� `-��—/ location• ,o)�� 1 n� )�) l�C�� .� , . � r�C�c�h . C� 3 � � - � l am a h eowner pertorming all work myself. � f am a sole proprietor�� ha�e no one��orking in am•capaciry � I am an employer pro�iding workers' compensation for my employees working on this job. om n • nam : V f. � ��ss 5i �I:a� ►n ��r��, _ �} IV�51 YU I 1 ln , �Y`R l�2(�7� phone ti• I��00 �� I _ �I�J / r.��+ insurance co. 5�� '� li # VvC�� I � � I am a sole proprietor. general contractor, or homeowner(circle one/ and ha�•e hired the contractors listed beloµ� ��ho ha�e the follo��in��orker�' �ompensation polices: m nv n r � ohone�• insur�ncc co oolicv# m n s�, ohoee#• in��rance co R�v M Failure to seeure coverage as required under Secrioo 25A of MGL 1S2 eas lad to t6e iopoaidon oterisi�al pe.altia o(a ti�e op to S1�00.00 a�d/or one years'imprisonment aa w•ell aa eivil peaalties io thc form of a STOP WORK ORDER tod a tine of 5100.00 a day at�iost ma i s�denta�d tbat a copy of thy statement may be forwsrded to the OtTiee of Investigations ottht DIA[or eovenge veritieatiw. I do hrreby cerrij�•under Nre poins and penalties of perjury that rhe injorniation provided above is tnre and conect Signaturc � i� "�� Print name �� Phone� �� ' J O�� ., olTicial use only do not M rite in this ares to be completed by ciry or town ot'lleial city or town• Y�MOUTQ _ permit/lieease N nBuildiog Department — �Licensiog Board �check if immediate response is required 261 QSelectmen's ORee �H-alth Departmeot contact person: phone q;_ �508� 398--2231 est. nOther (revised 7;95 P1A1 . ... . . � �,�! � � �� 3 r '� 4�1 � ��.\/t/�f�Im Vi�� r � /■ '�VI1 �iw `i/� .-.;,�F\}�� tr�� t `� � � Y i."` w`- P�oDucER- ' '�'t��CER�� TE 45;JS��iEO AS A MATTER OF INFORMATtON ONLY AND T1ART I NS AGENCY I NG - ' "" j`�C�FERS�N��I�HTS'UPfJN�THE CERTIFICRTE HOLDER. THtS CERTIFICATE r „, � DOES NOT��AI�6ND, E�CT�ND OR jALTER�THE COVERAGE AFFOROED BY THE 240 MA I N ST �� - .�, Ppt,1Cl� ES�F�VI►,� `�'� � �.,_.,,_ : BOX 700 �� ;C�DI4RpA9�1ES AFFO�t��1�CG COVERAG� I BUZZAflDS BAY MA 025��2�-0 i�30 , ��d�` � '��. �� s�!�. - �� ^UMPANY ��_�',�; .v�,rs r �,.:� r � � , . � LETTER �� i � � � ...., _ ,...... _..�_-. . ,,_u. . _._. . _: . .., ��^�iT i iG.t t'�`"rf[, . . � .... . ._. . .. _ .._.,.,, . . , „. COMPANY � ' 'p "� �, . , LETfER INSURED t I ,,.. . CAPE COD 1 R I SH V I LLAGE-. - �-°:�- ----.-- - -�_. COMPANY �. 512 MA I N S T ''�E`� , _, .-. �... _ _ W YARMOUTH M'A 02&�� co�rP�NY � EASIRERN CASUALTY , �:�a � ,�'. COMPANY � :' , i i',.n-: : LETTER , �OVERAGES "� _��:: ..,, THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE 11STEQ BEL011� HAVE ETFFAI tSSUBD TE?.THE INSURED•`?NATu1Ed�ABOVE FOR'THE POLICY PERIOD , INDICATED, NOTWI7HSTANDING ANY REQUIREMENT. T�PM OA.��JQCI'tD:V;OF.9�,1LT.�ONTBACT,U9,OTH�F1 DOGIlIV,I�N:C ,W17}l RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE I�USU%iAh1CF kFFORQEO EiV 7HF POI i�tES 7ERCRIBED HEHEIN�18�'.SWBJ�CT TO AlL THE TBRMS. EXClUS10NS AND CONbITIONS O�SUCH POUCIES.LIM17S SHQWiv.MrY NAVEf�EEN-t"aEQUC�c'0Y PRtD Gf_AIMS. � �,r, CO TVPE OF INSURANCE POLIC�iJUMBFR , POLICM�fFECTIVE POElCY EXPIRATION � I.IMITS +. £,� OATE(IaMIDQ/� �ATE(MMIDDIY� tR _ ., . y f,� G�; � --- GENERAL LIABILITY `.t ''. ,.: GEN�RN.��'iGREGA7E $ �^ . ... P 4�U.�.•T;�CAMP/QP.AGG. $ '! COMMEFiCIAI OENERAL UABILITY ' ,F _ t, '' �:q� �,� ` CLAfMS MADE OCCUR. � � , ' - PERS�ON k�,ADV,IN,I�1ptY $ ( . ,� �� . ___, r, _ . e._ .... d E71CH OCCUF�RENCE" `' , a ' ` OWNHR'S&CONTRACTOR'S PROT. ' . ... _,,. . ..i�..,,.. . ,..,, „ ,,:. . ._... � .� � �� . � .,,, � � FlRE DAMAQE'(Any one fiie) S ' ` _ s'!;. MED.EXPENSE(Itry one person)E .i,,,;:. a.,. . .—. AUTOMOBILE LIABILITY �� COMBINED SINGLE s . �.... ... s ,.. .. �.. GlMIT ANY AUTO ._ ! �. . ; � � s .. �'` (' '`J{l� ,. ��`.S� . i"``� � 3 ,�r r ��': . ALL OWNED AUTO5 � � BOOII.Y iNJURY � (Per per8on) � SCHEOUIED AUTOS BODILY INJURV � HIRED AUTOS ` A " (Per.acCidetd},. :.. , $ ; NON-0WNED AUTOS � _ ._ . e.,`��l,t� �: d��:s�`,5;•4 „. . ..-. . GAflAGE LIABILITY ' __ , � � �r�r' '�',. �.;_, "''� pEiOP�Q'FX�;[�AMA6E:� i' S� P ., ...........