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Home My WebLink AboutApplications, WC, Certs. of Inspection and Licenses �..�, . ��- ��.'�i�?�, �� ' � � � TOWN OF YARMOUTH BOARD OT�L.� . ' � � APPLICATION FOR LICENSE/PERN�� 0�9 � �;'1�� d1r8 Od P * Please com lete form and attach all necessary doc�ients'`by ece�b r � --. �::��,- Failure to do so will result in the return of your application pac . ' �'�3 � ' � _ -- --- NAME OF ESTABLISHMENT: � TEL. #�f�-3bZ' �/3� � LOCATION ADDRESS: l2 � �" MAILING ADDRESS: � OWNER NAME:�'.�P� �YJ �fS�.�ns ��'c,�.�/�'c�- TAX ID (FEIN or SSN): /� CORAORATION NAME (IF APPLICABLE):/'�.��''/) ��[�yD.S Lr� ,t.,��C. -�� /NL° � MANAGER'S NAME: C � �'L " f� , TEL. ,��2-�/3Z,�— MAILING ADDRESS: ` S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(sj and attach a copy of the certification to this foi-m. 1. �� 2. Pool operators must list a minunum of two eniployees currentl�certified in basic water safety, standard First Aid and Community Casdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food seivice establislunents are requu ed to have at least one full-time employee who is cei-tified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. � 2• � F PERSON 1N CHARGE: ' Each food establislunent must have at least one Person In Charge (PIC} on site during liours of oper�.tion. ; �� i. '�'��,�� z. , , ' HEIMLICH CERTIFICATIONS: j All food service establislunents with 25 seats or more must have at least one employee trained in the Heunlich � Maneuver on the premises at all tunes. Please list your employees trained in anti-cllokmg procedures below and 1 attach copies of employee certifications to this form. The Health Department will not use past years' records. ! You must provide new copies and maintain a file at your place of business. l. 2. � 3. 4• j RESTAURANT SEATING: TOTAL # , i OFFICE USE ONLY /��D/�� (1��t' �Q��- LODGING: ; � LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S55 _CABIN �55 _MOTEL �55 � S>j �GAMp �Sj �Q� _SvVINIlVIINUPOOL �80ea. LODGE S55 _TRAILERPARK �105 WHIItLPOOL $80ea. : �,,,- ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �'" ' OR ' WORI�R'S COMP.. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �s N� No MOTELS Al�TD O'rHER LODGING ESTABLISHI��NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall 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 a,re NOT allowed to srt m the pool area until the pool has been mspected 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 Depariment by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. ,•*•�•••,�•-��• ,• , _„ n---- T-.------' �- '-'------'---,,, TTTC��7ATTTTTC�71ll1►TC�Tf)Tf7T�7T/1nL'TTTi�TT �' �1�, �i4S I ��' � � �� _� ��- �L� � r TC� WN UF YARMOUT � � � ��;r��o� = 1146 ROIJTE 28,SOIJTH YARM4iTTH,MASSACHUSETTS 02664-24 1 t��.��--�� '� • o,.,�• Telephone(508)398-2231,e�rt. 241 Fax(508)760-3472 Division APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHII.DREN (Use back of application if additional spxce is necessary) FEE: S55.00 Name af Camp: �mP �/�,�la��'� Site Address: �2�' �j�/��-�, ��17DU4h' �rr �J'1,� cy26� Site Address: Tax ID Number(FEIN or SSl�: �� Type of Camp: Day(less than 24 hrs.)� Residential(24 hrs.) Hours of Opera.tion: ��/l� — �P �/1�l�, !' ��'j�',�� Dates of Qperation: Opening: ��2��8 � Closing: G�� Name of Camp Owner: �,��/�t'S G°aL_�1_yC '�ZL� Office Address: ��f� W/��f/��/j'f��T�'I,rq �� O�ce Telephone Number:, �D�-3�2- �f3 2�-- Name of Camp Operator(if different): Address: �,{-�'`� J Telephone Nu�ber: - __ _ - Camp Director: �Gf��,�/,�/ Address: �1�_��f�1.�es7_�.��f��L�� Z6 y�-� Age: (�O � Telephone Number. �.��.-,25�� 7Zt�'7 �-` Coursework in Camping Administration:��/!f�,�,��^s 7_��f�L��1f�'�� Previous Camp Administration experience: �A�l1/J c�J�� Heatth Care Consultant:��,�yiY�7�'� �OS�i� Type of Medical License: /!7/� MA License number: �5�,�6� Address• ` ,7 Telephone: ! �19,08 1 af 2 i Hospital for Emergency Services: ��i��Sp/O��L Health 5upervisor• Age: Type of Medical License,Registration or Training: Swimming Area: Yes� No Tf Yes: Fresh Water� Ocean Pool CPO Specific Onsite Locations: �,�1-�l'I/��Dl.Jit�� D�/) Water Quality Testing Performed By:� � Aquatics Director: � LS ��' � � /'• Submit Certifications: CPR First Aid �, Water Safety '�� J� � —� Other Lifeguards and Crederrtials:�S - L!f'� �� Watercra,f�lBoa.ting Activities: Yes� No Describe: ��4 �d d�S Food Service: ��,5 Ts food handles, served or prepared? Yes No� To what e�ent? Snacks Cooked and Served by Staff If cooked onsite, Food Manager(submit copy of ServSafe) Catered if so,by whom? Is refrigeration available for perisbable foods? Yes� No Backgroand Check,,c: Has the Camp-O�er or�ir�ctor obtai�d a�d r�v�wed the CORI aaa SORI-o€eaEh staff pe�son_ar� _ _ -_ volurrteer who may have contact with a camper? Yes /� No / ' IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS PRIOR � TO OPENING TO SCHEDULE AN INSPECTIdN! THIS IS MANDATQRY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. SIGNED: PRINTED:_��',��,��'f,�'� DATED: /Z/'�! f.� � See the nezt page attached for a list of documents that must be completed and submitted before your application can be fully processed You are strongly encouraged to complete these documents � as soon as possible and submit them in advance. This will egpedite the process. I �„9108 2 of 2 1 � . C�� e �o�IcE N � -r�o�c�cE � � ��, � � To � � a =� � ° EMPL(lYE]E S � w . EIVIPL(�YEE S � ,� /� V '9M Sy6 j The Commanwealth of Massachusetts DEPARTMENT QF INDUSTRIAL ACCIDENTS 600 Washingt�n Street, Boston, lVlassachusetts 02111 617-727-4900 -- http://�c�rww.mass.gov/dia As required by Massachusetis General Law, Chapter 152,Sections 21,22&30, this will give yau notice that I(we) have provided for payment to our injured ernployees under the abave mentioned chapter by insuring vv�th: THE TRAVELERS INSURANCE COM?ANIES NAME_�F IIVSTJRAr3CE COMPAI�IY p,D. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY ��i (7PJUB-5960B18-1—08) 03-31—OS TO 03-31—09 POLIC�NUMBER EFFECTIVE DATES � HOLLIS PERRTN & BLACK 31 MILK ST STE 101Q �-- m� BOSTON MA 02109 �-- NAME OF INSIJI��►NCE AGENT ADD1tESS PHONE# .