HomeMy WebLinkAboutApplications, WC and Licenses .� _� '►- —
�, °� �� TOWN OF YARMOUTH BOARD OF HEAL � � D
T��,-..� ,
APPLICATION FOR LICENSE/PE R M��� 2 U�� . NOV 2 6 2008
e.,.e . - �
* Please complete form and attach all necessat�y d�c'u�e�t .�'_e�cem er
a
Failure to do so will result in the return of;yo�a�p cation pa �D�PT.
NAME �F ESTABLISHMENT: �A TA N �c�NA T�� I� CY�f �. TEL. #�-����-�'��jQ
� LOCATION ADDRESS: T� T UT U T ZQ l��--
� MAILING ADDRESS: SA�YI E
OWNER NAME:���( S }}1�LT TAX ID (FEIN or SSNZ�
CORFORATION NAME (IF APPLICABLE}:�(��'-�A�'�'1�� V� ,AT1�1 'PROPE'�T 1 E S
; MANAGER'S NAME: p'1� TEL. #r-�,��-3�{ -�3 �
� MAILING ADDRESS: V � i- �
�
POOL CERTIFICATIONS: �
� The poal supervisar must be certified as a Paol Operator,as required by State law. Please�list the designated
, Pool Operator(s) and attach a copy of the certification to this forin.
;
1 . . �� r !� � 2. .
Pool operators must list a muumu� _ V � � ;ertified in basic water safety,standard First Aid and
Community Ca.rdiopulmona.iy Re:���� t;�(��� hese employees below and attach capies ofemployee
certifications to this farm. The f �se past years' records. You must provide new
� copies and maintain a file at ya IiJ1 �� �t � �p(-'�'�
� ���
1. ����i ���'L�(j';. 2.
3• . 4.
,
� FOOD PROTECTION MAN. —h � � :
All food service establishmen � e� i� �� �t one full-time employee who is certified as a Food
Pro tec tion Manager, as de fi ne 1^(i Q� � Q,��'� � �r Food Service Establishxnents, 105 CMR 590.000.
� Please attach copies of certific iealth Department will not use past years'records.
You must provide new copi� �11� ��'� j � ��' r est�tblishment.
�
� 1• _2.
PERSON 1N CHARGE: -
' �ach food establis7unent must have at least one Person In Charge (PIC) on site during hours of operation.
l. Z.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich
Maneuver on the premises at all tunes. Please list your employees trained ui anti-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 �le 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 PERNIIT#
_B&B sss _caBnv �ss 1Mo�L �ss 6 "—Gla--
_,rn,�r _ __�55 _--- _ _CRivir _ ��5 _JWIMMING YOOL �$�ea.
_LODGE S55 _TRAILERPARK �105 �Vfi1RLPOOL �80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS S85 _CONTINENTAL �35 NON-PROFTI �30
_>100 SEATS - �160 _COMMON VIC. $60 WHOLESALE S80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. 550 _>25,000 sq.ft. �225 VENDING-FOOD �25
<25,000 sq.ft. �80 _FROZEN DESSERT $40 TOBACCO $55
�a:�E c��vcE: sio AMOUNT DUE _ �_ cS�S.00
�
****•PLEASE TITR�ti OVER AIV'D COMPLETE OTHER SIDE OF FOIttvl****'� 4
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ADMINI5TRATION
Under Chapter 152, Section ZSC, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ;
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's �
Compensation Insurance. THE ATTACHED 5TATE WORKER'S COMPENSATION INSURANCE ;
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED
OR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES 'r NO
MOTELS AND OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use;Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. '
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy ',
Excise, as defined in M.G.L. c. 64G or 830 CNIR 64G, as amended, shall generally be considered Transient. '
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days
pnor to opemng.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of
closing.
� FOOD SERVICE ;
;
CATERING POLICY: '.
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required �
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the `:
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
UUTDOOR COOKING:
Outdoor cookin��reparation, or display of any food product by a retail or food service establishment is prohibited. ,.
NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ':
�
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
E
DATE:r� 8��_ SIGNAT .
, 1i,
PRINT NAME&TITLE.
ioizvos �
---- _ , .�. ._,y—� �•"�"� — -
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
NAf�/N�iM�
600 Washington Street, 7`h Floor '
Boston,Mass. �2111
Workers'Compensstiou ieserance Af�davir B�ilding/Plembing/EleMrical Coatractors
t�atf�t: P'kase PRllVT 1�Wv
name• � J ��1 1 1� I�I G �i 1 \�� � `
address: 1��� �1\�V�� �(�
ciri�v t � \�1����� state•B 1 f� zip�1� Dhone# �- � 1����
work site locafion ffull address)_
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction�Remodel
Q�I atn a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing worke.�s'compensation far my empioyees worlcing on Wis job.
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❑ I am a sole proprietor,gegeral co4tractor,or homeowa�(circle one)and have lrired the conhact�s listed below who have
the following workers'compensation polices:
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Pa�m�e'/a sccme ow�e�aeder sal�a 1SA et MGL 152 e..ind a ue Mrp.dtMr.f ai.mal pea.Nia.f a�e.p a si,SN.M aaa/sr
o'e yairs'Imptiso�mt as�dl as dv�pe�aitla fs t�e form ot a 3T0!WORK ORDER ied�8ne et 5109.OS a day agal�st me. 1 aOderNaad tbat a
cepq�f this�ta/m�e�my be fonvarded�n the O�ce ef la�Hona ef We DIA tor avcrage veriAeatlee.
/do h y c ' xnder Nre pafns es pery' tlYat tbe t�fo►�waHow provided above is bxe aad cernct
s, � ns� �11��o�
Print name Plwne#�`��,8���l�
official ase only do not�vrite i�this area te 6e�mpkY�d by cHy er pwa e�clai
city or te�vn: permitlGcease# OBuidio8 Depar�en�
❑c4eck if immt�a�e napeme is reqaired QSdeelmen's�ce
ceatad pasoa: p�oae#, �� �t
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Client#:19901 [ciar�runwv
DATE(MMN[NS'YS'1�)
ACORD� CERTIFICATE OF LiABILiTY iNSURANCE 11/20/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dowlin S O'Nei)Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFtCATE
a A�ER THEHCOVERAGE A ORDEED BYT�POLIC ES BE OW.
Agency
973 lyannough Rd., PO Box 1980 NAIC t�
Hyannis,MA 02601 INSURERS AFFORDING COYERAGE
INSURED INSURERA Vermont Mutual
Sagamare Vacation Properties,Inc. DBA INSURER B:
The Captain Jonathan Motel iNsuR�c:
1237 Route 28 uvsuReR a:
South Yarmouth,MA 02664 INSURER E:
COVERACaES
THE POUCIES OF iNSURANCE L�STED BELOW HAVE BEEN ISSUED TO THE INSURED NAA�AED ABOVE FOR THE POUCY PERIOD fNDICATED.N0TIM�THSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH�HIS CERTIFICATE MAY BE fSSUEO OR
MAY PERTAIN.THE iNSURANCE AFFORDED BY THE POIICIES QESCRIBED HEREIN iS SUBJECT TO ALL THE TERMS,EXCLU510NS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDU�ED BY PAID CLAIPM�S�Y EFFECTIVE Po1.1CY E7cPIRA'nON
LINiT3
LlR N R
TYPE OF INSURANCE POLICV NUMBER EqGH OCCURRENCE $� OOO OOO
p� cENew►�unsiurr BP11011158 03124/08 O3IZ4IO9 DAMAGE Tp RENTED Er,O QOQ
X COMMERCIAL GENERAL LU+BILITY , ���P{�Y���) Er�OOQ
CLAIM3 MADE a OCCUR
PERSONAI&ADV INJURY a1 OOO.�a�
_ -- __ _
- --- _ -- - - -- __ —__
_ . _ - -
GENERALAGGREGATE SZ OOO OOO
PRODUCTS-COMP/OP AGG S� OOO QOO
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PR� LOC
AUTOMOBiLE LIABIIITY COMBINED SINGLE LIMIT f
(Ea accident)
ANY AUTO
ALl OWNED AUTOS BODILY INJURY �
(Per persor+)
SCHEDULED AUTOS
BODILY INJURY S
NIRED AUTOS (Per accident)
NON-OWNEO AUTOS
PROPERTY DAMAGE $
(Per accident)
AUTO ONLY-EA ACC�DENT E
GARAGE LIABIUTY EA ACC S
OTHER TNAN -�
ANY AUTO AUTO ONLY: qGG $
EACH OCCURRENCE 5
EXCESSNMBRELLA LWBILITY
AGGREGATE $
OCCUR �CLAIMS MAOE $
3
DEDUCTIBLE §
RETENTION $ WC STATU- OT�'�•
WORKERS COMPENSATION AND E.L.EACH ACGDENT S
EMPLOYERS'LIABILtTY
ANY PROPRIE70WPARTNERtEXECUTIVE E.l.D�SEASE-EA EMPLOYEE E _�_
pFFICERtMEMBER EXCIUDED?
If yes,descri6e under E.L.DISEASE-POL�CY LIMIT S
SPECIAL PRpVIS10NS bebw
OTHER
DESCRIPTION OF OPERATiONS!LOCATlONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS
insurance coverage is limited to the terms,conditions,exclusions,other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be deemed to have altered,waived,or exte�ded the ,
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCEILATION
SHOUID ANY OF THE ABOVE DESCRfBE�POLIC�ES BE CAI'ICEI-L.E�BEF�E THE E7(PtRATIW
TOWl1 Of YBffItOUtil DATE THEREOF,THE ISSUING INSURER WILL ENDEAYOR TO MAIL �._ OAYS WRIT'TEN '
1146 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAiIURE TO DO SO SHALL
South Yarmouth,MA 02664 IMPOSE NO 08LIGATION OR lIA8�UT1'OF ANY KINO UPON THE INSURER,ITS AGENTS 8R
REPRESENTA S.
AUTHORIZED R PRESENTATIVE
��r a G:r...,._aa""'�'�
L�� � ACORD CORPORATION 1!
