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Home My WebLink AboutApplications, WC and Licenses , � ' `5-�b�'f _ ._ . _� . � � TOWN OF YARMOUTH BOARD OF HEALTH �'` '� ;�, � �'�� APPLICATION FOR LICENSEfPERMIT-20fl9 � �� o Q � �l �� , � � � * Please complete form and attach all necessary �umei�.�s b�� c i b� � ' Failure to do so will result in the return o� �a�icati . ' �� . 4r NAME OF ESTABLISHMENT: �" `� L.�-� ��P��TEL. # �'��;� LOCATION ADDRESS: �7� MAILING ADDRESS: D G OWNER NAME:�,��1,�1.�15�1�1 {��t,•OS TAX ID (FEIN or SSN1: �`�/��-� CORRORATION NAME (I T-�'LICAB E): MANAGER'S NAME: �� TEL. # / r C%7� MAILING ADDRESS: :7C(�YI2� C.�-- C�;�DI��C POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification ta this form. 1. 2. Pool operators must list a minimum of two employees ctu7 ently cei-tified in basic water safety, standard First Aid and Community Cas diopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who is certified as a Food Pratection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All foad service 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-choking procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT� _B&B S55 _CABIN $55 MOTEL S5� _INN S5� _CAMP �5� _SVVIMMINGPOOL �80ea. _LODGE S55 �TRAILERPARK �105 WHIRLPOOL $80ea. FOOD SERVICE: __ _ _ _ —_ LICENSE REQi.JIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFI7 �30 _>100 SEATS S160 �COMMON VIC. �60 WHOLESALB �,80 RETAIL SER��ICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERI�IIT# LICENSE REQL�IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# T<�0 sq.ft. �50 _>25,000 sq.ft. $225 VENDING-FOOD S25 / <25,000 sq.Yt. S80 ��j�-0��f _FROZEN DESSERT $40 �TOBACCO �5� .��2 va�-iE c�A�cE: sio AMOUNT DUE _ � /3S�po *W***PLEASE TLT�2:\OVERAND CO'VIPLETE UTHER SIDE OF FORfVI"**** t �,,�. ,� �•=--. . _ � ADMINISTRATION �` Under Chapter 1�2, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any ticense or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPEN5ATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid p � r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy 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 CNIR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools�vhich have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening. PLEASE NOTE: People are NOT allowed to 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 rnust be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required Temporary Food Service 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 RETIJRN � THE COMPLETED RENEWAL APPLICATION(S)AND REQUIlZED FEE(S)BY DECEMBER 15,2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � I� �� SIGNATURE: PRINT NAME&TITLE: �n��X iorzi�os M f ,��1_ � • ' * � The Commanwealth of Massachusetts Department of Industrial Accidents �Nb��ll� 600 Washington Street, fb Floor i Boston,Mass. 02111 + Workers'Compensatioa Insarance Affidavih Bailding/PlnmbinglEkctrical Contractors Aaeliea�t ir�ferer•�4 Pl�a�re P1tINT k�blv n�: �i�rl.�'i S�t�� (�f' �.Q,(1-L � LLC. �___�i D�1 aaa�s: �-r N1(,�,I�VI �`h'7°�� c� V�/C>�`I�1 V t V�`�- - state• r �` '/ ' zip•��~ I� ohone# �� /��1�� work s'ite location ffull address): �� ❑ I am a hom�wner perforniing all work myseIf. Project Type: ❑New Construction ORemodel �❑ am a sole proprietor and have no one working in any capacity. ❑Building Addition am an employer providing workers'compensation for my employees worlcing on this job. com �me- .� 'l'J r �,,, ��- I r�� p�sa-�F— �r.e�— ��ri-�r�, �� c� � �#- �� 1'l l �q� � �. u� ___ � �(� # pr5 c�� ' :.._ ..:: , ,..;� , , .:�' : ,' :.;. ._. . ..'�:' :' ,.�:�._, <. .:. :.' ,_.: :: +tY�£h.Faet.�4 .. - ❑ I azn a sole proprietor,generai coatractor,or homeowser(cirde one)and have hired tbe contractors lisced below who have} the following workers'compensataon polices: commsv�ame: address: citv n�oae#- insartace co. # . � , _ .. � cemwav aame• addreas• _ci_ty: ni�o�e#- iffima�ce co. . # �,. ri � ..:: Failate 0�secme ewerage u reqaired aadv Scclioa 2SA ef MGL 152 as lead b t�e isp�i�a�f erb�ioal pnaNks ef a Sne�te S1,SA9.00 and/or. one yeats'Imptieeament n wr8 as dvY peealtles in t6e form of a 3T0!WORK ORDER aed a 6ne et 5199.09 a day agalast me. I aedentand t6at a cepy ef tiis�fahmeat may 6e fonvarded 10 the Offiee o[lava�Neffi of t�e DIA fot c�venge veti�e�liee. !do 6enby ce fy under dlre pafns aad pene ' of perjury t/�st tGe i»foru�atlo�provided above Ls d�rre awd rnmct Signature �-'��'�� Date � � �� Q � Prim name �� .V"�.��r1't.Gt-� � Phone# �� t � �� officia!nae only do not write�thls area to 6e completed by dty or Mwa o�Cial city or town: permid�iceffie# OBuidinE DePartmcat ❑chtck if immdHa�e rcepeme is reqaited �1��8�'d �Sdectmen s O�ce �Heait6 Depa��ent ceatact peraon: phe�!E; QOfger (��M-�) i � . „ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-044 FEE: S80.00 In accordance��ith regularions promulgated under authority of Chapter 94,Section 305A and Chapter 11 l, Section 5 of the General Law�s,a permit is hereby granted to: Christy's of Cape Cod LLC, 441 Route 28, West Yarmouth, MA Whose place of business is: Christ,y's of Cape Cod#609 Type of business: Retail Food Service less than 25,004 square feet To operate a food establishment in: Town of Yarmouth Permit expues: December 31, 2009 BOARD OF HEALTH: ,��¢tt SP�tx�, J2i ..N., C'f�uvtrnare C!hicr�e�eo .�. 9Ce�,�'c�c `lJice ('l�ai�enur�rc J2a1�e�ct .`'t. J3�caurn, e� c� ��., �..N. ��• �i� Januarv 12,2009 Bruce G Murphy,MP , . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: #09-032 FEE: 55500 � T1�is is to cerrif��that� Christy's of Cane Cod LLC dfb/a Christ,y's of Ca�e Cod#609 441 R�ute 28, West Yarm�urh, MA IS HEREBY GRANTED A LICENSE For SALF AND DISTRiRUTtnN nF TORA('CO PRODIIC'TS AS PER T'HE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. T71is, e it is avt di�c forn in•with Article VI of the San'ta Code of The Common«�ealth of l��fassaclnisetts,and expi�es�eceii�er�1,_O(�� un�eSs sooner suspended or revo�Ce�d. lanuary� 1?.2009 BOARD OF HEALTH: J`�Ctt 5�� ✓�.JV.� ��ttQltt C'hicrxee�v 3E. 9�e1P�iR�, `lliee CHtavutuut 9�a�ct s. J3xacurc, C�ex� aruz �'aceere8acun., J2..Ar. E��• �� ce G.Murp y, M , . , Director of Health ~� � o.� �=�,e-�s�rs�#G a9 �`�Y�`k TOWN OF YARMOUTH BOARD OF HEALTH � , } �.�"r^ ��. APPLICATION FOR LICENSE/PERMIT �U �� r � S v- �` j�'.1 � a ��ii - *Please complete form and attach a11 necessary,�o��t��' December 31,�2007.� Failure to do so will result in the return>�f ytwr application packet. �� NAME OF ESTABLISHMENT: �1�15�-� �S D F (1r.,�.t C6� � �IoDCJ TEL. # Sl�-7'71;3%9� LUCATION ADDRESS: _ �l`I/ MA�/N ST j,,/ ' ��/�� d�7 MAILING ADDRESS: /OS �I�tSA��vi S`I, �YA-NN'rS , MA- 62/�D/ 4WN�R NAM�: GGir�S�y /`'��io5 TAX ID (FEIN or SSN): CORPORATION NAME (I APPLICABLE):G�V/S � D�'- �c�e Colrl Gl�� MANAGER'S NAME:�o�r�- ��ro� TEL. # 5b�-77/-6�7C�' MAILING ADDRESS: /D5� �/F�s�,r�� S� l7�khr��s, �`'1� �ZGD l � � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimuxn 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 eertifications to this form. The �ealth Dep�rt�ent will not use past yea�s' reeords. �'oa �us� provide ne�• copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food serviee establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Saiutary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. 3'he Health Departmer�t witl not use p�st 3�ears'recvrds. You must provide new copies and maintain a file at your estabiishment. I. 2. _PERS9I�T IN�'HA�.RC'iE: 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 an�the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The�ealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'vIIT# LICENSE REQL'IRED FEE PER'vIIT# LICENSE REQL'IRED FEE PER�r11T= B&B 550 CABTlv' S50 MOI'EL S50 INN 550 CA:1�IP S�0 S�t'1VI1�fIiVG POOL S75ea. LODGE �50 TR.AILER PARK S 100 t��iIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICEIVS£REQLTIRED FEE PER'�ZIT� LICENSE REQL'IRED FEE PERRbiIT= _0-100 SEATS S75 _CON7INENTAL S30 _NON-PROFI? S2� >100 SEATS 5150 CO�LLION VIC. S50 V4'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PERv1IT= LICENSE REQI;IRED FEE PER�fIT� _<50 sq.ft. S45 _>35,000 sq.ft. S200 _dENDING-FOOD S'0 /<25,000 sq.ft. 575 �Oq-O�j —FROZEN DESSERT S35 /TOBACCO S50 �o , � �tAl�CHA\TGE: �io AMOUNT DUE _ $ /25'.00 *****PLEASE TL'R\OVER A\D CO�iPLETE OTHER SIDE OF FOR�i'�*'�** 1, A � anMnvis�TTON �. 