HomeMy WebLinkAboutApplications, WC and Licenses ' C+���, C} (�G s•I� �`/ � i i
� ,J�Yq�ts TOWN OF YARMOUTH BOARD OF HEA �� �� �-�
-� s� � �' APPLICATION FOR LICENSE/PE . ��p� ' '•� � ;� 1 u�..���
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- * Please complete form a.nd attach all neces �� `
y�� �ecem� 3� �� �.,..�_
Failure to do so will result in the return'" ou plication packet. �
NAME OF ESTABLISHMENT: C`.C.�S ��-- �il��iA-�2.�5 TEL. #�f5-`1� 1 •S�S?Z
, LOCATION ADDRESS: (oS"1 R-T Z-� w�T �(.����-J ��A.
MAILING ADDRESS: �.a�� i-} V i.�►(s� �,�ct�a w4 w�v'� ��n t^tiv� p T s'7(a
� 4WN�R NAM�:PV�r�5-1'bP�tEr�— `D• �lw.��.v� T X ID �F�IN or SSNI-
CORPOR.ATION NAME (IF APPLICABLE): �. �3 .S. ���� ��-2�5
� MANAGER'S NAME: ("�r-,s�p��—r�. ��,M�,,� TEL. #
; MAILING ADDRESS: Li �EIC�P► �a� t�.)�T� c,.x�.riha-w� nn� c72�S-7lv
' �._._, .
� POOL CERTIFICATIQNS:
� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
I Pool Operator(s) and attach a copy of the certification to this form.
�
1. 2.
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� Poal operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulnnonary Resuscitation(CPR). Please list these employees below and attach copies of employee
� eertificaiions to this form. T�te Health Dep�rttnent will not use past vears' reeords. �'o� mt�s�provide new
, copies and maintain a fde at your place of business.
1. 2
3- 4.
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
iAll food service establishments are required to have at least one fiill-time employee who is certified as a Food
{ Protection Manager, as defined in the State Saiutary Code for Food Service Establislunents, 105 CMR 590.000.
Please attaeh copies of eertificationto this application. The Health Dep�rtmerct witl not nse past years'rPcords.
You must provide new copies and maintain a file at your establishment.
1. 2.
� P�RS9N_IN��A.RGE:
�
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
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HEIMLICH CERTIFICATIONS:
All faod service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and
attach copies of employe�e 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 Ol�LY
LODGING:
LICENSE REQUIRED FEE PER'1�IIT# LICENSE REQLrIRED FEE PER'1dII'# LICENSE REQLTIRED FEE PER�fIT=
—��8 5�� —C�� ��� _M07EL S50
_INN �50 _CAIVIP S�0 _SWI'_��I�IING POOL S75ea.
_LODGE SSU _T'RAILERPARK S100 _t�'HIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUiRED FE£ PERMIT# LIC£NSE REQUIRED FEE PER�iIT tt LICENSE REQliIRED FEE PERVi1T=
_0-100 SEATS S75 _CONTINENTAL S30 �lv'ON-PROFIT S2�
_>100 SEATS S150 _CO.'�rL'�ION VIC. S50 _`�4�-IOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMIT� LICENSE REQLTIRED FEE PERv1IT� LICE:v*SE REQL'IRED FEE PER�III'�
�<50 sq.ft. �45 b,g �0� _>>g,000 sq.ft. S200 _�'EI�'DIlVG-FOOD S20
_<25,000 sq.ft. 575 _FROZEN DESSERT S35 _TOBACCO SSO
va.�c�ta�rcE: sio AMOUI�T DUE = $ c���p�
*****PLEASE TL'R\OVER:�\D C0�IPLETE OTHER SIDE OF FOR�i*""**
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anNmvis�TTON
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificaxe of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED � `� �a �� Fw-���
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCGITPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarity and customarily associated with motel and hotel us�.
Transient accupants 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)mQnth 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.
* NOTE: Enclosed Motel Census must be completed and returned with t�is a�p�ication.
rooLs
PUOL 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
grior 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
closing.
FOOD 5ERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtain�i 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 Pennit urrtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofH�alth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN r
THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. �
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIVIENT, MOTEL OR POOL (i.e., PAlNTING, NEW `
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR ;
TO COMMENCEMENT. RENOVAT'IO'�iS MAY REQUIRE A SITE PLAN. �
DATE: ��v�n� �3�''2��`�s SIGNATUR '� 1�-�– � �—�" '
PRINT NAME&TITLE: C�r�����P1k�– �• ���`M�
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TOWN QF YA�,RMOUTH
BOARD OF�IEALTH
PERMIT TO OPERATE A Fi00D ESTABLISHMENT
PERMIT NUMBER: #08-055 FEE: 45.00
; In accordance with ref�ulations promulgated under au ority of Chapter 94,Secrion 305A and Chapter
11 l,Section 5 of the Z`ieneral Laws,a pemut is hereb granted to:
�
J.B.S. Billiards 657 Route 8 West Yarmouth MA
Whose place of business is: Classical Billiards
Type of business: Retail Food Service less than 5 s uare feet
, To operate a food establishment in: Town of Y outh
Permit expires: December 31, 2008 BOARD oF AL1't3: ,i�S/j�, �j�(,, (��
' P � •`���.�l�x�!�tce C'hai+rneara
�s�rlucr�otvs �a1vY: No food preparatian on remises.
i Only manufactured,pre-packaged foods_ Only canned beverag s. QIII� � �„/�(,
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a 7une 16.2008 Bruce G.Murphy, . .,CHO
i Director of Health
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e''" �
o`�R.y. TOWN OF YARMOUTH BOARD OF HEs�,.�H
� o � � �
' Y`: ��� APPLICATION FOR LICENSE/PER� �2b�0 JAN 1 2 2007
�- �� � ����,�
* Please complete form and attach all necessary dooume�its by Dec�mber 31, 2006.
Failure to da so will result in the return of your application packet.
NAME OF ESTABLIS�-IlVIENT: ` e ' TEL. # S$g 1"1 � ��?a--
LOCATION ADDRESS: _(,,�� r"� f�,�'Q ?4' 'U\Dl1�Sfi U(U�.nti. N�A �21�73
MAILING ADDRE S: Sr��. '
OWNER NAME: �I�P� I�i�k.�in.�S TAX ID(FEIN or SSN1�
CORPORATION NAME{IF APPLICABLE):
MANAGER'S NAME: ,�r�1 ��6��- TEL. # S�in�.�
MAILING ADDRESS: �Q�,�,
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool O�erator�s�and atta.ch_a copy of the certification to this form.
l. 2. �����
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Commu.nity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Heaith Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
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 Heatth Department will not use past years' records.
You must provide new copies and maintain a file at your establishmen� ;
1. 2. '
PE�tSO�i IN C��GE:- - _ __ _ _ _ - -- -___. __ ----___ _ __ _ �
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2.
HEIlVI[.,ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
m intain a file at our lace of business.
Y�u must rr�v��e ncw c�pies as� a y '
l. 2•
3. 4.
RESTAUR.ANT SEATING: TOTAL#
O�FICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
! BL�B �50 CABIN $50 _MOTEL $50
�' 1NN $50 CAMP $50 _SWIl�IIvIINGPOOL$75ea.
� — —
LODGE $50 TRAII,ERPARK $100 _WFIIRLPOOL $75ea.
FOOD SERVICE:
� LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUIItED FEE PERMI'P# LICENSE REQUIRED FEE PERNIIT#
a
� 0-100 SEATS $75 _CONTII�tENTAL $30 NON-PROFIT $25
>I00 SEATS $150 COMMON VIC. $50 WHOLESALE $'75
� RETAIL SERVICE: —RESID.KTTCHEN $75
LICENSE REQUIRED FEE PERMI'T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'T#
�<50 sq.ft. S45 �0 7"�l� _>25,000 sq.ft. $20(? _VENDING-FOOD $20
_45,000 sq.ft. $75 ,FROZEN]7ESSERT $35 _TOBACCO $50
} NAME CHANGE: $10 AMOUNT DUE _ $ S!�'•O O
� ••••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""'
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, ADMIlVIS'TI2ATION
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Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
af any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURA►NCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
- / ;
CERT. OF INSURANCE ATTACHED �/ i
OR i
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
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 ha.ve and be able to demonstrate that they maintain a principa1 place ofresidence 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 s�(6)month period. Use of a guest urut as a residence or �
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room �ccupancy `
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. �
PO�LS
PO4L OPENING:All swimzning,wading and whirlpools which have been closed for the season must be inspected
by the Health Depa.rtment prior to opening. Contact the Health Department ta schedule the inspection five(5)days
pnar 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 qua.rterly 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 filin�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 rnet.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTD04R COOKING: ;
Uutdoor cnok�_ng,_�renar�.ti_o�'a Qr�displ��-Qf a,ny_fQntl�xQ�iuc.tby aI 1� '
- �11..0�fQQL�SeTY1Ce P.S�ahlis mc��tt icrnrnhihi�j, �
�
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY k'OOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQIJIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR
TO COMIV�NCEMENT. RENOVATIONS MAY TE pLAN. '
DATE: �- SIGNATURE:
PRINT NAME&TITLE: .fl� S ��
1O/17/06
:::::::nnnnioonv:::::.,.:. '
::E`i;ii'�`iiiii� DATE
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,.:....:.::..:::::::::::::::::::::.......... .........
PRonucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
OCEANSIDE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BE�OW.