ACORD 25(Z001(OS)1 of 2 #54507
s � �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMUUTH
BOARD OF HEALTH
PERMIT NUMBER: #09-012 FEE: S55.00
This is to Cenifi�that Henry Edward Schultz d/b/a Cantain Jonath�n Motel
1237 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conforniitv«�ith the authorit�granted to the Board of Health,Uy Chapter 140,Sections 32A,3?B,
32C,32D and 32E as amended,and is subject to the provisions of the La«•s of the Commoin��ealth of Nlassachusetts relating
thereto,and upon such terms and conditions,and to the niles and regulations in regard to said Motels so licensed as adopted
bv the Board of Health,and expires December 31,?009 unless sooner suspended or re�oked.
DecemUer 11,2008 BOARD OF HEALTH: .`��¢�tt S��t� �..IV.� CptR(�iliRft
C!�ia�cee.� .�. ��£e�P.�if�ex'� `tl�ice C'�czi�Cnuut
*?0 linits;30 Bedrooms. ✓�A�¢� �. ��141uIt� �;Celtlt
I Cottage-2 Bedrooms. �Lft ��iGP�C�ft�iCUfft� �..lV.
t'""'J,.`�• .i�
ruce G Murphy,M ,R.S.,CHO
Direetor of Health
-� � �
�'"' CA��.�ToNt�-ld-A N
• =Y�'k� TOWN OF YARMOUTH BOARD OF HEAL
�� o
����? APPLICATION FOR LICENSE/P�+,�T���O �'_ r ;, l� C� � � M C D
�� >N � ��, I��N g 2008 �
- *Please complete form and attach a11 necessary d�cu�n�i ecemb r�3�Y;2 II0�.
Failure to do so will result in the return of��rour application pac t.HEALTH DEPT.
������ �_
NAME OF ESTABLISHMENT: Cc�,o I�:n .Io��«•+ M�-1 TEL. # SO£� 31 dr .�Y�
LOCATION ADDRESS: !L 3�' R Z� � . �,.�,e..l� M�¢ Dz6� y '
MAILING ADDRESS: /Z!e/ /2�. Z� S• Ya�,.�a.f�, �9- O26l� y
OWN�RNAM�: r, �L�..�e.�t �S'�,,/fs.. TAX ID (FEIN ar SSNI-
C(JRPORATION NAME (IF APPLICABLE): s'w•��s,.� (/c►cs��e., f'�.zs�ut•��yc.s , ('���. !
MANAGER'S NAME: �„ P- -�- TEL. # 12�Y 39 dr 3Yd�
MAILING ADDRESS:
/u.,: �.�. � .r S•�.�.-�►o ,�- d Z�s �
� t
POOL CERTIFICATIONS: '
T6e pool supervisor must be certified as a Pool Operator,as r.equired by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form. '
1. 1✓//� 2. N �-
Pool operators must list a minimum of two employees currently certified in basie water safety,standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
eertificatians to this form. T�te �ealth Dep�rt�ent will not use past years' reeords. 'Yoa �t�s� pravide new
copies and maintain a fde at your place of business.
1. 2.
3. 4.
_ .. _____, _ ____ .._ ._._ -- _----_ __ _ _ _ _ __ ,
E
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 Mana�er, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Flease attaeh copies of certifica�iontothis applieation. '�he Health Departrnent�vitl nat nse past years're��rcls.
You must provide new copies and maintain a file at your estabGshment.
1. �' 2.
P���91�1 IN��A�.R:GE:
Each food establishme t must have at least one Person In Charge (PIC) on site during hours of operation.
�. N � 2.
,
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 employee certifications to this form. �'he Heaith Department will not use past years' reeords.
You must pcovide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE QNLY
LQDGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE P£R�I1T� LICENSE REQUIRED FEE PER�IIT�
B&B S50 CABIN SSO 1 MOTEL S50 ����� �
TrrN sso c�.� sso �� . �� _
_ _ J
_LODGE �50 _1'RAILERPARK S100 ^t�'�3tRLPOOL S75ea.
FOOD SERVICE:
�__ _ . __—___ _ __
LIC£NS£REQUIRED FEE PERMIT� LICENSE REQLTI�tED FEE P£RMIT� LICENSE REQtiIRED FEE PERVSIT�
0-100 SEATS $75 _CONTINENTAL S30 _NON-PROFIT S25
>100 SEATS SI50 CO:�L'�ION VIC S50 _�VHOLESALE S'/S
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PER'�IIT= LICENSE REQL'IItED FEE PER'�fIT=
_<50 sq.8. $45 >25,000 sq;ft. 5200 _VENDIIv'G-FOOD �520
_<25,000 sq.ft. 575 _FROZEN DESSERT S35 _TOBACCO SSO
NA�'1�CHAVGE; sio � AMOUNT DUE = JSO•oa
4
I '�****PLEASE TL'R.�O�'ER A\D CO�TPLETE OTHER SIDE OF FOR�Z**"�**
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- ADNIINISTRATIUN
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 ogerate a business if a person or company does not have a Certificate of Worker's
Comper�sation_Insurance. THE ATTACH�� STATE ,V�OR�ER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE CQMP�.ETED AND,S�GNED,.OR ; ,
, ,, CERT. OF 1NSURANCE�TTACHED . s
. � � OR � '
. : ' �`, ' "W ORKER'S COMP.�AFFIDAVIT SIGNED AND ATTA�HE�,D ,
, _ , _ ,
Town of Yarmouth taa�es and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
R�iOTELS AND OTHER LODGING ESTABLISHMENTS- ' -
TRAN�IENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupanc,y shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motet and hotel us�.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence eL9ewhe.�e.
Transiern occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest utit as a residence or
dwelling unit sha11 not be considered transient. Occupancy thax 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 Cettsus must be completed and returned with this application.
POOLS
POOL OPENINGs All swimming,wading and whirlpools which have been closed for the season must be ins ed
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys
pnor to opening. �
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered withip�seven(7)days of
closing.
FOOD SERVICE
CATERING POLIC`i':
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depariment by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department. ,
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pennit 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 cooking,preparatioq or display of any food product by a retail or food service establishme�is prohibited. ',
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPUNSIBIIITY TO RETURN '
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER�20Q7.
�
ALL RENOVATIONS TO ANY FOOD ESTABLISF�ViViEENT', MOTEL OR POOL (i.e., PAINTING, NEW ,
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR '
TO COMMENCEMENT. RE:VOVATIO:�TS MAY REQUIRE A N.
DATE: / y � SIGNATU .
� N
ARINT NAME&TITLE: ii ..s �l � S �l ,�,
.
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pRppuCER E ATE ED A NIATTER OF INFORAAA
ONLY At�CO(�ERS NO RM3M�3 UPON 7HE CERTIFICATE
PAYCHEX AGENCY INC. HOLDER. 7tq8 CERTiFlCATE00E.S NOT AMENQ,EX7Ei�'f OR
vVEST H�F�IR�ETTA�,NY 14586 COMPANIES AFFORDING COVERAGE
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GUAROINSURANCE
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SAC3AMORE RERLTY TRllSI'GORF B
1261 WIAIN STREET
SOUTH YARI�WUTH,MA 02664 ��
CpdPANY
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THIS IS TO CERTIFY THAT THE PO�ICIES OF INSURANCE LIS'f�BELOW HAYE BEEN ISSU�TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ,
II�ICA'i'�,NOTYVlTt{5TIWDING ANY REQUIREMB+tT,TERM OR CONDITION OF ANY CONTRACT OR OTNER DOCUMENT W1TH RESPECT TO WH�H THIS
CER'fIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSttRANGE AFFORDED BY Tt�P041GIES DE9CRIBED HEREM IS SUBJEGT TO ALL THE 1ERMS,
EXCLUSIONS AND C4NDITIONS OF SUCH POUC�S,LIMRS SHOWN MAY HAVE BEEN REDUC�BY PA�CLAIMS.
� TYPE OF INSURANt;E POUCY NUMBER PouCr�Cr�ve POLICY EXPIRATION ��
lTR . DATE(NNlDWYY) 6AlE1MM/D[1/Y1� .
G6�RAL{.IABIL�YY GENERALA04flECiATE S �
COMMERCIAL dENERAI UABILITV PfiWUCTS-COMPX7P AOd $ �'�..
�',LA�MS MADE�CCUR pERSONAL d ADV INJURY $ ��
CNNNERS d,CQr+1 w�CT9F1'S P� ---- '
EACHQCCURRENCE S _
F1flE DAMAC+�E tAny on0 frce) $ ��:
MIED EXP(Any cme person} $ �
atnonaoe��uneiurr
ANY AUTO COhA&NED SINGLE L1tMT S i
ALL OwNED AUTO$
BODILY INJURV g
SCH�tKED AUTOS fPer Darso�a
HIRED AUTOS
BODILV INJI�iV S .
NON-OWNED AUTOS (Per accidem)
— PROPERTY DAMApE $ �.
QARAOE IJA�IITY ' AUTO ON4Y-EA ACGIDENT 8
ANY AUTO On+ER THnta AU ro Ohu.r
EAGH ACGDENT $ �
� ACvOREGATE � �.
EXCESS 11ABiUTY EACH aCGURRENCE S
tIMBREL4A FQRM AGGFlEciarE S
QTHER THAN UMBRELUI FORM g
WdiKEH'S COYPENSAI'bM AND )( w r iU- ..
A EMPI.OYER8'LIA8HJT1f
EL EACH AGCtDENT S 1 Op,a10.00
THEvtwvR�row INCL
PARTNERS+EXEGUTIVE � SAWC$13219 11/15/07 11/15108 ELDISEASE-PIXICVLIMIT a soo,000.00 -
cJFflCERS AF�E: �EXCL � EL DISEASE-EA EMPLOYSE $ 100,000.00 �.
oTM�
DE9CRN�TION OF�ERATqNBIIOCAT1pqSlVEMK:LE8�9VECIAL REM8 �
THE CAPTAIN JONATHAN MOTEL
<' '�'l�E::�::::::::<::::;::;::>;:�:::::z��:::::::::<:::.:>;:::<;::�:��::;:::::«:::<::::::>:;:::>�::;;::::;:::;;;::
::��f�C1t°i'���:tt.�t�::::::::z:::>:::::::�:�:�:�;<�:�:�:;�::::��>:::;�:`�>:�;��::�:=:::;;<:;:;;::::=:-:`:�=��i.�,A
$NpJLD ANY OF TNE ABQYE DESf:Fi16ED POLK:tEB BE CANCELLED BEFOHE 7NE
TOWN�F YARMOUTH EXPIRATiONDATETNEREOF,TNEISSUINtiC01�ANYWILLENDEItYORTOMAiI
1146 f iT 2$ � onrs wwrrew�witcE To n�c�nFlCate�an�rt�o ro twe t.ew�.
