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Home My WebLink AboutApplications, WC and Licenses � . ' � . � i ` " � TOWN OF YARMOUTH BOARD OF HEALTH � � ��; -' �� APPLICATION FOR LICENSE/PERMIT 20 � r,�j'� ,... �..,—�.� �� AN 2 s ?aoq * Please complete form and attach all necessary doc�t�er��y 1� c' " DEPT. Failure to do so will result in the return of your appli�at�o pac , NAME OF ESTABLISHMENT: �h9-9� ��rz. TEL. # ��- ��—d�oo LOCATION ADDRESS: �9 a y1��,.✓ �,5�; G,�. y"�,,,��,�� lhz ��-4 y� MAILING ADDRESS: ,Ti � d��„� �Sr� �- �1'qr�� ° �r- �z�-7.3 OWNER NAME: d cs,.,�✓ :�: /�y.✓� TAX ID (FEIN or SSN)• CORRORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: . POOL CERTIFICATIONS: a The pool supervisor must be certifed as a Paol 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 _...r---�j�.� �,,.c,,� '`fl�v�E> 2. Pool operators must list a minunum of two employees currently certified in basic water safety,standard First Aid and Community Ca1 diopulmonary Resuscitation(CPR). Please list these employees below and attach copies af employee certificatians 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. �� .:-j-t .�,7�� 2 3. �,��1`rn..��.lt, r�',.�.�2.c�, 1�1'� 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one fiill-time employee who is certified as a Food Pratection Manager, as defined in the State Sanitary Code foi Faod Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health DeparYment will not use past years' records. You must provide new copies and maintain a file at your establishraent. ; 1• 2. � PERSON 1N_CHARGE: _ _ __ _ __ _ ___ __ _ __ _ Eacli food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained 'ui the Heunlich Maneuver on the premises at all tunes. Please list your employees trained in anti-chokuig procedures below and ' attach co�ies of employee certifications to this form. The Health Department will not use past years' records. ' You must provide new copies and maintain a file at your place of business. ; 1. 2. ! 3 4. � RESTAURANT SEATING: TOTAL # , � OFFICE USE ONLY j LODGLNG: � LICENSE REQL�iRED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# _B&B S55 _CAB1N �55 �MOTEL �55 �'6�Q _INN S55 _CAMP �55 � St�"Ti`flvlIIv'G POOL �80ea. O�—GYcg _LODGE S55 _TRAILER PARK �105 _WHIRLPOOL �80ea. FOOD SERVICE: LICENSE REQI7IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# __0-100 SEATS �8� �CONTINENTAL S35 D l'�� NON-PROFIT �30 _>100 SEATS S160 _COMMON VIC. �60 _WHOLESALE $80 RETAIL SER��ICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERI�IIT# LICENSE REQUIRED FEE PERMIT# LICENSB REQLTIRED FEE PERMIT# _<�0 sq.ft ��0 _>25,000 sq.ft. �22� _VENDITTG-FOOD �25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 _TOBACCO 5�5 \'A�ZE CHANGE: �10 AMOUNT DUE _ �_/7p. Od *****PLEASE TL�'V OVER AND COMPLETE OTHER SIDE OF FORM*"*** r . ... .......,....,..,..�:. _..,.... .. � , � � . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED 5TATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � ,� $� ��.� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yasmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �-' NO YES MUTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. ; Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy 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 m 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 CLOSING: Every outdoor in ground swimming pool rnust 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 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 of Health. OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. j NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. i ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; i � DATE: SIGNATURE: � PRINT NAME&TITLE: i. io�2i!os � • JAQ�, 26. 2009 3:49PM HART INSURANCE N0, 824 P. 1 ;' ACORD�, CERTIFICATE OF LIABILITY INSURANCE oii2s�z�o s ,' :oavc�t TNIS GER7'lFlCAi'E IS ISSU�D A5 A M A TT E R O F 1 N F 0 1 2 M A T I Q N HART lNSURANCE AG�NCY, (NC. ONLY AND CONFERS NO RIGHTS UPON -M� c�Rr��icasE NOLDER. TF11S CERTIFICA7E DOFS N�T NNEND, EXTEND OR 243 MA1N STR�ET ALTER THE COVERAG� AFFORDED BY TI1E POLICIES BELOW. PO BOX 70.0 BUZZARDS BAY,MA 02532-0700 1NSUREEtS AFFORDtNG COYERAGE NAtC� suaeo �righ billage Restaurant and Pub,Inc. wsu�Ra. G NITE STATE INSURAN E 23809 512 West Main S'treet wsu�R s: We5t Yarmouth,MA 02673 iNsuac�c: INSURER D: � �NSURER E: � O��CaF$ '_ j 7H@ POEIGiES OF INSURANCE LtSTEO BELOW FIAVE BEEN ISSUED 7Q TME INSURED NAM�D ABOVE FOR 7ME PO�ICZ'PERIOp IPIDIGA7ED.NOT1AJfTh157ANDING I ANY REQUIREMENI'f,THRM OR COND1TfON OF AMl CON7RACT OR 07'1iER DOCUMENT 1NITH RESPECT Tp WFI{CH THI$CERI'IFICf�TE MAY 6E ISSUED OR NWY PERTAIN.7NE INSURAt�{CE AFPORDED BY 7HE PQLICIES OESCRIBED fi�REIN 1S SUB.IECT TO ALL TIiE TERMS,E7CCWSION$AND CONGn'10N&OF SUCH POLICI£S.AG¢REGR7E L�Pi'S SHOWN MAY HAVE BEEN REDUCED BY Pq�D QLAIMS. � D POI..ICY NUMBER POYCY EFPECTNE P0�DCPMTiON L1MRS OklrERAL LABILIIY : FJ4CH QCCURFENCE S CpMMERCtAC GENE�UABILIiY PREMIS aca+renee a � CLAIMS MADE ,❑OCCUR MED Ei� AMV�e Cer�aN i � PERSONAG&ACV INJURY 3 C,ENERqL q{aC+�EC,ATE 5 GEN't nGGNE6P,TE UMIi APPLIES 1�@R: PRQDUCTB-COMP�'AGG S POLCY PRO- LbC AUTOM08LE LIpB1LtYY �MBINED SING�LIMiT � ANY Au70 (Ea acGdwip a ; . � AiLOWNEDAU7PS BODILYINJURY s � SCHEOVLEDa1,ITU, (Pxpe�son) �� ' BOOIIY INJURY I NON-0WNEDA�7To5 (Persa�uerq S I . (Pee a�ee�denl�ANb►GE � GARAL�LIABILfrY ` A O QNLY-EA ACC OEM a ' rwY AGYO OTNBR TMAN �ACC S AUTO ONLY� A6G S EXC@SS/UMBREW►ilAB1LRY � EACHOCCURRENCE S OCCUR a ctA�8 rnaOE nctaReGnsE s . E oEouL"r1B�E s RE7fiN7�ON '''s S a w°r��,sq��wo V1/Cs842932 04/p1/08 a4/Ol/09 � a� - EMP40YERS'I.IA8IUTY E.L FAGH ACGDEPR a 500 000 ANv pROPRt�TOR/PARTNF3i/F�tECU7ryE o��coa�o,+a�occwoeo� �,�.as�nsE.EA EMP6WEE i 500 000 sa�Ci��v s oNs ne�ow E�asFase.POUCY uMIT s 500 000 oniER . �SCRPTION OF OPERATppNS I LOGA710N3!VEHICLES r pXCLtIS10N3 ADDED Br ENpORS��SPEWIL PROYIS�ONS AOtel G�3 l��J I�D � � :ERTIFICATE HOLDER CAIdCELLA710N L . • SNOYIA A�G��n80VE bESCRI6ED P�JCIES BE CANCEIIED BEFORE itiE E7tPIRATiON TQV1M OF YARMOUYH on��oF,n�issuMo wau�e wiu Enoenve�ro Ma� 30 unrs wa►rreH 1146 MAIN STREET "o�e T°TME c��c"r�"°�°�x"a�"E°T°TM��%eur RawRe To�o so swui 5 YAE2MOUTH, MR 02673 �e No osua►nar ae uaenmr oF,wr�uwo upo►�r��,NsuR�,rrs n�ars oe REpR�SlNTATNES. AIt7'NOR¢ID RFpRE5�17n11VE ►coRn 2s�zoovo8� �► ot�►t'�aN�sss e 1 � . , �, I THE COMMUNWEAL7'H OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #Q9-039 FEE: $55.00 This is to Certify that— ___ 7ohn J_ Hvnes,Jr_, Pres_ d/b/a Cane Traveler 492 Route 28. West Yarmouth. MA i HAS BEEN GRANTED A LICENSE TO ; OPERATE MOTELS { This License is issued in confarmity with the authority granted to the Board of Health,by Chapter 140,Secrions 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 condirions,and to the rules and regulations 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 28.2009 BOARD OF I-�ALTH: .��S�Q��..lv.� ��IttI�AK C!l�acl�e .��lil�x,� �tl,i,ce C'l�a�ixncaa *29 Units;29 Bedrooms J��.�'KBtUIt� (;�At� 1 Unit—2 Bedrooms downstairs Qftft(��q,ttm� �„,l�(, 1 Unit—3 Bedroams upstairs—manager's �'"�'�f'�'� �"�F�" { Director of Health' ' ��CHO � TOWN OF YARMOUTH BOARD OF HEALTI� PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiTMBER: #09-149 FEE: 35.Q0 In accordance with regulations pmmulgated under authority of Chapter 94,Section 305A and Chapter i l l,Section 5 of the General Laws,a permit is hereby granted to: John J. Hynes, Jr., Pres.,492 Raute 28, West Yarmouth, MA Whose place of business is: Ca�e Traveler Type of business: Continental Breakfast To operate a food establishment in:_ T�wn of Yarmou�h Permit expires: December 31, 2009 BOARD OF HEALTH: .��e�e�t S�, J�..N., ��uixen�an C'.�araileo �. 3'�e�tili�ex `tlice C'��wrn�acn J�o6�rt�.�B�raiva, e� ��"xeen�a�un, Jt..A�. Frr�:P- January 28.2009 ruce G.Murphy, H, .S.,CHO Director of Health � � . . , , THE CQMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIIMBER: #09-068 FEE: $80.00 This is to Certify that John J_ H;mes,Jr_,Prec_ d1 /a .ane Traveler � 492 Route 28 West Yarmouth MA � � IS HEREBY GRANTED A PERMIT To Operate a Public, Seari-Public Swimming or Wading Poot At Cane Traveler - OUTDOOR POOL 492 Route 28 West Yarmouth, MA This permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31 2009 unless sooner suspended or revoked. .r�,�y zg,zoog ao�v oF��.�x: 3f�en S�, ✓2..N., t'.�wrm�cua Cl�nnlee .�.3�e�ti�x `�ice C�awrman J2o6�r� �. `��a�cwt, G� Cluurc C�'ac�ert�aurn,J`t..N. ruce G.Murp y, . ., Director of Heal � i � �.�.«.ZC�I03 30 3QIS 2i3H.L0 3.L3'I�CO�Q\�'iI3A0\ZI.1.L 3Sd3'Idx.�.�� , 00 �ssi s = �na s�norn�� oIS �39h�H��k'dI� -.,� � OSS OJJdHOI. �I3SS3Q I�I3Z0?I3— SL5 'S'�000`SZ> �. 0�5 Q003-tJN '� •g•bs 000`SZ<� S� "8'�OS> _.LII�'?I3d 3 �1�3?I 3S!�I3Jt1 �I.IL�RI3d 333 Q3�IIIla3�I 3SN3JI'I a � ` � : << 11�IOIh'Y�OJ OSIS Sid3S OOI< <<S �I3I�tI.LI�IOJT SLS SiH3S OOI-0 =.LII1?I3d 333 ,H r+ � 13�I3ShI3Ji'I #.LIL�i2I3d �33 Q3�IIf1a32I35t13�I'I '' _ � • �'� -- _ �3�U�3S Q003 � ' SLS �,,n '��, 1 �,� . �,�n n � — _ ea - � e^ ' �_�-,^n `� J� tTI�2II OSS 3'J(IO'I SLO" S�� .gaSLS ZOt S S ,,,"�F ��f�-a4, � ,v1 � �°� �.�J OS� l�Il�i[ �� Ch9-5'o� oss y ,'�' �.