�.�......, .,.�. : _- —_ ��..�w, : .. . „�„ . -�„�a�, � EAC�1-{fC'1��UFiAENC�-' � I EXCESS lIABiLI7V , UMBRELLA FORM � � ��e'"�' ��` '`�� kG(3R��E� � , �� 3, OTHER THAN UMBRELLA FORM � - � � � � i •�6� r , ., .{�`�I�c. ..`l.�� '''�� - _�_......�._,T.. r;. ; 0� �,��: � ) i,' .' .1;','>,��47UT0'AY�LIMITS�' � WORKER'S COMPENSATION �., .; ', {tliCNR' ,��_+:�';- EAC�AC�UENT � $[' .rl O O � O O O j D nNo WC94945510 , $/I.�9 Q $/Z/�� '�o��Y;��+�T ' � 500 000 � EMPLOYERS'LIABILI7Y ��' '_ . ��' •�'"'"— ' ` DISEASE-EA�H EM�40YEE, $; ° . .,; ,...�„_.....,_ ,... .i , . „ OTHER .:..,...,.. ,...�..:... . ,.....,,,..._�,. ....,....., < �. ,.,.:.ti, ;.;_i ._.e,a..,k _ ,:a.o..__ . .. � s:: x':�;� . . � �-.�L; :a(�+; ' _ DE Pt ON F TIO L �:A HICLE8 P L K ��P��a �, �`��-{'..��'�-��$-T�`�'� - ��" ��Y TQ 70M;. DAi!1�� AT CC �i R I 5H V I I.LAGE y� .. , ,. ' .�`h� . . . .. ,. :�°b . } '.. . .. .. CERTIFICATE HOLDEI� 'CAIVCELLATION • - ' ; ; ••IT SHOULD Ai�Y OF TtiE MBOVE DESCRIBED'POLICIES BE CANCELLED BEFORE THE j TOWI�I OF YARMOUTH � " ' EXPIRAT�L�l�t7ATE TtiEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO 80AAD OF HEALTH � `' ` '"MF41L �., ";`�AY3 WRI7TEN NOTIGE TO THE GERTIFICATE HOLDER NAMED TO TME ' � LEFT, BUT �AI��URE'TO MAIL SUCH NOTI4E,$HALL IMPOSE NO 08UGATION OR � ;��,; . � ' �I;tABILITY OF°�11�Y KIND UPON THE;COMPANY iTS AGENTS OR REPRESENTATIVES. `'IGSk1`HORIZED.R�P. ENTATI�I� - u � L,14 � �. .... . . �� k, �A/� � .. Y � .ts �' I. � ` .. . . ...•.. ." AGORD 2S-S 7/90 ,.. _...:- ,: .:.:•..,_,�::,� ��<.,, ` _,� :: .�1Q CO,RPORATIQN.1990. t •d 99EG 65�L 8[�� . ��39'�� ;��!d�1.f1S�!I 121dH ' dG T �is0 00 t� �aQ TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-085 ' FEE: $150.00 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: Trish Vill ge Holding:,5, S12 M in St_rPe /Ro � e R, West YarmoLth,MA Whose place of business is: Cane Cod Irish Villa.�e Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires:�ecember 31.2001 BOARD OF HEALTH: �d� j1e#�, �raursKa�,c sEa�rwG: 2�s elranP� r�f. xa�i, �/iee �,'odext� �'�u�c. L?�irk �l� d '.C'G� �'e�c' �. .D. Februarv 15 ,2001 Bruce G.Murphy,MP R.S. O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTIi PERMIT NUMBER: #01-026 FEE: $50.00 This is to Certify that Irish Villa�e Hol i �s d/b/a Cane Cod Irish Village 512 Main StreetlRoute 28. West Yarmouth. MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31,2001 unless sooner suspended or revoked. Februarv I S ,2001 BOARD OF HEALTH: �� et�ed. � �ra�rled s� � . `�/�ee el�abr.ua�,cc �ade�rt? �ioue�, L� �l�clrae� 0 ".C'c� �eo�1a�rrir,c �. . � Bruce G.Murphy,N1PH, .S., Director of Health THE COMMONV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BO�RD OF HEALTH PERMIT NUMBER: #O1-044 ' FEE: $50.00 This is to Certify that il 1 e o V' 12 Y IS HEREB GRANTED A PERMIT To Operate a Public,S�mi-Public Swimming or Wading Pool At - OU O R P Y This permit is granted in confornuty with Article�I of the Sanitary Code of The Commonwealth of MassachusettS,and expires December 3 l.2001 unless sooner susp�nded or revoked. Fe 15 ,2001 BO�RD OF HEALTH: �d� �e�t`ed, �u�vuua�t L�it�ed`�, i��. �/ice ��ra�c ' ,��it� �'r�, �� 7;�� d ',C' .D. I, D'rector of Healtl�i � � THE COMMONW�ALTH OF MASSACHUSETTS TOWI'�1 OF YARMOUTH PERMIT NUMBER: #01-053 ' FEE: $50.00 This is to Certify that Irish Villa.ee Ho dings d/h/a Cane Cod Lnish Village 512 Main �treet/R � e 28}West Yarmouth�MA IS REBY GRANTED A COIVIMON V�CTUALLER'S LICENSE In said Town of Yarmouth and at tha.t pla�e only and expires December thirty-first 2001 unless sooner suspended or revoked for violationl of the laws of the Commonwealth respecting the licensing of common victualler's. This li�ense is issued in conformity vv�th the authonty granted to the licensing authorities by General La.