HomeMy WebLinkAboutApplications, WC and Licenses . ' C-r�fz�sr�PH��Zs
�� ► TOWN OF YARMOUTH BOARD OF HE
���"' _
� � APPLICATION FOR LICENSE 1��T�-�009 Cr�G C�i'{��'MI C� 'UD
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* Please complete form and attach all nece ` � d �n�by ece�,�r
Failure to do so will result in the ret``� of �`ur applicat n acket.
HpEALTH DEP
NAME OF ESTABLISHMENT:�,��h,h p��� TEL. # �- ��l I-SI 's�
LOCATION ADDRESS: �
MAILING ADDRESS: U ` 33 .��e_�
OWNER NAME: � � TAX ID FE1N or SSN : `�
CORFOR.ATION NAME F APPLICABLE}: '(�, 1 � C'.�.tL. �� c;
MANAGER'S NAME: ��. � � 'Z.c� TEL. # -��},�- 7 7/- Sl��/
MAILING ADDRESS: �, ���,�� ��-�-c
POOL CERTIFICATIONS:
The pool supervisar must be certi�ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two enlployees cui-�ently cei-tified in basic water safety, standard First Aid and
Community Ca1 diopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies of employee
certificatians to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are requued to have at least one full-tune 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. ��� ����� 2.
PERSON IN CHARGE:
__ _ _ _ _ _ __ _ __
Each food establislunent mtiist have at least one Persoii In Charge (PIC) on site during hours of operation.
1. r Vc�.►1�• 1� �it�'1 �< < 2.
HEIMLICH CERTIFICATIONS:
All food seivice establishments 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 ui anti-choktng 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 yaur place of business.
,' / .
1.' I-�CLL� �GI m,��i� 2. �1/GtY1Cag���, ��'Yl /.��, S
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQL�IRED FEE PER�IIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIRED FEE PERivIIT�?
B&B �55 CABIN $55 MOTEL S5�
Pv'i�I S55 GAivIP S55 SGV"tMMING POOL S&Oea.
LODGE S55 TRAILER PARK �105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS S85 _CONfINENTAL S35 NON-PROFIT �30
�>100 SEATS S160 4 y- � � GOMMON VIC. $6Q ,�f%�/'/C/�G' _��HOLESALE �80
RETAIL SERVICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERIVIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#,
_<�0 sq.ft. S�0 _>25,000 sq.ft. $225 _VENDING-FOOD S25
_<25,000 sq.ft. S80 _FROZEN DESSERT �40 _TOBACCO S55
�AME CHANGE: S10 AMOUNT DUE _ $ ZZU.Od
*****PLEASE TURti OVER AND CO.'VIPLETE OTHER SIDE OF FOR�'I*****
:��:..: _
*
. .. ..,
ADMINISTRATION
Under Chapter 152, 5ectionY25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any lice� ar;permit to;operate a business if a person or company does not have a Certificate of Worker's
Compensation Yrtst�tance. 'THE ATTACHED STATE WORKER'S COMPEN5ATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED R'
OR
WORKER'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:
YES NO
MOTELS AND OTHEIt�,ODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any 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 opemng. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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 establishmerrt is prohibited.
_
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISI�V�NT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�E BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE�UIRE A SITE P .
�
DATE: � ��`j�� SIGNATURE:
PRINT NAME&TITLE: � � .�_�1 C�'� �GL ��f'V� I�� r_5
e
ioizvoa �
Date: 4/2/2009 Time: 8:03 AM To: � 9,15087603472 Faqe: 002
Client#: 20821 2CHRISTOFH:ERSAM
ACORD,� CERTIFICATE OF LIABILITY INSURANCE o4;02,o9°"Y""'
PRooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON TWE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
973 lyannough Rd., PO Box 1990
Wyannis, MA 02601 INSURERS AFFORDING COVERAGE NAIC i!
�INSURED �NsuReRn: Mass Retail Merchants Work Comp Trus
Mill Creek, Inc. D!BlAChristopher's INSURER6:
American Rib&Seafood Eatery
INSURER G:
C/O Yarmouth House; 335 Main Street INSURERD:
VNestYarmouth, MA 02673 msuReRe: �
COVERAGES
THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD DICA . O W..H ING
ANY REQUIREMENT.TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VdHICH THIS CERTIF ATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFOROED BY THE POLICIES DESGRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIO S�,GQj��riQySAR�."1r.
POLICIES.kGGREGATELIWIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Cf�\L.��7 ��Gr �
TYPE OF INSURANCE POLICY NUMBER P��CY EFFECTIVE POLICY E7(PIRAT70N LIMRS
LTR NSR �DATE N�AIDD/YY DpTE.MM/DD/YY
GENERAL LIABILRY EACH OCGURRENCE $
COA1��IERGHL GENERAL LIHBILITV � � .DRM1MGETO RE�NTED� $
ClAIMS MHDE �OCCUR MED EXP(Any one person) $
�PEFSONAL&ADVINJURY $
. GENERAL AGGREGNTE $ �
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $ � �
POLIGV PE� LOC
AUTDMOBILE IIABILITY COMBINED SINGLE LI�11T
ANY AUTO . (Ea acddeM) $
ALL O1NNE�NUTOS BDDILY INJURY
SCHEDULED AUTOS (Per person) $
HIREDAUTOS B�DILY INJURV
NON-OINNED AUTOS (Per acddenl) $
PROPERTYCAMAGE $
� (Per accidenl)
GARAGE LIAB�ITY AUTO ONLY-EA HGGIDENT $
� ANW AUTO EA ACC 5
OTHER THAN
AUTO ONLY: AGG $
EXCESSNMBRELLALIA6ILITV EACHOCCURRENCE $
OGCUR �CLAIPASMADE . AGGREGATE $
$
DE CUCT IBLE �$
RETENTION� $ . �
/4 WQRKERSCOMPENSATIONANO 014005031059109 01/01/09 Q����)�� �( 'NCSTATU- OTH-
EMPL�YERS'LIABILITY
ANYFROPRIETOW'PARTNEWEXECUTIVE E.LEACHACCIDENT $SOO,OOO
OFFICEWMEMBEREXCLUDED? NO E.L.DISEASE-EA EIdFLOYEE $SOO,OQQ
Ityes,tlescriti�urce!
� SPECIqL.PROVISIONS below E.L DISEASE-POLIGY LIMIT $SQO OQO
OTHER
DESCRIPTION OF OPERATI�NS 1lOCATIDNS/YEHfCLE51 EXCLUSIONS AD�EO BY ENDORSEMENT/SPECIAL PROVISIONS
Insurance coverage is limited to fhe terms,conditions,exclusions,other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be deemed to have altered,waived,ar extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER GANCELLATION
� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIItAT10N
TOWf1 Of Y3fRlOUtI1 DA7E THEREOf,THE ISSUING INSUREK WILL ENDEAVOR TO MAIL �� DAYS WRfTTEN
� �'I4O ROUte YS � NOT7CE TO THE CERTIFICATE HOLDER NAMED TO THE IEFf,BUT FAILURE TD DO 50 SHALL
South Yarmo uth, MA 02664 IMPOSE NO OBLIGATION OR IIABILRY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRES ENTATIVES.
AUTHORIZE�PRESE NTATIV�E
es v.Cw�/u-.�..��'�����
`r.�Y�fw �.�.
ACORD 25(2001/08)� of 2 #56116 LS1 � ACORD CORPORATION 1988
TOW1V OF YARMOUTH
B4ARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-177 FEE: 5160.00
In accordance���ith regulations promulgated under authoriry of Chapter 44, Section 305A and Chapter
1 I 1,Section�of the General La�us,a pernlit is hereb��granted to:
Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2009 BOARD OF HEALTH: .�Ee�ert SPea�Pt ✓�.JV. C.'�tawcmcr�t
sEarmG: 382 J'. .1��, �Iice �!�uutfnl�rtt
RESTRICTIONS: 1982 Septic system designed as folloa-s: ���u��� e.Srtl'S�Wt�CfL �rl �.Wi(z
a)�'�'ater usaee not to exceed 3,333 eallons per day_ J CrIZt�,(l`��litulG)Q/Z
'S �+
b)Seasonal usa�e—not to esceed 180 da}'s. � � .fJ �J
Mav 7.3009
� Bruce .Mu y,M . ., H
Direetor of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMUUTH
PERMIT NLIMBER: #09-106 FEE: S60.00
This is to Certify that Mill Creek, Inc. d/b/a Christonher's
769 Route 28, Sauth Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town af Yarmouth and at that place only and expires December thirty-first 2009 unless
soaner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .�Ee�ri Sfl�a�, J2..N., C.'l�av�r►uut
SEaT�G: 382 �, ��¢4, `v[C¢ t�ftCYtt
RESTRICTIONS: 1982 Septic s��stem designed as follo��s: �� e. SrIOWI�PrfL III ��
a)R'ater usage not to esceed 3.333 eallans per day: J lYl1(� � (R/t
b)Seasonal usage—uot to esceed 180 da}•s. ✓J � J�� -S
Mav 7.2009
Brnce G.Mu y,�1P > .,CHO
Director of Health
�---- �t1S��� cy,2rS7aP��ies
Jt,YAk TOWN OF YARMOUTH BOARD OF HEALTH ��z ` ` � -�
� � � ,�� �.,� � �� �� '�, C�
,: s�: x ' APPLICATION FOR LICENSE/PERM�1'-�8 i,� � �`
. !�i ,�--t , �� � �:: > �' � d ��J l��
{.
* Plea,se complete form and attach all necessary doc�n , '��` embe 31; ���7"
Failure to do so will result in the return ofyo�ap ication pack t.�����-y�� ������-
NAME OF ESTABLISHMENT: ��('I S'�[�,(�I'12�.�j TEL. #�- � �1- �1 S�
LOCATION ADDRESS: �1` I'Y)l',t.�r� ,5-���t.'t
MAILING ADDRESS: ' �
OWN�R NAM�: �2G1 TAX D F IN r N : � , �
CORPORATION NAME (I PLICABLE): m �l � �(��k `—�� •
MANAGER'S NAME: '��(� Z(�m 1'�t i 5 TEL. # r-,�- -1 ��� ��S�
MAILING ADDRESS: __�3S �� �1 5 p�y,�
POOL CERTIFIeATIONS:
The pool supervisor must be certified as a Pool Operator,as required b3�State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. T�te Health Depart�nent will not use past years' reeords. 'Yoa must provide ne�r
copies and maintain a file at your place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establisUments 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 Establislunents, 105 CMR 590.000.
Please attach copies of eertificationto this applieation. The Health Department�viN not use past years'rerords.
You must provide new copies and maintain a file at your establishment.
1. �� � � �� 1� � 2. ��� �l��i���--'�
_PERSUN IN:��1��Z�E: _ .. _ _ _ __ _ ___
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 2. _
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedwes below and
attach copies of employee certifications to this form. The I�ealth Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
.
