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Home My WebLink AboutApplications, WC and Licenses ��. ` � �► TOWN OF YARMOUTH BOARD OF HEAL��' ' �� APPLICATION FOR LICENSElPERNIIT-_�0" �� g ~• * � � � 17M �� Io Please complete form and attach all necessary.c� a�m„ �y ecember ��. � � Failure to do so will result in the return of�ur�plicabon pac et N 0 V 4 2008 1 NAME OF ESTABLISHMENT: i v7J Gt.�l L l.C� TEL. �Fil�D LOCATIONADDRESS: � I Q✓dnv �0�.�73�-D "7 MAILING ADDRESS: OWNER NAME: 1�(p l'T'H �G�-�w� TAX ID tFEIN or SSN): �/ �- CORPORATION NAME (IF APPLICABLE}: C'�L[C��C �I,u��1U-�ij p1�.,(_ MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Poo!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 cun ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach eopies of employee certifications to this form. The Health Department �vill not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at Ieast one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 145 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. � L �� i �--1 l��,GL� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �o t �-f �'1Gc��j � 2 HEIMLICH �ERTffICATIONS: All food service establishments with 25 seats or more must have at least ane employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # �" OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIr# LICENSE REQUIItED FEE PERMIT.# _B&B �55 _CABIN $55 MOTEL S5� _INN S55 _CAMP 555 _SWIl�IIvIING POOL 580ea. _LODGE S55 _TRAILERPARK $105 �VHIRLPOOL 580ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �C 0.100 SEATS S85 'I�'() –(}/ _CONTINENTAL S35 NON-PROFIT �30 _>100 SEATS 5160 _COMMON VIC. $60 WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD �25 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO $55 �iA�ZE CHANGE: S10 AMOITNT DITE _ $ � � ""*"'PLEASE TL'Rr OVER AA'�D CO'bIPLETE OTHER SIDE OF FORivI***** . � 80iili0i � l�� 1 C/�'I �3ZLI.L�8 3I�IdN.I.I�II?Id =32If1,L�'NtJIS � � �1Q� �3.L�dQ 'N�'Id 3ZIS d �IIf1�32I ��'Y�I SI�IOI.LdAON32i '.Ll�I3J�T3�N�Y�iY�iO� O.L ZIORId H,L'I��I 30 Q2I�Og�-I.L 1�g Q�AOZIddK QI�I�OZ Q�.L2IOdS2i�g.LSIlY1I `�'�.L�`.LI�I�1idI[l�� M�l�t `Jl�IIZI�d `'a'i) 'IOOd 2I0 'I�,LOJ�1i `J.l�I�-iSI'IS�,LS� Q003 �L�I�' O.L SNOIZ�AOI�t�?I 'I'I�' �sooz `S t 2I��NI��Q�g�S)��Q�21Ifl��I QI�Td�S)1�IOIZ��I'Idd�'I`dM�l�i�2I Q�.L�'IdY1I0��LL I�RI(1.L�2I OZ 1�.LI'IIgISI�tOdS�I N1101i SI.LI 'i£iaquiaoaQ o� i�renu�r uio.r��Snuue uiu s�.iauad=�Is,Ol�t •pa;�q�qwd si�uauiys�q��.sa a�in.xas poo�io Ire�a.��q�npoid poo��tre3o�Bidscp io`uoqB.iedaid`8ur.�000.�oop�np �JI�I00�2i004.L110 ��ea�o preog a�cuo.��eno.�dd�e ioud an��sncu`(a�u�.ias ssa.r�ren��.ia�renn�nn gur��eas ioop�no`�a•t)sa�apis�np �S��S.Ll10 ��atu uaaq an�u suua�anoqe a� ti�un�iuuad�assaQ uazoi,�mo��o uoi��onai io uoisuadsns au�ui �.jnsai i�nn os op o�am�3 '�uau�edaQ u�teag aq�o�luas aq�sncu s�.insai�saZ •q�i pag�a�a�B�s B�iq sisEq�i�uow B uo pa�sa�aq�snui s�.tassap uazoi3 �S.L�I�SS�Q 1�I�'ZON.►I '��Q�i�H ac��e paurea.qo aq ue�suuo�asa�, •�uana pa.ia�ga ac�o�ioud smoq ZL uuo�uoq��dd�aou�aS F�3��Z pa.imbai ai�BuRg�q�uau�daQ�IeaH�p:now.ire�a��ou�snru�nouuB�3o unnoZ a�u�cnn s.ia�o�n�auo�u� �1�I'I4d��.L�� IA�I�S Q003 -Suisoi� �o s��p (�)uanas un��u,�paiano�io paureip aq�snut jood�utunurnns puno.r�ut ioop�no�.iang :��SO'I�'IOOd �ia}�aiaq��iia�.renb pue `Su�uado o�ioud `q�t Pag�a�a;g�S �e�q �uno�a�.�jd pxepue�s pue uuo�tlo��.o�`s�uouxopnasd io3 paasa�aq�snuz.ia��m ac�,L :91�II,LS�,L g�y�'A�ZOOd �pauado pue pa�adsui uaaq s�u tood a��un ga.�iood aq�ni��s o�P��atL�ZOI�I arg at� :g.LOI�I�Sd�'Id'�ucuado o�ioud s��p(�)ang uoi�aadsui au�ainpaq�s o��uau�.rec�aQ��aH q��s�uo� �8 0 0�ioua�uau�daQ��aag au�. q ��adsui aq�sriui uos�as a�ia�pasoi�uaaq anBc{u��m s�oodi�nn pu��pB�n`Su�ucu�nas�:��ap ZpQd szooa ��ua�sueis paiapisuo�aq�C�eiaua�il�is `PaPuacaB sg `rJb9�I�0£8 jo jJt9 '� 'TjJ'Y1I m PaugaP ss `as�x� ��u�dn��p uioo��o uoi�atto� aq�al�afqns si�.�u�dn�p ��uatsu8.q PaiaP�suo� aq�ou ii�s ��IIa�P io a�uapisai�se�iun�sanS B�o asn �pouad c�uoui(9)xis�ue u��nn s�BP(06)��aiou��ou�o a�s8a.�88� � p� `s��P �0£) �i� �u� aioux �ou�o ��uedn�o snonut�uo� o� ia�ai ��aua8 �s �uedtr�o �uatsueiy �aiaunnasia a�uap�sai3o a�Id ied�uud�e ute�u�u�a��u�a��.qsuouiaP��aIRB aQ Pu�anBt��snw s�dn�c��s�s �asn ia�ot�pue ta�oui q��pa�.Bt�oss��Ir.reuio�sn�puB�jr.�utpio `�uedn��o uua��oqs pue�oduaa�a�.o�Pa�i aq�s�uedncr�o�uatsueis`asn ia�.oH.zo ta�oy��o suoR��ac�3o sasodmd io3 :��0 ZAI�Sl�i�s S.LI�i�Ai.HSIrI�'.LS��l�IIJQO'I 2I�H.LO QI�I�'S'I�.LOL1t O1�I /� S� � ��'d�1�'I�.L�RId02idd�' �I��I��S�'�'Id 's�tuuad ino�C�o a�uensst io Tennauai o�ioud pied aq�sncu sua�pu�sa�u�nouu��3o unnay Q�I��'Z.Ld QN� Q�t�ItJIS .LIA��33�1 'dY�IO� S�2I�PdOM XD � a��zi��x�xnsru�o �ix�� xo `Q�x�Ts ax�a��z�oa�g ssnrn�.i.rn�� u�nsru uo�.�su�a.�o� s�x�xxon� ��zs Q��,r.�� .� �oa�a�o� s�iax.�oM�o a�B��a� �e an�u �ou saop �Cuedcuo� .