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Home My WebLink AboutApplications, WC and Licenses � �sn�s�62o °` Y�k� TOWN OF YARMOUTH BOARD�F� ; �� . � ^ 4��„ ��=s APPLICATION FOR LICENSElPE�I��.� i ,,� ; -,-, __t... ;� .� � :,,�� 2uur *Please complete form and attach all necessary documents by Decemb�r 31, 2007. Failure to do so will result in the return of your applicaxion packet. NAME OF ESTABLISHMENT: ri s �' C' Co `.�C #(o� TEL. # Sd�'7�0�/6�'G LIQCATION ADDRESS: 35 A- N � � �t,�g � MAILING ADDRESS: 0� �a Sk.., ��,' iq OZ-lo0 OWN�R NAM�: ��is , GlIS iN r N - � CORPORATION NAME (IF APPLICABLE): n ` �.�' C MANAGER'S NAME: �',.e.-i" �^ � ' MAILING ADDRESS:__�pS 0%� �L __�jy�„�,�;s !`IA � 6/ TEL. # 5��77/-D DD 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 Cardiopulrnonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this form. T�te �ealth Dep�rtmeot will not use past years' records, 1'0� �us�prQvidE 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 Sanita r y Code for Foo d Service Establishments, 105 CMR 590.000. Please attaeh copies of certificationto this appfication. The Health Department witl nvt nse p�st years'recards. You must provide new copies and maintain a file at your estabGshment. 1. 2. _P�R�9T�t IN_��-IA�GE: _ : Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. J 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 certificarions to this form. The Health Department will noi use past years' records. You must provide new copies and maintain a file at your place of business. 1. i 3 2 4. RESTAURANI' SEATING: TOTAL # LOD�nvG: OFFICE USE ONLY LICENSE REQiJIRED FEE PER'�11T# LICENSE REQUIRED FEE PER'1rIIT# T T _B&B LICEI�SE REQL IRED FEE PER4iIT= S50 CABIN � —� SSO _A�IOTEL S50 — S50 _CAi�IP S50 _LODGE —....SV4'I�'IING POOL S75ea. �50 _TRAILERPARI{ S100 FOOD SERVICE: -------- —_._�H�-POOL S75ea. 1 LICENSE REQUII2ED FEE PERMIT# LIC£NS£RECIUIRED F£E P£R�111T� _0-100 SEATS 575 LICENSE REQUIR£D FEE PERViIT= ----- _CONTINENTAI. S30 _,>100 SEATS 51$p _NON-PROFIT �>> ---_ _CO'4L1qON VIC S50 —'— RETAIL SERVICE: -- —�H�LESALE g7g --__ LICENSE REQUIRED FEE PERMII'� —RESID.KITCHEN S75 LICENSE REQL�IRED FEE PERVIIT= _<50 sq.ft. LICENSE RE(ZUIRED FEE PER'41IT� �45 >>>g,000 sq.2�. g�pp �<25,OOOsq.ft. S7g p�.�(� _�'ENDIIvG-FOOD S20 _FROZEN DESSERT S35 / TOBACCO SSO �_ :vAl�IE CHANGE: �,10 �— — #O OO AMOUNT DUE _ $ /25.40 *"***PLEASE TL'R\OVER�\D C0�IPLETE OTHER SIDE OF FOR�7 ..».. P ADNiINISTRATION � ' Under Chapter 152, Section 25C, Subsection b,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 dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, UR i i � k CERT. OF INSURANCE ATTACHED � : OR �� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � i � Town of Yarmouth t�es and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK � � APPROPRIATELY IF PAID: YES ND � MOTELS AND OTHER LODGING ESTABLISHMENTS � i 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 us�. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. TransieYrt occupancy sha11 genera.11y 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)manth 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: Enclosed Motel Census must be completed and returned with this application. POOL� POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be insF�ted by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5; days pnor to opening. POOL WATER TESTIl�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 closin�. FOOD SERVICE CATERING POL�CY' An one who caters within the Town of Yarmouth must notify the Yarmd eveme These�fo ns canbybe ob�tained�at�th�e Temporary Food Service Application form 72 hours pnor to the cate e Health Department. ' FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis hy a State ce vi�fice�d ion of eour Frlozen Dessert Permit uritil he Department. Failure to do so will result in the suspension or re Y above terms have been met. r QUTSIDE CAFES: ' e cafes i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heatth• ;i Outsid ( OUTDOOR COOKING: � f��ct b}�a r�ai}or food se�vice�s�ablisl��t��hibited. ' Ot�doa��ael�i�g,�eepa�at�°n�,°r dis��y of a�cy oo�p ; NOTICE:Permits run annually from January 1 to December 31. IT IS O�U C�4RNSIB oII•�TO RE'TCJRN THE COMPLETED APPLICATION(S)AN1�REQUTRED FEE(S)B AL,L RENOV ATIONS TO ANY FOOD ESTABLISHIViEN'T, MOTEL OR POOL (i.e.O, ��P�OR EQjJIpMEri'I',ETC.),NNST BE REPOR T E D T O A N D A l'P R O V E D B Y'T H B B O TO COMME�tCEMENT. RENOVATIONS MAY RE QUIRE A SITE PLAN. �✓ (� �/ ��,� v� SIGNATURE: ////1� � DATE: �'A�r l��[ J/ V•� pRINT NAME&TITLE: I�nn� � io;n o? � ' � The Commonwealth ofMassachusetts , Department of Industrial Accirlents N�,'1��1� 600 Witshington Stree� 7�"'Floo� Boston,Mass. 02111 Workera'Compessatioa I�araace qffid�avyi�t�;�gyaild�ng/plamb1sglEk�m�Contraetors .... � . . . ��rR��■ ��V . . . �: hr1 �'s d� C�x Cod G� � �ZD address: �3J� /-/�//�/ J�'• .7�//f. �(/f�M 0�7 h M/f' ��6 city �aJl� Y�,�,a� , state• /'/A` zin OL�y ohone# a /l0� �lo�� work site locatian full address: ❑❑ I am a hom�wner performing all wa�lc myself. Project Type: �New Ca�stnx.Kion QRemodel I am a sole proprietor attd have no one worlcing in any ca�pacity• ❑Building Addition �, I am an employer providing workers'compensation far my e,mployees worlcing on this job. aommeviame•: �j/'I��S df" -� �� r._ _ � --- __ � f� ��i SGv..� St � �hann�s l'�A- 6ZG 1 �# /—S�� 77/ 0 90� i �. Ass M Rel� N/.�� WG G,�,, � 6 r aoos6� 3� iio-.7 � .� , .,.,�_ ��__ �. .�� r..�� _�_.��..__._��-� . . ; ❑ I am a sole Prc�prietoi'>geBersl coetractor,or Lomeown�(circle o�)and have hired We �. �:� `:�.�� k j tl�following workers'co �II��s listed below who have mpensation polices: i � �v�: aaai,ess: citv �� co. # �: S�Y: _ D�O�!#` >: # - Faiimt�s�ecme cwerase�udtr 3ectlo�ZSA K MGL 1S2 eu lad t�fYe ' < , °�Ya*�'�ptira�nmmt n w+r�as clvY ��!'crfi�iai pwaNks�f a�e�p b S1,3M.N andl�r�� PeaaNies ig tbe fors of a 3TOt WORK ORDER a�d a ane af S1M.M a day�t�e, I�de�tlnt a cepy ef tlda atalesmt may be ferw�arded�e tAe O�ce of Inve�as ot t6e DIA for coverage v�Catle,. I do henby cufrfy rrader tAie pofiu aad pt�relttts ofp�r�i�rr�,dY�t tbe iw � for�rallow pro�dded aboae ts Iwe awd onm�ct Signature ' / / �+ Date !r J �S�G � Pturtnatne /C � �gf'�/!� J�' Phone# ��77�—Q��(� �(Z2?j effiwia!ax only do Hat wrNe�this area to 6e co�picted 6Y dlY�'�nre a�Cial city er ta�vn: �# �Baildie�Depar�n� ❑c�eck if��ax ia reqo�+ed �i.k�en�ieE Beand ' �'s Of6oe �ct�n: pgsae#, ��t �Uthet t 9 w , � t ' T�,.. ��x� cor��vsaTzorr�a�,� F . ..�'IPLOYERS LIABL?