�. �-�d �m b�e�l�+s 2. ,�Q r� Za m � � � 5
3. 4•
RESTAURANT SEATiNG: TOTAL #
OFFICE USE ONLY
LqDGING:
LICENSE REQUIRED FEE PER'bIIT* LICENSE REQLTIRED FEE PER'�rIIT# LICENSE REQL'IRED FEE PERVIIT=
BBcB S50 CABIN SSO _MOTEL SSO
INN �50 CA.'�IP S�0 _SV4'I'YI�3ING POOL S75ea.
LQDGE SSQ I'RAILERPARK S100 _��-IIRLPOOL S75ea.
FOOD SERVICE:
LICE1�iSE REQUIRED FEE PERMIT� LICENSE I�QUIRED F£E P£R'��fIT* LICENSE REQti IRED FEE PER'�iIT=
0-100 SEATS �75 ._CONTINENTAL S30 1VON-PROFIT S2�
�>100 SEATS 5150 0�'��� LCO;VL'��ON VIC. S50 O�-' (I _VS`HOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERviIT= LICENSE REQL'IRED FEE PERi�IIT-
_<50 sq.t�. S45 _>2�,000 sq.ft. S200 _VENDING-FOOD S'_'0
_<25,000 sq.ft. S75 _FROZEN DESSERT S35 _TOBACCO SSO
;va��c�vcE: sio AMOUNT DUE _ $ a0a.00
*****PLEASE I'L'R\OVER A\D COJiPLETE OTHER SIDE OF FORJT*'"*'�*
_ :�
�
M
ADIVIINISTRATION � '
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPR�PRIATELY IF PAID:
YES �' NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUFANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the ternporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�.
Transient accupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)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.
* NOTE: Enciosed Motel Census must be com�leted and returned with this appiication.
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(S�days
pnor to opening.
POOL WAT`ER 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
ciosing.
FOOD SERVICE
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the r�uired
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
O�tdoor e-eel�ng;�reparatic�,or dis�,ay of�.n}�food product by a retail or food service establishment is�rohibited.
N�TICE: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, 2007.
AI.L RENOVATI�NS TO ANY FOOD ESTABLISHIViENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMME�tCEME�TT. RE�tOVATIO:VS MAY REQ A SITE P . .
DATE: � SIGNATURE: ��'
.. - �
PRINT NAME&TITLE: a,
i��o n�
.. . _ .--__._..____ raye: uul
Client#:20821 2CHRISTOPHERSAM
AC��'���, CERTIFICATE QF LI�BfLITY INSURANCE a3i�21o8°`"`'"'
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER Of fNFORMATION
Dowling&O'Neil Insurance ONLYAND CONFERS NO RIGNTS UPON YHE CERTIFIGATE
Agency HOLDER.THIS CERTiFICATE DOES NOT AMEND,EXTEND OR
ALT�R THE COVERAGE AFFORDED BY THE POLICIES BELOW.
973 lyanough Rd., PO Box 199Q
Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC#
wsuRea �Nsu�R A Mass Retail Merchants Work Comp Trus
Mill Creek, Inc.DIB/AChristopher's �NsuReRs
American Rib 8 Seafnod Eatery
INSURER C�.
C(O Yarmouth House; 335 Main Street �NsuReR o.
West Yarmouth, MA b2673 wsur�k e
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N 4MED ABOVE FOR THE POLICY PERIOQ INDIGATEQ-NOTWITHSTANpWG
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'fb WHICH THIS CERTIFICATE MAY BE ISSUED OR
4qAY PEkTA1N.THE INSURANCE AFFORQED BY THE POUCIES QESGRIBEU HEREIN IS SUBJEGT T4 AlL THE TERMS.EXCLUSIONS AND GbNDft10NS OF SUCN
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS.
POLiCY EFFECTIVE POLICY EXPIRATION
LTR NS TYPE OF INSURANCE P6UCY NUMBER DATE MM/001YY OATE (YYHIDD/YY' LtMRS
GENERAL LIABILIiY EACH OCCURRENCE $
COMMERCIAL GENERAL LiA61LITY DAMAGE TO RENTED �
_MI . acc� � $
CLAfMS MAUE ❑OCCUR MED EXP(An ona pe�soni $
PERSGNAL&ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER� PRODUCTS-COMPlQP AGG $
POLICY �� LOC
AUTOMQBIIE LWB�ITY
COMB�NED SINGLE LIMIT $
ANY AUTO (Ea accitlanli
ALL OWNEO AUTOS
60DILY INJURY $
SCHEDULEU AUT08 - �P����j
HIRFD AUT�S
BODILV INJURY $
NON-OV�JEO AUTOS (Peracatlenl)
PROPERTVDAMAGE �
(Peracadenll
GARAGE LIABILITY AUTO ONLY-EA ACCiDENT $
ANY AUTO EA ACC $
OTtiER TtWN
AUTO ONL.Y�. NGG $
EXCESSRJMBRELtA LIABILITY EACH OCCURRENCE $
UCCUR ❑CLAIMS MAOE AGGREGATE $
$
DEDUCTi6LE
$
RETENTION $ $
A WORKBRSCOMPENSATIONAND Q14005Q31Q591Q$ O�/O'I/QS Q�/O�IOS X tiNCSTATU- OTH-
EMPLOYERS'LIAF3IL(fY
ANY PROPRIETOPoPARTNERlEXECUTNE El.EACH ACCIDENT $SQO QQO
OFFICEWMEWIB[R EXCLUDEC' N� EL.DiSEASE-ER FMPLOYEE $rJ'QQ,UOO
If yes,descri6e under
SPECIA�PROVISIONS Uelow EL DISEASE-POLICY LIMIT �500 OQd
O7HER
UESCRIPTION�OPERATIQNS t LOCATIONS I VEHICLES 1 EXClU51QN5 ApDED BY EN�ORSEMENT I SPECIAL PROVISIONS
Insurance coverage is limited to the terms,conditions,exclusions,other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions. Evangelia Zambelis is covered under the
(See Attached Descriptians)
CERTIFICATE HOLDER CANCELLATION
� SHOULD ANY OF THE ABQVE DESCR�ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town of Yarmouth DATE TNEREOF,THE ISSUWG IN5URER YMILL ENDEAVOR TO MA� �� DAYS WRRTEN
9140 Route 28 NOTICE T47HE CER7IFICATE HOLOER NAPAED TO TNE LEFf,BUT FAiLURE 7D DO SO SHALL
South Yarmo uth,MA 62664 IMPOSE NO OBLiGATION OR 11ABIlfTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED R PRESEMTA7IVE
�-yi✓'j �. � c..�;`,a:,.,:'�`:-._._.,,,.
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ACORD 25(2001108)� of 3 #Si23T L$� O ACORD CORPORATION 1988
TOWI� OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #08-170 FEE: S 150.00
In accordance�ti�ith ree�►lations promulgated under authoriri�of Chapter 94,Section 30�A and Chapter
111,Section 5 of the General Laws,a perniit is hereUv granted to:
Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's
Type of business: Food Service
To operate a food establishment in: Town af Yarmouth
Permit expires: December 31, 2008 BOARD OF HEALTH: ���fQe_ee�•n/� $�ia�e,c7�J�',,.Q✓:VQ._,-,��tcwcnqu�ut����
SEATIlvG: 38? l.11Wt�GCA �. J�k�i:G[�[YJL`yC�(�ICC u[K(�t/1ttXtt
RESTRICTIONS: 1982 Septic system designed as follo4vs: J� 3� ��(AtlltL� a
a)�8ater usage not to exceed 3_333 eallons per dac: U.lifL �L[�CYUf1L� JI..JV.
b)Seasonal usaee—not to eYceed 180 da}'s. .:�
Deceniber 1,2008
ruce . Murp y M ,R. ., HO
Director of Healt
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #08-103 FEE: 550.00
This is to Certify that Mill Creek, Ine. d/b/a Christopher's
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said To�vn of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: ��eeen S�, J`�.✓Y., C.f�a.vr�tuut
sEartr�: 382 ('l�arx�¢4 .�. �'�el�i/t�X�� `U�ice C'f�ai�e�tuut
RESTRICTIONS: 198?Septic system designed as folio�t�s: �h�A�'-PJILt �. ��tOUIiL �:CQ1LR
n-___ �Q_����� � ,�r
a)\�'ater usage not tn exceed 3.333 gallons per day�: l.UllL ��Cti(1�(�f(�e!/L� �.JY.
b)Seasonal usaee--not to ezceed 180 da}�s.
Decemher l,2Q08
ntce G.Murphv MPH,R.S.,CHO
Director of Health
` f
1
� o�';aR.y TOWN OF YARMOUTH BOARD OF:�I�.T� `°' -i D
o�� � APPLICATION FOR LICENSE/PER]�T�'`-2�to;b MAR � �4 2G0� �
EiF;��.Z' � � E
�� * Please complete form and attach all necessary documenfs by Decemb r��QQS,.
Failure to do so will result in the return of your application pac . � �' '-'��`� •
NAME OF EST.ABLIS��VVIEEN'T: '� �Sk I'� TEL. #,L�(�k-3�7��QO�
LOCATION ADDRESS: A
MAILING ADDRESS: �3
OWNER NAlV�: TAX ID E or
CORPORATION NAME APPLICABLE): `'Yl� � , C f eP �—i-�'1C o
MANAGER'S NAME-: ` 5 TEL. #���9�C�Bo��
MAILING ADDRESS: �
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated
Pool Operator�s)_and attach a cop�Qf t�ie certi�ica�inn io thi�fc�rm__ -_ ___. - - - -
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. �'(Y1�1 � ���1.(Z,L� 2. ��'Ll.-�2_ ��,�X�l",�Il� �_
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
ProtectiQn 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.
PERSQN IN CHARGE. _ __ _-- ____ __
Each food establishment must have at least one Person In Charge(PIC} on site during hours of operation.
1. fi V a��P_�1 !'�1.� /�(�_(��� 1 V 2._ � —
HEIlb#��CH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
at�ae�i 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.
f �
1.��.C�'1�D�(P �G��(Y1�3P�,� b 2. ��/flr1C.��,�1 L� � YYl�` �� ,
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQtJ1RED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
B&B $50 CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWIIvIlvIII�TG POOL$75ea. -
_LODGE $50 _T12AILER PARK $50 WHIIZLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25
�>100 SEATS $150 0(e-((�V � COMMON VIC. $50 �O�o'IO( �WHOLESALE $7S
RETAIL SERVICE:
LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_QS,OOQsq.ft. $75 _FROZENDESSERT $35 `TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ 200.00
R R R R RpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM R R R�R
, �\"��
\
�
.% �
w
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 WORI�ER'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 31. IT IS YOUR RESPQNSIBII.ITY TO RETURN
'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISHIVIVIEENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO
CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDTTIONAL 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 autdoor in ground swimming pool must be drained or covered within seven(7) days of
clasing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone 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 dess�rt�must be tested en a monthly basis by a State certified lab. Test results mus�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 fromthe Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service es bli ern is prohibited.