; 724 MAIN STREET � ' , COMPANIES AFFORDING COVERAGE
;. HYANN I S MA O 2 G O 1 COMPANY (i ;. . :
, A THE HARTFORD.
INSURED '" _ . ' COMPANY . .._,.,
�ROBERT WILKINS DBA B
CLAS S I CAL B I LL IARDS connP,aNv ~ '
5 6 LAKE LAND AVENUE � N I 6 2��7
SOUTH YARMOUTH MA 0 2 6 6 4 COMPANY
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..::...:.....:...:..:....................:::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::.::.::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:.::::::::::::.:..:.::::::::::::::::::::::::::.:::::::::::::::::::::::::.
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..........................................................................................................................................................................................................................:::.:.vE F::R THE POLICY:::::::PERIOD::::
:::.:::::::.�::::::.�:::.�::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::.:::::::::.................................................................................................................................
THIS IS TO CERTIFY THAT THE POLIC�ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO O
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCIUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS.
CO 7ypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $
CLAIMS MADE �OCCUR PERSONAL&ADV INJURY $ _
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $
FIRE DAMAGE(My one fire) $
MED EXP(My one person) $
AUTOMOBILE LIABILJTY
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDSILED AU16S _ (Per person) $
' '� . HIRED AUTOS BODILY INJURY
._. _._ $
_. . _
NON-OWNED AUTOS " - (Per accident)
PROPERN DAMAGE $
GARAGE LIABILITY "' AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBREILA FORM $
WORKERS COMPENSATION AND . O H WE CNL 1�J 4_G _ O C O�J l O 6 O 6J_O 7/O 7 X ���` E H- _ �---_�
EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 1 O O� O O O
THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ 5 O O� O O O
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 1 O O� O O O
OTHER
DESCRIPTION OF OPERAl70NS/LOCATIONSNEHICLES/SPECIAL ITEMS
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� � � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
� TOWN OF YARMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
1� 1 O DAYS WRITTEN NOTICE TO THE CERI7FICATE HOLDER NAMED TO THE LEFT,
114 6 ROUTE 2 8 BUT FAILURE TO MAIL SUCH NOTICE ALL IMPOSE NO OBLIGATION OR LIABILITY
� SOUTH YARMOUTH� MA 02 6 64 OF ANY KIND UPON THE CO ANY ITS AGENTS PRESENTATIVES.
�
i AUTHORIZED REPRESENTATIV
STACEY L. ' . MR B
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. .
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMI'I'TO OPERATE A FOOD ESTABLISHIV�NT
PERMIT NUMBER: #07-051 FEE: $45.00
In accordance with regu1at�ons promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a peimit is hereby granted to:
Robert�. Willcins, 657 Route�28, West Yarmouth, MA
Whose place of business is: Classical Billiards
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 200? BOARD oF HEALTH: L�e� ri��S. /�l.`h., '
���'s� .�, v�e��.�
RES'rluc'rIONs �ANY: No food preparation on premises. RoGwJ��Bh�,wt, �
Only manufaciured,pre-packaged foods. Only canned beverages. p����
. �itit
Apri14.2007 ruce G. Murphy, S.,CHO
Director of Health
I
t f _ } ���� ✓ -'
� ~ � �=Y'�R � TOWN OF YARMOUTH BOARD OF HEALTH ��� � � � � � � '� �"
�
! o� � ''� APPLICATION FOR LICENSE/PERMIT 2 �_��f�'"�
� JAN 1 8 2006
� .,— ,4 �..,,.,� �� �� � ,
* Plea.se complete form and attach all necessany��� ?�,�ceu�be 3���:H D E PT.
Failure to do so will result in the return.af"yo �,; ion pack .
� NAME OF ESTABLIS��VIVIEENT': � Gt55 t La.Q �i�I��ti��� TEL. # Sb$�� � ;�'��-
LOCATION ADDRESS: .e $�
MAILING ADDRESS: S wr-e_
OWNER NAME: �bP�� ( �1k.� t�5 TAX ID�.FEIN or SSN1: �
I CORPORATION NAlV�(IF APPLICABLE):
' MANAGER'S NAME: Gi�r�5 (�b -�-c �� TEL. # � �D 2 3 81�
MAILING ADDRESS: 1'1 l�?m,Prvr..P (�-e 1�.�-�.�-f o. ��Un�►n• Y�� �2(P(o�
� _ - ___-_.
� I I
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool4perator(s) and attach a copy of the certification to this forrn.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and
, Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. T6e Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
l. 2.
i 3. 4.
i
�
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
j All food service establishments are required to have at least one fiill-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 t'ile at yoar establishment.
i
L 2.
; -
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlb��CH CERTIFICATIONS:
� All food service establishments with 25 sea.ts or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and
� at�aeli eopies of employee certifications to this form: The Health Department witl 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 4NLY
i LODGING:
� LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICEN5E REQUII2ED FEE PERMTP#
�
B&B $50 CABIN $50 MOTEL $50
_INN $50 CAMf' $50 _SWIlVIlvIII1G POOL$75ea.
I
I �LODGE $50 _TRAII,ER PARK $50 _WHI[tLPOOL �75ea.
FOOD SERVICE:
LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# �
�0-100 SEATS $75 COrfTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 ,COMMON VIC. $50 WHOLESALE S7S
RETAIL SERVICE:
LICENSE REQUIIZED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
� <50 s .ft. $45 0��(S� >25 000 s .ft. 200
_ 9 � _ , q $ _VENDING-FOOD $20
_Q5,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE = S �{� OO
"'*""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••*"" �
�
I - � �
� � � 1
ADMINISTRATION
i
�
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 taxes and liens must be paid prior t renewal or issuance of your permits. _PLEASE CHE�K �
i
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT TI�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 "
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO i
COMN�NCEMENT. RENOVATIONS MAY REQUIlZE A SITE PLAN. �
f
ADDITIONAL REGULATIONS
�
. , _ __ _ _ _ -- �
POOLS --
POOL OPENING: All swimming,wading and whirlpools which have been closed far the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained 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 ca.ters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
- --- -- -
Frozen desserts must be testeii on a monthlyTasis by a State certi�ied lab. "�est results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the '
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING: '
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: ��" O� SIGNATURE:
PRINT NAME&TITLE: C�'�Z.�
09/28/05
r--•�.._....ti
CcAssccq� biuiA�¢.Ds
j • • `;AR.� TOWN OF YARMOUTH BOARD OF HEALTH Q � � � � M
I o z �:='� APPLICATION FOR LICENSE/PERMIT-2006 � �
�: , ,,/s Fr�
* Please complete form and attach all necessary documents by D bei 3I', �0�52005
Failure to do so will result in the return ofyour application a���TH �EPT.
' NAME OF ESTABLISHMENT: CL�S iC�_ t3� � L t �k-P �S TEL. # 5ll R`��1 SS�,]�-
�" LOCATIONADDRESS:�P,�� �S 2e,.�-t_ 2$' �f��-�- �l�ma-t�-fih MA
MAII.,ING ADDRESS: ��vw�-�
OWNER NAME: o I�Pi►�-k- W i t�i �� TAX ID{FEIN or S SN���
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: NY'i S Co 1�i� TEL. #_,�n R �L D Z 3�'D
MAILING ADDRESS: 0
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
---- n��l n.,P,-fl�)and��ach-a co�y of the-ser�ification to this form_ _
--- -r------�- _ . .
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 ofemployee
i certifications to this form. The Health Department wilt not use past years' records. You must provide new
copies and maintain a file at your place of business.
l. 2.
� 3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
A11 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.
I
� 1. 2.
_ — _--�ERSflN��H.AR�= — ----- ----- -- - __. __ ___ _ -- - -
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
; HEIlt�I�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-choking procedures below and
attae�i copies of employee certifications to this form. The Health Department wiil not use past years' records.
You must provide new copies and maintain a tile at your place of business.
1. 2.
3.-._ - 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQITIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
B&B $50 CABIN $50 MOTEL $50
�1NN $50 CAMP $50 _SWIIvIlvIIl1GPOOL$75ea.
LODGE $50 _TRAILER PARK $50 WHTItLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS �150 _COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIItED FEE PERMI"t'# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMTT#
1 <50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $
_QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25
NAME CHANGE: $10 AMOUNT DiTE _ $ .O�
"•"""PLEASE TURN OVER AND COMPLETE OTHER SIdE OF FORM•••
us
�����
` _
ADMINISTRATION
Under Chapter 152, Sect�on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of.any, license�or perntit to operate a business if a person or company does not have a Certificate of Worker's ,
Compensa.tion Insurance. THE ATTACHED STATE WORI�ER'S C�MPENSATION 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETiJRN
TI� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT T'HE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPENING FOR TI-� SEASON. �
i
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO �
COI��IlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
i
�
;
r
ADDITIONAL REGULATIONS I
�
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.
PUOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing. �
�
FOOD SERVICE �
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post �
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DES5ERTS: '
__ -��en-�esse�Es-t�ntts��e-tes�ed-cm a mortt�ii�basis b�astate ee�i€ted-�xb. Test resuits rnust-�e sem toti�e-�Ieaith - I
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product b a retail or food service establishment is prohibited.
DATE: I 0 v SIGNATURE:
PRINT NAME&TITLE: �,�J�-� S C�Tn�� N►-��
09/28lOS
1
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:::::: i..LLti�ir... '�i�It:���f,,,�����',,,iY...t...��':::'�����.�.���...��. ... �.� :. : '.' � � ) .:
:.......................................::::::.�::::::::.....................................................:....�:.�:::::::::::::....................................................�.s.�.......��......�.�......��...::::.:::::::::.......:::::::::.
