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Home My WebLink AboutApplications, WC and Licenses . �" ' _" , -� ,�.� �' ��:R�3/6V�C.(.E �JE--Y�k„S TOWN OF YARMOUTH BOARD OF,.�EAT:� ��' �� APPLICATION FOR LICENSE/PERIYIIT.��00 "� � � � � d � UD � �'s @� - *Please com lete form and attach all neces �k � ` R 2007 p sary doci�trlents by ece�►b r 3�;r2�04. Failure to do so will result in the return of your application pac etHEAL7'H DEPT. NAME OF ESTABLISHMENT: q'' 7�{ T . #?(y S�J C�G� LOCATION ADDRESS: �O � MAILING ADDRESS: l�'1Q � • � OWNER NAM�: �l� ' � AX IN r N • - CORPORATION NAME PLICABLE): MANAGER'S NAME: ,e TEL. # MAILING ADDRESS:� � G r� (�o C' POOL CERTIFICATIQNS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifi�ations to this form. T#te �ealth Dep�rtment will not use past years' reeords. 1'0� t�us� prQvide nev�� copies and maintain a file at your place of business. l. 2. 3. 4, FOOD PROTECTION Mt�NAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please afitach cogies of certificationto this appfication. The Health Department�vitl not nse past years'retards. You mus provide new copies and maintain a file at your establishment. I. � � V� � 2. �C� � P�RS(�I�i_IN��R�`iE; __ -- _ _ _ .._ _ . _ _ ___ _ _ -- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �, J l.�� cl 2. �I �� 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�mployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and roaintain a file at your place of business. �. ��.�� ,�� 2.��; � .5�,---e � 3. 4. RESTAURANT SEATING: TOTAL # �� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'vIIT# LICENSE REQUIRED FEE PER'1�IIT* LiCENSE REQLTIRED FEE PER'1IIT= TB&B 550 _CABIN S50 _MOTEL S50 _INN S50 _CA:'�IP S50 _S�t'IVLVIIiVG POOL S75ea. _LODGE �SO _TRAILERPARK S100 _V�Z-IIRLPOOL S75ea. FOOD SERVICE: LICENS£REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P£R�<fIT� LICENSE REQUIRED FEE PER'�IIT= I 0-100 SEATS S75 �08-1.37 _CONTINENTAL S30 _lv'ON-PROFIT S35 >100 SEATS 5150 �CO�L'�ION VIC. S50 ��O _V4'HOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIRED FEE PERMII'� LICENSE REQLTIRED FEE PERyfIT= LICENSE REQL'IRED FEE PER�II?= _<50 sq.ft. �45 >25,000 sq.ft. S200 VENDP.vG-FOOD S20 _<25,000 sq.ft. 575 _FROZEN DESSERT S3� TOBACCO S50 NA1�IE CHANGE: sio AMOUNT DUE _ $ /2�,p p *****PLEASE TL'R\OVER�\D CO��IPLETE OTFIER SIDE OF FOR�1'*"�** ' . - �t . �' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or gernut to ogerate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCITPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shallbe '' limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hetel us�: Transient accupants must have and be able to demonstrate that they ma.intain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than th'vty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or f dwelling unit sha11 not be considered transient. Occupa.ncy tha.t is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: En�los�Motel Census must be compdeted and returned with t�is a�p�ication. POOLS PUOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�S days 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 c�uarterly thereafter. - � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ' closing. � f i FOOD SERVICE ' CATERING POLICY: ; Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health DepartmeYrt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit u�til the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. � I OUTDOOR COOKING: Outdoor cooking;preparation,or�ic ispray o��y bod pr�dn�tby�r�tait or fa�d service�stab�ishmentis-prohibited: ; 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, 2007. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCE ENT. RENOVATIONS MAY RE E AN. DATE: ��(/ ' SIGNATURE: ; � PRINT NAME&TITLE: � � ` io:o o� - � . . � � � The Commonwealtl�of Massachusetts Depart�neat of Industrzal Accidents �� 600 Washington Street, f"'Floor Bostoty Mass. 02111 Workers'Compeesation Iasaranee Affidavih Bailding/Plambi�glElectrical Contractors . - �: � eG aaa�s_ 7 � G` � 2c � �t��a_vl i�t 1 S state•�rI- zio:(J iVo d � nhone# �� TZ d � 7 �\ / work site location ffull addressl: ❑ I am a homeowner perfomiing all work myself. Project Type: ❑New Constructiar��Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Build'u►�;Addition � I am an employer providing workecs'cotnpensati�f�my employees worleing�this job. �� ( . __ c4maa�v seuue: " — �" ' �T`-��'1 f�C f'i.'��'-�.-�/' /��-{,�_--- _ � � � cI � #• ` "�y � �� : . �..� . , ,:: '. �..: .s.;,. . �� .�::' , . ._. � .:, . {:,.ho ,.v .,,.;: Sk 5,�,�ei�.�i 95E,�4 � � � , �. , a, e « ..., .,: ❑ I am a sole ptoprietor,geseral costraetor,or 6omeows�Earde owe)and have lrired tbe co�actors listed below who have the following workers'compensation polices: somw`v r�• address• ci�• n4o�c#; # �: cll�v oretie#- _--- -- _-------- -- -- — -- ___— _ -- _ — - - -_ __ _ _-__ # . . Pe�a16a . . - ,nr ..r ,._ FaBm^e M secare erverade af requi�+ed oder Satlea 2f�A�f MGL 1S2 aa lad b IYe irp�dtl��f erfi�ial �f a�e�p b=1,SM.N a�dl�r, ose ynn'Imptieea�eat as we8 as civi pe�aWa id t6e for�of a 3TOt WOItK ORDER a�d a�a[f1A0.�A a day aaahst ee. 1 aadeistaad that a c�py�f fYis�ateme�t my 6e firwarded�o tAe Omce e�[lavatlptlom af fhe DIA tor esverage vr.r�atlee. I do beneby ce ' e d ltles of pery'ay that tlYe infon�r�lo�provPded abone is lrue m� rrect � Uate �d � � �� Plwne# �Z�� e�ciai ese�nly do eet write�tris area to be cevpleted by dty er 1nm e�Cial city ar ta�vu• per�N�cense# �BaidinE Depu�Gment ❑c�cct if imme�iale n�pe�e is teqaQ+ed �+s pma �llealt�Depar�ent co�ct persoa: phose#; � t,��eca sM-2om) _ 12f?8l=067 14:17 508-796-0249 GOLD�IAN & ASSOC. � P�GE 01/01 A�oR,�► CEl�TIFICaTE OF LII�►BILITY INSURA PRODUCER �C E CSR AB DA�(��'r'1 f �I'�� 6 ASSOCIATES INSURANCE THIS CER7'�FICpTE I,�a�,$VEa A� A i�TT�sR OF tNFpRMATl�Na 07 FINANCIAL 3ERVICES irtC, oNLY AN�C�►nr�Et¢g�Q RrGHr� ul� 933 F23I.MOUTH RD. HOLDER.THi9 C�RTIF�ATE�O :S V�T RMEN�TIFICA'�'E HY191d1.12g MA 02�O1 ALTER THE CpVERAGE AFFORC r3D 8Y THE POUCESEB LOSN. �'hoae:508-7T5-5010 Fax:5a8-7gp_p299 � ItasuR� ""----^----_ INSUI2ERS AFFORDIAlG CCtVERAG ; . uysu�R a; � NAtC� �Ys� c�sv�;:�r�r cor��nr T.R.p.S. I� D� CgAIGVILLE ��'� PIZZA �.O7y 1yAIN 3t nasvR�R e; ' . — � Y��r ru� o26sa „�suR�o: _ --�--- - COYERAGES iresuRER E: .—_ ..— pNY REOUIRp,�EMt,T RM OR CONDtTiON pF qt.t�-CON�7RqCT OR OTM$R pOCU��N7��{qES ECT TO WHl '�R THE P'OL1CY P�up��A�.NO WI"H3TANDINC} 11EnY P�RTqUU,TN�INSURANCE AfFORpEp BY TN�pp��ES DESCRIBED HFR�1�V�g gl/g,�C-CT TO Ai.�'n{�7�py�5,EXGLVSION8 pND CON�11 �M:a OF,SUCF{ PQLlCI6S,A�(�EGrtT�UMIT5 S1iOWN IV�4qy►�{�BE�N qEDUCED DY PAID CL.AIM$, CH THI�CERTIFICATfi NtqY OE i9t,ED OR 4TR NSR "�---,,. Y 7'�PR OF INSURANCE pp��Cy N�MBER GENERAI NA6(LI7Y �AT6 MI{1/D DaT@ M DD/VY ------�--.