DATE: SIGNATURE:
PRINT NAME&TITLE: � �
09/28/OS
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TOWN OF YARMQUTH
BOARD OF�EALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-166 FEE: $150.Q0
In accordance with reQulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the Zieneral Laws,a permit is hereby-granted to:
_ Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's
Typ�of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit e�ires: December 31, 2006 BOARD OF H�ALTH: B�/ �/ �/S. ���� ,J19/��,5.,•G_j�r�sc
SEATING: 382 dY¢����¢fL c7KG��t� �C.l�.� (�fC6(ifl��6lll�'s�ft
RESTRICTION3: See reverse side. Rv�� (;�yy� ��
/'Gi�l�s[CR/��P�
� i K
I��I'll 7,2��
Bruce G.Murphy ,R S., HO
Director of Hea1
THE,COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #06-101 FEE: $50.00
This is to Certify that Mill Creek,Inc d/b/a Christopher's
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMQN VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�ires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers_ This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof, the undersigned have hereunto a.ff�ed their official signatures.
BOARD OF HEALTH: l3�e/ir��n/ _`7/�. �a�us, A9._`?S.,
SEATING: 3H2 dYell il e�il�fL, ./V., ?/sce�s�viyu�
RESTIucTtolvs: See reverse side. /rp�,t� $�,�,rsyr �,
/��119c_`73�
�t��j , R.N.
Apri17,2006
Bruce G.Murp y, I-� . .,CHO
Director of Health
Restrictions:
1982 Septic system designed as follows: a}Water usage not to exceed 3333 gallons per da.y;
b) Seasonal usage-not to exceed 180 days.
RESTRICTIONS:
1982 Septic system designed as follows: A)Water usage not to exceed 3333 gallo�s per day;
B) Seasonal usage- not to exceed 180 days.
.
� � = .��(.f��2rSraPtt�2.s
�f�--"'!R TOWN OF YARMOUTH BOARD OF HEAI1 � �°
2 '" �o '� f� (� � i�� MC� CD
� - '�� APPLICATI(}N FOR LICENSE/PERMTf»�0
�; ,!,� ,.. �:-�_� �� � 2 2007
* Please complete form and attach all necessary�doc�in ��y . ecemb r 3�,�0(�'G6.
Failure to do so will result in the return of yikir a�plication pac etHEAL�H DEPT.
NAME OF ESTABLISF�VIENT: � Y � EL. #L�;?�q�l-��
LOCATION ADDRESS:
MAILING ADDRESS: ` a r�v i �
OWNER NAME: T ID r -
CORPORATION NAME APPLICABLE).���XPp k.. �[^ • �L. # Sr ?>1 S/.'S�
MANAGER S NAME: �(� �,�;M����S �—�- �
MAILING ADDRES S: �,� �rv�•P
POOL CERTIFI+�ATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
l. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies af 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 MANAGERS - CERTIFICATIONS:
All food service establishments aze 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. ��1� ��I2�I ��'� ��"��
PERSON IN CHARGE: . . .
�ach food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
< <
1. 2.
HEIMLICH CER'I`IFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcing 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. �.
���m� � � � 2. . �
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PHRMIT# LICENSE REQUIRED FEE PERMIT#
BBcB $50 _CABIN $50 _MOTEL $50
� $50 _CAMP $50 _SWIlVIlvIII1GPOOL$75ea.
LODGE $50 _TRAII,ER PAItK $100 _WHIIZLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMTI'# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
/ >I00 SEATS $150 ��-168 I COMMON VIC. $50 O-� �"l63 ���5� $75
— .—RESID.KTfCHEN $75
RETAIL 5ERVICE:
LICENSE REQUIlZED FEB PERNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIltED FEE PERMIT#
>25,000 sq.ft. $200 _VENDING-FOOD $20
<50 sq.ft. $45 — —
TQ5,000 sq.ft. $75 _FROZFNDESSERT $35 _TOBACCO $50
NAME CHANGE: $10 AMOITNT DUE _ $ 200.�O
41k1k*�
PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""'"`
- -,
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 aperate 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 1NSURANCE ATTACHED `�
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � Np
---_____^
MOTELS ANp OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
� Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling urut 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, sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspectian five(5�days
pnor to opening.
POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POO$CLOSING: Every outdoor in gound swimming pool xnust be drained or covered within seven(7)days of
FOOD SERVICE
CATERING POLIC'Y:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtalned at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOK,ING;
OutdQ4t�oQ�ing,�r�paration,or_dis�iay c�f any food prc�duct by a retail or fnod seruice establishxnent is prnhibited.
NOTICE;Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETUR1v
THE COMPLETED APPLICATION(S) AND REQiJIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIl1�EENT, MOTEL OR POOL (i.e., PAINTING, NEW�
EQUII'MENT, ETC.), MUST BE REPORTED TO AND AppROVED BY TI�BpARD pF HEAI,TH PRIOR
TO COMN�NCEMENT. RENOVATIONS MAY REQUIRB A S PL
,�,.
DATE: -- ��~�
1 SIGNATURE:
PRINTNAME&TITLE:_ ��tAS'1G p ` �rEY1[I`t,.5
�o����
„ -�- r" ��C�:ud�i�
Date: 2/26/20Q7 Time: 10:23 AM Tos � 7,15087902801 Domlinq � O'Neil Paqe: 002-004
, ' CIieM#:20821 2CHRISTOPHERSAM
ACORDT� CERTIFICATE �F LIABILITY INSURANCE atiZs,o";°°'""'"'
eFeoouceR 7MIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowling$O'Neil Insurance OHLYAND CONFERS NO RIGHTS UPON THE CERTIFIGATE
A9e�y HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE GOYERAGE AfFORDED BY THE POLICIES BELOW.
222 West Main St.PO Box 1990
Hyannis,MA Q2601 INSURERS AFFORGING COVERAGE NAIC#
'"�o �Nsu�Rn: Mass Retail MerchaMs Work Comp Trus
Mill Creek,Inc.DIBlA Christopher's �Msu�R B:
American Rib 8 Seafood Eatery �NSURER C:
Cl0 Yarmouth House;335 Main Street INSURER D:
West Yarmouth,MA d2673 INSURERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIGATED.NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPEGT TO WHtGH THIS CERTIFICATE MAY 8E ISSUEO OR
MAY PERTAIN,THE RVSURANGE AFFQRQED BY THE POIiC�S DESGRIBEQ HEREIN IS SUBJECT TO ALL THE TER6AS.EXCLUSIONS AND CONDITIONS OF SUCH
POIICIES.AGGREGATE LIMRS SHpWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LlTt TYPE OF INSURANCE POLICY NUMBER Pp�p7E��yp�� Pp�p�Ex��p�yy UMITS
GENERAL LIABiLRY EACN OCCVRRENCE $
COMMERCIAL GENERAL LIABILIN DAMAGE TO RENTED $� � ��
CLAIMS�AADE Q OCCUR G,�p EXP M one person S
PERSOMAL BADV INJURY $
GENERALAGGREGATE $
GEML AGGREGATf LIMIT APALIES PER: PROOUCTS-COMPIOP AGG $
POLICY � LOC
������'B�Y COMBINED SINGLE UMIT
qryy A�Q (Ea aratlemj $
AlL OWNED AUiOS BODILY INJURY
SCHEOULEDAUTOS (P���^� $
H1RED AUTOS
BODILY IfJJURY $
NON-�WME�AUTOS (Peracatlenq
PROPERTYDAMAGE $
(Per acadenl)
GARA6E LIABriTY AUTO ONLY-EA ACCIDENT $
ANY AUT� OTHER THAN EA ACC S
�AUTO Ot�Y: AGG $
EXCESSAIMBRELLALUIBILITY EACH OCCURRENCE �
OCCUR �CLAIMS MADE AGGREGATE S
$
DEDUCTIBLE g
RETENTION $ $
A WORKERSCOMPENSATIONAND Q14QQ5031d591QT Q1/01107 01/Q1108 X WCSTATU• OTH-
EMPLOYERS'LUBILITY
ANY PROPRIEfORiPARTNER/EXECUTNE E.L.EACHACC�DENT aSOQ QOQ
OFFICERIMEMBER EXCIUDED? NO E.L OISEASE-EA EMPLO� $S�Q,QO�
If yes,tlescribe under
SPECIALPROVISIONSDeIow E,LOISEASE-POLICYlIM1T $Sa}��
OTHER
DESCRIFTION OF OPERATX]HS/LOCATpNS f YEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISqNS
insurance coverage ls limited to the terms,conditians,exclusions,other
limitations and endorsements. Nothing contained in the cert�cate of
insurance shall be deemed to have altered,waived,or eztended the
coverage provided by the policy provisions.Evangelia Zambelis is covered by the workers
(See Attached Descriptions)
CERTIFlCATE HOLDER CANCELLATION
SNOUtD ANY OF THE ABOVE DESCI�EO P�IpES BE CANCELLEO BEFORE THE EXPIRATION
Town of Yarmouth nwrE n+e�oF,THE ISSUWG INSURER YMLL Et�EAVOR TQ M/1< �Q,_ owrs wwr�a
1140 Route 28 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO 50 SNALL
South Yarmo uth,MA Q2664 IMPOSE NO OBlIGATION OR LIABILITY OF ANY KM1D UPON THE INSURER,ITS pGENTS IXt
aev�seNranves.
AUTHORtZED PRESENTATIVE
"y,�'�� c.e�`'""W,�
ACORD 25(2001148�� of 3 #46560 LS1 m ACORO CORPORATlON 1988
TOWN OF YARMOUTH
BOARD OF HEALTH :
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #07-168 EEE: 150.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the eral Laws,a permit is hereby granted to:
Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's American Eaterv
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2007 BOARD oF HBALTH: B r��1. �i�oss,/f9.`h., G�l�i��
SEA'rIlVG: 382 o��e���t, ./{�., �/ice�i�u�tc«rc
xESTTucT�oxs: See reverse side. RoG��s. Bnuswa, L'?�a
n�����
�rrsc(�'n�t�u�, .
Apri15.2007 r�
Bruce G. urp , H,R.S.,CH
Director of He th
THE COMII�IONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #07-103 FEE: $50.00
This is to Certify that Mill Creek, Inc. d/b/a Christopher's American Eaterv
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: 8�����r�s� `1�/S. �v��1' ,ru�1s,�/LI.��/S., �� .
SEATING: 3g2 � L e�f[!"sfL� ✓Iy''I/_[l'7B C'.flG�lRNl�1L
RESTRICTIONs: See reverse side. Ko�wltt�f. B�o«Ift, L�
A�k A�t���`
�l.in nee.id�r�.,i, R .
A_pri15,2007
Bruce G.Murphy, H,R.S.,CHQ
Director of Heal
� �oF:qR,� TOWN OF YARMOUTH BOARD OF H���`��� ��`"tf���`J "�
� ° . � ,_ , _ �
o _. -;-`i APPLICATION FOR LICENSE/PERMI�,T �0`!�5 , �'� �
� ., .-;r � ;
* Please complete form and attach all necessary d �� ` �a �` ��rr,��ie 1, 2004
Failure to do so will result in the return of "` ap��i��on packe . HEALTH DEPT.