___r n�— CAPE CQD & ISLAIVDS COUhIGIL INC 247 WILLOW STREE7 o�. BOY S��UTS OF AMERICA YARMOUTHPORT 6� o� MA Q2664 ' �'— EMPLCIYER ADDRESS � �� ^� EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANS� DATE �_ �- MEDICAL TI�EATIVIENT � �'— Th� above named insurer is required in cases of personal injuries arising out of and in the course of a-- employment to fur�ish adequale and reasanable hospital and medical services in accordance wilh the p= provisians of the Workers' Compensation Act. A copy of the First Report oL Injury must be given to the �"""" injured employee. The employee may select his or her own physician. The reasonable cost of the servic�s �---, provided by the treating physician ��vilt be paid by the insurer, if the treatment is necessary anc� reasanably _-� connecied la the work related injury. In cases requiring hospital aitentian, employees are hereby notified `' � that the insurer has arranged for such attenlion at the `� �-- �� s �'� ��1s ,�� NAME OF HOSPITAL V ADDRESS TQ �E PGISTED B�.' EMPLOYER � , : . i , � I j' / � i ;-��,� ' � YARMOUTH FIRE DEPARTMENT � ��i�� 96 OLD MAIN STREET I �� SOUTH YARMOUTH, MASSACHUSETTS 02664 ;; ��;� �-^'; � �Tat ;� Telephone: (508) 398-2212 Fax: (508) 760-4861 ��,��. csherman(a�varmouth.ma.us , � � MEMO 1 I i TO: C&I Council SA 24 � � FROM: 'i�� P�e�unac�z (_Pue� 508 760 4859 ext 214 RE: Letter of Understanding DATE: June 10, 2008 The Yarmouth Fire Department provides fire, emergency medical,hazardous materials, and technical rescue services for the Town including Camp Grreenough. . � Our average response time in the area of Camp Greenough for an Emergency Medical ( Unit at the Advanced Life Support level is 5 minutes or less. We expect that all participants and counselors would follow standard$SA procedures when dealing with open fire to include unmediately available water supply, shovel and fire watch assignment. Please let us know if we can be of any assistance during your camping season at Camp Greenough. � . � ' i ' ¢ � . 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LN!(K � , � TI�E COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-405 FEE: 555.00 { 1�his is ro cercify that Ca�e Cod& Istands Council„ BSA#224 Inc � __ d/h/ mn (Treennu�ji, 227 p'ne treet,�Y�rmoLth��ort,l`�A E ! � HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERrTIGHT CAMPS This License is issued in confornuty with the aathority�ranted to the Board ofHealth,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and cvndirions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner suspended ar revoked. I _Januarv 13,2009 BOARD OF HEALTH: ��¢iL S�IY�� .Jv.� �ttlt�Z (',ffaur�ea .�.3G�'QilEex `Uiee C'�cti�ru�cn Q�nrt ��'J2.� j : ��- ,�� Bruce G.Murphy,M , .5., CHO � Director of Health ! TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #09-142 FEE: $30.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 ofthe General Laws,a pernut is hereby granted to: Cape Cod& Islands Council, BSA #224, Inc., 227 Pine Street, Yarmouthport, MA Whose place of business is: Camp Greenou�h Scout Reservation Type of business: Nan-Profit Food Service - To aperate a faod establishment in: Town of Yazmauth Permit expires:_ December 31. 20Q9 BOARD OF HEALTH: .�fe�e�t Sf�, �JZ..A�., C'Rc�evtnutn C'l�aacleo .�. .�CeUihex `tliee C'f�ainnu�en 5�a�6.e�rt 3.��co�, C'� �y��, J2..N. January• 13,2009 ruce . Murphy, , R.S.,CHO Director of Health i j . \ \ ' � H � � . . .o^ � ' _ . . . . . I..L � O � .� ry •� � ;.: - . . •� LL O W C� , _ � � � � i • � � �� U c� a " ' . . 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B O A R D O F H E A L T H APPLICATION FOR A LICENSE TO CONDUCT A M RECREATIONAL CANLP FOR CHILDREN INuuoEo oN�� (Use back of applicalion if additional space is necessary) FEE:-�59:88' �' Name of Camp: �;,t�c' �$'t� D►J Site Address: 2 ��' � U D �' Site Address: Tax ID Number(FEIN or SSl�: Type of Camp: Day(less than 24 hrs.)_ (� Residential(24 hrs.) 'i Hours of Operation: O�OD - ��bD /�D�'/L2� �' _/` /!�� Dates of Operation: Opening: �/ g/D �" Closing:��/D �' Name of Camp Owner: ��n� �/J�,L�Z�'�/D �_G��/.fJL'1L ��i� Office Address: �� !✓t/!u-d w �/T��_��/��GI�N l"�/��/� Office Telephone Number: �Dcg-362— �32 Z--- Name of Camp Operator(if different): �'��Y1� � . � Address: � Telephone Number: i Camp Director: �`��.,�,,�Q-_n r� ,�i�-°.s,c� � , � ' Address: 2 Lr/ILL� t,J �� OGl(/� l2?, DZf�,�i� ��Z ��-,-- ---�- Age: 4�� Telephone Number: ,��,�°°�Z� �,3 Z Z— Coursework in Camping Administration: /I/,��'L�2YJ��J�"OC,L_ Previous Camp Administration experience: ,D '� � � Health Care Consultant:�/,�'I ��/�7��.f�� I � � Type of Medical License: m/) MA License number: � � Address: �!1/� I �v� elephone: - C�- � 1 Of 2 �� Printed on 11lOS � Recycied � � Paper , i� . � ; Hospital for Emergency Services: ��,�5 ��r;I�'j,q� Healt6 Supervisor• ��,�� Age:__��_ Type of Medical License,Registra�ion ar Training:__�j/Il� ,�L,� , iQ�L'�j • Swimming Area: Yes� No ; .> � - � If Yes: Fresh Water� �cean Pool CPO � Specific Onsite Lc�ations: /_��10�DG✓,c.�� N/� i I Water Quality Testing Performed By: /,� p �-�`�9�r�a�u7��h�i? ��T— Aqua.tics Director. � I ,q/�, i Submit Certifications: CPR , 11�i First Aid� Water Safet�,q,,��s�j/� 6�03 / j Other Lifeguards and Credentials:�j�� . �_��i/�— 0.3 � � , ; Watercraf}Baating Ac�ivities: Yes� No Describe: �� a j'�Jc.�/�d,g,0� � Food Service; �� Is food handles,served or prepared? Yes No� To what e�rtent? Snacks Cooked and Served by Staff If cooked onsite,Food Manager(submit copy of ServSafe) Gatered if so,by whom? Is refrigerat�ion availahle for perishable foods? Yes }� No �� " Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staffpezson and volunteex who may have contact with a camper? Yes No ! IMPORTANT! CONTACT THE YARMpUTH HEAL DEPARTMENT 48 HOURS PRIOR TO OPENII�TG TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVEI2NIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. . SIGNED• � PRINTED:�cy/, �2��,�'�� DATED: i � See the negt page attached for a list af documents that m�rst be completed and submitted before your applica�ian can be fuI[y pracessed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will egpedite the process. i vos 2 of 2 �, � ��_ . - .. �;� � � . , �.�` - �,� °�� ' N�TIC� � � � NOTICE � � + TU TO � a , . . . A � . .. . �.. EMPLOYEES a �! E�VIPLOYEES T �,'" _ • ` !O y � . , 1M S�� The Commonwealth of Massachusetts � DEPARTMEN'� OF INDU5TRIAL ACCIDENTS ' 600 Washington Street, Soston, Massachusetts 02111 617-727-4900 — hxtpc//www•mass.gov/dia � As required by Massachusetts General Law,Chapter 152,Sections 21,22&30;this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by __. insuring with: 'Tt-E TRAVELERS INSURANCE CON�ANIES � NAME OF INSURANCE COMPANY ONE TOWER SQUARE . HARTFORD CT 06183� ` � ADDRESS OF INSURANCE COMPANY ' � (7PJUB-5960B18-1-06) 03-31-06 TO 03-31-07 POLICY NUMBER EFFECTTVE DATES �� • HOLLIS PEI�RIN & BLACK 31 MILK ST STE 1010 . ,�-- ,� BOSTON MA 02109 = NAME OF INSURANCE AGENT ADDRESS PHONE# �— CAPE COD & ISLA1�5 COUIdCIL INC 247 WILLOW STREET ��. BOY SCOUTS OF AN�RICA YARMOUTHPORT ��` MA 02664� a-= EMPLOYER . ADDRESS „= � �� EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY} DATE ~_ '- MEDICAL TREATMENT �- _ — The above named insurer is required in cases of personal injuries arising out of and in the course of r' : employment to furnish adequate and reasonable hospital and medical services in accordance vwith the � �= -provisions•of-the Workers' Compensation Act A.copy-of the F'ust Report of Injury must be given to the �= injured employee. The ernployee may select his or her own physician. The