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 APPROPRIATELY IF PAID: / YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocrupancy shall be limited to the temporary and short term occupancy, ordinarity and customarily associated with motel and hotel us�. Transient occupants must have and be able to demonstrate thax 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 tha.n 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: En�losed Motel Census must be completed and returned with t�is app�i�ation. 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(�days pnor 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 c�uarterly 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 Departme�by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtasned 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 urrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: �utd�ar�aai�ing,preparation,�r disptay af any foo�praduet by a retail or f�d serviee establishrne�is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIDNS TO ANY FOOD ESTABLISfIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIO:�TS MAY REQUIRE A SITE PLAN. DATE: /I 1� d� SIG'_VATURE: . i—' �� ` FRINT NAME&TITLE: �c.thnalZ� �i►/. �/l� �• �/P io?o n� i ! • � �'he Commonwealth of Massachusetts °' Department of Indushzal Accidents ' MAfc��ws� 600 Washington Street, 7`�`Floor Boston,Mass. 02111 Workers'Compe�sation Iesarnnee Atii�tvih Bailding/PlumbiaglElectrical Contractors �: G��,s�s � C�� Co � #- �09 a�s: �y� Ma�N St. �ity '"Je`71� 1�YM v�� state: �A' ziQ: D�Io7� nh�e# .��-7� /",�l�� work site location(full addressl: ❑ I am a homeowner performing all work myself. Project Type: ❑New Conslruction(]Remodel ❑ I am a sole proprietor and have no one working in any ca�city. ❑Building Addition [�,I am an employer pmviding warkers'compensation for my employees worlcing an this job. oomasnv aame: ��r!�j�`S 0"r �f.;�4t l..Bt� i�- � zadress: ��3 y f�Lk 5G�' � citr: N�an h�5 ��' ��D 1 olto�ae#: J�f`"�/-- �� 1�1Q5S �c� �o�w�3 � � t�f OODSO/3�//O � . .; , ..e.... . ,: ❑ I am a sole proprietor,geeeral eo�tractor,or�omeowaer(cxrcle onc)and have hired tbe contractors listed below who have the following workers'compensation polices: comnaav eame: address• citv ohowe#: iesara�ce ca # a�noaav'ame• ad�+ess: sitw oro,c#• i's�ra�e,e eo. __ ---- -__ _oolicv# _ __ _ ��t#rrRfl�� FaHm�e m xcme aweraSe n reqaired aader Sayba gA sf MGL 152 eu lad b lie i�itloa of ut�ieal pnaNks sf a��p a SI,SM-M aadlor ene yens'impthonmeat as w�as civY penaitlea in tbe farm ot a 3TOP WORK ORDER aed a}Ine a[5160.M a day agaiast me. 1 oaderslaad t6at a cepy e[this�atemeet may 6e farwardcd�o tAe b�x ot lave�igatlsffi ot tke DUl far ceverage vtri9eatlsa /ro Aer+�by certijy rt�der tlYe pA�ns and pehelties of per��ry tlrat tbe i�fonitatlo�pro�ded aboWe fs lrue and rn Signature ��✓` I� Date 1��/ " � Print natne L� �°w� C�1g/�'1/LL� J� Phone# ��'77��t�� /` Z� o�ciai nx oniy do uot write i�this area to 6e��pkYed by clty er Mwn official city er town• permifJH�e# �Boildiug Deputimeat Ql.icen�Board ❑chcck if�mcdfah respeax is reqaired �'s Offiee �HaNk De�rf�eat contact person: phese#; �Other cRvmea s�,c 2om) _ � , ; . ' � `�' 'ERa COMFEI3SATIGN A:'�' F..�'IPLOYERS LIA�1?��'r'Y INSURANCE C�RTI�'ICA.TE INF�RMATION PAGR. ?.�.FE4:AI� �GREEME,.n?'L Producer: Agent�� 960 MA Retail Merchants WC Group Inc. AssociaLion �3enefitc Ins Agc,T r�c 10 British American Blvd. 529 Ma�n St Ste 605 Latham, NY 12110 Boston, MA 02129 (Carrier Code: 34355) �ertificate 4�: i,14000501361107 Prior Certificate �f: O'.40005�13ti1106 1. The Employer: Christy's of Cape Cod, LLC Type of Business: Partnership Mailing Address: 105 Pleasant Street Hyannis„ MA 02601 Other workplaces not shown above: Fein: SEE SCHEDULE OF OPERATIONS Risk ID: 2. The certificate period is from 12:01 a.m. on 1/O1/2007 to 12:01 a.m. on 1/O1/2008 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part One of the certificate applies to thE Workers Compensation Law of the states liste� here: MA B. Employers Liability Coverage: Part I�ao of the certificate app.'_ies t� aor�: in each state :�isted in I�em 3.A. 'T_'Y�e limits of our liabili;:�� :.�rz�e:� Part 'T�;;o are� Bodily Injur�r by Accident $ 5U0.000 each accid�n� Bodily 7njury b�r Disease $ 500.00� cer,�::.�icate limit Bodily Injlir�r by Disease �_ SOO.�O�C__ ea�.� r��lt)�r2P. C. Other States Coverage: D. This certificate inc.ludes these endorsemei�ts and schedules: WCOOOOOOAl04/92) WC000113(Ol/05j ' '`�C0004C6r�,(C!3/�`)•�Tr;^?'0'��r��Ci'/°D� G;C.�20�30J.(04/�/�? WC200302(GS/R$) WC200303B(07/99) 4]C2C�405;.ti6/O1) "vJC20060�(06/92.� 4. The contribution for this certificate will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Al1 information required .below is_:subjeGt to verification and change by audit. Classificatior_s Code Contribution Basis Rate Per Estimated ' No. Total Estimated $100 of Annual �� Annual Remuneration Remuneration Contribution ' SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution 17,210.00 i�Iinimum Contributian S , 267.00 �,xpens? Constant .� .OG WC 00 00 Oi A Issue Date: 12/28/2006 Counter_sigr.ed by . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-008 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby�granted to: Christy's of Cape Cod LLC, 441 Route 28, West Yarmouth, MA Whose place of business is: Christy's of Ca�e Cod#609 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Peimit expires: December 3 l. 2008 BOARD OF HEALTH: .��E�¢tZ S�P�, J2../V., C'P�avuttarrt C'Pcavr.�e,o .�.�'feP�i��c `t�ice C!Pcrxiacnucn J2r+r�re�ct s.J3acc+v.ua, e�exP� ' Q/t!L��ceerc�p.C,tirii J2...lV. November 27_2007 ruce G.Murphy,MP , .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #08-007 FEE: $50.00 This is to Certify that Christy's of Cane Cod LLC dlbla Christy's of Cane Cod#609 441 Route 28, We�t Yarm�uth, MA IS HEREBY GRANTED A LICENSE For SAT. . AND T�TSTRiBIJTION OF TOBAC'C'O PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. �pi�es�ece�ieit3l.��S�or�'t�with Articl pVI of the Sax�ar�Code of The Commonwealth of Massachusetts,and e s sooner sus ended or revo e . November 27.2007 BOARD OF HEALTH: .��eQ¢fZ SP[(X�� .Jv., ��tttziL ��d .`�. .�i�f:�� [Ce��,�lX(�1Yfit.�tZ 5�.e�et�.J`3�uu�un, C!eexP� Q�e(�aceeri�aucm, ✓`�...�v. Bruce G.Murp y,MP . ., Director of Health � ° c,D��2;�a . �°`;"�R� TOWN OF YARMOUTH BOARD OF HE�I.3'H �� , �::_ -,s APPLICATION FOR LICENSE/PERN�TI��- �U11*7, `` NOV 2 8 2006 * Please complete form and attach a11 necessary documents by Decemb r�j�Qf�}{ �j�PT. Failure to do so will result in the return of your application packe . NAME OF ESTABLIS�-IlVIENT: ` � EL. #`'�0�,�`�7/. �J�F� LOCATION ADDRESS: - , �,�j. , MAII.,ING ADDRESS: , . t��O OWNER NAME: C l�c;s�v_�Y1:hn�5 /C�,,,�;s�r.so�'('�a� Cod TAX ID(FEIN or SSNI� �,�� CORPORATION NAME(IF APPLICABLE): (`t,,c; � .�� „� J�.� MANAGER S NAME: ', TEL. #�Q��B MAILING ADDRESS: ` Oa�O POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and �ommunity Cardiopulmonary Resuscitation(CPR). Please list these emplayees below and attach copies of employee certificaxions to this form. The Health Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. l. 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 Cade for Food Service Establishments, 1Q5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmen� 1. 2. PEIZSON IN CHARGE: _ _ �ach food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. HEIl�IL,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained,in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department wiU not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiTIItED FEE PERNIIT# LICENSE REQUIIt.ED FEE PERMIT# LICENSE REQUIl2�D FEE PERMIT# _B&B �50 _CAB1N $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIlvIlVIING POOL$75ea. _LODGE $50 _TRAII,ER PA,RK $100 WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PF_RMIT# LICENSE REQUIItED FEE PERNII'P# LICENSE REQtJIItED FEE PERMIT# _0-100 SEATS $75 _CONTIlVENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAQ.SERVICE: —RESID.KTTCHEN $75 LICENSE REQIJIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMTI'# LICENSE REQiJII2ED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 �45,OOOsq.ft. $75 D?