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Home My WebLink AboutApplications, WC and Licenses ~ ` /��7l ��sr�;r �6ia �;'`��Y"1�s� TOWN OF YARMOUTH BOARD OF HEA��'H ".��<_ APPLICATION FOR LICENSE/PERN��T' �f�8 ��a " � � a Please com lete form and attach all necess doc ",��en�s-ii jR t � ember 31 �v j:±� � � `�;I;� * p �'Y ;� �'� , 2007. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: G�►�r� � � � C�G� L�� /Z TEL. # �6�- 790�'�� LOCATION�UDRESS: . /"JA/�tl Hd✓ g 02�73 MAILING ADDRESS: /DS� 0/flSkn��, ��'A-NN�S MA OZ�l� OWN�R NAM�:� �_l�r��l-ti /"f,ho� TAX ID (FEIN or SSNI• � CORPORATION NAME APPLICABLE): G1�►�ss �S p.� 6 G,GG• MANAGER'S NAME: o GAv2r� TEL. # S0� -�7/-d MAILING ADDRESS: . � W+f S' s�n�� /"l� 6ZLo/ �_ 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 eertifieations to this form. T�te I�eatth Dep�rtFneat will nat use past years' reeords. 'Yo� mt�st prov�de 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 Establislunents, 105 CMR 590.000. Please attaeh copies of eertification to this applieation. The Health Department witl not use past 3�e�rs'records. You must provide new copies and maintain a file at your establishment. 1. 2. P�RSOI�T IN��A�RGE: 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-chokuig proced`ures below and attach copies of employee certifications to this form. The I�ealth Department will not use past years' records. You must provide new copies and maintain a File at your place of business. 1. 2, 3• 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'vIIT� LICENSE REQUIRED FEE PER'1rIlT� LICENSE REQL?IRED FEE PERVIIT= _B&B S50 _CABIIv' S50 _MOTEL S50 _INN S50 _CA:�IP S�0 !S�'b'I'_bIVIIiVGPOOLS75ea. _LODGE SSQ _TR4ILER PARK S 100 `t'HIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LICENSE REQL�IRED FEE PER'141T� LICENSE REQL IRED FEE PER'YiIT= _0.100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25 _>100 SEATS S150 _CO:�rL'4fON VIC. S50 ��`H(�LESALE 575 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMIT� LICENSE REQL?IRED FEE PERVIIT» LICENSE REQti IRED FEE PER�fIT- _<50 sq.ft. S45 T>35,000 sq.ft. S200 VENDI'vG-FOOD S20 �<25,000 sq.ft. S75 Og' _FROZEN DESSERT S35 �TOBACCO S50 ��8-�n8 vA:�c�vcE: sio AMOUNT DUE _ $ /d S,o0 '�*"**PLEASE TtiR\OVER�\D CO�ZI'LETE OTHER SIDE OF FOR�i*"x** 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 germit 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, QR CERT. OF INSURANCE ATTACHED 1/ OR � / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/ Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: / YES 1/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiJPANCY: 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 htatel us�. Transient accupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Enc�osed Motel Census must be completed and returned with tnis app�icat�on. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days prior to opening. POOL WATER TESTII�TG: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cosk�ng,preparatior�,or display of any food groduct by a reta�l or food s��vice�stab�sh�n�nt�s prahibited. NOTICE:Permits run annually from January l to December 31. IT IS YOUR RESPONSIBII.ITY TO RETLTRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: C/ �� SIGNATURE: G�/`� FRINT NAME&T'ITLE: ��1�e� � ��''"'' �� ' �� lo?o o� . ' � The Cominonwealth of Massachusetts Departinent of Industrial Accidents > �'1�� 60(! Washington Street, 7`"'Floor Boston,Mass. 02111 Workers'Compenaatioe I�saraace ASdavir Bailding/Plumbi�g/EleMrical Coatractors �= �eare PRiIV'1'Ie�iMs name: �G1�'�5�'/5 p� c t� �DO� �� "� �� address: �'7 G . /"'14/N�'� 5itv h/1S� �G/M�t/7h state� �/.�- zio• dLro`J� phoae# ��' �90��U�� work site lceation(fnll address): ❑ I am a homeowner performing all work myseif. Project Type: ❑New Constructi��Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition (�I am an employer providing workers'compensation for my employees wo�lcing on this job. como�nvaame: . �Yr�i��s $'f� �� L6la( L-[-�..• _ _ _ _ �aa�- /�S' �/lr�sct...� rjf• y G��nS �!j D��O � e#: �(�'77/'O`�D� �- �f '- � �' � ol a0 sa/3G. !/�� , . . .�::�... .. ❑ I am a sole proprietor,geeeral coatraetor,or 6omeowner(cirde one)and have lured the contractars listed below who have the following workers'compe�sation polices: aummav�ame- address• citv �#. � � # .. ` . . . .... .'. . . . ... . � - .. . . .,�., � �� A '. ,"�:', k �`.::: �m�t�� l{S� �� . . .. ._.. . . .. ...... .. ... .. . .. .__._.__. � �1�j� # �'7��i��' ��.�'' .... .' . . , ..��. � . .. , , Fa�n�e bo xcme ovveraae as reqsired.ader 3utlon 2SA ef MGL is2 c�Iad a tYe h�itl.a of eri�loal pwaltla sf a 8�e q�a s1,S�f�.O�aad/or one ye�rs'imptbenment aa�r�eU as civi peaalUes in the for�of a STOI'WORK ORDER aed a Ase e[S10s.b a day aaaimt me. 1 aedmhad that a ceNy of trls sfatemeat may be fer�varded to tAe Omce of lnve�gaflaffi of the DIA for ceverage veNaealMa. I do fienby ctrhfy under tl i� peesftFes olPerjurf'tbet tAie i�fo��rratlow provlde�abowe fs due axd correct S'8nature�//Y � Date // /f D � Print name �C- , i Y. („�/'F"/�'�r/l�G �r Phone# ��— ��"Or9� 7'�ZL3 effiMial ax only do not wrke ia this area to 6e comp{eted by cHY or Mwn officiai city or te�vn: permiMicenx# �BoildiuE Dep�rtmen� ❑check if immedi�h n�ape�e is reqared ��a�� s O�ce contact pe[son: pho�#; ❑��t (��-�) �� 1 • ` � • `F:." ERS COMFII3SATIGN AI�Tr' F.,�IPLOYERS LIAL:CT�TY INSURANCE CE._RTI�IC�?.TE ' INF�RMATION PAGE ��,�4?A7, �,��F1YtFr��y ,:, � Producer: Agent�� 960 MA Retail Merchants WC Group Inc. Association Benefits Ins Agc;= T�c 10 British American Blvd. 529 Ma�n St Ste b05 Latham, NY 12110 Boston, MA 02129 (Carrier Code: 34355) �ertificate ��: �14000501361107 Prior Certificate �f: Q."_40005�13e1106 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: Eein: 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 listP� here: MA B. Employers Liability Coverage: Part I�ro of the certificate app�ies �� aor?_ in each state :.isted in ?tem 3.A. '?'Y�e limits of our liabili�;�� :.tnde_- Part '�'�.;0 3re� Bodily Injury by Accident $ 5U0.000 eacii a�ciden� Bodily Injury b�r Disease $_ 500.000 cer;::.�icate limit Bodily Injur�r by Disease �. 500 �0�__ ea�.� a��].t>�T2P. C. Other States Coverage: D. This certificate includes these endorsemei�ts and schedules: WCOOOOOOAf 04/92) 4�iC000113(O1/06 j � t��CU00406A(.�.r8i �)':�;�;^�O��hl�_��Ci/a�,` Y;r�O�?0],(04/�?/�? WC200302(G5/R6) WC2003U3B(07/99j 41C2��405 ;.�6/�1) ylC20060�(06/9�? 4. The contribution for this certificate will be determined by our Man�als of Rules, Classifications, Rates and Rating Plans. All information required� below is. subje�t 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 Minimum ContributiQn S 267.00 �xpensQ Constant:.� .OG WC 00 00 Oi A Issue Date: 12/28/2006 Gountersigr.ed by , , TOWN OF YARMOUTH BOARD OF HEALTH : PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-009 FEE: $75.00 �n 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: Christy's of Cape Cod LLC, 14 East Main Street, West Yarmouth, MA Whose place of business is: Christy's of C�e Cod#612 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, 2008 BOARD OF HEALTH: .`�Ee¢fL SK.[1',Pi, J`�i .,.11�., C',Rr.aur,�ruut C!Paviceea .