reasc�nable cost of the services- � provided by the treating physician will be paid by"the insurer, if the treatment is necessary,and reasonably- •—. connected'to the work relatedsnj�ry. In cases requiring hospital a�tention, employees are�ereby notified � that the insurer has ananged for such attention at the )� � , NAME OF HOSPITAL - , ADDRESS TO BE PO STE� BY EMPLOY�R ooaea2 W20P1G02� , _ . � THE CpMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH B4ARD OF HEALTH j PERMIT NLJMBER: #07-012 � FEE: $50.00 � This is to certify that Caue Cod&Islands Council BSA#224, Inc ; d/bla Camo Greenough Scout Reservation, � 7� n reet, ort, � HAS BEEN GRANTED A LICENSE TO OPERATE R.ECREATI4NAL CAMPS,flVERNIGHT CAMPS ; 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 . I thereto,and upon such terms and conditions,and to the ruies and regularions in regard to said Cabins so licensed as adapted i by the Board of Health,and expires December 31,2007 unless sooner suspended or revoked. i June 27 2U07 BOARD OF H�ALTH: �. .l�-1�.� ��L�tt I J�E�e��f�, (��.n`�J[Ce(?R�a�acnttxrt i J�ita�eact,y. J`3�u�n, C'�e�cP� � J'a�xic�.�Kcl�exnwtt Qnrz C�ceerr.�aucfn, J`�..IV. , � � � Bruce G.Murphy; ,RS.,CHO Director of Heaith i � __ _ __ _ _ __ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: #07-184 FEE: 25.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion S of the General Laws,a permit is hereby granted to: Cape Cod&Isiands Council, BSA#224; Inc_, 227 Pine Street, Yarmouthport, MA Whose place of business is: Camp Greenough Scout Reservarion Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2007 BOARD OF HEALTH: `Jf3 1�.��'..,,�N.�`�1'��C�ia.i�ut ��llC�, , tCe LLYft 5►Zo.Bpact 3.J`3�ctrutn, C'�c� � � � � J ar�r�� ct��, �..�v. 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S^� � • £ t � BOARD OF HEALT' H �`�r� --� Q �� -- '�� N E TO CONDUCT A � '1� � APPLICATION FOR A LICE S � RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) FEE: $50.00 Name of Camp: ��0 �i��G�2,e�1 cJ�ic?&G✓`�" �5�.?T!/��/f� �/ Site Address: ��'��/iV��,�� /�u71f 1`-a�� rh�9-�' Site Telephone: ��3� � ,��2 - 3�Z� Tax ID Number (FEIN or SSN) : � �{�� Type of Camp: Day (less than 24 hrs.)�_ Residential (24 hrs.) Hours of Operation: �'Db - /640 /�2.tJ�� ii(>>�� Dates of Operation: Opening: ��/��p� Closing: f.,��I��(o Name of Camp Owner:�G�=- '��O�IIX ��/�t/G'�L �,q-' �J Office Address: p2�� G✓LL L�G.J S � ��IYI'JOGI/�- /a/�T�--' Office Telephone Number: �Of�� d� - �f3z2— � Name of Camp Operator(if different): �SQ1�'� Address: ITelephon.e Number: II Camp Director: �C,�/l�l �-/ Address: �1/'� �/c/1 LLat,J ��ll� Y�il�OuG}� 6 2%' !�� f.�?,�� Age: _,�� Telephone: �d��.�b2-�o�-�"" j Coursework in Camping Administration: ��S!-} QJ�J��,��,i/.,�'��d L � � Previous Camp Administration experience:�.�/ /P�/ ��i�'I� /�i4t/��i�/yI� � � Health Care Consultant: ��,Q ��7�'t �D y� Type of Medical License: MA License number: ��g � .� �i'' ZE,L Telephone:_�U - ��s� r Address: � � Se s • � �/28/03 1 of 2 � A�c�� Pa�� 1 i . , � Hospital for Emergency Services: C�� aD f7"DS,�/%/�C., � Health Supervisor: �,/� �/QE,4�t Age:�,h�Type of Medical License, Registration or Training:�/�/,�5 ,l��S Swimming Area: Yes� No � If Yes: Fresh Water�( _ Ocean Pool: CPO: Specific Onsite Locations: ��1�- �GJ,(�Lsl� )`''DN� � Water Quality Testing Performed By:�/�� D� �/�/�� lit�i��/�?� � Aquatics Director: �•(S�� y/�/ Submit Certifications:CPR�� 1�`Aid��_ Water Safety��Cg Q j/�, ��03 Other Lifeguards and Credentials:c�5�} �/,f'`6'��_�� Watercraft/Boating Activities: Yes� No Describe: ow�J ! Food Service: Cr�� Is food handled, served or prepared? Yes No�_ To what extent? Snacks Cooked and Served by Staff If cooked onsite, Food Manager(submit copy of 5ervSafe) � Catered if so,by whom? Is refrigeration available for perishable foods? Yes� No Backround Checks: i Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff � person and volunteer who may have contact with a camper?Yes�No � _ � IlVIPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOUR5 PRIOR TO � OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND�IRE DEPARTMENTS. � SIGNED: `/ PRINTED: �" DATED: �02� �._,/C'�,�fl/�C� //� See the nezt page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete � these documents as soon as possible and submit them in advance. This will egpedite the �rocess. j 3/28/03 2 of 2 1 . - � �� ----__-j The Comnanwealth of Massachusetts �� _---� _ De,parlme�t of Industrial Accidents � =-_ = N�'��i�s�/MM� � _ _= 600 R'ashingto�e Stree� f"`Floor � ; ' ' - i � c��t�ia�� i : e � � NOTICE _ � W NOTICE ; M � i � _ : � TO � a TO :� ; EMPLOYEE S �= EMPLOYEE 5 !� � / , �r, �/ / V O,�M S�b The Commonwealth of Massachusetts ' �,., DEPARTMENT 4F INDUSTRIAL ACCIDENTS ; 600 Washington Street, Boston, Massachusetts 02111 � � 617-727-4900 — httpc//www.mass.gov/dia I � iAs required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I I(we) have provided for payment to our injured employees under the above mentioned chapter by iE msuring vinth: TI-� TRAVELERS INSURANCE COI�ANIES ; �� NAME OF INSURANCE COMPANY � ONE TOWER SQUARE � HARTFORD. CT 06183 ' �'� � ADDRESS OF INSURANCE COMPANY � � (7PJU6-5960618-1 —06) 03-31-06 TO 03-31-07 POLICY NUMBER EFFECTTVE DATES _ �� • HOLLIS PERRIN & BLACK 31 MILK ST STE 1010 ; � ; �� BOSTON NIA 02109 ; � ' = NAME OF INSURANCE AGENT ADDRESS PHONE# _ , ,� CAPE COD & ISLANDS COUNCIL INC 247 WILLOW STREET , ��, BOY SCOUTS OF AN�RICA YARMOUTHPORT �� MA 02664 �' — EMPLOYER � ADDRESS ' „_ � ; � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE � � � ,= MEDICAL TREATMENT � �•� The above named insurer is required in cases of personal injuries arising out of and in the course of � � employment to fumish adequate and reasonable hospital and medical services in accordance with the i °= provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the '= injured employee. The employee may select his or her own physician. The reasonable cost of the services = provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '� •� connected to the work related.injury. In cases requiring hospital attention, employees are hereby notified � ' � that the insurer has ananged for such attention at the � ; � NAME OF HOSPI'TAL ADDRESS j i TO BE PO STED BY ENiPLOYER � ooasa2 WZOP7G0? • _ ; � �..- � ! THE COMMONWEALTH QF MASSACHUSETTS ' TOWN OF YARMOUTH � BOARD OF HEALTH ; PERMIT NUMBER: #06-010 FEE: $50.00 . This is to Certify that Cape Cod&Islands Council. BSA#224�Inc. dlb/a Camp Greenough j 227 Pine treet, Yarmoi�thnor , MA � ; HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERNIGHT CAMPS 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 Massachi�setts 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 31,2006 unless sooner suspended or revoked. May 18,2006 BOARD OF HEALTH: B �. ,��., ' ��st�, .�., v�e�� a��. e�, e� �� v,� , R.