�ivs, Chapter 140, and amenc�ments thereto. In Testimony Whereof,the undersigned h�.ve hereunto affixed their official signatures. BOARIp OF HEALTH: �d�1L. �et�ea, �uu�xau SEA'rtrtG: 278 ' (��e�ed�, i�e+�l�. �/tCe �tQvu�cQ� ,�a�i�rt� t�tou��c, (� '' ��ic�ra� d :�' '' �t*,� . . February 15 ,2001 ', Bruce G.Murphy,MP R.S. O Director of Health THE COMMONW�ALTH OF MASSACHUSETTS TOWI'�1 OF YARMOUTH BOA�RD OF HEALTH PERMIT NUMBER: #O 1-016 , I FEE: $25.00 This is to Certify that Lrish Village Holdin�}s d/h/a Cane Cod Irish Villa�e 5 2 outh HAS BEEN RANTED A LICENSE TO ENGAGE IN BUSINESS OR PRACTICE OF - GIVIN�OF VAPOR BATHS This License is issued in conformity with the autho�ity granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws, and amendments thereto,and lis subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such ter�ns and conditions,and to the rules and regulations in regard to the carrying on of the occupation so licensed as adop�ed by the Boazd of Health,and expires December 31,2001 unless sooner revoked. ' Fe 15 ,2001 BO I�t1'GRD OF HEALTH: �� ett`ed, � L�iuled�. � ' . �lice L�ca:br.na.rc ', ,�a�t� �iQu�,c, �� ' �;�� d '.C' ,, �e�� . ��, .D. ', Bruce G.Murphy, , .,CHO , Director of Health THE COMMONW�ALTH OF MASSACHUSETTS TOWI'�T OF YARMOUTH BOA�tD OF HEALTH PERMIT NUMBER: #01-045 '' FEE: $50.00 This is to Certify that ill o e d 'sh V' 51 M ' e We t Y outh MA IS HEREB GRANTED A PERMIT To Operate a Public, Se�ni-Public Swimming or Wading Pool At Cane Cod Irish Vill�asP -INDOOR POOL 12 M ' West Yarmouth This permit is granted in conformity with Article of the Sanitaiy Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless sooner suspe�ded or revoked. February.,15 ,2001 BOA�tD OF HEALTH: �� et�`ed. �u�btur�t ' L�uvr�'�. i�e��. `l/ice L�ra;vr.,ra.a '',, �o�rt� i'ratu�. L� � �� d '.C' , D ��• 711.D. � � Director of H�e.alth � , , . ' � THE COMMOl'�1WEALTH OF MASSACHUSETTS T(�WN OF YARMOUTH �OARD OF HEALTH PERMIT NLTMBER: #01-030 ', FEE: $20.00 This is to Certify that Irish Vill e�H ' s a Ca e od Iri h Vill e S 12 Main S et/Route 28. West Yarmouth,MA IS HER�BY GRANTED A LICENSE For SAL AND B TIO TO O PR U S AS PER THE Y�RMOUTH O�R� OF HFAT TH TOBACCO REGULATION. This permit is granted in conformity with Art�cle VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2001 unless.sooner�uspended or revoked. Februarv 15 ,2001 �OARD OF HEALTH: �� ett`ed, �� ,', �ictn�P.d�. /��'tF�. �/iCe ;�iavt�u�t ', i�o�� tifi4tu�l, (� ' 1�ticlr� d '.G'�e�r,� � �`�`�` ��..�a. ', Dir ctor of Ha ltYl�i � . , ,_ , � ! , , , : x ' � . __ i 1 . � �- , I��l I L I : F= �., " w �,a " � D � TOWN OF YARMOUT��;RU QF HEALTH 0�C 2 9 1999 � ,:� APPLICATION FOR IxiC&�T�GPERMI�T- 2000 i : �#r�az �o� �-�-is68 �r�6� HEALTH DEPT. I * Please camplete form and attach all necessary documents�by December 31, 1999. Failure to do so will result in ' the return of your application packet. � NAME OF ESTABLI�NT � C�[--��--G�---�-r�iS l. ---Ili l�4 s 2 -------------TEL -#-77/-O l6 0�----• '' LQ�ATIQN A,DDRESSx �l�2 �'la i h s'� �es� �a r�..o K-�'�T� �dG 7 3 , L D ' N o � c r� ✓��/ . MANAG�R'S.NAME: .To�+-� V• L�,k r S TEL. MAII..INGADDRESS: 5la Nat S !�l�s�f ��.s��. M� 6�673 �'OOL CERTIFICATIONS: �, The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law, Please list the ; designated Pool Operator(s) and attach a copy of the certification ta tlus form. � 1. �r'�� i� C �� 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 atta.ch copies of '; employ�certifications to this form. The Health Departmcnt wilt not use past years' records. You must provide ' new copies and maintain a file at your place of business. ' 1. �d��S .!/lc Ur S Z. r�-�i-�G l� � ri Lt f ' , H !' I� 3. 4. HEIl�iL,ICH CERTIFICATIONS: ` All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and f 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 fite at your place of business. 1. � ��. De ��rn� 2. I 3. � � � � � 4. �� _ RESTAURANT SEATING: TOTAL# _I�TOI�I SA�OKINC�SEATS: TQTAL�_#_______ . _ _ _ ___-�} ______------------------------------•-------------------------------------�-------------------_--__----------------------------------------� � OFFICE U,�E ONLY LODGINGs � LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 — — � r INN $50 CAMP $50 j LODGE $50 TRAILER PARK $50 � !0�`l2�.