�.9G�'�if�ex `lliee C'R�aeiKnurn J`�.8�ct 3.J`�3�Cotu�t, C'�exP � CZrixi C��ceerc�iacecrn, .12..N. November 27.2007 ruce G.Murphy,MP , .,CHO Director of Health THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF FIEALTH PERMIT NUMBEl�: #08-008 FEE: $50.00 This is to Certify that Christy's of Cane Cod LLC d/b/a Christy's of Cane Cod#612 - 14 F.ast Main Street, WeSt Yarmouth, MA IS HEREBY GRANTED A LICENSE For SAi,F. AND DTSTRTRiJTTnN OF TnBAC'C;O PRODI7('TS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION Tlus, e t is td c o �y with Article VI of the S t Code of The Commonwealth of Massachusetts,and exp�es�ece��1.�0(��un�e§s sooner suspended or revoke�c. November 27.2007 BOARD OF HEALTH: .`��C�ft 5�.�� ..lv.� ��i�t t�l�e4 .� `.��P��l�1Rld� �[C6 ��tt(rtt J?.�B�eXt .`"t.J3�u:curt, C'ee�e� (.Znxi ��ceer�a�m, ✓`�..iV. ce G.M hy,MP , . . H Director of Health � - �' Ca,�✓Z�a �%�Snls��iz �O`;aR�o TOWN OF YARMOUTH BOARD OF HEALT ��' 32 - -�� APPLICATION FOR LICENSE/PERMIT-2f1�i7�'� � � � � � M (� DD 0.� �-7 �, ., � ,.iS � �, * Please complete form and attach a11 necessary documeirts by Decemb 31N(��0� 8 2006 Failure to do so will result in the return ofyour��plication pack t.HEALTH DEPT. ;' NAME OF ESTABLIS�-IlVIENT: � .(-,,�;�-� �� - TEL. # ,�`(-�Q",�'7�j,��j LOCATION ADDRESS: "� � � f- , ?� MAII..ING ADDRESS: OWNER NAME:�; - S TAX ID (FEIN or SSNI� ��,[ � CORPORATION NAME(� PLICABLE): , ` � ,L,L.� MANAGER'S NAME:��,-�-} � La;YPX�-�I TEL. # �7 d�o?�rj MAILING ADDREss: l<�o��P l� a,sa nf- ,rt. f}T ►-,,`�,_� f}�� POOL CERTIFICATIONS: The poal supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. = 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 certifica.tions to this form. The Health Department will not use past years' recards. 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 emgloyee 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. T6e Health Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� 1. Z. PERSON IN CHARGE: _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of aperation. 1. 2, HEIlVILICH CER'I�ICATIONS: 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-cholcmg 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# O�FICE U5E ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _B&B $50 CABIN $50 MOTEL $50 INN $50 `CAMP $50 _SWIM1vIINGPOOL$75ea. _LODGE $50 TRAII,ERPARK $100 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PF,RMPf# LICENSE REQUIlZED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAII.SERVICE: —RESID.KTTCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 LQ5,000 sq.ft. $75 ��1� _FROZEN DE3SERT $35 / TOBACCO $50 a7�U/I NAME CHANGE: $10 AMOUNT DUE = S /Z S..o O **""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•""* D� " � 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 persan 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 taa�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 occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Dega.rtment prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to openuig. POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirnming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior ta the catered event. These forms can be obta.med 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 cookin�,pre�ar�tiQn,or display of an�food pro�iuct by a retail or food servi�� t�bl�e�n i i _i�t�. _____ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILI'I'I'TO RETiJRN TI-�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:�1 � � ` SIGNATURE:_�u%�.. ��!(,�� PRINT NAME&TITLE: r�'A-1�.� 1�'IG�v� l.%�� v,� /� ion�io6 r _ �ry � The Commonwealth of Massachusetts Department of Industirial Accidents > N�f/f�i�R 600 R'asl�isgton Street, �"`Floor Boston,Mas� OZlll _ wo��c��s i��a..�c-B� ��cooax� -Er c. ..�tl '?-- e .�;s;� - �� ,� �,�.,�,�� s� °�.� a� �y;: '= �'�. �qy -Y: i3 name• /�'V� �f`i��5 Q� � _...�p�� i v2., � address• `� �0�°�mdl� (� S�� itv w e�k 4 a�rn o�J 1h�1�. s�te: (�1 �( zio_ C7.�L. n�xxie# ,v-ri�S�.`��(�� '`7 work site locati�(fnll address)_ ❑ I am a homeowner performing all wark myseif. Project Type: ❑New C�stnicti��Reanodel I am a sole 'etar and have no�e w in an ca ❑Buil ' Addition . a _ _ . �[] I am an e�nployer providing workels'compensatio�fo�my employees wo�cing oaz this job. _ • 4 t _ � . _ �� C� � �� r.C a � 5-t- �T �—�—��-=�.+n-�l1 �T,..LL ' l�� nl�a�#: :�i O�� /� ' �V�U� - • � t o �d i �6 i I d� ❑ I am a sole praprietor,g�eral coatrnMr,or homeo�vaer(cirde o�)and have}vred ihe conir�ctois listed below who have the following workers'compensation polices: S�Y� �x.. �; ul�ose#c # e�mv me: �►d�• cltv: , �� , — — -- -- - --.— __-- --- _ —--- ---__ __ _ # Fa�m+e 1.aecere c�e..req.6+ea.�der Se�ZSE►.t MGL 152 e..ina a a�hrp.itls..caiwl.al pnaMia.t a�.p a s1,sM.M aaar.r oae yan'imptbe�amt as�re8 as dH pmNla fo tYe for�of a STO!'WORK ORDER a�d a�ee e[S1AO.OS t day a�aimt a�e.I aadersfatd t6at a npy of trb�a�my be finnrdcd b tAe Omce of 1�Hoffi sf t6e DIA for osrerage verHiatls■. I do beirby cererfy under dbe pelns mid pena(tiaes of perjra y dYet tbe iufor�x�lo�prodded aboae te leue e�d oomcx Signahu�e �a�tl.�.,(,� �'/�`I6pt�,,.✓ Date //�lb��d Prii►t narne '�0��<"`�[I��C�P n�.y t� Phone# ��O � � �� . U �� — e�cial sse eHly da sot�rrife�t�is uea te 6e ao�Pkfed bY dt7 er w�rn effiejal cily ar te�vn: P�# ��E�� Qi�g Beard ❑e�edc if imetediale re�e�t ie reqaiored �'s O�oe D�� : ��#; �m� c�,�a saK-zoas� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-014 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, 14 East Main Street, West Yarmouth, MA Whose place of business is: Christ.�'s of Cape Cod#612 Type of business: Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yannouth Permit expires: December 31�2007 BOARD oF HEALTH: /.3 r� _`n. , /l�I�., ' aN��>�1s, �ice G�l�vi�u.,ri Rol�t`� B�, C� P�,t�ibl��tt �4.ut('j�cee.r�u�, R.1V. January 24,2007 Bruce G_Murphy, H .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-011 FEE: $50.00 This is to Certify that Christ�'s of Cane Cod LLC d/b/a Christ�'s of a�e Cod#612 14 Fa�t Main �treet�We� Yarm�uth,MA IS HEREBY GRANTED A LICENSE For SAT F AND nTSTRIBI7TION llF TfIRA(`(`(�PRn1�i1C`T� AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. e�pi�es�t i�s�ant�i i�00��un�e�s s�o�one�r suspend�or r vo�ced.Code of The Commonwealth of Massachusetts,and si � January 24,2007 BOARD OF HEALTH: �Q �. �Nu�u�, /��., ' ��r�, a.�., v� e�� R�d�t�. a�, Gl�k p�,k�19�� 1�� R.N. � G- M Y�MP � -� Director of Health � 'f ,%'�n.�A� ` f ♦ • � Y- '�f`R.� TOWN OF YARMOUTH BOARD OF HEALTH �� M � n �� -'� APPLICATION FOR LICENSE/PERMIT 2006 .' °,;- „�� ., , , �o- �� DEC 2 3 2005 * Please complete form and attach all necess�ry��rt�e t by Decemb r�� DEPT. Failure to do so will result in the return of your application pac NAME OF ESTABLIS�IlVIENT: ��;�-�.�5 TEL. #�D�3-79'b•ZOQS' LOCATIONADDRESS: �1LI ��- �vl�,n S+ � l,c�e.5�- `laxrvto�� NtK} �Z�73 MAILINGADDRE5S: �05 P�easo_r,+ s+- . �.,�, n ;s n-ta c,z�o,� OWNER NAlV�: ��c'�s M; T ID or S : CORPORATION NAME APPLICABLE): �1,";ak•,� a�' �, � C'c.,c� Z i.ca MANAGER'S NAME: ��. L�v�-�- �- � TEL. # SZ�- �`1� `.2� MAILING ADDRESS: o S�7" �, ` �� 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. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wilt not use past years' records. You must provide new copies and maintain a file at your establishment. L 2. PERSON 1N C�IARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIll+�;�eH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and at�a�#i eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&$ $50 CABIN $50 MOT'EL $50 INN $50 CAMP $50 SWIlvIlvID1G POOL$75ea. LODGE $50 TRAII,ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 �QS,OOQ sq.ft. $75 �OG-03�. _FROZEN DESSERT $35 �TOBACCO $25 �(,�Q'�I� NAME CHANGE: $10 AMOUNT DUE _ $ /00.00 "••*•PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM""""" w.. "n, ADMIl�IISTRATION , 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 ANID ATTACHED Town of Yarmouth taa�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 RESPONSIBII.ITY TO RETURN 'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION?- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COn�IlV�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 autdoor in graund 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 Appfication form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FRQZEN DESSE__RTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. DATE: t� � c��' SIGNATURE: =�i��„ ��16 e�— PRINT NAME&TITLE: �A'r .1C.4.✓ +�CKP.�i�v� �iX2�- ��P CJJ 09/28lOS . � , . � �� The Commonwealth of Massachusetts . �� =__� _ __� . - Deparlment of Industruil Accidents str' 1 � =- -__ N�/f�Mi� 600 Washuigtoa Stree� 7`�`Floor _- �,�'�� Boston,Mass. 02111 _ wnrkers'com�sxhoa Lsnraece Affi�.�it:B�ilau�g/Pl�m leedncnl cu traccors � � . r a. � : , � . �_ .�,r . _ ,w �r �# r�� , � m �: . . : ,F, �.�� ..��li�. � ,.��, �s � � name: �Iti�i s�-i S �� CQ OE: L-bC� � �D /'Z aaa�s:_ I 4 �c�s—i— �c�;�r� S-� ci�y j �`��- �C��Pbt[�� srate_ FM 1� zio: �ZZlo�3 nLme# JSf��`=7 90• 2��5 avork site lceati�(fall addnssl- ❑ I am a hom�wnex performing all work myseif. Project Type: ❑New C�structio��Re.model I am a sole 'etor and have no a�e w � in any ca ' . Buil ' Addition �. � �,_.� K� �� n,4r. �; . : �. r �I am an e.mployer providing w�kers'compensatia�fa�my e.mployees wadcing�this job. ��,,�: ��,��s+..,'s a � �� C'�c� L L � �; /05 Pl�czscin+- �+ �- �ti �nn;S M14 bZl� o� ��: �t�d- 771 - 0 �'0� o.� e.�E-e�,1 (�e.r e.1�c�vi45 � �� I O o S �o !I O.i ❑ I am a sole praprietor,geeeral co'tractor,or hom�wacr(cirde oae)and have hired tbe cantractors listed below who have the following workers'compensation polices: � dtv oiwr�e Ak: , . � . � . . # ...;< _ ,_ ;, .,. ,:. .. „ , . sea�nasv r�e• sd�rr�• �attv� n�#: _ _ - ca # _ _. _ :,, � ._ ,� � . FaHve is secve�rwera�e�reqaired��er Scc�a ZS�A�f MGL 152 aa lead b tl�e i�p�itlK�cri�ial pnaMks�f a IIoe q�b t1,SM.N aidl�r oAe ya�°�,��wa�c��ee ror�.ra s�ror woiex oteo�a�a a ede.c siee.a.aay�.�. i�aea ce�c a cepy ef thb atahmest may 6e forRarded 1a tAe O�ce�lar�af tYe DIA tar orverage veripatlw. I do 6ertby ctre�;jy xnder dYe palns ewd penalf�es ojperytury tliet r1Ye i»for��io�prov�ded abov�e is true m�d cornct Signatnc�e_��a.�X, �I��LI.�.�� I�te L�1 & J�� — —1 Print natne ��"C+C��L ��p.oCil� Phone# �C�x'-�'7 t �d��d effiMiat ase oaly ao aot�erite Is t�is ar+ea to 6e cempk.ted 6Y eitY�mwn e�Cial cily ar te�vn: P�� 8�� ❑e�eck if imme�ia�e rapesse is roq�cd �Sdcct� O�oe 's OH�De�ar6�e�t ceatad petsea: phoae#; �et tTMvieed s�yt ZOro) TOWN OF YARM4UTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #06-036 FBE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Christy MihoslChristy's of Cape Cod, 14 East Main Street, West Yarmouth, MA Whose place of business is: Christv's#612 Type of business: Retail Food Service less,than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2006 BOARD OF HEALTH: � ,us$. o� /1�1._`7�►., ' ' ��s�, �.�v., v�e�� R�t� ��, et�,� n�iiiol�/�c�e!`nso� �!�� , R.N. February 2.2006 Bru� .Murphy,MP , .,CHO Director of Health ��°a o�' Y�� :M - . � � YA �TT f��^ �/.a�(�,,'� ]146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 " MATTACHEES " Telephone (508) 398-2231,Ext. 241 — Fa�c (508l 760-t� y � h��ACORA1E0�69� 7' . / J41� (�' Boara � o � x � � L � x �----�.... ._ �� -- _ y -� To: Yarmouth Board of Health Permit Holders � � � � � � E`:- ° From: David D. Flaherty Jr., RS. ��. --- . .�.�W_.. _� Health Inspector Town of Yarmouth Re: Federal Tax ID Number C�ate: Ii�Iarch 22, 2005 The Massachusetts Deparhnent of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIN}otherwise knawn as your"T�ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSI� 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 regarding this matter, please do not hesitate to ca11. The Q#�ice �hours are 1l�Io��day to Friday, 830 a.m to 4:�d p.�. The telephone number is(508) 398-2231,e�.241. Establishment: _ �,v1,R LSfi�t S � b 1�, (F��IN�or SSN: Location Address: I� �. �Gi.w� ��' � 1,�',�(c,�,,,,p� S ignature: —1��, ��e.�.�,..� Print: _ ��IL� �C lCe.c>r„!✓l Title: _��,-P Il. � _� �� Printea'on , �led � r�r ,. �- l.W'�`6�� K�tS7�t s /cF� M�t rnl _°`�R o TOWN OF YARMOUTH BOAR�"�OF:�E�LTH rZ � �� APPLICATION FOR LIGEP�SE �4 �-2005 i�� ,� �� ;�; �? ,__ ��, � ��E * Please complete form and attach all necessary documents by Decemb r 3�(�'tp0�.Q 2 Q Q 4 Failure to do so will result in the return of your application pac et. NAME OF ESTABLISHMENT: d TEL. # - oa 2a�S LOCATION ADDRESS: ' a..r ww �. MAILING ADDRESS: I oS (��ec�3c,� S1'r� _ I-fuc:e,v►►�u� ,�1 r4 O��SD� OWNER/CORPORATION NAME: e.I�R.ig�"u �h'1:.�.�s \ T� ,,�``t u� �� P�_ �� . 1.�L MANAGER'S NAME: 1�e.�n�n�'l1n Cce:w��o. TEI,. # MAILING ADDRESS: IoS Pl�c�c,� S�fire� , N��'g , J►1�A o�6ot POOL CERTIFICATIONS: The poot 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 Communit� 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 CNIR 590.000. Please attach copies of certification to this applica.tion. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. PERSON 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 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. RESTAURt�NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQtJII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 _INN $50 _ _CAMP $50 _SWIlVi(VIING POOL$'75ea. _LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $75ea. FOOD SER'VICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNII'P# LICENSE REQiJIl2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 �VENDING-FOOD $20 �<25,000 sq.ft. $75 �(� �FROZEN DBSSERT $35 �TOBACCO $25 �O .�(jI NAME CHANGE: $10 AMOITNT DUE _ $ l00.00 "'�•"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 ar 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 NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ES TABLISHMENT S ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-� SEASON. 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 COMI��NCEMENT. RENO�ATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS _ POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. 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 faod service establishment is prnhibited. DAT'E: 1 I�I�4 SIGNATLTRE: �� (vIc��,u,.., PR1NT NAME& TITLE: P�A`�(��C� ►MC ��v��1 �Z�u.�'�¢ �/.O• 10/22/04 . , � `�� The Commonwealth of Massachusetts -_:__—� �� -� Department of Industrial Accidents -- = N�f/i�Ml� � — _ _= 60l/Washington Stree� ?"�`Floor — ,,,,., Boston,Mas� 02111 , Worl�ers'Compeeaahoe Iaa�aaee Affidavih B'il leclrical Cootnctors ��- ..p. ,.. �„,� . _�.... , 3€-Sce_Q, .t,l..k `` �:.�' � .9 .a,�,�� f�'��'' � o,,�.y' �: �sF'.y�, �s:z .:. .��. _ ..., .. ;�a, s �n. ,e wRr, M ' ' �, �• �In R tStu`S J-� A.� �, � �� aaa�s• 1�{ � 1�(.uM .S`�7e��" �ty In� l�t�.��o �n• �19 �ip• F,26�„� r�# 51�8- �-i�- �00� work site locati�a�(full addressl- ❑ I am a homeowner perfonroing all wark myseif. Proje,ct Type: ❑New Ca�an�Re�naodel I am a sole 'etar and have no one w ' in any ca ' . Buil ' Addition . � , , x.. � ...._ . . . __u_ . I am an employer�tt+nviding waskers'compensation f�my employces warking�►this job. , � . _ _� � _ IOS N� � �: S� 4U z.