�v. Bruce G. Murphy,MP .,CHO Director of Health TOWN OF YARMOUTH BOARD QF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHIV�NT PERMIT NUNIBER: #06-178 FEE: $25.00 � In accordance with regulations promulgatsd under authority of Chapter 94,Section 305A and Chapter ; 111,Section 5 of the General Laws,a pemut is hereby granted to: Cape Cod&Islands Council, BSA#224, Inc., 227 Pine Street, Yarmouthport, MA Whose place of business is: Camp Greenough � Type of business: Non-Profit Food Service � � To operate a food establishment in: Town of Yarmouth ; Permit expires: December 31, 20Q6 BOARD OF HEALTH: 13 �urz`�. o�urz,/LI.$., ' � d�eless S!�li, �.N., ?/sce G�nu�s j R�t� B�, Gl� p�A��t �I��j�.�, R.N. May 18,2006 ce . hy, ,RS.,CHO Director of Heal i ' T -•-� .� ..�. _ °f:"R o TOWN OF YARMOUTH.$QARD OF HEAL �P �� F� -�c f_,�.._..e;�I �V i- `: .,,� APPLICATI�N F4��•TCENSE/PE�iMIT-2 �'� ` 7 L L) •., ...., * �..�� '�� s i;:� � � � �?� Please complete form and attach � ece'ss�y documents by D ber��, �06�`.` Failure to do so will result in�e return of your applicatio p��.�-�� E�� ' NAME OF ESTABLISHMENT: /"��_�'�L�O��G'N TEL #�bB�G2-�,/2B LOCATICIN ADDRES S� 22'� �irr�<Sr�P�T; f��3r��f �� ' MAII.,ING ADDRESS: 2� !�/u.vt.J rI?�T �f�� °D/1T; .�'Jr4 O1.d�S OWNER/CORPORATION NAME• �'A �i /�'LAND� �r�v�ticl� E� ' MANAGER'S NAME: �'1/Cf`f1�2 iP>L�Y TEL # ;3�d 2-�f�?Z ' MAILINGADDRESS� 2��} 1�1�L[.vi.J S��p�i�u �0�/li rIJA 0263f , ' POOL CERTIFICATIONS: i The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated , Pool Operator(s)and attach a copy of the certification to this form. 1. _ ------- ___------ _—. , 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wiit not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food � Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ; Please attach copies of certification to this applica�ion. The Healt6 Department will not use past years' records. i Yoa must provide new copies and maintain a fde at your establishment. � 1.��'Nf? .Q �//�E,�t� 2. ; PERSON IN CHARGE: ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. - I �� ,�1 l.�l�l9U1tL �La ��t�' 2. LA�✓/��/1l� S8/.B�L HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employe�e 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 fonn. 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. , � i RESTAURANT SEATING: TOTAL#_�-� I 1 � OFFICE USE ONLY LODGIlVG: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $50 MUTEL $50 j _INN $50 _ �CAMP $50 �O —O � �SWA2IVvmJG POOL$75ea. I _LODGE $50 _TRAII,ER PARK $50 _V�LpppL $75ea. ; _ _ ___—_ —_�----- — _ __ ___— ___ _— _ FOOD SERVICE: -- _ -- — — LICENSE REQUIRED FEE PERMTP# LICENSE REQUIItEp FEg pERMIT# LICENSE REQUIIZED FEE PERMIT# ; _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VTCT. $50 _WHOLESALE $?5 RETAIL SERVICE: LICENSE REQUIlZED FEE PBRMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE pERMIT# _<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 _ $ $��Q Q '•"•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMAR�ltlR . r ADMINISTRATION Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yarmouth is now required to hpld issuance or renewal : of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR . CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEL�IF PAID: YES�_ NO : NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED APPLICATION(S)AND RE(�UIRED FEE(S)BY DECEMBER 31, 2004. i SEASONAL ESTABLISHMENTS ARE TO CONTACT TF�HEALTH DEPARTT�NT FOR INSPECTION 7-10 ; DAYS PRIOR TO OPENING FOR TI� SEASON. � � s ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIEEN'T, MOTEL OR POOL (i.e., PAINTING, NEW ; EQUIl'MENT,ETC.}, MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COr�IlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must b inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard late count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. 4 4 FOOD SERVICE ` CONSUMER ADVISORY: Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor 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. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. _ _ _ I OUTSIDE CAFES: ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ; � OUTDOOR COOHING• � Outdoor cooking,preparation,or display of any faod product by a retail or food service establishment is prohibited. DATE: SIGNATURE: PRINT NAME&TITLE: - 10/22/04 r � �� -� � : ,�"� � � � � �� ;� ;`� �✓� �:� � � " - � � � � � �� 1146 ROliTE 28 SOLITH YAR�vIOUTH MASSACHUSETTS 02664-44 1 �� 5 � � MATPAGNEES � ��oqa `639'� T�le,�hone (SC�i 39fi-2231, Ext 241 — Fax(508)398-2365 H��T� ��T OAATEq � 1J � Ll R � 0 1' I1 E � 1.. 1 ll .yl�r l,� �� , � . � . �"'ed 9 ; ; . APPLICATION FOR A LICENSE TO CONDUCT A �� , r i RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) FEE: $50.00 Name of Camp:� /'�_�Ol,c�t� �,��uT �€S�iPI�A�'7a� Site Address: �Z� S�i�lE �jT/�� .Ph9t��/y}t ��PT. �'I/-1- 026 r�5'� Site Telephone: ti0� - 36 2-,3�f�8 Type of Camp: Day (less than 24 hrs.)�. Residential (24 hrs.) Hours of Operation: �800 ' /v100 /�D�tJDi9�i�0�4-� Dates of Operation: Qpening: '��J��O s Closing: �1/��5� Name of Camp Owner:�,o� ��p � /S�AN,DS �c�,UC/��,�5s�}- Office Address: �� GG��✓ �vi''�,Prilc�cl'7N��Pi'. /1�i� Dz6�� Office Telephone Number: �U� - 3�Z- �322- Name of Camp Operator(if different): S,4,a�1� Address: Telephone Number: Camp Director:��,q�,,t�� , Address: Z�/� � /LLUcJ Sf �,92i�'JDcr7tf/UQ� /'j'1�4 DL,� �.� Age: �_ Telephone: �D 8- 36 L �f3�Z--- Coursework in Camping Administration:�5A- r�f�T/D,✓,�-� l''�� .S�ffDd� Previous Camp Administration experience:tQ��/n�,J �S/,p,�C�11�� l'��'+! Health Care Consultant: tQ,�', ��,/�•�'�� Type of Medical License: �� MA License number:��,�� Address:�3�' ��jT'�' �� . �' ,��j�IQu/(�-�Telephone:�jOf�'-�6d_ZD�� ,��7= 3�2g��3 1 Of 2 � Priaitet�en � � Recycled Paper ! � Hospital for Emergency Services: �'nP� �'Zn �tOSP1 TACd Health Supervisor: �tJ,/l/)')f/- �/l�E��f , Age: ��,� Type of Medical License, Registration or Training: �/�, �l u-1 , ,�CL� � Swimming Area: Yes� No � If Yes: Fresh Water� Ocean Pool: CPO: � Specific Onsite Locations: ��/hP- �i.�JNC�D 1�a�� Water Quality Testing Performed By: /�cY,�',J a� l'g�P/rl��.l4}f.� AT�i ��,��/I7� Aquatics Director: � Submit Certifications:CPR � 1�`A,id y-/r]1 Water Safety �//�, 6/63 ._�*�_ Other Lifeguards and Credentials: �S� L/�rG,�J9�PD -6/0.� Watercra.ftJBo�ting Activities: Yes_� No Describe: �!3 �S Food Service: �'�� '� Is food handled, served or prepared? Yes No�� To what extent? Snacks Cooked and Served by Staff If cooked onsite,Food Mana.ger(subnut copy of ServSafe) � Catered if so,by whom? Is refri�eration available for perishable foods? Yes�,� No Backround Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and volunteer who may have contact with a camper?Yes�No IlVIPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS PRIOR TO OPENIl�TG TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVEItNIGHT CAMPS MUST ALSO SCHEDiJLE AN INSPECTION"i�VITH THE BI�II:DING AND FIR�DEPARTMENTS. SIGNED• PRINTED:�G��j ,Q �//��/l f DATED: �� 9 D See the neat page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will egpedite the pro�ess. 3/28/03 2 of 2 1 ! . . s 1 '� . __- -—_--� The Commonwealth of Massachusetts � _ -=- - - DepaR�ent of industrial Aecidenls - - �N�rl'MMR - -- � 606 R'ashiagto�e Stree� �"Floor j -,,� Bo�,Mas� 02117 Workera'Com�aahos Lava'ee Affidavi�Bdd tambi�lEleebricai Co�tra � ,.