S4UTH YARNIOUTH,MA 02664 `
BUT RAILURE TO YAIl.SUCX NO110E SNALL MP06E/W OBLpATWp OR UABILRY
OF ANY KWD UPON TME COAIPANY.ITS AQENTS OR HEPRESENTA7tYES.
A REPRES�ITA�iVE
� /4 �+ ��/'�._
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�:A�DQRQ: '
>::<�>:�A'�13RD:�tC1RP.�ili#:t1Ef[I<i8B8
�� ��5���� ��:�� Paych�x, Inc. ��� �
Date: 1/8/2008 Timex 10:54 AM To: 9 9,150839868B5 Paqe: 002
� � Glient#: 19901 2CAPtAINJO
ACORDTM ��RTIFICATE QF LIABILITY INSURANCE ���Q$�Q$�YYYY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFQRMATtON �
Dowling 8 O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agen HOLDER.THi3 CERTIFICATE DOES NOT AMEND,EXTEND OR
� ALTER THE COVERAGEAFFORDED BYTHE POLICIES BELOW.
9731yanough Rd., PO Box 1990
Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# '
INSURED INSURER A Vermont Mutual '
Sagamore Vacation Properties,Inc. DBA INSURER&
The Captain Jonathan Motei �r,suRER a
c!o Barnstable Laundry,32 Baxter Road INSURER D:
Hyannis, MA Q2601
INSURER E: �
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANQING
ANY REQUIREMENT,TERM OR CdNDITiON OF ANY CONTRACT OR OTHER DOGUMENT WITH RESPECT TQ WHICH THIS CERTIFICATE MAY BE fSSUED OR �
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRI6ED HEREIN IS SUB,IECT TO ALI.THE TERMS.EXCLUSIONSAND CONDfTIONS OF SUCN
POLICIES.AGGREGATE LIMITS SFIOWN MAY IiAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EF�ECTIVE POLICY EXPIRATION LIMITS �.
A GENEFiAL LIABILITY BP1101115$ Q�Z��Q7 0�24�� EACH 6CCURRENCE $� QQQ QQQ ��.
X COMMERCWL CaENERAL LIABIUTY DAMAGE TO RENTED $$Q�O .
CLAIMS MADE a OCCUR MED EXP(Any ane person) $rj QQQ �.
PERSONAL 8 ADV INJURY $� �O OOO .
GENERAL AGGF2EGATE $Z OOO O(}O �.
GEN'L AGGREGATE LIMIT APPUES PER: PROW CTS-COMP/OP AGG $� OOQ OQO �.
POLICY PRO- LOC ..
AUTOMOBILE LIABILITY �
COMBINED SINGIE LIMIT $ �
ANY AUTO (Ea accideM} ��
AlL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS {Per pereon} $ I.
HIRED AUT4S
BODILY INJURY $
N4NAWNED AUTOS (Pe�amdenQ ..
PROPERTY DAMAGE $ �
{Per acadeM) ��
GARA6E LIABILITY AUTO ONLY-EA ACCIDENT $ .
ANY AUTO OTHER THAN EA ACG $ '.
RUTO ONLY: AGG $ ��.
EXCESS/UMBRELLA LIAB1lRY EACH OCCURRENCE $
OCCUR ❑CLAIMS MADE ACaGREGATE $ � �� ` �.�
$
DEDUCTIBLE a
RETENTION $ $
W�2KERS GOMPENSATION AND WC STATU- OTM- ,
EMPLOYERS'UABILRY `
ANY PROPRIETOR/PARTNERIEXECUTNE EL EACH RCqDENT $ -
OFFICEWMEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $ ��
If yae,desai6e under �.
SPE IA PR VI 1 S b ow E.L.DISEASE-POLIGY lIM1T $
OTHER
DESCRIPTION OF OPERATIONS I LOCATION$i VEHICLES/EXGLUSION8 ADDED BV ENDOR3EMENT!SPECIAL PROYISION$ ��
Insurance coverage is limited to tho terms,conditions,exclusions,other
limitations and endorsements. Nothing cor�tai�ed in the certificate of
insurance shall be deemed to have aitered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DE3CRiBED POLICIES BE CANCELLED BEFORE THE EXPIRATION �
Town of Yarmouth DATE THEREOP.THE I5SUINCa MSURER WILI ENDEAYOR TO MAIL �_ DAY$WRITfEN
1148 Main Street NOTIGE TO THE CERTIF4GATE HOLDER NAMED TO TME LEFT,BUT FAILURE TO DO 30 SHALL
South Yarmouth,MA 02664 IMPO$E NO OBLIGATION OR LIABILRY OF ANY KIND UPON THE INSURER,RS AGENT$OR
REPRESENTATIVES. I.
AU'��IZEDR PRESENTATIY� �'�.
�` tr�..�+/a+�......��.`�w
ACORD 25(2001108j� pf 2 #504y1 �,$� a ACORD CORPORATION 7988 '
MAY 23,2007 01:39 page 2
. - i
� THE CONIlYIONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH ,
PERMIT NUMBER: #08-041 FEE: $50.00 '
This is to Certify that He�r;Edward Schultz d/b/a Cant in Jonathan M��el
1237 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
QPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regula#ions in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked.
January 28,2008 BOARD OF HEALTH: ��t 5��� �..1v., ��Latt
('�� �.�£e�i(fr�J'G� `U�iCe('Rrc�cfutltR.rt
*20 Units;20 Bedrooms. J�O��S.J��llllU�t, �X.�Jli�
1 Cottage-2 Bedrooms. �� � �-�-
�:t�e�r�ri J• .��Ear�
Bruce .Murp y,MP , . .,CHO
Director of Health
�
i
�
i
.� ��
' 'Qf r Rai TOWN OF YARMOUTH BOARD O���L�'H `��
��t �,s APPLICATION FOR LICENSE/PERMIT���90 �gr ti�
' K - �� JAN 1 1 2007
*Please complete form and attach a11 necessary documents by ecernber 31, 2006.
Failure to do so will result in the return of yaur application packet.
: NAME OF ESTABLISHMENT: 1� ��'j'�(1` k -}�n 6�c��e i TEL. #5U�3`l$-3�t 8 0
� LOCATION ADDRESS: ��a �1 '� 1q Q �y '
�u,nv�aDnxEss: a � �y
OWNER NAME: Z. r � '� - ��
CORPORATION NAME APPLICAB ):
, MANAGER'S NAME: TEL. #
MA.ILING ADDRESS: l a (' �-}- (� �
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 capy of the certification to this form.
�.vasm� `� � 2. C��n��� ���nt�lfi Z--
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
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� l z. C,h� 5 5� lfi Z.
i
3• 4.'�f���r�,�,�('
,' 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 S90.00Q.
; Please attach copies of certification to this application. The Health Department will not ase past years'records.
� You must provide new copies and maintain a file at your establishmen�
�
� 1• 2.
PERSON IN CHARGE:
Each food establishment must have at least one Per n In Charge(PIC) on site during hours of operation.
1- 2.
' HEIMLICH CERT`IFICATIONS:
All food service establishments with ZS 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
' LODGIl�TG:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMLT#
_.B&B �50 _CABIN $50 ( MOTEL �50 O7�OLy
_INN $50 _CAMP $50 ( SWIlVA�IING L$75ea. �D7�3
_LODGE $50 _TRAII,ER PARK $100 _W��,pppi � �$75ea. �
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
0-100 SEATS $75 _CONTINENTqI, $3p NON-PROFIT $25
_>100 SEATS $150 _COMMON VIC. $50 _WHOLESALE �'75
RET.�.SERVICE: —RESID.KTfCHEN $75
LICENSE REQU]REp FEE PERMI'r# LICENSE REQUIRED FEE PERMTT# LICENSE REQiJIRED FEB PERMTT#
T<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING_FOOD $20
_QS,OOOsq.B. $75 _.FROZENDESSERT �35 _TOBACGO $50
NAME CHANGE: $10 AMOITNT DUE _ $ �07,��
`*•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
.....
` � �
,
ADMINISTRATION
y
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth is now required to hold issuance or renewal ;
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's i
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURA►NCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: , /
YES I/ NO
MOTELS ANp OTHER LQDGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they ma,intain 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. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Tra.nsient.
POOLS
POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to openu►g. Contact the Health Department to schedule the inspection five(5�days
pnor to opening.
POpL 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�nust be drained or covered within seven(7}days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTD40R COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmeirt is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
'THE COMPLETED APPLICATION(S)AND REQL7IItED FEE(S)BY DECEMBER 31, 2006. R
ANY OOD ESTABLISFIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW �
ALL RENOVATIONS TO F
EQIJIpMENT,ETC.),MUST BE REPURTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR !
T4 CONIlVIENCEMENT. RENOVATIC?NS Y REQUIRE A SI LAN. `
�
DATE: �� V SIGNA �,'
PRINT NAME&TITLE: � � �
io�i�io6
r
♦ S �\
�'he Commonwealth of Massachusetts
Depart�ent of Industrial Accidents
����
6lI8 WoshiAgton S`treeg 7`�'Floor
Boston,Mass. 02111
— ----- Work�s'Com tios Ls�anee A�davi�Bail bis�lectrical Coetractors
. �. _.�,�. � � _ �x �,�. .- �;� , �a�- . ,.
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- � � 3� - 3�l�O
����i��rr�u�s�-
o � a�„�,����„�m,,�: Proje�ct Type: ❑New C�ructiaa��Reanodel
am a sole anci have no a�e w in an ca ❑Buil ' Addition
❑ I am an e�pioyer providing wazkers'compens�ion fa�my emplay�s wcrrlcing ari this job.