- 2 ` � MOTEL $50 � Z SWIlvIMIlVG POOL $SOea.(_� �(�,1c-53 � — — I �WHIRLPOUL $25ea.. �/?.�G�ZO � FOOD 5ERVICE: ! LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# i 0-100 SEATS $75 CONTINENTAL $30 I >100 SEATS $150 y2�-�2b NON-PROFIT $25 I COMMON VICT. $50 2k WHOLESALE $75 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# ' i _<50 sq.ft. $45 �TOBACCO $20 YZ(��3�F _<25,000 sq.ft. $75 FROZEN DESSERT $35 � >25,000 sq.ft. $200 , NAME CHANGE: $10 3��6 � AMOUNT DUE = $ — """"PLEASE TURN UVER AND COMPLETE OTHER SIDE OF FORM•""" ` , E __ _ . _ � � � _� � ADMINISTRATION ' UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-�TOWN OF YARMOUTH IS NOW R�EQUIltED TQ_H•OLD.iSS�A1�C� l�R RENEWAL OF ANY LICENSE OR PERNIIT 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 'I MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED � ' ; WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' � TOWN l�F 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 RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY ' i DECEMBER 31, 1998. ', � � SEASONAL ESTABLISHIVV�ENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 �'�, DAYS PRIOR TO OPEI�TING FOR THE SEASON. I, ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL i.e. PAINTING NEW I , � , � EQUII'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO I COIVIlV�N�EM�NT. RENOVATIONS 1VI�,Y REQUIRE A SITE PLAN. i I'', �i DITIQNAL REGt,�ATIONS POOLS POOL OPEMNG: ALL SVVIMMING, WADING AND WHIRLPOOLS VYHICH HAVE BEEN CLOSED FOR ' • THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR I� PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, I PRIOR TO OPENING, AND QUARTERLY THEREAFTER. ; I POOL CLOSING:EVERY OUTDOOR IN GROUND SVVINIl��IING POOL MUST BE DR,AINED QR COVERED � WITHIN SEVEN(7)DAYS OF CLOSING. ( i i FOOD SERVICE ; � i �ATERING POLICY: " �- ANYONE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NO'TIFY TI�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 Ii DEPARTMENT. FR,��ESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT, FAILURE TO DO SO WII,L RESULT IN TI-� SUSFENSION OR REVOCATION OF YOURFROZEN DES SERT PERMIT UNTII,TI-�ABOVE TERMS HAVE ! � BEEN 1VIE'IT- - , OI,7TSIDE CAFES: OiJTSIDE CAFES(i,e., OUTDOOR SEATING WITH VUAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD � SERVICE ESTABLIS�A�iENT IS PROHIBITED. i �Y� DATE: �7��i� SIGNATURE: � '�-- �° ;'—=� ,.� 6-� � �-- PRINT NAME& TITLE:� �.�(-��:�� , �`iz. i 11/12/99 . . � �` The Commonweulth ojMassachusetts ' � � Department of Industrial.-1 ccidents � ; Olflce o/I�estlos�liis � + 600 Washington Street ' ,,•� Bnston.Mass. 02111 ' �'" "� �L'orkers' Compensation Insurance A[fidavit ARr�licant intormallon: P►essepR�'T'ie�."i�ia namr� CG�IO � �d C �Y'%�� l��GCi � � � �t� s f' �, � • �a,rw,6�;-l'� , f'L� D .?( 7 3 o°,g�� 77l-0�00 � I am a homeow�ner pert�rmin,all work myself. � ( am a sole proprizror�r.� ha�e no one ��orkin� in am•capacin• �am an employer pro�i�ins w�orkers' compensation for my empioyees workine on this job. __ _ _ _ sQmaan�• name: C�� C,d� LY!.� '1 V d�(�G-� Q address• �� Q/h ��- CItY: �r ��q/'�LdGC�I 1/ �-G�/T D R�{7 � � nhone M. �� ` 1 � d/d Q � insurance co. �.S T�h. �G(SQQ l�'�l p�y tr W� 9�f 9y�/o � I am a sole proprietor. general contractor, or homeow�ner(circle onel and ha�•e hired the contractors listed belo� �tho ha�e the follu��in_ ��orl:zr�� :ompensation polices: companv name• address �tx•: ohone#!• insur�ncc co. policy# — comRan�name• add ress• __ sjjy: nhoee M• insuran��n_ �* 1 Failure to secure coverage as required uode�Secnoo 2SA of MGL 1S2 ea�lud to the iepaitioa o(eriai�tl pe�dtla of a O�e op to 51�00.00 a�d/or one years'imprisonment a�w•ell a�civil peaaiNee io the form of a STOP WORK ORDER aad a tiee of S100.00 a day apiost me. I a�derstt�d tbat a copy of thh statement may be fonvarded to the ORice of Invcsti��tiom of tbe DU(or eoven`e veri8eatio�. /do hrreby certijj•under the pains and penal�ies ojperjury that�l�e injorniation provrded abovt is true wtd correct Signature Date Print name