� ....................................................:..:::::::.�::::.:�::::::::::::.::.::.........................................::::::::::::::.:�:.�:.::::::::::::::::::::::.�.�::::...............................................::.:::::::::::::::::::::::. 1 �•::
, ...........................................:..:..:::::::::::::::::::::::::.�::::::::::::::::::::::::::::::::..................................::::::.:::::.:::::::::::::::::::.:�:::::::::::::::::::::::::::::::::::::::. 2/20/05 :.;:
PRODUCER THIS CERIIFICATE IS ISSUED AS A MATTER OF INFORMATION
OCEANSIDE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CER'1'IFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
724 MAIN STREET COMPANIES AFFORDING COVERAGE
i HYANNI S MA 0 2 6 01 COMPANY
- A THE HARTFORD
INSURED -
ROBERT WILKINS DBA coBnrvv G� � � (�s' O NI � �
CLASSICAL BILLIARDS �a„iP,e,NY DE 2 � ZOO
56 LAKELAND AVENUE �
SOUTH YARMOUTH MA 0 2 6 64 coMParvv H�ALT
D
.:.......:.........:..:.......:::::::::::::::::::::::::::::.�:.�::::::::::.�::::::::::::.:�:.::::::::::.�::::::::::.::::::::::::::::::::::::::::::::::::::::::::::.�:::.:�::::::::::::::::.�::::::::.:.�::::.:�::::::::::.:_::::::.�::.�:.�:.�:::::::.:�.�::::::::::::::::::::::::::::::::::::::;:::::::.:
�:�f�t/@�i�iE$:::::::::::>::»::>::>::::>;::>::>::»:i:::;>::>::>::::»:::»»>:::»::::::>::»»:::<:>:::::<::::::::::<::>::»::>::::>::>:>:>::>::>::>::::»>::>::>::>;:;::::<:>::>:::;:»::>::»::»>::»::>::»>::::;:>::;:::::>:::»:<:::>::>�;;:�:;.:;::.;;;;:.;>;:.;:.»:;;;::;.;;:.;:.;:.:�:;;;>;::.:::.;:.;:.;;;;;:.>;;:.::.::.:;;;;>;>:.;::::::::::::::::::::::::::::.::::.::.:
:•::.�.THIS.IS.TO'::::::RT:F:::::..................................................................................................................................................... .............................................................................................
...........................:::::::•:::::::::::::.�:::•::•:::.�:::::::::•.�::::.:::.�::.�::::•::::::::::::::::•:•:•:•:�:•;:•;;>;::�;:;.;>::;:•::;:•:;:�:�;:�;;:�;:>:>:»s::;:�;:�:�;;:;.::•:>:;;;:>;>;:�;:�:<:::•;;:•>:�:s::?zz�>:�:;>:�»»:z<::�s>:>.�»>:<>.�»>:<:»>:s>s:a>:s»>s>:�»>:;:;.
CE I Y THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TypE OF INSURANCE POLICY NUMBER �UCY EFFECTiVE POLICY EXPIRATION
LTR DATE(MM/DD/YY) DATE(MMIDD/YY) LIMITS
GENERAI UABILJTY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILIN PflODUCTS-COMP/OP AGG $
CLAIMS MADE �OCCUR PERSONAL&ADV INJURY $
OWNER'S&CONTflACTOR'S PROT EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED EXP(My one person) $
AUTOMOBILE LIABILITY
ANY AUTO _ _.. COMBINED SINGLE LIMIT $
ALL OWNED AUTOS ,
BODILY INJURY $
SCHEDULED AUTO$ (Per person)
_
HIRED AUTO$ ',
BODILY INJURY $
NON-0WNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABWTY AUTO ONLY•EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS UABILITY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
_ , -
W�7FitCE�S CaAAPENSATION AND _ O�.F,'CI�L Z��� _ -- b �'� � 6 � �b X � �
EMPLOYERS'LIABIUTY
TORY CIMITS ER >
EL EACH ACCIDENT $ 1 O O� O O O
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE EL DISEASE-POLICY LIMIT $ S O O� O O O
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 1 O O� O O O
OTHER
DESCRIPiION OF OPERATIONS/LOCATIpN3/{/EHICLES/SPECIAL ITEMS
:,/..�y. �.+.Y.►..y. :.;:, ,..:.. :.;;:.i::>::;::.::.:::i::>:.>;::.�.::.:i::;>�.::.::.;::.;::>::;<:>:.:::.:::;:i::>:;::.::.::.;::>:.>::;:.>�::.::.:;:.>::.;;::.::;:.i::;;:.;::.:....:... .::: ... � . .
� ::ili! t.�'�c F::tX� '': ::i:. •. :. . �1
.��..
...... .�:::::::::::::::::::::t:i::;::ii::>:i::::::::::::i:i::::'t::::::::>:::::::::::::::>::::::::2>i>:.::.>:o->o->::po->:>:>:.>o-»»:»::::.>:.>::.>::: . : >.: '.. ...:>y::»::>:.:a:::::::::>:»::>o-:::o-i»i::.:::.>:.>o-:::>::>;::.:::.:>io-i:.t:r::.:::::»:.::.:::::;.:>:>::::.>i`»>'.>:'t.::<t.i>o->r:t.>::a
.. �:::::::.��F�
......... ���'
........ �:.x�»i::i::i{:�:�i:�::�::i£:�::�Si:�i:�i:'i::::�:S;ii:%:z:i::y:•:::;_:_::.>::o::�:::•r>::�»::::::•S:u•>:•>:»::>:•:::i;:�::�:>:�.>:+•t:•::;.:
........................................................:..::.�::::::::::
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TOWN OF YARMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
ATTN: BOARD OF HEALTH 1 O DAYS WRITTEN NOTICE TO THE CERl1FlCATE HOLDER NAMED TO THE LEFT,
14 C ROUTE 2 8 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
SOUTH YARMOUTH� MA 0 2 6 6 4 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTA7IVES.
AUTHORIZEO REPRESENTA7IVE �,,� �
:.:.::::::::::::::::::::):::::::::::::.:::::::::::.::::::::::::::::::::::::::::::......................... ........ .......... STACEY L. MORAN� . ���..�_
„�. . . :::,: ,.
...r.....Cfi�I�` " - "SM B
�.:: ��y�y
�'`�..•h�r.''.:'..:. . ',:::::�:::>�::::;::::>::>:>:::<<:::>:>::::::::::::�::::»::»::::::::;>:;::>::>:;::;:>':»:::::::»>::>:<:»:>::::::;<::::»>:::><::::<>::>:::::::::::<::�>::::>::::::::::>:�>::>::»»»;_;;:>::::>::::::;::>:»::»�:<:>::::::::::::;:<:>:;:::::>;:::::>;:::<::<:::»>::>:::><::<:>;;::>>+>::.::::::::::<»>::.r:;::.:.�.;.:,�:.:::::::,�:::::»::.;�:;:;:.;
:............................:.�'��::::::::::::::...................::::::::::::.:�::::::::::.....................:.:.::::::::::::::::::.........................:::::::.�.�:::::::::.....................::::::.�::.:::::::::�a,. � .::.. . . �x... •
............................................::::::.:�:::::::::::::::.�:::::::.:�::.::::;::;.>:::.>o->;;;>;:o-;:.>:.>:n::::o::»:<.;::..>::.:::::::;;::>:::::::::::::;:::::>;;;;>:.>:::o:::.::>:.:;�HtN!:�!'lt+it.ti/.F��'.>. :. . : ' ::::> : .
.........................................::::�������!i�.::��.,
�
� � TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-020 FEE: $45.00
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:
Robert D. Wilkins, 657 Route 28, West Yarmouth, MA
Whose place of business is: Classical Billiards
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2006 BOARD oF HEALTH: L� `?�. �i�,/19.`75., '
� ����, .�, v�e���
�s'rx�c'rtoivs �at�tY: No food preparation on premises. Qo,�wJtt�. Bhoti�vt �
Only manufactured,pre-packaged foods. Only canned beverages. p�/�a�eh�x�
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iJanuary 23.2006 Bruce G.Murphy, RS.,CHO
, Director of Health
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�, -- �., _ �, 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
MATTACH£ES Telephone (508} 398-2231,Ext. 241 — F� {508) 760-3472
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To: Yarmouth Board of Health Permit Hoiders ~
MAY 1 0 2005
� From: David D. Flaheriy h., RS. ;��r H
� Heahh Inspector ✓ EALTH GEPT.
' Town of Yarmouth
i
i Re: Federal Tax ID Number
� Date: March 22, 20(!�
The Massachusetts Department 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(FEI1V)otlierwise
� known as your"T�ID Number". This is purely for administrative purposes only.
Sor� businesses use the owner's Social Security Number (SSI� for this purpose. If this is the
case for yaur 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
�armouth Health Depart�nent
I 146 Route 28
South Yarmouth, MA 02664
� "Thank you for your anticipated compliance. If you have any questions regarding this matter,
please do not�esitate tc�_call. The offace h.n�ars are 1�rlan�da.y�o:,F���, 8�3Q�.m._.�c, 4:3D g.�. The -
telephone number is(508)398-2231,ext. 241.