�.T�TY_ INSIIRANCF: C�RmIFIC?.TE INFQRMATION PAGF ?�.�E4iA� ��REEME��.r"` MA Retail Merchants WC Group Inc. Producer: Agent�� 960 10 British American Blvd. Association Aenefits Ins Agc;= r�� Latham, NY 12110 529 Ma�n St Ste b05 (Carrier Code: 34355) Boston, MA 02129 �ertific3te ��: i,14000501361107 Prior Certificate �f: O�40005�13ti1106 1• The Employer: Christy's of Cape Cod, LLC Mailing Address: 105 Pleasant Street �'YPe of Business: Partnership Hyannis„ MA 02601 Other workplaces not shown above: Fein: SEE SCHEDULE OF OPERATIONS Risk ID: ' 2• The certificate p_eriod__is_from_12�01_a.m, Qn 1�0� /2nn� 1/0�/2008 at the insured's mailin� address, t4 12:01 a.m. on ' 3. A. Workers Compensation Coverage: Part One of the certificate applies to the � Workers Compensation Law of the states liste� here: i � � B• Employers Liability Coverage: Part T4ao of the certificate app'ies ;,c, +�rori_ in each state :�isted in Item 3.A. '�'he limits of our liabili;:�� :.�r�de:- part ?�.;o are� Bodily Injury by Accident $__ 5U0 000 Bodily Injury b�r Disease each acciden;. Bodily Injur�r by Disease $ 500 OOQ cer;�:;�icate limit - _ 500 0�__ e��.._ ��1n•T 2 P. C. Other States Coverage: D• This certificate includes these endorsemetits and schedules: WCOOOOOOA(04/92) WC000113(O1/O61 " ��'CU004�E�.(C8i:F�,;T„L,:��r��xr�;/g�` ��,p��OJ.(04,/��1 WC200302(G5/R6) WC200303B(07/99j y�c2e��fos;�6/O1) "t•1C20060�(06/9�� 4• The contribution for this certificate will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required .below is..subj�.�t to verification and change by audit. Classificatior_s Code Contribution Basis �o Rate Per Estimated ` Total Estimated $100 of ' Annual Remuneration itemurieration �ual ,:- ; Contribu��on ' SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution 17,210.00 Minimum ContributiQn S , 267.00 - . �pensQ �onstant...$ :OC. WC 00 00 Oi A Issue Date: 12/28/2006 Countersigr.ed by TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-010 FEE: $75.00 In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eneral Laws,a permit is hereby-granted to: Chris 's of Cape Cod LLC, 1353 Route 28, South Yarmouth, MA Whose place of business is: Christv's of Ca�e Cod#62U 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 HEAI.'IT�: ��fe�e�t Sf1�aH�, J`�..N., C'�av�nun j C'ffa�r� .�3f��i�i�c `tlice C!f'r�unnu�crz � ��✓3�cawn,�e� � � , November 27_2007 ruce G.Murphy,MP ,R .,CHO Director of Health � � � � THE COMMONWEALTH OF MASSACHUSETTS TO�VN OF YARMOUTg �30ARD OF HEALTH PERMIT TTIJMBER: #08-009 FEE: $50.00 This is to Certify that C ri.ty'�ne Cad LT� �/a C1Lri tv'��f�ane C'••� �#620 _ 135� Rc�i�tP �8, �nuth Yarm�nth R�A + IS HEREBY GRANTED A LICENSE For SALF Al*]T) 1)i�TRTBITTT07`i nF TnRA('r'n nunnrrr�r� AS PER THE YARiV10UTH BOARD OF HEALTH TOBACCO RE iULATION This. e t is t c o ty with Article VI of the S Code of The Commonw�alth of Massachusetts,and exp�es�ece�enr�.�Og�un�e§s sooner suspended or revo e . November 27 2007 BOARD OF HEALTH: .`��t$(�f�� ,�(,� (?�� d .� �E�i�t�fG� �ICC t��l�(lltttlxlt � J&r�.eAtt 3 J`3�turt, C!