-Ol _FROZENDESSERT $35 / TOBACGO $50 �"07—OjO NAME CHANGE: �10 AMOUNT DUE = S /2 S,00 "':"'pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"""• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED 4R 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 APPROPRTATELY IF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the tempora�-y 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 af residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. 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,wadin�and whirlpools which have been closed for the season must be ins ect�i by the Health Dega,rtment prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to operung. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly therea.fter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Foad 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. OUT5IDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. OUTDUOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibit�ed. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN TI-�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 3 l, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQITIPMENT,ETC.),MUST BE REPURTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �' lb t36 SIGNATURE: �� _� PRINT NAME&TITLE: t�A'T l2[GK 1yI U��o r.Jn � �� GvtJ 10/17/06 i � � �i � The Commonwealtl�of Massachusetxs Depart�nent of Iadustirial Accidents > N�riNlirw�l� 60o w�h;�gr.,n sr� f"FraoT Boston,Mass. 02111 Worlcers'Compe�aatios Iesaragee Affidavit:B�W ' bi��tEleetrical Coatnctors r.<. .:. ... :. � �. _ ..>� , � � �� .�, ��,. �-� �c. , . � �� -� _ ,.� ... . , �, �„r, e>. �� -� ',� ��a£�_ �. �' �=��5� r� ['�� .,,� Cr�d �� addtess• '--f� r A�!i �'�'• �itv I�?��Ek(c�YY►n Ji'h state: m H' zip•��, �h�e# �Q�.7`��1-I j� work site locati�(fnll addressl: ❑ I am a ho�owner petforn�ing all work myself. Project Type: ❑New Co�nstructi��R�nodel I am a sole 'etor and have no ame w ' in any ca ' ❑Buil ' A�ition :r ��=: , . __ � I am an eanployer providing workers'compensatian fo�my employees woricing�tl�is job. ��• �� Y�!`�C�-- �`-._,__�C D��` .�_��',,a,�Q� 1--�--�--^ _ � 10 S �P��c. sa.�� : �.�,�-,�� !'�'��.�,�t��l ��• ��R�7/• 0 9oD . . . � id� ❑ I am a sole�oprietor,ge�eral costractor,or homea�vaer(c�rde o�)and have hirEd the contrdctors listed below who have the following wotk�s'compensation polices: �� c�s: ��- � ��• �c � �� ____ ___ _— _ _ - - -- -—_— --- _ # _ _ __ Fa�m�e f�aee�re a+era�e n reqei�ed u�der Satla�2SA�f MGL 152 cu ind b tl�e��f criwial pc�aNks�f a�e�b S1,3N.Ai aadhr s�e yea�s'ioprbon�mt as wdl as dv�paudtles ia tbe 6ra�ef a 3T0!WORK ORDER a�d a Aae ef 5190.i0 a day�ne. 1 ndastud t6at a cepy af fiie etaleaeat mp 6e finvat+ded b Ne Of6ce otlav�tloffi•t t6e DIA tar average veriAeatlw. !ro benby ce�jy xwder tbe pai�s ax/peeaTties ofPe�irr�'tbet tlYe i�forerrt�ior pno�ded abovr Is true and onmct Signature_�_�A�k. ��i6e_/s._.••� Date 6 Prurt name___�I'_T�� e�+ �C �j;�L2t "� Phone# .T 9 � e�ial ose only do aAt�vrite is thia area to 6e oampleted bY dty ar vwa e�! dly ar tewn: �q �E�� ❑eheck if�mediale reapeme is t+eqa'ved ��B�td �'s O�ce e��tsd person. p�eae#, D�O�� t T4WN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-013 FEE: $75.OQ In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby>granted to: Christy's of Cape Cod LLC, 441 Route 28, West Yarmouth, MA Whose place of business is: Christy's of Cape Cod#609 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2007 BOARD OF HEALTH: Q _`h. , /l�l._`n., ' a�/e��i��i, �iu;e C�:cr�iar.�rs Ro�t�. B� Gl�k �� t4.��, R.N. �� January 24,2007 Bruce G.Murphy, .5.,CHO Director of Health• � ; THE COMMONWEALTH QF MASSACHUSETTS TOWN OF YARMOUTH BOARD UF HEALTH PERMIT NUMBER: #07-010 FEE: $50.00 This is to certify that Christ�'s of Cave Cod LLC dlb/a Christ�'s of Cane Cod#b09 441 R�ute 28, Wesr Yarm�uth MA IS HEREBY GRANTED A LICENSE For SALE AND DTSTRTRITTTQN OF TQBAC:C;n PROi�I7C'T� AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. expSi�es�D t leceu�ier�.�0�7 �un�e�s�so�on�suspend�oi e ok�Code of The Commonwealth of Massachusetts,and January 24,2007 BOARD OF HEALTH: � �. �o�t,/��., ' ��s�, R.�., v�e�� Ro�t�1 l��ou�, G'!� /�c�ick/Glc`�� 4� ��,.�, R./V. � - ruce G. Murphy,MP , . ., Director of Health �`` � cP�-�'��°� � . ,. ` ' `�;;�R.y TOWN OF YARMOUTH BOARD OF HEAL�II�-, � `� - ��' 1�'� ;� i c� o�: �'� APPLICATION FOR LICENSE/��R�IT�-�006 �, . ;��. � � , UEC 2 3 2005 * Please complete form and attach all necessa�d cum,�ri�-b�Dece b A�2�(S��T Failure to do so will result in the ret!u�of�tiui application p . NAME OF ESTABLIS�IlVIENT: �..��,.j�, � TEL. # S�P�-�771 -:31�S LOCATION ADDRESS: E-(41 Mo._;,n 5� � t,��s�- ��a�rn-��,✓�-1,. �t Y+ ozio7 3 MAII.,ING ADDRESS: /�� Q�ea�a.r,�+r S�- . 1-�.,� ,�5 Mr�- a��o o k OWNER NAME: �,t�.c�5•��,r V�1��c�s TAX ID (FEIN or S SNI: CORPORATION NAME(IF APPLIC.ABLE): � � ' � � � r L� MANAGER'S NAME: `��c � r TEL. # �� -3��t MAILING ADDRESS: o a,. S t�" d�.6� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool �perator(s) and attach a copy of the certificatxon 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 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 Sarritary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIlb�FCH 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 att��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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# �,ICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 INN $50 CAMP $50 _SWIIvIIvIIl1GPOOL$75ea. LODGE $50 TRAII,ER PARK $50 WHIIZLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQtTII2ED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS �150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQLJIRED FEE PERMIT# LICENSE REQi7IRED FEE PERMIT# LICENSE REQtJIRED FEE PERNIIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 / <25,OOQsq.ft. $75 ��`'�� _FROZENDESSERT $35 / TOBACCO $25 � r Z-�O NAME CHANGE: $10 AMOUNT DUE _ $ /Od. Q O , "•'�*•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 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 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 RESPONSIBII.ITY TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 3l, 2005. SEASONAL ESTABLIS�-�IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COT�IlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be 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 ar 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 Depa.rtment 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. _ ___ �ROZEPI-DESSERTS: _ ______ ___ Frozen desserts must be tested on a monthly basis 6y 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: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmern is prohibited. DATE: d � SIGNATURE: ��,`� �I�I��,,g�,N,Y PR1NT NAME&TITLE: �A`C��R,�G� �'iC 1C�P��..t�n �C��.2, �� /Lvc) 09/28/OS ... � . . . � ' �� 'he Commonwealth of Massachusetxs -._--� _��__>__ = Department of Induserial Accidents � � _ = N�riMrwW�M�s ` -_ =_- 60o w��n s�� Froor < _ . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT N UMBER: #06-026 FEE: $25.00 This is to ce�tify that Christy Mihos/C1Lrist�' os f Cane Cod d�h/a Christ�'s#609 441 Roi�te 28,West Yarm�iith MA IS HEREBY GRANTED A LICENSE For �AI F ANI�DT�TRTRIJTInN OF TOBACCO PROI?UCTS AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. e�p� ei�s��ieani-t�i��gfor�ity� with Artic�l�e VI of the Sanikta��Code of The Commonwealth of Massachusetts,and e s sooner s ended or revo February 2.2006 BOARD OF HEALTH: Q �. �oh�t�s,/��-� � ��s�, R.�., v�e�� R�d�t�. 