�, ..�_ � _ , .._ A� �_, �, „ �� - ,, �� t �,�...... , v- ., _, �� ' ,,L /c,+SF�-��i�l� address_ Z 1eL 6J � ��.n.�r,�t �� - ✓r��t- a�2�.��' .�c�d-��Z-y32� work site locati�rrnll aaamss 2� f-iAl� PE'rT � /Yl�c/�/- F', /Y�i9� oz6�,� ❑ 1 am a homeowne�perfomning all wo�k myself. �—Projed Type: ❑New C,w�tructia��Reanodel I am a sole 'exor and have no one w in an B ' ' Addition I I am an employer pc+oviding w�kecs'oompeasati�fa�r my employees wadcing a�this job. I L , , - --- - ; �� 2.�� L,�,��,, �r.,�,�_�' ' �- �fl�r.t ,��`_" �� ,�f� - � Z - �f32-,Z> ❑ I am a sole p�roprietor,geaeral co�tracber,or komeewser(iarde aue)and have hi�+od the co�ractors listed below wla have the following workets'comp�ion polices: a�: ��t- �; s�s �� ' � Failere r sx�e er�veera�e as reqeired oder 3ectl�2SA�f MGL 132 at kad b tl�e i�lpaitlu�f criwid pafl�es�a�e�p b s1,SM.N aidhr oae Ye�rs'i�ptbe�ent as we!as dvY pealtla i�tre foa sf a 3T0!WORK ORDER a�d a Sae e[S1N.M a day a`aidt s�a 1 ade�d t6at a cepy ot tYb sh6emeat may be forwarded�n the OIDce ef leve�tlena ef tlie DIA far a�e veripa�tln. I do bnrby ceNffy�rndee dis �e�es of tJYet t1Ye iujonw�ior�provlded aboae ia�rrre as�i oe �t � s�� z� p�" Print na� /L � Phone# J�cy��— '73�2— offidat.se o�ly aa■ot wdce L�t�.am to be os�plaed�Y dly er I�wi s�cial � cily or tswn: P�� Deputmeat a� � ❑check if ia�me�ale re.�psme is r�qaired �Sdeet��Offioe � �� ceatad pvsas: p�e#; QOfha, c�s�c mao� c�° �"��.Yq�� T O W N O F Y A R M O U T � _.: [ H �H `y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 . " • MATTACHEES � � , ��OAppp�T�0�6�� Telephone (508) 398-2231,Ext. 241 — Fa�c (508) 760-3472 � � � n G � 1 � r„n � B OARD OF HEALTH � �� `� � P ✓`�, � 7 ?�� ' To: Yazmouth Boazd of Health Permit Holders t`��,�1 L rN � _ �p-r. From David D. F�aherty Jr.,RS. ;��r Heahh Inspector � i Town of Yarmouth � � � Re: Federal Tax ID Number l i Date: March 22,2005 I , I � The Massachusetts Department of Revenue is now requ�ring that we furnish detailed information { to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIN}otherwise � known as your"T�ID Number". This is purely for administra.tive purposes oniy. Some businesses use tl� owner's Social Security Number (SSI� for this purpase. If this is tl� case for your establishment, be assured that we will not allow this informa.tion to be public � record � Please fill out the fields below and return this letter to ; � Yazmouth Heatth Department ; 1146 Route 28 � � � South Yarmouth, MA 02664 � Thank you for your anticipated compliance. If you have any questions regarding this matter, ' piease do not hesitate to cali. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m, The telephone number is(508) 398-2231,e�. 241. Establishment: � v'''�='�� FEIN or SSN: � �(�/ � Location Address: �°� � ��- � � Signature: G�yt ��^-�� 9 � � Print: ��`��yP� /�� l/�1�P � -�}�� '� Title: �C� �X�'c �� Printed on � � Recycled Paper , ,; �,,� '� � � Y , . � � ' � �� '��P12S.� �e�i � 2°`:�.R o TOWN OF YARMOUTH BO � �TH � �' � - � �° _ �� ;� APPLICATION FOR � IT-2004 FEB 2 5 2004 �•. ...��. * Please compiete form and attach all nece, documents by December 3 2`�,H�1LTH DEPT. Failure to do so will result in the ret of your application packet. T rt2�.c.�� TEI, #S6��r'�z--�y i�F Luc:a i io1� DRE : �a z �;�� ft y�,��.o�. �o�� • G/Y l��law .f'� �r�•�� ,1�6,-b G�'IH Q�2.d_1S" OWNER/CORPOR.ATI N NAME: �'�OL« + l.r)o 1 Cr,,:,,�C� G3t'A MANAGER'S NAME• �f'?��a-�l ,�'�'►1<�, TE # ��'36 2-y:l L Z- MAILING A D F�S• y 7 /./,2/ld� �S't y,�r v h a�.j�.For� �"��' va 6 7S` �OOL CERTIFICATIONS• '; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3• 4. � " FOOD PROTECTION M NA('ERS C RTIPICA'I'ION • All food service establishments are required to have at least one full-time employee who is certified as a Food ' Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �I ��°I ,�j,��n 2 PERSON IN IiARC�F.� Each food establishrnent must have at least one Person In Charge(PIC)on site during hours of operation. 1. �Ucv�� t� �T�c�<. .� �. F.il�fi IC CERTIFICATION • All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. � You must provide new copies and maintain a file at your place of business. „ 1. �- ll ��V�.-�;-�,'� l,J��,� f,�;�� 3. 2' 4. � RFSTAURANT SEATINCT: TOTAL#�_ � �(?DGING: OFFICE U�F' ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _B&B $50 _CABIN $50 _MOTEL $50 —� S50 I CAMP �50 O�F�OO'� _SWIMMING POOL$75ea. - _LC1DG.�:-_-- --- SS(l - �._ _ =�'RA?�,�l�P.AE�I�--�34 -_ _ iL�+ffIRLI'6@L �75� - --- — L— - --- -_ �D S— ERVIC� LICENSE REQUIRED FEE PERMIT# L(CGNSE REQUIRGD FEE PBRMIT# LICENSE REQUIRED FEE PERMIT# ,.,LO-l00 SEATS �75 O`��I`(" _,CONTINENTAL $30 NON-PROFIT $25 T>100 SEATS $I50 _COMMON VICT. �50 WHOLESALE $75 RFTAIL4FRVI E• — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. 5200 VENDMG-FOOD $20 _<25,000 sq.ft. S75 _FROT,EN DC;SS(iR"I' S35 _TO[3ACC0 S25 NAMF.c, �v F. $lo AMOUNTDUE _ $_12.S.00 "*"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* �„ + � : v ' ADMINISTRATION ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ; of any license or permit to operate a business if a person or company does not have a Certificate of Worker's . Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_�� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 � , DAYS PRIOR TO OPENING FOR THE SEASON. C ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. �� POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ; closing. � FOOD SERVICE ('ONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ' � G �ATERN� POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. ,� FRQZEN DESSERTS: Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE c�i+'�S: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Boazd of Health. � 4` 1 OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �7 y 0 � SIGNATURC � -��-�`�� : � y PRINT NAME&TITLE: ��te I ��Ir z 5�� _ Xcc:wl��e - 10/22/03 _ � v�i�� NUTICE � � � � NQTICE � � . . TO � o T4 w � ` ElV�P'L' QYEES � �T El��PLOYEES _ .� ,�M SV$ �, t � Th� Commonwealth of Massachusetts DEPA►R.TMENT OF INDUSTRIA.L ACCIDENTS 600 Washiagton Street, Boston, Massachusetts 02111 61?