�e� llrui C'�,cee�r�asu�n, J�„N B c .Murph ,MPH, . , Director of Health � : � Y �-3�° c.w,¢rsr,s �6 20 °`:�R�s TOWN OF YARMOUTH BOARD OF HEALT� � ; �� - _;� � �` G3 � C5C 01�IC� D Y`: ,,� APPLICATION FOR LICENSE/PERMIT-2007�, '� N O V 2 $ 2006 i * Please complete form and attach all necessary doc�n��s�Decem r 31, 2006. Failure to do so will result in the return of yaur a�phcation pac etMEALTH DEPT. NAME OF ESTABLISHMENT:��.�.� ��.T� ��('� TEL. #;�0$•��p•I C� 8'(0 LOCATION ADDRESS: 1 35� rYl�, n pC,� . ��,z{�� r,��}�'4� I(Yt� �� MAILING ADDRESS: � 6 p I OWNER NAME: �; T r � CORPORATION NAME(IF PLICABLE): ��r i C�-�! �C C�' �,��,t (��c5 � L.(r MANAGER'S NAME: e �a TEL. #_.5b�. `71..�, I�0�� MAIL.ING ADDRESS: �1Y1 ' M � 5/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated ; Pool Operator(s) and a�tach a copy of the certification to this form. — i j 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 Healt6 Department will not use past years' records. You must prnvide new copies and maintain a file at your place of business. 1• 2. ' 3• 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� l. 2. '� - PERSaN IN CHARGE: _ . _ _ _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. HEIMLICH CERT'IFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-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 fde at your place of business. l. 2. 3. 4. RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PfiRMiT# LICENSE REQUIItF.,D FEE PERMIT# _B&B �50 , _CABIN $50 _MOTEL $50 INN $50 CAMP $50 SWIlvIlv1II1G POOL$75ea. LODGE $50 TRAII,ERPARK $100 WHII2LPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIItED FEE PERNIIT# 0-100 SEATS $75 _CONTIlVENTAL $30 NON-PROFIT $25 >100 SEATS $I50 COMMON VIC. $50 WHOLESALE $75 RETAII.SERVICE: —RESID.KITCHEN $75 LICENSE REQUIIZED FEE PERMIT# LICENSE REQIJIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 �45,OOOsq.B. $75 �6 -Q ,.FROZENDESSERT $35 �TOBACCO $5� �'07—01� NAME CHANGE: $10 AMOUNT DUE = S �ZS.00 ••"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*••'°" , , ��.; -.�., f r � . . . � �. - _� ; � ADMINISTRATION � ; Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth 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 taxes 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 TRANSTENT 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 ha.ve 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, sha11 generally be considered Transient. PO�LS POOL OPENING:All sv�rimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Degartment prior to opening. Contact the Health Department ta schedule the inspection five(S�days ; pnor to opening. ; POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirnming pool�nust be drained or covered within seven(7)days of closing. � � ; FOOD SERVICE � CATERING POLICY: Anyone 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: Froaen 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 ha.ve been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDQOR COOKING: tC�OQiC04��,.n��par ion,�r__c�icnl�nf�-fOOGI�'DCli16t��-��f.t�i��u'�9Ad . . iS-�1'�hi�i�C�: NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN TflE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DBCEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISHHIViEENT', MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR ' TO C4MN�NCEMENT. RENOVATI�NS MAY REQUIRE A SITE PLAN. DATE: ,( �� SIGNATURE: ��,� ��,�'�e+,�✓ PRINT NAME&TITLE: t��Cl� /yIC l�P�c�JvJ„ ,�iC I/.