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� Establishment: FEIN or -
; 1 t �— SSN: (� . ��
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Location Address: �S� �01�'e Z� � �
Signature:
Pru�t: �.�'Li t ��'�D �� Title:
�� Prinke "
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° e- R� TOWN OF YARMOUTH BOARD OF HEALTH;
� -� � � � � ", �`JE� Q
�:. ,�� APPLICATION FOR LICENS�'� '� �,)0�
� -���� MAR i� � 20�5 '
* Please complete form and attach a11 neces�� �`c�u��nts by December 1, 2004.
Failure to do so will result in the return�yow applicat�on pack H�ALTH DEPT.
NAME OF ESTABLISF�VVIEENT: ��5���\ � �� S TEL. # �g–��/--�`�Z
LOCATION ADDRESS: �5� �3 �2-� '�
MAILING ADDRESS: w- � ���
OWNER/CORPORATION NAME: � t�-J`l�i r� S
MANAGER'S NAME: L " �� TEI,. # � 6 7-r�.t 2�'^
MATf,ING ADDRESS:� �--�'i-^� �
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 emplo ees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (YCPR). 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
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 applica.tion. T6e Health Department will not use p�st years' records.
You must provide new copies and maintain a file at your establishment.
1, 2.
_ _gE��O�V IN£H�4T�G�: ____ -- _ _ - __ _ -_—___ _. : _ - - --_ —_-- _
Each food establishment must have at least one Person In Charge(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 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 fde at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIIZED FEE PERNIIT# LICENSE REQiJIFtED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B8cB $50 CABIN $50 MOTEL �50
INN $50 _ CAMI' �50 _SWIlVIlvIII1G POOL$75ea.
LODGE $50 _TRAILER PARK $50 WHIRI.P(NJL $75ea.
FOOD SER'VICE:
LICENSE REQIJIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT#
0-100 SEATS �75 _COTITINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 WHOLESAI,E $75
RETAtL SERVICE:
LICENSE REQUIlZED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIf2ED FEE PERMIT#
�<50 sq.ft. $45 6 �0� _>25,000 sq.ft. 5200 VENDING-FOOD $20
j _<25,Q60 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25
�
� NAME CHANGE: $10 AMOUNT DUE _ $ �S•O�
� '*•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•"""
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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
AFFIDAVTT 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 prio o 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
TF�C4MPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004, j
i
SEASONALESTABLISHMENTSARETOCONTACTTI-�HEALTHDEPARTMENTFORINSPECTION7-10 �
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 COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS �
E
POOLS '
POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opeiung.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count ;
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVIS�RY:
Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yarmouth must notify the Yarmouth H�alth Department by filing the
reqwred Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be
obtained at the Health Department. �
R
FRO�E�T DESSERTS: - __ E
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must ha�e prior approval from the Board ofHealth. '
OUTDOOR COOI�NNG• � �
Outdoor cooking,preparation,or display of any food produ y a ret � o d service establishment is pro6ibited. �
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DATE: SIGNATURE: :
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PR1NT NAME& TITLE: �� � � �` �� ,� �
10/22/04 ;
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TU OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-058 FEE: 45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pennit is hereby granted to:
Robert D. Wilkins, b57B Route 28,West Yarmouth, MA
Whose place of business'is: Classical Billiards
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit e�ires: December 3 l, 2005 BOARD oF HEALTH: Be�a�i�c$. (�'o�i�uc, A�l..n. '
p��r�s� v�e�.�.�
xEs�rtucTlorrs �ax�r: No food preparation on premises. ��. Bnuursi, e�Jtl�a
Only manufactured,pre-packaged foods. Only canned beverages. cl�fti IQ./V
� �l��'�i�e.idr�w, R.N. �
March�G:-�S ruce G. urphy, ,RS.,CHO
Director of Health
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o. R TOWN OF YARMOUTH BOA O n ��,1:�3H - - � �
o, =� ' � APPLICATION FOR LIC E � �T 20�14 qpR � 3 2004
+r .!s �\ "
•. * Please com lete form and attach all necess do�i�nents b Dece
p �* y �i�AL��i�EPT.
Failure to do so will result in the returri�of your application pa
AME O S M NT: E . # 7Z,
L CATI N ADDRESS:
M I RE • ` ��
OWNER/ ORATION NAME: J
MANA ER'S NAME: � TEL. # � -Z �
LING ADDRESS: L �
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Opera.tor(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 Sta.te Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2•
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1, 2.
3. 4•
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABiN $50 _MOTEL $50
I INN $50 _CAMP $50 _SWIMMING POOL$75ea.
LODGE $50 TRAILER PE1RK $50 _WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>l00 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75
' RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�(�..�<50 sq.ft. $45 ��'� >25,000 sq.ft. $200 _VENDING-FOOD $20
�<25,000 sq.ft. $75 _FROZEN DESSERT $35 I TOBACCO $25 NOT SEU-1 NG'
NAME CHANGE: $10 AMOUNT DUE _ $�,� �g'�cco PK.o�?
i **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �5..OO
�
i
�
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
2�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid prior 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 R,ESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2403.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR iNSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTTNG, 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
i
�
POOLS �
s
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 Sta.te certified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimrning 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.
�ATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporaty 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 C�FFS:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have p�ior approval fram thz Board of Health.
(LUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ,
�
� i
DATE: ti� - SIGNATURE: �
PRINT NAME& TITLE: �/�,�,. �,
.
10/22/03
� �
�
The Conrmonwealth of Massachusetts �`1 �'�,�,
� � Deportment of Industrial.-f ccidents
T ; Olflceo/%s�Ostbis
600 Washrngton Street
�, .� Bnston.Mass. 02111
�'" "�y V4'orkers' Compensation lnsurance Affidavit
ARM!�ant infi�rmatinn� P�C9sepRlp'TTld�'ItT�t
n�mr� +b�� � � �/� :
�catian• � � l_._���.A,��_�lr�c
• � ?�(o C� y ►t � -t�
` � I am homeowner pert�rming all w�ork myself.
� I am a sole proprizror ��,�, ha�e no one��orkin_ in am•capaciry
(�I am an empio�er pro�idino workers' compensation for my empioyees w•orkine o.n this job.
��Ra n� n a me C ` / P@–�S-� �4-�\ �f�\1 V�-� �
�,ddress• ��� �� � � '
S1Ll" �n.� I ��*'"`""�� nhone fl• ��(J 7� ����.� ?7 �Z
insur�nce co policy!�
� I am a sole proprietor. generai contractor, or homeowner(circle one/ and hace hired the contractors listed below ��ho ha�e
the follo��in� �.orkzr��,ompensation polices:
comR.��v n�me•
address•
�- Rhone k• —
insur�ncc co p���«�
com�nv name•
address•
� ohoee l�•
insurance co �*
�
Failure to sccure covera�e as required uader Secnoa 25A of MGL 152 n�lad to tbe i�paitio�of erivi�i peadtle�o(a��e ap to 51,500.00 a�d/or
oar yan'imprisonment a�w•elf a�civii ptaatHe�io the[orm oi a STOP WORK ORDER aed a liat ot2100.00�dar Ktiost me. I udersta�d tsat a
copy of thy satement mav be fonwrded to the OlTice ot Inve�tiguiom of t6e DU tor eovera�e veritfado�.
I do hrreby cen' under ih peins and pe �ies of perjury tkat tht injornrotion provided above is ttue and correct
Signature _ �:7�z- '�rr�
t
Print name o one 1�r��_,� ' � 7 �
o(Ticial use onl� do not.►rite in this area to be completed by citv or towa oAleial
citv or town: Y�M�IIT� _ pertoitAieea�e M n8uildiog Departmen[
• — �Lieea�iog Board
�check if immediate response i�required 261 QSelectmen'�ORiee
�Healt6 Departmest
; contace person: pfione N:_ (508) 398�2231 ext. nOther
1
,
1
I
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�aa�a.�gn s ps u�eu�ssaj aouuag poo3��.ag :ssact�saq�o ad�iZ
sp.ret��ig���ss�t3 :si ssauisnq�o a���d asoy�
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OO�S�$ =� £90-i�0# �2I��Nit11�I,LII�i2I�d
1.1�t�Z1IHSI'IB�,LS�Q003�'�.L�2I�d0 OZ ZIL�RI�d
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2�'�;aR.� TOWN OF YARMOUTH BOARD OF HE�`��'I� --�" ,�
� �����c APPLICATION FOR LICENSE/PE ���� G� '` ��� � � � � �
o._-
� ��,,s a � �'�� 2 5 ���7
* Please complete form and attach all necessan��� LL � ecem er��1, 2002.
Failure to do so will result in the return `��:' ur ° ication pac efi �� i Ti 3 _"�T
�;\ Y 'r"Z._,r�i�a t ? ��.r
- �� .__.�,...�_�...�.. .
� T SH E : ��1 � L. 0 • -5 'Io�
� L I DD 5 -��` �'13
MAILING ADDRESS: SA�-E �
wlv xP �rr w�uc l N�
R'S AME• h i D TE #
MAILING ADDRESS: JQ�
�
i
POOL CERTIFICATIONS:
The pvol supervisor must be certified as a Poal Operator,as required by State law. Please list the desi�nated
� �'ool Op�rator(s;�uld at#ach a-co�y of the�ert.�ficati�i: tc�th�s f�rn�. - __ —
� l. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies 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 Se�vice 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 tile at your establishment.
�
1. 2.