—?27-4900 — http:/lwvvw.mass.gov/dia ,As requi�ed by Massachusetts General Law,Chapter 152,Sections 21,22&3t?,this will give y�ou notice that I(we) have provided for payment to our inSjured emgloy�es under the above�entioned chapter by u�suring vv�ith: ThE ST. PAUL YNSt�2ANCE COMPANIES NAME OF INSURANCE COMPANY �IE TOWER SQUARE HARTFa2D, CT 06183 ADDRESS 4F WSURANCE COMPANY (651611�-7391 A88-3-03) 04-02-03 TO 03-31-04 POLICY NUMBER EFFEGTNE DATES � HOLLIS PERRIN & BLAdC 31 MILK ST 5TE 1Q10 � � � •BOSTON MA 02109 � NAME OF INSURANCE AGENT ADDRESS PHONE# � � CAPE COD & ISLAPDS COUNCIL INC 'C/0 MIQHAEL RII�Y BOY SCOUtS OF� AMERICA 207 WILLOW ST � YARMOUTF�P�tT . � MA 02664 � EMPLOYER � ADDRESS � � � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF AN� ' DATE � MEDICAL TI�',EATI4IENT � The above named insurer is rec}uired in cases of personal injuries arising out of and in the course of � , � employment to furnish adequate and reasonable haspital and medical services in accordance with the � rovisions of the Workers' Com nsation Act. A co of xhe First Re rt of In u must be ven to the � P Pe PY Po ) rY � � injured employee. The employee may select his or her own physician. The reasonable c.ost of the servic�s �� provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasanably ,connecteii to the w�ork related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has ananged for such attention at the NAME OF HOSPITAL � ADDRESS �4,4 ,��,� TO BE POSTED BY EMPLUYER , , � , THE COMMONWEALTH OF MASSACHUSETTS 3 TOWN OF YARMOUTH � BOARD OF HEALTH ; PERNIIT NUIyBER: #04-00? FEE: $50.04 ' This is to certify that Cape Cod& Islands Council Bov Scouts of America d/b/a Camp Crreenougl� 227 Pine Street,, Y�rmouth�ort, MA i � HAS BE�N GRANTED A LICENSE T� � ' OPERATE RECREATIOATAL CAMPS, OVERNIGHT CAMPS � This License is issued in couformity with the authority granted to the Board of Health,by Chapter I40,Sections 32A,32B, � 32C,32D and 32E as amendeci,and is subject to the proviisions of the Laws of the Co�unonwealth of Massachusdts relating i theneto,and upon such teims and conditions,and to the nxles and regutations in regard to said Cabins so ticensed as a�apt�d by the Board of Health,and expires December 3 l,2004 vntess sooner suspended ar revoked. � ��i,aoo4 Bo,�xn o��.�: 8�:.�`7�. �j'o�d�w,. �tl.�i. ' ��.�� E�� i �e�.s��R y.A►� , j f4�� 1e.N. � � . G.Murphy,MP O � Director of Health � I � � i I � TOWN OF YARMOUTH • BOARD OF HEALTH PERMIT TO OPERATE�FOOD ESTABLISHMENT I � PER1ViIT NUMBER: #04-174 FEE: $75.00 In accordance with n�ons proxnulgated under authority of Chapter 94,Section 305A ax►d Chapter 111,Section 5 of the eral Laws,a permit is hereby granted to: � _ _Cape Cod& Islands Council Boy Scouts of America, 227 Pine Street, Yarmouthport Whose place of business is: Cam� Greenough Type of business: �ood Service , To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2004 BOARD oF HEaLTH: Be�rau$. �, I�1.$. ' ; ��.� v:� �;�:�� ' Rodwt�i. B�, Gle� I �� R R,N. � � March 11 2004 Director of Heal�th� 'R .,CHO " ' c�i�5�s1 :. of_YaR ��q(rIP CrR�1JOUCr}1 2 ;r �. TOWN OF YARMOUTH BOARD OF HE Y . �'� APPLICATION FOR LICENSE/PF� - Q � � � � M � � .,,.. �� Y Q 7 �O(�3 * Please complete form and attach all necessary '� ' � b ecember 31 2 Failure to do so will result in the return "" o p ication packet. HEAL7H [�EPT. N T S T• L'.��i° ,C�e*�-.�ac.�c f/ # se�3c�-,�s�z� LOCATION ADD F • �x 7 �.v.E�s>.e��r, y.�,c,..a�s�-��,e�' ,�,,� o�c�s- �IAILING ADDRE S• ��f7 C�i�.lo c,� s1, �/.¢2.na d�lf�a,e i .�s� c.,?6 7s OWNER/COIZPOR.t�TIONNAME• �''��E coa wrs,��v� �y s�a�rs �I AGER'S N MF,� �.�:s�.st� ,�,�Ey T #sa�.34.�-��aa �ING ADDRESS• �'y�' �.��o� s�, yA.e.�o v��,��,�� o�,��.s- POOL CERTIFTC'ATION • . The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated — F� -the certifica�ion to t�iis form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1• 2. 3. q,. FOOD PROTECTION 1VLANAGER S - CERTIFICATION�• All food service esta.blishments are required to have at least one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Gs.�.0 �d.¢m.r.�z a r..�,s�E-,J l.s�.�,P ,�s op�'�%Fa 2. _---pFRCQ1�I_� HAR(''TF.• - _ _ _ -- ._ _-_— -- - -- - - _ _ - __- _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l. 2 HEIMLICH CER TIFICATION�• All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. _ You must provide new copies and maintain a file at your place of business. i j 3. 2. � 4 � RESTA RANT EATING: TOTAL# I�I?GING: �FF�CF tT E ��Y LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# j _B&B $50 _CABIN $50 _MOTEL $50 .—� $50 —�c`�M�' $so 0�1 3�l� _SWIMMING POOL$SOea _LODGE $SO �TRAILER PARK $50 WHIRLPOOL �25ea. �D SERVI F• — , LICENSE REQI1IItED FEE PERMIT# LICENSE REQI7IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 O '�G7 _CONTINENTqL, $30 _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 �TAii,sFAvrCE• — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,:._TOBACCO $20 _C25,000 sc�.ft. $�5 TOBACCO $Zp _<50 sq.8. $45 ,>25,000 sq.8. 5200 _FROZEN DESSERT$35 NAMF C AN E• $io AMOUNT DUE _ $ 12S.00 *****PLEASE TUR1V pVER AND COMPLETE OTHER SIDE OF FORM*�*** — _ � - � - � -- , _ � ADMINISTRATION ,i Under,Chapter 1;52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any �ic�nse dr permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION TNSURANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' 4 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 N� NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. 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 PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � ADDITIONAL REGULATIONS k � , POOLS _ -- _ _ _ POOL OPElVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openmg. POOL WATER TESTING: 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. FOOD SERVICE ' r'ONSUMER ADVISORY: Each food establishment wluch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters wrthinServi ce A �1 cat on�form 72thour�p or ta theuca ed eve�ntpaThsestforms cantbe required Temporary Food pp obtained at the Health Department. FROZEN DESSERTS: � Frozen desserts must be tested on a mont-hly�asis by a State cert�edIa�. �st results must�e sent to tfie I�-ea�th 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 of Health. UTD R OKING: � Q 00 C,'O - � Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment is prohibite . . � .,� d--� SIGNATURE: %� —l DATE. PRINT NAME &TITLE:�%�� -�'1� 10/18/02 � �� _ .' ;� � The Conimonwealth ojMassachusetts � � Department of Industrial.-1 ccidents � ; Of/ICOOJ/OYCs�pslll/f ; 600 Washington Street �, ,,.= Bosron,Mass. 02111 �'"' "� V4'orkers' Compensation Insurance Atfidavit A,�IICant infnrmatinn� P1C8SCPI�I'�T_Tldt�}�1[ ^^m�� rigir//° Cs.�EEiJa cl G f/ lucation: =.t�7 �,v E �T ) - _ �� l"�9.e.�la rf�f!�.L�� !�'lA o a?c7.5� phone q-✓�'d S�G�-�J�� I am a homecwner pertorming all work myself. � I am a sole proprizror�-� ha�e no one��orkin_ in am•capaciri� - ____[� I am an em��er pro��din�µ�orker�_compensation for my empioyees w•orking on this job. S9s►+s�1' name• C'`f}�E L''o� ►� �.S�C.9.v�S �oS' Seo.�7'S ,idress• �5�7 �/.C.latJ S� SLtY- yA��e cJ 7'��0.2� �/� phone N•Sa ��Ga?