�o uosiad B� ssauisnq B a��e.�ado o� �auad io asuao� �ue 30 �n�auai io a�usnssi pjou o�pa.imbai mou si�nour.��o unsos a�`9 uoq�as4nS `�SZ��5 `ZS t��i��Pul1 I�tOI.L�2I.LSIl�IIy1iQ�' . � The Commonwealth o Massachusedts f Deparhnent of Industrial Accidents M1�uiilMr�iftlf�s 600 Washiagton Street, 7`�'Floor Boston,Mass. 0211 i Woricers'Compensation I�arance Affidavih Bailding/Plambiag/Electricat Contractors A��t fefarm�li�►• p"kase pRINT k�ylrl,y �: �.�u n ��?-1 1'l�lG��c,� C�l c� �Cu,h r.� � address: ,� �t � �-(/ ci ) � Y '� state• zi : h�e SU - ��7 ' v U� w site location address- I am a homeowner perfom�ing all work myself. Project Type: ❑New Construction�Remodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees wo�lcing on this job. com�ev aame• addreas- citv- nhoae#• ins ca # � .. ; � � � _ ;, _';�-. � ' � ,« ;:� �: e � «�� ...A.�: ��,. �;_ ❑ I azn a sole proprietor,generai coetraetor,or homeowner(circle one)and have hired the contractors listeci below wlm have tt►e following workers'compensation polices: somnaav Hame: address• citv nh�t#- insmaace co. # _ . . ._ ,�- , _ commav eame• addras: cltq: oko�e#. ias eo. • # . . ; , ��- ".>., ��.. ... �.-. -..�. ": :.: . _ .�:. ,.. � �.y' •.:; h S'� ��e Fa�7m�c ro secore eaverage u req�ired aeda SeNiaa LSA ef MGL 152 caa Ind b the i�aitlas�f cri�i�al penNies�f a Bne�te;1,3A6-00 andler �Y�'�p�ment aa we8 as dvi pe�alti�in t8e form o[a 3TOr WORK ORDER and a 6ne o[S19�OA i day agaivat me. 1 aadenlaud that a cepy o[thi�tta�emeat may be forwardtd to the Omce ot lave�igat[sa4 of t4e DIA far coverage veri6catlso. I do 6enby ce&fy sader die palns arwd peealties of prrjrrry tket tAe lxjo�arotto�provided above is lrxe and comct Signattu�e Date Priat I/G��ITf� � GI!// Phone# _ J`��l ' �ZJ�'' o� �' efficial ese only do not write fm thls area to be compkted by dty or Nwn official city or tewn: Pt��°�� Baiding Depar�tent ❑check if�me�ate rdpenx is reqaind OLken�g Boar+d OSdectmea s O�ee ceatad penon: ��t cTM�ca s�r-mm� phaae#; ❑pWer TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-�19 FEE: S85.00 In accordance w•ith regulations promul�ated under�uthoriri�of Chapter 94, Section 30�A and Chapter 11 i, Section 5 of the Generai La�vs,a pern�it is hereby granted to: Judith Mann, 7 Rita Avenue, South Yarmouth, MA Whose place of business is: Celiac Solution LLC Type of business: Food Ser��ice/Caterin¢ (per State Code) To operate a food establishment in_ Town of Yarmouth Permit expires: December 31, 2009 BOARD OF HEALTH: .�Ee�e�t Sf�, J2.JV., CR�aL�neaa. C.'fta�e�eo 3E. ��iR�e�c, `Uice ePeavururn J�ita�t s. J3�c�v.cwz, C'�ex� Qrt�z C�'�eeeFc�aufn, `J�.✓V. Eu`e�iJ.�e J• ,f�Ear�e.� No��ember 17.2008 � Bruce G.Murphy,MPH,R.S.,CHO Director of Health ` " � i Jt•Y�k� TOWN OF YARMOUTH BOARD OF q�' ��.,e�'`� � � � � d � D �.� �'=' APPLICATION FOR LICENSE/P _ �0 ' �'O r ,. �� ; '`� DEC272007 - * Please complete form and attach all necessary doct�ments by Decemb r��'� DEPT. Failure to do so will result in the return of your application pac . NAME OF ESTABLISHMENT: �i(� �1�,c�1 Ui� LL� ,�$/� °p . L. # �G�j .�-U��"�' LOCATION AIDDRESS: � � v ��} MAILING ADDRESS: �` '` ' ' OWN�R NAM�: (.t0 t%}) �'VlG'c TAX F IN r N : `.� � CORPORATION NAME (I APPLICABLE): �`e(.►� L L� D PJ KI �'—l� � �'��" MANAGER'S NAME: ��-n l�") m� �-�J TEL. # �-�3�-�oY � MAILING ADDRESS: �Q-ri� ._�_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list tlie 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 Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attacli copies of employee eertifieations to this form. The Health Dep�rtment will not use past years' reeords. '�'oa must provide new copies and maintain a file at your place of business. l. 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 Sa�utary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certificationto this appfieation. The Health De�artrnent w�ll not use past years'rerords. You must provide new copies and maintain a fite at your estabiishment. l. 2. _PERS9I�T_IN�H.AR�E:_ ___ _ _ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past ye�rs' 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 REQUIRED FEE PERtiIIT# LICENSE REQUIRED FEE PER'1rIII# L10EI�'SE REQL'IRED FEE PERVIIT� _B&B S50 _CABIN S50 _MOTEL SSp _INN S50 _CA1�IP S�0 _S�'IVLVIINGPOOL S75ea. �LODCrE �a50 _TRAILERPARK S100 w�iIRLPOOL S75ea. FOOD SERVICE: LICEI+ISE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P£1�A�IT� LICENSE REQti IRED FEE PER'�SIT= �0-100 SEAI'S S75 ��vi' –�-U _CONTINENTAL S30 _NON-PROFIT S25 _>100 SEATS S150 CO:�L'�ION VIC. S50 �VHOLESALE S75 RETAIL SERVICE: —�tESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQLrIRED FEE PERytIT= LICE:�7SE REQti IRED FEE PER\iI?- _<50 sq.ft. �45 ____>35,000 sq.t�. 5200 _VEND1IvG-FOOD S20 _<25,000 sq.ft. 575 _FROZEN DESSERT S3� 70BACC0 SSO NAlKE CHANGE: sio AMOUI�T DUE _ $ 75.00 *****PLEASE TL'R.