��
+clt�: alt�te�-
❑ I am a sole praprietor,ge�erst co�tractor,or tiomearv�er(cirde ow�)and have hic+ad the c�tors listed below who have
the following wotkeds'compensation polices:
�� �
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�.v� �#:
#�
�r�e: .,,
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Fall�e a sec�e or.era�e a.req.hed.Ma safM.24A.t AlGI,lst m Ie�a tMe brpaw�r.t�paaNies.f a�e�p�.t1,sM.M a.dA.r
s�e yean'ispr�t as we!as cM paakies ia t6�fir�sta STO!WOR1C ORDER ud a 6ae df1a9.M t dap ataimt�e. !mdaslud tLat a
apy�f tYk ftale�my 6e forwaMed ts He Omce e[l��f 16e DIA!rr ewenge veetAadoi.
1�o b y rtnder of peejr�y tNat tJie iuforsr�lon provided abov�e ia dus and on .t
Si I�te � `� V� '
P�� pbo�# �� 3`l� -a3�I
����,. d.�.���.��.��� K��
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p��t��.a����y�a �� ;
O�� '
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c�m sm�wa+� ,
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THE CUMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-024 FEE: $50.00
�
This is to Certify thai Henrv Schultz d/h/a The Cantain Jonathan Motel
1237 Route 28 South Yannouthh MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issue�in conformity with the mrthority granted to the Board of Health,by Ghapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subj�t to the provisions of the I,aws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2007 unless sooner suspended or revoked."
Februazy 22.2007 BOARD�F HEALTH: B �. ,J��., .
���s�, �'�`�, v�e���
a�t�. B�, et�
��a���
�o�r�.�� R.�v
. Bruce G.Murphy, S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-043 FEE: $75.00
This is to Certify that Henrv�chul .d/b/a The a.ntain Tonathan Motel
1237 Route 28, South Yarmouth.MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At_ The Captain Jonathan Motel - OUTDOOR POOL
1237 Route 28
South Yannouth, MA
This pernut is granted in conforn►ity with Article VI of the Sanitazy Code of The Commonwealth of Massachusetts,and
expires December 31_2007 unless sooner suspende�or revoked.
Februaiy 22_2007 BOARD OF HEALTH: � $. /��., .
��s�, ��e��
� ��,, R�t� B�, e�
� v S ���r��
' ,� �J���.�, R.JY.
�� � (,�d� �
� Bruce .M MP R .
� H'
Director of H�ealth� �
i �
. :_ , CAstt-�t.T 2-33� CaP cNa�N
or'_Y'qR
� ,. .� TOWN OF YARMOUTH BOARD OF HE T� � G3 j� � i� � ��r , , ;�,
o: -'� APPLICATION FOR LICENSElP��T*�- 0`� �A; ;
' MAR 3 0 2006
� .. �,,;:� -
* Please complete form and attach all necessary do�uments by December 1 2005.
Failure to do so will result in the return of yow application packet �IEALTH DEPT.
NAME OF ESTABLIS��VIEENT': `� � ` o� � �o_. TEL. # 5"08����3`l�0
LOCATION ADDRESS: !� 3 � �o� � 2 8' So� � ` ��� �ZG6
MAII,ING ADDRESS: Z �,,fc z SB✓ � �Z�'
OWNER NAME: e � ,, � T ID E r -
CORPORATIONN (IF APPLICAB E):S�«o�,G ��a-�o �'i'o�r ��S ��
MANAGER'S NAME: o S � TEL. #se S-3��- ��/�v
MAILING ADDRESS: 2 „ 2 $ sQ � D
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list th�designated
Poal Qpera�er{���-a�t�ch a ca�y c�f t�ce�ification to this fo�n. _ __
1. ��5� �'I ��2 � ��-� �. ��r�`5/�i1T�P�/��l ri �—� ���
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 thas form. The Health Department will not use past years' recards. You must provide new
copies and maintain a file at your place of business. '
1. �l D�� S �� � 2 G � � �r�,- S��i� �-
3. � 4. `7
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
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 Establishrtients, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a fde at your establishment.
1. 2.
�
P�RSON�1��t��:- _ _ _ _ —_ _ _ _ !
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ;
l. 2. ,
HE��CH 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 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 REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 CABIN $50 I MOTEL $50 ��9
_INN $50 CAMP $50 I SWIMNIDIG FOOL$75ea. F�"0�,3
_LODGE $50 TRAII,ER PARK $50 _WHIRLPOOL $75ea. '
FOOD SERVICE: I
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS $75 I CONTINENTAL $30 O6'����I NON-PROFIT $25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIItED FEE PERMTf# LICENSE REQL7IRED FEE PERMIT# I,ICENSE REQUIl2ED FEE PERMTf#
_�SO sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 ;
_45,000 sq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 '
NAME CHANGE: $10 AMOUNT DUE _ $ I S5. o0
fY*R R RpLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM'*'�** '��.
�
� _ . �
a a (
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 �
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 IF PAID:
YES �', ~` NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETURN
TI-� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. �
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- �
10 DAYS PRIQR TO OPElVING FOR TI� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW :
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO
COMN�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. '
ADDITIONAL REGULATIONS �
POOLS
POOL OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count }
by a State certified lab, prior to opening, and quarterly thereafter. �
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ,
closing. ;
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS: ,
��bzen d�sserts mus���tested on a morithly basis by a State certified lat�: Test results must be sen�to the I-�eat�h - �
Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the �
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health.
i
OUTDOOR COOKING: �
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited.
DATE: 3� �� SIGNATURE: ° - �'�,
PRINT NAME&TITLE:� � � � �w� �� '�
� 09/28lOS
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' �� The Commonwealth o Massachusetts
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- Depa�rinent of Industrial Accidentc
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l = -= 6/IO Washington Streeg �""Floor
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_�,� Bosto�e,Mass. 02111
� Worl�ers Com sahoa Lsm�aaee Affidavi� ' ' IecdricAt Co�tneturs
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address• Z 3 Z-
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work site 1 '� full�s: - V v n 1 �, �'/l 6/�
❑ I am a homeawner performing wak my�elf. Ptaject Type: ❑Nevr C�ia��odel
I am a sole 'etar und have�a�e w in an Buil ' Additian
❑ I am an eanployer ptoviding wa�s'compensation far my e.mployees working a�this job.
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❑ I am a sole proprietor,gc�eral coitrxMr,or homeo�vaer(cQde ow�e)and have hired the co�ctors listed below who have
the following woikas'compensa�on polices:
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FaH�re�o aec�re�e as reqtired aader SaliM ISA�t'MGL 152 aa Idid t�tl�e i�lp�itln�f cri�id pafNw�f a fe ap b 11,SN�N aid/�r
oYe yean'imptb�a�t as wd as dv�pmlfiea ia the f�rir of�3TOt WORK OR1/ER ard a�te a[f1M.00 s day aphK'e. 1 a�der�d t6at a
c.pq of tl�e�tatement my 6e forwatdcd to He Omce e[lave�af fMe DIA fat eeverase vei'i�eatly.
I�o heneby ce►�ijy xn�dee tlie sn1 ' of tN dYe ieforiwado�provided aboae ia bxe wid c�o t
s�s� � ,�n 3� �-�
P,int name �s !, ` �t� /oa- Phone# SQ � 3��'= '�% �U
effieiai aee ealy do gat write ia t�s ara ta be es�plaed bY eitY ar Mwa�elal
dly ar tewn: pe�f/�oeme/ f�IRai��e Dep�at
❑e�eck if imme�ale reapsme b rai�ed �d�n's�oe
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ee�act Pet'ssa: Phaie#; �016n'
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A V ORD pATE(M MIDD/YYYh
,� CERTIFICATE tJF LIABILITY INSURANCE 1/6/06
���� TF�,4 C6zTi FIC ATE IS lSStFD AS A MATTER�II�ORMATpN
Chagaon Znsuraace Agency, 2ac. OI�..YAND CONFERSNO WGHTS UPONTHECERTFICATE
411 Rte. 28 NO�.D62.TN�S CBtTiFlCATEDOESNAT AMB�,EXTB�OR
PO Box 3 5 5 + ALTBt THE COVERAGE AFFORDED BY THE POL1 CIES B�.OW.
FTest Yarmauth. MA 02673 INSUF�S A�'FORDING COVBiAGE NAIC#
��R� INSURER A
Sean Saright INSURER B: Commesce Iasuance Co an
DSA Eariglit Conatruction Compa �NsuR�c: Commerce Insuaace Com aa
PO Box 1093
INSURER D:
West Yarmouth, MA 02673
INSURER E
C�V��
THE POLIClES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.N07WITHSTANDING
ANY REQUIREMENT,TERM Ot�CONDlTION OF ANY,CONTRACT OR OTHER OOCUW�NT WITH RESPECT TO WHICH THIS CERtIFiCATE MAY 8E fSSUED OR
MAY PERTAtN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIB�D HEREIN IS SUBJECT TO ALL 7HE TERMS.EXClUS10NS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
iN D' VOLICYNUM69t POLICYEPEEC111iE � POIiCYEXP�t�IDN LNdRS
�+�N-���uT�' �oc++ocCURR�uCE ' s 1,OOO,OOO
g g COMMERCIALGENERN.LIABtLITV SBP YX9931 11/3/05 11�3J06 �p,��1�,�,��__�s 50,000
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8 i cua�as raAne 0 occua I M��ta�ro�v�s«,) ' s 5,0 0 0
� _ ' �soHa�aa�VtNJURY S 1,OOO,OQO
c�r�Er��ca�Ec�'re a 0 0 0 0 0 0
� GEN'L AGGREGATE tlMR APPLIES PER: � PRppUCTS-COMPlOP AGG S 2�O O O�O O O
P�ICY J�C-C7 �
AIfTOMOBiLE LUBIL.ITY ; _ � �COM6WE0 SNJGLE UMR I S
� . ANYAUTO � I ; (EaacadeM)
! �
ALL OWNED AUTQS BODILY INJURY O O O
C � $ SCHEDUI.EDAU70S f NJ2629 � 6/19/05� 6/19/06� �j �'�'sm� $ 100,
� , HIRE�AUT� .. � � ..... � �BpDILY INJURY s .