�� b� J��? �� oss g�g � =iIY4?I3d 333 Q3?IIi S,�,po�3 »�.�,,,� .��I�I3JIT ?#iIIh'2I3d 333 Q32I[Ila32I 3SI�I3JI"I 1 y) � � �_ �:.�U �SR ��I330 ��aoz � # "I�'.LO.L �J1�II.LH3S .Ll�id2ifl�'.LS32I �� '£ � �Z 't ' •ssauisnq o a�B�d.�no,f�u ap,� B uig�uigm puB saidoa �+au apino.�d;sntu no� •sp.�oaa.� �s.�Ba��sxd asn;ou�itn��uaw�ag�aQ q�iga�aqs �uuo�sic�� 01 suvu��ua�aa�Eojduza�o saido��e�� pere motaq sampa�o�d�u�oq�-i�ue u� pautea� saa�oidu�a mo�C �s� as�ajd •sauz�l � 1� sasnuaad a�� uo.�annatrey� � u��unaH au1 ui pau��.c� aa�ColdLua auo �sBaj �� an�u �snux a.�ouz .�o s��as SZ c��inn sluau�s�q�isa a�in.ias poo� � �SNOI.LdJI3I.L2I3J H�I'INII3H �z 'I �uotle.�ado 3o sanou�uunp a�is uo (�Id)a�.��uI uosaad auo�seai ��an�u�snLu ivau�s�q��sa poo��8� �3��1�5 l�II 1'��?��d �Z 'I � •�uawqsiiqB�sa.�no�f�B ai� g aig�aiBw puB saido� �au apino.�d;snw no� •sp.�o�a.��s.�Ba�f�s�d asn aou i{��aaw.a.��da�qa��ag aqy •uoi��ildd�s�q�o�uot��yi�a��o satdo��B�e asgaid '000'06S 2IL�IJ SOi `s�uauzqsiiq�;s3 a�in.�as poo3 .�03 apoJ �;nies a�e�s aq; u��paugap s� `aaR�ugy�uou�a�oad ' poo3 � se pagi�a� sc ounn aa�ojduza aun�-jin� auo lseai �e an�u o� pa.nnba.� aai s�uacu�s�qe�sa a�in.ias poo3 �y i �SI�IOI.L�JI3I.L2I3J - S2I3jJdI�IdL�t NOI.LJ3.L02Id Q003 ��' '£ _�� Z i 4��,► ''�1�. •ssauisnq;o a�B�d.�no��u ap,� B atB�aiBw puB saido� � .�au ap�no.�d �s�� a�{ •sp.�aaa.� �s.�xa��sBd asn �oa i�� uaa��daQ ��a� a�{J, •uuo3 sn�a o� suot�B��ta,taa aa!�oidcua�o saido�tt��pue nnolaq saa�oiduza asa�;�s�as�atd.'��Td�)Aoj��}�snsa��euouz�ndotp.��mnuxazo,� pue p��sn3 p.��pue�s `,i�a3es aalem�is�q ut pagTua��I�ua.rm��saa�oj uia onn��o umuziucux e is��sritu sao��iado lood 'z - �_� 'I �uuo�siu�o�uoT��gt�a�ac��o�do� g��uB paB (s)ao��aadp jood pa��uatsap a��sii as�ajd •M�i a�g�s.fq pa.�inbas s�°.�o�g.�adp iood e sg payi�aa aq�snw.�osin.iadns iood aq,J, =S1�IdI.LdJI3I.L?I3,� 'IOOd .. . . .. 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INSURERA GRANITE STATE INSURANGE 236�9 512 West Main Strset n�sur�R�: West Yarmoafh.MA Q2673 msu��x a m►sur�R a �r►sur�rt�: _ GOV�i�At3ES THE POLICIES QF INSURANCE LISTED BELOW HAVE BEEN 15SU�D 70 T1iE 1NSURED NAMED ABOVE FOR 7fiE POLICY PERIdD INDICATED.N01'WrtHSTANDndG ANY R�QU�REMElV1',T'@RM OR CONDITION OF ANY CONTRACT OR 0111ER DOCUMENT WIT11 RESPECT TO WH1CH THIS CER7tF7CAT'E bu►Y sE 1SSUED�R MAY PERTAIN.TIiE INSURANCE AFFORDED BY TF[E POLICIES D6SCRIBED 11EREIN I$SUBJECT 70 ALL 7N�7ERt1A5,EXCLUSlOIVS AND CONDf1701VS OF SUCH POIJCIES.AGGRE¢ATE�IMIT$SHOWN MAY HA1/E BEEN l��DUCBD BY PAID CLA�S. 1NSR AbIJGY NUN06F! PO�JCY EFFEClIYE POLICY EXPSiA110N w� 6ENeRAL uA91ux EACM URRENCE s COMMERCIAL GENERAI.UABIU7Y ' EM cu f ce s ClAIMS MAD6 �OCCUR MED EJ�(A�ry one psBoN s PERSONAL i AOV INJuRY S CiENERAL AC3bRECiATE S GEN'{.AGGREGATE LIM�T APPLIES pEl'G PRODt1CT3•COMP/OP A66 S pouc�r � �oc - AVTOMOBILE LIAB1L17Y COMBtI�SINGLE L16lIT a ANY AUTO (Fa aCWenU ALL OWNED AUTOS BOOILY INJYRY y SCHEDULED AUTOS ro�� FIIRED AUTOS 9pDILY INJURY s NON.OWNED AUTOS (P6r aoOiCBIM) ��n�e S GRRAGE LIABILITf AlIfO P�tY•EA I�CG�DE1'R S aNv atn0 OTI�IER THAN EA ACC 5 AUTO CN�Y: A00 S ��e�v,p WppJ7Y EACH Ol"�CURRFJuC� S OC�UR �ClA1M3 MADE AOOREOATE s S 4EDUGTIBI.E S RETENTfON s s q wowceRscauw�r,so,naa,wo W�C6832452 04/01/07 04/01/08 �""�$rnsu- ��m EL E4CM ACpDEtJT S rJDO OOQ ANY PROPRNxTOR/PaR7N9vF.%ECUiNE OFFlCERMIEMBER EkCLUO�p� �,��_Eq�p�yr[-� s 500 000 ��y�d0�'AB� E. OISEnSE-oOuCY LIMir S 500 0� SPEdA�PR�SIONS below 0'n+ER DESCRIP710N OF OpERa770NS�40CAnpNS�VEH�q,E3!fiXCLUSlON3 ADDED BY BIOORSeIHENT!SPEdAL PROyWlOK6 CERTIFICATE HOLDER CANCELtATION sHau�.o nNv oF nie neove oas�wem roua�s re uwce,.,�n sffore�n+e�w►n�, TOWN QF YI�RAAOUYI"� ��TME��T��UYIG INSORER YY61 ENDL1►tlQR TO Mµ1L 3O pAYS WR�TEN 6�TiCE TO TIIE CERSaICAT[MOLGlA NAMED 7'0�E IEFY.81JT FAIWRE TO DO 90 SYl1� ' 1146 RT 28 WPOSE NO OBY6AlION OR W1B1LflY OF+4NY IN�D IJPQAt riiE�NSU�i,�'�5 A3ENT8 OR ! � S't!ARMOUTH,MA 02644 I t��TAmres. � 1WTf101i�D R6PR68ENTA � C.. � ACORD 25(200il0$) �►ACORD CORPORATION'9 988 i THE COMMONWEALTH OF MASSACHUSETTS T4WN OF YARMOUTH BOARD UF HEALTH PERMIT NUMBER: #08-047 FEE: $50.00 This is to Certify that rich Villa�e Holdings d/h_/a Cane Traveler 492 Route 28 West Yannouth MA HAS BEEN GRANTED A LICENSE TO OPERATE MQTELS This License is issued in confornuty 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 Massachuseus relating thereto,and upon such terms and con�itions,.and to the rules and regulations in regard to said Motels so licensed as adopted . by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. March 10,Zoox Boaxn o��.�: .�eBerc Sf#a�, J2..lV., C'f�aiacntan (',f�urlea .�.�.�i�rea'c� `?l�ice(',�acvxnuxn *29 Units;29 Bedrooms .�i�P!/�3.��4[UyL� �;CQ1[t� 1 Unit—2 Bedrooms downstairs QK�t � �..lV- 1 Unit—3 Bedrooms upstairs—manager's t�114�(f.tt�-��@6 _ _, . . . _, : .:. ruce G.Murphy, RS.,CHO �r Director of Health r , � ± TOWN OF YARMOUTH �' BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � � PERMTT NUMBER: #08-165 FEE: $30.00 In accordance with regularions promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a pemut is hereby granted to: Irish Village Holdings, 492 Route 28, West Yarmouth, MA Whose place of business is: Cane Traveler Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Pemut expires: December 31, 2008 BOARD oF��.TH: .�Ee�.en S�, �., C'l�aixtnarft ('.harx�ee :�. �'�eUi�e�c `vice C!�aiaceuYn J?.a8�t :�.�I�n, C� ��+�� - March 10.2008 Bruce G.Murp y, .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-075 FEE: $75.00 This is to Certify that Irish Village Hol ' gs d/b/a C.ane Traveler 492 Route 28. West Yarmouth, MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Ca T veler - OUTDOOR POOL 49 Route 28 West Yarmouth MA This permit isgranted in conformity with Article VI of the Sanitary Caie of The Commonwealth of Massachusetts,and expires December 31,2008 unless sooner suspended or revoked. March 10.2008 BOARD OF HEALTH: .`�Cl(!/L S�� ✓�../v.� ��/tlxlt C',�icw�,e�s �. J'Celli�c `tJice C!�icixneeacn ��E 3.��ca�un, e� Qiui�!xee,��Praurn, ✓2..IV. Eue�C�' Director of Healt' � � � -� '. �� f Yq G i� ,T1 l �' 2° �. R� TOWN OF YARMOUTH BOARD OF�EA�T`� {�1 F: "$ APPLICATION FOR LICENS��fP`E�t1�Ifi �+(1�0�j�`�' �E C 1 9 2006 ..•� � ,�(�:[3" `�` * Please complete form and attach a11 necessa�y do�ie�ts by Decembe 3��}-{ DEPT. Failure to do so will result in the retum of your application pack . NAME OF ESTABLISFIlVIENT:�'a/� t a�t ��e� /'ja�C � T'EL. # �0� 77/-41vU LOCATION ADDRESS: ��C� Ieor.��t t�'! Wt,3r Y�i-,•,v��u.� f2t� MAILING ADDRESS: OWNER NAME: V ok h !��cr Tt�X T� (FEIN or SSN1� CORPORATION NAME(IF APPLICABLE): J MANAGER'S NAME: tj ok.� �.��5 TEL. # MAII.ING ADDRESS: 51� �la�� f- W cs�F �.�w..� �f�' /�.26 7 3 POOL CERTIFICATIONS: The poal supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Fool Operator(s) and attach a copy of the certificat�on to this form. � 1•__ /_�16�1n.l�-�' �t/a � 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 emplayees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. ok•. �.t3 2. /k� ��'��i Gc� 3. '�►or�.Rs GH-�S 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food � Protection Manager, as defined in the State Sanitary Cade for Food Service Establishments, 1Q5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. � You must provide new copies and maintain a file at your est�blis6men� � l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. 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 a11 times. Please list your employees trained in anti-choking pracedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OF'FICE USE ONLY LODGWG: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# B&B �50 CABIN �50 �MOTEL $50 �Q,��' 6 _INN $50 `CAMP $50 r SWIIvRvIIt�iG POOL$75ea. 7�4��J' _LODGE $50 _TRAII,ERPARK $100 _WHIRI,POOL $75ea. t � FOOD SERVICE: r LICENSE REQUIRED FEE PERNIIT# LICENSE REQUTRED FEE PERMI'P# LICENSE REQUIltED FEE PERMI'T# � 0-100 SEATS $75 �CONTINENTAL $30 O�� NON-PROFIT $25 ' >100 SEATS $150 COMMON VIC. $50 WHOLESALE S75 � — — — RETAII.SERVICE: �RESID.KITCHEN $75 � LICENSE REQUIRED FEE PERMIT# LICENSE REQIJII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# T<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $2d i _45,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE = S l 55•O� •••"•PLEASE TU1tN OVER AND COMPLETE OTHER SIDE OF FORM""""* � L- .. I ADMINISTRATION ' i Under Chapter 152, Section 25C, Subsection 6,the Town af Yartnouth is now required to hold issuance or renewal of any license or pennit to operate a business if a person or company does not have a Certificate of Worker's ! Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT, OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO� - - __ __ _ _ _ __ _- - - __ MOTELS AND OTHER LODGING ESTABLISHIV�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short tenn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place afresidence 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 se�son must be ins ected by the Health Department prior ta opening. Contact the Health Department to schedule the inspection five(S�days pnor to openuig. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. . FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta�ned 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 Boazd ofHealth. OUTDOOR COOKING: Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. 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, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQIJIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR T4 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �Z��'�,�, SIGNATLTRE: PRINT NAME&TITLE: '��. ion�� A�,� C�RTI�ICATE C�� I.IAB�LI7Y IN�URANCE �"�'"�'°°""�'� 19117 006 � P�O�� THIS CERi1FICAT£ IS ISSUED AS A-�IAT'iER OF INFt3RYA71pN HART INSURANCE AGENCY, tNC, oN�v a�Q coN��s Na w�Hts uaow rEr� c�rxnF�ca� 243 MAlN STREET HOI.oER. 7H�S ��xT1�iCATE obES NOT �tINENa, EXIENO oR pQ BOX 700 p`�'�� THE �� `ORD�D 61f 7ME POLICI�S �ELaW. BUZ7ARDS BAY, MA 02532-0700 �Nsu�Rs�o�nuc cov�►�E r�a�c� ��D Irish Village Restau.rant and Pub.Inc. IN6URERA: AIM IN URAN E C.O PA1V1� 7892 St�West Main Sfiraet ir�ua�R� West Yamnbuth,MA 02673 ,�E�c iHsurt�h o: IN$URER E: COVERp,GEs - rHE POuc�S o�1NSl1R�wGE Us1�o BELO�nr HAVE eEEN ISsUED TO TME:INSUREDI+uMED ABovE FOR ni�PO��C�f P��oA IPtb1cATED.N07vV�7H8TAriouuG ANY REGtnRF,MENT.TERM OR CONDmqN OF�WY CON'I'RACT OR 0'1'tiER DOCUAaENT WrtH R�SPECT 7o WHlCFI THIS CERTIFICAT�MqY Be 19Su�p OR MAY PERTAlN,7H�iNSuRANC6 AFFpRpEu BY 7FiE POLICIEB DESCR�ED HEREIN IS SUBJECY Ta ALL TH�TERM6,EXGLUSIONS ANp Cc�NDITIGNS QF$UGH POUC�S,AGGREGATE LMIYS BHOWN MAY HAVE BEEN FIEDUCED BY PAIO CLA�LNS. . IN9R ' P�LICY kYNBER POI.IC1f P'4NC1f E7tP�1A710M yMRS �teRa�tL�91Niv EACH:4CC61RRENCE COMMERCIALGENERALLIABII►ry I • oco oe i aAIb18 MADE �OCCilli MIEQ EXP otte' rsorU i PERSpNA�6ADYJNJURY S CiENERAL A6GRE TE i �EN'l AGOREGqTE WMIT APPLIES PER: PRCOUCTS•GOMplOP.AGG � POUCY ��' lOC . AY'roY0816E W1B�,ITY CQM�NEO SINGLE ululT = ANYAUTO fE`a�Jtler�U ALL OWN�O AUfQ3 BOCI6Y INJURY � SCFED4J�,ED AUTOS (��AM90n) HIREDAUT06 eODIW WJURY NON.pWN$DAUTp6 I�'�) S �E��MAOE i. . �'�� AIJTO:GNL -EA�CIDEN7 . ` ANY AVTO OTk(ER TWAN �"'� S .,. AUTOGNLYr �° S EXCE.S�i16RELLA k.G8L1fY EACH ENCE i OC(xJR �CLAIM9 MAOE p�+REt` }E ; i . . aEDUCYIB�E : � . RBtENTION f S A ��u�e�n�0N""D WMZ8004199012005 04/0'l/06 04/09/07 v�:sr� u: o►�= ANY PROPR�E1'ORIPMTNEf�CUTNE E.i.EA N#OCiIbENI' i rJ OO OfFIGERAAkT.tBEREXCLUD�P7 E.LOOSE�16E-fA.EIYtPLOYEE S ,.-- .S OO SPyEi'�AL�PR�OVI1 S�S CqOW E.L.dSEA6E.p0114' GiNR S rJ� � OTMER ofscR��►ON oF oPe�►�or�a r�ocA�oNs�v�+�s�Exa-U516ris aoom 6Y�aooRse�ENr rs�cui vRou�oa8 MOtAI � CEariF�CATE Ho�EI� �_ _ .. . C�wC�LLAnoN ' 6HOULS MNY OF TNE ABtOYE OESGRI�D POIJGI!$BE CANClLLED BEFpRp THE EXPIpA'f10N ' TOWIV OF YAh�MQUTF) d"�T"�,T��a iNsua�rt wrci e�+q�►vae to Ma�. 30 DAYS WRI'REN ' 1146 RT 2$ �ro ti+e cr�n�uc��No�ww�Te,r��r,e�rt F�ur�,n oo so at+au. { S YARMOUTH MA 02$44 MPOS!NO 06UWYION OR WBWiY OP�NY KIHQ UPON TNE NBUYiHR IT$J�NTS OR i i ' RE bOiTATl1l�5. �un�owx��xEseqr � ACOiiD x5(2G01/08) . O ACORI]��f1E��lT10N i986 THE CQMN�QNWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #07-030 FEE: $50.00 � Tlris is to Certify that �o n J Hvnes,Jr dlhla Cane Traveler Motel 492 Route 28, West YannouthLMA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS Ttris License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E�s amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusel.Ls relating thereto,and upon such terms and canditions,and to the rules and regulations in regard to said Motels so licensed as adopted by the Board of Health,and e�ires Decembex 31,2007 unless sooner suspended or revoked. �n a�,Zoo� Bo�oF��,�: Q �. a�o�,iLl.�., . df�e�e��i, �.JV., 'Usce�G�l:�i�t�,r�t Rod�t 4 B�u,�rs, G�lenk n��r�� 4.t.a�� R.N. . _ Bruce G.Murp , , .,CHO Director of Health __ ___ _ _ _ __ __ _. __ __ _ _ _ _ __ TQWN 4F YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD E5TABLISffiV�NT PERMIT NUMBER: #07-107 FEE: $30.00 In accordance with regulatior�s promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permrt is hereby granted to: John J. Hynes, Jr., 492 Route 28, West Yarmouth, MA Whose place of business is: Ca�e Traveler Motor Inn Type of business: Continental Breal�ast To operate a food establishment in• Town of Yarmouth Pernut e�ires: December 31 2007 BO�tD oF HE�,TH: B _`1S. ,/YI.-`n•, ' �� '�, v�e�� R�t 4. e�, Gl� � p�,�A��s�t �4��, R.N. I � March 27.2007 �' ``� j Bruce G.Murphy,MP , .,CHO j Director of Health i THE COMMONV�EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #07-052 FEE: $75.Q0 � This is to Certify that JolLn J H�Le�, Jr__ d/t�1a Cane Traveler Motel 492 Route 28 West Yarmouth MA IS HEREBY GF:AN1''ED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Traveler Motel - OUTDOOR POOL 492 Route 28 West Yarmouth, MA This permit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2007 unless sooner suspended or revoked. March 27 2007 BOARD OF HEALTH: 8 �S. ,/��., . d►�eayi��5'lsali, �sce G��u.� Rol�t�.B�eou,�, G� n�� 4.�� , R.N. _ _ . _ _. . _ _ ru G.M y,MP :, Director of Health �^ „rw" ��7�J� . F.'TRAJ6/ o ;�R,y TOWN OF YARMOUTH BOARD OF H�+A�$-� e� � � (� (� � M C� D o�� ='c APPLICATION FOR LICENSE/PE�� 6` ' ? � ,, ,,s � 5 - DEC � 0' 2005 * Please complete form and attach all necessary dpciame�s b�I�ecember l, 2005. Failure to do so will result in the return of your application packet HEAL�fi H JE�'`!�. NAME OF ESTABLISHMENT: C�,De /rc�vc�� lyo-�a�. -�� TEL. #S5�� ?7!-0!�� LOCATION ADDRESS: Zf�fa /"1�:n v�'- �' R f a�' j,J��+ �a�,�e��'I.� !� d.��l 3 MAII.,ING ADDRESS: OWNER NAME: �ei�.� T c S TAX ID(FEIN or SSI�' !� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: la�ii.. �`�H �S TEL. #�.5'087�/-o/v c MAILING ADDRESS: -_. - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated --�eal- of the c�tificat�on to this form. 1. �d��t. C �trl��.`x.� 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 ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � r�� 1. a� k �S 2. �°� �w� S 3. a t" -►'i i.�. 4. - FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this agplication. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CHARGE:_ - __ _ . _ _ . _ _----__ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlb��CH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and at��e�i eapies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# _, - OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �g �50 CABIN $50 �MOTEL $50 H O�e-O 3 7 ; INN $50 _CAMP $50 � SWIIvIlVIIl�IG POOL$75ea. �OG'"QG / LODGE $50 _TRAII,ER PARK $50 WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j 0-100 SEATS $75 � CONTII�IENTAL $30 � �{( NON-PROFTT $25 �>100 SEATS $150 �COMMON VIC. $50 WHOLESALE $7S RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 � _Q5,00�sq.ft. $75 _FROZENDESSERT $35 `TOBACCO $25 � NAME CHANGE: $10 AMOUNT DUE _ $ 155.00 "•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'�•"" � i - .. �... � � 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 Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ✓ OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i Town of Yarmouth 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 RESPONSIBIIITY TO RETiTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlViENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; � � ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspecte�i by the Health Department prior to operung. 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 gound swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ' CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. � FROZEN DESSERTS: � Frozerr desser��rt�us� be�es�e�e�-�.�enth�y has�s by-�S�at�e�rtif�d-�ab:-Test r�ts��e sent to t�-Hea1t�_ _ 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 of Health. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmerrt is prohibited. � DATE: ��-Z��- Q 5� SIGNATURE: � PRINT NAME&TITLE: �d�� V. (��e 5 P�P-�� +-�:-I- � 09/28lOS ��,� ��TI�'I��►TE ID� LIABt�,ITY INS�lRANCE °��,�""�'�' ��t��oa� p�� THIS CERTIFICA7E 1S !$$U�13 A��A MATC�R OF dNF�i2�91Fe'TttBk�! FfA(�1'fhJStJR,�htCE AG�N�GY, 1NC. ONLY AND CON�ERS NO RlGF�ITS UPON THE C�R1'9PiC�T€i ! HOLDER. THIS C�RTIFICATE qOEiS NbT AM�NO, �� t�F: ; 2$3 MAIh)S7REET ALTE12 YHE C01/�RAGE AFFORDED 6Y THE p0l.ICfE� ��L.R��'d. � �o sox 7ao . y �, ��3�7ARDS�AY, CutA 02532-0700 INSUIiERS AFFOitdlNCy CpV�RAGE__ NAiC M ; 8p$L'R�a ��$h Viilage Res3surant arid Pub,InC• � . � INSURERA SC TSDALE INS RA �� --CO � � � ��. .41297 �.�„� � �1�West Main Street in►su�R a IM INSU NCE CaM ►I+1„ Y_�__�____,,,. 1$92$ � V�est Y'�rmduth,tdlA 02873 wsu�c: " � RER 0• ' i INSLIRf,R 8, �;�3li��4C�5 ` TN�P�7LiCIES OF INSURANC�USTED 9ELOW FiAVE BEEN ISSUEd TO THE INSUfiED NAMEO ABOVE FOR TIiE pOLICY PEI�GD INDICATED.NO7WITHS7AtIDlNG hNY REQUtREM�N7, 7ERFd OR GflNDl710N �F ANY CON'fRACT OR Q7N�R DOCUNtEN7 W�I'H RE&P�C7 70 WMICH 7HI3 �ER7IFIGA7E h1P�Y BE!$6U�p�R Rt+AY PEftTAJiV,7HE INSURANCE AfFORDED BY THE POUCIES OESCVt18F�HER�IN IS SUBJECT TO AL�7HE TERMS,EXCLU�510N&AND CONDITl4Nv�5F�UC!i ?�?4fWlE�.r�GGREGATE LI[V�IT58HOWN MAY HAVE BEEN REDUCED BYPAIO CWM3. � l7JSi5 a�S6T6 PO►JCYNYh16ER PO PONCYE7LPR/l Oy ��- -- � {� � �'��'TM BCSd071199 09101/05 09/01/06 � ocYURR�� s 1.QUO,Cu�� ca�sMeRcu�c�N�aA+.�u+s�urv _�E�ISEs rE.