�. G d a ❑ I am a sole proprietor,geserat costrntor,or homeow�a�(czrde ou�)and have hired the co�racta�s listeci below who have tl�following woskers'compensation polices: ��• �dt�a« �' ntra�e�: # �t*a�e• �; dxs: oio�c�: , i� _ Faihn^e e.secore orvna�e as nquiree..aer SeclMa 2SA st t►iGi l.0 aw le.a b ue�.tcrii.i.a� .[a�e one ye�rs'Imptbonment a�wr8 as dvr peealtlea ia tM fora�ota 3TOr WORIC ORDER aad a Q�e[5160.OS t day ataio�t oe. I•ndnsW�d t6at a cepy of this sta�ement may be firwardM 10 tLe Omce�lave�tlptloffi of the D1A tat eov�erage veri�ntlea. !ro her,eby ceraJ'y xnder dYe paPws ax�pcaalti�s of prrjary tlYet tAie i»fo�aHon provlded abo�e is dne and oo� s�� c�� Q,dti.., nen ir1�6lok Prim name P�- I R LC� lyI GI�,F D W 11 Phone# •�8- ��'f' �`140 •�cial ese oaiy do aet svtite ii t�a area to 6e wmplefed by eity et Ewva efficial city ar ts�vn• pern�iNBoease!� �Deparbmmt Board ❑chect if immdBate n�snse is ral� �'s Office OHaN6 Dqar�at ,�,��a��r.�n= p6eee#; �' r , F ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-018 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, 14 East Main Street, West Yarmouth, MA Whose place of business is: Christds of Cat�e Cod #612 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 HEAI,TH: Best�ts�t�S. !�'o�ic�,orr�/�`n. • P��l�l�� v:��.,�� R�t� B�, G'l� �� sl�, R.N. �4�!�' , R.A! January 11.2005 ruce G.Murphy, .5.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-014 FEE: $25.Q0 This is to certify that Christy Mihos/Christy's of e Cod d/bla C1Lristd o t' e Cod#612 14 F.ast Main �Yr . .t, West Yarm�i�th MA IS HEREBY GRANTED A LICENSE For SAT.F. ANn nT�TRTRiTTTON OF TORAC:C:n PRnDIT(';T� AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION �s�er$it i�s�ant�i��on�r i�with Articl p VI of the San��Code of The Commonwealth of Massachusetts,and e es er e s sooner sus ended or revo J�,�y i i,Zoos Bo�oF��.�: B��`n. ,�jo�o.�,�GI.`?�,, • ��r��s� v�e�� a�t�. ��, et� a� s�, R.nr ,�.�� , R.iv. Bruce .Murphy,MP ., H Director of Health : � �,.�2�31��✓ ��+��5-�,�5 �-�� pF��.qR i�. �`�. � ��S 11� �Y �.�' L".' � 3= e �G TOWN OF YARMOUTH BOARD OF HEALT � APPLICATION : �'�,I�GENSE/FEK1k1IT -2004 �EC 0 9 Z003 ' ��5 �� * Please complete form and attach �� ec�sar�"`c�ocuments by Dece b�E3�3�t�Q�.jEF�`�� _; Failure to do so will result in e return of your application pa . " NAMF OF ESTA3LISI�MENT: �- � ;�,S� #6», TEL, # �i- �Qv--�.ov5" LOCATION ADDRESS: l� E. �"Itui� S-t�tee�' i�/< t,�ai'r►iow� o t o WNER/C RAT ON NA E: �. ' T ' o A ER'S NAME: T L .�k- � MAILING ADDRESS: IvS P�Ci3ee�nfi St f�Ra�tr�� /YI/3 G':L�O/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opera�or(s) r�nd attac?� a��py �f t'�e ce�2i.fic�tic;xi to tJ��s :far�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 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. l. 2. . �Fff��l�"V'��l1K�E: ___ _ 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. Piease 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# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FGE PERMIT# L(CENSE REQUIRED FEE PERMIT# _E&B $50 _��"-.E;N �50 _tv10T�L $50 INN $50 CAMP $50 _SWIMMING POOL$75ea. LODGE $50 TRAILER PARK a50 WHIRLPOOL $75ea k'OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERM[T# _0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VICT. S50 WHOLESALE $7S R�TAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSf RGQUIRED FEG PGRMIT# LICBNSE RGQIJIRED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 _VCNDING-FOOD $20 �<25,000 sq.ft. $75 �I�033 _FRO"LEN DESSGR'C S35 �TOBACCO S25 d �'fJ � NAME CHANGE: $10 AMOUNT DUE _ $ lOo.("X'1 *****PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM***** L � 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 annualiy from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE 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 FCi LATION� 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 gound swimming pool must be drained or covered within seven (7)days of closing. FOOD SERVICE CQNSUMER VISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERNG PO�I _Y_. Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Depattment 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. � � __ i � �t� _ _ ___ Frozen esserts must e 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 FF:S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOI�N� Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: 1�-�3I�� SIGNATUR�: �C� f�� PRINT NAME& TITLE: Q f�'�RLUC 11�C, ��awn LX i0 � 10/22/03 ' . � The Co►nmonwealth of Massachusetts � � Department ojlndustrial,-lccidents � o OfJlceall�vestlpstliis 600 Washington S�reet ' �� Boston. Mass. 02111 �~ ��y W'orkers' Compensation (nsurance Affidavit ARniicant information: PleasepR�'['Te�'Wa n1m�' \JV1�;'.l1?��C b� � � iT�l��. J1 V ,�,!� � ,,j.,,��- Lucation� !� �. /'1(.Vt��1 ��/c�.GC �li� W< Nf.0 ln�� s ohone� ��`` �Q- � � I am a homecwner pert�rmin,all work myself. ^ � I am a sole proprieror �-,a, ha�e no one �rorkine in am•capacitt� � I am an emplo�er pro��dino w�orkers' compensa[ion for my employ�ees w�orking on this job. comnan�• name• ('�� RS � � � /�l� address: I�J' P�1vtCx+w�' C�-�-f� sit�': ��CtM�,�1,i�3 �rl j}�,(�CJ� nhone tl• �8- �3'�_Q,�/00 iosurance co. �Ct�. f..P�1� N'lel�� :.f�i ��w�D. olicy# r-l�ly " C7� � I am a sole proprietor. generai contractor, or homeow�ner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follo��in_ ��orker�� :ompensation polices: s4mpa�v name: address: ��n" Rhone M• insurancc co. olic}•# comn�ny name: — ___ _ --- __ __ _ _-- _._ _ addresr. . _ _ _ _ _- titv: nbone It• insurance co. �� i Failure to secure coverage as requ�red under Secnou 15A of MGL 1S2 ea�lad to tbe iopaidoa o(erisiad peadtld of�fi�e op to SI¢00.00 a�d/or one years'imprisonment s�w•ell as eivil penaldn io the torm o[a STOP WORK ORDER aad a Ase of 5100.00�day K�iott ma I a■dersn.d mar a copy of tha statement may be fonvarded to the ORce ot Inve�ti��tiom of tAe DU for eoven�e verifiatfo�. !do hrreby certij}•under t6e pains end prna!li�s ojperjury that t6e injormatinn providtd abovt is trne and cvrrtct Signature "1� ��KP,et,t�n✓ Date 1.L�03rd'� Print name �� f'IGA�,06.1a'1 Phone M .5�� '� ��l' �6b .- ofTicia! use onl� do not w ritr in this area to be eompleted by eiry or towa ofllti�l ciry or rown: YA��TQ _ permitAiceeu M nBuildiog Department OLiceasio6 Board �check if immediate respoese i�required 261 �Seleetmen'e OtTice �HeaitA Departmeat contact person: phone M;_ �508} 398�2231 egt. nOtder .. ._� .� �,,� � . = TOWN OF YARM�UTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-033 FEE: $75.40 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: Christy Mihos/Christv's of Cape Cod, 14 East Main Street, West Yarmouth, MA Whose place of business is: Christy's of ape Cod #612 Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2004 BOARD oF xEALTH: BeKycr,r�$. Cfihdo,t, /1'�S. ' �� v� e�..� Rad e�t�. B� G� �� 1�, R.N. � Januazv 29.2004 ruce G.Murphy,MP ,R. HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-024 FEE: $25.00 This is to certify that Christv Mihos/Chri�', o�pe Cod d/b/a Christ�'s of Cane Cod#612 , 14 F.ast Main Street, West Yarmn�th, MA IS HEREBY GRANTED A LICENSE For SAT,F. ANn DTS'T�TRLITTnN nF T��3A('('n PR(�17TT("TS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This�er$it i�ant�i�c�r�for�'t�y with Article VI of the San�tary Code of The Commonwealth of Massachusetts,and e� es e er e s sooner suspended or revo ed Januarv 29.2004 B0�1RD OF HEALTH: Qers�-.