�NON-OV4NED/U1TOS � ; t��c�aern� � 3 0 0,0 0 0
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; � I �°�TM°^""^� i a 100.000
i � . tPer acciaern)
G��E�����TY ' ' j �� AUTO ONLY-EA ACCIDENT��1��$���_��_-_��-
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�ANY AUTO '� '�. I i E4 ACC � s --- �.
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AGC3 3
D(CESSNMBREILALUIBILITY ; � � EACHOCCURRENCE $
^�OCCUR CINMSM/10E I
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j DEDUCTIBLE i i i j - --- -- -- �
I REfENTION S — _'_ a -
�WORKB2SCQMPENSQIOWAND I i ,--_:.�t'P.'_�p��?g:�__��R t__
EMPI OYERS'LIABI LITY 'I
ANYPROPRlEfpRIPPRtNERiD(ECU7I4E � 1 j E.L.EACkACC{DENT j $
, �FICER/MEMBER fl(CW DED? I E.L DISEASE-FJIEMPLOYEE � $
If�s descri be urMer ..
SPECIALPROVISICTJSbebw � E.I..DISEA$E•POLICYLMA �R$
OTlER I j �
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D BCRIPTIO N OF O PERATIONS I LOCATION51 VEN C LES i EXCLilS10N5 ADDED BY END 4R�YIENT!SPECIAL PROV1510N5
SBPTIC Pt7MPING & SEPTTC CONSTRUCTION
COLLAPSS � SXPL03ION T3XCLIIDBD
CERf IFIC ATE HQI.DER CAt�ELLATION
SF{OtSLD ANY OF THE ABOVE DE�Rf�POLIC�SBE CANCEL�EO BEFORE THE EXPIRAT�11
DATE TNEREOF,YHE ISSUING MSURER W RL ENDEAVOR TO MAIL 1 O D AYS W RR1EW
CAPT JONATHON MOTSS. NOTIC ETO TME CERT�ICATE HOLDER NAMED TO THE LEFT,8UT FNLURE TO D O50�IA�L
1237 RTE ZS it�OSENO�LiGATWNOR�1A80.1TYpFIWVKp�lOUPONTNEINSURER.Rsar�rsoR
S YARMOUTH, MA 02664 REPRESENT ee r
AUT��t R ESEl1 IVff C ;;_.� �`+
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ACORD 25(2001108j � 0 ACORf1 COF�ORATION 1988
THfS ENDC)RSEMENT CHANGES THE POUCY. PLEASE READ {T CAREFULLY.
AMENDMENT OF INFORMATION PAGE
Revised Payrolls
'
This endorsement is atlached io the policy indiceted be�w�+er�tl is e�octive on the date swted herein,at 12:01 A.M.,standard ume
at the address af the insured as descnbed in the informaiion page.
Policy No. Safety Group Expiration Date of Policy Effec6ve Date of Endorsement Endorsement Na.
wNrz$aos�7�a12oos osoo 04/Ol/2006 o4ioil�aos
Additional Premium Return Premium
Issued to 543.00
Sa amore Realt &Trust Co . dba Beach N' Towne Motel
ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUl"UAL INSURANCE COMPANY
BOUND BY: shuot 03107/2Q05
PLACING OFFICE 804
Countersipnod
hon�ed Representa�iv�
THE CQMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-049 FEE: $50.00
This is to Certify that S�gamore Vacation Pronerties Inc_ d/bJa Cant in 7�nathan Motel
123?Route 28 South Yarmouth MA '
HAS BEEN GRANTED A LIGENSE TO
OPERATE MOTELS '
This License is issued in confornuty with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subj�t to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the ntles and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2006 unless sooner suspended or revoked.
Apri17,2006 BOARD OF HEALTH: B ist�. ona�ort,��., '
���r�, k��v, v� e��
R�t�. a�, e�
�����
Q����, R.�v.
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Bruce G.Murphy, ,RS.,CHO
I?irector of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NIJMBER: #06-083 FEE: $75.00 '
This is�o Certify that S gamore Vaca.tion Propertiec inc_ d/b/a a�tain Tonathan Motel
1237 Route 28, South Yarmouth, MA '
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Captain Jonathan Motel - OUTDOOR POOL ,
123 7 Route 28 ;
South Yarmouth MA '
This peimit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31,2006 unless sooner suspended or revoked. '.
A��i17_2006 BOARD OF HEAI,TH: Q �i �' v�e .��
0���4�t �cl�uJ�i, �
� Red�t`� B� �
P����� '
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,
Bruce .Murphy, .,
Director of Health
i
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-167 FEE: $30.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pennit is hereby granted to:
Sa�amore Vacation Properties�Inc., 1237 Route 28, South Yarmouth, MA
Whose place of business is: Captain Jonathan Motel '
Type of business: Continental Breakfast
To operate a food establishment in: TQwn of Yarmouth
Permit expires: December 31, 2006 BOARD OF HEALTH: B `1S. �o��i,r�,J19.`?5., '
, d���i, JV., ?lu;e G��vufu�rs ,
Rad�`�. l��, G'l,�
P��iLl��� '
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Apri17.2006
� �
ruce . uiP Y�M� �
Director of Health
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3�° .�:R�o TOWN OF YARMOUTH BOARD OF HEALTH I� f� � q� � 1� (� ,(�
o �. -;y APPLICATION FOR LICENSE -2005
� ., ;� .� ° .:,�� �,k-:=` MAY 1 6 200�
* Please complete form and attach all n s `�ecem r 004. ;
Failure to do so will result in the k� -,� ;; pplicaxion pac ��TH DEPT.
NAME OF ESTABLISHMENT: �• T TEL. #sb$- 3� - 3 a
LOCATIC?N ADDRESS: z Z 5'�-_ �.
MAILING ADDRESS: 2 Z� ' ��
OWNER/CORPORATION NAME: �'� .�_ � � ' C
MANA ER'S NAME: . . 'e c TEL. # 30�-3y��-��'�"�
MAILING ADDRESS: Z � � � � �
POOL CERTIFICATIONS: ��N �
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.�l,r; sfvn f�e� ��6� � ,�f�-- 2. i
Pool operators must list a minimum of two emplo ees 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. Jb e h .��� ���� 2. es=iri ` �-��
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: i
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 eopies of certification to this application. The Health Department will not use past years' records. �
You must provide new copies and maintain a fde at your establishment. ;
�
1. 2. ;
I
PE�1'��i CHAR��: ---- _ _ _ _ _ i
Each food esta.blishment must have at least one Person In Charge(PIC) on site during hours of operation. �
l. 2.
HEA�LICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich ';
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedwes below and
attach copies of employee certifications to this form. The Health Department will not use past years' reeords. ;
You must provide new copies and maintain a fde at your place of business. '
1. 2.
3. 4.
RESTALTRANT SEATING: TOTAL# '
OFFICE USE ONLY
LODGING:
LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIItED FEE PERMtT# LICENSE REQiJIRED FEE PERMII'# '
BBcB $50 CABIN $50 l MOTEL $50
_INN $50 _ CAMP $50 �3WIlVIlvIII�IG POOL$75ea.
LODGE $50 TRAII.ER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 �CONfiNENTAL $30 NON-PROFIT' $25
>100 SEATS $I50 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# LICENSE REQiJIRED FEE PERMIT#
_<50 sq.ft. $45 >25,000 sq.ft. $200 �VENDING-FOOD $20
J�25,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25 ,
NAME CHANGE: $10 AMOUNT DUE = S /ScS� OQ '
'"'�'�"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'"""
i
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' � , r +
ADMINISTRATION I
,
Under Chapter 15�,;Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSTJRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR i
CERT. OF INSURANCE ATTACHED ��
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO �
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN i
'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. �
i
SEASONALESTABLISHIVIENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION'7-10
DAYS PRIOR TO OPENING FOR TI� SEASON.
ALL RENQVATIONS 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
�
I
�
ADDITIONAL REGULATIONS r
POOLS
POQL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i
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 ADVISURY:
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 Health Department by filing the
required Temporary Food Service Application form 72 hours prior t4 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),mnst ha�e prior approval from the Board ofHealth.
OUTDOOR COOI�NG•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. `
E
, �
DATE: Q` G1 SIGNATURE: � '
i
PRINT NAlV�& TITLE:�� �,�,—��u-,� ; �
10/22/04
�
"�� The Comnwmveatth o Massachusetts
-=_-� .f
��=____
- Depart�nent of Indastrial Accidents
� ___- _ N�fIf�MMi
� _= 6(10 R'asbiagton Stree� �"`Floor
__,� Bos�on,Mas� 02111
Worl�era'Com�aatios I�sn�ace Affi�vit:Ba1 ' bi�Eleetr�cal CootncMrs
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name: �� d n a � � G I9tC G �dG /
addtess: j2 ( /t�2 �
Ci�yf/1�a�/�� S�tC: ���L ZtD:OZ G 6 L� Dll(fnC# 7�� ��p � 3y0 �
WOI�C S1tC lOC8t1����5�: ..7 C1/�'N.'S .
p I am a hom�.,�r perfoaning su wak m,�ei�: rm;ecc T,�pe: ❑xew G�uc�o�pttemaaea
I am a sole 'etor aad have no a�e w in an Buil ' Addition
❑ I am an empbyer p�ovid'mg work�s'co 'a�for my employees wo�cing on this job.