�,� � �'0 ti Q cwr�sMaCe ��cCUR Meo�4 one i �s � � P�Rsowu.8 qp�IPUURY 1 �QO�� ! oENEwu_ 3are s 2 000 t�6D � � I�G�EIV.'LP.GGR��4Tkt,IMITAPPLIESPER� PRODUCf:,.CO P10PAOG $ 'E O�] C�I� _ � I 1 POS.I(:Y I �P L� . � . . � f �Atl7Q�Rt�3U:L7A61UTY COMBIIYED SlNGLE IIMIT � .aNYAU1'0 (EeaaWen� $ � �—^ A66 4VYNE8 AUT03 BOOII,Y INJURY ( I SCHeDu�EDAUTOS (PerPeaon: � I I HIREO AUTps BOQII.Y IMJURY S %I noN.t3wN�0AUYC6 (PeravafWvO � � --^' � � � PRQPERTY DJWA6E ( ( i (Perewddar•t> . � iy ��nkRkGE!.lN�81LI'IY �JTO ONLI'•EA ACGDB►�R 5 { I �AtJY AUTR . A��WI.NV'� �a� $ . �� i �� E�.'C8S3�:�WIL'�ELLALWBIEJTY CMOC{x1RJlE S i ; �CCUR �CLfdM$1qADE AGOREIiATH $�_�_ � I . . , .. � � �EGuCT1BLE ; ..... _..., $ .. __ H=1'ENTION S .. ,<. ..., ... ' $. Ff —,... . g �wo�aco�P�,snrar+nr+a WMZ80�369001200� 04/01/Ob a4l01/O6 ., �fF60YERS'LIAS1lITY e,�.�►cr+Acao��ur ' _ �t�Ci.Cfl fiNY AROP�IETORlPARTn1�ke�X.CIJT}VE ,. �cFFrc��+�ase�Exc�uaEar �.�.o� e�r�eMP�ovg� " _ $f10.bti �ts yas,dexr�a�a+dar s�ec� paovis: Ns bacw : .. �:�a_ . �-_ --- CtKi►T...g__�__.__ 5 Ati � arHea �`' I , . ,...- .. :_�-'"` w.. __ .. bESCk31PYlS3H�OPERATtddB!tQCA1tAH9 l VEFIICIYS/E%CLYSIONS J�q�D BY ENOORS@Y�Mf!SPECIAI.PROY161pN9 _ . __._`� ,... e� ._ . :. _ __ � � �. �.�-- �— ��.TiFl�ATE H�LDElt CANCELLA7IGN � � ��wr oR�nre n�ove oEscwaeu wuc�ve e�wc�uFo e�r�n��wi�anaa i "fdWIV t7�YAFZMGUTH a►r��►+E+�.YME 166YWB INSYR�R WI�l HNpRhNOR TO MRIL 30 oavs wru�r��i ! '11�6 R7'2$ NOTIC�TO 7HE CPA71FI4ATE NOLOlR NAh1ED TO 1Y1E I.EFT�QU7 FiqK,YRB TO OC 80 SHA4. i s IMP08E NO OBU6ATIQN QR LIA66JTY 0�MIY N711D UPON TNB W3tIR�t,!TS AG�NTS OFt � � r�. Y�I�M�UTF'�� O�LG�� R 9ENTN17VpS. .. ..... � � Ai1TNOR�Eo REPfiESEN7w � ��J �1� ��r�IU ~V d�O i ��0�2�(2601/R8) BA�CORD CORPOFWTlC�!i��F( � � � � Z0 3Jdd 1�Jd 3�NtiaflSNI 12JdH 99EL69L805 90�ST 500z!$�/T-t THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #Ob-034 FEE: $50.00 This is to Certify that JolLn J Hynes, Pres d/b/a Cane Traveler Motor Tnn 492 Route 28 West Yarmouth�MA HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in wnformity 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 adopt�i by the Board of Health,and expires December 31,2006 unless sooner susgended or revoked. February 3,2Q06 BOARD OF HEALTH: Qe �. �ohc�o+t,/�-nv � �`�s`�, .�, v�e�� . R�t� a�, e� � p��s� ,Q.�,�!�'��.,�, R./V. . , �- Bruce G.Murphy, S.,CHO � Director of Health TOWN OF YARMOUTH B4ARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT, PERMIT NUN�ER: #06-141 FEE: $30.00 In accordance with regulattons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: 7ohn J. Hynes, Pres., 492 Route 28, West Yarmouth,MA Whose place of business is:_��ae Traveler Motor Inn Type of business: Continental Breal�ast To operate a food establishment in- Town of Yarmouth Permit e�ires: December 31, 2006 BOARD OF HEALTH: B _`�1. ��usy A9-`h•, ��s�, k�rr, v�e�,� R�d�t� B�, e� �� v��, a.�v. February 3,2006 G.M hy, , .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS � T4WN OF YARMOUTH , BOARD OF HEALTH PERMIT NUMBER: #06-063 FEE: $75.00 This is to Certify that John J_ Hvnes, Pres_ d/t�/a C;a:pe Traveler Motor Lnn 492 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Traveler Motor Inn - OUTD��R POOL 492 Route 28 West Yarmouth MA This pernut is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e�ires December 31.2006 unless sooner suspended or revoked. Februaty 3,2006 BOARD OF HEALTH: ga��sle�st eS"�ji, �i��avuttasi Rod�t 4.Bnuu�c, C� ��isc�/�c��itxo� �sus , /�./�. I ��, B .M hy,MP Director of Health �.�.;:` �,6e..� �o �cs� a.. F�A j % � .. R� TOWN OF YARMOUTH BOARD OF HF�1c�.�f ��`� � �`: � -,� APPLICATIO�T F4A LICENSE/PER�I'-2oos FEB 0 7 2005 ,,,. * Please com lete form and attach all neces d `�'l t§� December 1H� ; P �'Y a� Y l H DEPT. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: s �9 pc �.e�✓E�E,c TEL. #�oY- ��- r�i oc� LOCATIONADDRESS: �9m? H4��1 sr,e�E,— cJEs, y.4.eKc,u�r� N� o�G73 MAILING ADDRESS: �'ia ��,,� �"�.e��; c-s� �sl.t K eo/�y.� N 1� o��3 � OWNER/CORPORATION NAME: MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. { 1. �r,.✓nJ i c–' �w�h�:�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 Healt6 Department will not use past years' records. You must � provide new copies and maintain a file at your place of business. � ,-- , 1. �rfA.2ciF �E�A�IEy 2 ..�1 �IcX of�lGS 3. 4. � � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies o�certification to this applica.tion. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. � 1. 2. PERSON IN CHA�iC£: -_ ___ . _ _ _ ____— Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ; 1. 2. � HEIlViLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures t�elow and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY 1 LODGING: LICENSE REQiJIIZED FEfi P�RM[T# LICENSE REQUIIZED FEE PERNIIT# LICENSE REQUIIZED FEE PERMIT# BBtB $50 CABIN $50 �MOTEL $50 CS �O � � _INN $50 CAMP $50 / SWIlVIlVIDIG POOL$75e&. O S�d � � LODGE $50 _TRAII,ER PARK $50 WHIItLPOOL $75ea. � FOOD SER'VICE: i LICENSE REQUIRED FEE PERMI'P# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# � 0-100 SEATS . $75 1CONTINENTAL $30 �'OS��f� NON-PROFiT $25 i — � >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 � — — — 3 RETAIL SERVICE: I � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTP# LICENSE REQiJIl2ED FEE PERNIIT# <50 sq.ft $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 � — — � _Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 � , � NAME CHANGE: $10 AMOUNT DUE _ $�SS.O O � """""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""�" i . - � \:. __.._ a ,. E , � ADMINISTRATION i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal '' of any license or permit to operate a business if a person or company does not have a Certificate of Worker's ' Compensation Insurance. THE ATTACHED �TATE WORI�R'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK ' APPROPRIATELY IF PAID: I YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T'HE Cl?MPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. ', SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR ', TO CONA�NCEMENT. RENO�ATIONS MAY REQUIRE A SITE PLAN. , ADDITIONAL REGULATIONS POOLS P40L OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i by the Health Depa.rtment prior to opemng. li 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 ' clasing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requu-ed Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ��i��L1�DE��ERTS• _ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the : above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING• t3utdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ; I j � DATE: �,5 I fl� SIGNATURE: PRINT NAME& TITLE: --J'`f cz" Y �s ,r�p . 10/22/04 � f a r , ' t'��.�'\ ----� The Comnionwealth�f Massachusetts ��- _— DepaRMent of Industnial�ccidents = �Nrws�1M� � - 6(l�Washington Stree� 7"�`Floor - _: � - ,� Boston,Mass. 02111 .,,. Workaa'Com�tho�i�s�aaee AiSdavi�Baii bi�/Bkedncal Coitraetors � �_ ,.... � .�� , ��r_ < , a s _� ; , �._� �, , ., �r . ,-,. ; , , .T �-��,, . , � � �: i��;� �y.�E s address: �/�:t l�'liQ�nI �b7pE�FT �� s" �,t r(o ot T� state. J"/ � zip. D•�G�3 ohaae# �p-�� -O/O O work site locati�(fnll addressl• p I am a�O,vn�perfo�i�all Wo�C m,r�l�: Projecc T,rpe: ❑xew ca�ucaa�►pRemaaea I am a sole 'etar and have no�e w in an Buil ' Addition [+�]�I am an e.n�ployer providin�g warkeas'compensatia�t f�my emgloy�s warlcing�this job. /� � q�mu��au�ae. ``.4 PC^ ��t AJ��,C �: �9a �l 9�� r�e Fs� rffn: �E5; r�4�e1-/au%� ��- �0�-77 /—D/oc5 , �ss,oC. �•J�=�sT,t,�s cF }'�/� P�u-suq� �.JS C-o GcJ�(Z �oos�iQ9ar.?oo� ❑ I am a sole proprietor,geaeral c�tracMr,or homeo�(cirdi oae)and have hircd the contractors listed below who have the following wotkeis'�on Polices: ��t � ciiv; �c�: #� S�tlil4� � �= d19: v��: Fail�e tr aecas orvense a�requie�ed uder Salioa ZSA�t MGL 132 eu kad b tl�e hrpaitl��f c�i�i�d pnal�es�f a�e�p b S1,3M.N aadhr oue yan'6eptiee,�eat as we8 as dv/pwitla it t6e f�rs�ta 3TOt WORK ORUEA ud a Sre dS1N M t dsy aaa6st ie. I a�dnsdud tiat a c�py�f fiie�falea�my be firwardM b He O�ce of lwed�atlys�t tlrc DIA ter av�a�age v�eatl�a. I do beneby ce�ijy�d�e pwlna ewl peadbea of per}�rrry dUet dYe ierforiwsAto�provided aboae!a b�e awd onmr� Sign�ure � Date Print name c C �y/•�/F5 Phone# �O�-77/-O/QO efficial ase oely ds a.t wrke t�this am b 6e ce�Pkted bY dlY e�'Mwa�ffidal dlp or ts�vn: p�fl�emse� �lBoidi�D�t Qlice�sg Bsard ❑c�eck K�1e rdpsese is req�i�ed �Sdect�'s Offioe ��t eeatact pec'san: p�e�; �Q tTM�e s�r.mo�sa � . �- 1 , � j THE COMMONWEALTH OF MASSACHUSETTS � . TOWN OF YARMOUTH • � BOARD OF HEALTH � PERNIIT NUMBER: #OS-038 FEE: $50.00 Tlus is to Certify that Jac�$�e,�, Pres_,d!b/a C'ane Traveler I 492 Route 28. West Yarmouth. MA � ! HAS BEEN GF:ANTED 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 Cpmmonwealth 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,�d expires December 31,2005 unless sooner suspended or revoked February 8.2005 BOARD OF HEALTH: Best�rss�s�. �N�,ost,/��. ' A�� v�e�.� �s�R�.�+�►� �v��,,a�, R.