Phone�l ., olTicial use only do not w�ite in this area to be compieted by ciry or towa oAleial ciry or town: Y�M�DT� _ permiNiceau M nBuildiog Dcpartmeot �Liceasiog Board �eheck if immedi�te�esponse is requi�ed 261 QSeiectmen'�Ofiice �Health Department cont�ct person: phone N:_ �508� 398-�?231 ext. nOther I .. _ <�,�. i • THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-20 FEE: $25.00 This is to Certify that John J Hvnes/Irish Villa.ge Holdings d/b/a Cane Cod Irish Village 512 Main Street West Yannouth MA HAS BEEN GRANTED A LICENSE TO ENGAGE iN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformiry with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regazd to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31,2000 unless sooner revoked. January 21 ,2000 BOARD OF HEALTH: �c`� �e%�e�, ��iairman �oan� �uldivan� �//.� Vice ��irman KoberE�t. 9�i»wn, C.ler� a�rie[[e�a�ole�Z�-.�toope� • ��0' ou��,� Bruce G. Murphy, MPH .S. O Director of Health � � r a THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-53 FEE: $50.00 This is to Certify that John J Hvr�es/Irish Villa�e Holdings d/b/a Cane Cod Irish Villa�e 512 Main Street West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Ca.pe Cod Irish Villa�e -INDOOR POOL 512 Main Street We t Yarmo th MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked JanUary 21 ,2000 BOARD OF HEALTH: �i` ///. �etfa�, C��iairmarc �oan� �u[�ivan, �//., Vice C.hairman ,�066�� row,�, c�.� a�rieGle�akoG��Zc�-,�tooped � ��O' o�� - ruce . y, . Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-52 FEE: $50.00 This is to Cercify that John J Hvnes/Irish Villa�e Holdings d/b/a Cane Cod r'sh Village 512 Main Street. West Yannouth. MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool A� Ca�e Cod Irish Village - OUTDOOR POOL 512 Main Street West Yannouth MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked 7anUarv 21 ,2000 BOARD OF HEALTH: �c` ///. �efte�, C�zairman �oan� �ul�ivan, K.//., Vice C��irman Kobert..J�. v,rourn, C.[erh a�ris[le�a�o(.��i y-✓�tooPe� ic G O� h[in ' 111 • UTP � � • Director of Health � • q�j�aH 3o io��al�Q O 'S' `HdY�i`�qd.my� •�a�n.� j OOOZ` I Z n u''y�no `O�am� � � cadoo��iz�y�o�v�a��a�rqv /0 0 � `,0� `�umarce •.F-��a�o G/ L� vmu��v�'� a�n '•/�•)/ �vvn�fn� � x�no 8LZ �rJNLLd3S / / b UD CJl � �mu��m,� ��a� � p� -H.L'I�v'3H 30 Q?I�'Og •sam��u�ts I�i��o.zia�pax�� o�una�aq an�u pau�is.�apun a� `�oaaa��fuouxt�saZ uI •o�a.�a�s�uauzpuaure pue `p�j �a�d�u� `snn�Z�auarJ�q sat�uoq�ne�uisua�ii a�o� pa�u�a��uo�n�au��inn�tuuo�uo�ui panssi st asua�ij s�,I, •s��ai��in uouzuzo��o�utsua�ti aq��ui��adsa.z�I�annuotuuTo�a��o snn�i a��o uoi��ioin ao3 paxona.�.�o papuadsns iauoos ssaiun OOOZ�s��-��.zaquta�aQ sa.�t xa pue�iuo aa�jd��pu�cgnow.re��o unnoZ pt�s uI �SI�I��I'I S�2I�'I'I�f1.L�IA I�iOb1INi0� H Q�.L1�Id2IJ Afi�2I�I SI a �IIIA usuI po a ��q/p s i joH a �IITA uS�TI/Sa H ' �I�f i��i�a� o�st s�,I, 00' S ��3 6 -�IZ� �2I�gY�If11�I.LIT^I?I�d H.LIlONi2i�'1�30 I�IAAOZ S.L.L�Sf1H��'SS�'L1I 30 H.L'I�'�MI�iOL1INt0� �H.L THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-34 FEE: $20.00 This is to certify that John J. Hynes/Irish Village Holdings d/b/a Ca�ae Cod Lr�sh Villa�e 512 Main Street, West Yannouth.MA IS IIEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS � AS PER THE YARMOUTH BOt�RD OF HEALTH TOBACCO RFGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. Januarv 21 ,2000 BOARD OF HEALTH: �c`� �ef�e�, C�airman �oan C�. �u[livan, K.//, Vice l..hairman �obert..t. 6�rown, C,lar� �a�rie[le�akoG��tooPe� [ � o a Dire tor of H lth ' TOWN OF YARMOUT�I BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-126 FEE: $150.00 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: John J_ Hynes/irish Village H�ldings, 512 Main Street, West Yarmonth, MA Whose place of business is: Cane Cod Irish Village Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. ��t��, C'�tr�h SEATING: 278 �oan� �ullivan, ��/., Vice l,hairma �o�ert.�`. O.�rown, �[ev� abrie[le�a�o(.��-J�too es ic �. /� ouyhlin yanuary�i ,20�U Bruce G.Murphy,M ,R .