� . ,�� I,IIY�ITS COMMERCIAI,(;�,1Eqq��q��Ry CeACH )C�:URRENC� y .. CLAIMBMnDL � T3ARiA T'p-�p7�p--.. � OCCUR �'R� 3£,•(Ee oewre�on S _. M�D t tP�nrry ona fle�eon� � � pER8 NA.6 AOV ItdJURY �, GEN'1.qGGR�C,q�LIM(T�nPP11�8 PER: G@N�•AL 4GGREpq� g � P��'��Y JGC�T LOt PROD CT3-COMPIOp,q(i(� � AUTOAqOBILE[1n�pry ^' ,.�....._ kNY AUTO ' �B��E[t$INpI,EltnelT � ALL OWN�O AUTOS SCHEDUIED AUTOS _ 8f)D!L IN.�1Ry _- NIREDAUTOS �p�'P� :�'1 � NON-OWNFQ qUT03 BODtL' IN.Uf�T ' IParnc (deh(� 7� GARWl9E U60lL PPOPF.�tTt DAMAGC 1ry l�r�e �rervt� s nN,r awro. �ura�.k�...E,,,accroew�. s ._._._"'� OTHEF rFIi,N EA AC� �� @xC@93�UI�BREL4q UABIU7Y RUTO�.vL". • AOfl A OCCUR �j��MB MADE [aCH c :CIIRRENCE � _ nGOP$ 3A7 E $ .` DFOVtTIBLC "� �-- REi'ErmON y — 3 – WORKER3 CONfPEN8p1rypN pND � — ,� " � EMPLOYER9'LWgiim ""�' ' k nwvP�oP�iE 0262867700 X ro•�'L�� ER- � TOR�arttwEa�xEcuTwe 11/06/07 1��6�08 E.LEA� NA�CI�ENT OFFICERrMEMBER ExCLUDED9 • Ifygs deecru�,u�pgr --- !+1D0000 BNE�IALPRpV�$IONSbelow E,I..ql9 n3i.&AEMP(,pY $�OQOOO _— � �� E.6.Dt8 wS:-PQI.ICY�J�T SS�OOQO D��7ldH Of dPERqT1pH9l LOCATtpN&/VEffIGLES i EXCLug10N9 ADpEp BY ENQORSEMFNY'!9PEGInL PROv1S�pN8 V�,, I , � — �r,=> . CERTtFICATE HOt,DER CANCELLATIOM — TOWNQ� 3HOUCD ANY OF 7'}IE ppOyE p@�RIBEO POLN �3 BE CaIVGCLLED BF.ROR6 THE 2XPIRA'11pN D47E THER�OF�THL�+ISSUIN6 NJSUElER Uw11.EL'OE�IYOR TalQML Z O NOT�C�TO THE CERTIF�Cq'('E HOLDPJt NAA��p �p y��T gU7 FdtLUJ3&7p pQ 9pg�pLL TOWN OF Y,'��fiH �uPose roo osu6ar�ok�uaer 119 6 ROUTE 2@ ��a�n .rr+c�tJPON TNE 1lvSUReR.n's nar�+,-rs oR �. Y1�IRMOVTH MA 02664 REPRE9EN TTYE3. . AUTHOR�E L•PRESENtA '— ..� �CORD 3S{Z8a1/48) 'ANN ISE LAN+GER --: _ C�7 ACORb CORPOFtAT10N 1988 , � ; . . � , � ; I � � ! THE COMMONWEALTH OF MASSACHUSETTS ; TUWN OF YARMOUTH i �ERMIT NUMBER: #08-fl86 FEE: $50.00 � This is to Certify that TRPS d/b/a Craigville Pizza&Me�cican 1077 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMQN VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victual�ers. This ficense is issued in couformity with the authority grauted to the hcensu�g authoriries by General Laws, Chapter 14U, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ;��El�e�ee��iat�S� f�atflt,7�J2_�.�J�V., C'fnlu�iti�r.nt�a�tt_�� SEATING: �4 l.lul�D � .�,/1.GGis�� V�l� �..�/�.l�/ll�llfL J�al�ext 3.J��uutxtt, t:Ce�rt� Qtttt(�ceer�J2..iY January 25,2008 Bruce G. urphy ,R.S.,CHO Director of Heal _ __ _ _ ___ . ___ _ _ _ __ _ TOWN OF YARMOUTH - BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHN�NT PERMIT NUN�BER: #08-137 FEE: $75.00 In accordance with regu1arions promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,SecUon 5 of the General Laws,a permit is hereby granted to: Ti2PS; i077 Route 28, South Yarmouth, MA Whose place of business is: Crai�ville Pizza&Mexican Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2008 BOARD OF HEALTH: .�eeeri Sf�ac�i, J�..N., C'�crvrnuut SEn'rn�tG: 74 C'�r.R�Y�e� .`�.�Ge��if�eX `�1tCC C'�av�ntcut J�aB.e�t 3.Jl3�aeun, C!�eac� � l.Irui t�ceer�uccrn, ✓t..N. �. Januar�25,2008 ruce G.Murphy,MP .5.,CHO Director of Health , . . C:.a.Ac�vwc.E p�zzEt ' �F'.YA � 2° ;._R o TOWN OF YARMOUTH BOARD OF HEALTH 6� o: :"�y APPLICATION FUR LICENSE/PERMIT-2Q07 �� AN 0 2 20U l � . .-:� - �, �� * Please complete form and attach all necessary documents by December�31, 2006. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHIVIENT:� ' c.�, TEL. #�`��j �Z.�C�C� LOCATION ADDRESS: `� � r ` �,� MAILING ADDRESS: lt� .�ef' .,��-. OWNER NAME: �Pt �r� S c� TAX ID IFEIN or SSTT�: CORPORATION NAME APPLICABLE): '�' P S MANAGER'S NAME: ti. S' � � TEL. #�Sp�'-��''-�,��2 MAILING ADDRE5S a� c_ r` � v POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operatar,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach capies 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. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food , Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 1�5 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use p�st years' records. You must provide new copies and maintain a file at your establishmen� 1."��.�!`- S�1 � �. 2. �.J' f>� �.`�I:I�C S' ��t _ __�'�:�i�4N-�C�FE:----- -- ---- _--- -- _ - -- __-- - —- -- --_ ; Each food establishment must have at least o e Person In Charge(PIC) on site during hours of operation. 1.Cfi�� n�u �C 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 file at your place of business. l. �-✓'� �1 ��'C. 2. ��c 3. � 4. RESTAURANT SEATING: TOTAL# �'� O�FICE U5E ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUfftED FEE PERMIT# B&B $50 CABIN $50 MOTEL �50 INN $50 CAMP $50 SWIIvIlvIING POOL$75ea. LODGE $50 TRAII.ER PARK $100 WHIItLPOOL $75ea. FOQD SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRF.D FEE PERMTf# LICENSE REQtJIItED FEE PERM[T# �0-100 SEATS $75 �I'�7��J 0 _CONTIIIENTAL $30 NON-PROFIT S25 >100 SEATS $150 � COMMON VIC. $50 v� _WHOLESALE S75 RETAQ.SERVICE: —RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERNIIT# LICENSE RF.QUII2ED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _Q5,000 aq.ft. $75 _.FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE = S IZ.S,OO '••"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•""* j P .- . I � I ADMINISTRATION ! 't i Under Chapter 152, Section 25C, Subsection 6,the Town af Yarmauth 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 Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED_� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: / YES V NO MOTELS ANA 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. � Transie�occupants must ha.ve and be able to demonstrate that they maintain a principal 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 six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupa.ncy that is subject to the collection of Room Occupancy � Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � � POOLS POOL OPENING:All swimming,wadin�and whirlpools which have been clased for the season must be ins ected by the Health Degartment prior to ogening. Contact the Health Department to 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 quarterly thereafter.__ POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. � i FOOD SERVICE r I CATERING POLICY: � Anyone who caters within the Town of Yarmouth must notify the�armouth Health Department by filing the required ; Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtau�ed at the ; Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: '. _ _ _Qutdoor_cQQlcing,pteparatio.nT o�displa�af any_f�gd_�roduct by a retail or-food senr�ce�stablish�ent is prohibited. i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN TI�COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOT�L OR POOL (i.e., PAINTTNG, NEW i EQIJIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMl��NCEMENT. RENOVATIONS MAY REQUIRE SI LAN. k �DATE: �� SIGNATURE: j PRINT NAME&TITLE: � L�� rL�S,- I ioii�io6 ` � � The Commonwealth of Massachusetts Depa�nent of Indushial Accidents > M�fNrw�1M� 60�R'ashington Stree� 7`�'Floor Boston,Mass. 02111 - ----- -- Worken'Com tioa I�s�aaee Affidavit:B'ii ' bieglBleetrknt Co�traeton name• acki�ess- ci state• zi� nhcme# work site locati�tfnll addressl: ❑ I am a homoowner perfomiing all wadc myself. Project Type: ❑New Co�ructi�QRemodel I am a sole 'etor and lmve no ame w in an ❑Buit ' Addition ❑ I am an�npbyer�viding worke�s'compensati�for m employ�s wo�cing�this job. _ , _ �. _ _ _ _ _ -_ _ : �_- , ��,�� , • �„� ,�� . , ' � �� _ � �� l`s' > " ' . 2Cit.�` / �' s►� CS��`-' � ❑ I am a sole proprietor,g�at eostractor,or�omeowter(cucli oAe)and have hiced the comractats listed below who have the following wot�Ce.rs'compensation Polices: �� , � � � � � � � f�d''= ��'s_, #� �t� . ». ad�r,�: � Faihite�see8+e or�era�e as reqdred u�ler 3eelin 2SA et MGL IS2 eu Iaid N tie 6rp�itiu�f cri�ial pmllks�f a�e�p�S1,SM.M aadl� eae y�a�s'h�pti�nt as we�as cM peadtln ia t6e 6�eta 3TOt WORK ORDBR ud a be�[5160.N a dsy apimt ste. I oden�d tiat a apy�f tik shle�nt my 6e firwu�ded M tYe Oma�[Im��t tlie DIA for owerage v�ady. I do bd+eby �er e d of pt�xry dYtt t1Ys i+rforar�Jou provddad eboae ia trxe a+id c�o �g� �� ._ � " ��' �j:� Print name Phone# e�1 ase a�ly as aoc write L chis are.a 6e eo�plaed by dly.r bwn.e6chi dly or ts�vn: permifl�ioe�ee# I�l�D�t ❑chect if�me�abe rapseae b req�ired ��Y , �D�r�t cenfict Pe�sa�: Ph�e#; �014� c�sm�-�) 12/28/06 12:32 FA% 5087900249 GOLDM9N ASSOC 1�01 oR _ CERTIFICATE OF LIABILlTY INSURANCE GSR ,s,B DATE�MM/Dp/YYYY) TAPSI50 12 28 06 vROOVCER THIS CERTIFICATE IS ISSUEd AS A MATTER OF INFORMATfON �� ' �Ss�Ia'�s I�� ON4Y AND CONFERS NO RIGHTS UPON 7HE CERTtFICATE FTNANCIAL SEAVICES INC. HOLOER.TH15 CERTiFiCATE D�ES NOT AMEND,EXTEND OR 933 FAIMOUTH RL1, ALTER THE COVERAGE AFFOROED BY THE POLICIES BELOW. HYANNIS 1�A 42601 PhoaQ: 508-775-6�10 Fax:508-79d-0249 1NSURERSAFFpROtN6COVERAGE �C� m�+simeo INSURER A G1i712iITE 9TATE INStJRAbTCB CO PISSA'S. INC DHlsi CRPiIGVZLLE aasuaEn c•. 1Q77 MAIN 3t ir�Eao� S YARI�DUTH t�lA 02664 MSUREFi E. COVERAGES THE POLICIES OF INSUFLWCE LISIED BELOW HAVE BEEN tSSUED TO THE INSUREp NAMEp a90VE FOR THE POIICV PENIQO lNDICATE�.NOT1MiH5TANpING ANY qE0U1REMENT,TERM OR CONDI7tON OF s.MY CONTRACT OR pTNER DOCIJMENT WITH RESPECT Tp WkiCH THIS CEfiTIRCRTE MAY 8E ISSUEO OR MAY PERtIUN,THE INSURANCE AFFORQED BY THE POLICIES OESCRIBED HEREIN IS SUBJECT T�ALL THE TEAMS.FaCCLUSXJNS ANO CONDRIONS OF SUCN POL�GIES AGGREGATE LMAITS SHOWN MAY FUVE BEEN REOUCE[}BY PAtp CLAIMS. LTR NSR TYPE OF INSURANCL POIICY NUMBQR OA E M1MID0 OATE MMlpdW IMIITS GENEi�AL LIABIUTY EAGH OCCURAENGE t COMMERC1Al OENERAL I.UBILIIY PREtdISES fEa oceuren�j i � CLAIMS MAOE �OCCUR MED EXP lArry one porson) _ j PER90NAl 6 AC1V INJURY S i � ' GENERALAGGREGATE S GEN"l AGGREGATE LIMIT APPLIES PEp. PRODUCTS-COI�/OP AGQ S POLICY PRQ' JECT LOC AUTO1ND91LE�IABILIlY :COMBINED SINGIE lIM1T I ANY AVTO (Ee accident) i � All�WNE�AUTOS � SCHEDUIEOAUTOS BO�DI�I�N,URY � P � HIREp AUTOS ' � INON-OWNEGAUTOS � p��j Y � - i PROPEpTY DAI�UIGE f I (Por acciderq) GARAGE LIABILI'fY AUTO ONLY-EA ACCIDENT S aNY AUTO OTHERTHAN �ACC f AUTO ONLY: AGG i E7(CESSNYBRELLA LUtBILITY EACH OGCURRENCE S OCCUR � CLAIMS MAOE AGGREGATE s �eoucrie� s s aerenr�or� s : 1NORKERS GOMPENSATION AND EMPLDYERS'LIA9IUTY TOFtY LIMRS E ' A i ANYPROPRIETOR/PARTNEFVEXECUTiVE ?"796704 11.�OG�OC) ZZ�O��O7 E.L.EACHqCCIOENT S ZOOOOO 't OFFICERJMEMBEIi EXGLU�ED7 ' � It yea,de.��5e�naw E.L.DI5EASE-EA EMPLOtlEE S 1 O O O O O ' SPEClAI PRa1l131QN5 betow E.L�ISEASE-POLICY LINNT S�j00�Q Q ' OTHER ' UESCAIP7WN OF OPEf(AiTf6NSlL.00ATIQNS lVEHICLES!E7CGLtlStON3 ADQEII BY'ENbQRSEMENT`/SPECGLL PROVtSK7N9 � � CERTIFICATE HOLDER CANGELLATION � �y�Y� SMOIKD ANY OF THE,9DVE DESCRIBED POLIC�$86 CANCELLEd BEFORE TtfE EXPIRAT�N DATE TXEREOF,THE ISSIANG INSURER M!1{.L END@AVOR TO NAIL �.O DAVS WRITTEN TOWN OS YARMC(�Tj� N017CE TO TXE CEqTIFICATE HOLbER NAMEO TO TM6 LEfT,BIJT FNLURE TO DO 50 SHiLL FAX 508-398—�836 I,ICENS ING DEPT IMPOSE NO 4pUGAT1pN OR I.IABIUTV OF ANY KIND UPON iHE INSURER,ITS/iGENTS OR RTE 28 REPRBSEHTA YARMdVTH MA 02664 aurNo�u r ANN IAV SELANtiBR ACQRD 25(2001/08) 0 ACORD CORPt3RATION 1988 i i TowN oF��ou� BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-130 FEE: $75.00 In accordance with regu1at7ons promulgated under authority of Chapter 94,Section 305A and Chagter 111,Section 5 of the General Laws,a pemut is hereby granted to: TRPS, Inc., 1077 Route 28,�South Yarmouth, MA Whose plaee of business is: Craigville Pizza&Me�can Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: Llecember 31, 2007 BOARD OF HEALTH: B�/� ��/ $`. ,�l.�$/.,�� ' SEATING: 74 d16��6it dK�Ny �r �%O&4"�QN/luilt Ro��} B�u�a, G�le�a �scv�a/�c_`21e�o� � �4�(�'�e�, R./Y. 1Vlarch 30.2�7 ruce G. Murphy, ,R S.,CHO Direc#or of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-08b FEE: $50.00 This is to Certify that TRPS, Ipc. dlb/a Craigville Pizza&Me�can 1077 Route 28, South Yarmouth, MA IS HEREBY GRANI'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers_ This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Be��pi�'t�'5. �jo�nt,'/�1.n�'5., ' SEATING: 74 e�/6/�/L e�ifQ�� K�.� (/fl7e(iK�l1G�L " Jli�e�t 4. B�u�u,sg C� p��k A�l�i� �!��j��, R.N. March 30,2007 . Bruce G.Murphy,MPH, .,CHO Director of Health i F �a : , c��s�3 «�� R-� �F;r R.y TOWN OF YARMOUTH BOARD OF HEA�r,T`,��'� � ' I �".'� �� -'� APPLICATION FOR LICENS��;�t11�' ` ; � �; .�� ` �`>'.>�. �,: � DE2C�9 2005 * Please complete form and attach all necessary do��ts y Decem r 31, 0 . Failure to do so will result in the retu��bf your application pac e�EqLTF-► pEpT NAME OF ESTABLIS�IlVIENT: (`��(��(�� Q 122f1- � 1`1�X1 Cf�N , TEL. #S��-�6�� . LOCATION ADDRESS: 10�-� ("�A=�� S�-f ��,� c��(�- v �� L�. MAIL,ING ADDRESS: t o�� ("�A�rv C��. S- �1(�.��i�� g� o��C� - OWNERNAME: (��'Tz�S��c fi1 TAX ID lFEIN or SSNI: CORPORATION NAME(IF APPLICABLE): �`(�`�S �N� , MANAGER'S NAME: P�� S K�£Pt � TEL. #g�o 8�b 8--�!��-, MAILINGADDRESS: io�-�- (�'1�;� S'�sZ c , S� �F�no�� (`� oa � Gi.