�v. Bruce G.Murphy, ,RS.,CHO Director of Health � i � TOWN OF YARMOUTH � BOARD OF HEALTH �'i PERMIT TO OPERATE A FOOD ESTABLISHIV�NT �� ' PERMIT NUMBER: #OS-142 FEE: $30.00 � In accordance with regulations pramulgated under suthority of Chapter 94,Section 305A and Chapter . 111,Section 5 of the General Laws,a petmit is hereby granted ta Jack H es, Pres.,492 Route 28,West Yannouth, MA Whose place of business is: Ca�e Traveler Type of business: Continental Breakfast To operate a food establishment in`_ Town of Yarmouth Pernut expires: December 31, 2005 BOARD OF HEALTH: Be�ars�`h. �'o�oli,/�$. ' ��r�� v�e�� a�t� B�, e� �s�, R�v �4��j��, R.N. February 8,2005 ruce G.Murphy, S.,CHO Director of Health #�°" i , , • THE COMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT NUMBER: #QS-061 FEE: $75.Q0 I � This is to Certify that Jack H�,_Pres_ d/i/a Cane Traveler � 492 Route 28 West Yarmouth MA IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool j At Cape Traveler - OUTDOOR POOL ( 492 Route 28 � __ West Yarmouth, MA This pezmit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2005 unless sooner suspended or revoked. February 8.2005 BOARD OF HEALTH: Bess�tist$. �'Q?�t,J��. ' p��s�, v�e�� Rad�t`�B� � ��5'l�k, R.N. �4 R.N. Director of Healtli •� � ; �� --� ��353a ,. � a , as c � �f r R o TOWN OF YARMOUTH BOARD OF � k . [1,?,��, '� I�, 'i� N? ,__ o � �: ;,;s APPLICATION FOR LICENSE/P �; NOV 2 5 2003 �.. ...• =�:� �: � * Please complete form and attach all necessary do�ment��y Dece b 3d��jEPT. Failure to do so will result in the return of yo��pplication p . � ' �o� ��c�✓�� o:c.� �/�l 775-/�5 � LOCATION ADDRESS• ��a q ��' ��c�Fr� ;� �a� ! R/ .1-�4 c Z! � �' I MANAGER'S NAME: �� TE # � MAILING ADDRESS: Sp`�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ; Pool Operator(s)and attach a copy of the certification to this form. 1• C��^9-� ��cJc"c� l`�7'`�� 2. i Pool operators must list a minimum of iwo employees currently eertified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 1� � �� Z+��—y 2. c��IC �� 3. �LrwK,. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification to this applicatian. The Heatth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. --- — _ —----- - - - _ -- -- (, ARG�:-- ___ -— — . _ : _ ------ - __ __ . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i l. 2. i HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '' Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and ! attach copies of employee certifications to this form. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATiNG: TOTAL# QFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# L[CENSE REQUIRED FEE PERMIT# _BBcB �50 _CABM $SO I MOTEL $50 0 �6a� _INN $50 _CAMP $50 _J,_SWIMMING POOL$75ea. �0`�'b�.0 _LODGE a50 _TRAILER PARK $50 _WHIRLPOOL $75ea �OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS a75 I_CONTINENTAL $30 �O�F�D _NON-PROFIT $25 >100 SEATS a150 _COMMON VICT. a50 _WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PEitMIT# LICENSE RGQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD S20 _<25,000 sq.ft. S75 _FROZEN DESSGR"T �35 _TOBACCO S25 NAME CHANGE: a10 AMOUNT DUE _ $ � 'rJS•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** _ F �` + < � � 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 ATTAC�TED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED i/ Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Tawn of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRTATELY IF PAID: YES� NO NOTICE:Permits run annualiy from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRI4R TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RFGUL,ATIONS POOLS POOL OPEl�1ING: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. ': i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of � closing. i � FOOD SERVICE CONSUMER ADVISORY: Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters rv�nthin 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. , �RQ�EI�t�DES3Ei��'S: _ _ _ ' 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. OUT$IDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: �1��e-� SIGNATURE: PRINT NAME&TITLE: � � �� w-�-�s �-• 10l22/03 ACORD�, �E�TI�ICATE OF LlAB1�.ITY �IVSURANCE °�iiz rzoo` Peoeuc� THIS C�R7IFICAIE IS ISSUED k5 A MATTER OF INFORIYIATION MART INSURANGE AGENCY, iNC_ 4N�Y ANo CONFERS HO Rl:GH7S UP�N THE CERTIFlCATE HOLD�R. THIS CERTIF[CAT� DOES NOT AMEND, EXTEND OR 240 MAIN STREET AL7ER 7H� COVERAGE qFFO.RD�D �Y THE POUCl�3 BELOW. PO BOX 700 W BUZZARDS BAY, MA 02532-07Q0 INSURERS AFFORDING GOVERASa� NAIC# INSURED �rish Village Resffiurant and Pub,Inc.-Metel iNsurteRa AIM (NSURANCE COMI�ANY 18929 512 West Main Str+eet �r+sukERe; _ W�St Y8fIT10LtfI1, MA OZG73 IN6URER G: � tNbURER D: INSURER E: '. COVERAGE8 THE POLtCIES OF INStJRANCE USTEO BELOW HAVE BEEN ISSUED Ta 7ME INSURE�ruuN�D naove FOR n�E Poucv Pr_i;ipp INQlCr►7E�.NO7WI7F1STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTAACT OR OTHER DOCUMF1dT W1TH R�SPEC7 TO WIiICM TY115 CERTIFICATE MAY BE ISSUED OR MAY PERTAtN,THE�NSURANCF�FORDED BY THE POI.IC�ES DF_SCRIBED HEREIN 13 SU6J�CT TO ALL THE TERMS,EXCLU$IONS AND CONC11710NS Of SUCN POLICI�S.AGGREGA7E LtM17S SH04VIV MAY NAVE�EEN R�DUCED BY PAID CWMS. _ INSR 0'L PpLICY NUI�I� PQUCY Ep E P�C �CYUiA710N _ UWIY$ GENEAALUR�ILIIY EACFItiCCURRENCE S , COMtaE�YCInL GENERnI LW3IUTY WxE1A�.6s�E�e�o�an,anm S C W M5 MADE �OCCUR MED E7 P An ona nwn 5 _ PER&�VAL 6 ADV INJURY S C�NEkq�pppp�pA7E 5 GFSIL AGGREGATE LIMIT APPUE3 PER: PRODU�TS-l',pMPl�P nGG 5 .. POUCY P LOC — AUI�DYDBLLEUA&LRY COMEIt1ED81NGLELIIAIT s ANY AU70 (Ea aeayonU AiLOWNEDAUT05 BOdlYINJURY s SC�ouLED Atlros (por pucon) HIREDMUfOS BODILYINJt1RY $ NON-0WNED AUTOS (Per e�xida�iq PROPBiTY DMAAGE _ (Puf iXldertt) OkNAGE W191L1'IY AUTO C NLY•EA ACGOENT 5 ANY Atl1'0 oTHE�7W W ��C $ Auro cr��v: qGG a p�CGESS1utABREUA uASIUTY EACH CCCURRENCE i OCCUR �CWMSNADE nGGRE3ATE 5 s DF�UCTIBLE — . S RETEMION S � 'hC SiA7U- OTH• A �yQ�p$GOYPENSA'f10N AN0 WMz$pQ4199012003 03/31/03 04/01/04 �,exum�' er,�v�or�rts'uue�un' EL.EU:MACCIDENT s 5d0000 ANY PROPRIE�CtiP�Tn�vexECUY1Vr OFFlCEWMEMGER EXCLUDE69 EL.D SEASE•ER EMPL�YEE S rJOO OOO n vea aaurw.�.,dx E.L.D SFASE.aoucv u�nR c 500 000 SPECUIL PROVI$IONS�� OTHER OkSGRIPTION OF OPERA710N5I LOCA710NS I VEHICI,E$1 El(CWSIOMS AODED BY FJiDORSEMENT!SPECYIL PROY1610N5 . CERTIFICATE HOLD�R CANCELUI'i'ION � SMOULD ANY OF TME ABOVE DE3CWBE0 POUCIES BE GNCELLED 6EfORE TNE EXPIIiATiON OA7E TMEREOF,THE ISSUWG INSURER WILL ENOEAVOR TO AAAII 3Q DAYS YVRfTTEN TOWN OF YARMOl1TH MpTIGE TO THE CER7IFlCATE XIX.�Eft NAME C TO TIE LEFf,BUT FAIWRE TO DO 30 31114LL 1146 RT 28 ��Ipp$e NO OBl.IGMTIpN pR LU181UTY DP��Y wND UPON THE IN$URER 1T3 AGENTS OR S YARMOUTM, MA 026A4508-398-0836 RBpRP.SP.N'rA'�NES- p PREg��](�TN �[ U��x`��(/"`-'� 'c :.''C 1. ACORD 26(�0011U6) �ACORQ CORPQRATION 1988 ' Ee �gdd 1��t1 3�Nd�If1SNI l�IdH 99EL6SLSBS 9b�5Z eeez�5z�tz THE COMMONWEALTH OF MASSACHUSETTS TOWN UF YARMOUTH BOARI)OF HEALTH PERNIIT NUMBER: #04-022 FEE: $50.00 This is to Certify that TriSh Vllag�Hol � gc dn�/aS��g�Tr�"P�Pr MntPt 492 Route 28 West Yarmouth MA HAS BEEN GRANTED A LICENSE TO OPERA.TE MOTELS This License is issued in conformity with the authority grxnted 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 tt�:rules and regulations in regard tc>said Motels so licensed as adopted by the Board of Health,and expires Decernber 31,2004 unless sooner suspended or revoked. Januatv 23,2004 BOARD OF F�ALTH: Be�cfa�n�3. �jr'o�,��. p��ra�t� v��.� �� Bruce G.Murp y, .5.,CHO Direc�ir-�f�3ealth TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-086 FEE: $30.00 In accordance with regutations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby gi'anted to: Irish Village Holdings, 492 Route 28, West Yarmouth, MA Whose place of business is:��P Traveler Motel Type of business: Continental Breakfast To operate a food establishmerrt in: Town of Yarmouth Permit expires: December 31. 2004 BOA�tD oF HEAI,�'H: Besrf�+r�s�_`7l. (�''o�a+r,./l�-`n• p�tit��. v�e�� ; R�t�. B� � , � s'l.�, R./V. � ; ; � � Januarv 23,2004 , Bruce G.Murphy, , S.,CHO ! Director of Health � { : � I { . , . � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-040 FEE: $75.00 This is to Certify that Irich Villaoe Holdings d/b/a CapP Tra�eler M�tel 492 Route 28�West Yarmoutt� MA I IS HEREBY GRANTED A PERMIT j To Operate a Public, Semi-Pu61ic 5wimming or Wading Pooi � At Cape Traveler Motel - OUTDOOR POOL 492 Route 28 i West Yarmouth, MA i This pemut is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2004 unless sooner suspended or revoked. � I January 23,2004 BOARD OF HEALTH: Be��tr��. �I�o�, J��. � � A�M��tt, v�ei��,� ! Rode�t 4 Bnourn, �e�k � d��k, R.N. i _ i . ; � Bruce G. Mwph , � ., Director of Health I ; � ..� ., c,��ilc . —�// (� oF�-v'aR UU E5 l�J LS � V LS D � ,� �o TOWN OF YARMOUTH BOARD OF F_��s APPLICATION FOR LI�CENSE R MAY O 8 z�1�13 �� .,.� �� °: � * Please complete form and attach all neces � �" y December l I��TH DEPT. Failure to do so will result in the return;:, yo�'application packet. '; ' � -� � -o/va °l �- ��'�r_ u? �AILING ADDRESS: �v�+.-t Q�ER/CORPORATION N E• ��-�.+� U��`�� /�0�1 MANAGER'S N�M�: �Gk�L� �L1�L-s TEL # —7�71—o>�� MAILING ADDRESS: �t•o-�•�.