�
NAME OF ESTABLIS�IlVIENT: � ��� TEL. # d�� - b�(,
LOCATION ADDRESS: Ct/ �-
MAILING ADDRESS: 3 �. �(�,
OWNER/CORPORATION NAME: !G- c_
MANA ER'S NAME: � TEL. # � 7 7/�Si�/
MAILING ADDRESS: t�3� �1/�. i�l ,S Q D"�, �,�,_l�,�,p��1Y� YYl I� O�Co?3
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 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. T6e Health Department will not use past years' records. Yau must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Healt6 Department will not use past years'records.
Yoa must provide new copies and maintain a fde at your establishment.
1. � ,C�J
�u ,� �l��.�, Z.�.m�:�2�r��
PERSO��1V CHARGE: _ _ __
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ��l/� t ,^^ r
�� I 1 L � 2.
HEIMLTCH CERTIFICATIONS: ' �
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures 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�� L)✓ �/'Y) _l� �
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQi7IRED FEE P�RMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT'#
_B&B $50 _CABIN $50 MOTEL �50
_INN $50 _ �CAMP $50 _SWIIVIlVIIlIG POOL$75ea.
_LODGE $50 _TRAII,ER PARK $50 W�IIRLPOOL $75ea.
• FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERNIIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFTI' $25
I� >100 SEATS $150 � Q /COMMON VICT. $50 O � � �WHOLESALE $75
RETAIL SERVICE:
LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# LICENSE REQUII2ED FEE PERMIT#
_<50 sq.ft $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_Q5,000 sq.ft. $75 FROZEN DEySSERT $35 TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ a0Q .00
"'�•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••'"
_ —_ _
- :; �.
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 af Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION IN5URANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal ar 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 Ct3MPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISHMENTS ARE TO CONTACT'TI-�HEALTH DEPAR'TMENTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR TI� SEAS4N.
ALL REN4VATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO ANll APPROVED BY T'HE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITTONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opemng.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd 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 ADVIS�RY:
Each food estab �shment 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 pnor to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DES�ER�: -
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.,outdo�r seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by ta.il o d service establishment is prnhibited.
DATE: O 2I �SIGNATURE:
�
PR1NT NAME& TITLE: �''f Cr�� �r�-�-:��Z-� S. , �iL�'S j �
10/22/04
,-�
.. ..... .� .. .. ,,..._. '....,........, .... . .,,�..... ........... _, �
ACORD CERTIFICATE OF LIABILITY INSURANCE �ATo3�zoosrr'
na.
P�?o�iuCER Phone "Us-432-i25G Faz roS-4'so-t532 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BENSON YOUNG 8 DOWNS INSURANCE AGENCY INC. ONLY AND CONFERS NO RI6HT5 UpON THE CERTIFICATE
49 MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMENO, EXTEND OR
P O BOX 548 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELQW.
WEST HARYYICH MA 02671
INSURERS AFFOROING COVERAGE NAIC#
INSURED INSURERa: Nartford Fire Insurance Company 19682
GREAT FOODS REALTY TRUST&MILL CREEKJNC INSURER B:
DBA CHRISTOPHER'5 AMERICAPI RIB&SEAFOOD EATERY INSURER C:
Ci0 THE YARMOUTH HOUSE
335 MAIN STREET INSURER D:
WEST YARMOUTH MA 02673-4661 INsuaER E:
COVERAGES
THE POUCIES GF INSURAPICE I.ISTED BELG'✓V HAVE BEEN I�SUE6 TO THE IM�URFD NA69EQ.ABnVE FOR THE P01_ICr PERIOG INDICATED,NOT�4dTHSTANGING
Ahdr REu�JIREMEf1T,TEFP.1 OF'.CONDITIOfd��F AN`i COfJTRACT GG nTHER C��CUt.1EfJT OVITH RESPGCT TO`.:'MCH THIS CERT�FI��kTE tdA'f pE I�SUED��R
MAY FERTAIhI,THE INSUP.Fh10E AFFOF.'C�ED B'+THE POUGE5 DESCRIBED HEREIN IS 3UBJECT Tp ALLTHE TERP.IS,E.'CLUSIOfJS AND COMDfT10N5 OF SUCH
FOLICIES.AGGP.EGATELIFdITS�SHC�U"!tJ M.qY Hhti%E 6EEf!P.EDUCED 8Y PA.IG CLAIPAS. � � '
INSR ADD1 TypE OF INSURANCE POUCY NUMBER POLICY EFFEC7IVE POLICY E%PIRATION
LTR Iti�RD O�TE MIWDO�'YY 011TE MM+DO.'YY LIMITS .
GENERAL LWBILfTY � R
EACH OCCURkEPdCE
COh1MERCIkL 6EMERP.L LI%•.BI�ITr D?MP.GE TO REN7ED �
CLARvIj t.1HpE � n��_� � PREfe11SES(Ea ocCuren�;e)
��l,R MED.E�P(Any one person)� g
� � PER�PNAL&A.DY MJI�RY E
� GEfJERF�A.�3GREGATE $ �
GEN'L aGGREGATE LI�•!IIT APPLIES FEk: � � PFvDUC7S-rpraFiO�AGG. �
PvLICY jE a LvC . . �
AUTOMOBI�E LIABIUTY COM6INED SINGLE LIMIT �
pp�y;,,i,�7n SEaaccidant; � �
� ALL OWNFD AUTO; 6001LY MJURY � �
SCMEDiJLED A.UT05 t�'��Gerson). g �
HIRED AUTOS
� 60DILY INJURV $ �
NGN-OVa�NED H.UTOS , . � . (Per accident)
� � PROFER7i D�.PdAGE � g
(F?r accidan[) � �
GARAGE LIABILIIY � � AUTO ONLY-EA ACCIGGNT �
Afd;AUTG � �
� OTHER THAN EA Ar� `�
� � � AUTO ONLY: . n�� � �
EXCESSlUMBRELIAUABILITY EACHOCCURREF�CE $
OCCUR �I CLAiMS trlpDE A.GGREGATE $
�
DEDUCTIELE �
RETENTION R
S
WORKERSCOMPENSATIONAND 08WECPD5740 OH/O'Il04 OHlO1IO`J RSTuw7s O7HEa
EMPLOYERS'LIABILITY ..
E L EFCH acclGef�r � 500,000
A� Arvv VRpPRIETOR�'vaRTNER�ExEC VT�YE . _
OCFICER�'MEMBER E%CLu0E0? EL.DISEA.SE-EA EI�iPL�YEE $ SOO�OOO
If yos.Aascnba unCvr � ----�---
SPECI1ll PROVISIONS below E L.DISEASE-PC�LICY LII�11T � ' SDO�OOO �
OTHER:
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
70WN OF YARMOUTH � SHC1UlG ANv GF 7HE.ABOVE GES�"'kIEED FGUCIES BE CANCEILED BEFr_,F�E THE E::�.P�RpT�ON
DA.TE THERE��F,THE 1SSUIfd�.IfdSUREF`h9LLENDEAV��RTv 69AIL 10 DAYg+hiRITTEPJ tJ�"�710E TO
1146 RTE 28 THE CERTIFIC�TE HC,�I.DER fJAMEO TO THE LEFT,6UT FAILUF.E T���60 SG SHF�L UdPCuE fd���
S.YARflAOUTH,MA 02664 06LI��ATIOYJ���R LIn61Li1'r OF APJY 4iING UPON THE INSUREF.,ITS FGEDIT3���F.PEPRESEIVT.ATIL`ES
HUTHORIZEL�REPRESENTATIVE /''''`��
Attentlon: V �Paul R. ilva '
ACORD 25(2001108} CeAificate# 290� O ACORD CORPORATION 1988
s •
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-169 FEE: $150.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2005 BOARD oF HEI�LTH: Besc��r,urs `.$. �j'o�tclor�,/bl.$. G��S�r.�ar�rs
SEATIlVG: 382 n�iltcl�/�c�e�iyta�, �/ice e�ic•i�i�ta�t
RESTRICTIONS: Sce ieverse side. Ro�wJ�� B�tlN�ffl, �:se�sle
dYCf�IL e�KG�L, K�.
fY � � .
Apri15,2005
Bruce G.Murph", H,R.S.,CHO
Director of Heal
RESTRICTIONS:
1982 Septic system designed as follows: A)Water usage not to exceed 3333 gallons per day;
B) Seasonal usage- not to exceed 180 days.
� � , t
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NiJNIBER: #OS-1Q2 FEE: $50.00
This is to Certify that Mill Creek, Inc. d/b/a Christopher's
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless
sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authonty granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures.
BOARD OF HEALTH: Be��n.`?S. C�'�asz,/I�I$. •
SEA'rnvG: 382 (J�/j�J��� Q/���u.�y
RESTRICT'IONS: See reverse side. Rp�pl�v�.B�O[�L, (:�e�
. �s�, R.�v.
�i • R
Apill$,2�0$
Bruce G.M hy, .5.,CHO
Director of Heal
_ _ _
Restrictions:
1982 Septic system designed as follows: a)Water usage not to exceed 3333 gallons per day;
b) Seasonal usage-not to exceed 180 days.
. � '
" ' c.=ItRIS'tv�N�S
�`;''R.� TOWN OF YARMOUTH BOARD OF HEALTH
a . _,a
� -'�� APPLICATION FOR LICENSE/PERMIT-2004 (,� � � �S G M C� D
°:: .ls
....
* Please complete form and attach all necessary documents by Decem er�1Q�0�3b 2004
Failure to do so will result in the return of your application pac et.
ST � r - � ��b
L TI N AD RES : ' r YYZ�- �
I y.
R/ N NA � ��
A ER' AME: 1 �OC�cN T � %- S"�
MAILING ADDRESS: 33'�' (�,t � � o S?-� 1 J�, �''a� YYIc-.'�l-�p;'1 1Pr��.(�ll '�
i
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State taw. Please list the designated
Pool Operatar�s) and at�ach a copy of the certification to thrs forrr�.
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 wiIl not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 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. a 1�1
_ _ -__ _
_____ ___ _---____ ___
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �rn ��� 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Pleaselist 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. ,
l. �VCI. 2. 1 f ►��L� (�%►�,� X .c .a.�
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM(T# LICENSE REQUIRED FEE PERMIT#
B&B S50 CABIN S50 _MOTEL $50
INN $50 CAMP S50 _SWIMMING POOL$75ea.
LODGE S50 TRAILER PARK $50 WHIRLPOOL $75ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
_0-100 SEATS S75 _CONTMENTAL $30 NON-PROFIT S25
I >100 SEATS $150 �COMMON VICT. S50 _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSG RGQUIRCD FEG PERMIT� LICENSE RGQl11RED FEE PGRMIT#
_<50 sq.ft. $45 _>25,OOU sy.R. $200 _VGNDING-rOOD S20
<25,000 sq.ft. �75 _�R07.EN DGSSI:R"T S35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ 150•O� -k- �SO.OQ
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****'�
f. `�
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �
CERT. OF INSURANCE ATTACHED�
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
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 REPORT�D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL�rtti ATtnNC
POOLS
POOL OPEI�tING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomon�s,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CONSU R DVISORY•
Eaeh food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
S'ATERING POI.ICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FR�Z •,�1 DE,�fiF.R'�i'�: __
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE C �'F' •
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�n.ust have prior approval from the Boazd of Health.