� POOL CERTIFICATIONS: The pool supervisar must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. __ Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR)_ Please list these employees below and attach copies of employee ' certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place af business. l. 2. ' 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time ernployee who is certified as a Food ProtectiQn Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. ��b lfiil/ �✓l•91��L-� 2. - - P_ERSOI�T 1N('HARGE: _ -- — - - _ _ ' _- - -- --- - _ __ __. Each food est lishment must have at least one Person In Charge(PIC) on site during hours of operation. l. 2. , �_ �� HEIlbf��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 at�ae�i evpies 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 REQUIIZED FEE PERMI'P# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMTI'# B&B $50 CABIN $50 MOTEL $50 INN �50 CAMP $50 SWIIvIlVIING POOL$75ea. LODGE $50 T'RAII,ER PARK $50 WHIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 ��°'O7 7 CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS $150 I COMMON VIC. $50 �-Q�( _WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIRED FEE PERMI'P# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMTT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _<25;000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 125. OO *""*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'""" � � . � � � � � AD1ViINISTRATION ' i ; , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any lic�nse 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ' YES NO �,,; j NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETLTRN ' TI�COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005. j � SEASONAL ESTABLIS��VIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- ` 10 DAYS PRIOR TO OPENING FOR THE SEASON. i ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO ' COl��IlV�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. I ADDTTIONAL REGULATIONS POOLS � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. ; 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. I � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. ' i � 4 i FOOD SERVICE ' CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze 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. _ ��t�S= _ __ __ _ _--- _ _ � Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health � Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. � OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � I DATE: l � a ��SIGNATURE: � � PR1NT NAME&TITLE: �i � �v�C'-� � S 09l28/OS � [ ! 6 � . � ! �y � __ `�� Tlie Comnwnweahb of Mossachusetts ----____—� =_-- = Departr�ent of Industrial Accidenls -- N�If�i�' -- _ _ = 60o w�h��s� �Fr�T - �,. Bosto�e,Mass. 02111 ` work�a'com uu�La�ra.ce Affidavik B�il • • leedrieal co■aYeta�rs . s ,. . ,. _ . �!. � � .:.�.: �;,_ .�. name_ C' Q Q-�C�ll..1�� 2-� addcess: �"��- /`/�,y� �� ry �_��Q�`1�J�"` sat�: IWk ri�_ DoZ��o�# .��(i—��c� v�rork site locatia�(full addnssl: ❑ I am a homeownea perfam�ing alI wo�k myself. Ptajed Type: ❑New C�siructioa��Reanodel I am a sole 'etor and have��e w in an Buil ' Additian y � �I am an�ployer ptoviding wadcets'compensation f�my e.mploy�s wadcing on tbis job. _ � ��.-C,J I , �--�- --- - -- a�v a�nr. �- . �• �c��r�- rv�,,� ��`c�2_� �►: . _S� � A�P�►c�� ,�;�: �� afC�..-�Z7E a, � TC s�� . ❑ I am a sole propriewr,ge�al co�tractor,or homeowfer(cirde owe)and have hired the contractors listed below who have the following workas'compemsation polices: ��: : �: ' citv; „��ks •,, � ��: �T � ' �. � . � . � �r�: � r'l��^t r fEL'8'!ErYQ�!Sf TE��ld 11dQ.gEC1�N�!��s�.�ql�b�!��Q�pWW�li�i�!�1 a f1�.M�1�i OHt y�ar!'imptb9l�ERt af n!1 af dW pmUtles iH tll!6[�Of a STO!WORK�RDER a�d a�6[t1M.M a day s6lMt�e. 1 Oede�Hd thlt f npy ef tY��talemeut my be f�rwardcd te He Otlloe o[Itv�om of t6e DIA fer averase Ma'Matlei. I do heneby c ' e� t s d psweltiGs of pe�rrry tNot dYe i�forArado�provided abov�e is Irws axd onr t s�s� � �� Print natne � Phone# ( �L�� ffieial ese only do aot write i thb am b be c�plded 6Y e3tY e�ir�ra s�ial cit�or te�va: permif�eeese# D�rent ❑ckedc if immedhle n�pssae�reqeed �Sdcel�'s O�ee �Deparbeeat centact perass: �e�e�; �101her c�a sy�c ma+) ACORD CERTIFICATE OF LIABILITY INSURANCE �SR � DATE(MM/DD/VYW) TRPSI50 12 29 05 PRoouceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GOLDMPiDT & ASSOCIATES INSUI2ANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FINANCIAL SERVICES INC. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 933 FALMOUTH RD. ALTER THE COVERAGE AFFORDED BY THE POLICIES BE�OW. HYANNIS MA 02601 Phone: 508-775-6010 Fax:508-790-0249 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: GRANITE STATE IN3URANCE CO INSURER B: T.R.P.S. INC DBA CRAIGVILLE PI INSURER C: 1077 MAIN St INSURERD: S YARMOUTH 1�, 02664 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea oxurence) $ CLAIMS MADE �OCCUR MED EXP(My one person) S PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTp (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per peBon) HIRED AUTOS BODIIY INJURY NON-OWNEDAUTOS (Peraccident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ ', AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR � CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ g WORKERS COMPENSATION AND " " ' TORY LIMITS ER A EMPIOYERS'LIABILITY 2�g6704 11/06/05 11/06/06 E.L.EACHACCIDENT S 1��00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EAEMPLOYEE $ZOOOOO If yes,describe under SPECIALPROVISIONSbelow E.L.DISEASE-POLICYLIMIT $ rJOOOOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWNOE'Y SHOULD ANY OF THE ABOVE DESCRIBED POIICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOWN OF YARMOUTH IMPOSE NO OBLIGATION LIABILITY OF ANY K D UPON THE INSURER,ITS AGENTS OR WIRING INSPECTOR 1146 ROUTE 28 REPRESENTATIVES. f S. YARMOUTH I� 02664 AUTHORIZED REPRESEN E ANN LOUISE BELANGER ACORD 25(2001108) �ACORD CORPORATION 1988 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-077 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter i l l,Section 5 of the General Laws,a pemut is hereby granted to: TRPS Inc., 1077 Route 28, South Yarmouth, MA Whose place of business is: Crai�ville Pizza&Mexican Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31, 2006 BOARD OF HEALTH: �t, �/ `?/S. ��o�o�nt,`/�/.`�?��.,�� . SEATING: 74 a7�ea�P.�t e7ffGiL� �� f/LC�t"+K('sl/l�dtrs�ft Ro�ient�. Bnu�ust, G� P��1�,� �4��.,��, R.N. , January 1 i,2006 ruce G. Murphy, , .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-061 FEE: $50.00 This is to Certify that TRPS, Inc. dlb/a Craigville Pizza&Mexican 1077 Route 28, South Yarmouth, MA IS HEREBY GRAN'TED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing autharities by General Laws, Chapter 140, and amendments thereta In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B / `�/. ��,/1�1.$., . SEATIIVG: 74 �e�I�KG�{L, rv, v� e�� R�t� B�, et� �� ,�� R.�v. Janualv 11.2006 l_. � Bruce G.Murphy, S.,CHO Director of Health i a � � c�r6`�o r�°°� �, •Of r R�s TOWN OF YARMOUTH BOARD OF � - -�o G3 � rrI� OMI� DD � o�� -�y - APPLICATION FOR LI " �5 �: .. , ;� �� :.