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�5so�,•� � �� v ��'�-5 S G//n Z �00��7�D/��J�
❑ I am a sole praprietor,ge�al c�tractor,or i�om�waet(c�rcle o,te)and have hired the corn�ctors listed below who have
the following workets'compensation polices:
�• '
addr+d�
t�v: olra�ell:
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t�v�e:
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Fain�e�s secve eevera�e�reqirM oder Seel�ZSA�f MGL 1S2 aa ind t�lie h�W�deri�id pe�fl�a�f a�e�p b t1,SM.N a�r
ane yan'impthen�mt as we�as dvr pw�ltla ia tie br�eta 3T0!WORK ORDER aed a�oe�[f1M.N a day apidt re. 1 oderslud tYat a
apy ef th��t�my 6e fer�varded ts the OAtoe•tleve��t tlu DIA tat av�e ver�ealiw
I ro ber+eby c xn NYe patns and ofP�7i�'tlYtt tbe brjan�r�lton provldad ebov�e la d4re aed mc�
Si Dan
� a pa
Print name v Phonc# ���'3�0 ���O �/
effidai ax osly a.aoe wdte i t6h area a 6e esmpkted by eily or rnrn seBe�l
cily ar te�rn: permifJ�ae�e!t I�IBeYdIn�D�eet
Qlioe�Bsard
❑e6eck if�me�a�e reapome B req�ed �•s Q�K
���
c�ahct perssa: pg�e#; �Of�er
��a s�c ma+�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-059 FEE; $SO.OQ
This is to Certify that Sagamore Vacation Pr�nertie� arn d!I/a�a�t in TQnathan Mo 1
1237 Route 28 South Yarmouth, MA
HAS BEEN GRANTED A LICENSE TQ '
• OPERATE MOTELS '
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachu�tts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted ,
by the Board of Health,and e�ires D�ember 31,2005 unless sooner suspendsd or revoked. '
M�Zo:Zoos Bo�oF�ai.�: B�.�`?�. �'o�P,o�,�t9.�h�,.s •
na�iic�/�a$�, �/u�C:�s���c
Rodent� B�uuwi, �
� s�, a�v
� �a���.�, R.�v.
,
ruce G.M hy, H, S.,CHO '
Director of Health
TOWN OF YARMOUTH
- BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #OS-182 FEE: 30.00
In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Sagamore Vacation Properties Corp., 1237 Route 28, South Yarmouth, MA
Whose place of business is: Captain 7onathan Motel
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Pernut e�ires: December 31, 2005 BOARD oF HEALTH: l3e�urz `�S. �jio�,wg/�I.`�. '
���r��, v�e��
R�t� e� �!�
' d�Sl�, R.N.
y4��j���, R./V.
May 20,2005
Dir�tor of He�alth� ?
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #OS-080 FEE: $75.Q0
This is to Certify that_�g�more Vaca.ti�n Pronerties C'orp. d!b/a Cant in 7�nathan Mntel
1237 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool '
At Captain Jonathan Motel -OUTDQOR POC?L
1237 Route 28
South Yarmouth MA
This permit is granted in confornuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�ires December 31.2005 unless sooner suspended ar revok�i.
M�y Zo.Zoos Bo�oF��.�: B �. l�on�o�,iLl.�., •
p i����, v�e��
Ra6�t� B�, �
� �� �, R.N.
�4.�� R
J �
ruce G.MuiP Y, �R •,
Director of Health
�
�. �,la
�� ,._R�o TOWN OF YARMOUTH BOARDxQ�+ � � � � � o
-�� APPLICATION FOR LIE�T��1�' ; 00
�;; .�s � w�
, � D E C 0 8 2004
* Please complete form and attach all nec � 4 ents by Dece ber 31, 2004.
F a.i lure to do so w i ll result in the r of your application p k�ALTH DEPT.
NAME OF ESTABLIS�IlVIENT: qi� �a�nA aH Mo4-c� TEL. # 50$-39 —
LOCATICIN ADDRESS: ('Z 3�( 'R�• 2�S �a�ye�.� o���i M�4 -0 2 � 6 y 3 4�C o
MAILING ADDRESS: S �• a
OWNER/CORPORATION NAME: � �f'�(' i Q vE. A - S i o�i['���i C�t P e e v� }-- �,�'3L—
MANAGER'S NAME: �} T�('i C�v t /4- ��D�j�U� �— TEL. # S a�—�9$—�4$o
MAILING ADDRESS: �• A.- A '
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
l. �rt'�'; Q�� �• g���iQ��- 2. �t�.�c�,4 g;oq;qv�
Pool operators must list a minimum of two emplo ees currently certified in hasic 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 fde at your place of business.
1. ���'�Q�e.- �4• ��t��i��i 2. 41Z�11r{ A �1 b Pl L��►1
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 Mana.ger, 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.
Yoa must provide new copies and maintain a fde at your establishment. �I
1. 2. �
PERSf3AT IN£��E=-- __ _ _ - _ ______ _ __ __ ._- - - _ _ l
Each food establishment must have at least one Person In Charge(PIC) on site d�ring hours of operation `
1. 2.
HEIlVILICH CERTIFICATIONS: '
All food service establishments with 25 seats or more must have at least one employe�e trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures t�elow 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.
RESTAURt�NT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
BBtB $50 _CABIN �$50 I MOTEL S50 �'�I S�O17
_INN $50 ; _CAMP �, �50 �SWIMMING POOL�75ea. O S�
LODGE $50 TRAILER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE: '
LICENS�REQiJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERIWIIT# !
0-100 SEATS $75 �,CONTINENTAL $30 OS�O O NON-PROFIT $25
>100 SEATS $150 COMMON VTCT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PfiRNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERNIIT#
_<50 sq.ft. $45 _>25,000 sq.R. $200 �VENDIN(3-FOOD �20
_Q5,000 sq.ft. �75 FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ /��,OO
'•""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•"
� ^ � !_ I
�
ADMINISTRATION
Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.IT3�T�'RETIJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLIS�IlyENTS ARE TO CONTACT T'HE HEAL'TH DEPARTMENT FORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEAS4N.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTIlVG,� NEW
EQUIPMENT, ETC.}, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POQL 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.
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 Health Department by filing the
required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be
obtained at the Health Department.
FROZ�N DE�ER'FS: _
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/wa.itress service),must have prior approval from the Board of Health.
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any faod product by a retail or food service establishment is prnhibited.
e--��
DATE:/�—01/— b LI SIGNATURE: �65�1
PRINT NAME& TITLE: ���(��C � • �S�i�D 1�u i
10/22/04
_ _�-
a �
� . . �
_- -=--� The Commomveohh of Massachusetts
� =� � Deparhnent of Industrial AcciJents
��--- - N�'a�i�MMi
-- _- 60o w�h��,�sr,� �F�T
_-- Boston,Mas� 02111
,-�
workera'com�aho■I�ars�ce.a►ffiaav�c: • lee�r�al cu.traetors
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�� �o� ��w�o��� ��: M ►� ap�2�6� �#.��g-3 9�-3 4 �o
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p I am a homeo„m�perfo�in�au Wo�k m,r�f: rra;ecc T,rpe: p xew ca�„�c►�Dti�moaei
I am a sole 'etor and have�ane w in an Buil ' Addition
� I am an ea�ployer providing wo�s'compensation fas my e,mployees working aa th�job. :
r ame: ��'pt K�"z-; A�3 ��v�
adiren;
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...... w��L,'c4•��'+��. ��ov A ZG' i.�, C. g2�--(2 —p
❑ I am a sole praprietor,ge�eral co'tractor,or lameawa�(�ard�a�e)and have hi�d the co�rs listed below who have
the following worlcess'compeagation polices:
eoa����v�;,,
a�
$�Y= niwe�:
�
c�f�e:
��
�s giueire�t
�
FaOm�e ts secare evvera�e n reqained uder Sa1i�2SA�MGL IS2 eu Mad b tlie��teri�id ps�n�t'a�se ap b i1,SKM aidhr
ase yars'ie�ptb�t as wU as dv�pwiltles i�tYe for��f a 3TOt WORK OBDEA aad a Aae et t190.N�day saaidt�e. 1�dnsh�d tbat a
apy ottYb ttalewnt my 6e firwanded b Ne Oflke�tlmafi�tlas o[tie DIA hravcra�e ra'Ukatle,.
I�o benby cerdfy rtnder NYe pai�s swd paiahies of parjary thet Me iufor��to�provlded aboae ia bxe asd c»n+ert
Signature �� Date �.�—o '7—� �
.
Print name �'��t Q v� ,�4 �i'D`�1 b c)j Phoae# So g —3 9 ii— 3���
.
efficia!ax oely de aot wdte is t�is am te 6e er�pkhd bY dtF or 1�wn�eLl
cilp ar to�vn: �er�l6oede# I�l�ild6�De�tmeat
❑e�eck if immedia�e nspease is req�red OSdxt�s Offioe
❑NnNt Depar�t
ce�et prs�ssH: p�t�ae M; �
cnvicd S�w-�1)
. ' ' mU�
GFtANITE STATE INSURANCE COMPANY 70509-0000 i�` .
�3 t o 2 --------------------------------------------
0�3-66-0804-00
. PENNSYLVANiA
CAPE COMFORTS TRUST �� Member Companies of
1237 ROUTE 28
SOUTH YARMOUTH, MA 02664-0000 American fntemational Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 70270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D#
HART INSURANCE AGENCY INC
WORKERS COMPENSATtON AND EMPLOYERS PO BOX 700
LIABILtTY POLICY INFORMATION PAGE 240 MA I N ST
BUZZARDS BAY MA 02 2-0 00
iNSURED iS PREVIOUS POLICY NUMBER
TRUST RENEWAL 0081672$2
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE — WC 0610
trE�z naacr a�nwo�za�aeA.seanaara time a�ene��su�ea•s
mailing address FROM �8��Z�D�i TO O8��Z���j
rr�M 3 A. Workers Compensation lasurance: Part One o#the policy applies to the Worksrs Compensation Law of the states listed
here:
MA
B. Employers Lisbility insursnc� Part Two of the poliCy epplies to the work in esch ttste listed in Item 3J1.
The limits of our liability under Part Two are:
Bodilrr Mjury by Accident : 100,000 ssch accidsnt
Bodily Injury by Disease $ 500.000 policy limit
Bodily injury by Disease S 100.000 each emptoyee
C. Other States insurance: Part Three M the policy applies to the sbtes, if any, listed her�
SEE ENDORSEMENT - WC2003Q6A
�4 The premium tor this policy wili be determined bV our Manusls of Rules, Gassifieations. Rates snd Rating Plans.