(�TDOOR COOI�N =• ,
Outdoor cooking,preparation,or display of any food product by,�retail or f d;s�xvice stablishment is prohibited.
�.�
�_... _ �
DATE:�►g�p� SIGNATU ,. �lr�
PRINT NAME& TITLE: � m �
r
�_/'
10/22/03
��.�. ___.__-. _ __ _ - _ _
� 3iIflFiir�# I3:57 f5U8-�#�7-�i3� Ise►tson Youl�g & i)uKns Katny Jc�nes-rjuantte �f3
` � �C��D A C O i'1c 1�►A TL /�C 1 1 A�N ��/ 1 w1@/1�/�A �� I QATE(MM/DpJY`l)
Tr�: �V�li► i 1ri�/� /� Lr L�l1G3iL� f i lf��3iiiitF/�Lr�r iy���p¢
r vUUick � TMIS GERT�iCATE IS iSSUEO A$A NWTTER QF q1FORMATION �
BfNSQN YOUNG 8�DOWNS INSURANCE AGENCY INC. e�p�v �un rrweepc wn eir_ure irerw rue �eo�ex+erE
�49 MAIN STREET MOI.DER. TM�CERTIFICATE DOES NOT AMEND EX'1'�ND OR
r v[�.uit�u � s�.�trc Ti-1��v�+c�wt�-r"vrc�eu rs r �ifc e�uiis:cc"s ae�v'ru.
�$T HA�VYI�'fl�AA�2fi71
PHONE: 508d3?-7256 INSURERS AFFORDING COYERAGE � NAIC#
��lG��RED INSURER A: ARBECLA PROt�CTiON IN3 COMPANY
�GREAT FOODS REALTY TRUST 8�MILL CREEK tNC INSURER B:
DBA�iiRISTO�'iiER'S Af�ERIG��1 iti6 S�SEAF�OG�TERY
�f^v T,��'�!�?4'.^!�T�'!Y.^.��ce �tNSURER C:
335 MAIN STREET �INSURER D: � �
WES7 YARMOUTH IYL0. 0267�-4661 INSURER E: i
S�YERAGES
TtiE POUCIES OF uVSURAPJCE USTEG BELOW HAVE BEEN ISSUEQ TU THE IMSURED NAMEG r+BOVE FOR TriE POUCYPERlUD INGiC.4TE0,NUTVvTn�TANGiNG
� A�.M P.Ff11�IRFRIFP.(T �FRM!1p l"fMiC1(iN7N nF ANY f`ftN1RArT f1p pT{FR pp1'1 N�.nFM1(T;1+TTH pESPECT Tf_f tNHICH TMIS f_'Fp71FIrp7F MAY RF ISCI IFp nR
MAY F'tH1AW, tHt INSUitHN(;t RFFOh'Utii t3Y IHt F'OLtC;ItS Ut5(:KIt3tU HtFttIN�S SUtlJtC;l 1C1 ALL IHt ItHMS,tX{;IUS�ONS ANIJ C;OPlUIIIONS Oh's`UC;H
P01 N'IFS AGC:d?FI;pTF I IMRS SMONM MAY HAVF RFFN RFI�t If,Fn RY PAIn CI AIti1S
INS� TYPE OF INSURANCE POUCY NUM�BER POLICY EFFECTIVE � POLICY EXFlRRTION � IIMIT$
LT DATE MM�DQ+YY D1lTE MM+DDrYYf
�������� � I � �EACH OCCURRENCE �
� � (,UMMtIK(�IAi l�tNtKAL Lliat;iLl l Y I ± � I ..... E T E%:'cu �
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� qrrv a�rr� I f f '{Ea a�idam� �$
ALL OWNEC�aLRnc i f � �.
BOC�ILY INJI�RY
�—{ ( �� ( i{t'erperson� '�
I f SCHEDI�IED AUTOS �
� HIRED AUTOS �
I anni�y ini,x tov
nNON-OWtdED efJ70S ' I a (iPer atculerrt) i D �
f I ! � I c.t�' F�h �,,...yi;C �
1 GARAGE 11A81�17Y i
�_ A�JTO DNLY-EA ACCfDEtJT $
I + ANY A.UTO I
�__� � ' 'QTHER THAN EA ACG $
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E�o����.� � I I f r �T5 � ; ��o;o�
F i car�prrir�nR c
/; A11Y PROPRIE7'pfUP/4RTNER/EEFGIlRYE � �
� 'OFi�CER1MeM8ERExCLUDEO? I I .E.L.DISEAcE�Ea EM9PLOYFE :.$ ��,�Q
In ps.Msensa unaer I �E L.DISEpSE-POLICY UMfT S $QQ;Q(�i
,SPECi4L PROYIS�ON4 se�ew
OTHER:
i I ! I i
DESCRIPTION OF OPERpT10NSlLOCATIONNEHICLES/fXCLUStONS ADbED ENDORSEMENTI SPECIAL PRbVISIONS
FAX:508-790-2803
a
CE TiFICAiE HOLtiER � �r�amowu.�tisur�Ec;trasu�R���: G�1PI LI.fiiT��l
TiuWN O�i`ARAfl�i�i7H }�^ ra , r r ,��; � + �.
114�RTE 28 e�TE THEREOF�THE ISSUING COMPAMf lMl.LENC?EAVORTQ MAIL 10 CAtS NlRITTEN NOflCE1J �
T ?ur r ,.Tlr�q�u � c,. �ra I',T.-,TNE iE^'.�J �ai���r>Ern�r_ rua�i 1^nnr,1r
SOUTH YARMOUTH MA 02664 C3BLtGATION OR t1ABILRi 9F�4NY Kif�t1PON 7}�NUSURER tT'S AGEMS OF2 REPRESENTATt'v'E�
AUT}10RIZED REPRESENTA7IVE �
Arierrtfon: ��►��"" ' ����e�'°�'�'�
ACORD 25�2001f08) Ceriificate# 1120 Paul R.Silva
.. . . . . . . . Y. ___ . ____ . .
. ` ..;c.�:� .
TQWN UF YARMOUTH
BOARD��'HEA�TH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-178 FEE: $150.00
Fn accorc3ance with regul ations promulg�ted under authority of Chapter 94,Sectiaa 305A and Chagter
111,Section 5 of the General Laws,a permit is hereby granted to:
Mill Greek, Inc., '769 Route 28, South Yarmouth, MA
Whose place of business is: Christopher's
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 3�, 2Q04 BOARD oF HEALTH: f��c�'s�$. fj''r��.or��,J�/1�$�.f G�lu�i�
SEATING: 382 . A��/ �� ������ �v/kB(:ilQ�lpL�iL
RESTRICTIONS: SeC ieV6Ts6 Slde. ROIl�f� �. �3�JLYk� (:f�+ll�
� s�, R.N:
�4.6.���.�G��� R.N.
March 26,2004 �
. ruce . MurP Y,1�+IP ., H
Director of Heatth
Restrictions:
1982 Septic system designed as follows: a) Water usage not to exceed 3333 gallons per day;
b) Seasonat usage -not to exceed I8Q days.
�
s ;
y.�....;
� R w,�
THE COMMONWEALTH OF MAS5ACHUSETTS
TOWN OF YARMOUTH
PERMIT NCTMBER: #04-104 FEE: 50.00
This is to Certify tha.t Mill Creek Inc. d/b/a Christo�her's
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMhIQN VICTUALLER'S LICENSE
In said Town of Yarfnouth and at that place only and expires Decemb�-thirty-f rst 2004 unless
soo�er suspended or revoked for violat�on of the laws of the Comtnonwealth respecting the
licensing of common victual�ers. This license is issued in conformity with the authority granted to
the licensu�g authorities by Ceneral Lavvs, Chapter 140, and amendments thereto.
In Testimony�Vhereof, the undersigned nave hereunto affixed their ofliciat signatures.
� BOE3RD OF HEALTH: Best�a�rri�,``?S. �`�ri, /I�.$. '
SEATING: 3H2 An��� 's�1/l/7��, v�e��
RESTRICTIONS: See reverse side. rc,w/��,�u� �.iB?4u/N�y�A�c;�zre
d/��L e�NG�, /�./I./�
fY/lil�d�E31P�JL�lipl� K�.
March 26.2004
Bru�e G.MutPhy> .,CHO
Dire�tor of Health
RESTRICTIONS:
1982 Septic system designed as follows: A) Water usage not to exceed 3333 gallons per day;
B) Seasonal usage -not to exceed 180 da.ys.
�
�
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. ` ` �-� r
, o'�, '�k
�2 �._�G TOWN OF YARMOUTH BOARD �'�H �,;. , �(����Ft,� ,,;
o z. �.� APPLICATION FOR LICENS� ��;�13
` •.,. .,.,���' - � ���. � _ �59�� `'�NIAR 2 6 2003
* Please complete form"and attach al l necessary`docurn�nts by Decem r 31 20p�
Failure to do so witl result in the return of your application pac t.H�ALTH DEPT.
S ,
• �t� ` R.�t ' a$ So�, b
I�IAILIN� ADDRESS: 33S YY1Q�r1 �-� �,�). �rxvrnrti��Y, Y1naA- n�12��
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� ' , o -�71-S�S�
MgILING ADDRESS� �3s �,,,� �;�,� �a�n�ot� , vn� �a,c��
POOL CER'�CATIONS:
The pool supervisor mvst be certffied as a Pool Operator,as required by State law. Please list the designated
PooT Operator(s) and attach a copy of the certification to this form.
1. � � . � ,� � , . � �
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary ResuscitatiQn(CFR�'.� Please list these emp�oyees belovt+'and attach copies of
employee certifications to this form. The Heal�h De���rtmen�wi1! not use past years' records. Ynu must
provide new copies and maintain a file at your;p�ace ofbus�uess.
. , .
_ �_
1. ;�.
3. � 4. _
FOOD PR�I�CTIl,�1VIANAG�RS -CEI�TIF'��ATIO�,N�
All food service esta.blishments are required to have at least one full-tiine employee who is certified as a Food
Protection Manager, a� defined in tlie Stafe Sanitary Coc�e for Food 5ervice Establishments, 105 C1VI�. 590.000.
Please attach copies of certification to this application. The'Health Department wili not use past years'��cords.
You must provide new copies and maiwtaiQ a�ile at your establish e�t.
� . .
1. 2. G��
��SO�T,�CHARG�.
Each foad establishment must have at least one Person i� Charge(FIC) on site'during hours of opera�ion.
� ��
1. �VQ � (;t . , z .