_ P�:����IV��ARCi�:_ . . - --- -:-----. -_
Each food establishment must have at least on�Person In Chazge(PIC) on site during hours of oper�tion.
l. 2• ;
HEIMI,ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
1 imes. Please list our em lo ees trained in anti-chokin rocedures below and
Maneuver on the premises at al t y p y S P
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 q, _ _.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
• LICENSE REQUIRED FEE PERMIT# L(CENSE RGQUIRGD FEE PERMiT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABiiv S50 _MOTEL_ $50
INN $50 CAMP $50 _SWIMMING POOL$75ea.
_LODGE $50 �TRAILER PARK $50 _WHIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-]00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25
�, .�;,_���QU�Et�T� ,�.,,$150 _ COMMON V[CT $50 _WHOLESALE $75
—�--�— –�--
� s � � �� � , �
�� � 1� � 1 ,� � ' � � ' �n ,� , , '� - � > � t � �
,�..�.._.. � � � a� ��'y�'� : '�'y��4�-�ft'w'^�f-�r3 ktv""�.:• �t �`��.;t �Y `�.k#��r .: $ A..'k�` .�? .�*5�....;� J� {�"��''r.s.ren-!: :h,.r}i{ Y'6 -�,:? k ' � F M '..
.,... ,..,,......�..................._................._,...��.. .-�...__..... r.»__�..�.�.._...>,,...� ,_»._.__�._�.�.._. �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�� �ER]�1T`�""" `""����1����R�Q�iJIR�{D-��'"�::.-`#��'F�"`�._r.W
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
�<25,000 sq.ft. $75 �6�� _FROZEN nESSF,RT �35 �TOE3ACC0 ����I
NAMECHANGE: $to AMOUNT DUE _ $ IOo,p4
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
.� _ �_
ADMINISTRATION
Under Chapter 152, Section 2SC, 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 1NSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK �
APPROPRIATELY IF PAID: �
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ,
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�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. '
i
��DI'T'IONAL REGULATIONS �
i
�
POOLS
POOL OPE1o1ING:All swimming,wading and whirlpools which have been closed for the season rriust 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. ;
i
E
FOOD SERVICE
�NSUMER ADVISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
rATERNG 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
obtamed at the Health Department. �
FROZEN DESSERTS•_ _—_——__------ ---- —-- — -�
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�nust 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:_�I j�1 - GNATURE:
�
PRINT NAME& TITLE: � �
10/18/02
C�rPc� oF ��«�s Co rn� � f.�sErca hy �ti s. co�,���,�,r� :
.�� , _ .. �
The Commoawealth of Massachusetts
� � Depa�tment ojlndustrial,-1 ccidents
� ; Of!lcao!/�es�l�s�liis
� + 600 Washington St�eet
, = B�ston.Mass. 02111
�" ��y W'orkers' Compensation Insurance Affidavit
Anolicant informallon• P►esaep'R�'T'Ti�.'Wic
n�m�nL�� �jl 1�.�N�
lucation: �� L'��.��� �w�i
�it� �� U��14AJ� cp� ehone� ��C6' �� •Q�Q '
� 1 am a homecw�ner pertorming all w�ork myself.
� ( am a sole propri�ror�:-,', ha�e no one ��orkin� in am•capacin•
I am an e�o�e_r ro�iai�w�ori:�rs' compensatio2for_m��,gmploy�ge.��_carkinsaa_this_job.
L�CI_-— — _ —
a n • n : �✓�^ �J 1� ��l.l.i I�� -
d d res : �S� � U
citv• � U�1�T�N (J�(.Q�� ehoneM• �(� � � � ` � ` �"��
insurance co. ��� N�T��I� R.4!!S)'# �-J �'E C. -��Q SQ7
� I am a soie proprietor. _enerai contracror. or homeoK�oer(ci�cle oneJ and ha�•e hired the contractors listed below ��ho ha�e
thz follu��in� ��orker� �ompensation polices:
comQanv name•
address•
ci�y: nhone 1!•
insurancc co. Folic}#
company name•
addresr
slly: pboee 1!•
insarance co. noliev�t
t
Failure to secure cove�aee as�equired under Secnoo 2SA o(MGI.1S2 n�lad to t6e iepaitioe of eri■ivi peadtles of a 6�e ap to 51,500.00 a�d/or
one yean'imprisoement»w•ell s�eivil penaltie�io the form of a STOY WORK ORDER aad a tise of S100.0A a dar Kainst ma I s�dersta�d that a
copy of tha statement m . fonvarded to the 011ice of investig�tioo�of tbe DU for coven;e veriflatio�.
/do hrreby c ifj•under tb� d prnal�ies ojpery'ury that tht infornrativn provrded abovt is tntt and coritct
�_
Signatu v�— T�J�T `�
Print name ` one M 7�U / �f �7 $ ��
., ofticial use only do not..rite in this area to be completed by ciry or tewa oAleial
city or town: Y�M�IIT� _ permitAicease M nBuilding Departmeut
�Lieea�iog Board
�eheck if immediate respoese ie required 261 �Seieetmen'�OlTiee
�Health DeQartmeet
con�ace person: -- --- pdone k:_ �50$) 398�2231 ext. nOthe�–
,.. .Y. .<��1.: .
1
; � ,
� '.......................................................................................................................................................................................................................................................................................
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,.. :::;: :::;: ::;:.;: ":: ".::>:;: :]�.!..:,: . 2;::.>:: . ;::: �i: f�"i::;: :;::: : ...::;:: :::::: :: .�:::�i1��: : ::;:: :::: :::::.. :::::: . • :. '•.: :;: : .. :::. .:: ' :;:.>:: ...::::::::::::i::i::i::;::;::;::;::;::;::;::Y.::: � � :;.;
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.......�........:.::::::::::::::::::.::::::::::::::::::::::::::::::::.:::..�..�....�.:::.:::::::::::::::.....�.1.�`..::::::::::::::::::::::::::.::::::::.. 11 2 0 0 2 ::>:`
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:.;::::>::;::>::>;::>:::>::>::>::>::>::>::>::>::»>::;:.;:::.>;>::>::>::>::>::>::>::::>::>::>::»::;:>::>:;:>:<:;:;<:>;;:<:>;:.::.;:.;:>;:.;:.;:.;;;;;;:.;:.;�::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::......
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
OCEANSIDE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
724 MAIN STREET COMPANIES AFFORDING COVERAGE
HYANN I S MA �2 6�1 COMPANY
+ A THE HARTFORD
INSURED COMPANY
ROBERT WILKINS DBA B �� , �%� ^ �-
CLASSICAL BILLIARDS COMPANY �
� 657B ROUTE 28 � 4� ' "c
WE S T YARMOUTH MA 0 2 6 7 3-5 0 3 4 COMPANV
D �—��- �.$ ;-5�-r�
, • . .'.....................:::::,::::::::::.:::
I ::::. ..::.....:..:..:.....::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::..�:.
�L�(3k1f E#�iGE$::>::::>::::>::::>::::>::::>::::>:z::«:::>::::>z:z:>::::>:<::zi:>:z::<:;:z:::>::>::;i::::::<:>:>:>:::>::;>::>:>;::::>::::::::>::::>::::>::::>::::>:::::::::::::z::<:>:i:::::::::;::;><:>::>::>::>z;:<:>::>::::>::::>::::>::>:::<:::>::;:::;::::::>:<:::>:<::<zi:::::::>:<::<:::;::;;:::;:::;::::s:::;::'>::;:::;:::;:;:;:::::;:::?;::::::;?::>::::>::>::::>::::>::::>::::>::::::::>::::»::r;:::::::>:::<::<::»:::>;:::::;<::
.......................................................................................................................................................................................................::::::AB::.VE.F�R�THE POLICY:::::::PERIOD:::::
..........................................................................................................................................................................
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED O O
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
� EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFECTIVE POLICY EXPIPATION
TYPE OF INSURANCE POUCY NUM@ER ��_ LJM1T�
LTR __ _ - -- _ _ �ATEjMM[DD/YY1- _DAIB(MMtD�)"` — --- --- - __- . ___---
GENERAL LIABILITY GENERAL AGGREGATE $
+ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $
� CLAIMS MADE �OCCUR PERSONAL 8 ADV INJURY $
OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $
i FIRE DAMAGE(My one fire) $
� MED EXP(Any one person) $
i AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
i
AL�OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
I ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
, AGGREGATE $
, EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
,
_ _ waa��ts�a�vsa,mr,arv� - -�3--6+F�� EN �-59'�_— b�-8_7�� __ D-7 03 X Fo��a,Fs �a ; _ - ' ----_
EMPLOYERS'LIABILITY
EL EACH ACCIDENT $ 1 O O� O O O
THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ S O O� O O O
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 1.O O� O O O
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
��y �yy� u.�............. ......................... ...... .... . . .. ....... .... . .. *� .�wy ..... . �.i. . . . . . .. . .......................:................ .....
� . : 1 �.1
...y.�rCh.��t}vl��+�+�i.�:',F:�!�+.�.�.`�;.:::<:::. �. � :::i::c::i:f::i:::::: .........�r:tM4�t�r:�'4«`'.���*`!E 'E:::::::::::::?::E::i
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TOWN OF YARMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
ATT: BOARD OF HEALTH 1 O DAYS WRITTEN NOTICE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT,
114 6 ROUTE 2 H BUT FAILURE TO MAIL SUCH NOl10E SHALL IMPOSE NO OBLIGATION OR LIABILITY
SOUTH YARMOUTH MA 0 2 6 6 4 OF ANY KIND UPON THE OMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATI
::::::::::.::::::1::::::.:::::::::::::::::::::::::::::::::::::.�:::::.:�::::::.::::::::.::::.::::::::::::::::::::::.::::::::::::::::::::::.:::::.:Catherine....A................:...:.� ........................KS....B..........................