\O�'ER��D CO�tPLETE OTHER SIDE OF FORJ1x***� \ ) AD1ViINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TAE 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 pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCITPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customa.rily associated with motel and hotel us�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more tha.n ninety(90) days within any six(6)mQnth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy thax is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Enclosed Motel Census must be completed and returned with tnis app�ication. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days 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 CA'I'ERING 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 Pernut 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: ._--Outd��irtg,pr�paration,�r�isplay of any foad-produet by a r�nr food serv�;,�A��`�i�=:3�ent is�r•ehibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMI'LETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEME�TT. RE�tOVATIO�TS MAY REQUIRE A SITE PLAN. DATE: I'Z � Z�7�_ SIGNATURE: FRPVT NAME&TITLE: �u-��!`R-J !� �G�1�1 iu;n o- �\ The Commonwealth of Massachusetts Depar[ment of Industrial Accidents �� 600 Washington Stree� 7f�Floor Boston,Mas� 02111 Workers'Compessatioa Iesaranee AiSdavit:Beilding/PlambiaglElectrical Contractors �iee�atis�t: �tre PRllV I'k�biv �: Jc,�fl��—i � ��h address- � 1�--� 'T�� ci �� ` �y�l'IOYL� state: �G� zi : U��J hone ✓'�U' Z?J�� 7�3 work site location fnll�dress_ I am a horneowner performing all work myself. Project Type: ❑New Construcbion�Remodel I am a sole proprietor and have no one working in any capacity. ❑Bailding Addition ❑ I am an employer providing workers'wmpensation for my employees wo�lcing on this job. com �me: C'C}�tfic:� �3��fovc �:�= Q P.3� �t�tJ� .�G��.-�'' gddress: � �.C. � �/P ��: �v r,c,�t-1 1(c��mau`�-I Wt�. �Z� ta� .��a: �1�g -��3 —v��,�" �. # ❑ I am a sole proprietor,geeeral co�tractor,or bomeowser�crrcle owe and have hirEd tbe cornractors listed below w �� ( ' ) ho have the following workets'compensation polices: comuanv uame• address• citv: n�aae#: ies �. # aomouv Lme• �d_d�: citv oYosc#• -- _ —__ ___ _ __ -- --_ _-- -- - _ _ . - - i�s�ce co. �oli�# Xi�rdi�aiii�lY�N�+ifiwur�ti��rr� Failore i�xc�e ewerage a�reqdrad�dv Sectlat 2SA ef MGL 152 cu ktd b 1Ye�a e[criri�al pe�aNia�f a 8�tp b SI,SN-9i aadlor o�e yan'I�prbea�ent as we8 as civi peealtks in the for�ot a 3T01'WORK ORDER aed a Sne of 5186.OS a day agaivat me. 1 oaderstaad that a capy af t6is�ahmeot may be finrardcd to tAe OIHa of lavestlgadem of t6e D1A tot covenge veHlfcatisa. !do he�by cerlify rteder tbe palns awd penalties of per}r�ry thet tbe i�for�nafto�provlded aboWe is uwe and correct signature ��'�'�� Date �� Print name `l��t �� -�'�'7 Phone# o�cial ase oaly do not�vrite�this area to be�mpleted 6y dly er Eewn a�cial city ar te�vn• pern�it/�Ce�e# QBaiding Department ❑check if imtnedia�e t+e�enx is roqaircd �Sdref�ee's O�a �Hdltb lkparbeegt ce�ad pet�n: pho�#; QOW� . tTMviecd Sat 20(16) � � � � , : ACORD,� CERTIFIGATE OF LIABtLITY INSURANCE °ArE'MM,°°,�' 12/28/07 PRooucea ______.--�-�--�-•�-, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MARSH USA; INC. ^ � � ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 200 CLARENDON STREET � ' �`-' � � HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR TEL:(617)421-0200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BOSTON,MA 02116 0,�;"��°+,j � '�� ?��-�'�a � COMPANIES AFFORDING COVERAGE S02908-ALL-LINES-OS/09 � co p?nNv AMERICAN HOME ASSURANCE CO HEALTH I��p�• INSURED COMPANY CVS CAREMARK CORPORATION AND ITS B AI SOUTH INSURANCE CO. SUBSIDIARIES AND AFFILIATES -- — ONE CVS DRIVE COMPANY WOONSOCKET, RI 02895 C NEW HAMPSHIRE INSURANCE CO. � COMPANY � D NATIONAL UNION FIRE INS.CO. OF PITTSBURGH,PA COVERAGES This certificate supersedes and replaces any'previously issued,'cer#ificate. ' 1 THIS IS TO CERTIFY THAT THE PO�ICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE�IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —; --- —T CO I POLICY EFPECTIVE POUCY EXPIRATION LIMITS LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDlYY) DATE(MM/DDlYY� GENERAL LIABILITY I I X COMMERCIAL GENERAL LIABILITY I I I GENER4L 4GGREGPTE I$ 'I H2OOO,OOO PRODUCTS-COMP/OPAGG $ INCLUDED A CLAIMSMADE �OCCUR 159-57-90(Premises/Operations) 01/01/08 iQ�/Q1/Q9 ERSONAL&ADV INJURY ,$ 4,5�0,�� OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE � 4,SOO,OOO X QQQO/WCLLIQUQ FIRE DAMAGE(Any one fire) � �,000,0�� MED EXP(Any one person) $ AUTOMO&LE LIABILITY COMBINED SINGLE LIMIT $ 'I,OOO,OOO X ANY AUTO a ALLOWNEDAUTOS 160-73-48{AOS} ��/��/�$ 01/01/09 BODILYINJURY A SCHEDULEDAUTOS I160-73-49{MA) 