1��, Lt�k /��ii�ck til�$�` i4�us�'�iee�r�r�c, R.N. � ruce G. Murphy,M . ., H Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMTI'TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #06-Q34 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Christy Mihos/Christy's of Cape Cod, 441 Route 28, West Yarmouth,MA Whose place of business is: ChristX's#609 Type of business: Retail Food Service less than 25 000 sc�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2006 BOARD OF HEALTH: B _`?S. ,/�l.-`n•, ' a��st�, ��v.'�`�, v� e�� R�t� a�, e1� ��tilc`n�� , Februa�2,2006 ruce G. Murphy, , .5.,CHO Director of Health ��,,�r�� (+�t,Q � ��' ._ _ .�� F � A. U T �t�'^ -M �`'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 " MATTACHE qs" '� Zelephone (508) 398-2231,Ext 241 — F� (508) 760-34`72 f � ��9VOFATE0�6'f'� „ . .. , .. .. . . �..�... �. .. . t B OAItD OF HEALTH � � � . To: Yarmouth Boazd of Health Permit Holders } 4 k-;_ From: David D. Flaherty Jr., R.S. ;��r Health Inspector � Town of Yarmouth Re: Federal Tax ID Number �ate: �arch 22, 2005 T'he Massachusetts Department of Revenue is now requiring that we fiirnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federa.l Employer ldentification Number(FEIN}otherwise known as your"Tax ID Number". This is purely for administrative purposes only. So� businesses use the owner's Social Security Number (SSN} for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to ca11. 'The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is(508)39°-2231,ext. 241. Establishment: ��i.�bfi�S �60�1 (r�EIN�r SSN: � � Location Address: �� fi� ln�- t�U-r� Signature: `�a�� 141h�'�,.•-.� Print: `��R �C� i��e,o W r� Tit le: ��(2.t,c�.,�,i.�e 10', � ,;, �� Printedon � ( Recxeled �` P� �'. � of_YaR �'I,�� CIiYtJ 5'Rt S� �/y f R-r�28 � d:_�o TOWN OF YARMOUTH BOAR�-,Q,I+'HEALTH �--�--�� -- -.�_A..� � -'� APPLICATION FO � E �E �I�IIT- 2005 ' � �� _. .,� :� � � h * Please complete form and attach all n�ces ' documents by Decemb r 31, Z�0#. � ��'� Failure to do so will result in the return of your application pac t.HEALTH DEF'�. NAME OF ESTABLISHMENT: G TEL. # LOCATION ADDRESS: M � a.t� MAILING ADDRESS: I o � OWNER/CORPORATION NAME: Nl` o � - MANAGER'S NAME: �ev�n�fil� r,,w��,(� TEL. # .�D$- �� i� �.,nvG aDnx�ss: 1 oS Pb.�u�.� sta.e�- l�u li,�,�� 9 az�o J P40L 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. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food 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 cogies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. FER�OA��I�F C�4RfiE: - ------- - --- -- _ _ _ ___ _ . . __ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich Maneuver on the premises at 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. l. 2. 3. 4. RESTAUR�iNT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE P�RMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 _CABIN $50 MOTEL $S0 INN $50 CAMP $50 SWIlvIlvIIl1G POOL$75ea. LODGE $50 TRAII,ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LIGENSE REQUII2ED FEE PERMIT# LICENSE REQUIlZED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FFE PERMIT# _�50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 �Q5,000 sq.ft. $75 D��O� rFROZEN DESSERT $35 / TOBACCO $25 � �O{ NAME CHANGE: $10 AMOUNT DUE _ $ /00.00 •""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" y.'- ? , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not ha,ve a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: j YES v' 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, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL REN4VATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO CONA�NCEMENT. 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 ADVIS�RY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY• Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours pnor to the catered event. Thses forms can be 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: i i �I6 I��fi SIGNATURE: �'c�.� ,��li Q��_, PRINT NAME& TITLE: P�� eUw�l �x�cc��i.�e ✓�ce. Po.sicf� 10/22/04 �� The Commonwealth of Mwssachusetts `=�..�__-=_-_� �� _ = Departinent of Industrial Accidents � -_ __= M�'1N�Mi� - - __= 6�t1 Washington Stree� 7`�`Floor _�,.�` Boston,Mass. 02111 , Workera'Com�aaho'Ies�agee Affida leetr�exi a . ,., ...r .>,. ,. � Cu , .k, �. . . .,. „ . y �„ *,i § '� +��,?' r� -�'.i.. � � �az,��,�.� ��;,:.�r'�s�. ..:; �R�fi�� o.� �.�e, � 1#6o�i . a�s: ��I �NI� ��R.�t- �ih+ In�. VCtf 1�►'l0� s�te• ��1 zin• ��3 ohane# ��f- ��'f- 214g avork site location(fnll addressl: p �am a homeo„�r performing all Wo�m,�f rro;ect T,�pe: p xew ca�sh„�a�r,pRe�n«k� ❑ I am a sole 'etar and have no ame wo ' in any c;a . ' ❑Buil ' Additioa ... . , ;... , � . � [� I am an employer providing wa�kers'compensatio�fa�my employces wc�rking on this job. � -� �,c� C'o� � �t L _ _ __ _ �� In�.��.a.� � _ �s , l o S �Pl��sa,,,�� Sf-rcQe� , _.,_. �: ��►c�n�n� d�l� 0 6 0l ��• ,SbB- 33�- O y o0 er DD U ❑ I am a sole p�opri�or,geserai eoatractor,or bomeo��(czrde o�)and have hited ihe contractors listed below who have tbe following workers'compensation polices: �: �: dtr: oiwrc�k• � �: c3_�: ��. � . . .., �. � ,�� . FaBm^e a xeee ow�ra�e as reqd�+ed�ader Sec�foa 2SA ef MGL 1S2 aa le�d a tYe��f criwi�l peaNia�'a��p a t1,3M.N aidl� one yeus'Imprbonmeat a��as civ/pemdties in the fsr�of a STOI'WORK ORDER a�d a IIae etS160.M a day�t me. 1 a�dastagd tlut a apy�f tl�ie�ale�mt my be forwardM�s Hc Ofice of Ime�af t6e DIA for teverage verUkttls�. I ro hehby cer(ify rt�der the pat�ees aw�pe��r(fies of perjr�ry dYet tlie iwforanadon provlded aboNe£s d�re awd rnrr+�rt s�� P�-�.le. M£I�e�:u..y �n «I�b1�4 Prim name a�T Q I G� r•I�/le,c�W N1 Phone# �" �J��' O�IQc� effiiciai ax anly do aot�vrke Ia this area t9 be cempkted by c�Y er 1.wn e�Cial eity ar tswn: permif/�ccase# �� ❑c�Cck if imme�aie re.apeese is iequired Q�Bsard ❑Sdxtan s O�oe �P�*s�: ph°ae#' ��t TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OFERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-019 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Christy Mihos/Christy's of Cape Cod, 441 Route 28, West Yarmouth, MA Whose place of business is: Chris 's of Cat�e Cod #609 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l. 2005 BOARD oF HEALTH: Besr�r,�srs`h. !�'o�,/1�1`?S. • ��tir��tt, v�e�� R�� e�, e� �F� �� R.N. �4�!�'��,��, R.N. Janua�y 1.2005 ruce G. urphy, ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-015 FEE: $25.00 This is to Certify that Ch ' Miho�/ ri tv's c�f Ga�e Cod d/b/a(".hrictv'S c�f Ga�e Cod#609 441 Rn�rt . .8, Wect Yarm�uth MA IS HEREBY GRANTED A LICENSE For SAT,E AN7�DTSTRTRITTTON OF TOBAC:C'n PRnnTTC`T _ AS PER TI�YARMOUTH BOARD OF HEALTH TOBAC O RE iTLATION Thisl�e�it is��t�i�i��or�'tv with Article VI of the S �y Code of The Commonwealth of Massachusetts,and eap es s i e�s sooner suspended or reoked. J�,�i i,Zoos Boax�oF�al.�rx: Q��. ��,i119.`h., • p�� v�e�� RaG�t�. B�, Gl�k � s�, �.�v. �v�r��, R.�v. Bruce G.Murp y,MP ., �H Director of Health e `" �2�3�� ._?!CQL C � f�YA �� .r_R o TOWN OF YARMOUTH ,+�F ��.ALT � ��7 �7 (�`� �': ''�� APPLICATION FOR LIC l'� T' -'200 �: .!� �` • DEC 0 � �� •... ...� ��, � * Please complete form and attach all necessaty documents by Dece b 2,D03 ` Failure to do so will result in the return of your application p ��'-. `- �--N�u�----� N ' � i- C T N ADDRESS: 4 ' � ' o �fi WNE C T N A �t ' A ER' NAME: I� T MAILING ADDRESS: Pt�s PI�t,,�.u,fi �`i' �cc,�„v,,n,>� Mt� v2.L�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated Pacl O�e.atcr(s) a.rd attaci.a co}�y�f.h:, certificc.'�ic.3 to t�_is f�3r�n. 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 wilt 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. _ - - -- - -_ _ __ _ __ _ - - ------- PERSON IN CHARUE: _ _ — - --- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIMMING POOL$75ea. LODGE $50 TRAILER PARK S50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L(CGNSE REQUIRED FEE PGRMIT# L[CENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINEN"CAL �30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQtIIRED FEE PERMIT# LICGNSE REQ111RED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VI;NDING-FOOD $20 �<25,000 sq.ft. $75 �b�'�3�' _FR07EN DGSSfiR"I' $35 �TOliACCO S25 �� jVAME CHANGE: $10 AMOUNT DUE _ $ (�Q .