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
j PERMIT NUMBER: #03-021 FEE: $75.00
,
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of ffie eneral Laws,a permit is hereby granted to:
Robert D. Wilkins, 657B Route 28, West Yannouth, MA
Whose place of business is: Classical Billiards
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 Bo�oF�r�.Tx: �aArlea s� x�, �a�r�ca�c
_ _ _ __-- -__ _ _ __,
_ � ?>.. �.o7alaK, yll.?�..�u;e
xEs'r1t[C'r�olvs ��: No food preparation on premises. �a��. ��'to�rac. L�lat�
Only manufactured,pre-packaged foods. Only canned beverages. �a�tte���
�e+�t�c Sl�. ��
December 17 ,2002 ruce G.Murphy, .,CHO
Director of Health
THE COMMONWEALT�OF MASSACHUSETTS �
. , ,,: TOW1�:,OT YARMOUTH > . _. `
BOARD OF HEALTH �
PERMIT NUMBER: #03-014 FEE: $25.00
(
_ :,This is to Certifythat Robert D. Wi�kins'd/b/a�lassical Billiards
�: 657B Route 28, �Vest Yarmouth,MA : _ ;-
_ __ .. .
.
IS HEREBY GRANTED A LICENSE
, r;� For SALE A1�FD DI�TRIBUTION OF TOBA�CQ PRODLJCTS. : �. , � . : � . ..;
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. :
e�$'es�t i�s�ante3dl i���fom�t�with Article Vi�f�he S�Code of The Commonwealth of Massachusetts,and .,,,
xp� ss sooner suspen e or rer�d e .
December 17 ,2002 BOARD OF HEALTH: ��� i�e�'cet, �al�iria�
__. bce�a1a�r�.c D, G�imralo�. �K D., 2/iu ��awc
�o6�t�. �noao�c, G�lark
���D�
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�
ce G.Murp ,MPH, .
Director of Health
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�' � ' � ��� �� WN OF YARMOUTH BOARD OF HEALTH
� � LICATION FOR LICENSE/PERMIT -2002 s � �'�, �
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* Please co ple��orm and attac�all�essary documents by December 31, 2001. Fa�lur��dc�sa���'esu�t in
the return of your application packet. � �
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LING SS:
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 co�y of the certification to this form.
l. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies 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 Sta.te 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•
__ ____�EI���N IN CHAR�E:-_ --- --- ------ _--- � _ __ _ �
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2•
HEIMLICH CER�'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-choking procedures below and
attach copies of employee certifications to tlus form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at-your place of business.
L 2.
3. 4.
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.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 _COMMON YICT. $50 WHOLESALE $75
RETALI SERVICE•
LI���TSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBA�O $20 � <25,000 sq.ft. $75 �a-d 27 �TOBACGO $20 �Q��
_<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35
NAME CHANGE:� �i9 AMOUNT DUE _ $ �S•OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION
!
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Under Cha.pter 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 � � �� � CL� 6
CA � �
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WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid priar to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES d NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiIRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 200L
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�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 REQUIIZE 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 Sta.te 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 of Health.
OUTDOOR COOKING:
Outdoor cooking,prepara.tion,or display of any food product by a retail or food service establishment is prohibited. _
�
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DATE: �' SIGNATIJRE:
PRiNT NAME&TITLE: ` �
09/11/Ol
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MAITER OF INFORMA
� OCEANSIDE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
{ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
� ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
� 724 MAIN STREET COMPANIES AFFORDING COVERAGE
HYANNI S MA 0 2 6 01 coMP,�wv _._ . _
A ONE BEACON INSUR.I�NCE
i INSURED COMPANY _
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I ROBERT WILKINS DBA B ONE BEACON INSURANCE'',.
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THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO 7ypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
�' �eNeRa�une►uTr QBR4 3 3 5 5 6 �3�2 4���. 0 3 f 2 4 O 2 GENERAL AGfiRE('.,ATE $2� ���� ���
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $1� O O O� O O O
CLAIMS MADE a OCCUR PERSONAL&ADV INJUAY $ S O O� O O O
OWNEFi'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $1� O O O� O O O
FIRE DAMAGE(My one fire) $ r'J�� ���
MED EXP(My one person) $ 5� ���
AUTOMOBILE UABILITY
COMBINED SINGLE LIMIT $
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ALL OWNED AUTOS BODILY INJURY - $ -
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NON-OWNED AUTOS
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GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE y
EXCESS LIABIUTY EACH OCCURRENCE $
UMBRELLAFORM AGGREGATE $
OTHER THAN UMBRELLA FORM �
WORKERS COMPENSATION AND QBH2 0 8 3 51 6 O 7 O Z G O�I O 2 X TORY LIMITS ER
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OFFICERS AHE: EXCL EL DISEASE-EA EMPLOYEE $ 1 O O� O O O
OTHER
DESCRIPTION OF OPEHATiOMS/LOCA710NSNEHICLES/SPECIAL ITEMS
BILLIARD HALL
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEILED BEFORE THE
TOWN OF YARMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
THE BOARD OF HEALTH DEPARTMENT 10 DAYS WRIITEN NO110E TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT,
114 6 ROUTE 2 H BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
S OUTH YARMOUTH MA 0 2 6 6 4 OF ANY KIND UPON THE P Y, ITS AGEN S OR EPRESENTATIVES.
AUTHORIZED REPRESENTATIV
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WEST YARMOUTH MA 02673-5034 �PANY
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IN�ICATED, NOTWITHSTAfVDING ANY FEQUIREMENT, TERM OR CONDITION OF ANY CANTRACT Ofl OTNER DOCUMENT WITH RESPECT TO WHICH THIS
CERTfFICATE MAY BE ISSUED OR MAY PEFTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEFiE1N 1S SU�IECT TO �l.l. THE TERMS,
EX(�.USiONS AND CONOITipNS OF SUCN pOLiCIES, UM17S SHOWN MAY HAVE B�EN REDUCED BY PAID CLAIMS.
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BODILY INJURV S
SCHEDULED AUTOS (Po�Do�)
HIRE�AUTOS 9pDN,V INJURY ._... . ^-.•-•-- ---�
NOM-OWNEDAlfT05 IPerqppQenq a
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�PAOPFRTV pAMAGF S
GANAGE LIABILIIY AUTO ONLY-EA ACJCIOENT $
ANY AUTO DTHER THAN AUTO ONLV:
�_, _. EACH ACCIDENT �
AGGREGATE S
EXCE99 LIA6ILITY EACM OCCURRENCE $
�UM6FEllAFOflM AGGREGATE §
OTHEFi THAN UMBHELLA FOliM �Y ^ a �
wo�es coMv�sanoN nr�o QBH 2 0 8 3 51 6 0 7 01 6 0 7 0 2 X ' "'
TORY LIMITS ER ..........:..........................
EMPLOYER8'WIBILJ7Y EL EACH ACCIDENT a 1 O O� O O O
P„ARTNER3/EXIE ECUT{VE INCL El�ISEASE•POIICY ItMIT S 5 O O� O O O
OFFICERS ARE: tlfCL EL DISEASE-EA EMPLOYEE 5 1 O O� O O O
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DE9CRIPnoN OF OPERA710N9a0C�110N9NENICLES�SPEGA�ITEAA$
BILLIARD HALL
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9HOUI.p ANY OF THE ABpYE OlSGtlSED POLJqES BE CANCELLED BEFORE THE
TOWN OF YARMOUTH EXPIAA�70N OATE TNlRlpF, Tlie ISSUING COAADANY WILL ENDEAVOR TO MAIL
THE BOARD OF HEALTH DEPARTMENT 1�pqYS WRITTEN NOTICE TO TME CERT1i7CATE HOLDER NAMED TD 1HE LEFT,
114 6 ROLJTE 2 B 9UT FAIWRH TO MAIL SUCFI NOTICE SMALL IMP03E NO OBLIGATION OR LIABILIlY
SOUTH YARMOt7TH MA 0 2 6 6 4 OF ANV KIND UPON TNE PANY, ITS AOENT9 �R FEPRE9E1iTA71VE5.
AUTNORIZED pEPRESENTATIVE
,., : I .., Catherine A.
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TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
,
PERMIT NUMBER: #02-027 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to:
R�bert T�. Wilkins, 6 7B R� � . 8,West VarmoLth, MA
Whose place of business is: Classical Billiards
Type of business: Retail Food Service less than 25,000 square feet
To opera.te a food establislunent in: Town of Yarmouth
Pernut expires: December 31,.2002 Bo�oF t-�EEAI.TH: �4a�.� xd,luF�c, ��,ra�c
�cfa�ri�c D. �ia�td°"c, '�D., `j/iee
�s'r1uC'rtorrs IF.�tvSt: No food prepazation on premises. ,�o�tt� �, �i�
Only manufactured,pre-packaged foods. Only canned beverages. �a�rlck'�e�aco�t
�� s�, �n
A nn '15 ,2002 ruce G.Murphy, .5.,CHO
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #02-021 FEE: $20.00
'rhis is to Certify that Robert D. Wilkins d/b/a Classical Billiards
657B Route 28, West Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRiBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
This permit is granted in confornvty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31_2002 unless sooner suspended or revoked.