�� . Ci�u ':� 9 2004 * Please complete form and attach all necessar�do y Decem er 31, 2004. ; Failure to do so will result in the return rif your application pac e�{ ALT ri u t PT. � NAME OF ESTABLISHMENT��'.2ac �s�v c +P • c, �n'le�rr TEL. #44�5'3 v�o LOCATION ADDRESS� ��- �/!'larh �{��-,�f S �'a,�,,,,�:..��"G,_�s'�A- c9'�t�fo`� ' �II,nvG A�nREss: .jv��- rh��; pih.�t- S', '�,,,w,��. �G, v►�� Y' � OWNERJCORPORATION NAME: I2 �S '' ' MANA ER'S NAME: n o. TEL. # MAILING ADDRESS: r Z�C�e. , ' ( 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 att�.ch a copy of the certific�tion t�this far�rt`i. � ^,� . _ .--_ � _ _ _ -- --- ' 1. 2. � Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (yCPR). Please hst these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification to this application. The Health�epartment will not use past years' records. � You must provide new copies and maintain a fde at your establishmen� 'j�� r ,�y� 1 - i 1. / � .�,,/I � 2. �C9�1.�'l. I D l�t Y1.4 �� —,— ,__ p�ucn�r rrr r�u�121,F• - _ _— ___ ___...� _,_--�. .� __ Each food establishment must have at lea.st one Person In Charge(1'IC) on site ring hours of op ration. i. � �� `� 2.��r►. c9�. C�a �c�� HEIlVILICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employee tra.ined 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 Healt6 Department will not use past years' records. a You must provide new copies and maintain a file at your place of business. � l. m,�� a �. �'��- S�� 3-� 4. a RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE P�RMIT# LICENSE I2EQUIItED FEB PERMIT# LICENSE REQUIRED FEE PERMIT# BBcB -',&54 _EABIN $50 MOTEL $50 INN $50 T �CAMP $50 _SWIlViIvIING POOL$75ea. � _LODGE $50 _TRAII,ER PARK $50 _WHIRLpOOL $75ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMfP# a �0-100 SEATS �75 �Os-117 _CONTINENTAL $30 NON-PROFTT' $25 >100 SEATS $150 I COMMON VICT. $50 O � $Q _WHOLESALE $75 RETAIL SERVICE: i LICENSE REQUII2ED FEE PERMIT# �,ICENSE REQUIItF,D FEE PERMTT# LICENSE REQiJII2ED k'EE PERMIT# j _<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 FROZEN DESSERT S35 �TOBACCO $25 NAME CHANGE: �10 AMOUNT DiTE _ $ /oZ S.O� •""""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM"•••• � _ ,_ . � � k x f ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ; APPROPRIATELY lF PAID: YES �' NO __ �.., _�- _ NOTICE:Permits run annually from January 1 to December 31. I'�'�IS R �SPO�TSIBIt,I'Y . O i THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLIS��MENTS ARE TO CONTACT TI�HEALTH DEPARTMENTFORINSPECTION?-14 ' DAYS PRIOR TO OPENING FOR THE SEAS4N. ; ALL RENQVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. : , ADDITIONAL REGULATIONS POOLS PQQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspect� by the Health Department prior to opetung. 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 i C4NSUMER ADVISORY: Each food estab ishment which serves or sells rea.dy-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 Temporar� Food Service Application form 72 hours prior ta the catered event. Thses forms can be ; obtained at the Health Department. ` f Frozen dess9ESSF��S: _ ----__ _ ___—.__ _ _._.– — __- _ ^ _� -_-�_�___; FRO�EN] rts 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 tertns have been met. OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. � OUTDOOR COOHING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited. € € /J S �' _ � DATE: -G l SIGNATURE: � � � PRINT NAME& TITLE:�� i � C 10/22/04 ,,._ �.^- �_ _ ,.�_ __w_ � - ! � q Y � � =-=_=.� The Co�monweahl�ofMassachr�setts - - _ = D�ent of I�dustrial Accidents = - N�eiN _ - - - 600 R'ashiRgton Stneg 7`�`Floor � —,.. Bos�ar,Mas� 02�11 .j; ' workera'cem�eaa,uua I��asoe affidavi� • kedricat cu�aaee�ers p �a....t ..: :,..... .. ;..t�.. .., . �.,V-.�`N. t�.q --ii: �� . ._..... � . 'A .s, ..�-.y .... .� � µ. ` �. .�� e - name: !Z Z�i . e G G �: o � S� � � a u;f"�, -- �;� � Yun.��..�~F� �n� Vl� � �o ��(��i�# �`?�8' ��£r � �t'�i2 work site loca6on trutl a�dressl• ❑ I am a homeownea perfcummg all wark myself. Praject Type: ❑New Ca�o�ORemodel I am a sole 'etor and have��e w ' in an ' � • • p�� I am an�ployer providinS w , '�far mY emPloYees wo�in$an this job. ; - _�.__. _ _-�-�-�--- ' - � . � C.,�.. �--�y - �c-: , _- -_. �_�V � �C l v} ��r'l�-�...� �l �/�✓�'��/ "'L�.�..._� .S. «,z�G�. � � b ' �`G_�Y �- �� z � -�b- (�� ❑ I am a sole Proprietrn',g�'a1 coitracMr,or lomeo�vser(cirde owe)and have hinod the contr�ctors listed below who}have the following work�s'compen�ation polices: ' �.�.� _._...... � � i �. iri�.: : �+ � �� . . . . I i � . . . .. �� .. . . . � . . . . . -.-... .. ,. .. ...r. � . . .... . .< . . _.. . ._ . . . . . .. . . .. . .. _ . . . . � � �r. . . . .. . � y� I - — _ �� ,_ _ � . +R�..... � _._�_. '_. _- �.._. .. . - ._ ..—__.__.. i ' . . .. .. . . .. � F�IIIYalLt�l! . ..b .. . � .. .. � .:� � . � � i'e9�'��der Sectlw�ZSA KMGL 152 en k�d b IYe irpolly�t'eti�inl peaaNics�f a�e�p�=1,SN�N�. � ctlw� Y�n'�Pt�o�meat a�wM as dv1 paialtles ia t�r f�nr�f a 3TOl WORIC ORDER a�d a Spe dS1M.N a e�py�f t6ia stalea�ent my 6e[envardal oe He O�ce a[I�p�K tYe DIA for owcrage ve�p��, �7�ie. 1 odpsbtd tgat a , I 10 bexby c r e ofperjr�ry dFet dlre iw ` �� „� fo�14Nou provlded oboNe is trxe and onrr+cc� Signadue �/'�' � � �� Ptint name � Pbo�# ��r_�`�Y S?� � o �1 ax�iy ae eot wrke 1�tYs arn a be aatpl�ed 69 d�1�r�nvn e�oLi dty or te�: P�o�se 8_ ❑e�eck if imme�ale re�psax b�y� �� 's� c�ad ��t l�..d� p4aae#; � . ___ _---- _ . ._ _. f ( ' � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #OS-117 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pernut is hereby granted to: TRPS, Inc., 1077 Route 28, South Yarmouth, MA Whose place of business is: Crai�ville Pizza&Mexican Type of business: Food Service ' To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2005 BOARD oF HEALTH: Bes�r fr��/,rrs�s$. ('�o�o�r/y�/�1�`�r�.f �� ' SEATING: 74 AG��/ �� @3plG/�� (/�f176 tiflfit/lpl['rfl R�O�B?��YOlIR/Z� (iLPJi/6 � �l�k, R.N. �I��, R.N. February 2.2005 ruce G.Murph , ,RS.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-080 FEE: $50.00 This is to Certify that TRPS, Inc. d!b/a Craig�ille Pizza&Mexican 1077 Route 28, South Yarmouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at tha.t place only and expires December thirty-first 2005 unless sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a.ffu�ed their official signatures. BOARD OF HEALTH: Be�rt�ts�s`h. �j'��,/N._`2S. . SEA�G: �4 p�� v�e�� R�t�B�, � �s� Rrv �4��j R.N. February 2 2005, , Bruce G.Murphy, S.,CHO Director of Health �t � �.�f� ( C.l�f(T{/fLC.E � �f;;�R.s TOWN OF YARMOUTH BOARD OF HEALTi�.,�i .,� [� � 32 - � �� APPLICATION FOR LICENSE/PEFR,�VIIT =�004 � �� J �n � n �• . ....''