01/01/08 01/01/09 (Perperson) $ A X HIREDAUTOS 160-73-50(VA) 01J01/08 01/01/09 BODILY INJURY $ X NON-OWNEDAUTOS (Peraccident) X jSELF-INSURED PHY.DMG. PRoaeRrv o,annncE $ GARAGE�IA&LITY AUTO ONLY-EA ACqDENT $ ANY AUTO I OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIA&LITY AGGREGATE � EACH OCCURRENCE � UMBRELLAFORM AGGREGATE $ I OTHER 7HAN UMBRELLA FORM $ B WORl�RSCOMPENSATIONAND 514-53-11 SEE2NDPAGE 01/01/08 01/01/09 X WCSTATU- OTH- EMPLOYERS'LIABILITY TORYLIMITS ER C i514-53-12 SEE 2ND PAGE 01/01/O8 01/01/09 E.acHncci�ENr $ 2,000,000 THE PROPRIETOR! A X iNri_ i514-53-13(CAl 01/d1/08 01/01/09 DISEASE-POLICYLIMIT $ �,v0"v,G00 PARTNERS/EXECUTNE � —__— C oFFiceRsnRe: Exc� 514-53-14{MN, NY,W�� I�l/��/�$ 01/01/09 jDISE4SE-EACH EMPLOYE$ 2,��,�� E OTHER WC&EL 514-53-15(OR) 01/01/08 01/01/09 'SAME AS WC ABOVE C WC 8 EL 514-53-16(TX) 01/01/08 01/01/09 SAME AS WC ABOVE D EXCESS WORKERS'COMP. 469-80-16 01/01/08 01/01/09 SEE 2ND PAGE I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTERESTS MAY APPEAR,AS RESPECTS THE LEASED PREMISES,BUT ONLY TO THE EXTENT REQUIRED UNDER THE LEASE OF THE PREMISES OR UNDER ANY OTHER WRITTEN CONTRACT OR AGREEMENT. VARIOUS LOCATIONS,STORE#161,735 8 944. CERTlFIC/iTE HQLDER NYC-�00415285-08 GANCELLA710N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE INSURANCE COMPANY WILL ENDEAVOR TO MAIL THE TOWN OF YARMOUTH 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ATTN: BRUCE MURPHY BOARD OF HEALTH BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABIIJTY OF 1146 ROUTE 28 ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. SOUTH YARMOUTH, MA 02664 AUTHORIZED REPRESENTATIVE M USA IN �.rT'/f Edward R Ford ' ��'OC ACOR�35:{11lU5} p ACORE}GORPd�ATiDN 19$8< '. DATE(MM/DDIYY) �� ADD(TIONAL INFORMATIQN NYC-000415285-08 12/28/07 _ _ _ _ -- _ PRODUCER COMPANIES AFFORDING COVERAGE MARSH USA, INC. � COMPANY 200 CLARENDON STREET , TEL:(617)421-0200 � E INSURANCE CO OF THE STATE OF PENNSYLVANIA BOSTON,MA 02116 COMPANY F S02908-ALL-LI N ES-08/09 INSURED '�� COMPANY CVS CAREMARK CORPORATION AND ITS ' SUBSIDIARIES AND AFFILIATES G ONE CVS DRNE : WOONSOCKET, RI 02895 COMPANY H TEXT WORKERS COMPENSATION CON'T: POLICY#514-53-11 -(AR,GA,HI,IL,IN,KS,KY,LA,MD,MO,MS,NM,OK,PA,SC,SD,TN) POLICY#514-53-12-(AL,AZ,CO,DE,IA,ME,MI,MT,NE,NH,NV,UT,VT) EXCESS WC-CON'T: S.I.R.$500,000-DC,MA,OH, RI S.I.R.$1MM-CT, NC, NJ,VA S.I.R.$2MM-FL COVERAGE A:Workers Compensation: Statutory COVERAGE B: Employers Liability Limits:$500,000/$500,000/$500,000 CERTIFICATE HOLDER THE TOWN OF YARMOUTH ATTN:BRUCE MURPHY BOARD OF HEALTH 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664 MARSH USA INC.BY Edward R Ford G�/`, Td'� ' Pa r . . 4 MARSH USA, INC. 200 CLARENDON STREET TEL:(617)421-0200 BOSTON,MA 02116 033555 THE TOWN OF YARMOUTH ATTN:BRUCE MURPHY M-033555 BOARD OF HEALTH 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 021 ��u��i��n��n��i��n�i��n��n��i� oaiss9 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-118 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the General Laws,a pernut is hereby ganted to: Celiac Solution LLC, 7 Rita Avenue, South Yarmouth, MA Whose place of business is: Good J�u Bake�v Type of business: Food Service/Caterin� (per State Gode) To operate a food establishment in: Town of Yarmouth Fermit expires: December 3 i�2008 BOARD OF HEALTH: .�e�.ett SR�'/�t, J2..N., C',Peavunaa C'l'urx.eea 3�. �'Ce@�iR►,eac, `Uu:e C�'Pic�wc»tacra � `J�'aBe�ct�.J3�ac�u�,C'.�icP� c��, �..nr. ��•�i� January 23,2008 Bruce G.1Vlurphy ,R.S.,CHO Director of Heal Dates 1/23/2007 Time: 3:43 PM To: Q 9,1,508 437-0222 B�G Ine. Aqcy. Paqes 001 CIieM#:48248 CELISOL ACOR� CERTIFICATE OF LIABILITY INSURANCE 01I23I0T rrrrn PROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers 8 Gray Ins.So.Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Rou69134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 02660-1601 INSURERS AFFORDING COYERAGE NAIC M �r�uRE° INSURER A SCottsdele(f1Suf�nCA Comp CeliacSolution,LL INSURERB: � `� � D 7 Rita Aven� �NsurtErt C: � �O V� South Yarrrwuth,MA 02664 INSURER D: INSURER E: covew►�Es H DEPT TFE POI.IC�S OF INSURANCE LISTEQ BELOW HAVE BffN IS�IED TO THE INSUI�D NAMED ABOVE FOR THE POLICY PERI�MJDICATED.NOTWITHS ANY REQUN2EMENT,7ERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPEGT TO 4VH�H THIS CERTIFICATE MAY BE 6SSUED OR MAY PERTAIN,TtiE NSURANCE AFFORDED BY THE POLIC�S DESCRBED NERENI IS SI�JECT TO ALL Ti�TERMS,EXCIUSIONS AND C�dDITIONS OF SUCH POLIC�S.AGGREfi�lE LMtITS SHOWN MAY HAVE BE9J REDUCED BY PAID CLAUAS. L7R TYPE OF MISURAN� POLJCY NUNBER ��CY EFFECTNE POLIGY EXPRATION u1�RTS A c�+��+�' CLS119833'1 QTJ16106 OZ/1S10T enncr+occuw��ce s1000000 x COMMERC44L GEt�RAI LIA&LRY RAfl81N'dI OZh 6A0T 02/1 GA8 �oe�r.