Apri15 ,2002 BOARD OF HEALTH: �ca�recd�s�, �e�i, ��t�uxu.c
�e.��D. G��acde.r, 7??l.D.. 2/ice C�a�acc
,��tt� �aouWc, ��
�a.�uc��fcD�xo�
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Director of Ha lth�
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; TOWN OF YARMOUTH BOARD O�"H�`�,�I'H �
APPLICATION FOR LICENSE/PERMIT-2001 �� �EC O 7 ZOOO
HEAL; :�� UEa..
....._...._..... .
* Please complete form and atta.ch all necessary documents by December 31,2000. Failure to do so will result in
the return of your application packet.
--------------------------------------------------------------------------------------------------------------------------------------------
• G� SSiI' � �/[.�/i(,�S .5 �7 l•,5 7�
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POQ�CERTIFICATIONS:
The poal supervisor must be certified as � Pool Operator, as rec�uired by new State law. Please list the
designated Pool Opera.tor(s)and attach a copy of the certification to ttus form.
1. 2.
Pool opera.tors must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Deparlment will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
; HEIMLICH CER`I'IFICATIONS.
All food service establishments with 2S 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 Departmeat will not use past years' records.
You must provide new copies and maiatain a file at your place of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SM4KING SEATS: TOTAL#
� � ___�_—:-----_---�----•---�-----------�-----�---�-_ --_- -_-�------�- - -
_ _ ___ _- _ _- -- -- - - - - _ .
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
B&B $50 CABIN $SO
_INN $50 _CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMMING POOL $SOea.
WHiRLPOOL $25ea.
�'QOD SERVI�E: `�
NOTE: Per the new 105 CMR 594.000 State Sanitary Code for Food Establishments,the effective date for
food protection manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 'i
_0-100 SEATS $75 _CONTINENTAI., $30
_>100 SEATS $150 NON-PROFIT $25
iCOMMON VICT. $50 WHOLESALE $75
�TAIL SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 / TOBACCO $20 �'0�-�O�o
1 �L5,000 sq.ft. $75 �QO? FROZEN DESSERT $35
____>25,000 sq.ft. $200
NAME CHANGE: $2 0
AMOUNT DUE _ $ 96.00
**•'�*PLEASE TURN OVER AND COMPL�TE OTHER SIDE OF FORM*****
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?— - ± .- .....� +, ` y �
' ADMINISTRATION
:
; s
i ..Uxide�;Chapte�1�2,�ection 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 �NSUitANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR _ _ - '
, _
CERT. OF INSURANCE ATTACHED �
�
W�RKER'S COMP. A�'FIDAVIT SIGNED AND ATTACHED `�
Town of�armouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: .
YES � NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLISHaVIENTS ARE TO CONTACT'THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENIlVG 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.
;
ADDITi4NAL 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
cerhfied lab,prior to opemng, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
I
FOOD SERVICE
NEW STATE SANITA Y CODE FOR FOOD ESTABLISHMENTS• :
The effective date for food prntection manager certification is October 1, 200L As stated in 105 CMR
Sg0.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection
manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As sta.ted in 105 CMR 590.000(K), enforcement
of Consumer advisory,Food Code 3-603.11,will be implemented January l,2001. Only establislunents which sell
or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories.
�ATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours pnor to the catered event. T'hses farms can be ,
____�bt�n�d at the Health Department. _ i
FROZEN DESS�RTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results mi�st 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.
QUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),rnust 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.
1
• I f�D SIGNATU :
DATE.
PRINT NAME&TITLE:� 1`;i h ,���/iB� �(� r��'�'
11/16/00
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�+��R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
OCEANSIDE INSURANCE AGENCY INC ONLY AND CONFERS NO RIQHTS UPON THE CERTIFlCATE
HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR
17 EAST MAIN STREET ALTER THE COVERA(iE AFFORDED BY THE POLICIES BELOW.
P O BOX 2 9 0 6 COMPANIES AFFORDIN(i COVERAQE
HYANN I S MA O 2 F>O 1 CpMPANY
A CGU INSURAI�TCE COMPANY
INSURED
COMPANY
ROBERT WILKINS DBA B
CLAS S I CAL B I LL IARDS �pMppNy
657B ROUTE 28 C
WE S T YARMOUTH MA 0 2 6 7 3-5 0 3 4 COMPANY
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THIS IS TO CERTIFY THAT THE POLJCIES OF INSURANCE LJSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLJCY PERIOD
INDICAT�D, NOTWITIfSTANDING ANY REQUIREMENT,TERM OR{IONDIfi1PiS�1 OF kMY CflR1TRACT CjFi OTHEI��OCUAt�fdT WITI#f�ESf�Et�.T i0 WHIE9H'FHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF N�URANCE POLICY NUMBFA DA7E(MIAIDD/YY) POLICY�MIDD/YnY N L�ARS
L7R
aE�+��� CBR4 3 3 5 5 6 0 3/2 4/0 0 0 3/2 4/O 1 GENERAL AGGREGATE s 2, 0 0 0, 0 0 0
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG SZ� O O O� O O O
CLAIMS MADE �OCCUR PERSONAL&ADV INJURY $ S O O� O O O
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1� O O O� O O O
FlRE DAMACiE(My one fire) $ rj�� �Q�
: Mm EXP(MY Ons Pe►son) S S� O O O
AUTOAAOBN.E LIABRITY
ANY AUTO COMBINED SINGLE LIM(T S
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (�Pe�)
HIRm AUTOS BODILY INJURY
NONAWNm AUTOS (PM acciden�) $
PROPERTY DAMAGE S
(S'ARAQ'E LIABLRY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCE$$LlAB�Y EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
07HER THMI UMBRELLA FORM S
won�ns coM�s�ron e� QBH 2 0 8 3 51 6��7��� 6��7�Q 1 X 7pRY LIMITS ER
EMPLOYERS'WBNITY
EL EACH ACCIDENT $ 1 O O� O O O
TME P�PR��� �� EL DISEASE-POLICY LIMIT $ S O O� O O O
PARTNERS/EXECUTIVE
OFFICERS ARE: DCCL EL DISEASE-EA EMPLOYEE $ 1.O O� O O O
07}ER
DESCRPTION OF OPEAA710118ILOCA CIAL REIA$
BILLIARD HALL
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................................................
SNOULD ANY OF iFE ABOVE DE8CR�ED POLK;ES BE CANOELLEp BEFppE iHE
TOWN OF YARMOUTH EXPIRA710N DA7E iHEREOF, n� �ssur�x3 co��nr wu e�o�rwon ro�
L I CENSE & PERM I T DEPAR.TMENT Q unrs wnrrrgN rwnc�ro n�c�rrs�c���n wweo ro n+e�r,
�14 6 ROUTE 2 8 _- __ _ _ ____
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BUT FAILURE TO MAIL SUCH NOi10E 8F44LL.YiitP08E NO OBLIQ,A710N OR LIpBILIT1f
SOUTH YARMOUTH MA 0 2 6 6 4 0� u�r K� uPo� n� carP , rrs Aa�rs on R�p�EMArn�s.
aun+on�o r�PnesErrumrE
CATHERIN
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� THE COMMONWEALTH OF MASSACHUSETTS 6
' TOWN OF YARMOUTH
� BOARD OF HEALTH
i
PERMIT NUMBER:_ #01-006 FEE: $20.00
�
' This is to Certify that Robert D Wilkin d/b/a Cl sical Billiards
;
657B Route 28 West Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DI�TRIB ITION OF TOBA CO PROD CT
TIOri
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
Januarv 26 ,2001 BOARD OF HEALTH: �� ��, ��1�' ��
�oawc � Su�i��c. �7'l. . ?/u:e elaa�ra.�
��it? �'�au�c. C�
'l��iclr� d ',C��cy�c
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Director of H alth
I
TOWN OF YARMOUTH
BUARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER;_ #01-007 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:
R� D �x�ilkin�, 657R Ro � R,�IeS Y rmouth, MA
Whose place of business is:_ Classical Billiard
Type of business: Retail Food Service le�s than 25 (l�n sa�feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31_ �nn� BOARD OF HEALTH: �d� et�ea., �lr��„�
C�a�ed� xa!l�i, ?/ice �?a'�ar,r„aa�c
�tEs'rx�c'rioNs �,41vY: No food preparation on premises. ��� �?,��� ��
Only manufactured,pre-packaged foods. Only canned beverages. 7f�cCd� d .L�
�� • o��. .�.
Januarv�6 �2001 Bruce G.Mutphy,MPH, .5., p
Director of Health '
i
G lc��si Ca l T�� L L ia��cl.s
+ � TOWN OF YARMOUTH BOARD,OF HEALTH (� � (C; � f? M (� [�p
APPLICATION FOR LICEI�ISE'/PERMIT-2000 3�
� � ����'r ��C Z 2 1999
* Please complete form and attach a11 necessary documents by DeCember 31, 1999. F r��v�a�s;q��jsult in �
�
the return of your application packet. '
------------F ES-------------------------CL SS l C L. �I[_(_/.d t'U�S _.._ _ ,------------------#-�7�-5 8�a---
i n('ATiON ADDRESS Lo57 o'lg, � /1/� (�Du � �I .Q Oa��3 �
MAiLnvG AvnREss� sQn� E
N ,�C'�E
T /�. /N 5 �
' �S �'1' # ,
D D � �5 3
------- ------------------- --------------------------- -----------------------------�-----_-----------______------------------------------�
POOL CERTIF'r�ATIONS- `
The pool supervisor must be certified as a Pool 4perator, as rec�uired by new State law, Please list the `
designated��Op�ator(s) and attach a copy of the cert�fication to tlus forin. - �
1. 2, k
Pool operators must list a minimum of two employees currently certified in basic water sa�ety, 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.