All iMormation roquired below is subject to verification and change by audit.
EstFinatsd Total Rata Per EstFinated
Classificetions Cade Number Remun�ption 5100 OF Re- Premium
❑X Mnual❑3 Year mu�ratia► a Annual ❑3 Yea
SEE EXTENSION OF INFORMATION PAGE — WC7754
TAXESjAS5E5SMENTS/SURCHARGES $12
DIPENSE CONSTANT(El(CEPT WHERE APPLICABLE BY STATEj $26�F MA
MINIMUMPREMiUM S225 MA TOT�-��+���� 5519
It indicated 6aVow, interim adjustments of premium shall be made:
� Semi-Annually � Quarterly � Monthly DEPpSIi PR£MfUM
ENDOFISEMENTS�FONM NUMBER) S E E ATTACH E D F ORh{ S CH E D U L E - WC990612
09/10/04 ASSIGNED RISK 66
Issue Date Issufny Ottice Authorized Representative WC 00 00
39967
t0.t�.1.tR.ED'C�ADV
.
� THE COMMONWEALTH OF MASSACHLTSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
FERMIT NUMBER: #OS-017 FEE: $50.00
This is to Certify that_Attinue A. Sidd4Li/C'a�n� omfo T �� d/h/a �ptain Jonath n �0 1
1237 Route 28 South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
Tlus License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amende�i,and is subject to the provisions of the Laws of the Commonwealth of Massac�usetLs relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and expires December 31,2005 unless sooner suspended or revoked.
Januazy 21.2005 BOARD OF HEALTH: B��$. ('o�� �I.�i. •
��/��S` �u�tt, ?/ic�Gfi�
�s�R.��
�� 4 , R.N.
ruce G. hy, S.,CHO
Director of Health
TOWN OF YARMOUTH '
BOARD OF HEALTH '
PERMIT TO OPERATE A FOOD ESTABLISHN�NT
PERMIT NUMBER: #OS-070 FEE: $30.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted ta
Attique A. Siddiqui/Cape Comfort Trust, 1237 Route 28, South Yannouth,MA
Whose place of business is: Canta.in Jonathan Matel
Type of business: Continental Breal�ast
To operate a food establishment in: Town of Yarmouth
Pernut ea�pires: December 31, 2005 Bo�xD oF HEALTH: Be�sr�.$. (�'i�idorrti�N`n. '
r��.t��� v�e�.�-.�
R�t� a�, e�
� s� R�v.
�l,��'��,�, R.�V
7anuary 21.2005
ruce
Director of e�alth _.,..,..'�._._
i
f . ``.
THE COMMONWEALTH OF MASSACHUSETTS ,
TOWN OF YARMOUTH "
BOARD OF HEALTH
PERMIT NUMBER: #OS-029 FEE: $'75.00 �
�
Tlus is to Certify that
123?Route 28, Sou Yarmouth, MA '
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Poal
At Captain Jonathan Motel -OUTDOOR POOL '
1237 Route 28
South Yarmouth,MA
This pennit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2005 unless sooner suspended or revoked.
J�u�zi_aoos Bo�oF�.Tx: G �S. �joado��11.�., .
p���r�� v�e�,�
Rad�`�8� �
�Sl�, R.N.
�l�!�' , R.IV.
ruce G.Murp Y, •,
Director of Health
—�
, � �,� �� _' �� i
� 5 u
_`+ ���-�'�R�.` TOWN OF YARMOUTH BOA '�� -� C ' � �
�: _. �� APPLICATION FOR LICENS - 04 D E C � 9 2003
..•
* Please complete form and attach all necessary doc ents by December 3 , ���qLTH �EPT.
Failure to do so will result in the return of your application packet.
��ME OF ESTABLISHMENT• ��-sa.:� f�/� �-1ofcP C�qB� TEL # 39 — o
LOCATION ADDRES S• f,2 '27 ,,P_sul� 2 F ��rt�� y'�� tti!- 0 2 6 6 y
9WNER/CORPORATION NAME: ,���� A• ' :��' '
MA�IAGER'S NAME: ��.A TEL. #
M�IILING ADDRESS: „�•R •/l�
�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated '
Po�l G�peratar(s)and attacl:�:co�y o�the e€�ti.ficati�n�a this form. - , �
1.����(�UE • ��D.�i , l�1 2. �le�i�, f� �1�.l�td U1�
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 He�lth Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. s�rr�-�j u E �. ��.�� ��' 2. �.� ��i 1�A- ��p�j� �j
3. 4.
i
FOOD PROTECT�ON MANAGERS - CERTIFICATIONS: ,
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. '
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment. �
1. 2. �
�
___ - —_ _ — — l
__I��I�5U1� IN CHA�U�: --_ — _ __ _ _ �
Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '
Maneuver on the premises at all times. Please list your employees trained in anti-chok�ng procedures below and ;
attaeh copies of employee certifications to this form. The Health Department will not use past years' records. ;
You must provide new copies and maintain a file at your place of business.
;
l. 2• �
3. 4•
i
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
�ODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM(T# LICENSE REQU(RED FEE PERMIT#
_B&B $SU CABIN S50 �MOTEL S50 ��'Q
INN $50 CAMP S50 �SWIMMING POOL$75ea. �`f�
— — i
_LODGE S50 _TRAILER PARK S50 _WHIRLPOOL �75ea. f
I
�OOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-]00 SEATS S75 ( CONTINENTAL $30 ���o NON-PROFIT $25
>100 SEATS $150 _COMMON VICT. S50 _WHOLESALE $75
RETAIL SERVICE: �
�
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PBRMIT# �
<50 sq.ft. $45 _>25,000 sq.ft. $200 _VGNDING-FOOD $20
_<25,000 sq.ft. $75 _FROZEN DESSGRT S35 _TOBACCO S25
NAME CHANGE: $io AMOUNT DUE _ $ ►55•�O
**"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"*
�
–' I
r-�
� `
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 COMPENSATIUN INSURANCE
AFFIDAVIT'£MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED k
�
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 �
APPROPRIA.TELY IF PAID: /
YES �/ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN '
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
�
ADDITIONAL RFGULATIONS
'
POOLS
POOL OFENII'�G: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: T'he water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to o�ening, 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 A1�VISORY• '
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories. '
C'ATERN�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 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� :
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOOR COOKIN •
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
_—�-
DATE: /�a4-��l°3 SIGNATURE:__����.
PRINT NAME& TITLE: _!} T j�p�E �. �j��y',Gy'
10/22103
�
-�-- !
s � , �
�. �
_ The Conrmonwealth ojMassachusetts
� � Departrnent ojlndustrial.-lccidents
� ; olllceolleres�ostliis
� � 600 Washington Street
' ,,•� Bnston.Mass 02111
�N "� V4'orkers' Compensation Insurance Atfidavit
Aonlicant informallon: PleasePR�'i"Ter�'1Jic
nam�: ��/�c/� �d)'LOt nH �6��PJ`'
lucati�n• l��S,� ���� � � ��L(/�• �c�iN�4L��
cit� �� �c.����,� /`'� OZ��� ehone� S�g-39g— 3�t b�
� t am a homecw�ner pertorming all work myself.
� I am a sole proprizror�r.� ha�e no one��orkine in am•capacin�
� I am an employer pro���ing workers' compensation for m��employ�ees workine on this job.
�� - .�a��_ -
comnan�• name• ���/y '
address• ��i��2�
��t,�� f�u�E 7� rI�}- 02 6 6�f nhone t1• so�'- 3�g-3� �
r
insurance co. /�I,I�rC'�h��� �-�^/�a/�/� psjjs,y# /�3 b30
� I am a sole proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu�cin� ��orker ,ompensation polices:
com a�nv name•
address•
�•: phone k•
insur:►ncc co. Qolicy# ,
�moany name• —- — ----- -
�ddress•
c�,y: ohoee M•
insnrance co. eoiier M'
t
Failu�e to seeure coverage as required under Seenoo 25A of MGL!S2 n�ind to the iepaitioe of erisi�fl pesdtla o(�O�e op to 51�00.00 a�d/or
one yean'imprisonment as w•efl a�eivil peaaide�io the form o[a STOP WORK ORDER asd a Aae of 5106.00 a dar q�iost ma i s■dena.d e�a�a
copy of thH statement may be fonvarded to the ORce of inve�tigsdom of the D1A tor eoven`e veriAeado�.
I do hrreby cerrijj�under the Poins and penel�ies ojptry'ury tkw tht inforniatfon provedtd above is btte and corred
Signature �' ate �.�—2�1�-.0 3
�_ ,
Print name �}T�/�( uE �4 . �%��/�C)t� Phone M �D�'� 3 !d ��� �O j
.. olTicial use only do not w�ite in this area to be completed by eiry or toaa oAltial
ciry or town: y�M�IITQ _ permitAiceau N nBuiidiog Departmmt
�Liceosiog Board
�cheek if immediate response i�required 261 QSeieetmenb OlTiee
(508), 398�?231 �t, �Hnite Departmeot ,
coot�c[person: phone M;_ __, _ nOther
,.. ..� � <��,: i
a THE CQNiMONVVEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NIJMBER: #04-037 FEE: $50.00
This is to Certify that�ttiqiie A Sidcliniii d/bJa Cantain Jonathart Motel
1237 Raute 28 South Yarmouth.MA '
HAS BEEN GRANTED A LICENSE TO
� OPERATE MOTELS
This License is issued in conformity with the suthority granted to the Bo�d of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachuseits relating
thereto,and upon such te2ms and conditions,and to the niles and regulations in regard to said Motels so licensed as adopteci
by the Board of Health,and e�ires Deceinber 31,2004 unless sooner suspended or revok�.
Feb 5,2�4 BOARD OF HEALTH: Beafa���S. �j�'a3c�,,1�$. '
� p���� v�e�,�.