- ;�?o?-Z _ iosur�nce co.��'v� f/�''E� /��✓E J�LS �a �icy# GS/6��-�-�X/63- �f-a-Z� � I am a sole proprietor. _enerai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed beloa ��ho ha�e the follo�cin: ��orkzr� ,ompensation polices: S9l��v name• -�dress �n ehone fl• � insur�ncc co Rolic}•# — � com a�nY name• ' -- - -- --- - ---_ --- -- _ ---- _-- __- - , -- - �i address• 1 �,, pbone 11• ��••��nce co i��n'* t Failure to sccure coveraee as required under Secaon 2SA o(MGL 152 ca�lad to t`e i�paido�of erisi�al pe�dtla ot a O�e op to 51,500.00 a�d/or one yean'imprisonmeet as w�eU a�eivii penaida io the form oi a STOP WORK ORDER aad a tiee of 5100.00 a d�y apio�[ma I a�denn.d ma�a ; copy of thN statement mav be fonvarded to the Oliice of Invati��tiont of the DIA(or eoven�e veritiatfo�. i !do hrreby cerrij}�under the poins and penalties ojpery'ury thot t/re infornration provid�d ebove is true and corr�ct � s-�s� o.� � Signaturc � � ' /,� � Z ,l L2 � Print name �(� �' �/��h Phone 1! `S �� 'T� 7"7 � .. ofticial use onl� do not..�ite in this area to be completed by ciry or town oAleial , ; eity or town: Y�M�IIT� _ pt�mitAieeau p nBuildiog Department � - �Lieensiog Board �cheek if immediate response is required 261 ❑Stlectmen'e ORiee i �HnItA Department contace person: pbonel�;_ (508) 398�?231 eat. nOther ; � � � � � .. ._� :<�,,� � i � y � � i TOWN OF YARMOUTH � BOARD OF HEALTH , ; PERMIT TO OPERATE A FOOD ESTABLISHMENT i ; PERMIT NUMBER: #03-185 FEE: $75.00 ; ' In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ; 111,Sec6on 5 of the General Laws,a permit is hereby granted to: E ' ' Cape Cod&Islands Council Boy Scouts of America,227 Pine Street, Yarmouthport ; � Whose place of business is: Cam�Greenou�h , . ' ': ; Type of busmess: Food Service , � Ta�operate a food establishn�ent in: � To�n�of��outh:-��; � � � � �`� Pe�tnit expires:��December 3 i, 2003 Bo;��F��EPrI.TH: �;-�kanlea r�f. �elll�ac, (tF�a�,rar�. , � �u�a.xuc D. GfmrdoK. 'lAG.D., 2/rec k ' �'e6�it�. �rnaa�C, (�lark = � �a�rlck'��catl` I �f $ �� -, i I ` May 7.2003 , : � Bruce G.Murphy,MP ,CHO i Director of Health - . . _ . . M , - �._. ;, I ,..�.. > ..�.,,� : THE COIVIMONWEALTH<O�;MASSACHUSETTS.,,, � : ; , < . TQWN OF YARMOUTH ' . � , BOARD OF HEALTH PERMIT NUMBER: #03-010 ` . ` ; �EE:_.$50.00 � 'rhis is to cercify wat Cape Cod&Islands Council Boy Scouts of Arnerica clfb/a Camp Greenough 227 Pine=Street. �armouthport.MA _ _ , ' 'HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS, OVERTTICFHT CAMPS This License is issu�ci in canfnrmity with the authority granted to the Board of Healt�,by Ch�ter 1?t0;Sections 32A,32B, 32C,32D and 32E as amendsd,and is subject to the provisi�s ofthe Laws offihe C.ommonw�lth ofMassachusetts relating _ thereto,and upon such#ertns and conditioas,and to the rules and regulations in regard to said eabins so licensed as adopted by the Board of Hea1�,and etcpires Deeember 31,2003 unless sooner suspended or revoked. _ Mav 7.2003 BOARD OF HEALTH: �� s`�f. �ellfi�aa, �iavr� $ewcfaMcuc?�. �%oRalarr. J11.D,. �/lee ,�ade�t�, b'7ovaaMc, (�.le�rk �a��e�tt �ele�c S .�l. ruce G.Murphy, .S.,CHO Director of Health � �`�' a • � � c:F}MP GR.�"'�1�ooCrN ,�. TOWN OF YARMOUTH BOARD OF HEALTH Z�v �,�E�- APPLICA ION FOR LICENSE/PERMIT-2002 * s�a s�o 2 �y8g� �a�°%� .._..._._. .. . _ � �c �(� `�� 1 `,��! �r� �i�� ; Please complete form and attach necessary documents by December 31, 2001. Failure �o so will result in the return of your application packet. MAY � � �� S r�cx�,•o o�o� � /�,n e ,1'-1� y�-n�+.%6� a�� G�91�' O o26 7s" !./� !d i� S� �� Pa� e�i�i9 v�-6 �.r� OWNER/C:()R PnR A TTC1N N A T�i��'• ��C a Z.f .s (,c-nc� ,,�5� ' • /�'�i� �� 513�"�,�2 y.32z �LING ADDRE • �'/7 l.J;'//m�,� f� y'.r�mp,.�� , d'IA o�6 7�' POOL CERTIFICATION • The pool supervisor must be certified as a Pool Ope�-ator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2 Pool opera.tors must list a minimum of two employees currently certified in basic water safety, standard F'irst 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• 4. ; FOOD PROTECTION aNACTFRS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and m�intaia a file at your establishment. 1. 2 ' I �QLL.�N��.�.� _ ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. E 1 2 � HELMLICH CERTIFICATIOI�TS• � All food service esta.blishments with 25 seats or more must have at least one employee trained in the Heimlich i Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and . atta�h copies of employee certifications to this form. The Health Department will nat use past years' records. a You must provide new copies and maintain a file at�your place of business. � 1• 2. 3. 4 �STA NT EATINCT: TOTAL# � IADGING: OFFICE USE ONI�Y LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM17'# `B�r.S S50 _CABiN S50 _MOTEL $50 ± �� aso 1 CAMP $50 .�Oa"�f �SWIMMING POOL$SOea �LODGE $50 �TRAIL�R PARK $50 _ _WHIRI,pOOL $25ea FOOD SERVI(' .� LICENSE R�QIi�REL)_FE� __;PB�MIT#__ _ __I,ICEl��_BEQ�JI$E�_�E� _PERMLT�_ LICEI�SL 12EOt11SED_EE�___PERMIT# �0-100 SEATS $75 �oa_I6 I _CONTINENTAL $30 _NON-PROFIT $25 �>I00 SEATS a150 �COMMON VICT. $50 �WHOLESALE $75 RFTAit.SFRVI � LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FE� PERMIT# LICENSE 1tEQUIR�b FEE PEItMIT# �TOBACCO $20 �<25,000 sq.ft. $75 _ �TOBACCO $2p ____<50 sq.ft. $45 �,>25,000 sq.ft. ,$280 �FROZEN bESSERT$35 �E c�nrcE• $io AMOtJNT DUE _ $ !2 5.n0 � *****PLEASE TURN OVER AND COMPLETE OTHER SIlyE OF FORM***** - 1 � . . . . . _. 4s.�.�_ �� y�3: / f ; ADMINISTRATION ` - � - _ . . � Under Chapter 152, �ection 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal � of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's ; Compen'sation Insurance. THE ATTACHED STATE WORKER'S COMPENSA'�'ION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR , . CERT. OF INSURANC�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 � NO ' NO�'ICE:Peimits run annuaily from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO R�TLJI�N THE C�MPLETED APPLICATION(S�AND REQUIffED FEE(S)�Y DEC�IVIBER 31, 2001. SEASONAL ESTABLISHIvIENTS ARE TO CONTACT'THE HEALTH DEPARI"MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING F4R THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND API�ROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. enrnTmNAi RF.(''ULATIONS �° POOLS POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior�o opening. POOL V�%ATER TES'TING: �"he water must be tested for pseudomonas,�ota1 coli�'orm and standard plate courit�- --- by a Sta.te certified lab,prior to �pening, and quarterly thereafter. POOL CLOSING• Every outdaor in ground swimming pool must be drained or covered within seven(7) days of closing. � FOOD SERVICE rnNcrtt�tFR ADVISORY: Each food establishment which�rves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. ["ATF.RTNG,POLICY: Anyone who caters within the �own of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Servi�;e Application form 72 hours prior to the catered event. Thses forms c�.n be obtamed at the Health Departme�st. ; , _ _ __ ____ _ . Fi20 EN D�SfiEItTS: 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. � OLITSIDE CAF�S: � have rior a oval from the Board of Health. - C3utside cafes(i.