�TM�,ICH CERTIFICATI�NS_
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 af employee certifications to this form. T6e Health Department will not use past years' records.
You must provide new copies �nd maintain a file at your place of business.
1. 2.
3. 4.
RESTA�IRANT SEATING: TDTALx#- - - -�IQI�=�h n�rnTrT SF.,,�TS: '�DT�.�_— _ --- _
---------------------------------------•------------------___----------------*------------------------------------------__--------------------�
OFFICE USE ONLY �
T.ODGING: i
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# �
B&B $50 CABIN $50 �
S9 z CAMP �r50 , , � ,
� p�l s}'�.� � �'.a �f r+�+' YI°?t�W��_ i,���t� 1t� .�� » ���" a **�,'', _' f ,� ���j -4 +.;� ,� �� �� � x �
� a.0 r u �r R��`- �, ,*.3 ��,r�� , `�`r.,� �.; 5 _ i,, t"�°t=f , ,�`,�'�`1F'�`�'+t"i� .:.T:u�.+"�'3'� •.t"s:"'n�,,a,a'�,'"i
� y�«�� 4��r9 7 , �i. a h � j�:���k��,T a�'''/ ": ��`�� � �4 ����d���A„���.�'�, �;t`�� s`'a�+rar a 4 r„y'� � ,,,�° ,
'� " �_����.�it��. �: � a���'S '���� � ;�r��'�'�f � �"���� �Sa '� `� '�t ,t+> r'�� ,e —n—�-.t»a 3~ ,.
,� �-�-�SWIlVIlVIlNG POOL N $SOea. F �
MOTEL $50 ________ —
WI�RLPOOL $25ea..
FOOD SERV�CE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 �CONTINEN'TAL $30
>100 SEATS $150 NON-PROFIT $25 �—
�—
COMMON VICT. $50 WHOLESALE $75 -
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERNIIT #
<50 sq:ft. $45 _ _ _ _ �TOBACCO $20 2K-
,�.FRpZEN DESSEI�T $35 /
j � <25;000 sq.ft. $75 ��-3� --�.--------
1 — . _ _ _ '_,
� >25,000 sq.ft. �200 . ; �. � _ . � - ,
� , , — -
� � ` �vaMF ['RANGE• $10 __________ �
AMOUNT DUE = $�'► 'rJ
�
� PLEASE TURN OVER AND COMPLETE UTHER SIDE OF FORM"`"" �
�krt1tR■ ,
1
r..�.... ...... .. . . .. F �
ADMINISTRATION
UNDER CHAP'TER 152; SECTION 25C, SUBSECTION 6, T'HE TOWN OF YARMOUTH IS NOW REQUIRED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS`IF A '
P�R50N OR: CQ�IPA�NY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INS+(JRAIVCE. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR.
CERT. OF INSURANCE ATTACHED
�
VVORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID:
YES � NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN T'HE COMI'LETED APPLICATION(S) AATD REQUIRED FEE(S) BY
DECEMBER 31, 199$.
SEASONAL ESTABLISHN�NTS ARE TO CONTACT THE HEAI,'TH DEFARTMENT FOR INSPECTION 7-10
DAYS PRIOR T4 OPENIlVG FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE ItEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH pRIOR TO
COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�DITION I RF 1i ATIONS
POOLS
POOL OPENING: ALL SV'VIl��IlVIIlVG, WADING AND WHIRLpOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEpARTMENT�A1�J�'�WATER TESTED FOR
--- PSEUDOMONAS, TQT�L,COLIF0�2M AND STANDARD pLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEI�IING, AND QtJARTERLY THEREAFTER.
POOL CLOSING:EVERY OUTDOOR IN GROUND SVVII��IlVIIlVG pppL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
� ('ATFRiN(�pQi T('y
, ANYONE WHO CATERS WITHIN THE TOWN OF I�ARMOIJTH MUST NOTIFY TI�YARMOUTH HEALTH
J' DEPARTMENT BY FII,ING THE REQUIRED TEMpORARY FOOD SERVICE APPLICATION FORM ?2
1 HOURS PRIOR TO TI� CATERED EVENT, THESE FORMS CAN BE OBTAINED AT T'HE
DEPAR,TMElv'I'. ��TH
FROZEN�E �FRT�
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
� RESULTS MUST BE SENT TO TI�HEAI,TH DEpARTMENT pAII,�T��p SO WII.,L RESULT IN TF� i
SUSFENSIONORRE �
_ VO ,
CATIO
__ _ N OF YOUR
- - - FROZENDE
SSERT PERMIT LTNTII,THE AgOVE TERMS HAVE
BEEN MET. - __ _ _. - - . _ '
OUTSmF CAFE��
OiJTSIDE CAFES(i.e., OUTDOOR SEAT'ING WITH WAITEI�/WAITR�,SS SERVICE), �,JST HAVE pRIOR
APPROVAL FROM THE BOARD OF HEALTH.
�OOR COOi���
4UTDOOR COOKING,pREpARA'TTON, OR DISPL OF ANY FOOD P ODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHMENT IS pROHIBITED
DATE: , �� � SIGNATURE:
�
PRINT NAME& TITLE: �1�,�� d�
'99
. �
� The Conrmonwealth ojMassachusetts
� � Department ojladustrial,-fccidents
` A � ; OJ1lceoll�s�lostJyis
� 600 Washington Street
' ,,•� Boston, Mass. 02111
~ �� W'orkers' Compentation (nsurance Affidavit
nam�� d���� !L-k 1 l�.1S
Iocati�n� �OS� � 1�10 U� a B
�►�, 1��5T u�a r,uov y M/1 ���3 h°$� ti�i-�8��
� I am a homeoµner pert�rmin�all w�ork myself.
� f �m a sole proprieror�r,� h��e no one ��orkin_ in am•capacit�•
�am an employer pro�idino workers' compensation for m1_employees workiaQ on t�is�ol�_:_._-_-__ _-_ - ---
--- _ _ _ _ _ _ _
comnanv name: �-L���<���-- �l�/iQ�C�-�
ddres : �057 � �bU7�� a'Ja r�l.((�U�j f�jo`�3
�—
citv: j.U�T [��/l/t0(/�l �1/1 �`lo`��' ehone q• �8 77 I-�$7a
iesurance co. �A��nl� �SU/C�C_/ 7 0o icy tt �(JGY30D0 o�a$
� I am a soie proprietor. generai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the follu�cin_ ��orkzr .ompensation polices:
�ompanv n�me•
address•
citv• ohone It•
insur�ncc co. Felic�•#
comoanv name• - --
-- -
a�d resr
citv: ohone M•
insurance co. p�y�f
t
Failure to secure coverage as required under Secdoo 25A of MGL 1S2 n�Ind to the iopo�idoa o(erivi�l peadtla of a d�e op to 51�00.00 a�d/o�
oae yean' risonment a�w•ell a�eivil penaide�io tAe fo�m of a STOP WORK ORDER aad a tiae otS100.00 a day Kaio�t me. I a�dersta�d that a
copy of t H st ement ma nwrded to the Otiiee of lavestig�tiom of tbe DU for eoven�t veriBaeb�.
/do hrr erri und r rh� ` s and penatties ojperjury tAat tht injorneation provrd�d abovt is true and eorred
Signature ate Iz ' ��" �/
Print name � ► one�f�7 �`�z' ��r-��
.
.- olTicial use only do not w rite in this area to bt completed by eiN o�towe oflttial
city or town: Y�M�DTQ _ permitAiceau M flBuildiag Departmeot
OLieeasiog Boa�d
�cheek if immediate�esponse ie required 261 QSeieetmen's Ofliee
�HealtA DeQartmeet
contacc person: phone N;_ �508� 398�?231 eat. nOther
.. . ��,,:
TOWN OF YARMOUTH
, � BOARD OF HEALTH
;
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-34 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:
Robert D Wilkins, 657B Route 28, WPst Yarmn»th_MA
Whose place of business is: Classical Billiards
Type of business: Retail Food Service less than 25,5100 s�.uare feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:��/. .�et��, C'�t.,,�,�
�oan� �ullivar�, �//., Vice (�hairma
�s'rlucTtorts ��: No food preparation on premises. l�o6art� �i�ocv� C�er�
Only manufactured,pre-packaged foods. Only canned beverages. /a�rie�la�a�ol��y-�oopea
///ichaaL OoCo �[in
�
7anuay 13 .2000 Bruce G.Murphy,MPH,R ., O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-27 FEE: $20.00
'rhis is to Cer�ify that Robert D Wilkins d/b/a Classical Billiazds
657B Route 28 West Yarmouth.MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31,2000 unless sooner suspended or revoked.
Januarv 13 ,2000 BOARD OF HEALTH: Ld ///. ..ta�, (��airman
'I �oan G. �ul�an, K.//•� Vice �hairmua
�a66,�� /3rowK
�a�rie�[e�a�ol��r��oope�
' L�oC �aLin
� ' ruce . urp y, , . .,
� Director of Health