(�� 10/17/06 � - ' . � Tbe Com�namveolth of Massachusetxs Depart�rrent of Indusbzal Accidenls > N�fei�irr� 6t1� Washington Ste�ee� f"`Floor Bos�on,Mass. 02111 _------ worh�s'com tioH I.s.raace A�avt�swii bii�/Llecdrxat co■eracMrs name: � �f` ��_�r�� _. �- 1� �� 1'�0.:� �+ • cj�y�)'F� V c�(M n V � �^- slate: �1� ziR: Q��o6'I nh�e# •C�O • / b(.J' 1 �i� work site locati�(full addressY ❑ I am a homeowner performing all wo�k myself. Projext Type: ❑New Ca�Iructio��Reanodel I am a sole and have no one w in an ❑Buil ' Additiaa � I am an e.mployer pcoviding w�cers'compen�i�f�my e,mpbyces woiking on this job. , — �fi �� .�."'T.,.�e,��{e�� . ,��.�.` . . � . � . .. L'�Y ��. ,��,..+�.� , \. r`1�S�� O�!�: �L171� ��. l J-/U[1 � iJ , � ❑ I am a sole proprietor,�ai eo�tracter,or�omeaw�er(e�rclt a�rt)and l�ve himd the co�ractois listed below who have the following work.ers'compensation polices: �xs _ ��: ' �,,, � c�tr 0�• a�nt dtr �one�: � Fa�ve U aee�+t ea�erase as req�ieed ud�SeeW�2S�A�f MGL I3Z cu le�d�Ike�rpaMMa�t'ai�al pnd�es�f a�ae�b t1,3M.N a�dhr o'e yeus'6�pria,mt a�wdl as dvll pmltles h tie fera eta 3T0!WORK ORDER a�d a me a[51�.0!s day��oe.I odn�d tlut a apy�t/Yie stale�eit my be firwardcd b He d�ce otlive�tlose�f Ike DIA Ar osvrrase ve�ali�e. 1�o lYeneby c �aeder d�e patru aad peerl�es ojperjxry dut NYt iufo�ador�provided eboae la b�e aud oemcR �� '�.. rnsl��,�...� � ��`` o� Print na� ---_�(�`�"+("1 �.�,�C��e �L�_1'� Phone# ��1 � / � ' . ��vQ a�dd.se�ly ds aat�vrite Ia thh ar�ea to be oe�piaed by dty er 1r�v8 e�ial c�p or ts�va: permi�6oeme� �lB�idia�D�t ❑eLedc if imae�abe �Be�rd resps�e ia reqared �'s�oe �� ct Pet'�es: �ae S, � c.�s�r.zaa+� � � , � � TOWN OF YARMOUTH { BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT ; ! PERMIT NL7MBER: #07-015 FEE: $75.00 � , i In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter � 111,Section 5 of the General Laws,a pernut is hereby;granted to: � Christy's of Cape Cod LLC, 1353 Route 28, South Yarmouth, MA � Whose place of business is: Christy's of Cape Cod#620 � Type of business: Retail Food Service less than 25 000 square feet I � To operate a food establishment in_ Town of Yarmouth Permit expires: December 31, 2007 BOARD OF HEALTH: B ��r,u�s_`?S. , /1�1.$., a��le��, ��?/�e L'ls� Radent� B�ou�, 'G�le� n�� , R.N. January 24,2007 Bruce G.Murp y,MP .,CHO Director of Hea1th THE COMI�ZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NLTMBER: #07-012 FEE: $50.00 This is to Certify that Christv's of Cane Cod LLC d/b/a Christv's of Cane Cod#620 135� R�nte 28, ��nth Yarm�nth, MA IS HEREBY GRANTED A LICENSE For S T.F. AND ISTRTBITTiON OF TnBA(' .O PRO1�iT .T� AS PER TI�YARMOUTH BOARD OF HEALTH T(JBACCO REGULATION. �s.�eer$it is�ant�2 c�, ,�for�it�y with Articls�e n of the Sanikta��Code of The Commonwealth of Massachusetts,and e s sooner ded or revo January 24.2007 BOARD OF HEALTH: ,� �. �jlo�'o�t, J��., . ��r�, R.N, v�e�� Ro6�t�. B�, L•� /�G�/{9c$� �l�f�'�r�e�, R./V. � ruce G.Murphy,MP ., H Director of Health ' � � ��7 ' i ��'�:.,y,o TOWN OF YARMOUTH BOARD OF HEALTH ' � � � � � d � � � � -�� APPLICATION FOR LICENSE/PER�I�-2006 { � ; Y; .;�,� �. D E C 2 3 2005 { �� * Plea,se complete form and attach all necessary d " . Y��er�s��ecembe 3��l�(►�3�H DEPT. a Failure to do so will result in the return of��apphcation packe . � � NAME OF ESTABLIS��VVIEENT: �(,L�;s�l-•r 5 TEL. #SO L�,°7lo O • I to�'S�„ LOCATION ADDRESS: /3 53 MQ,n g+� So,r+� Yo..c n.