�ts�t�. �j�� //H�., . ��.y��, v� e�� R�t� a�, e�,� �� sl�, R./V. ruce G.Murphy,MPH . Director of Health , � �,��°�,, • �,., ClfiP/STt�c -/E. � �f�a'�.� TOWN OF YARMOUTH BOARD I�EAi,TI� s � ; t�° �� " J; ;�� ,- � .�' f1� C� � C� �; � C , 3�� APPLICAT[ON FOR LICEN��I'�RMIT -200��. � °��.'? �� ,;:��. . ;.�,�rC$�`�; �g i��,� "� q i`r �s 1 * Please complete form and attach a(1 necessary`�urr�e�its by December 3 a;,2(�Q2,�. __,.�.�_ Failure to do so will result in the return o our application packe�,.._�, �=•�'- �"� �'��',�� NAME OF ESTABLISHMENT: C risty s of Cape Cod # 612 TEL. # 508-7�0-�005 �CATION ADDRESS: ��a� Main Street, W. Yarmouth MAILING ADDRESS: 105 Pleasant Street, x�ann; G, Ma p2�� ER/ RA N MANAGER'SNAME: Kenneth camillP • # ��—�-g��,05 MAILIN�ADDRESS: � n� P1 aacant c�roo �T��},.��.�,,, POOL CERTIFICATIONS: The pool�upervisor�nust be certified as a Pool Operator,as required by State law� Please list the designated Pool Uperator(s) and attacn a copy oi the c�rtification to this torm. 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. l. 2. Y�I��ON li`V t;HAKGE. . _ _ 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. ,TZF.STAIIRANT SEATING: TOTAL# OFFICE USE ONL.Y LODGING: � LICENSE REQUIRED F�E PERMIT# LICENSE REQUIRGD FEF, PERMIT# LICENSE REQUIRED FEE PERMIT# 38cg $50 CAB,^�I �'� _MOTEI, $50 ______ INN $50 CAMP $50 _ _SWIMMING POOL$75ea LODGE $50 TRA[LER PARK $50 _WH(RLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL S30 NON-PROFIT $25 >100 SEATS $150 COMMON V1CT. $50 _WHOLESALE $75 RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQIIIRED �EG PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VFNDING-FOOD $20 �<25,000 sq.ft. $75 �U,3—D�l _FROZ.GN DF•.SSF.R"T $35 I TOE3ACC0 �03-od8 NAME CHANGE: $10 AMOUNT DUE _ $ /OO.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** • # e 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. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces 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, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT T�-�E 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, tolal coliform a�3d 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 �Q,�VSUMER ADVIS4RY: 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 ca.fes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. U�TDOOR COOKING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: ��C��- �� PRINT NAME& TITLE: patri c-k Mt�KPnwn/ Pr�»t� �� Vir"e P�es�� 10/18/02 � . _ Y � r w � The Conrmonwealth of Massachusetts � � Department ojlndustrial.-�ccidents T o Olflce o/%ves�lpstliis + 600 Washington Streel ' ` Mass 02111 � Bnston, �~ �•y V4'orkers' Compensatioa Insurance Affidavit ARnlicant intormation• PlessePR '� �am� Christv' s of Cape Cod # 61 2 Is�cation: 1 d Fa�t Mai n St-raat ��c� W. Yarmouth , Ma p�o��p 508-790-2005 � I am a homecwner pzrt�rmin,all w�ork myself. � I am a sole proprizror�� ha�e no one��orkine in am�capacin� � I am an em�l�er pr�s i,iiao w�orkers' compensation for my employees w�orkine on this job. comnam• name• [�hr; ci-�' c nf r�']�(�r�� T T C' ^ �ddress 105 Pleasant Street cit�•: Hyanni �, Ma 02601 phonep• 508-771 0900 in5uranceco.Ma _ Rc�tail Marrhant� Wnrkt�rG' ('nm�L_policy# 1Atif1 (1� � I am a sole proprietor. ;enerai contractor. or homeow�ner(ci�cle oneJ and ha�•e hired the contractors listed below ��ho ha�e the follu��in_ ��orker_ �ompensation polices: sQm�anv name• address citv• nhone tf• insurancc co. Rolicr•# comoanv name• _ - — -- -- — - -- - _ address• - - __ - __ __ _. _ _ _ -- -- _ _ �� '� ohoee M• insuranctso. ��n+* t Failure to secu�e coverage as requlred under Secnoo 25A of MGL 1S2 ca�lad to t6e iopaitioa o(erivi�fl pesdtla of a d�e ap to 51.500.00 a�d/o� one yean'imprisoement a�w•eil a�eivil penalda io the[orm of a Si'OP WORK ORDER aed a ffae of S100A0 a day atainst ma [a�dentz�d t�at a copy of th'n statement mav be fonv�rded to the OtTiee of[nvestigadom of tbt DU for eoven`t veritfatia. I do hrreby cerrij}�unde�rhr pains and penalties of perjury that the information provided abovt is trtte and eonect Signature�i�.�. �`� Date !/�l y��v Print name Patrick McKeown Phone+� ��R-771 _nAnn .. o(Ticial use onl� do not write in this area to be completed by eity or town oAlcial city or town: Y�M�IIT$ _ permitAieeeu a nBuilding Department �Liceosiog Board Q cheek if immediate respoose i�required 261 �Seiettmen'�Ofiiee �HealtA Departmeot cont�ct person: phone N;_ �508� 398�2231 ext. nOtAer .. ._„ < .,..: \ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-011 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, 14 East Main Street, West Yarmouth, MA Whose place of business is: Chris 's of Ca�e Cod #612 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, 2003 BOARv OF��,�: �� e!lu�i, eka�ca.a ___ _ __ _ __be��D. G�imrda�, 711.�.. ?/use , __ �o�t�. �ioawc. L� �a�ttt��t�cott �efe.�Slcak. �?Z. � . November 29 ,2002 ruce G. urp , R.S.,CHO Director of H THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLTMBER: #03-008 FEE: $25.00 This is to Certify that Christy MihoslChristy's of Cape Cod, d/b/a Christ s of Cape Cod#612 14 East 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, e it is fo �y with Article VI ofthe San'tary Code of'The Commonwealth ofMassachusetts,and, exp�es�ece�ie�.�0(�� e§s sooner suspended or re�o�Ced. November 29 ,2002 BOARD OF HEALTH: (� s�+f, i�efli�i, �Cacr�nra�c be�1a.�clwc`D. G�iondo.�, 'f11.D., 2/is;e �o6ait�. �'6'�u.c, �� a�tek�D� � Sl�, .72. ruce G.Murp y, , .S.,CHO Director of Health ` ' � c..�2 t S'r'-,s #b!2.. w � � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2002 " C�?.<�'�'" ; � , * Please complete form and attach all necessary documents by December 31, 2001. Failur to ��vil��i��t in the return of your application packet. HFALT�-i i��l�. NAME OF ESTABLISHMENT: r,h r; s t,�T� ��._r��,A r.n� :;� ti� � TEL. #K n R_Ta�=2�-�..5 LOCATION ADDRESS: 14 East P��Tain St. , ��°d. Yarmouth MAILING ADDRESS: 10� Pleasant St. , Hyannis, Ma. 02601 OWNER/CORPORATION NAME: Ch��r�t� '�i hnS, C`,hri et�r' c n-f ra=A �nr� � LL!" - MANAGER'S NAME: Kenneth Camille� TEL. # 508-771-0900 MAILINGADDRESS: 10S Pleasant S . , Hya.nnis, P�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. �ERSON I�T CI-IARGE: _ _ _ _ - _ _ _ _ __ __ 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. RESTAURANT SEATING: TOTAL# OFFICE 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 PARK $50 _WHIRLPOOL $25ea. F90D 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 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICBNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 �<25,000 sq.ft. $75 Oa'CJ,� I TOBACCO $20 �6a��a'7 _<50 sq.ft. $45 >25,000 sq.R. $200 _FROZEN DESSERT$35 NAME CHANGE: $lo AMOUNT DUE _ $ �5•00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Q k, c � ` a ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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 � VriTORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS�-�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: 'The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CQNSUMER 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. DATE: SIGNATURE: y��z� /�`��.�.� PR1NT NAME &TITLE: �'��'IC� �'p'IC��C��-w� ��-�. .��. 4�'�.. ��..� 09/11/Ol . , .. , � The Commonwealth of Massachusetts � � Department ojlndustrial.