�?' � �E(, � I 8 2003 * Please complete form and attach all neeessary docum nts by�;j�e�'m�er 3 , �Q Q3. Failure to do so will result in the return of your�3lication packet. ntALTf-► [.�EP T. I A� c 3 5� f> L T D a � •� � • (`] /'1'/ ��, �"h eu.�'" a�- R' N ME: �- � � ING ADDRESS: �°��1 C�� '�- j Y c�c�vl �S (�')A f9,��t� 1 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated I�oc�3 Operator(s� ��d�tt�e'�a c��y c�f the ce�-tif catieln�a this f�,�rm. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this farm. 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 P OTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies�nd maintain a file at your establishment. 1. ��°(L �� t 2. �c�� t ' lCt �vvt`e-� _ PERSON IN CHARGE: - .,,_ . _ _ - - _ _ __ _ _------ ----- _ ---; Each food establishment must ha.ve at least one Person In Chazge(PIC)on site during hours of operation. l. �'��P �'L- �V1,"�Gl _ 2. ► I t �� `-� �� HFIML 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 all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � l. ��,��- S��.� -- 2. ►�'Vl �.��,�, c�� 3. 4. RFSTAURANT SEATING: TOTAL#--Z--� QFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S50 CABiN S50 ,_MOTEL S50 INN $50 CAMP S50 SWIMMING POOL S75ea. LODGE S50 TRAILER PARK SSO _WHIRLPOOL $75ea FOOD SERYICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CCNSE REQUIRED FEG PERMIT# I 0-100 SEATS S75 �-E�Olol� _CONTINENTAL $30 NON-PROFIT $25 _>100 SEATS 5150 �COMMON VICT. S50 �O'f"U`C7 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE RC;QUIRED FEE PCRMIT# LICENSE REQLJIREQ FEE PGRMIT# <50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _C25,000 sq.ft. S75 _FR07..F.N nGSSGR'C $35 _TOBACCO �25 NAME CHANGE: �to AMOUNT DUE _ $ I 2-S-00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** p � � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 C�MPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taaces and liens must be paid rior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ''. NO NOTICE:Permits run annuatly from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR 1NSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR P�OL (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. ADDITIONAI�c:[ri,ATIONS ' 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 openin�, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ' closing. ' FOOD SERVICE C'UNSIJ FR VI�ORY• Each food esta.blishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERt_N 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. ' FR4��lv t)FC4FIz'rC. _ _ __ ___ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE C F�:S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),tnust have prior approval from the Board of Health. OUTDOOR COO iN� Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , DATE: �f- r� � SIGNATURE: ��, PRINT NAME& TITLE: r2 �� ' 10/22l03 i _ , I � d i -� • �'�"�\ . The Corrimoawealth ojMossachusetts z : Department ojlndrutrial.-�ccidents ' ; Dfllcaol/�es�l�stltis �; 600 Washington Street ', ,: Boston.Mass. 02111 " '�� W'orkers' Compensation lnsurance Affidavit ARplicant information: _ P►easePRiNT'Ti�.'Wir -�-.- �m•• .�Ct 1 \(I � � 4- C�C,�� . � . . Q 7Z 1 !�°�Pi t.{. � � �`'�- � vl.� 2 W1��t.. �'1 # "� �� t, �(�-Z��,� � I am a homeow�ner pertormin,all work myself. � I am a sole proprieror �r.,a. ha�e no one��orkin_ in am•capacin• �am an empioyer pro��dino w�orkers' compensation for my employees w•oricine on this job. � _ - , _ ( _ a n • � • ` '` � ' �_ � _- l, ��l�° f'�-�-� ��1�° �dress• /� 7�� C( l"� ��1`�� ( �� 1 � � � ��.� �� L. �. � � 3�� — -�� o � d� i ur�nc �- 4t p �� I am a solz proprietor. :eneral contraetor. or homeowner(eircle oneJ and ha��e hired the contractors listed below �tho ha�e the follu��in_ ��orl:zrs� ;ompensation polices: comnanv name: � address• ci�}: phone t�: insurancc co. �lie}� eom�an,v name• a�d ress sitY' ehoee!i• insuranct co. ��* • Fsilure to secure covera;e as required under Secnoa 25A o[MGL 1S2 es�iead to tbe iopwitioa o(erisi�al peaaltla of a 6te op to SI�00.00 a�dJor oae vears'imprisonment as well as eivil peoalda io the torm of a STOP WORK ORDER asd a tfee of 5100.80 a dar apiott ma [e�denti�d t5at a copy of tha statement mav be fonvarded to tht Otlice of lavqtiqadom of Me DiA!or eovera�t verifiatio�. ►do hrreby certif}• n r p ' prRalti�s ojpery'ury that 11rr injormatfan providtd abovt is due and eo�rai Signature ' �/� / V � , P�int name ��- �� -� Phone 11 ��'�'��.� r J� � � ofTicial use onl� do not..rite in this�rea to be completed by eih o�towa oflleial citv or town: Y�� _ pensitAicense a nBuildiog Departmeo� �Lieensiog Board �check if immediate response i�requi�ed 261 QSelectmen'�ORee Qiieal2D Departmeae , contact person: phoeeM:_ �508) 398-�2231 ext. nOther � TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-062 FEE: 75.00 In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter I i l,Section 5 of the General Laws,a pernut is hereby granted to: TRPS, Inc., 107'7 Route 28, South Yarmouth, MA Whose place of business is: Crai�qville Pizza&Mexican Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31}2004 BOARD oF HEAL'rH: B�s� o��rir'�s$�h. �n/,`/.$.f SEATIlVG: 74 �G�f�7/B/I7fS.lJ�iNf�y (/K��r�`lCtlh�Q�iL dY�fBli ��G�y�� ___ _ December 24,2003 ruce G.Murphy, .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-047 FEE: 50.00 This is to Certify that TRPS, Inc. d!b/a eraigville Pizza&Mexican 1077 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Toum of Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the of-eammon vie�ua�ler�-�'hi�lice�se-�s is ' the a�t�or��d-- - to the licensing authorities by General Laws, Chapter 140, and amendments thereta _ In Testimony Whereof, the undersigned have hereunto a�ed their official signatures. '. BOARD OF HEALTH: Beryaycix_`n. �"a+t�o.ry M.$. � s��rnvG: �a Aa�a Morbe�t, ?lsccs G''�� dfe�er�S�i�li,�JVG�I�i(i e December 24,2003 ruce G. urphy, ,R.S.,CHO Director of Health � of=aR TOWN OF YARMOUTH BOARD OF HE �'��P1�` � '' � L u j % ��; C' a,,� �� !� "�O APPLICATION FOR LICENSE/PE �1 v `� 3 -',c o.�• /S �;, � � � ��' �o�Z. ��•, * Please complete form and attach all necess ;r � �ece ber �, ��2 Failure to do so will result in the ret��yct?�`� , ication P c��L-�-}.� ��F-�-. Z' • Qf t// �- 1/'"L , /1')� I C'iCl # � ` I � 7 , . � fi �' A C TI .S' T�, � : ✓1/o�c S �e c/`t -.�' T . # .��r � .� D f��S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)a.�d�ttach a copy of`�h�certifrcatioir tv-�his 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. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishnnents are required to have at least one full-time em�loyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. _ �F,R�ON TN C:NAR(`TF.� -_ __- - - _ _ --- _ _. ___. _ _------ _ -- _ _ _ _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishtnents 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. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LQDGING: LICENSE REQLIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIlVIMING POOL$SOea. _LODGE $50 ____TRAILER PARK $50 _WHIRLPOOL �25ea FQOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FERMIT# �0-100 SEATS $75 3�0'j� _CONTINENTAL $30 `NON-PROFIT $25 >100 SEATS $150 1 COMMON VICT. $50 63�06,?j _WgOLESALE $75 ��'AIL SERVICE: LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. �200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ I Z 5.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"�*** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate 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 o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT T'HE 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 � ; , ADDITIONAL REGULATIONS POOLS POOL OP�IVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. i i 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. 4 F POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of f 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 Temporazy Food Service Application form 72 hours prior to the catered event. Thses forms can be � obtained at the Health Department. FROZEN DESSERTS: Frozen d�ssertsmust��test�t�an a-month�y b��y a-St��rtifi�d lab:�est r�su�ts�ust b��rit ta-th��th . Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. ' � OUTSII�E CAFES: ; Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. 3 I OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by '1 r fo d service establishment is prohibited. � DATE: � � SIGNATURE: PRINT NAME&TITLE: � � � t%�.. 10/18/02 r r �r.� v�� uc ,.v.�1 ['t�A JU0/7lUUL41! liU1.UffiAN AS�UC: t�JJ 01 A—�_ CERTIFICATE OF LIABILITY INSURANGF�� °"i2,o"'�°z � THIS CERTIFICATE LS ISS!/ED AS A MATTEI!OF HIIFORMAt10N GOI+D�N Sr AS30CIATEB INSQRA'D7CE ONLY AND CONFERS NO liIGNTB ttPON'fNE CERTffiCATE FINANCIAI, $ERVICE$ INC. HOL�ER 7}!IS CERT�ICYTE D�ES NOT AMEND,EJ(TEIItD OR 933 FAZid�U'1'H RD, a�TElt 11iE cOvEw►SE AFFORDED BY THE POLNC�S sELAW. HYANit2B MA. Q2601 Phone: 506-775-601� Faa:508-790-0249 ��F�G��E � INsuRER n; PAiiTUCF�T 1d0TID►L iN3 COl4PANY �►t+Tl'O�lIO REVIB B��'TE�RI3E$ INC. �stx�rte: PROF.LI]s,H. INS. CO. OP I+jL+�RIG ..V___.._ 6 T.R.P.S.�7C. D/8/A •--r� CRAIGVZLLE PI�ZA & �XICAti ��- 618 CRAZGVIT T V g� g� �� CENTER�ILLE lA 02632 NSURER E: co�r�►r,Es n�po�ac�s oFr�N+ae�.�a e��wr ww�er�ssum To nf nrs�,�v wwE,o,►Bove r-aR�FcxK:r�r�on worw�o.iuoTrnmr�r�u� AdV'��+�4tI,TEfn11 q�COF�tiIOrFOF ANY CONIRAG'f OR 07FIER OiOCt�iTW(17�4 R6SPECT TO MM1�H TF65 CERTIFIGITE 1AAY BE�OR NYIY PEKiM4 TFE 9�IBtAi1{NC�N�9r i'!�PCUCEB OESCR�EO t£�V i6 SNBJEGf TO ALL TF�7ERMB,FJACL.l610NS MD CO�DfYIONS OF SUCFI POl#yES.�7E L11/'FS SFIOWN-IW[T WIVE�ti�8y PAD CI.Af�S_ LTR TrPE CF NS�IGE POLICr Mi1BER QA7E �� ... ., .•`_. LMis--- OE�RAt.L1i�RY EACNOCCU�tENC� i ZOUOQUO A x �«�cw.r��u.u�er.,�Y is2000i�s5 o2/oe/o2 o2/oa/o3 �o.wc�c,�,�.d.� s 50000 � �''"� �°� ��wn,p»o«� :5000 - a�ttsa�w.:�oivn�r :l000000 __._ ..._ c,�n��c,w� s 1000000 �'�� v�eooucrs-ca��x� s 1000000 P�otJCY � �qc 4tliopOW1.E tde6p.fT�' ANYaU1�0 ��D S1P1GLb{.IIIT s AL1,oYY1�E0AtfTpB SCFF_OIICEDAlJTDB �Pify�9w� s FiiED AIJiL?S r101�WN�EDN7iffi {P�ieelW�q s �� i QARADE Lf�.liY AUTO ON.Y.F�I�CC�qYi i N�tAIJTO EAAGC S OTF�R Th�N AUTOONLY: nGG i �ccese u�e�.rrr �+aax� s � n�� ;��,��._._.�...� _ _...__.__...� s o�ic� : —"....^ �rExnoni s : w__.,. wo�oor�ersR��w X t+oRY � B �"�T �C.200005600 il/oi/o2 11/Di/o3 �a..��t� :l00000 I � e.�.acr�c�-�►�¢ s�00000 att�a �om��-r+�oucrurrt s 5000D0 �oF over� �ooeuey pn�artsaMs F�SE 7�OC�►TI0�7: I077 MA�N 3TIi�ET SOO't� YAii�DUTB D9� 02664 CERi7FlCATE NOLDER I�1 �oarnow�a�w�R t�TTEtt: CANCELLATION �y� 9FIOULD IWY CF THE AB011E 065�PotJC�i�t�.�effo�n�FF��'r1oM onTr 11oSt��1is�sstaliD liSUAERrYq.L�VOR TO IIAR. �1_onYs wwTiF7lI TOWI�T OF YA�ITB �To�ea�rFrr►�rio�aExx�e te tHE e�Fr�9u�F�uae ro 0o so afuai FA?C 508-398-0836 LICBN� � pEi�TTs DEpAR�1�1T u�ose xo wt�nar crt t�u1Y aF AwY It�D uvoN THE�au�.Rs�ra ort lld6 RT 28 �s�xr�rn�s. B�_Yl,RMOLITH IrA 02664 wnvE . , . � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #03-079 FEE: $75.00 In accordance with regulations promulgat�d under authority of Chapter 94,Section 305A and Chapter 111,Section 5 ofthe General Laws,a permit is hereby granted to: TRPS, Inc.,107�Route 28, South Yarmouth,MA Whose place of busi�ess is: Craig�ville Pizza&Mexican . } :.. _____ • =- Food S ' To operate a food establishment m: Town of Yarmouth Permit e�ires: Dece�nbei 3`l, 2403 so,vtn oF�.�LTH: �lea-� �e�ac, L�a�c SEa'ra•1G: 74 ��9�.��ji�rdo�c�?�.. �Ieee . . �aairck�Dear«ra�t �e�Slra�C .?Z. December 19 _,2002_ ., ; ' ; , ruce G.Murphy; .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLTMBER: #03-053 FEE: $50.00 ` This is to Certify that TRPS, Inc. d1bla Craigville Pizza 8c Mexican 1077 Route 28, South Yarmouth, MA _ _ ._ ____. _ __ IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at tha.t place only and expires December thirty-first 2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140,and amendn�ents thereto. In Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �lea r?�. i�dlt�rac. L�aLr.�ca�c SEATING: 74 cj� D. y�, 7'!l.D., ?/�ee �,afe� S��roa�c, �(,lork �a�k�leT�ez.xvt� � s ,� December 19 ,2002 Director of Health � f �-____. r � TOWN OF YARMOUTH BOAY2D OF HEALT ` I� [� � j� � �� APPLICATION FOR LICENSE/PE T- 2 apR � 7 2002 }�. * Please complete form and attach all necessary documents by Decem ��", , .`,�ail /f c��sa�r�sult in , the return of your apphcation packet. � �� EPT. NAME OF ESTABLISHME,N : a ��v► 11� �zzc-> � n'teX[c.c��-, TEL. #sv�3°l�/ S�4��' V G1 v�J � �� Ist� � ' f'o o �r " e. ��c o8-3 � -SZ�(�v �-� �c ,' u d'.�6�1 � POOL CERTIFICATIONS: . The pool supervisor must be certified as a Pool Operntar,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees b�low and atta.ch copies of employee certifications to this form. The Health Deprartment will not use past ye�rs' 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 �ull-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 pravide new copies and maintain a file at your establishment. 1.�(o,l�'t'Z Rl��-�1 2. � t �"' � PERSON IN.CHARGE: Each food establishrnent must have at least one Person Ir�Charge (PIC)on site during hours of operation. �. � ��,�e��s '��rl s 2. ��--�� S��-� ' HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar more must have at least one employee trained ir�the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and atta,ch 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..: � � . C / 1. �h ��'t )nS �� Grt S 2. � �`�1L J �'1��. 3. 