HEIMI,ICH CE$TIFICATIONS:
All food service establishm�n�� with 25 seats or inore r�ust ha�� at least one.ernplayee trained in the Heirrilich
Maneuver on the prer�ises at aii t�mes. Please li�i�our ernp�ay�es train�d in anti=choking procedures below and
attach copie�of empit��e�;ceFt�:�eatio�s to t�is,fQ,rm, Th�He�1t6.Depart�nent will not use past years' records�
Yoa must provide aew copies and maintain a��le at yoar p�ace of business. �
�. v a � _.� ,�� �, s
� Z..��n�.l�_ �
3. , 4.
RF�TAURANT S�.ATIN : TOTAL# . %" �k `
� . OFFIC� �S��, >�.Y ` '
LODGING: �
• LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FCG PERMIT# LICENSE REQUII�EU FE�`. PERMiT#
_B&B , $SO ,CABIN S50 !`'MOTEL $50 ,
_INN �50 CAMP ` SSO _SWIMMING POOL�75ca.,_,,,�;,
_LODGE SSO TRA[LER PARK S50 � WHIRLPOOL $75�a.,�,,�
�'OOD SERVICE: , ; ' ,
LICENSE REQUIItED`�E� PER�vtIT# '' L'(�ENSE:RE(��1(t£b FEE°: �ERMIT# L(CENSE itEQUIRGD FEE PER�VIIT�F
_0-100 SEATS "�"7� �Y ,,,�„_edir(TINE�(TAL , S3Q, _NON-PROFIT $25
/ >100 SEATS �150 ?J'��7� / COMMON^V1CT: $SO �03"f OO ,WNOLESALE E75
R__FT_AII�9ERVI�E: •
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I.ICENSE REQUIRED FEE PERMIT#
�<SO sq.ft. $45 _>25,000 sq:R. 5200 VENDING-FOOD S20
. , r:..::
_<25,000 sq.ft. $75 _FROZF.N DESSERT S35 TTOtiACCO $25
NaM�cHANGE; $io AMOUNT D�E = S Zo o� 00
"****PLEASE TURN OVER AND COMPLETE OTHER SIDE O�FQRM"*««*
�miNisTxaT�oN
Under:Chapter 152,Se�nqtt,25C, SWbsecti�o�t f��the Town of Yarr�auth is naw required to hold issuance or renewal
of anx license or perrnit to operate a,business if a`;person or cor�npany does not have a Certificate of Worker's
Compensation Insurance. THE ATTACH�D� ��a�E �V+��R�s COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIG�TED, Oit
CERT.OF TNSURANCE 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
APPRQPRIATELY IF PAID;
YES' NO �
NUTICE:Permits run annually from January] to December 31. IT IS YO�JR RESPONSIBILITY.TO RETURN
THE COMPLETED APPLIGATIQN(S)AND REQUT�ED FEE(S)BY DECEMBER 31, 2002.
SEASONAL ESTA�LISH�iV�E�I�'.�,-��.RE Tf]�011IT�CT�E H�ALTH A�PARTMENT FOR iNSPECTION 7-10
DAYS PRIOR T� Q�EI�ING���TI-�E S���C}1�1. . �: ._�;.� �, �
ALL RENOVATIONS TO AN� FOOD ESTA��,I�HME1�fiT, MOTEL OR �FOOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), �VIU5T B�REP�ORTED TQ AND APi'R'OVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMBI�(T. RENOV�TIONS MAY RE,(�UIRE A SIT`�:PLAN.
. - � .. .� . � '��. �.�. . . . , , jti;..�; . .. . . .
. . . � . : � � . . . � . .� . .:[�,r.., ...:.i ,
� . . . � .. � ... . , . ..�. _ . � . . . . ..
. � . . .,\;. ' .
t1�t4?NAL REGUI,�ITIONS '
: POULS _ . , ,
POOL OPENING:All��vimming,wading and whiclpap.ls whieh have been closed for tFte s�ason m�st be inspected
by the Health Departmer�t pric�r'�tr�:t�penang. � '
POUL WATER TESTING: T1ie water.tnust�be L�ste.d.for ps�udomonas,total coliform and standazd plate count
by a State certified lab, prior to opening, and quarte`rly�ereafter.
FOOL CLOSING: Every outdoor in gcound swirnming pooi must be'drained or�overed within seven('T)days of
closing. :
;
FOOD SERVICE
,;
�
CONSUMF,R:ADVIS4B� '� �
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are.req��;to post
Consumer Advisories. : ,�:;
�AT �LY��X� ,
Anyone who caters w�thin the Town<of Yarmouth must notify� the Yarmouth Health Department by filing�.��e
required Temporary Food Service Application fvrm �2 hours prior to the catered event. Ths� forms can �,:R
obtained at the Health Uepartment. ' ' ,
FROZEI�DESS� �
Frozen desser�s rn��t be test�d.on,a ma��i�ly basis;by a State certified iab. Test results must be sent to the Health
Departrnent. Fail�re to ida so vvilI result��n't��sus,�ension or:re�acation of yo�r;F�vzen Des.sert'Permit untit the
above terms have beea met.
Q�TSIDE CAF �S: . . , , . :
Outside cafes(i.e.,outdoor seating with waiier/waitres��ervice),��iave prior approval from the Board of Healt�.
QUTD4����G� �
Qutc�oor cooking,prepazation,or displ�y of any food product 1�'a:retail or food service establishment is prohibited.
_ .�'_�
DATE: ` 4v? 3 t SIGNATURE:
PRINT NAME &TITLE:
{=;,
l O118/02 _
, �� _
.�.....� Y� . � . . . :..... ."noi��� ._ -.. J � _ _
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/� {M� # ..�:::::: DATE�MM/OD/YY) :::
4�D ( w - I : � . '- ; .�. .
��,i :N�#%%:.' ,'. .: �N ' �:..���� �� i'��.�. ; : ... :-.
"C �+�— .....\��w��.. ...�.���:�w1'�::k����...� �.� .�.. .... ....... .. .. ... ..�����#w�>ti:i[;c[;[i[:.[,':t;i];i;c[ii::::':;c
.................................::::::::::::.:::::::::::.�::..::::::::::.::.::::::::::::.::::.::::::::..:.:::.:::::::::::::::::::::::::.:::::::.:::::::.:::::::::::::::::::::::::::::::::.::::::::::.:.:::::.:::::::::::::::.::::::::::::. 03 06 03 <::;
........................................::::::::::::::::::::::::.:::::::.:::::::::..::.�::::::::::::::::::::::::::::.:.:.�::::::::::::::::::::::::............................................................................................................
�ooucEa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BENSON YOUNG & DOWNS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OH
INSURANCE AGENCY INC. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO BOX 548 COMPANIES AFFORDINCi COVERAGE
WEST HARWICH MA 02671-0548 COMPANY
A ARBELLA PROTECTION INS COMPANY
MISURED
COMPANY
MILL CREEK INC DBA B
CHRISTOPHER'S AM RIB & SEAFOOD COMPANY
C/O YARMOUTH HOUSE 335 MAIN ST � � �
W YARMOUTH MA 0 2 6 7 3-4 6 61 COMPANY
D
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�i�v�� �...................................................... ....................................
���� THI..�I �.T��.�...ERTIFY THAT THE.P.�LI..IE�.��.F.IN..�.�RAN..E�LI��TED�BELOW.HAVE BEEN�ISSUED�TO THE�INSURED NAMED ABOVE�FOR THE�POLICY�.PERIOD.� �
S S OC O C SO SU C S
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTNER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCAIBED HEREIN IS SUBJECT TO ALl THE TERMS,
�Xi,i.iiSiviJS Aiviu GGN['ii i ivivS OF SUCN POLICiCS. LIh11TS SH041i�i Ml�Y HAVE BEEiJ r1EDUi,Ea 6Y PAID CLAiiY(S.
CO TypE OF NiSURANCE POLICY NUMBER POLICY EFFECTNE POUCY EXPIRATION ��
�7R DA7E(MM/DD/YY) DATE(MM/DO/YY)
GENERAL LIABILITY GENERAL AGGREGATE S
COMMERCIAL GENERAL LIABILfTY PRODUCTS-COMP/OP AGG S
CLAIMS MADE �OCCUR PERSONAL 3 ADV INJURY E
OWNER'S 6 CONTRACTOR'S PROT EACH OCCURRENCE $
FIRE DAMAGE(My one fire) E
MED EXP(My one person) S
- AUTOMOBILE LIABILITY � . � � .
ANY AUTO COMBINED SINGLE LIMIT S
ALL OWNED AUTOS
80DILY INJURY S
SCHEDULED AUTOS (P��«��
HIRED AUTOS
BOD�LY INJURY a
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
GSARAGE LIABILT/ AUTO ONLY•EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILIfY EACH OCCURRENCE E
UMBRELLA FORM AGGREGATE S
OTHER THAN UMBRELLA FORM $
W ORKERS COMPENSATON AND 9 0 9 2 9 3 0 8 0 2 8/O 1/0 2 8/01/0 3 X ORY LIMITS _ER
EMPLOYERS'W181LlTY
EL EACH ACCIDENT $ 'Jr O O O O O
THE PROPRIETOR/ X INCL EL DISEASE-POLICY LIMIT $ S O O O O O
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE S 5 O O O O O
07HEH
DESCRIPTION OF OPERATIONSILOCATONSNEHICLESBPECIAL REM$ �
. . >
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-174 FEE: $150.00
In accordance with regulations promulgated under authority ofChapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to: ,
k•
Mill Creek, Inc., 769 Route 28, South Yarmouth, MA
l
Whose pla.ce of business is: Christopher's
Type of business: : Food Service �
To operate a food establishment in: Town of Yarmout�
Perti�it expires: December`31. 2003 Bo�RD oF H��I:;TH: �ilea:r�:.xc�ez, ��ua�� ,,
SEA'rnvG: 382 bnt.�fa�tri��. Gl°�rdn�. �D., �/ice �cuut�rccus
. ItESTRICTIOI�IS IF ANY: See reverse side. , ��t�• ��. �
: �adrick'JAIcD�
_ : ?fele.�Slra�k, �yl•
March 31.2003
. ruce G. ,MP .,CHQ
.< Director of Health
,
.��:.. � :
,, . . .. u:;,
Restrictions:
1982 Septic system designed as follows: a) Water ttsage not'to exceed 3333 gall�ris per day;j
b) Seasonal usage - not to exceed 180 da.y.
� '_.__._... . ._ __ _._ _.... _..
, . . . , � . � ..._'.. .
THE COMM4NWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #03-100 FEE: $50.00
This is to Certify that Mill Creek, Inc. d/b/a Christonher's
�:r;
769 Route 28, 5outh Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2Q03 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respEcting the
licensing of common victualler's. This license is issued in confornuty with the authority granted to
.the lieen�ing authorities by General Laws, Chapter 140, and amendme�rts fi.h.�reto. , :
In Testimony Whereo� the undersigned have hereunto affixed their official signat�res,
'BOARD OF HEALTH: ��s� Z�. ��x�
S�aTING: , 382 : . :�'e�esa�xi�c D, C�iozd°�c, 7K,D.. Q/iee - '
RESTRIGTIONS: See reverse side. �o�P�t jt. �caao�c, e�
�adrt�k�1�lcD�
� s�, ��t
March 31 2003 ,
� ruce G. hY; .S.,CHO
: Director of Health .