�.ce To a�N�o ��O CLAMAS MP1DE Q OCCUR � MED EXP(Arry arre pa'san) SS OOO PERSONAL 6 ADY INd1RY $��Q(�Q GeNERnL nGGREGpTE S�I OOO OOO GENL AGGREGATE LIMT APPLIES PER: PROWCTS-CdAP/OP AGG SZ OOO OOO POLICY �CT LOC AVT�B��Y COMBINED SINGLE LIYHT ANYAUTO (EeaccidaM) S AlL OWNED AUTOS BODILY MJURY SCHEOULED AUTO6 (Pe�pereon) E HIRED AUfOS BOD�Y INJURY S NON-0VYNED AUTOS (Per aaid�t) PROPERTY DAMAGE E (Per acadmA) 6ARA6E LU1&LRY AUTO ONLY-EA ACCDENT $ ANY AUTO OTHER THAN �ACC S AUTO ONLY: ACaG $ exxcEs�ure�u w�eam �occur�tEwce S OCCUR ❑CLAMS MADE AGd2EGATE S S DEq1GTIBlE _ RETENTION $ $ MKIRKERS COMPB/SATIdN AND WC STATU• OTH- EMPLOYERS'WBi1TY . E.L EACM ACGDENT $ ANY PROPRIEfOR1PARTNEWE7(ECUTIVE OFF�ER/MEMBER EICCLUOED? E.L.DISEASE-EA EMPLOYEE $ Hyne,dascr�e uMar SPECULL PROV1510NS belnw E.L.DISEASE•POLICY LIMR $ OTMER OE8CFEPTION OF OPERATION$1 LOCAilON81 VEH�LES 1 ElCCLU�ONS ADDED BY ElIDORSEMENT I S�CIAL PROWSIONS CERTIFICATE HOLDER CANCELLATION SHOIR.D ANT OF TXE ABOYE DESCRIBE�POL@pE8 BE CdWCELLm BEFORE TI1E EXPRATION Town of Yarmoukh DATE THEREOF,THE ISSUMI6 INSURER iMll ENDEAVOR TO MA� _'jQ_ OAY$WRRTEN 114B Main Straet,RouOB 28 NOTICE TO TME CERTIFICATE HOLDER NAMEO TO THE LEFf,BUT FAI W RE TO DO SO SHALL South Yarmouth�MA OPBBr{ III�O�NO OBLIGATION OR LIABRiTY OF ANY KWD UPON THE IN9URER,IT$AGENTS OR Rears�sorTaTives. aurHort�o r��tEsarnnrre ! ....�., AGORD 25(2001108)1 of 2 �26756 WQg �ACORD CORPORATION 1988 Date� 1/23/2007 Times 3:43 PN To� e 9,1,508 437-0322 R6G Ias. Aqcy. Paqes 002 IMPORTANT If the cerfificate holder is an ADDITIONAL INSURED,the pol�y(ies)must be endorsed. A statement on this certifirate dces not confer rights to the cert'rf'icafle holder in lieu of such endorsemerrt(s). If SUBROGATION IS WAIVED, subjec# to the terms and conditions oFthe policy,oerfain policies may require an endorsement A statemerrt on this certificate dces not confer rights to the certificate hdder in lieu of s�h endorserrrerrt(s). DISCLAIMER The CertiFicate of Insurance on the reverse side of this form does not oonstitute a contrad between the issuing insurer(s), authw¢ed represerriative or producer,and the certificate holder, nor does it affiRnatively or negatively amend, extend or atter the coverage afforded by the policies listed th�eon. ACORD 25-S(2001l08f 2 pf y �67rrg ._...�___ � y � � _ ��°r°�" G� .� �� ''� �O`r R� TOWN OF YARMOUTH BOAI�D OF HEALTH�� N O V } � _ .,0 2 0 2006 �`: .:�;� APPLICATION FOR LICENSE/PERMIT-2�07 * Please complete form and attach all necessary documents by Decem e �EPT. Failure to do so will result in the return of your application packet. � NAME OF ESTABLISHII�IENT:__ �2I,t Cl,{� �b ��'(�� 1.1�C TEL. # S(i�- �"��-�� LOCATION ADDRESS: '� ��-Ct '►4✓�',. �t� "�►Q r✓rt ou�-1 �� D Z�!_c y MAILING ADDRESS: '�- 12Lt� 14✓� �-n ��r vnr�,�,sr+ m� �2c��e� OWNER NAME: �up 7 �H � a n..r� TA�ID (FEIN or SSI�,I� CORPORATION NAME{IF APPLICABLE): Ce 1 t c�C Su Ju�"d U�� LLG MANAGER'S NAME: �JU.lJ i�N jYl�i-�J TEL. # �U� - �-3 3 -l�� MAILING ADDRE S S: � ��T{� �4-�'� � �)a rrnoi,c�`-�� r�t c� U 2!�u� 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. l. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifica.tions 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 PROTECTI4N MANAGERS - CERTIFICATIONS: All food service establishments a.re required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. t�l�(�t 3?� � /�1'1�-� Z. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �J�SsiCct l��he�'tsr�r� 2 �'/��, YY1Gz.�.-� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. �ulJ r TN j7/1 a,2.i� 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQtJIRED FEE PFRMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL $50 _INN $50 `CAMP $50 _SWIlVIlvIING POOL$75ea. _LODGE $50 _TRAII,ERPARK $100 WE�RLLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENS�REQiJIItED FEE PERMI'P# �0-100 SEATS $75 (�'f�0� _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: —RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIlZED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _45,000 sq.ft. $75 _FROZENDESSERT $35 TOBACGO $50 NAME CHANGE: $10 AMOUNT DUE = S 7$-.aQ /!f ARpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""'" ... - _ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth 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 C4MPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �Q Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short terrn 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 af 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 six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. 