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-34 FEE: $50.00 This is to Certify that John J Hvnes/Irish Villag�Holdin�s d/b/a Cane Cod Irish Villa�e 512 Main Street West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked. January 21 ,2000 BOARD OF HEALTH: �cl///. �effe�, C`i,airman �oan� �ul[ivan, �1/., �ice (..�rman �obe�E� �rown, �le�� a�riel[e�a�o[�ky-✓dooPee • �l ' a��,� Bruce G. Murphy, ., CHO Director of Health ,_- r '` . . �, �'�,�„ ��U �r 15�1 V 111 C�. i �� "' TOWN OF YARMOUTH BOARD OF HEALTH �,'� � [� (� [� � 1�J/ [� p APPLICATION FOR LICENSE/PERMIT- 1999�„� a � � . _� � � D E C 1 4 1998 � * Please complete form and attach a11 necessary documents by ` � 1��3,1,.�99�. �'a�l re��v��ult � the return of your application packet. --� � � :,�.� , ` , --------------------------------------------------------------------------------------------------------------------------------------�-- NAME OF ESTABLIS��NT� Ca-d� Co� �v;5� (/, l�i� 2 TEL. # 7_7/i� /v v , LOCATION ADDRESS' Sl.i /'9�.:s. �f'. GI• r�s.o� �jA D.t(o 7 3 ' MAILING ADDRES S• �WNER/CORPORATION NA_1vtF� , ER' N o l� �% n e # jyLi��11�lJ t]iJLi�L'17 J� ..A�l7�'1 �7��'C /. Jrt.. Y /ba +a. j �i ��_��..��..��N___��M��_��_��_��_� �i POOL CERTIFICATI�NS: ! The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the , designated Pool Operator(s) and attach a copy of the cerhfication to tlus form. ; 1. - -- 2• _ , Pool operators must list a minimum of two emp loyees currently certified in basic water safety, standard First Aid and Commututy Cazdio�ulmonary Resuscitation(CPR). Please list these employces 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. � �,'E' 2. ��... 3. � 4. NFIlVII.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-chokuig procedures below and M 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. Q 2.�G� �x�%d�1,� 3. 4. RESTALTRANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---- ---- ----- -------------------------------------------- -- -- _ __ _ _ ___ -- --- - —'-fl�F�CE USE UATLY _ . _; LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 — i LODGE $50 TRAILER PARK $50 �_ � � � MOTEL $50 Qq_�_ �SV'V]aVIlVIING PQOL $SOea. �Q-�___ � �–�— �� WHIIt�LPOOL $25ea. , FnnD 5ERVICE: 'I LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 5EATS $75 CONTINENTAL $30 �>100 SEATS $150 qq_Z� NON-PROFIT $25 I COMMON VICT. $50 �� WHOLESALE�� $75 $,FTAIL SE,� LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 � TOBACCO $2� "� �<25,000 sq.ft. $75 FROZEN DESSERT $25 , >25,000 sq.ft. $200 N�iM CHANGE• $10 �_ �n AMOUNT DUE _ $ (�1�� ._ I� **"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•"" r 1 � + • ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOLJTH IS NOW REQUIRED i TO I�OLD ISSUANCE �R RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINES5 IF A � pEgSON OR CfJ1VIPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION ; INSURANCE. THE ATTACHED STA�E WORKER'S COMPENSATION INSURANCE AFFIDAVIT � MUST BE COMPLETED AND SIGNED, OR ! CERT. OF INSURANCE ATTACHED � ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK AP ROPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS��NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE 5EASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIPMENT, ETC.), MUST BE REPORTED TO ANU APPROVED BY'TI�BOARD OF HEALTH PRIOR , TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I i ADDITIONAL REGULATIONS ' POOLS � POOL OPENING: ALL SV'VIlVIMING, WADING AND WHIlZLPOOLS WHICH HAVE BEEN CLOSED FOR i TI�SEASON MUST BE INSPECTED BY TI�HEALTH DEPART'MENT,AND THE WATER TESTED FOR " � PSEUDOMONUS, TOTAL CpLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TI-�REAFTER. POOL GLOSING: EVERY OUTDOOR IN GROUND SVVIMNIING POOL MUST BE DRAINED OR COVERED { WITHIN SEVEN(7)DAYS OF CLOSING. � � f4 f � FOOD SERVICE G CATERING POI,ICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI-� YARMOUTH HEALTH DEPARTMENT BY FILING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. F�.OZEN DESSERTS: FROZEN DESSERTS MU5T BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIELI LAB. TEST RESULTS MUST BE SENT T�THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS i - — - -- ---- --- — - _ _ _ ------ _ � - - --- -- --- - --- -- HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.OR FOOD SERVICE ESTABLIS�-IlVIENT IS PROHIBITED. i DATE: 1�j�1 zl a i� SIGNATURE: � PRINT NAME& TITLE: - . ) a�,,,� �• �v��v�s �2e3 , ., � . � I ` _ The Conrmonwealth ojMassuchusetts � � W Department ojlndustrial,-iccidents T ; olflceo/%s�l�s�liis � 600 Washington Street .