�p **k**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 of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtTRN 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 S�ASON. 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 RFGULATION� POOLS POOL OPEl�1ING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. 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. FRO�E��?�:��'��; ____ _ 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 FES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. QUTDOOR COO iNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: i�.,I3I�3 SIGNATURE: `��, �� PRINTNAME& TITLE: _ Pc�R,+�e,,�R. �IG��pw� �c �L,:�",`,,0 1/,,�,�, �j,�;,,�� 10/22/03 � � � The Commonwealth ojMassuchusetts � � Department oj lndustrial,-1 ccidents o Of!!ce o/l�ves�lostliis 600 Washington Street ' �� Bnston, Mass. 02111 �'~ '��y W'orkers' Compensation Insurance Affidavit ��nlicant intormation: P►easeYR�'T'Ted.'wa nam�� .V1�61 VIS DQ- ��4�.�.- l t�L �0�'1 � —_-- location• �'�'�'� Vr:G.�,u� �� c�c� ��. ��-(�� Qhonea .�bK� �3�- 3cyx � I am a homecwner err�rmin,all w�ork myself. � I am a sole proprietor��,', ha�e no one ��orking in anv capacit�� I am an empdoyer pro�i�ins w�orkers' compensa[ion for my�empioyees w�orking on this job. c9m�an}' name• �QI.S�t,u� GQ V(,�.(�L ll.�� f�L� ed d ress �;!9� (I�,B.4C.t�rvt �11(�ee.G tiC•• �-iC.�.v�J1ISi i�'1� (7oL(7U1 nhone a• '�'k � �3�- D�j'D!� insurance co. �l•![2.. ��6C�a,C. �Ca�.J,B �cr�'� ('b�, policy# f�''1(4—l�t�c � I am a sole proprietor. ;eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu��in: ��orker ;ompensation polices: s4m�v name• address� citv'• nhone I!• insurancc co. Rolicv# eomt�anv name• a�d ress• �: ehoee i1• insurance co. poliev�f a Failure to sccure coveraee as required uader Secnoo 25A of MGL 1S2 n�iad to the iepaitioe of erioi�a!peaaltla of a O�e ap to 51,500.00 a�d/or one years'imprisonment as w�eU a�eivil pendtla io the torm of a STOP WORK ORDER aed a Aae of 5100.00 a day a=aiost ma t a�dersta�d thit a copy of tha statement may be fonvarded to tht OtTiee of Inve�tig�tiom of t6e DiA fa eoven`e verifieatfo�. /do hrreby cerrijj•under the porns and p�nalties of pery'ury that!ht injo►n�ation provided above is true and cnriect Signature 'L�� ICN.c_�„�v Date �;c�"� � Print name Q�TR,�� C:��(�,t�l��l Phonel� `��Fl" �-�1' (7�idC�' .- o(Ticial use onl� do not�rite in this area to bt tompleted by citv or fowa oAleial city or town: YARMOIITQ _ permi�/liceeee M �'1Building Dcpartmeot �Lieensiog Board �check if immediate response is required 261 �Seleetmtn'�OtTiet (508) 398�?231 eat. �HealtADepartmeet contac[person: phone p•_ _,_ _ nOther .. � ��,. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-032 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Christy Mihos/Christy's of Cape Cod, 441 Route 28, West Yarmouth, MA Whose place of business is: Christy's of Cane Cod #609 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2004 BOARD OF HEALTH: Best�ci�s�S. l�'a+�dorz, /6�_`h. ' p�� v��.,� - Ro�t� B� G'le� �.� �, R.N. January 29,2004 ruce G.Murphy,MPH, ., O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #04-023 FEE: $25.00 This is to certify that Christy Mihos/Christv's of Cane Cod d/b/a Christy's of Cane Cod #609 441 R�ute 28, West Yarm�iith, MA IS HEREBY GRANTED A LICENSE For SAT.F AT�Tn DTSTRTF3iTTinN nF TnBAC:C:O PRn1�iTCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATIQN. This.�er$it is�anrt�i��c8r�►forn��iei�s��icl��oi ean�tarv Code of The Commonwealth of Massachusetts,and ed January 29,2004 BOARD OF��ALTH: Be�r�tist�. �'t�o�c, /��., " /��1c.�` e�uirol�, ?/rce G��+c R�de�t�. B3ouat, G''le�i� � s�, a.n�. . Bruce . Murp ,MP D'uector of Health ;, .� , G/fiQ(SZ?r_� ,. . �_-. �F;�R.� TOWN OF YARMOUTH BOARD OF HF,�1��.�'['H : Uu � � r� � r� `J ' a �� 3 - -�� APPLICATION FOR LICENSE/PE �'I'-200 ' � .�f t�e�. Y: ,,s � `�° ��'�� ;� r��u�. (��. * Please complete form and attach all necessary �ments by Decem�ber'31�,� _ , � ;�-�� Failure to do so will result in the return o _.��-ur application packeY. -.-'�`� ` �_=`�" �IAME OF ESTABLISHMENT• Chr i s t�' G n f c�a�LP,_C.n_� �ti n a TEL # r�.g Q ��s;g g LOCATION ADDRESS• d a� �,V[,a i n c+-,-ot� y�, g.�.�.�Pa�� MAILING ADDRFSS• � n� ni o��n+- ��-�.e��}s, �+��--��^' QWNER/CORPORATION NAME•r�� es,'-E��}s��-eF �.� ^e� MANAGER'S NAME• Kenneth Cam� 11P TEL. # _50�-771 -�1 A8 MAILINGADDRESS' � n� P1Paaant ct-,-Aot� uT��„}s.,—�4as A�6A1 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Qp�rator(s) and attac�t a��pS�of the ce�if;cation�o ti►is fv:r1. 1. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 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 establis6ment. 1. 2• _- P�R��IV iN L`ri�licCir. _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4• RE�TA�IRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERM[T# I.ICENSE REQUIRI:D FEi; PERMIT# LICENSG REQUIRGD FEE PERMIT# �&� P�gp _CABIN $50 _ _MOTEL $50 INN $50 _CAMP $50 ,_SWIMMING POOL$75ea. LODGE $50 ,'1`RA[LER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# LICENSE R�QUIRED FEE PERMIT# 0-]00 SEATS $75 _CONTINENTAL $30 �NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE• ' LiCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>Z5,000 sq.ft. $200 _VENDING-FOOD $ZO J <25,000 sq.ft. $75 �OJ?'"�IO _FROZEN DF,SSF,RT $35 �TODACCO . � ��3"d6? NAME CHANGE: $10 AMOUNT DUE _ $ /OD.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**""* T �A 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 OR WORKER'S COMP. AFFTDAVIT 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 l to December 31. IT IS YOUR RESPONSIBiLITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENO�ATIONS 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, totai 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 CO�TSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ,�ATERING 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. F�tOZEN DESSERTS: � � T T .. 4l. �'T'f)Z2I'i t�c�S�T'tS riTYt��et� �II�TT'iBll'�l'iiy�as�s by a �tate cz�if;�d i1�'i. i�S�YCSi`i�iS iii�Si�3�5�13�t��il� i i�a�ui 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 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,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE:�` I��i`'�, SIGNATURE: ��P�cJI,Z I��I��, � 4 PRINT NAME& TITLE: Patrick McKeown�Fxec �t-i vP v; �e p,-o�; �ao„+- 10/18/�2 '' ` � The Commonwealth ojMassachasetts � � Department ojlndustrial.-lccidents o OJ1Ice oll�stJostliis ; 600 Washington Street � : Boston. Mass. 02111 ��'" "•y W'orkers' Compensation l�surance Affidavit Annlicant informallon: PleasepRiNTTe�'}� n�m�� Chrlsty' s nf CanP C'nrl �tinq - � - lucation: 4d1 Mai n StrPAi- �it� W _.Yaxmoutl, phoneq �-A�7�, �, �� I am a homecwner pert�rming ail w�ork myself. � I am a sole proprieror�:-� ha�e no one��orkin: in am� capacin� � I am an emplQ�er proti�dingµ�orkers' compensa[ion for my employ�ees w•orkins on_this job. comPanv name: E��!9 �f---ErttZ9e—tC . - address: 1 (1S P�CaCaFI� ctr��t� •�a-��-sT�� A�6�^1 r r ��t?.; Hyannis, Ma, nhonea: 508-771 -0900 �sur�nceco Ma R ail MPrr�hantg ��rkor� � �e�,P oolicy# 1A��n� � I am a sole proprietor. generai contractor, or homeowner(circle onel and ha��e hired the contractors listed below ��ho ha�e the follu��in� ��orkzr_ ,ompensation polices: sompanv name• address• riry• �hOnt M• insur�ncc co Qolicv# com�anv name• __ __ - - -- _ --- . _ __ _ _. tdd ress• sjjy• nhene 1i: incnran��rn pp�n+� —- 1 Failure to secure coverage as requ�red under Secnon 2SA o(MGL 152 ae ind to t6e iopaidoa of erisiafl pesdtla of a O�e op to Sl¢00.00 a�d/or one yean'imprisonment a�w�ell a�civil penaitla io the form o(a STOP WORK ORDER aed a fiae of 5100.00 a day Kainst me. I a�dersta�d tlat a eopy of thy statement may be fonvarded to the 0lfiee ot Imestig�dom of t6e DIA for eovenge veritiado�. /do hrreby cenifj•under the pains and p�naltits ojpery'ury thot Iht info►mation provided abovt is tttte and cor►td Signature �c,Jl n�� !'1-I1�1�.-.� Date _l!T o�. Print name pgt,-; �ti pq,��e��,�� Phone M .