�. � POOL CERTIFIC'ATic»y�_ The pool supervisor must be certified as a Poof Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. � 1. ��>v a ;c S c�.�e c�1�,� 2. � Pool operators must list a minimum of two employees currentl certified in basic water safe standard First Aid � and Community Cardiopulmonary Resuscitatibn(CPR). Please list these employees below and attach copies of j employee certifications to this f4rm. Th� Heaith Depat�tmet�°fi will not�use�p�st years' records. You must i provide new copies and maintaid a file at yourplace of business. : ; ; 1. P�c'fY�.�� l� z :.��.,i�'�,�,'� . �: ,. 2. _ �., ..� r� `� ; , ; 4_ � 3 � �� .x �� _�_ � _ . FOOD PROTECTION,Iv1ANAGERS - CERTIFICATIONS: � All food service estab�ishments are required to have at least one full time employee who is certified as a Food � Protection Manager,�s defined in the State Sanitary Code for Food Service Establishments, 105 C1VIR 590.000. � Please attach copi�s of certification to this application. The Health Department will not use past years'records. � You must provi,de new copies and maintain a file at your establishment. j 1' 2. ��t�[�N CHARGE: Each f96d establishment must have at least one Person in Chaz�e(PIC)on site during hours of operation. l. _ 2: _ ��iEIMLICH CERTIFICATION�� ;' All food service esta.blishments with 25 seats or_more must have at teast one employee trained in the Heimlich Maneuver on the premises at all tirnes. P�ease list your emptoyees 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 fle at your place of business: l. 2. 3. 4. ,. RFSTALTR ANT EATIN : TOTAL# , : , - OFFICE USE ONLY � LODGING: ' LICENSE R�QUIRED FEE PERMIT# LICENSE REQUIRGD FGG PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CAB[N �50 �MOTEL a50 �� _INN $50 _CAMP SSO ,�SWIMMING POOL$75ea.��'�9.3 ... ._, _LODGE $50 ; _TRAILER PARK $50 _WHIRLPOOL S75ea. FOOD SERVICE: . , , _ _ LICENSE REQUIRED`FEE� PERMIT# ' L.ICENSC R�(,�UIREb FEE ' PERMIT�! CICENSE REQUIRED `FEE PERMIT# �0-100 SEATS $75 � f CONTtNENTALry S30� '' O,3" NON-PROFIT �25 >100 SEATS �150 �COMMON VICT, �50 _WHOLESALE $75 RETAIL SERV� . - LICENSE RGQU(RED FEE PERMIT# LICENSE RGQUIRED FGG PERMI'f# L(CENSE RCQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 <25,000 sq.ft. $75 ^I�RO'LEN DESS�RT S35 _TUBACCO �25 NAME CHANGE: s�o AMOUNT DUE = $ I S�. � *****PLEASE TURN OVER AND CQMPLETE OTHER SIDE OF FORM*"*** T� . . . . . . ..._.,. . .. .:...... ... f � .. . ... .. _.........._.a-Z... . .. . �,.� .. . ...:_ ; . . , . t .. .. _ '' � . 4 . A _..._......... ... .. : .. � . . �. . `. � , . � � � . �„ .:- , . . . . .. S � A, .. �.. 'ii��. � . � .,.. : L � ADfirIINISTRAT�ON ; ; �j � 4 f, j � , -. � �:.� �% �� N . . : . �._ L,��e�apt�r �52;Section 25C,Subs�t�`6,the`I"ow��'armouth is now required to hold issuance or renewal i ess i.f a` erson or com an does not have a Certificate of Worker's � of any ticense or permit to operate a bus n p P Y Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION`INSURANCE � AFFIDAVIT MUST BE COMPLET�D AND SIGNED, OI� , ;,, „ , �� -�� :,�;:, CERT. OF INSURANCE ATTACHED � � ��a -�,�. ., � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 3 � Town of Yarmouth taxes and liens must be paid:prior to renewal or issuarice of your permits. PLEASE CHECK ; APPROPRIATELY IF PAID: � YES �,�'_ NO ,� _. NOTICE:Perrnits run annua�ly from January ] to December 31. IT 1S YOU�RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND R�QUIRED FEE(S)BY DE�EMBER 31,2002. SEASONAL ESTABLISHM�'NT��A.�E:�O COl*1T�CT THE HEALTH DEPAiZTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR;THE SEASON. , - : . t. - � ;. ; ALL RENOVATIONS TO ANY FQOD E�TABLI�HMENT, MOTEL OR� I��OL (i.e., PAIN�'INC�,i�NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY T�TE'B�ARD b� HEALTH P�tI�R TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �, ?.,� �;:�. , , . _ , ,. :_ n ,, ,, ;� •, _ ' _ x ._. t� ADDI'�ONAL. RF(;I1i.:ATIONS� \e� POOLS . �<;, ; � '�, POOL OPEriING:All swimming,wading and whirlpools which have been closed for the season must be i�.�,spected by the Health Department prior�aopenmg. ; POOL WA'TER TESTING: The water must be tested for pseudomonas,total coliform and stand�d plate coi.�t by a State certified lab,prior to opening, and quarterly thereaft�r. ' POOL CLOSING: Every outdoor in ground swimmingpool must be drained or cov�red vv�thin��ev�n;(7)��ay`of �, closing. � � � . .. �'7"19., ��. FOOII SERVICE �ONSUMFR ADVISORY: . Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATE121NG POLICY: Anyone who caters within the Town of Yarmoufh mus�notify the: YarmQuth Health Department by'filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obta�ned 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. Faiture to do so will result in the suspension or revocation of your Frozen Dessert.Permit until th,e above terms have been met. OITTSIDE CAF�S: , . Outside cafes(i.e.,outdoor seating with waiter/waitress service�,must have prior approval from the Boarcl of Health. � � OUTDOOR COOKING• " � � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i ' , ; : , DATE: �� 5 SIGNATURE: ; — ; PRINT NAME&TITLE: ~ - �s �� I i � 10/18/02 - - __ �� . �.r�i'g ,� ";;' �_'?�. ,,.,s��,r�� . r._'i' j._. �5 ' _ �� , � s�, � ,....,... ,x _. � .r. , . :L -':ir� ,.ffi-,�.- _ - r a�_ i:- -- -� } 3 �.p .r♦ r_ c�_ 't, li�.�y ~��. " ' ' .-,.�} ".,$�. _,:tiH�, d ti ��>� �f� i...�.l�:.b. �♦ r x.-� - . - ..... . •� - 1r�t - ,i...�:, .,. . .... . .,. ,�.. .. . , . _ .., ,. .,,i��_-t� �.a..�'S. ,_�._... 1N::f .v t-:� . ....�. .. h:-+ � _ " . ...��-i s . �::o -: . . �'�' _ . a Y i - Y �� . E' ' _ _ _ :_ � .t�. _ �. ' .��, 1.. , . �^ ) e�. �} �le.�. ..-" • Y a.,� �aR e�.� 7.. �'3 - ��Y`�� 7. ' . ._.... ,,r.::� ... .v:-..�, n �,.... ... ,� � __' a.' - '"'�> -.s . ..-.�, -. � �.; � , — -_ �( _. -.,T i . .. :�-.� "�S"".;£ ,�k.i.� y-'�� ,v 7 . �F��,.� , .> : . . � _�_ � -._. _ .. ..�. __ _ �� ,.�._ ;� , ,. .., ---- > � ._... . .,s �"�� , ..� � "��:'�� .:� . .. .�..1:'f R __...'..,'1 �� .,i"i�. iS iC� -!i i.�.7 ?��..� ��F" `- . _ � r_�;. :.Y" 7'.' — � .l `e--.. l` :�:ti,T ' - '�4_y.�; . �f y.�a+.r.r. . .�._�, ` �-`- . -r_, a: �..� . a ... . .�.., m�:.-w.. '- -� Y. _� y-i.. . . , _-�- �:_:� ..� ..:.. ... .. �. i ::...., ,..+.�5';: �. t: �� _ _ � 1nIF �� ..� .. - �� .,T�.�tf 'f.`.�-'fif Y , ,F'd;.'aA ..: 4'-`-'' �*, � {_ _ yl:. � THE CUMMONWEALTH OF MASSACHUSETTS ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #03-058 FEE: $50.00 This is to certify that Irish Village Holdang,s d/b/a Cape Traveler Motel � 442 Route 28, West Yarmouth MA � i � HAS BEEN GRANTED A LICENSE TO OPERATE MOTELS This License is issued in conformity with the authority granted to the Boazd of Healtl�,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as am�d�,and is subject to the provisions ofthe Laws ofthe Commonwealth ofMassachusetts relating thereto,and upon such terms and�nditions,and to the rules and regulations in regard to said Cabins so licensed as a�pted � by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked. May 14.2003 BOARD OF HEALTH: ei(raaled� i�el�c, �al�a�c _ _ __ _ _ D. ��rdo�c. 7K�.. �/lce __ �a�'�. �r�, �(,l�a+rk �a�ctck�Dar.,�ott '�file�c.S�c. �.?Z. ruce G.Murphy, RS.,CHO Director of Health THE COIVIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH = PERMIT NLTMBER: #03-093 - FEE: $75.00 i _ _ 1 This is to certify that Irish V' e Holdings d/b/a Cane Traveler Motel 492 Route 28 West Yannouth: MA IS HEREB� GRANTED A PERMIT � To Operate a Public, Semi-PubGc Swimming or Wading Pool � At Gape Traveler Motel - OUTDOOR POOL 492 Route 28 West Yarmouth_ MA This permit is granted in confarmity with Article VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and expires December 31.2003 unless sooner suspended or revoked. ' May 14.2003 BOARD OF HEALTH: �led� Z�at, �abt.�a� ! i5'e�cfa.x�D. �jimralo�. 7K.D.. `l/ice i ,�o�aat�, b`'�roao�c, ela�k �a�rte�'I1�Dar.aatt � .S . .yl. Bruce . urp y, ., Director of Heal � 1 , � � y � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT I PERMIT NUMBER: #03-186 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Secfion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby grant�to: Irish Village Holdings, 492 Route 28, West Yarmouth, MA � Whose p]ace of business is: Cape Tra.veler Motel � Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2003 BOARn oF HE�,'rx: �kaaleQ�f. Z�i, ��a.� �e«c�iu�c?�. C%�. �D.. �l/tce �o�t� �, � �a�rtek�Da� � S .7Z. � May 14,2003 ruce G.Murphy,MP .,CHO ! Dire�tor of Health � i �� CRPE�RAV�IL. �r., , TOWN OF YARMOUTH BO r; c _ Z"'� �ue54' APPLICATION FOR LICENS ERMIT-200� �'°' �,, �., �� . � ��r' U 1 1�G? � '` � ' ;�� * Please complete form and attach all necessary documents by D cember 31, 2001. Fai �to d s8 v►nll resul " the return of your application packet. H E A�TN r��r T, �a�� TAME OF ESTABLISHMENT• (•�'►-� '�2s--✓� TEL. #7?/ -� �� T (1(`ATT(lN AT�nRFCC• �Z /�usv..t , �J��i �-- OWNER/CORPORATION NAME• .--�"� �� ayT��°��`�`�-� S� � 7��4« MANAGRR'S NAMF.� K �y,,� EL.#. MAILYN DRESS• S�4-� 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. �- ..�'K9Z��✓wz�,; � i. �.�n9�� 2. _ - - - Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Dep��rtment will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. � � � 2. ��/ ..