�o�k_ d zlo(o y ; MAII,INGADDRESS: �o �j�Qso�n+ 3+ o� ;s q. oz�o I OWNERNAME: C..lti�,s .�„e T ID r S : � CORP'ORATION NAME( APPLICABLE): 'Ll�.c�.4.,�'s o� Ca.ee C� LLC � MANAGER'S NAME: �J�b oca�l� 'N� TEL. # �8-�-6D-/�ce'6 �,nvG aDDxEss: �� l s .� r r�.�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by 5tate law. Please list the designated � Pool Qperator(s) and attach a copy of the certificat�on to-this fo}-m. - j 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. i � . 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 will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. � PEI��ON IN CHARGE: __ _ ____ _ Each faod estabhshment must have at least one Person In Charge(PIC) on srte during hours of operation. � L � 2. HEDb��H 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-chokmg procedures below and at�a.�i copies of employee certifications to this form. The Health Department will not use past years' records. ' You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAITRANT 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 $50 _SWIIvINIING POOL$�5ea. LODGE $50 _TRAII�ER PARK $50 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS �150 �COMMON VIC. $50 WHOLESALE $7S RETAIL SERVICE: LICENSE REQUIItF_D FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 Vh'NDING-FOOD $20 �Q5,000 sq.ft. $75 �O6�0� _FROZEN DESSERT $35 LTOBACCO $25 �—�Z? NAME CHANGE: $10 AMOITNT DUE _ $ /QO.Od Ilk�!R RpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""*"" # ADMINISTRATION . rtlnder Chapter l�2,�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 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS��IENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR 1NSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO ', COI��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 outdoor in ground swimming pool must be drained or covered within seven(7)days af closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to�st Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaztment 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: Fraz�n dess�rt�rnus��e testezl on�manthty ba�is l�y a�tate certifre�l lab. �estresaits must i�e 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 waiterlwaitress 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 establishmerrt is prohibited. DATE: 1z, � SIGNATiJRE: ��,� M`�rt,ee�.... �op.. ✓�F• ILva PR1NT NAlVIE&TITLE: ��.lC.� �?CKe�w►� �X¢e r•P• ��O 09/28/OS � � a r !� . - -----� The Comniomvealth of Massachusetts _ � � = Departane�t of Industrial Accidents � :_- - - - N�'�Ifiw�� \ - -- � 600 R'ashington St�+ee� 7f"'Floor --,,,�� Bos�o�,Mas� OZlll ,_W ' work�s'com�saboa IasQasee A�davi�B�il bi�/Eleedricnl Co�haetors ,.�..�,. ,, `��.� � "�x'". „9 ,e .�,..�� ,._�, ..,. �:C.k.��5-1-.� � 0� CczP� �'ta� � (oZ0 r �S_ I 3�3 Mr��n S+ �i�v�o��-1� ��Gt�rv�o��. �• Nl 14 zin- OZ�(0 4 u,�aae# �QR �le U i (o�� work site locati�(fall address)• ❑ I am a homeow�r perfomoing all wo�k myseif: Project Type: ❑New Ca�tructia�OReanodel I am a sole 'etor and have no a�e w in an Addition . . �,I am an e.mployer providing workeas°compensaho�f�my empioyees warking a�rhis job. o�v�:• ��c'�5��5 ��k- �.