- oRci�l use onl� do not�rite in this area to be completed by eiN or town otflcial city or town: Y�M�IITQ _ permitAieeose M I'18uiidiog Department �Liceasiog Board �cheek if immediate response i�rcquired 261 �Seieetmen's Olfiee �HealtD Department contact person: phone M;_ �508� 398�?231 eat. nOther .. . ..,,, TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-010 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Christy Mihos/Christy's of Cape Cod, 441 Route 28, West Yarmouth, MA Whose pla.ce of business is: Christy's of Cape Cod #609 Type of business: Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yarmouth _ __ Pernut expires: December 31, 2003 BOAtt�oF HE�.�: �a�rlsa�. �ellikat, eka.ar.�ca.�c . _ iiece ,�odart� �'araac�c, � , , �at3uek'I�cZ�auxot� r'�ele.i.S�fa.k, ,�.'�l. November 29 ,2002 Bruce G.Mutph , RS.,CHO Director of H THE COMMONWEALTH OF MASSACHUSETTS TOWN O�'YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-007 FEE: $25.00 �is is to certiry that Christv Mihos/Christy's of Ca.pe Cod d/b/a Cliristy's of Cane Cod#609 441 Route 28 West Yarxnouth,MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS # : - ' � AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This. ermit is an di �ty with Article V I of the San�y Code of The Commonw�alth of Massachusetts,and exp�es Dece�ier�1.�Ot��e§s sooner suspended or revo�ced. November 29 ,2002 BOARD OF HEALTH: (�.`�. i�ellu�i, (�xct�c �'e.ileunt.r D. G�iando�c, 711.�., `1/iee �a6ar•t�, b'naar.r, � �a�rtc+��D� � S •�l. ruce G.M y, . ., O Director of Health � �� C(+R-�s i�s #,6oq + �, TOWN OF YARMOUTH BOARD OF HEALTH . APPLICATION FOR LICENSE/PERMIT -2002 Gi ;�.«� �` �a ;, ':�'"�"kk-..�, T�_w, � k'�'� : * Please complete form and attach all necessary documents by December 31, 2001. Fail e t��1�sb� v�i1�4��ult '' the return of your application packet. f� �I07 A'/9�, o� F-fEALTd-i L��:f�';", NAME OF ESTABLISHMENT: ('h r i �t�� f' ('a�,�_(',n rl ,.�,,�.h n;� TEL. # � o_�� T.(�('ATION ADDRESS• 4��1 r�`iain Street '�'d. Yarmouth MAILING ADDRESS: 105 Pleasant Street, H annis, l�:a. 02601 OWNER/CORPORATION NAME• �hristy T';'i1�10S Chrzsty' s of Cape Cod LLC. MANAGER'S NAME• T<_enneth C!�nille TEL. # 508-7'71-0900 MAILINGADDRESS• 105 Pleasa.nt St. , HVannis, �'Ia. 02601 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 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• PERSON tIV CHA�GE: 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 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• 3. 4. RESTAURANT SEATING: TOTAL# pFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 INN $50 _CAMP $50 _SWIMMING POOL$SOea. LODGE $50 TRAILER PAItK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 R�TAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TOBACCO $20 I <25,000 sq.ft. $75 0��63d' �TOBACCO $20 ��fo _<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35 NAME CHANGE: $io AMOUNT DUE _ $ q S.O p *****PLEASE TURN OVER A1�TD COMPLETE OTHER SIDE OF FORM***** D�C, � ' . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license ar 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��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS 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 outdoar 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. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DAT'E: /� �z� t�> SIGNATURE: ��.,�,�. I�`��,,,._ PRINT NAME& TITLE: Ratrick i�,�!c'-�.eown/ T��ecutive �Tice President 09/11/Ol � ' . � The Commonwealth ojMossachusetts � � Department vf Industrial,-iccidents o Olflce a1l�stlosd'ris 600 Washington Street ' ` Bnston. lVfass. 02111 . �'" "�y V4'orkers' Compensation lnsurance Affidavit Annlicant information: PleasepRiNT'Te�."i.i� nam� Chr'isty' s af Cape Cod ;;~ 609 location� 4!I-1 ��'Iain �treet �,;tiT. Yarrnouth J0�-'?'�1--319�{ �� ohone� � I am a homeoµner pert�rming ail work myself. � I am a sole proprieror �-� h��e no one ��orkin� in am• capacit�� I am an emplo�er pro��dins w�orkers' compensation for mv employ�ees w•orkine on this job. . l�� ._, U?T' ._. V-!r _ J��.\ ^,. _ _ comnan�• name: � _ address: _ _ _ . _ : �: - ,::. . cit��: , :". _ : - phone t1: " -. insur:►nceco -=� ^�i��,_'��s ''��Or'r�21^S' �0��' ��,# 1��0-01 � l am a sole proprietor. _enerai contractor. or homeowner(circle onel and ha��e hired the contractors listed belo� �►ho ha�e the follu��in_ ��orker �ompensation polices: som�anv name• address• city: �hone�• insur�ncc co Qolic}•# companv name• — _ __ __ _-- _ _ _ _ __ _- - -- — . z�d ress _ tjiy: nhoee M• insurancsso �y�f - � Failure to secure coverage as required uoder Secnon 2SA of MGL 1S2 na Ind to tbe iopaitioa ottrioi�al pesdtla of a O�e ap to 51�00.00 a�d/or one yean'imprisonment a�w•ell a�eivi)penaltiee in the form of�STOP WORK ORDER aod a line of 5100.00 a day a�aiost ma I a�dersta�d tbst a topy of thie statement mav be forw�rded to the OfTice of Invatigadom of tbt DIA for eoveraae veriBatfo�. 1 do hrreby cerrij}�under rhe poins and penalties ojperjury thet t6e rnfornration p�ovidtd abovt is ttue and evned Signaturc �:.�l�t�e /�/�/��Z� Date //�,�G�O/ Print name Patrick �:�c?,eovan Pt,one� �08-7'71-Oq00 .. ofTicial use only do not..rite in this�rea to be completed by ciN o�town oflleial ciry or town: Y�M�IITQ _ permiNicense M n8uiiding Departmeot �Liceasiog Board � check if immediate respoose ie required 261 �Selectmen'�OlTiee �Healt6 Department cont�ct person: phoneM;_ (508) 398�2231 ext. nOther / �:� TOWN OF YARMOUTH BOARD OF HEALTA PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-032 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: hris Mih�s/Christr't�f a=e Cod,y�� ddl AAain cr.�PPt/Rn»tP 28, Wes Y rmo � h_ 1V�A Whose place of business is: Christv's of Ca�e Cod #609 Type of business: Retail Food Service less than 25 000 sauare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2002 BOARD OF HEAI.TH: elcanfea� Z�i. C�xa�c �e.r�a�rt.c D. G�c°'ado.t, �?�.. ?/u:e ,�o6�rt� �r.otv�. L�fe�rk �a�ek�er�ot� �feeewc S�, ,�?Z April 17 2002 ruce G.Murphy,MP ,R .,CHO THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-026 FEE: $20.00 This is to Certify that Christ�Mihos/Christv's of Cape Cod.LLC d/b/a Christy's of Cape Cod#609 441 Main Street/Raute 28,West Yarmouth,MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. ��ri1 �� ,aoo2 Bo�oF��.`rt-�: L'e�anlea�f. �e�, Gkavr�ra.� �e.t�D. C%ando.,c. 7fL.D.. �J�ee ,�o6�tt� �aaur.a, L� �a�uck�e�uxat� `�fe� S�i. �� . • Director of He lth � � - , � F � � � b p � � TOWN OF YARMOUTH BOARD�F�-�IE;AI.TH . �' AEC Z Q ZOOO APPLICATION FOR LICENSE/P �� T?;� ` `� ` ��G HERLTH DEP �- �:� �`� �� T * Please complete form and atta.ch all necessary documents by Decem r 31, 2000. F"ailure to do so will resu t m the return of your application packet. ------------------------------------------------------------------------------------------------------------------------------------------- NAME OF ESTABLISHMENT: Christy's of Ca�e Cod 4�609 �L. # 508-771-3198 LOCATION ADDRESS: 441 Main Street, w. Yarmouth, Ma. MAILING ADDRESS: 105 Pleasant Street, Hyannis, Ma. 02601 QWN��/CORPORATION AMEChristy Mihos/ Christy's of Cape Cod, LLC. MANAGER'S NAME: Denny Camille TEL. # 0 -��.-O�b MAILINGADDRESS: 105 Pleasant Street, Hyannis, Ma. �b --------------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICA'�ONS: The poal supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)arid attach a capy 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 Resuscita.tion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past yeara' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Man�uver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your plaee of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMQKING SEATS: TOTAL# ------------�---------- -----�---------------<--------- ------------- - - - — _ __ ___- -- __ _ OFFICE USE ONLY 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. �OOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAI., $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 / TOBACCO $20 �62 �<25,000 sq.ft. $75 �Q 1-0 33 FROZEN DESSERT $35 _>25,000 sq.ft. $200 �1AME CHANGE: $10 AMOUNT DUE _ $ 9 S•D 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** .. . . .., .. � h �. ....... .. ..�.... j ..