4ccupancy that is subject ta 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 PO4L OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be inspect� by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5)days pnor to operung. PO4L WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirnming pool�nust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERiNG POLICY: Anyone wno 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: 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. �UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDUOR COOKING: - Qutdoor�ooking,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 RESPONSIBII.ITY TO RETLJRN 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 EQITIPMENT,ETC.), MUST BE REPORTED TQ AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMN�NCEMEATT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �� 2�, �� SIGNATURE: �� PRINTNAME&TITLE: ✓i-tD t �1-1 F I�IG�c�� Pl`�S1cLc� 10/17l06 � The Commomvealth of Massachusetxs Department of Industrial Accidents > �aarr.�aw� 60D R'oshiRgton Stree� f"`Floor Boston,Mas� 02111 - - worl�era'com�ss�uoe Ies�agee A�fiaa.�it:Bu7 lecdruat cuernecors .� .� , a ,, .. _-.� ,. . .... „ .,� � �� :�_��._ _. . � �� r"'�,�'��a�� n'.�,;t�s' , .. _. - s� �.. ; . name: J I�fJ t'�}-f Y�l Lv't-vl . addnss- �� Lf� ��'VL �ty �C� ��GL✓t'Vt0(.l.�i state_ �IG� zip_ D`Z(¢!p�- nha�e# �S • ��-D`�g� work site locati� fnll addcess: I am a homoowner performing all wo�lc myself. Projed Type: ❑New Caaistructia�OR�nodel I am a sole 'exor aud have no one w in an ❑Buil ' Addition , .. _ ❑ I am an eayployer prDYiding waa�kecs'compensati�for my empioy�s working�this job. � � L�..c �� e(,ca-� �v I ut rr�� _ � �-� '�4-v� � �a �a�r�vu�ir� 1� ,��: 3b8 �3� �o�-� �- ❑ I am a sole praprietor,g�eral cogtractor,or�omeowe�(cude aue)and have hined tbe co�iractars listed below who have the following wo�ce,�s'compensation polices: e�a�� .�i f$�� y ol�atrc#c � �[��ue: �� eliy: uir�e�. FaOm�e i�seeve orRrase n req��ed odv 3a1�ZSA�f MGL 152 cu Ind b tke��f eririN paiaNia rf a�e�p b:1,3N.N aadl�r �e yars'imprManseet�s wea as dM pnalt�i`me fira sta STOr WORK ORDER a'd a 8ae o[5160.OS a day�s�. 1 udersW�d tiat a cepy�t fib statement my be farwatdcd to He OQfce af l�ve�atloffi of the DIA fat arrnge vertllatly. /do l�enby ce�ify xndrr d�e paP�s aw/P�nie7Nas n.f pe*�Tru�'tAret dre infonxRtio�prov�ded arboWe fs bue aud�� Si$nature �� U�L�, Date �� ZO� _ Print name �l/l�G 1�� /LGZ-<'�Yl Phone# J�� - �' �� e�cial ax ealy do eot�vrite�t6B ara te be oo�plaed bY dty'er lrwn s�Cial cily or tswn: per�H�ceme# �lBaidf�Departe�est QI3o�tm�Bsard ❑t�edc if imme�i�le respsase is ral�ed �Sdec�n's O�ce �He�kY IkparUrtat ce�t petsoa: P�e#; Dp� c,�a s�p-zaa+� • z � LoweI1,N1A 01851 A MISSOURI CORPORATION,HOME OFFICE,KANSAS CITY,MISSOURI (978�i51-9900 FAX:(978)551-9917 PREMIUM FINANCE AGREEMENT . .--•--•--___....•--•----------•----.......---------.. .__-------•-------...•----•-----•-------_•_••-•.._..-•-----•---•-----------------------_.•--------__.----____._....•••--•--_._..___---•-•-•••---......___---...._-----.._._..._.. � CASH PRICE ' $780.OQ' AGENT : 1NSURED ` 4 � (TOTAL PREMIUMS) (��P��of business) : (Name and�side�ce or business : ROGERS R GRAY INSURANCE : Celiac Solution,LlC � casH nowN S�ss.00 3 � PAYMENT ' P O BOX 1601 : 7 Rita Avenue r+ � PRINCIPAL BALANCE Z585.00 SOU7H DENNIS MA 02660 : Souih Yartnouth MA 02664 � : (A MINUS$) ' (508}760-4690 ': (508�98-4317 ---�-----•-----•-•--•-------------•-------•-----.._.....:----•---•---•------------•------•-----..;-------------•-•-------------------------- - ----------------------•-----=-----....__•------------•----•-----.__.___ ___._-W..•--._..._W__..______...? - LOAN DISCLOSURE Quote Number:739293 -- ..... ��------ �-�---�---�--..._ ---��---- ----------------------------�-�-- ........................�----�--- --� ANNUAL PERCENTAGE RATE FINANCE CHARGE ' Amount Fina�ed : Tota!of Payments The cast of ywir credd as a yearly The doNar amouM the aeclit wifl = The amouM of credit pmvided to The amount you w�l have paid after you �e. cost You• you w on your betralf. : have made ap paymeMs as scheduled. 13% $32.13 ; $585.00; $617.13 ; _....----•---•---•-------------------••-�----.......----......---•--_-.............._.._...............................................•••-......: ; YOUR PAYMENT SCHEDULE WILL BE ITEMIZATION OF THE AMOUNT FINANCED: J�pw6er of Payments AmourR of Payments When Paymeots Are Due MONTHIY THE FU�L AMOUNT FINANCED WAS PAID g $68.57 Be9��9� 3/14/2006 TO THE INSURANCE COMPANY. �urity:You are giving a�curity inte�est in fhe uneamed premiums and,on commercial polic�es,loss payments which will reduce the unearned �mi�un of the policies. abe Charges: Late payment wi�l incur a late payment charge.See Page 2. `repayment: If you pay your account off early,you will not have to pay a pe�alty and may be entiUed to a�efund of part of the fina�ce charge. ee ya►r contract documents for any addi6onal infortnation about non-payment,default,required repayment in fiull before the scheduled date,and repayrnent refunds and penal6es. ......:.......:.....::.:..