�?�P� l-�� t. 'L �• J6S P l�� S�- �: 1-1 van n;s M)4 ��-�o i � �a�s �� o q Q r, Mo.bs Zed-a:, c�. fi5 GJC_ 6co� O��1boo so �3� r I�s ❑ I am a sole p�oprietor,geaeral c�tracter,or komeew�(c�rde o�)and have hit+ed the conlr�tors listed below who have the following worke�s'comPensation Polices: s�oe�r�: �: dt�: uiarr�F- � ��: �s; s�tr: ��. Fa�u�e b aec�e cr�ase a.raq.Tuee.,aa S«li�.ZSA.t MGL Lu ea.lna a IYe i�itly.tatv.d pe..Nies.c a 8�e�p a s1,s�wM aaahr oae years'ieq�tbe�mt an we9 aa dv/p�ia tie 6�ra�ota 31�d!WORIC OR1/ER a�d a 1be ef f1M.N a day aphst me. 1 odaslatd that a c�rq•t Wt etale�e�t my be fir�varded!s Ne 011ke�f Im�ot 1Ye DIA hr a�rage vn'lAatlee. /do ha+eby ee�fy w�der dYe patna end peMlNes ofPerJxr�'tlYat NYe iefor�r�l/on provdded aboae ia bare aed oa� Signafiue �n� ��2.A�w•�.. Date 1�.1�IOS� P,�;��_��-r��k Mc.k�wr. P��.�� -o4eo •�ial aae aely �got wrke ia this anea ta be�apl��bY dtY.r lwva.�dal c#y or taw¢: ! '�''ieo`"�'Depfur�Ymt ❑eLect if�ie re�pene b reqmed �'s O� ce�ut pers.B: �g� ��WrOa�t t,�.�e smc zars) { • � i ; � ' TOWN OF YARMQUTH � BOARD OF HEALTH '' PERMIT TO OPERATE A FOOD ESTABLISHMENT ; � PERMIT NUMBER: #06-035 FEE: $75.00 � In accordance with reguiat�ons 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, LLC, 1353 Route 28, South Yarmouth,MA a � � Whose place of business is: Christy's#620 � Type of business: Retail Food Service less than 25 000 square feet i � To operate a food establishment in: Town of Yarmouth � Permit expires: December 31. 2006 BOARD oF I-�AI,TH: B �srs `.�5. o�, /�l._`7�., ' ��`��, k�.�, v,�e�� a�t�. s� e� � � �� February 2,2006 ruce G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMQUTH BOARD OF HEALTH PERMIT NUMBER: #06-035 FEE: $25.00 . This is to certify that Christy Mihos/Christ,y's of Cane Cod, �C d/(/a Christy's#620 135� R��te 28, �nnth Yarm�uth, MA IS HEREBY GRANTED A LiCENSE For �Ai F ANn 1�T�TRTRI TTTON OF TOBA('('O PROI�i T(`T� AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. Tlusi�en�it is ant�i��forr��it�with Article VI of the San�taec�Code of The Commonwealth of Massachusetts,and exp es er t�d e s sooner sus-pended or revo February 2,2006 BOARD OF HEALTH: B �. �j�,/��., � �,��sl�, R�v, v�e�� Rode�t�} B�cou�sc, � p�a�a��,tt �4� , R.1V. ce .Nturphy,n� , ., Director of Health _ F'o-R�►�t.C�-y 8A'��t V�2�x,oN ` °`e R�. TOWN OF YARMOUTH BOARD OF HEALTH �-�-e� �2: _�,s APPLICATION FOR LICENSE/PERMIT-2005 �i '- v ' � ,� �' � . ..... * �� 2��5�. Please complete form and attach all neces documents by De.cemb r 3�,��0�. Failure to do so will result in the re rn of your application pac .�Ep��T�--� U�F'� NAME OF ESTABLISHIVIENT: TEL. # - �fo- LOCATION ADDRESS: 3 So. M MAILING ADDRESS: 11�� P � �'11� Da OWNER/CC)RPORATION NAME: � 1�I X �1> F��N�SS�1 ; - " ,�� MANA ER'S NAME: 1 TEL. # MAILING ADDREss: 1353 tiNlce.w, S+ S�. �C�rwto•�. M� o2t,6�{ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. The Heatth Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach cogies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a fde at your estabtishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at lea.st one Person In Chargs(PIC) on site during hours of operation. 