-�ccidents a Ol11ce o/lav�sllp�tliis 600 Washington Street ' -� Bnston. Mass. 02111 �" ��y V4'orkers' Compensation Insurance Affidavit ARnlicant informaiion: PlessePR11�'T"LbL'�. ��m`. Christy' s of Cape Cod, �� 612 location: 1G� East T��ain St. �� `;'�. Yarmouth, ��a. phone k 508-790-2005 � I am a homeowner pert�rming all w�ork myself. � I am a sole proprieror �-� ha�e no one ��orkin� in am�capaciry � I am an emplo�er pro�i�ins µ�orkers' compensation for my employees working on this job. comoam� name: �hz'�-sty' s of Cape Cod� LLC. addr�ss: 105 Pleasant Street Hyannis, T�a. 02601 508-771-0900 cit�•• nhone i1• T•�iass. Retail T."erchants �"�orkers' Com 1960-01 insur:►nce co. olicy# � I am a sole proprietor. ;enerai contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below �►ho ha�e the follu��in_ ��orkzr �ompensation polices: s�mpanv name• address• c�tt" phone It• insurancc co. oolicv# com�nv name• z�d resr �h': t�hoee 1f• insurancsso. �p� � Failure to secure covenge as requ�red under Secnon 25A of MGL 152 n�ind to tbe ioposidoa oterfsi�d pesdtles of a 0oe ap to Sl¢00.00 a�d/or one yean'imprisonmeet a�w•ell a�civil penalda io the form of a STOP WORK ORDER aed a Ase of 5100.00 a day a�ainst ma t a■denn.d msc a topy of thH statement mav be fonvarded to the OfTice of Inve�tig�tion�of t6e DU for eovenge veritiatiw. /do hrreby cerrif}�under th�poins and ptnalties of perjury thut 1lrt rnjornralion p�ovidtd abovt is tritt aAd eor►rd Signature _ Dc,�(�kec�'� �C/��,� Date I/�3�n�al Printname Patria� T��eKeown Phone�t508-771-0900 .. o(Ticial use onl� do no�+.rite in this ana to be completed by eiry or towa oflleial ciN or town: YA��IIT� _ permitAieense q nBuilding Departmeat �Lieeasiog Beard � check if immediste respoese ie required 261 �Sdeetmen'i OtTice �Heaitb Department contact person: p�o��p._ (508� 398�?231 eat. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-033 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: Christ;Mihos/Christ;'s of Cane Cod, LLCi l4 East Main Street West Yarmouth,MA Whose place of business is: Christy's of Cape Cod #612 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 31.2002 BOAx�OF�A�,T�-�: ��?f. �e��, ��ca�c se.��D. C�mcd,o.i, �L.D.. `l/�ce ,�o6�t� ��, e� ��k�� s�. ��t April 17 ,2002 ruce G.Murphy,MPH,R. ., C THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-027 FEE: $20.00 This is to Certify that Christy Mihos/Christy's of Ca�e Cod.LLC d/b/a Christy's of Cape Cod#612 __ 14 East 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. T'his permit is granted in conformity with Article VI of the Sanitary Code of T'he Commonwealth of Massachusetts,and expires December 31.2002 unless sooner suspended or revoked. A�r� i� ,aoo2 Bo�xv oF�ai.�: �eed� xe�, C'l�a� �eac�?�. G�ou�. �11.D., ?/�ce ,�o�eat� �r�or�a�, L� �a�rlck'�e�� `�ele.� S�ak. ,�?Z. ruce . urP Y� • -, Director of Health • / �. � C-�f72�S7'zj 5 #6/Z . . � � � � � � � � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT,-2Qb ,; � DEC 2 Q ZOOO � � „�;�x �� : �� H A TH D PT. * Please complete form and atta.ch all necessary documents by De ` ber�l, 000. ai in the return of your application packet. -------------------------�----------------------------------------------------------------------------------------------------------------- �tAME OF ESTABLISHMENT: Christv's of Cape Cod ��612 T,�L. # 508-790-2005 LOC�TION AD�RESS: 14 East Main Street, W. Yarmouth, Ma. 105 Pleasant Street, Hyanns, Ma. 02601 (�WNER/CORPORATION�iAME�hristy Mihos Christy's of Cape Cod, LLC MANAG R'S NAME: xenny CAmi11e TEL. # 50 8-7�0900 M�1,�,ING ADDRESS' �- 5 Pleasant Street, �yannis, Ffa��bZTl --------------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonazy Resuscita.tion(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 bnsiness. 1. 2. 3. 4. HEIMLICH CERTIFI�ATIONS: All food service establishments with 25 seats or mor� 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 file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMQKING SEATS: TOTAL# -----..--------------------------- -------------�_ ________________ OFFICE USE_4NLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMMING POOL $SOea. _WHIRLPOOL $25ea. FOOD.S�+,RVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protecnon manager certification is October 1,2001. 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 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 / TOBACCO $20 �_--Q2�. 1 �'15,000 sq.ft. $75 �D 1—d3� �FROZEN DESSERT $35 !>25,000 sq.ft. $200 N.�ME CHANGE: $10 AMOUNT DUE _ $ 9S 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** s � ; � . . ^ ; ADMINISTRATION � Ur�der..�hapter,1,52�_S,�c�ti�n 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of anyy li�cens�-�iir perinrt~�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 ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLISHN�'NTS ARE TO CONTACT THE HEALTH DEPAR'TMENT 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,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to operung, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NE�S�ATE 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-charge who is a certified food protection manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000. T6e effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.1 l,will be implemented January 1,2001. Only establishnnents which sell or serve ready-to-eat,raw or undercooked animal products are required to have consurner advisories. CAT�RING 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 D�artment. - �tOZEN DES5ERTS: 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. DATE: v SIGNATURE: P��, j�'�`j�,.._ PRINT NAME& TITLE: Q�)��C� t'►')CI��,�� J/_Q 11/16/00 r � \ + � _ The Commonwealth ojMassachusetts � W Department ojlndustrial,-lccidents � ; Of/Iceo1/�s�l�rs�liis � 600 Was/rington Street •' Boston,Mass. 02111 �" � y` W'orkers' Compensation Insurance Affidavit Anolicant information: P►easeFRl_lQ'TTt�dv mmr Christy's of Cape Cod 4�612 location: 14 East Main Street cit� W Ya mouth, Ma phone�508-771-0900 � l am a homeowner periormin�all work myself.. � t am a sole proprieror�:;� ha�e no one ��orking in am�capacin� � I am an employer pro�idine workers' compensation for my employees working on this job. � .. . .. . �. _ . comnan�• name• Christy's of Cape Cod, LLC address: 105 Pleasant Street ��t�.; Hyannis, 1`�a. phoneN: 508--771-0900 insuranceco. Ma.ss. Retail Merehants Workers' Comn. policy# 19fi�—f)1 � I am a sole proprietor. ;eneral contractor, or homeowner(circle oneJ and have hired the contractors listed below ��ho ha�e the follo�cin� ��orker� �ompensation polices: companv name: address• s�: Ahone#• insurancc co. Qoli�y!! _ ___ _ company name: __ - -- -_ address• ci�y: phoee l�• insurance co. j}oliey i! Failure to secure coverage as required under Seetioa ISA of MGL 132 ea�lad to t6e iopoeidoo of crisi�a!pe�dtla of a A�e op to 51,500.00 a�d/or one years'imprisooment as w•ell as civil peaaldes io the form o[a STOP WORK ORDER aod a fioe of 5100.09 a day a�aiost.a [a■dersa.d ma�a eopy of tha satemeat may be forwarded to the OfTice of IavestigaGo�u of the DU for eovenge veriAettlw. /do hrreby certij}�under rht pains and penallies of perjury 1ha1 tht injornwtion providtd abovt is fnte aed conec� Signature Q�� I�G� Date �1�1(X� Print name I��tL I�G ►��1,✓� Phone# .Sabr- ��I� O�'Io0 ., olTicial use onl�� do not M rite in this ares to be completed by ciry or town oflicial city or town: Y�M�DTR _ permit/license N nBuilding Departmeut �Licensiog Board ❑check if immediate response is required 261 �Selectmen'�OfTiee contact erson: 508 398�2231 egt. �H�alth Departmeot p phone M;_ �__� _ nOtber d ,-- q�I�aH�o.