«.. .. . . ` � � i � ADMINISTRATION Under��iapte� 1�32,.Se�tion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of ai�y 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:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEl�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opemng, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establishments which sell or serve ready-to-eat, raw or undercooked animal products are required to have consumer advisories. �ATERING 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. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING; Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment is prohibited. DATE:� v SIGNATURE: �� irl�,r.� PR1NT NAME& TITLE: pf9�lefC� /�C�e�n .�iCe�. j/.� 11/16/00 � . . . . � _ The Commonwealth of Massachusetts v W Department ojlndustrial�ccidents ^ o OfJIC00J/avesl/oldllf � 600 Washington Street ,�M �•� B�ston, Mass. 02111 '�� Workers' Compensation Insurance Affidavit Annlicant information: PfeasePRllaTT�"t� namr: Christy�s o� C ape Cod �1�609 location: 441 Main Street �� W. Yarmouth, NTa. phone# 508-771-3198 � I am a homeowner pertorming all work my�self, � I am a sole proprietor�r,� ha�e no one��orkine in anv capacit}� � I am an emplo��er pro�i�ing workers' compensation for my employees working on this job. compan�• name: Christy�s of Cape Cod; LLC address• 105 Pleasant Street cit3: Hyanni,s, I�a. Qhoneq: 508-771-0900 insurance co. Mass. Retail Merehants EJorkers' Comn. policy# 196�-(l l � I am a sole proprietor. ;eneral contractor,or homeowner(cire[e onel and ha��e hired the contractors listed below� «ho ha�e the follo��in� ��orker' �ompensation polices: companv name• address• c�n_ phone q• insur�ncc co ,policy k som a�n�name• ___ _- _ __ _ address• -- ciri• phone#• incnr9nr�cn_ ,Aoiity# Failure to secure coverage as required unde�Secaoo 25A of MGL 1S2 a�lead to tbe iopaidon oterisiad peaaltla ota ti�e op to S1.S00.00 a�d/or one yean'imprisonment aa w•ell aa civil penaltia io the form of a STOP WORK ORDER aod a Ifoe of 5100.00 a d�y at�io�t ma I a�denta�d that a copy of thH statement may be fonvarded to the ORce of Inve�tig�tiooe of the DIA for eovenge veri6estio�. /do hrreby cerrif}�under�he poins and penalties ojperjury thal the injormation provided abovt is tnre and eontd Signature i�� "r11f�Ju�� Date 1��1�/0� Print name t�R..�.G� Y'IC��L�r►n Phone�! S�D�" ��l- O'rlOc� ., olTicial use only do not w rite in this ares to be completed by tity or town olliei�l city or town: Y�M�IITQ _ permitAicense p nBuilding Department �Licensiog Board �check if immediate response i�required 261 �Selectmen's Of6ee (508) 398-a2231 ext. ❑H-alth Department contact person: phone tt;_ __ _ nOther �I�aH3o.�o�oa.�iQ ` ` `�i n aoru ��a , , ��, o �� '�� ' �� •��x•�� s� '��f� �f p3 �H.L"I�'�H d0 Q2IdOg I OOZ` I �Qa •paxona.�lo papuadsns iauoos ssai� I OOZ t£saQ�a�aQ sandxa pu�`s�asnqosssey�3o�Isannuocu�uo�ay,i,3o apo��iues a��o In aj�►��inn�iuuo3uo�uc pa�u�.r�st;iuuad�sit11, 'I�IOI �' O � g0 H 3 .L � .L � S � QO d O g .L 30 I.L g SI QN�' �03 �SI�I��I'I�'Q�.L��Ag�2i�H SI � nouu��satY1 SZ �no�aaa�S uT�Y�i itro 6 9#Po� a ��o � sr.�� e�q�p �-�-� po a �� s� suq �soqty� suu� ;E��a�o�s�siq,i, 00'OZ$ ��3 ZO-IO# ?I�gL�II1I�I.LIY�t?I�d H.L'I�'�H 30 (I2I�08 H.L110L�i2I�'�i 30 I�iAAO.L S.L.L�Sf1H��SS�'L1I 30 H,L'I�'�AA1�tOL1iL�t0� �H,L TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #O1-033 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: C'�tv Mih�s/ .hri� � '�of C'ane Cod, I I C',441 l��ain �tree /Ro � e 8, �xJest Yarm� �th, 1��A Whose place of business is:_ Christy's of Cape Cod #609 Type of business: Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d�11. �etred, ��ia�i�sra.a C�� f. �e��. `r/�ee �?��a;�u�a,a �'o�it� �nou�. C'� �i�lie`laee d '1' e� ' D. ' 711.D. . f,_ �. Februarv 13 ,2001 Bruce G. Murphy, H, ., CHO Director of Health C{1��31,�:.`? �L<OC{ � �:; TOWN 4F YARMOUTH BOARD OF HEAL��a , ; APPLICATION FOR LICENSE/PERMI'�-2�00 �''"''�` � � "''";� � ' �`� �. '` - � � i�' la_l_�� r� �.:'.-�. * Please cornplete form and attach a11 necessary documents by,Decer��e�1 1999. Failure so wi 1 result in the return of your application packet. :--� ��•�3a� �'^,�s �p�KM�� ----------------------------------------------------.---y�---------- -�' -S-Las_�� --------------- ��-------------------------------------� NA��_OF ESTABLISHMENT: Christ s TEL. # 508-771-3198 LOCATION ADDRESS: 1-Ffain treet, . armmuth�l�a.—�'Zb"7 MAILING ADDRESS: easant 5 r�'eet;�' yH annis, Fia: 'U"L6DT— OWNER/CO�PORATION NAME: ��'��'��yt�� ' -- -' MANAG R��.�ME: Kenny CAmille , TEL. # 5,g�� MAII.,ING ADDRESS: sd�-�rs-- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�aired by new State taw. 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 file at your ptace of business. 1. 2. 3, 4. HEIMLICH GERTIFICAT�.ONS: 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 Heatth Department will not use past years' records. You must provide new copies and maintain a file at yaur place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �TON-�SMDK.�TG S�ATS: TOTA��--_ __ _._ _ ___ _ __ ---------------------------------------•--------------------------------------*-----------------------------------------------------------------• OFFICE USE QNLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # B&B $50 _CABIN $50 INN ��0 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SV'V][MMIlVG POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 � TOBACCO $20 � �2 I <25,000 sq.ft. $75 �►�`�-Z� FROZEN DESSERT $35 � >25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ �►/�' """""PLEASE TiJRN dVER AND COMPLETE OTI�R SIDE OF FORM"""" � ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUAN�E OR RENEWAL OF ANY LICEN5E OR PERMIT TO OPERATE A BUSINESS*TF 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 COARP. 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 RESPONSIBII.ITY TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEM�NT. RENOVATIONS MAY REQUTRE A SITE PLAN. AI)DITIONAL REGULATIONS POOLS POOL OPENING: ALL SV'i�IlVINIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND'TI-�WATER TESTED FOR PSEUDOMONAS, TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE GERTIFIED LAB, PRIOR TO OPENII�tG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOl�IN GROUND SV�G POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TF�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMP4RARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT TI� HEALTH DEPARTMENT. FROZEN DE� S� ERTS.� FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN TI� SUSPENSION OR REVOCATION OF YOUR FROZEN DES SERT PERMIT UNTII,TI�ABOVE TERMS HAVE BEEN MET`.- --__ _ _ _ - - - _ - _� _ -- -- _ _ _ _ OLJTSIDE CAFES: OUTSIDE CAFES(i.e., OtTTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. QUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD SERVICE ESTABLIS�IlVIENT IS PROHIBITED. DATE: rl��9�I�i`7 SIGNATURE: n�� 0�'�'�;�.,�,` PRINT NAME& TITLE: j�c.f� j'✓�C--�t�c��. �CP.re��%,�. �/', 11/12/99 , � ' The Commonwealth of�Iassachusetts � � Department oJlndustrial,-lccidents � " o Of11C0 OJI��►eS�los�li/f + 600 Washington Street ' ` Mass. 02111 � Boston. �" '��y V4'orkers' Compensation Insurance Atfidavit Annlicant information: plessepRi}�'1'Ti•�,-hsr� namr� Christy's location: 441 Main Street, W Yarmouth , Ma 02673 �� WPS'r v mo � h, Ma 02683 phone� 508 771 3198 � I am a homeowner perturming all w�ork myself. � ( am a sole proprieror��,�, ha�e no one �.orkin� in anv capacity � I am an employer pro�iding workers' compensation for my empioy�ees w•orking on this job. comnan�• name: ��e e€ 6age—�ed3—��' 105 Pleasant Street .7ddress: Hy�annis, Ma. 508-7710900 tiri•• nhone t1• Travelers Property Casualt 7Pjub-518X637-4-99 insurance co. �oYVicy# � I am a sole proprietor. _enerai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follo��in� ��orker �ompensation polices: comoanv n�me• as�dress: ��n" ehone#• insur�ncc co. Qelic}•# comeanY name• address• �'� ohQee 11• insurance co. �Y* 1 Faiiure to sccure coverage�s�equ�red under Secnoo ISA o(MGL IS2 e��lad to the iopaitioe oterivi�ai pe�dffa of a Ooe op to 51.500.00 i�d/or one years'imprisonment a�w�ell a�eivil penaltie�io the torm o!a STOP WORK ORDER aad a tiae of 5100.00 t dar Kaintt ma I a�dertta�d tbat a copy of thi�statemen[may be fonvarded to the Ofiice of tnveatig�tiom of tAe DIA tor eoverage verifiutio�. /do hrreby certif}�under th�pains and prnaltits of perjury thm!ht injoinrotion providtd abovt is trtte and eoritet Signature r�� —N D� .: y Printname [cr.