` Bnston, Mass. OZlll �"' "•y W'orkers' Compensation insurance Affidavit Aoolicant informallon: PieasePR�'I'Te�`i�Tic namc: ,�/i J '1 V 1' l ll(,,(� .� location: �]� �� (.�/`'1 �� 4j,I,� � r �/Y N�-v�..'f � i �l�T Q oZ b / � one# 7 7 � � �� v � I am a homeowner pertorming all w�ork myself. � I am a sole proprietor�� ha�e no one��orkin� in am•capaciry f4(' I am an employer pro�i�ing workers' compensation for my employees working on this job. �r�� _ _ -- - _ _ _ _ , /. ��- �p - -- - - _ compan�name: .�l/(� � (/f �'��-�l i ' �ddress: �� /"l$i� J � __ ciri•• `^' ' ��Y''�*!J Ut-�. IK�' �LG 7 � ohone ti: insur�nce co �G�$Tz+i/!i► C.�c.fGts,,/ � policv# W�- �� -/ 7 J`�� U � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed beloµ �`ho ha�e the follu��in� ��orker� �ompensation polices: g,4mpanv name� ^ddress• �• phone#• _ insur�ncc co �o��'# comp��y name• _ _ - - ---- - - __-------- —-- _ ___ �x3ress• --- -- -- __ _ - __- -------- ,:,*�"- �hoee k• insurance co R4�M Failure to seeure coverage as required under Seetioo 25A of MGL 1S2 ns lad to t6e iopaition ottrioi�tl ptultla of a O�e op to 51�00.00 a�d/or one yean'imprisonment a�w•ell a�civil peaaltla io the form oi�STOP WORK ORDER aad a.liae of 5100.00 a d�y a�dost ma i a�dersta�d t�st a eopy of thH statement may be tonvarded to the 011iee of Invatig�tiom of the DIA for eoven�e veritieatio�. I do hrreby cerrij}�under th�pains and penalties of perjury thw the injorneotion providtd abovt is true aad eonteG Signature f�' �l` �d Print name d U � Phone# �7 f' �� ., oRcial use only do not w rite in this are�to be completed by eity or town oAleial ciry or town• yA��TQ _ permitAieease p nBuildiog Departmeut pLiceasing Board �eheek if immediate response is required 261 QSelectmen's Ofliee pHalt6 Departmeot contact person: phone p;_ �508} 398-•2231 e.gt. nOther Irecised i,95 P1A1 r i " THE COMMONWEALTH OF MAS5ACHUSETTS ; TOWN OF YARMOUTH ! I PERMIT NUMBER: 99-17 FEE: $50 00 � This is to Certify that Cane Cod Irish Vi11�gP ' 512 Main Street„Wett Yarmo ��th, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a.�ixed their official signatures. Bo� oF��.�: �d� �8��, c��,�� SEATTNG: 278 �oan G. �u[iivan, K.//.s Vi�ce l.�irmarc Ko�ert J. �rown, C��e/r� a�rie[[e�a�of��y-J�tooPe� �e�0' ��.►. December 16 , 19 98 ruce G.Murphy,MPH,R S. Director of Health TOWN OF YARMOUTH - BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: 99-25 FEE: $150.00 In accordance with regulations pmmulgated under audiority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ('_a,»e Cod Irich Villag�, 512 M in 4 r et, Wect Yarmnn�, MA Whose place of business is: Cane Cod Lr�sh ViLlagP Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 3�., 1999 BOARD OF HEALTH:��% �et��, C��.�� SEATING: 2�8 � �oan� �uiiivan,K.//., Vi�ce C�hairman KoberE� �rown., l.fer� � abrielda�a�ol��ct-.JdooPee 'ilic�a6 � o �lirc December 16 , 19 98 Bruce G.Murphy,MPH, S., O Director of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUNIBER: 99-1 FEE: $25.00 This is to certify that Cane Cod Irish Villa,ge 512 Main Street�West Yarmouth,MA HAS BEEN GRANTED A LICENSE TO ENGAGE IN THE BUSINESS OR PRACTICE OF - GIVING OF VAPOR BATHS This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 51,of the General Laws,and amendments thereto,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the tvles and regulations in regard to the carrying on of the occupation so licensed as adopted by the Board of Health,and expires December 31, 19�9 unless sooner revoked. �ecember 16 , 1998 BOARD OF HEALTH: �c�� e�ae� ��eairmare �oan� �ulLivan� K.i/-, Vice l.