4. �STAURANT SEATING: TOTAL#�_ OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMIT# LICENSE 1tEQUIIL�D FEE PERMIT# _„_B&B S50 _CABIN $50 _MOTEL $50 �1NN S50 _CAMP $50 _SWIMMING POOL a50ea. � ____LODGE $SO TTRAILER PARK $SO �WHIRLPOOL $25ea. EOOD SERVICE: LICENSE REQUIRED F�E PERMIT# LICENSB REQUIRED -FEE PERMIT# LICENSE REQUIRED FEE pERMI7`# �0-100 SEATS $�S , �'�1� _CONTINENTAL $30 �NON-PfiOFIT S25 >100 SEATS 5150 �COMMON VICT. �50 �Oc��J`� �WHOLESAL� $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE TtEQUIRED FEE PERMIT# LICENSE R.�QUIRED FEE P�itMIT# �� ,_,_,TOBACCO $20 _,_,_<25,000 sq.ft. S75 _ . �TOBACCb $20 __. �<SO sq.ft. S45 �.�25,000 sq.ft. $200 �FROZEN DESSERT$35 1�ME CHANGE: $io AMbUNT DUE _ $ /Z�,00 •; *****PLEASE TURN OVER AND COMPLETE OTHER SIDE bF FORM***** �� µ_ �.�.�. � � �,�`u F� �' '� � �� ADMINISTRATION � . ;� � �,w��ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i an license or pernut to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t 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 RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. i SEASONAL ESTABLIS�i1VIENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR 1NSPECTION 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. ; � � ! AUDITIONAL 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 aze required ta 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 ha.ve been met. OLITSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ; , OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. / � _�, __ � DATE: C( �l � � d �-SIGNATURE: ' PR1NT NAME& TITLE: ct a �- `I ,e n- � S�� 09/11/O 1 �. , _ � �.____ � •� � The Commonwealth of Mossachusetts � � Departmenl ojlndustriul.-�ccidents o OfJlceo/ter�s�l�stliis � 600 Washington Street ' •� Boston, Mass. 02111 �~ ��y W'orkers' Compensation Insurance Affidavit �Rnlicant information: PlessepRil�TTi�,-Wir n�mr �f1 �f�l�1(� S ��2t/' �S L�cation: , c�t� ,phone k � I am a homeowner pert�rmin,all w�ork myself. � f am a sole proprieror�-,', h��e no one ��orkin� in am•capacit�� . I am an emplo�er pro�idins workers' compensation for my empioyees w•orking on this job: ___ _ , _ _ _ __ —_ _ --- �9mna��• name: ��C4 i�-f/� t�"I`ZZ-C-( ;3" � ZC 1c�Ct � address: 1 V /. � 1 I /�(�'�l � � titt':� 1'('1 F'Z �9�.t - nhone tl• l��_ ��G�—�� O insurance co. t— E�� oolicy# �� 6� F%�1�' � �� I am a sole proprietor. :enerai contractor, or homeow�ner(ci�cle onel and ha��e hired the contractors listed below ��ho ha�e the follo��in� �corker� ,ompensation polices: com�anv name• address• ��n�' nhone H• ' insur�nce co. policy# s4moanv name• _—_ _ __ _ , address: _ -- eitv: �one M• insurance co. ��n,� t Failure to secure covenee as requ�red under Secnoo 25A of MGL IS2 ea�Ind to tht iopaidoa otcrivi�N pe�dtfa ota 0�e op to S1,500.00 a�d/or one years'imprisonment as w•eU a�civil penaiHe�io the form of a STOP WORK ORDER aad a One of 5100.00 a day K�inst ma [a�detsn�d t6at a eopy of t�hy ststemcnt may be fonv�rded to the OtTice of Invatigatioo�of the DU tor eoven;e veriBwtio�. 1 do hrreby cerrif}•under rh�poins and penelties ojperjury rhat�he injornration provided abovt is true and corrtci Signaturc - ( '�� i D� �/"�7 ,�- '�� 6 � Print name��(lr)S �t�(/� �.� Phonell .- o(Ticia!use onh do not w rite in this area ro be completed by city or towe oRleial ciry or town: Y�MDIIT� _ permit/licen�e N nBuilding Department ' �Liceasiog Board Q check it immediate respoese i�required 261 �Selectmen'�OlTitt �Heaith Department cont�ct person: phone p;_ �5Q8; 398�2231 eat. nOther ' ; � ACORD CERTIFICATE OF LIABILITY INSURANC� OPID J DATE(MMIDDIYY) RAIP50 04/17/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GOLDMAN & ASSOCIATE3 IN3URANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFiCATE FINANCIAL 3ERVICES INC. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 933 FALMOUTH RD. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. HYANNIS N�i 02601 Phone: 508-775-6010 Fax:508-790-0249 INSURERSAFFORDINGCOVERAGE INSURED INSURER A: PAWTUCKET MUTUAL INS COMPANY ANTONIO REVIB EN'�EF�PRISES INC. iNsuReR s: PROF.LIAB. INS. CO. OE AMERICA & T.R.P.S.INC. D/S/A CRAIGVILLE PIZZA � MEXICAN INSURERC: GZS CRAIGVILLE BEACH ROAD INSURERD: CENTERVILLE MA 02632 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDING ANY REQUIREMENT,TERM OR CANDITION 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR �E OF INSURANCE POLICY NUMBER DATE MMIDD DATE MMIDD LIMRS GENERAL LIABILITY EACH OCCURRENCE $ZOOOOOO A X COMMERCIALGENERALLIABILITY iB20001795 �2�04�02 02/04/03 FIREDAAAAGE(Anyonefire) $�j�0�� CLAIMS MADE � OCCUR MED EXP'(Anyone person) $�j000 PERSONAL&ADVINJURY $ZOOOOOO GENERALAGGREGATE $ZOOOOOO GEN'l AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1 OOOOOO POLICY PR� LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-0WNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per acddent) GARAGE LIABILRY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR � CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ REfENTION S $ WORKERS COMPENSATION AND X TORY IIMITS ER S EMPLOYERS'LIABILITY �200005600 11/01/O1 ZZ�OZ�OZ E.L.EACHACCIDENT $�.00OOO E.L.DISEASE-EAEMPLOYE $�.00OOO E.L.DISEASE-POLICYLIMIT $ rJ'OOOOO OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICIES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS LOC#1- 618 CRAIGVILLE BEACH RD. CENTERVILLE, I� 02632 LOC#2- 1077 MAIN ST. RT 28 SOUTH YARMOUTH, 1��, 02664 EFFEC 4/17/02 CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER IETTER: CANCELLATION TOWNYAR SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ��DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL TOWN OF YARMOUTH IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ZZQE RT 28 REPRESENTATIVES. SO.YARMOUTH 1�, 02 664 AUTHOR�D REPRESEMATIV JILL L. GOLDMAN ACORD 25S(7/97) OO ACORD COKFSORATION 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-114 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 ganted to: TRPS, 1077 Route 2R, Snuth Yarmouth, MA Whose place of business is: Craigville Pizza&Mexican Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31,2002 BOA1t�OF HEA�.TH: �ka�. r��.' xdP�i, Lka�xa�c s$a'rnvG: 74 �eu1a�xc�c 9. �jia7ala�, '�1L.?�.. `l/iee ,�:aded? �io�,c, ele�rk �a�rlck��a�t � S�ak ?Z. April 18 ,2002 Bruce G.Murphy,MP , ,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NiJMBER: #02-0�4 FEE: $50.00 This is to Certify that TRPS d/b/a Crai�ville Pizza&Mexican 1077 Ro rte .8, So� h Yarmo� h,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity vv�th the authority granted to the licensing authorities by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affxed their official signatures. BOARD OF HEALTH: eifanlea s?�. ��, �a�c SEATING: 74 '��`�. �� D., y� i�0��7t� �4alaa, � �?a�riek'l�e�rnrot� � S �?Z. a,�� is ,2002 e . y, Director of Hea1�t► � '