� 3�, � P�-� rv � 4. `"?Y1-�.-r�,� y.�..s � Fn(�n PROTECTION MANAGERS - CERTIFICATIONS• All food service esta.blishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service �stablishments, 105 CMR 590.000. Please attach copies of certific�tion to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. _.--��.RSQ?�I-��-- - -_ _ _ __ _. _ __ _ _ ---- _- Each food establishment must ha.ve at least one Person In Chazge(PIC)on site during hours of operation.� l. 2. HF.TMi ICH CERTLFICATIONS_ All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chok.uig procedures below and attach copies of employee certifications to this form. The Health Department will niot use past years' records. You must provide new copies and maintaiq a fde at�your place of business. 1. 2. 3. - 4. R�,STALIR A1vT SEA'�1G: TOTAL# . . dFFI�E USE ONLY LODGING: LICENSE ItEQUIRED FEE PERMIT# LIGENSE R�QUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT# _BBcB S50 �CABIN �SO �I�40T.�,'L $SU a'd�7 �INN S50 �CAMP $SO _ �SWIMMING POOL�SOea. '�� LODGE $50 ,TRAILER PARK $50 _WHIRLPOOL S25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PEItMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 I CONTINENTAL $30 ��R �NON-PROFIT $25 >100 SEATS 5150 - �COMMON VICT. $50 . �WHOLESAI.,E $75 _. _ _ . R�.TA L.SF.RVIC�• LICENS�REQUIREI) FEE PERMIT# LICENSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT# _;,_TO$ACCO $20 .. . . "<25,000 sq.ft. �75 �TOBACCO $20 <50 sq.ft. S45 _,_,_>25,000 sq.ft. $200 �FRO�EN DESSERT$35 rt�ME ck�Nc�- $lo AMdiJNT DUE _ $ /�D.0�0 _ *****PLEAS�TURN OVER AND COMPLETE OTHER SIDE OF FORM***** .� "` 1 �..,, , A�MINISTRATION � . F � . . .. : , . . � Under Chapter 152, Secfiun 2�Cr�,u�i,seqti��.f,t�e Town of Yarmouth is now required to hold issuance or renewal of any license or permit�e operate � busiriess if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIbN INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR i �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 APPROPRIATELY IF PAID: - � YES o/ � NO NOTICE:Permits run annually from 3anuary 1 to December 31. IT IS YOUR RESPONSIBILITY Tb RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT'THE HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT, ETC.), MUST BE REPORTED TO AND APT'ROVED BY THE BOAkD OF HEALTH PRIdR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � f Ai�DITION L F UL.ATION r � � POOLS POOL OPE1�tING: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. f POOL CLOSING: Every outdoor in ground svvimri�ing pool must be drained or covered within seven(7)days of I � closing. � � � � f FO�D SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health.Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �+'RB�Li'�'DE�3E�3'�:------ _ - _ _ __ _ _ ; Frozen desserts must be tested on a monthly basis by a State certified 1ab. 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. QUTSIDE CAF�S: j Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pr�hibited. ' V I DATE: � ��L- SIGNATURE: ; i PRINT NAME& TITLE:_ ��tti� �J L�y �,� ��t , 09/11/O1 � � , � � } TOWN OF YARMOUTH BOARD F ,�,r, . :,� O HEALTH �,`'p 3�� (°aOD- �� APP�ICATION FOR LICENSE�PERNLIT-2002 * Please complete form and attach all necessary documents:by December 31, 2001. ��re��to do so will re�ult in the returri of your application packet. � : - _ , � ; S T: ��1�� r�.b L SD�� o�� T OCATTON DRF�: �/9� ��t.�5�--. ` MAILING ADDRESS: OWNER/COR�'ORATION Nt�MF• T�,�' Gi //J%t c c,P L�/b l c�yw�i c MANAGER'S NA1�IE: cCf �K 6�� TEL # 3�y y2...�� MAILING ADDRESS: �',e� 3—�.�s 4 u.7,c'a Y,c r.��(� POOL CER'TIFICATTnN�� `�'�"` ' ' m� Please list the designated Pool Operator(s)and attach a copy of the certification to this form. l. 2, Pool operators must list a minimum of two employees currently certified iti basic water safety, standard First Aid and Community Cardiopulmonary Res below and a ' s of ess. , 1. � 2. 3. 4 All food s�rvice esta.blishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. _ a. Please atta.ch copies of certification to this lication. ` - W 1. �, � m I` � �d�� ' ��a,,...G � � food establishment must have at least one Person In Charge(PIC)on site during hours of opera.tion. 1. 2. ��t�� e��^�m�Pi� �i��,� � ��t��'� �a^ �,�q,_�, 5._ � � If � Ali food service establishments with 25 seats or mc�re must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. F � '.` g, Y� . . . . . ��„ �. 1. 2. 3. 4. RESTAURANT'.SEATING: TOTAL# � ` - � , .. � � OFFICE USE ONLY IADGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ". LICENSE REQUIRED FEE PERMIT# _BBcB $50 _CABIN SSO � MOTEL $50 �'C�G7 �iNN $SO CAMP $50 1 SWDviM1NG POOL$SOea�� _LODGE $50 TRAILER PARK $50 _WHIRLPOOL �25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _GONfiNENTAL a30 _NON-PROFIT $25 >IOQ SEATS $I50 _COMMON VICT. �SO _WHCILESALE $75 RETAIL SERVICE• � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. �45 >25,000 sq.ft. $200 =EROZEN DESSERT$35 NAME CHANGE: $io AMflUNT DUE _ $ /�� *****PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM***** _;� ,... __ ,, � � � ; ADMINISTRATION i ! Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or com�any does not have a Certifica�e of ZNorker's Compensation Insurance. THE ATTACHED STATE WORi�R'S COMPENSATIOI�' INSURANCE AFFIDAVIT MUST BE COMPLETED AND SI�NED, 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 APPROPRIATELY IF PAID: YE'S�� NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQ�JIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS�-IlVIEN°TS ARE TO�O1�ITACT�HEALTH DEPARTMENT FOR INSPECTION 7=10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. R:ENOVATIONS MAY REQUIRE A SITE PI,AN. ADDITIONAL REGULATIONS POOLS POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a Sta.te certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE -<�.��. }.�u. ��. ��,. e _ .,,,..., �.... : .. v_,,�µ. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yar�outh Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ; ; FROZEN DESSERTS: ', Frozen desserts must betested on a monthly basis by a Sta.te certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),m s have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ; DATE: �Zl3i� d� SIGNATURE: ' PRINT NAME&TITLE: ��-�( �. ' 09/11/O1 e ' ! � The Commonwealth of Massaclrusetts � � Department ojlndustrial.-iccidents � ; 011lceo/%s�lost�is ' � 600 Washington S�reet . . ` _ Bosran. Mass 02111 , , , �'"' �•" V4'orkers' Compen��tion tnsurance Affidavit' : Anolicant information: Plesse iNT'Te�.� namr ��G ��-�_�.c� �� _ I�cation: '�-7 S� Z n'i-ti-t� 5+�-- �tt� �• L1 �n� �' ehone� '72l -��C9c7 o I am a homeowner pert�rming all w�ork myself. � f am a sole proprieror ��,',ha�e no one��ori�in� in am•capacit�• �am an empioyer pro�rdin�w�orkers' compensation fo�my emplo��ees w•orking on this job. ' comPan�• name• address• �Z: phone tl• ' insur�nce co noli�y# � I am a soie proprietor. _enerai contractor, or homeowner tcircle onel and hace hired the contractors listed below ��ho ha�e the follu�cin��orkzr ;ompensation polices: tompanv �ame• address• ' �ty• phone k• insur�ncc co Qolic�•# comRan�name• a�dr�s•• ljly• ohone 1!• __ inenran��rn [!Q�lY� � Failure to secure covenee as required under Secnoo 2SA of MGL 1S2 aa�i to t0e iopaido�of erioi�fi pesdtles of a d�e op to 51�00.00 a�d/o� ane yean'imprisonment a�w•ell a�civii penaida io the form of a STOP WORK ORDER aad a Ase of SI00.00 a day qaio�t me. [a�dersta�d t6at a topy of thy statemrnt may be fonwrded to tAt 011ice of Inve�tig�qom of t6t DtA for eoven`t verifieatio�. l do hrreby certif}•undei rhe Pains and prna!lits ojperjury that tl�t�njoE�nation providtd abovt is tnte oitd contct Signature . �l�l�z- Print name � J''^"'u ` �� A. " Phone N � �1 ��o .- ofticial use onh do not r.�ite in this area ro be completed by titv or towa otlleial city or town: YA��DT� _ perrnitAicenu k nBuilding Departmeot �Lieeasiog Board �check if immediate response is«quired 261 �Sdectmen's O(fiee (508) 398+ QHea1tA Department contacc person: phone R;_ _„_ _ �31 ext. nOther � �+,�` � �. � .��r ti •+; ❑� o' • -*• ,• � ,� ♦• i�n�� .a t. .� t�' �n, M�' � . . . • r., r.' �� • r 7 ' � a- � �- .r �,,��F : r '=�r a � i. � •�� c ► r «_- c. r� .,. i •:r �._� t 1 •.I' . . !�. f( �7:Y t. f-,�.� 'i�! N•, _ iJ :.}.:� 1�.. KI Y 1�! - ..�- f�. . i �� : ! 7 �`� �ar • . -.t 'a�� '�. �a. �. � � .�. • �. ,i.! ; '��, .^..E , �i ' .,'�!, 'i �� ., .,3 �" f�• ti_...� .r. . �.. L��..�. �;• rr •• � '3- .Ei �! ....�M M ` •,.., '�� •' � -��• . ., . a:^,s-3� : •� . �y -�:, r �.�� r : . � r , � �. � Mi.,�. ` �',"3r' ,��"�....�C� -�t"''."::�� j�':`.��Cr"'�t � pi�� . , { . . � � 11A1�!!. � , `I . .. � .. rl�... . � �� R'i .. ..:, ::;'. _'- �� „*�. . �►�7' ic� r.i�r tc�K .�.:tc - iii w ; � � � � � � t•, • . . s��•. r . + « " 'M 1 1 �' . � �: .�. �'. "t'��.�� . 1�,. !.?" � 'q �,•1 � ,.� .��. �:. t-1�('�f.. �� f � � vr � ,i, •- r , �. � , _` 3 r • • r,�• ;�� • = � � # ��ti • �: a �. � � •� r• ; ra . a.. �f_ •7. �� rr. : R . + � t � . � a 1 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-017 FEE: $50.00 � This is to Certify that Irish Village Holdings d/b/a Cane Traveler Motel ; 492 Main Street/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 regazd to said Cabins so licensed as adopted by the Board of Health,and eacpires December 31,2002 unless sooner suspended or revoked. March 22 ,2002 BOARD OF HEALTH: ��D�G�io�rd,a,c. .