�irman Ko�ert� �row�� l..ferh a�rielfe�a�ol��ooPee �g�0' ��n Bruce G.Murphy,MPH, S., Director of Health THE COMMONWEALTH OF MASSACHUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: 99-5 FEE: $50.00 Tbis i�to cercify that Cane Cod Irish Vil�a.gs 512 Maui Street�West Yatmouth.MA IS HEREBY GRANTED A PERNIIT To Operate a Public, Semi-Public Swimming or Wading Pool At CaQe Cod Irish V'illage -INDOOR POOL 512 Main Street West Yarmouth,lVLA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonweatth of Massachusetts,and earpires December 31. 1999 unless sooner suspendecl or revoked. December 16 , 1998 BOARD OF HEALTH: �c`///. .}alfe�, ��usirman . � �oan G. �u[[ivan�K.//•, Vice l.hairmaa � KoberE p�� O�rown� l�(er� a�rfelis�a�ol��c�-✓dooPoe ' el��.� t ft/ j ruce Director of Health � " ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: 99-5 FEE: $50.00 This is to Certify chat Cane Cod Irish Vill�e 512 Main Street, West Y�*mouth,MA HAS BEEN GR:ANTED A LICENSE TO OPERATE MOTELS This License is isslied in contbrmity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisians of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Hea1W,and expires December 31, 1999 unless sooner suspended or revoked. December 16 , 1998 BOARD OF HEALTH: �c`ii/. �}e�ee, l,�iairmar� �oarc� �u[livan,/C.//., V�e (...�irmar� Kobert J. 9,rowra� C.lsrh a�rielle�a�ole�c��JdooPea ic�el O� u��lirc / �� Bruce G.Murphy,MPH,R .,CH Director of Health THE COMMONWEALTH OF MASSACHUSETTS - TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-4 FEE: $50.00 This is to cerafy that Cage Cod Irish Village II'� 512 M n tr W ; IS HEREBY GRANTED A PERMIT i To Operate a Public, Semi-Public Swimming or Wading Pool At Cane Cod Irish Villag� - OUTDOOR POOL 512 Main Street ; West Yarmouth, MA iThis permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and � expires December 31. 1999 unless sooner suspended or revoked. i �7 December 16 , I998 BOt1RD OF HEALTH: �c`� ..i�ette�, ��ma� • �oan� Juf�livan,K.�/•, Vica C.hairmarc Ko�erE J. Y�rotvn� (_.lerk a�riel��a�of��-�ooPe� • �8�0' �� - Director of Health� � THE COMMONWEALTH OF MAS5ACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: 99-8 FEE: $20.00 This is to Certify that Cape Cod Irish Village 512 Main Street_ West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31. 1999 unless sooner suspended or revoked. 'i December 16 , 19 98 BOARD OF HEALTH: �c`� �ef,fee, ��iairrnarc �oan � �u�[ivan�� ice l�hairntare Kobert J. O�rown, (_.lerh �a�riel��a�iol��c�-.�tooPe� �e�0' ��,� Director of Heal�i � � , i � I ( I il � � 12122,�1997 15:38 5@8-771-33�5 IRISH VILLAGE PAGE 62 � �rw�. cE�r��ca� oF �rtSURA�1� '�'"`°"�`�'"'" ��z��r ��apY�.�e �fF11S Cli11'�ICATE IB !=iUED�AS A�A1ATT� QF 11�'pqMATIQN ONi.I► ANC CONFE118 NO wtOMT� 1JP'CN TN! CE11TI►1G'rE NOLD@p• TFf18 CERTIFlCATE k�A R�1` t NS AG�M C:Y ! N C ��T 11MEwD, E�CTEE1/d�1 ALTEA Tl1�CQYE��iE AFFORDED�Y TNE 2.40 MA I N ST `.. �"„ ��, . .. �aX 7�Q C�lMPANI�S AFFOROINa C01IePiACE �' �uzxa�sr�s �AY a�A o��.�z••c�-raa OONPANY v��c�tr ryt�.t� �uae� � �€n�R A �v ��tt�R� g � �THE� !r4•;i C.dA�'t7R{I{I nl11 �rTEn"r C' � 'i 12 MA 1 N 5'T' co��rr . . f w�:;5-r Ynl?MbU°rF� M� ax��:3 s�rrEp � �„t:G� �N � N�c1�dNt,E co Cb'MPANY E LETTE}1 -._._..�� -- -...�..�.�.........................�..,..... .. ...._.._...�-.�.,.�....,,......�r......_......�-....��..�.......�...,...__................_,...,: . �� 'HIS rS TO C€qTIFY' TNAT Tfl� PpIIC�E� 4P iN6URANCE LiST�p pEtCW HAyE BEEN t53UEO Tp TEIE fN9UREG NAI�fGEQ ABO�'E fOR T!# POLNCY pERlOa WdICA?E8. NOTMTNSTANQdNQ ANY fiEbINREMEN?. TERAA (7fi QONpiT10H (,1C ANY CONTRAeT Oq Ot►tEA �OGUMENT WRF! A�SPECT T� WhIIC„ THI$ CEhr1�ICATE MAV BE IglILIEQ OR M�V PERTAM+i. 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IMPQ$E NO dBLtdATIdN OR LIA91LItY QF ANY KINb Upa�l TNE CbMPANY, tTS AflE�TS pR R�Pqf9�ITATIV�B. �u»+aMZEo MrwMrr,�t�vE �T�� {.��'�"'� �ao�a�s-s n� .,...,,,�,��,..... . ,rcona i�oN��na Z�D'd i0�� l�+�[ ei39 fiB�/ ��u�ansai �..t�rN c��sar iR-�a-o�n