�o�oa.�iQ n�-T;� `'�'N`H�W`�fqd.myv •r�a�ruR ,�ls ?�li ��S�i►�"J?r% �Q, ��Q � 1�r1�'�[� . S/ o''"/�'%�T.Lr �� mreuro� ay'/� �u��ax"�':�� f� '�f,� �� H.L'I�'3H d0 Q2Id08 I OOZ` £[ � ad •paxona.�ao papuadsns.�auoos ssat� I O Z I �aquaa�aQ sa.�dxa pu�`s�3asnqo�ssey�3o�I�an�uounuo�ay,i,3o apo��Le�►ues atg3o In aioiyn��cn��iiu�o3uoo m pa�u��si�iuuad�s►u,i, 'N I.L�' �' O Og .L O �H 2I�d S S Il O � d .L 30 NOI .LS Q � �'S ��3 �SI�i��I'I�'Q�.L1�I�'?I�1�g��H SI yy� �nouu�� m �aa.r� urey��s�g b t Z I 9#Po� a ��o s� suq ��q/p �Z-� � a �3o s� su��soqiy� s�� q��i�a�o;s�s�u,i, 00'OZ$ �3�3 ZO-IO# �2I�gL�if1N.LIY�t2t�d H,L'I��H 30 Q2I�'Og H.LIlOL�i?I�A,�O I�IAc10,L S.L.L�Sl1H��SS�Nt 30 H.L'I��AAI�IOI�IIL�IO� �Hs. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #01-032 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Christv Mihos/ .hrist�v's of C:a�e C'od, T.I.C', l4 .a� M in Str Pt, �xle�t YarmoLth, 11�A Whose place of business is: Christv's of Cape Cod #612 Type of business:_ Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d�l. �e�ed, ��iavr�ra.a �� . �e��. �/Ece ��i�a�c ,�o�t� ��ou�, C'?� 7�'��aeP d ;L' , se��e�� D. . �l D. . f� ' ; � � l �...�: ,�-- February 13_,2001 ' B'ruce G. Murphy, PH, .5., CHO Director of Health ; �h�i s�y� �c�1 y -; TOWN OF YARMOUTH BUARD OF HEALT$% � � � (� {? U/ � Qn '' g APPLICATION FOR LICENSE/PERMIT-2060 � �; D E C 1 6 1999 j * Please complete form and attach all necessary documents by De,cem�e�- �,�999 a�t�q ��ni#re lt in � the return of your application packet. � �'''`5� �` i ------------------------------------------ ------- --LTi r i`s�"y"-rs------------------�"��cF�-e---------------------SOS=?9�'=20'Q'S""�. F ES # L ATI L D � UWNER/CORPORATION NAME: �/ y MA1�jAG R��'�AME: KennX Camille TEL # 508-�771-0900 3 MAII..ING ADDRESS: Same as above � , POOL C��TIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rer�uired by new State law. Please list the designate�Pool Operator(s) and attach a copy of the certification to tlus 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 raust provide � new copies and maintain a file at your place of business. j 1. 2. { 3. 4. HEIlI�LLICH CEBTIFICATIONS: 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 c�rtifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fite at your place of business. 1. 2. 3. 4. i RESTAURANT SEATING: _TOTAL# _ NON-SMOKING_SEATS: TOTAL�._—__,___ ____ ____ -------------_---------------------------------------------------------------�-__�.�--------------------------------------------------------� OFFICE IT5E QNLY LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMIlVIING POOL $SOea. VVHIl�LPOOL $25ea.. FOOD SERVICE• LICENSE REQIJIRED 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 PERNIIT # LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 �TOBACCO $20 _ �<25,000 sq.ft. $75 – FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ G� ' """"'PLEASE TURN dVER AND COMPLETE OTI�R SIDE OF FORM•"`"" _ U V ,_ .... .. _ __. _._._..._, r ' # - ADMINISTRATION UNDER CHAPTER 152, SBCTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH I5 NOW R�QUIR�D TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE C1R PERNIIT TO OPERATE A BUSINESS IF A PER�OI�T< QR :COIV�PAN� DOES NpT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSiJRANCE:� THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSIJRANCE ATTACHED ' � VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' TOWN t�F 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. TT IS YOUR RESPONSIBILITY T(� RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIVV�ElVTS ARE TO CONTACT Tf�HEALTH DEFARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO �PENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR FOOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE�tEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIV�NCEM�NT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS ' POOL OPENING: ALL SVVIMIVIING, 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 5TATE CERTIFIED LAB, PRIOR TO OPElVING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIM1VIIlVG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �ATERING POLICY: ANYONE WHO CATERS WITHIN'THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HE.ALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DES5ERTS 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-� SUSPENSI�N ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNT1L TI�ABOVE TERMS HAVE BEEN MET. _ _ _ OI T'I'�IDE CAFES: OUTSIDE CAFES(i,e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. QUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: // � SIGNATURE: �/1�� a� PR1NT NAME& TITLE: �Cc,�2 IyI��:Pwr� �ire� I�re_ U rJ 11/12/99 � � � � � � The Commonwealth ojMassachusetts 1 i ` � � Department ojlndustrial.-�ccidents �� ; � Ofllceo/I�stl�s�iis ' 600 Washington Streel I ' ' -` Bnston. Mass. 02111 ~ '��y W'orkers' Compensation insurance Affidavit Anoiicant informallon: p►essepRil'Q7"T�,�i,i� - _ -- �, i namr� Christ 's of Cape Cod, LLC. location: 1 4 Faat Mai n StrPPr ttt� r.rp�r va,-,T,�„rt,� t�ta (1 F,7'i ohoneq 508 790 2�5 � I am a homeowner pertorming all w�ork my�self. � f am a sole proprizror�� ha�e no one ��orkin� in am•capacin• � � I am an emplo�er pro��ins workers' compensation for my employ�ees w�orking on this job. _ - — Ch=�sty's of Cape Cod; ZLC. _ - - - . s4moan�• name: address: 105 Pleasant Street Hyannis, Ma. 02601 508-771-0900 �t�'� phone tl• insur:►nce co. Travelers Property Casualty �Y� 7PJUB-51-8X637-4-99 � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e the follu�.in_ ��orker �ompensation polices: comnany_name• address• ��" nhone q• insurancc cn. �olicv# comoanv name• ad d ress- titv: ehen �• insurance co. ��ex� • Failure to secure coverage as requirrd under Secnoa 25A of MGL 1S2 a�ipd to tee iepaidoa of erivi�fl ptadtles of a O�e op to SI,S00.00 a�d/or onc yean'imprisonment a�w•ell a�eivil penddes io the form of a STOP WORK ORDER aad a Aoe of S100.00 a dar Kainst me. t a�dersta�d tbat a copy of thy statement mav be fonvarded to the OfTice of taveatig�tioo�of the DIA tor eovera;e veritiatio�. I do hrreby certifj•unde�rhr pains and penallies ojpery'ury tha lht iaformation pmvrdtd above is trrre and correct Signature 4i� /'/�iY��. p� //l� _�."_ Print name ��Ric�; /�C=.l�Goua� Phone N �k- ��/- c95oc� .. olTicia! use only do not M�ite in this area to be completed by eih or torvn olfleial ciry or town: Y�M�IIT� _ permitAtcease M nBuilding Department pLieensiog Board �cheek if immediate�esponse i�required 261 �Selectmen'�Otfiet �Heaits Departmeet contacc person: phone N;_ �508� 398�2231 eat. nOther .. < a�.� TOWN OF YARMOUTH ' BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-30 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:hrist;Mihos/Christv's of C:a,n, C'�d, 14 F.a�t Main � r .Pt� West Yarmo � h, 11�A Whose place of business is: Christv's#612 Type of business: Retail Food Service less than 25.000 s�uare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31.2000 BOARD OF HEALTH:�'d� �et��, C'��,�a�. �oan� �ul[ivah, ��, Vice �hairma Ko�ert.�`. �rowrc, �l.ark abriel.�e�a�o.�.��y-.�J�ooPe� ��l �o��,� December 22 , 19�Q ruce G.Murphy, MP ,R ., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-22 FEE: $20.00 This is to Certify that Christv Mihos/ hristv's of Ca�e Cod LLC d/b/a C1L' t�'s#612 14 East Main treet, West Y�rmnnth_1VLA IS HEREBY GRANTED A LICENSE For SALE�NT� DIST UTION OF TOBACCO PRODU TS AS PER THE YARMO TH BOARD OF HEALTH TOBACCO REG LATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. December 22 , 19 99 BOARD OF HEALTH: �� efte�, C�`iciirman �oan� �u6[ivan, /'C.