�,outdoor seatin with waiter/��ai�ess service),must p ppx' � OUTDOOR C'(�OKING: I Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i , r DATE: �^ ��- SIGNATURE: E PRINT NAME&TITLE: �'"l i �� e,�� ..�'�e�,�,.�ji�� I � 09/11/01 i ,. .r . _��• f Y :► • � � ��:sq�`�' T � � �T �� F UTH � . � YARMO � `3 11�6 ROUTE 28 SOUTH YARMOt?TH MAtiSACHt?SETTS 02664-=i451 � MAT7ACMC[S � ��,. ,�r� Telephone(508) 398-2231, Ext. 241 — Fax(SOt3) 398-23G5 �.ro..,�o � �, C� !�� , �� D BOARD OF HEALTH �`,'¢�. � 1 �� APPLICATION FOR A LICENSE TO CONDUCT H��LTw-� ��'Y• ' RECREATIONAL CAMP FOR CHILDREN . ' Name of Camp: � �/'�-/l�t� �`�. Site Address: �7 � ,e1� S�. �/ho�� ' Site Telephone: ��-��2.—��1� . Name of Camp Owner: �� '^'�-�r��no� �r�n c r ' Office Address: �`�7 �✓i��o t,� �• ��,�rr�� o F�' �elephone Number. �� .. Name of Camp Operator(if different): Address: Telephone Number: � Name of Health Care�onsultant: IC@/�n�� 6 vt �1� , � Addrsss: Telephone Number: � , i i . � Type of Camp: Day � Residential � � Hours of Operation: ; � Dates of Operation: Opening: � dL Closing: � Swimming Pool: Yes Pool Permit Number No ''� Bathing Beach: Yeg� No � Meals Provided: Yes X Food Permit Number No � . � . , Signature of Applicant: _ ; Official Tide: ��''� ,��c.'�'��e � D�te: f� ..27 4.Z. � i � See the next page for a list of documents that must be completed and submitted before your �'� ��o� application for a license can be fully processed. You are strongly encouraged to complete th�yt� � documents as soon as possible and submit them in advance. This will expedite the licensing process. ; -.. � � a . ; ♦ 4 `3 , , � f ' Camp Di ector Name: �aVi�C ��T►�c Age: �� t � D i Coursework in camping administration: �s� ��d� �`'4('�� s� � Previous camp administration experience: �� .Pa'S Scr r�n o� __C[t .-� /� i �.hT��.�.o�,7r.^ l��s i9-5 �a�,� E7,�PcTov' � � � Health Care Consultant � � Name: i'lpn��lPY1 ��,.� ' Type of Medical License(must be a physician,nurse practidoner, or physician assistant with pediatric haining): �?�� MA License Number: Health Supervisor Name: 1 V Df m� �i�QA1ti Age: Type of Medical License,Registration or Training(See 105 CMR 430.159(C): R�l Aquatics Director Name: J i,�..rc� �e-Q r� Age: S'�� Lifeguard Certificate issued by: o � ` s� � Expiration date:�3�i � O American Red Cross CPR Certificate: R� 1T C^/'o�S �lpu L l � l� , d Expiration date:�� a ( �' �/� ; Arnerican First Aid Certificate: S/,Q�vlS�c�.�� ../C�/'s%� .u/ � Expiration date: � ' o� j Previous aquatics supervisory e perience: A� .,r�.T;` f�i�'��or o�' � i . . " . ¢, Firearms Instructor Name: ��`� �'�e.a+.�.. National Rifle Association Instructor's card(or equivalent):/3� rj/fii�K9Y.4L CcQ�p,� Sc�� ,�p �t1/Q� Date certified: o Expiration date: Horseback Riding Instructor Name: v " License Number: Expiration date: Stable Location: �/� Licensed in accordance with MGL Ch.l l l § 155, 158: Yes No Attach the names, ages,applicable current certifications(if any), such as First Aid, and the anticipated role at the camp of all supervisory staff(see below). Use as many pages as necessary to complete fhis. Su�ervisorv staff means those persons with the responsibility, authority and training to provide direct supervision to camper groups. This may include counselors,junior co�nselors,general activity leaders or other staff who provide supervision to campers without assistance. � � i � a , � � � i 1 i' : 2' � r r NOTICE . N �� NOTICE � TO � o TO � EMPLOYEES �= EMPLOYEES y �W / V O,�M Sv� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 � As required by Massachusetts General Law, Chapter 152, Seetions 21, 22 & 30, this will gNe you notice that I (we) have provided for payment to our fnjured employees under the above mentioned chapter by insuring with: THE ST. PAUL INSURANCE COMPANIES ------------------------------------------------------------------ NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06183 ------------------------------------------------------------------ ADDRESS OF INSURANCE COMPANY (6516UB-854X163-4-02) 03-31 -02 TO 03-31-03 ------------------------------------------------------------------ POLICY NUMBER EFFECTIVE DATES _� HOLLIS PERRIN & BLACK 31 MILK ST STE 1010 �— � BOSTON MA 02109 °'� ----- -------------------------------- „= NAME OF INSURANCE AGENT ADDRESS PHONE M� CAPE COD & ISLANDS COUNCIL INC C/0 MICHAEL RILEY � BOY SCOUTS OF AMERICA 207 WILLOW ST • o� YARMOUTHPORT MA 02664 o� ---------------------------- ------------------------- � EMPLOYER ADDRESS �� m— � ------------------------- � EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) ! DATE �� = MEDICAL TREATMENT m- — The above named insurer is required in cases of personal injuries arising out of and in the course of employment to — � furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers '� Compensation Act. A copy of the First Report of injury must be given to the in)ured employee. The employee may �= select his or her,own physician. The reasonable cost of the services provided by the treating physician wiil be paid a— by the insurer, ff the treatment is necessary and reasonably connected to the work related injury. In cases requiring �— hospital attention, employees are hereby notified that the insurer has arranged for such atter�tion at the ._ C��cTrJl R�S�J��------- \_cLrk 5�-------�`-S`-�'ni s�Yril�p�[ogl--------- NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 013788 yy20P1H95 �e��' � ; . , � THE COMMONWEALTA OF MASSACHUSETTS � � TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT NLJMBER: #02-009 � FEE: $50.00 This is to Certify that Cane Cod&Islands Council BSA d/b/a Camp Greenough 227 Pine Street.Yarmouthportr MA HAS BEEN GRANTED A LICENSE TO OPERATE RECREATIONAL CAMPS,OVERNIGHT CAMPS T9ris License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or revoked. June 12 ,2002 BOARD OF HEALTH: ��jimrdaMc. .�lce ,�a�t� �tae�c. (�k �a��or.xotl s�eile.t .S�a�(c. ,�7Z Bruce G.Murphy,MP .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTIi PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #02-161 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernnit is hereby grantsd to: Cazne Cod &islands C:ouncil B_S_A_, 227 Pine Street,Yarmouth�nort Whose place of business is: Camn Greenough Type of business: Food Service To operate a food esta.blishment in: Town of Yarmouth Permit expires: December 31,2002 BOARD OF HEALTH: �a�r� �dll�Far. �at�r«ra�c i►'e.ricfaaruic?�. C��ardou. 'I�lG.T�.. �/lec �3 �• � �a�riek'�er«�' �� s�. ��t J�e 12 ,Zoo2 Bruce G.Murphy,MP ,CHO Director of Health