�::.:_:::_t�_v..._..::....,.::...:,..:,.:...._::=,:-_:.:.......,.._..__:.:... /�.'�.y. . .,. - -��_-:-��-:.-�::..:.....:......,.:..,:_::::::::::::::::.�::::...�.:,.:�:..;:-a•�� .. . ........ ... �y - - - - i�:ifr W.iKf�%.i:;;i::.::::; , :...."'.� . . . . ::::::.:::.:.::.:..-..:.: . �y - � -t.-�:. :. • �::.:::�:. �.:- :- �- ::;.::�.,-..-.::::"..�:.. . • �. . - - . . .._ ' . . ...... .. . ......................... . . . _:.-. .: .._t :: ' �t�22%:;:}:j:`>::i��.`.�`:5:5::::ii::::'•'r.:a:`•:��. .�r �y,� �r ��ee� �::."':::._.�.::.:.::x::::::.�.�: . --:.: .: �:.......... . . . ."'................... . .' 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'ENOfNG 2/14/2006 SCOTTSDALE INSURANCE COMPANY ' Gl 12 $750.00 XS BROKERS INS AGENCY INC TAXES $�'� , �� Q � ��,�� (qS _ _ _ _ __ __ CHECK CORRECT BOX) ❑ PERSONAI Q COMMERCIAL TOTAI 780.00 ie+mdersigned insured directs Premium Financing SpeciaGsts, Inc. relati�g to the listed insurance policies in furtherence of this erein,lender")to pay the premiums on the poliaes described above. agreement. consideration of such premium payments the i�sured agrees to pay 3. Understands fhat the finance charge begins to accrue as of the u�der at the branch office address shown above,or as othervvise directed ea�liest policy effective date. �Lender the amount stated as Total of Payments in accordance with the 4. Agrees to all provisions set ou#on pages 1 and 2 of this ayment Schedule,both as showm i�Loan Discbsure,subject to the agreement. ovisions herein set forth. NOTICE: ie named insured: A. Do not sign this agreement before you read it or if it Assigns to Lender as security for the total amount payable hereunder contains any blank space. uaeamed premiums and,on commercial poliaes,ioss payrr►ents B. You are entitled to a completely filled in copy of this iich wiii�educe the uneamed premium which become payable under agreement. e policies tisted above,as to aU of which insured gives to Lender a C. Under the law,you have the right to pay in advance the x�mty interest. full amount due and under certai�conditions to obtain a Irrevocably appoints Lender attorney-in-fact of the insured with full partial refund of tF�finance charge. n+ver of substitution and full authority upon default to cancel all D. Keep your copy of th�agreement to protect your legal d'ic�es above iden6fied,receive ail sums assigned to Lender or in which rights. ias granted Lender a security interest and to execute and deliver on �1��` :halfi of the insured documents,instruments,forms and na6ces Signature of Insured or Authorized Agent DATE undersigned hereby warrants a�agrees to AgenYs Representations set forth herein. SIGNATURE OF AGENT DATE 05)Copyright 7988 Premium Finandng Special�sls,tnc. pa Je� Of 2 02/08/O6 EQUOTE-GEN TOWN OF YARMOUTH BOARD OF HEALTH PERMTI' TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #07-011 FEE: $75.00 In accordance with regu1ahons promuigated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a peimit is hereby granted to: Judith E. Mann, 7 Rita Avenue, South Yarmouth, MA Whose place of business is: Celiac Solution LLC Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31, 2007 BOARD OF HEAI.TH: ,Q 11. l�o+rcP,or�,�l�l.:n., G�lr�,u� ��r� R.N, v�e�� RaL�t�. ,B� � A�� I�l�'�,�.,� R.N. November 28 2006 ��`�"� , Bruce G.Murphy, ,R.S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-01 lA FEE: $75_00 In accordance with re arions promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Secrion 5 of the eneral Laws,a pernut is hereby granted to: Judith E. Mann, 7 Rita Avenue, South Yarmouth, MA Whose place of business is: Celiac Solution LLC Type of business: Food Service/Catering (ner State Code) To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2007 BOARD OF HEALTH: .��Eeeea SPeal1�, J`�..lV., `?�ice C'f�avutuarri 5ta�&ent 3.J`3au�v�,rz, C'P,e�cl£ J at�ucR�.Mcl�eacma�#t � Qnxi(�.eexa&auen, `J�..IV. Sevtember 18,2007 Bruce G.Murphy,MP ,R.S O Director of Health � j � e-�-� ��a�,. L� [� C� � 0 M L D P'Y_ � ��R.� TOWN OF YARMOUTH BOARD O�E�T,�H� MAR 1 � 2006 ` � -� APPLICATION FOR LICENS�IP ��(�¢ 0 �y ��-�� 3� � •. 's * Please complete form and attach all necess�do�[iment by Decembe E H D E PT. Fai lure to do so wi l l resu lt in t he return o f your app lication pac ket. NAME OF ESTABLIS�IlVIENT: (°c?�,tGi.�, �U�,�t.t-�"Il/►n LLC.i TEL. # �� ' �2`}-�v� LOCATION ADDRESS: � l�t 1�C. `�i�_ c�'� 1Ir.�rvvr��i.Tl� U�(p c�� MAII,ING ADDRES S: � 12.�.� �i ii.e OWNER NAME: ��/LcD� �i I��n/n� TAX ID fFEEII�T or SSl�: CORPORATION NAME (IF APPLICABLE : Ce C<.c�.e v�t�l,urf 1 L L ' MANAGER�s N�: Juc�-�-i� Ir• ' c�� TEL. # MAIL.ING ADDRE S S: � 17_,i.� � ' �Q►/l,�,c.� c�? 1lGc✓�1-t�/Lt 77� ?