�, Vice �hairman Kobert._t. �roraa, (�[erh �a6rie[le�a�Of��-�ooPe� l0' � ;� ce Director of He�alth � T j . � ,� ��, _ ,9 ? .�D �/�� ivJ..,;..:.�1 ,�. `L TOWN OF YARMOUTH BOARD OF HEALTH � � C� �, �� , � � APPLICATION FOR LICENSE/PERMIT- 1999 D E C 3 1 1 9 9 8 . �� y � �, �� ti � r �� '' H F. LTH D PT. * Please complete form and attach all necessary documents b�D�e�t��3�,�'��'8 I�ail •�v- the return of your application packet. ` •' '� j - _� u1�N UN�oN l�i,�1�t ��'� ------------------T�-------------------�------J,�-�-;�---------�--��-��n�j-------------------#-------------------- A I D S: - ''1 Olt` � ' �- RAT N ;J' t d � /� � l.7 �'11 ER' L # � � rN q--s rs o v � POOL �ERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. L . 2. - Pool operators must list a minimum of two employees cturently certified in basic water safety, standard First Aid and Commwuty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' r�cords. You must provide new copies and maintain a tite at your place of business. 1. 2. � 3. 4. � i HE�1�(i.,ICH CERTIFICA I� 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-cholcmg 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. i RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ( -------------- ------ ------ ------- -------------------------------------------------- � _-- ----- -- - - - -4�i£��SE�}P�LIZ _ � i LODGING: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# 'i B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 MOTEL $50 SV�[1VIlVIlNG POOL $SOea. � WHIRI,POOL $25ea. FOOD 5ERVICE: ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # -100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NUN-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII.SE�� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � � ��`�0� <50 sq.ft. $45 �TOBACCO $20 �,�'3 C�-r�Is° �<25,000 sq.ft. $75 'q�'� FROZEN DESSERT $25 �,4� �y. y >25,000 sq.ft. $200 t� � ��`.tA � ::.��AME CHANGE: $10 —� AMOUNT DUE _ $ ��•~ "' �� """""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" _.. .,:a � �.�,:"� . - �'`` . �, � X ADMINISTRATION UNDER CHAPTER 152; SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOUTH IS NOW�QU�RED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION ' INSURANCE. THE ATTACHED STA'�'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AI'�D ATTACHED TOWN OF YARMOUTH TAXES LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE 4F YOUR PERMITS. PLEASE CHEC PROPRIATELY IF PAID: YES NO NOTICE: PERNIITS RUN ANNiJAI,LY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII,TTY TO RETURN TI-� COMPLETED 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 OPENING FOR THE SEASON. ' ALL RENOVATIONS TO ANY FOOD ESTABLISH.MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULAT�ONS i POOLS i POOL OPENII�tG: ALL SVVIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR i THE SEASON MUST BE INSPECTED BY THE HEALTH DEPART'MENT,AND Tf-�WATER TESTED FOR - PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENI1�iG, AND QUARTERLY TF�REAFTER. ', POOL CLOSING: EVERY OUTDOOR IN GROUND SVVINIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS C1F 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. TI�SE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. . FRO�EN 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 50 WII..L RESULT IN TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�AB�VE TERMS - - ----- _ _-- - _ _ -- _ --_ _ - - _HAVE BEEN 1VIET. _ - _--- __ __ _ _ - - __ ___ . OUTSIDE CAFES: OUTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRO�UCT$Y A RETAII,OR FOOD SERVICE ESTABLIS��VIEEN'T IS PRUHIBITED. s; �4 � r.t ' 3v ��,� F C ' 4 4� ¢9 �t� ' �/ 7 � tx�' � ��r � DATE: .�` SIGNATLTRE: `'>--�'j `�" � �� ` :� PRINT NAME& TITLE: �r.�e,- , -,�:..6� � _ . �� ! � ' ; � { . ' ' The Conimoawealth ojMossuchusetts M W Department ojlndustria/,accidents • W � ; Olflceol/�sl/�►s�liis � � 600 Washington Street o` Boston, Mass 02111 �" ��y Vb'orkers' Compensation Insurance Affidavit ARolicant intormation: PleasePRI1�T'TeaGi�Tir namc: location: � ��` phone# � I am a homeowner pertorming all work my�self. � ( am a sole proprieror�r,� ha�e no one��orking in am�capacity � I am an employer pro�iding workers� compensation for my employees working on this job. _ _. -- _ �,��% �`�/��' �� ,� �i�' ,�� comnan�� name• ��--�� - address: !' vo� ! /�»cJ�� / � /I�� .. 'v ��(�''� • ��0 / ��1� . �� insur�nce co. / /� ��lf�C�� olicy# ��!��r–�L��` !'L�� /%�� I am a sole proprietor. general contractor, or homeowner(circle oneJ and ha��e hired the contractors listed below «ho ha�e the follu��in� ��orker_' �ompensation polices: s�mp�nv name: address: ��' phone#• insurance co. policy# � company name: _- -- — � a�esr. --- — — -- -- �ih'� Ahoee M• insuransss4� �o(iey M Failure to seeure coverage as required under Secrion�A of MGL 1S2 eas lad to t6e iepoei0oo of erisl�al pe�dtla of a O�e op to 51,500.00 a�d/or one yean'imprisonment as w•ell a�c il nal a io t1Ye form of a STOP WORK ORDER and a liot of 5100.00 a d�y a=tinst ma I r�dersta�d t�at a eopy of thy statement may bc f�va�t�d th OfTie �of Inve�tigation�of t6e DU for eovenge veritieatM�. � j,� !� c� r /do hrreby cerrijj�u�der rh paj�� d pe !t' �'",,Jury thet the i�jormation provided nbovt is tnre and contct ��f`,��. , c��' Signaturc Print name Phone Il ��'J ' /��j�� c�� y .� ofTicial use only do not write in this ara to be completed by citv or town oflleial city or town: Y�M�IITQ _ permit/license N nBuildiag Department pLicrosiog Board �check if immediate response is required 261 �Selectmen'e Otiiee (508} 398�2231 ezt. �Health Departmeat contact person: phone q•_ _� _ nOther (mned i;05 P1A1 THE COMMONWEALTH OF MASSACHUSETTS . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-34 FEE: $20.00 This is to certifv thac Christv Mihos/Christv's of Cane Cod d/b/a Christv's of Cane Cod #612 14 East Main Street, West Yarmouth�MA IS HEREBY GRANTED A LICENSE i ; For _ SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This pernut 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. February 10 , 19 99 BOARD OF HEALTH: �d///. ..i�e�ee� ��iairmarc �oan. � �ulliva�, K.//., Vice l,.�irmare Ko�ert J'. 4�rown.� C��r� �a�rie[le�a�oG��xc�-�tooped e10� ou��lin / D1ieCtOT Of��1 � •� � i ` , � . t A, i '. . . � � ` f: . . ,`s�' - $ 'k s ,� �=+ f :.. � . � � � � -;, � � > ; �`��,��,� ��- ' a ��, _ . 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' �" . . -- �� 7 ,� ny.+'�' :' p�^ J Z hM � � �'?� . • . ' � =R� � ..� �� F`+`�� . r.'�y- y .y; t � .�" 4 :�., � _. i �r�,Y" v,'+ ✓�..' 's TOWN OF YARMOUTH � , , BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-60 FEE: $75.00 In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ('hri�tv Mihos/('hristda of('ane C�d_ 14 F.ast Main Street,West Yarm�uth, MA Whose place of business is: Christv's of Cane Cod#612 Type of business: Retail Food Service less than 25.,000 s�uare feet To operate a fofld establishment in: Town of Yarmouth Permit expires: December 31_ 1999 BOARD OF HEALTH:��/. �et��, C��rman , �oan � �u6�ivan,K.//.� Vice (,�irmarc Ko�ert.}. /�rown.t l.lerh adrielle�a�o[e�ic�-�oopee /�/ic�e6 oCou h[in. � 1 '��(, ; �ril l , 19 99 Bruce G. Murphy,MPH,R. .,C • j Director of Health � � _ _ ; ; _ , ; —-- --_ __ __�. ��_ a - �� - �..,, , _. ; ; 3 � j " i - � i i ; � ; � I , � 7 7 1 1 1 � ! • � , . � , 1 I