RESTRICTIOIVS:
1982 Septic system designed as follows: A) Water usage�not to exceed 3333 gallons per day;
B) Seasonal usage - not to exceed 180 days.
�� �; � � � r� o � � �
� TOWN OF YARMOUTH BOARD OF HEAL
. APPLICATIUN FOR LICENSElPERMIT o APR 0 5 2Q02
';.` � , ��� H T .
* Please complete form and attach all necessary documents by Decemb �, �il
the return of your application packet. �� `
.�
T L T: i' ' TE # 5< � �
LOCATION ADDRESS: '7�� /�'� .�.�' �S� -IJGL,/".rYI i� t /1?GC- Od(�,�
I IN RE : �3 � �.5% l�')C�tJ -c., 0�7
� �� i y��X ���
MAN,�GER'S N�ME: -�'h�c�l ofe Z h'1 b�%�5 TEL. v�'�'7/S/-�
MAILING ADDRESS: �3 `i �'1'IfCt,/7 �S�` . GtJ, �,/A�t°/�'IIJ�/� /7'�1�-l��i la.'�'
POOL CERTIFICATIONS: .
The pool supervisor must be certified as a Pool Opel�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 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 fde 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 Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health DepaMment will not use past years' records.
You must provide new copies and maintain a file at your estabtishment.
1. �OI'1 � � 2. �r=1 v�'� F) Z-U l C
�E�S�N Ih'CHAR�rE:
Each food establishment must have at least one Persdn In Chazge(PIC)on site during hours of operation.
1. �i���� � ��l���L-'�.C.. 2. �
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at�your place of business.
1. �U��'1C�,t.c� Z Am�� 2.��.� .ZArn��-�.
3. 4.
RESTAURANT SEATING: TOTAL#
OF�'ICE USE ONLY
LODCING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PET2MIT#
�B&B $50 �CABIN SSO _MOTEL $50
INN $50 CAMP $50 _SWTMMING POOL$SOea �,_�_._
�LODGE $SU _TRAILER PARK $50 _WHIRLPOOL $25ea
FOOD SERVIC�:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE TtEQUIRED FEE PERMIT#
I 0-100 SEATS $75 �'Qa-�o�" _CONTMENTAL $30 _NON-PROFIT $25
>100 SEATS $150 �CbMMON VICT. S50 �O�'0�' _WHOL�SALE S75
RETAIL SERVICE: �
LICENSE REQUIRED FEE PEItMIT# LICENSE ItEQUI]2ED FEE PE1tMIT# LICENSE REQUIRED F�E PERMIT#
,TOBACCO $20 �<25,000 sq.ft. �75 �TOBACCO S20
<50 sq.ft. S45 �>25,000 sq.ft. $200 _FROZ�N DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ f Z'J�. OQ
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF�'ORM*****
. v..�. v . � ' �� � . . � � j
�y
t �
ADMINISTRATION
! .t 1{s"'t F.,j i 1'-ti
`C7n�"er�apter'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 �'''
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces 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, 2001.
SEASONAL ESTABLISHI��IENTS 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 .,
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. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failwe to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
/'/;��''� �
DATE: v�I � �Z SIGNATURE: .�"t
PRINT NAME& TITL : a��� 2 Q,ti,_��2 �cr S
09/11/O1
......................:.:,.:.:::.::::.>::.::.;;:.;:.;:�:.;:.:�.:.;:.�;:::;::.>::>:::::>::>:<:>;::»:«:::>:::>::»:>:>;:>:::>:>::>:::>�;::<:::<:::::�>::>:;::>:<>::<;::::>:<.:;:>::.,;:<::.;::::>::<:«:::<>;>::>:�:�>:::::>:<'::::::.<:::��::::::::>::::..................rirooir.......,»�
............................::::::::::::::::::::::::<.>:�:.:o->.::::::.�:::::::::..>:..::�.::::..;:..:.r:.....::........:::..;.;:�•.:. ::. .. .. :.,:.: •. :::: � •.: � �. .:. � .. :.> �: �. . . ...:.:>:.::;:.::::::::::::::::.;: DA7EM YI .::.
:.::.......... ...
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. .
>:: ::`;::,.';.<.>:.:..�,::.:;.>>":>:.:.....:.."<::��::���<:.>: :.> ...<;<:,... . ,.::;::::: :::>:: <> ::: < : :::::: <.: ;>: ;<.:::> , ,. ..: ;.: , . .; 03 2
:>:: :::> . .:: ;;> :::�:: <::: ;::. :::::: ::�::;: ":; ���>���� ������ ::>:<.;:.;:.::::;;.;:.:::;.::.:;:.;>::.;:.;::::::.:
::: ,. ::<:» :�:���.��:����:>::»�:�:::»��:::::.;:::»:::�::>�;;;:.;:;.;:;;>:.::.:.�::::::::::::::.:::........ ...
.;; �� .:::�....................... ...................
.:::.,.::::::::::::::::::::::::::::::::::.:;.:;;;:.;:.;;:.;:.:;::;.::.;:.>::.»::::.;:::<:;:.::.>:::;;::;.::.;::.;:.;;:.;::.::::::::::::::::......................,.
��� THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATIO
ONLY AND CONFERS NO RI(3HTS UPON THE CERTIFlCATE
BENSON YOUNG & DOWNS A��R TME COVERAQE AFFORDED BYTTHE POLICIESEBELOW.
INSURANCE AGENCY INC.
PO BOX 548 COMPANIES AFFORDIN(i COVERAOE
WEST HARWICH MA 02671-0548 coA� EASTERN CASUALTY INSURANCE CO
�upEp COMPANY
� MILL CREEK INC. DBA B
CHRISTOPHER�S AM RIB & SEAFOOD coc,wr
335 MAIN STREET
W YARMOUTH MA 0 2 6 7 3—4 6 61 CpMp/Wy
D
. ���::::i':ii:<�i'�:i'ri%?�i:}t'L�i}::i'r:L�iiii�:::ii�h{�:?ii:}i�:vY2i�i'i'�iii:;;::i:i;i::.�.k:•i:�ii>iiiii:•:Si$i$:•iiiii?ii::+t�i$:'{Ci�>iii:•:iiii:i:iiii:{:4:•�:iii:ii:�:�iii:�i:viC�ii:>.i:v:�:i::•.�::'viii}iii:�:iiiiii:i+iiii::::�ii:i:::^:iii:i+::i�:•'•�k:i:::iYti:;i:y:;ij}v.rii•::i.:iiiii:.i?•i:?t;.;�:i:i��i..'•
:..'�.e..�,.Sl��.:::..::::::..,,.:.�:.>::>::.:.::.>::.>;::.>::..::.:.�::.::::.;::::.::;..::.::.w.::.:.>:.;:::»::•; .:.R THE�•POUCY�PERIOD. •..
�:::::::>:::..::::.............;..
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV
INDICATED, NOTWITHSTANDING ANY RE�UIREMENT,TERM OR.CONOfTION OF ANY CONTRACT OR OTHER DOCUMEKT W(TH RESPECT TO WHICH THIS
EXC USIO S AND CONDITIONS OF SUCH POJCIES. UMfTS SHOWNAMAYRHA EB E N REDI C DSSYEPA DI CLAIMS.EIN IS SUBJECT TO ALL THE TERMS,
pOLICY EFFEC7IVE POUCY EXP�iATIOM �rtg
� TYPE OF RlSUHANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DO/YY)
GENERAL AGGREGATE i
�iEIERAL LlAaL1��
PRODUCT8•C06AP/OP AGO i
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE �OGCUR PERSONAL 3 A�V qrJURY i
EACH OCCURRENCE f
OWNER'8�CONTRACTOR'8 PROT
FlRE DAMAGE(My orw�n) i
MED EXP(My WN W�) _
AUTOMOB�E LuB�R� COMBINm SINGLE LIMIT i �
AN1f AUiO . . _ _ .. _
:: ---- _ _ _
_ _
- `
__,_ . BODILY INJURY '
ALL OWNED AUTOS _ ___ ._ .. ._ - - (P���' :
gCF1EDULED AUTOS
HIRED AUT08 BODILY MUURY =
(P�r acdd�nq
NONAWNED AUTOS
PROPERTY DAMAGE :
AUTO ONLY•EA ACC�DENT t
OARAOE LIABllTY
OTHER THAN AUTO ONLY
ANY AUTO
EACH ACCIDENT S
AGGREGATE E
EACH OCCURRENCE i
EXCE8S LIAB�Jir
AGGREGATE i
UMBRELLA FORM
S
OTHEFi THAN UMBRFLLA FORM ' :
>::.
0], �1 H O 1 O 2 X TORY LIMRS ER :.:: ` ">
woa�as coM�+s�Tw�+n►o W C O lA9 2 0 2 7 $/ � � � 10 0 0 0 0
EMPLOYERS'LJABIlTY EL EACH ACCIDENT i
7HE PROPRIETOR/ X ��� EL DISEASEPOLICY LIMtT t �J O O O O O
PARTNERS/EXECUTNE EL DISEASE•EA EMPLOYEE i 1.O O O O O
OFFICERS ARE: EXCL
07HER
DESCRIP710M OF OPERATWNS/IOCATIONSNEl�CLES/SPECIAL REMS
. �ft
....................._........:..:........:.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.: ..:..._L�����.i::ii::':::;:::ii?ii:Eiii:ii;iEiiiiiiEEiiii?;iik::::`•:::"i;ii":?i:iii;i::`:;i:i::::;?:::;::::::;:',''•:::;:::::::�:i::::::::::ii:i:::::::ii:a:iii:iii::::ii;;;`:i;:'::::?EEE:%s
...... . . ... . ...........:.::::::::::::::.�:::::.:::::o->;::.>:::::.>:.::::;»::;:i;:::::::i:::iti::;:::;::::ii;;:::::::::'r.::ii::::r'i�.Ci� ...M��............ ............... .
�: .. .::. . ... .:::::::.::>:::::::::::::::::::::::.::.>:>:::::::::::::::::::.»:.::.::::::::::::::::<o::::.::a:.:::::<.::::;::::::::::::::.�:::::::::.......::::::::::::::::::::.
: ,:Fl 7`E:::>:H ....:E�:>::»>::>;;:;:>:.:»::>::»::r;::<::<:>::>::>:.;;:,:::>::»»:<:::;s:»>::»:::::.::.:::::,;;;>;;:;;:::::::::::.::::::. ................................
CERTI C,�( pLDE ....................
:;;;;::.>;>;::;>:.;;:•::;:;;>:.::.;::>:;;::•;:.::::::::::::::::::::::::.........................
.........SHOULD ANY OF 7HE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE 7HE
FAXED: �J O H �I 9 O 2 H O 1 EXPIRATION DATE TNEREOF, iHE �SSUMG CCMFANY WLL ENDEAVOR TO MAL
TOWN OF YARMOUTH �.SL� DAYS WR�77EN N0710E T�TM����A���M�TO TFE LEFT�
114 6 RTE 2 8 BUT FAILURE TO MAIL SUCH NOTICE BHAL�M�P����BUGATION O����
S YARMOUTH MA 0 2 6 6 4 OF ANY KMD UPON TF� C0IAPANY, R8 AGENTS OR p�EBENTA71VE8.