�t �21�Lo Y , _,_, 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 ta this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. �J u.n, �-►� r� : L1�(��-%-► 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �L[ D ► `I I� T �ZG'c�c-� 2. HEIlb�;�eH 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 at�aeii eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL $50 ^INN $50 _Ct1NII' $50 _SWIIvIIvIIlJGPOOL$75ea. LODGE $50 TI2AII.,ER PARK $50 WHIRLPOOL $?Sea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE I2EQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � 0-100 SEATS $75 �v—�(o CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQilIRED FEE PERMTT# LICENSE REQUII2ED FEE PERNIIT# `<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _QS,OOQsq.ft. $75 _FROZENDESSERT $35 _TOBAGCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ ••"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••**" ADIVIINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES '� NO NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO ANU APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the 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 ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any foad product by a retail or food service establishment is prohibited. DATE: �` 1 v ' 2vU� SIGNATURE: G��C��—. PR1NT NAME&TITLE: U lrt�l J7� ��' �CtK�'I ��,e�JIICG� 09/28lOS . ` s � The Commonwealth of Massachusetts Department of Industrial Accidents > Nl�aarw�rlf� 600 Washington Street, 7`"'Floor ' Boston,Mass. 021II Workers'Compeesatioa In4arance ABidavit:Bailding/Plembi�g/Elcch-ical Co�tractors A�e�rt�rfsr�tfe�t: �Ate PRINT l+�i�1r �: ;l u-o� �! � h�(a �t� 1��i�t �� i t�{-C' sv��c�orJ aaa�s: � �2 fG�.. �V�. city � 7��U u-`J { ' state: �� zip: V L��/ ph�e# J�77 ' �"�J��/7 7� � wo ite location full address: I am a homeow�r performing all work myself. Project Type: ❑New Construction�Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees working on this job. comaaav�►me• address: ciri: oi�a�ae#• co. # : . ,rk� . . .,- r . : .., .., .... ❑ I am a sole praprietor,geeeral coatraetor,or homeo�vaer(cirde on�)and have lvred the contractors listed below who have tbe following workers'compensation polices: comnaav uame• address• cltv n�oYc#: i�m�astx ca # s�nt�v game• addras• citv u�oie#• ca # �� Failm�e M xcare oavvase at req�r�ed uder Sectlea 2SA of MGL 152 caa k�d b tie�a of crisital pe�aNia�f a 8��p b i1,SN.M aallor ome yea�s'Imptbe�a�eent�s�re8 as civi pemltks In t6e form af a STOr WORK ORDER aed a 8ne d f160.Os a day agaimt oe. l oadenta�d t6at a ce(ry of this atatemeat may 6e forwarded ra tee O�.+e ai lav�de�of t�e DlA tor ceverage veripeatlse. !ro her+eby ceNify u�der dbe pri�ns and ptaeJties of perJxry tlYet tNe i�foraiatio�provJded abo►ie rs Irue and corr+e�ct Signature / �C �!�� Date �' /U� �(1 D�O Print natne t�/�iC�� Cti'l-�/ Phone# �7�' �7'�'- �T�i T e�ciai ux only do not�nite ia thfs atea to 6e co�pleted by dty er fown o�cial city ar ta�►n• permiH�ceffie# �Boiding Departm�et �ag Board ❑chccg if immediaFe rcspeme is reqnQed �Sde�n's O�ce OHaI�Dep�r�ent contad peraon: phone�!; QOfha' t��-�) � , - TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-161 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 pernut is hereby granted to: Judith E. Mann, 7 Rita Avenue, South Yarmouth,MA Whose place of business is: Celiac Solution LLC Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2006 BOARD OF HEAI.TH: /3 `n. Cj'�,o,�A�l.`n., G�k�vca�� r� R�v., v�e�� R�t�.�3� el�k ��Na�� 4.�.s�j�� R.N. March 14,2006 ruce G. Murphy, H,RS.,CHO Director of Health �� YA�� TOWN OF YARMOUTH � o H 1146 ROUTE 28 SOUTH YARMOUTH MASSA(1HUSETTS 02664-4451 " MATTACMEES � Telephone (508) 398-2231,Ext. 241 — Fax (508) 760-3472 � ��ACOA�TE0�6j9� 7' 'd (� B O A R D O F H E A L T H To: All 2006 Yarmouth Board of Health License/Permit Holders G� C� C� f� I] M � � From: Yarmouth Health Department �A� � l. 2 0 0 6 HEALrH [7EPT. Re: Tax Identification Numbers Date: March 15, 2006 The Massachusetts Department of Revenue requires that the Health Department furnish to them detailed information regarding all permits and licenses that we issue. One of the required details is to provide a t� identification number, whether it be an establishment's Federal Employer Identification Number(FEIN)or, in the case of an individual's license, a Social Security Number (SSl�. This information will be used by the Health Department purely for administrative purposes only. Since you did not enter this information on your business application, would you plea.se fill out the information below and return this letter to: _ __ Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to call. 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: Celiac Solution LLC FEIN or SSN: � Location Address: 7 Rita Avenue, South Yarmouth, MA Signature: ' '� '��'� _ , _ Print: ;,��D�/"H !�. �I�%b'IV� � � � Title: �1�`�t l�K.�` . � �� Printed on ( Recycled � y Paper