1. 2. HEIlVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em loye� e trained in the Heimlich P Maneuver on the premises at a11 times. Please list your employees tra.ined in anti-choking procedures below and � attach co ies of em lo ee certifications to this form. The Health De artment will not use ast ears records. P P Y P P Y 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 REQUII2ED FEE PERMIT# B&B $50 CABIN $50 MOTEL $50 _INN $50 _CAMP $50 _SWIMiVIII1G POOL$75ea. LODGE $50 _TRAII,ER PARK $50 WHIItLPOOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 COMMON VTCT. $50 WHOLESAI,E $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMI'T# LICENSE REQUIItED FEE PERMTT# LICENSE REQUII2ED FEE PERMIT# <50 sq.ft. $45 _>25,000 sq.ft. $200 vVENDING-FOOD $20 �Q5,000 sq.ft. �75 �� FROZEN DESSERT $35 �TOBACCO $25 �0 5-0`fc�" NAME CHANGE: $10 AMOIINT DUE _ $ fVv�O '"•'�'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*•"• � / ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE 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 Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. 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, 2004. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT'TI-iE HEALTH DEPART�NTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI-iE SEASON. ALL RENQVATIONS TO AN� FOOD ESTABLIS�IlVfENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-�E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , �, � E ADDITIONAL REGULATIONS POOLS POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Dep�.rtment 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 estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLYCY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours pnor ta 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. UUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ' SIGNATLJRE: ,�r.S�n� M��ee�...�.� PR1NT NAME& TITLE: Q�R,t,c.� I�G�CD�!h EXeec.� (J.P•�(� 10/22/04 ' �� -_—=_-� The Commonwealth of Massachusetxs -=- - Depart�nent of Industrial Accidents -- = N�.1t/firr� - = 600 R'ashiRgton Stree� f""Floor TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-061 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: Chris Mihos/Chris 's of Cape Cod, LLC, 1353 Route 28, South Yarmouth,MA Whose place of business is: ehri ,stv's of Cane Cod #620 Type of business: Reta,il Food Service less than 25 000 squaze feet To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 l, 2005 BOARD oF HEALTH: Be�rr;,�,��. 4'��f,��j, • u��,�t, v�e�:�� R�t� B� et� �st�, R.�. �4.��j��.td��, R.N. August 4.2005 Bruce G.Murphy,MPH,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NUMBER: #OS-042 FEE: $25.00 This is to Certify that ChtY�tv Mi o hri�ty,s of �e�"od, T�r �.n;;a C`,l�.ricty,s of ane�,�� #.��Q 1353 R�ute�8, S�nth Y rm�nth 1��A IS HEREBY GRANTED A LICENSE For�LE A1Vn iaiSTR ITTTON nF Tn�3AC' n PRnnIT(`TS AS PER TI-�Yt�RMpUTg BOARD OF HEALTH TOBACCO RE LTT ATION This�er�it i'�s�an�t�i��nforu��tv with Article VI of the S �y Code of The Commonwealth of Massachusetts,and xP 5 e�s sooner suspended ar rev�o�ced. Au�ust 4 2005 BOARD OF HEALTH: Beit�rs�y�. (�� /��}., ' P��ra��t� v�e�� t� B� � .� s�, a.n! �� R.� Bruce G_Murphy,MPH,R ., Director of Health