AUTt10RQED REPRESEHTATIVE
Mark R. Silva JS C
...................::::::::::::::::::::.;;:.;:.::.;:.;:.:�:.::<>::>::>:::::;:::»>::>::::;:::>::<::»::::::::�>:::;:>:>::»::;::>:;::»>::>��<<:>::::�:;::::.:::<:.::::::;::.�.:;�:.::.�;::::..:::;::::.;::•�se
....................:.::::::::::......:.::::::::::::....::..:.::::.�::.�........::::.::::.......:::::.::::::::.:::.::.>:.::.;:.::.:::.;;:.;:.;::.:::.::.;:<.;:.: . .c���:<::: . .�po�no�;::::�......:
i ...................:.::::::::::::::::::..:::::::::::::::::::...�::::::::::::::....::::::::::::.:.:::::::::::::::::::.::.:::::::::::::::.:.::::::::::::::::..::.:::::::::::.�::::.�:.::::.::.:�a:�..............�.................
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:::::::.�:::::::.�
;AGORD::>�...... ...............
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IlVI�NT
PERMITNUMBER: #02-122 FEE: $150.00
In accordance with regularions promulgated under authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
Mill Creek, Tnc_, 769 Route 28, South Yarm�uth, MA
Whose place of business is: Christo�her's
Type of business: Food Service
To operate a food establislunent in: Town of Yarmouth
Permit expires: December 31,2002 BOARD oF�A�,'I'x: ��� ��, �avr�rra�c
SEA'rII�rG: 382 beoc��. G�idralou, '11�D., 2/ice �aauxa,�
RESTiuCTIONs [F,�NY: See reverse side. �o�ezt? �, (�
�a�rie��ezurat�
� s� .
May 6 ,2002
ruce G.Murphy,MP , . .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERNIIT NLTMBER: #0079 FEE: $50.00
This is to Certify that Mill Creek,Inc. d1b/a Christonher's
769 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at tha.t place only and expires December thirty-first 2002 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity with the authority granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: L��a�rEe�r�f, i�d!likez, L�xa�t
SEATING: 382 �l�Kls�D. ��. ��., �/iCC
�s�cTTorrs �arrY: See reverse side. ,�o�xt jt �no�, (�
�a�711cD�
s �
MaY 6 ,2002
ce G. Murphy, .5.,CHO
Director of Healt
TOWN OF YARMOUTIt QOARD OF' HE r� a� ��� �-`� `' � � -
APYLICATION FOR LICENSE/PE `T 000';"` ti�', �
��� � , �� r��� 1 � zaoa
P� . 5� +
♦ R.
,* Please complete form and attach all necessary documents b�Decernber��;1999. Failure t dd�►
the return of your application packet. ', � �� "V
�=------------------------------------------------------------------------------------------ - ------------------------------------------
NA�V1E OF ESTABLISHMENT: Christopher's F�nerican Rib & Seafood Eatery TEL. # 394-8006
LOCATION ADDRESS: 769 Main Street, South Yarmouth, MA 02664
'�AILING ADDRESS:
�QWNER/CORPORATION NAME: MILL CREEK, INC.
MANAGER'S NAME: Theodore zambelis TEL. # ���—
IY�A�ILING ADDRESS:
--------------------------------------------------------------------------------------------------------------------------------------------•
POOL CERTIFICATIONS:
The pool supervi§or must be certified as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to ttus farrn.
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). Ptease 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.
-�EIMLICH CERTLFICATIONS:
All food �ervice 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-cholcing 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. Theodore Zambelis 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEAT5: TOTAL#
------------------------------------------------------
OFFICE U �1� O�
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT #
B&B $50 � _CABIN $50
INN $50 _CAMP $50
LODGE $50 ,TRAILER PARK $50
MOTEL $50 ____SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVI�_E_'
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
� 0-100 SEATS $75 '� _CONTINENTAL $30
>100 SEATS $150 � NON-PROFIT �25 ',
i ,
`, WHOLESALE $75
COMMON VICT. $50 T?.�'�O �
�
i?FTA�SFRV�,CE• D FEE PERNIIT #
FEE PERMIT # LICENSE REQUIRE
LICENSE REQUIRED �20
<50 sq.ft.
$45 �_ _TOBACCO
— $75 —_ FROZEN DESSERT $35
<25,000 sq.ft. —
>25,000 sq.ft. $200 ______—
NAMF cHANGE: $l� ------ AMOt1NTDUE _ $ IZ"/�
lIRAAfi
PLEASE'TLJRN�VER AND C�MPLETE OTHER SmE OF FORM�wwR•
\ � -
r�
r +`�=:�.
ADMINISTRATION
JNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED `
`:'•:" :�{f0 HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINES5 IF A
r�..
��;;� P'ERSON OR COMPANY DOES NOT HAVE A CERTIFICA,E OF WORKER'S COMPENSATION
INSURANCE. THE ATTACFIED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, �R.
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK,�-1PP PRIATELY IF PAID:
YES__� NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
R.ESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE T�C�NTACT THE HEAL'TH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE ItEPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SVV]C�vIMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND TI-�WATER 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 S@VI�VIMING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN (7) DAYS OF CLOSING.
�
FOOD SERVICE
�ATERING POLICY�
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI-iE YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE A.PPLICATION 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 TI-IE HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN T��
SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERNIIT UNTIL THE ABOVE TERMS HAVE
BEEN MET.
OUTSLI�E CAFES:
OVi SIDE CAFES (i.e., OUTDOOR SEATING'JVITT-�WAI1�It/VVAITRESS SERVICE), MUST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
I
UTDOOR COOKING•
� OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
�
SERVICE ESTABLIS�-IMENT IS PROHIBITED.
DATE: �'S �2 1�t7 SIGNATURE:
� PRINT NAME& T[TLE: �fht��Ze�} �av,�},j�r �'�/2�,J�,/T
11/12/99
�
� t �
Td %
,� The Conrmonwealth ojMassachusetts
� � Department of Industrial.-�ccidents
� • �� > Olflce ollav�s�lps�li�s
0
� 600 Washington Street
' ` Bnston, �lass. 02111
,
� "" '��y W'orkers' Compensation lnsurance Affidavit
Annlicant informaHon: P►eauPl�iNTTe�t.'t+i.r
namc� �`'iILL CREEK, INC.
loc�ti�n: 769 Route 28, South Yarmouth, :°fA 02664
c�t� ohone tt 394-8006
� f am a homeow�ner perturmin,all w�ork myself.
� 1 am a solz proprieror �-� h��e no one n�orkin� in am•capacin•
� I am an emplo��er pro�idino workers' compensation for my employees w�orking on this job. :
comnam• name: MILL CREEK, INC. dba �hri�toph�r's American Rib ..& S�a�ood Eatery
�ddress: 769 Main Street
�ti.; West Yarmouth, MA 02664 phone t�: 508-394-8006 _
TIG Insurance ������
i�surincc co R91icy#
� I am a sole proprietor. ;enerai contractor. or homeoµ�nerlcircle onel and ha��e hired the contractors listed below ��ho ha�e
the follu��in_ ��orkzr� .ompensation polices:
s4mpanv name•
address•
�its• phone�• —
insur�ncc co policv#1
sompanv name•
addr «•
eJ',Zy• nhone It•
incaran��rn ��j�+*
1
Failure to seeure covera;e as required under Secnoo 25A of MCL 152 e��Ind to tbe iepositioa oterioiad ptadtles of a d�e op to 51�00.00 a�d/o�
oae years'imprisonment as w•ell t�civil penaitiee io tAe form of a STOP WORK ORDER aed a tist of S100.00�dar a=ainst ma I s�dersea�d tLat=
copy of tha statement may be forwarded to t6e ORce of inveatiYations of t6e DiA i�eoven�e veritfatio�.
I dn hrreby ce '}•u der the pains an pr ics ojp tha��6t rnfor►nation provrdtd abov�is true and eeneeY
.
Signature " 8� c�S /Z/v �
_.___ Print name- Phone!t
.. oRcial use onl� do not M�ite in this area to be completed by eity or town oAleiil
ciry or toN�n: y�M�II� per�itAicense k �'16uildiog Departmeot
�Licensieg Boa�d
�cheek if immediate response i�required 261 �Seleetmen'e ORce
�Healt6 Department
contact person: pAoneM:_ (508} 398—?231 eat. nOther
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05/09/00 TLTE 13:56 FA% 508a497894 BY&D - WELLFLEET
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TFIIS BIWDER IS A TEAAPOIiAQY INSURANCE CO�ACr. SUBJECT �E�ND{TIONS SHOWN ON THE REVEiiS��DE OF 7NiS FORM,
w�ur�w 08-349-6311
BENSON YOUNG � DOWNS INS AGNCY SH SMITH —TIG INS L J R A N C E
15 BRIAR LANE °A7= �! X � �� X +�ot iu+
PO BOX 717
WELLFLEET MA 02667-0717 05 08 00 12: 01 rM 06 08 00 wooN
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���o: BMILC50-2 ��������pOPEA7Y(IneWmnp L��
,�� LOCATION: 769 MAIN STREET
MILL CREER INC SOUTH YARMOUTH, MA 02664
FRONTIER RIB & SEAFOOD HOUSE BUSINESS: SEASONAL RESTAURANT
769 MAIN STREET
YARMOUTH MA 02664 � a � �,�,..3� � . ., �.��� �KS�.:
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MILL CREEK INC DBA A
FRONTIER RZB b SEAFOOD HOUSE
769 MAIN STREET ��1���
OUTH MA 02 6564 i e . on . �,.-.-.�—��B�
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TOWN OF YARMOUTH
' BOARD OF HEALTH
' PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-106 FEE: $150.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Mill CrePk„Tnc ,,69 Main Street, South YarmoLth, MA
Whose place of business is: Christo�her's American Rib & Seafood Eater,�
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:���/. �eE��, C���.�.�
SEATING: 3g2 /Co�e�E J. �rowra, (�lerh
RESTRICTIONS IF ANY: S6e reveise side. abrielfe Ja�o(�h J�tooPe6
�i/ic lOdou �lirc
�
Mav 17 ,2000 MP ,R , CHO
ruce G.Murphy,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERNIIT NUMBER: Y2K-106 FEE: $50.00
This is to Certify that Mill Creek Inc dlb/a Christopher's American Rib & Seafood Eater�_
769 Main Street, S�uth Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity with the authonty granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
Bo� oF��.�: �d� �e��, c��„��
SEATING: 382 Ko�B.�� ��oW�� c�,�
RESTRICTIONS IF ANY: See reverse side. C�/'/�rielle Ja�o(�h�-J�toof,ea
Y'r ��' ��
/ e oa in ��
Mav 17 ,2000 �^'�� '�'`' "''
�G.M�ny, , .,cxo
Director of Health