�Ri� iP'1�-K�+.�•n PhoneAt �,8" �3� ' f�CiC� .. o(Ticial usc onl. do not M�ite in this area to be completed by ciry or town otflcisl ciry or tow�n: Y�M�IIT� _ permitAicenu q n8uildiog Departmeot pLiceasieg Board �check if immediate response i�required 261 �Selectmen'�Otfice �HealtA Department contact person: phone N;_ �508� 398�2231 egt. nOther .. . ..,,: TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-29 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws,a permit is hereby granted to: C'.hristy Mih�s/C hrist;'s of C:ane �nci, T.T.C,441 Main S r . , We�t Yarm� ith, 11�A Whose place of business is: Christv's#609 Type of business: Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:��/. ,�g��, C'��,.�� oa�� ullivan� �� V�e l��irm.a Kobert� p�rown, (.,ferh �//�rielle�a�ol��i�-.�tooPe� � O�o��,� December 22 , 19 99 ruce G. Murphy,MP .S. O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-21 FEE: $20.00 This is to Certify that Christy Mihos/Christv's of Ca�e Cod LLC d/b/a Christy's#609 441 Main Street West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS _ AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. December 22 , 19 99 BOARD OF HEALTH: �c�///. .tel�, C�iai.man �oan� �ullivan� K.//•, Vice (�hairma►t �oberE.}. 9�rown� l�levh �a�rielle�a�ola�c�-.�tooPe� g , � l o [in tl1Ce . L1T� y, Director of Health � �h r�s�� c�'i - ._-� �.- _ ,.� � , �� TowN oF YA�ouTH so�Rn�a�x��,LT� ' G�3 C� � C� � M � D APPLICATION FOR LICEN5E/PERMIT}i9�� ,( p��; 1 1 1998 ��2�`'I * Please complete form and attach all necessary documents by December 3 l, 1998. Fail e�{.��'psRlt i the return of your application packet. ---------------E---�-I---------------------------;:--------------------------------------------------------#---------------__�-- Christy s of Cape Cod �F609 508-771-3198 LnrATION ADDRESS� �,��_rf�--�o-�9 � MAILING ADDRESS' � Mill Street, QWNER/CORPORATION NAN�'Chris tv P M�hn� ��.. .. t 1VLASTAGER'S NAME� r �'`�`=�$�s�€ SaPe Se�, ��6 I�e��e t-1��e TEL. # 508-771-3198 MAII,ING ADDRESS' ��•��.��s.�e�t,-�� 0263Q ----------------------------------------------------------------------------------------------------------------------------------------- POOL�ERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Poot Operator(�rand attach-a�py of the certifieatio�to this-€orm. 1. 2. Pool operators must list a minimum of two employees currerrtly certified in basic water safety, standard First Aid and Commuiuty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yau must provide new copies and maintain a t"ile at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ----------------------------------------_ __ _ OFF�CE USE O�TLY _ LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 MOTEL $50 SWIMNI]CNG POOL $SOea. WHIR.LPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NUN-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SE�tVIC� LICENSE REQUIRED FEE �ERNIIT# LICENSE REQUIRED FEE PERMIT# <50 sc�.ft. $45 � TOBACC4 $20 -2.2 -- - --- __—-_- _ __ - �<25,000 sq.ft. $75 � � -Z� FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHA.NGE: $10 AMOUNT DUE _ $�" """"�PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""*" ADMINISTRATION � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOLJTH IS NOW REQUIRED TO HOLD I5SI3ANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES P�iOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STA'�E WORKER'S COMPENSATION INSUR,ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMpUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DEGEMBER 31, 1998. SEASONAL ESTABLIS�-IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS T� ANY FOOD ESTABLISf�VV1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. t�DI�ITIONAL REGULATIONS __ POOLS __ __ _ __ _ POOL OPENING: ALL SVVIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR TI-� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND TI�WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVf1VI1VII�1G POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERIl*�G POLICY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-� HE�TH DEPARTMENT.-_- __ __ ___ -_ _ . - - - __ __ __ __ _ _ _ ____ FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERMIT UNTIL TF�ABOVE TERLVIS __ HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),MIJST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: � � OUTDOOR COOKING,PREPARATION, OR DISPLAY OF AI�.�F�Q-E}D P�ODUCT$Y A RETAII. OR FOOD SERVICE ESTABLIS�-IMENT IS PROHIBITED. ` . . _ . ._ _. ,, ,� �',,_;. �.:� �. e ` DATE: SIGNATURE: ��/� �� /��7� . '2 —� �� PRINT NAME& TITLE: .� x .�wr _ _ P ` � �� The Commonwealth of Mossachusetts � W Department ojlndustrtal,-t ccidents � ; 011lce of/erestlDsdiis � 600 Washington St�eet ' •` Bnston, Mass. 02111 �'" ��y W'orkers' Compensation Insurance Affidavit Anolicant information: P`(essePRINTTe�'bi� namr� location: �s� vhone � I am a homeowner pertormin�all work myself. � I am a sole proprietor�^,� ha�e no one ��orkin� in am�capacity _ _ -- � I am an employer pro�i�ing w�o��s'compensation far m� empf�-ers w•orking on this jflb. — _ Christy's of Cape Cod, LLC comnan�• name• address: 3 Mill Street ��t}.: Dennisport, Ma. 02639 ohone q: 508-760-1111 insur:►nce co. First Return Insurance,Company, Inc. policy# WC-100-0000002-1998A � I am a sole proprietor. general contracror, or homeowner(circ/e one/ and have hired the contractors listed below ��ho ha�e the follo«in� ��orker �ompensation polices: companv name: addresr ` c��: phone�• insurancc co. poli�}•# company name: - --_ _ _ _ __ __ address: _ .__ _ _ _ - c�i y: nhone t1• insurance co. p�y 1t Failure to secure coverage as required under Sectioo 25A o(�jIGL 152 eaa lad to t6e iopoeidon of triviad pt�altla of a 6�e op to 51�00.00 a�d/or one ynn'imprisonment as w�ell aa ei ' pe 1 m e fontfr of a STOP WORK ORDBR aod a liee of 5100.00 a day a=aiost ma I a�dersh�d t5at a copy of thh statement may nvag�d t t��tTie�of I�Gestigation�of t6t DU for eoven=e veritiatio�. �.� ,�"• �' �, <2 /do hrreby certij}�under he po' �'`e `�a!lie�of,�l�r'urx�tha�tht injornwtion providtd abovt is true and conec� � �� ,�� ' ,ca Signature `'°4 ,� Date �� - � � /' Print name �� g ��z� �`7 ! - � � ��C� Phone p .�'�'��r�� ,.�; .,�.� .. o(Ticial use onl� do not..rite in this area to be completed by ciry or town otTieial ciry or town: Y�M�DT� _ permiNiecnse p nBuildiog Department OLiceasiog Board �check if immediate response is required 261 ❑Selectmen's Otfiee (508) 398--2231 egt. �Healt6 Department contact person: phone M;_ __ _ nOther (.e.�isxd i�95 P1A1 . - : THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NIJMBER: 99-22 FEE: $20.00 This is to certify that ChristX P. Mihos/Christv's of Ca�e Cod, LLC d/b/a Christy's of Cape Cod #609 441 Main Street, West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31. 1999 unless sooner suspended or revoked. Januarv 19 , 19 99. BOARD OF HEALTH: Gc`/I/. �ef,�ee, ��i.airman �oaic� �allivan�/C.//.� Vice l..�irmaic Ko�erE J. �rounc� lrler� �abriel[e Jahofeh�-..l�tooPe� hagl 0' u�� • Tl1Ce . UTp y, •, Director of Health TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLI5HMENT PERNIIT NUMBER: 99-27 FEE: $75.00 In accordance with re�ations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section of the General Laws,a peimit is hereby granted to: Christv P. Mihos/(;hristv's� of Cane C�d„j,ji�,441 Main Street, West Yarmouth�MA Whose place of business is: Christd s of Ca�e Cod#609 Type of business: Retail Food Service less than 25 U00 sauare feet To operate a food establishment in: Town of Yarmouth Permit e�ires: December 3 L 1999 BOARD OF HEALTH:�d�/. �at��, C��.�� . � �oan (�. �allivan,K.i/•, VFce l��irman Ko�ert J. /�rown� l,lerh a�rielfe�a�Zo[��rf-�ooPee �'i/ichae oCo �f.in. � Januaiv 19 . 19 99 ruce G.Murphy,MPH,RS.,C Director of Health