�lee ,�a�e�ct� fa�toaoMc, (� �aariek�11c�� S ruce G.Murp y,MP R.S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLTMBER: #02-030 FEE: $50.00 I i This is to certify that Irish Village Holding;s dlbla Cape Traveler Motel 492 Main Street/Route 28. West Yarmouth.MA IS HEREBY GRANTED A PERMIT To Operate a Public,Semi-Public Swimming or Wading Pool At T eler Mo 1 - OUTD OR P OL 49 Main Street West Yarmouth.MA __ This permit is granted in confornrity 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: .��ell�z. .�lee ,�aBazt� �roawr��(� �a�k�1leD�ott �f S�. . ru . uiP Y� , •� Director of Health � . ( � � I 3 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � � PERMIT NLTMBER: #02-119 FEE: 530.00 � In accordance witli regulationspromulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: irish VillaPe Holdings,492 Main StreetlRoLte 28, Wect Yarm��th_MA Whose place of business is: Cape Tra.veler � Type of business: Continental Breakfast To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEALTH: � �dli�i L�imca�c D �� 7�G.D., 2/icce ,�o�art� �,c, L?lark �adriek��.xo� � s�. .�t May 3 ,2002 ruce G.Murphy,MP ,CHO Director of Health i I � i � i � I 1 ' � � - - ��.. �. D ' TOWN OF YARMOUTH BOARD.��H�ALTH ' APPLICATION FOR LICEI�IS�/�ER��T--�00 b�j D�C 2 9 1999 �� ° �� ° �J� �`� HEALT�-i DEPT. * Please complete form and attach all necessary documents�y I�ec�mber 3I; 19�9. Fa in s the'return of your application packet. " -�`� � a -------------------------------------------- ----- ------- --------------------��^--------^------�---------------'--------�--�. F E g � .. � . # �L-jv��v � L ATI � z-- � �y _ .�„ta � D lZ - �� N �i t?. � i ' -L Ol�-w # - MAII.;ING ADDRESS: ��-� _ I ; --------- -----------_-----------------------------_--_--------------------------------------..�_---------------------------------________. POOL CE�TIFICATIONS: � The pool supervisor must be certified as a Pool Operator, as reqaired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. � � 1. �:G(� Ce��x� 2. � ; ; Pool operators must list a minimum of two employees currently certified in basic water safety, standa.rd First Aid j and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of ! employee certifications to this form. The Health Department will not use past years' records. You must provide i new capies and maintain a fite at your place of business. � 1. --r�,��s 1�«vLs z. P�-�.�� •��%r°- 3. 4. i � HEIMLICH CERTIFI ATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of ernployee certifications to this form. The Health Department will not use past years' records. � You must provide new copies and maintain a file at your place of business. � 1. 2. 3. 4. j RESTALIRANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# a ------------------------------------_-----------------------------_______.---�---------------------------------------------------------_--_____. UFFICE U„SE ONLY I,,ODGING: LICENSE REQUIRED FEE PERNIIT# LTCENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 ; INN $50 _CAMP $50 � LODGE $50 TRAILER PARK $50 � / dVIOTEL $50 r ,/ SWIMNIING POOL Ol $SOea. IG-5 � - - � � 1 WHIltLPOOL $25ea. ' FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 �CONTINENTAL $30 k��L'rJ >100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 � WHOLESALE $75 Ii�TAII.SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CHANGE: $10 � � AMO�TNT DUE = $ /�4,00 """•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""'•' . ...... ......... . ..__.. . Y a. _ �?• } ADMINISTRATION UI�IDER CHAPTER 152,SECTION 25C, SUBSECTION 6, 'THE TOWN OF YARMOUTH IS NOW REQUIRED T(� HQI��-��S�JATT�E�?R RENEWAL OF ANY LICENSE QR PERMIT TO OPERATE A BUSINES5 IF A PERSQ�1�� R�CQl'�IP'�NY DOES NOT HA�JE A CERTIFICATE OF WORKER'S COMPENSATION , INSLJR�NCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDA�TT 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 APP�OPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONALESTABLISHIV EIEN'TS ARE TO CONTACT THE HE.ALTH DEPAR'TMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENI1�iG FOR TI� SEASON. AI,L RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST$E REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEM��NT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DITIONAL REGULATIONS POOLS POOL OPENING: ALL SVVIlVIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLUSED FOR TI� SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT,AND THE WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE CDUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENINC, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DR,AINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN'THE TOWN OF YA.RMOUTH MUST NOTIF'Y THE YARMOUTH HEALTH DEPARTMENT BY FII.ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI�SE FORMS CAN BE OBTAINELI AT THE HEALTH DEPAR.TMENT. FROZEN DE S� ERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI-�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTIL TI�ABOVE TERMS HAVE BEEN MET. QUTSIDE CAFES: ' OIJTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. �UTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DI5PLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD ' SERVICE ESTABLIS�-�vIENT IS PROHIBITED. � DATE: I. ?� �1� SIGNATURE: � , PR1NT NAME 8c TITLE: t�1, � 5 Us ;z._ 11J12/99 ; � . , , � � The Commonwealth of Mossachusetts � � � � Department oJlndtutrial.-fccidents � " o Of1IC001/�es�lOflJ�Is ' � ` 600 Washington Street ! � ' ,,-` Boston,Mass. 02111 � �~ �� 1�L'orkers' Compensation Insurance Atfidavit ; ARolicant information• p/essepR '�• i --- ; n�mr: � �'P� �7/2��P�C'e�t., Loc�tion� !� G)�. l�'v�S-�, • � l,��-''�r '''"� ,� '� / --C�C� ��t I.t� , (/� /�!^' pbone '7 � I am a homeoµner pertormin,all w�ork mvself. � f am a sole proprieror�-� ha�e no one�►orkin� in am�capacin• �m an emplo4er pro��dins workers' compensation foc my empioy�ees w•orking on this job. comoan�• name: / �� re�it address• �g � �'�z�IJ.S`7F- Sit�': W' �//9""„"�'-y � � nhone 11• '7 � l �l c9c'� �suranceco. ��+9��-lrt, C_'�i`�c��5�q A91lSY� -� �/'� �.�1� � i am a sole proprietor. ;enerai contractor, or homeowaer(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu«in_ ��orker�� :ompensation polices: comoanv name• address• cin•• ehone fl• insurancc c9. Rolic}# comeanY namr. �ddress• �'� �ee#• insurance co. pQ(��,� • Failure to sccure covera�e as required under Secdon ISA of MGL IS2 a�kad to tbe iopo�idoa of erivivl peaaltlef o(a d�e op to Si¢00.00 a�d/or one yean'imprisonment��w•eil a�eiril peaaitla io t6e form of a STOP WORK ORDER aad a tiee otS100.00 a day apin�t ma I a�dersta�d t5at a copy of thH statement may be fonwrded to the 011ice of invc�tiguiom of t6e DIA f�eoven�e verifipti�. /do hrreby cerrifj•under rhe parns and prnal�ies of perjury that tht injorniation provided abovt is trtte ond centct Signaturc y'7�2�� Print name Phone li .- o(Ticial use only do not M rite in this area to be compieted by ciN or towa o111cial city or tow•n: YA��IIT� _ pennitAieenx M nBuildiog Department check if immediate res nse is re uired ❑Lieeasioe Boa�d � � q 261 OSeiectmen'�ORice �NealtA Department contact person: phonep;_ �508� 398�-2231 egt. nOther .. ._� < ,,,: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-33 FEE: $50.00 Tt►is is to Certify that Irish Village Holdings d/b/a Cane Traveler 492 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 ofthe Laws ofthe 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 Health,and expires December 31,2000 unless sooner suspended or revoked. January 21 ,2000 BOARD OF HEALTH: �c�� e�ee, ��i.airm,arc �oan� �u��ivan, �//., Vice C.,hairman Ko�e�t,}, p�rowit� (�lerh a�rie[le Ja�o(.��Zy-�oope� ic�[�� o �din ruce G.Murphy,MP ,R.S HO Director of Health � TOWN OF YARMOUTH i , BOARD OF AEALTH ` PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: Y2K-125 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Seetion 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: iri�h Village Holding�, 492 Main 4treet, WPct Yarmnnth_ MA Whose place of business is:�ane Traveler Type of business: Continental Breakfast j To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2000 BOARD OF HEALTH:�d�/. �elt�, C'�irman �oan� �uG�ivan, �//., Vice C.hairma �o�ert J. 9�rown, C��rh a�rie6le�a�of��iy- oopee a � /n• !C L d0[t� b Januarv 21 ,2000 ' Bruce G.Murphy, .5., CHO Direetor of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: Y2K-51 FEE: $50.00 This is to Certify that Irish Village Holdings d/b/a Cane Traveler __ 492 Main Street West Yarmou IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool At Cape Traveler -OUTDOOR POOL 492 Main Street West Yarmouth. MA This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked Janu ,ary 21._,2000 BOARD OF HEALTH: �c`� �eltee, �`iai�murc �oan C�. �ullivan, ��, Vice l.hairman Ko�ert,}. �rown, C.[erk a�rielle�a�o(.�hy-J�tooPe� L o hLia ru • urP Y, , •� Director of Health � � __ ------.— � �