R�t�. Bn«� �
���'l�, R.N.
ruce G. MinP Y, H, .,CHO
Director af Health
TOWN OF YARMOUTH
BOARD OF HEALTH '
PERMIT TO OPERATE A FOOD ESTABLISHMENT ,
� PERMIT NUMBER: #04-126 FEE: 30.00
In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the si Laws,a perm�t is hereby granted to:
Attique A Siddiqui, 1237 Route 28, South Yarmouth,MA ,
VVhose place of business is: Captain 7onathan Motel
Type of business: Continental Breal�ast
To operate a faod establishment in: Town of Ya�rn�outh
Permit expires: December 3 l. 2004 BOARD oF HEAL'rH: ������$��
Ro�t� B�, �
d� �, R.M.
February 5,2004
� > > -�
Director of Health
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #04-065 FEE: $75.04
This is to Certify that At�j,�ue A Siddl���� ���' rar�tain Tnnathan MntPl
1237 Route 28 South Yarmouth_ MA
IS HEREBY GRANTED A PERMIT
To Oper�te a Public, Semi-Public Swimming or Wading Poo1
At tain Jona han Motel -OUTDOOR P L
12 7 Route 28
South Yarmouth, MA -
This pernut is granted in confomuty with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2004 unless sooner suspended ar revoked.
February 5,2004 BOARD OF HEALTH: B �. �j�, ��•,
p��`�f�� v�e�.�
Rad�t�. B� Gl�
� �l�. R.N. :
� ,
ruce . Murp ,MP , . ;
Director of Health ;
I
�
, i �.�q, _i
,��,
=�; ;, ��
�� �`;;�R.y TOWN OF YARMOUTH BOARD OF H , � F�►pT TNA ,--
o{_. ."�c APPLICATION FOR LICENSE/P R� :- �' � ��i � ` '! `� ``�Y ` " ��
� � � fY\��'/� �v 4 i �a y� � � �,4i�la
* Please complete form and attach all neces =: c�tmen,:Ys�3"y Decemb�r 3�,'�002.
Failure tc�do so will result in the return of'your application pack t.,, �.-i E �"``��',
��
�tAME OF ESTABLISHMENT: C'..PI�,�elu� 7'0��'�.•� Mo�F- TEL #
�QCATIONADDRESS: 12�Z 'j2au1�. 2� �y,1� �c�Rwou\�" , M� . 02���{
MAILIN�i ADDRESS: 3a+�.c. -�s �b ov�•
OWNER/CORPORATION NAME• a�C �C i c�uc A g��SJI Qui
�VIANAGER'S N.�1V�E• ��rC i�,�u�A • C;t� �i Ca v i TEL # S o�— 3`� �'—
MAILING ADDRESS: SZ.A•/�I� 3�-(�o
� POOL CERTLFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator�s)and at�ach a copy of tl�e certification to thzs form.
1. ���;C�uc � - Sid��ut 2. �R�ti4CA- �4 S';���u,'
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 eopies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
.
1. ���\C�l]�. �• S�c�•�9,�t 1 2. �'��l�C��l DD 1 U �
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
l. 2.
--- �E: --- -_ - _. __
— . __ __ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. 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.
�STAURANT SEATING: TOTAL#
i
�
OFFICE USE ONLY I
��ODGING: '
I
� LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRGD FEE PERMIT# LIC SG REQUIRED FEE PERMIT#
_Blk.3 $SO ___ �CABIN $50 MOTEL $50 �03�'OL�
i
_INN $50 _CAMP $50 �SWIMMING POOL a75ea. �3�-0�(7
_LODGE $50 _TRA[LER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
I
LICENSE REQUIRED FEE PERMIT# LICENSG REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# :
_0-100 SEATS $75 ,.f�CONTINENTAL $30 �a3�Oh� _NON-PROFIT $25
_>100 SEATS $150 _COMMON VtCT. $50 _WHOI.ESALE $75 ;
RETAIL SERVICE: • �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERMIT# �
_<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 f
!
_<�5,000 sq.R. $75 _FRO'LGN DESSERT $35 _'I'OBACCO $25 �
NAMECHANGE: $10 AMOUNT DUE _ $ /SS.O�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
i
�
!
• { �
�y�" . `�
ADMINISTRATION
;
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal : ��
of any license or 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 COMPLF.TED AND SIGNED, OR , �
i
CERT. OF INSURANCE ATTACHED �✓ �
OR '
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
�
Town of Yarmouth ta��es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: f NO � '
YES .� '
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONS[BILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. �, i
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-1� k �
��:
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL REN4VATIONS 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
�
I
ADDITiONAL REGULATIONS ,_ �
i
POOLS
i
POOL OPEriING: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: T'he 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 i
r�NciTMFR A�VIS4RY:
Each food establishment wluch 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 farms can be
obtamed at the Health Department.
Fun7F.N D�SSERTS:
' �'Toz�n des�er s�mu�.�-�e tes�ed o�t a rnonti�lyfiasis by a Si�te certified iab. Test results must t�e s�nt to tTie�-Iea�t�
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.AF�S•
' Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,ar display of any food product by a retail or food service establishment is prohibited.
DATE: /����/d 2 SIGNATURE: ���
T PRINT NAME&TITLE: �!1 Ti f�. U C f� ����G�v� �a v'�",�--
10/18/02
:- ._
. � �+r
The Conrmonwealth ojMassachusetts
� � Department ojlndustrial.-lccidents
� o Oh/ceo/%s�loslliis
600 Washington Streel
' •` Bnston. Mass. 02111
�~ ��y` W'orkers' Compensation Insurance Affidavit
Aoolicant informatiom pq�Sepg�,�
nam� /F��I L7i l 1 A �i'i1 L�1 �V 1 D8� `—�W� � S fM g1�, M ol e.S�
- � ..�
Iszcati�n� �2�� I�o�t�-e. �.�C
��tt �o `/ �ui� ►�iA oZC�64 3 �o
� et,one a c ak `��' 3�{
� I am a homecwner perrurmm,all w�ork myself.
` � ( am a sole proprietor ��,a, ha�e no one ��orkin: in am•capacin�
•
__�I am an emplo�er pro�idin� workers' compensation for my�empio��ees w•orkine on this job.
s4mn�nv name• t�e��-g;\v. O�i\�a�. Mo�-¢�l .
�tldress; �23� 1�'o��a :�� �n• �'�,Q.w�..mul� �l� �Z ���
�
��' nhone p �o�� ���--3�f QO
insur�nce co !�/��/� 7r /�lJ UlQ Lj /j�/QGl��+�'1(�¢_ �JlSy N �✓G � ��j O O ��4S
� I am a sole proprietor. general contractor. or homeowner(circle oneJ and ha�•e hired the conaactors listed below �tiho ha�e
the follu��in: �+orker� �ompensation polices: :
comoanv name•
address
cit�••
nhone if•
insurancc co. policy# i
�
�
�
t�mnanv name•
.______- -
--------- ------
--- - —_ ---- ---- '
address _ ___ _--_ - - - - _ _ _ '
�iri�: nhoee 1!•
insurance co. ���,* ,
t i
Eailu�e to secure coveraee as�equired uoder Secnoo 2SA of MCL 1S2 n�iad to tbe iepaitioa o(erivi�al peaaltle�of a 6�e op to 51�00.00 a�d/or
oae yean'imprisonment a�w�ell a�ciril pendtia io tAe form of a SI'OP WORK ORDER aed a OatotSIOOAO a dar a��inst ma [a•denn.d ma�a �
copy of tAis sqtement may be fo�varded to the OfTiee of Inve�ti�adom of tbe DIA for eoven�e veritfutfo�. j
/do hrreby certif}�under dre pains and penaltits of ptrjury that tht injor►notion providtd abovt is tnte a�td cor►ed
Signature ��=� � ,� /0(�/02 ;
r �� � i
Print name �q/�f'i�u E A. �;�rt�� �,o��� sflg- 3�g- 3�1�o
.- olTicial use onl� do not w rite in this ares to be tompieted by citv or towp ollleial
ciry or town: Y�M�IIT� _ penei�/lieease M nBuilding Dcpartment
�Lieen�ioe Board
�chtek if immediate response i�required 261 �Seieetmen'e Ottice t
pHealtA Department
contact person: �on�p;_ (508) 398--2231 ext. nOther
i
.. ._� � ,,,,
+ . .,
CERTlFICATE �F INSUR�ANCE ISSUE DATE; 12-6-02
Ti-I1S CERTIFICATE IS 133UED AS A MATfER OF lNFORMATION OM1lL�'AIVD CONFERS NO RiGH7S UPOM THE CERT'1CATE-
HOLDER. TliiS CERTIFICATE DOES NDT AMENb,D(TEND OR AL7Ef t TFiE COVERAGE AFFORDED BELOW,
PRODUCER
NART INSURANCE A6ENCY INC COMPANI�S/hFFORDiNG COVERAOl:
240 MA1N ST, PO BQX 700 COMPA�IY
BUZ2ARD8 BAY, MA. 02532 A �
COMP,ANY
iNSURED: S ue!'RYIr M�IJTVAt INSURANCE
CAPE COMFORTS TRU$T DBf� C�PA�
CAPTAIN JONA'TNAH�1qOT8L �
'EZ37 RT 28 CdMPANY
SOUTFI YARMQUTN,MA, 02684 D
�
CQVERp6E&
7HfS 15 TO CERTIFY TMAT THE P tICIES iN ANC LISTED BELOW HAV�BEEN ISSUED TO THE WSURED NAtdIE[}
ASQVE FQR THE P�LfCY PERIOD INdICATED,PI07 W1TH$TANDING F,NY REQU�REFItENT,TERM OR CONDITION OF ANY
CONTRACT OR 4THER DOCUMENT WITH RESPECTTO WHICN THIS+;ERTi�ICTE MAY BE fSSUED OR MAY PERTAIN,THE
iNSURANCE AFFORDED BY THE POl.ICIES DESCRiBED HERE(N 15 SI.iBJECT TO ALl T'ERM&d(CLU810N3 ANIJ CONDI-
TIONS pF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCI:D BY FAiD CLAIMS
Co T po of Inawrwnae Poficy # !lfectiva Ex Iralion L)MITS
Coim�rwrclAl Gonaral (»n Agpn • �!Q S
; Liabillty ProductslCornp Op �
� Occurrenco X Parsonal 8�Adv Inj S
Cfatens M�de � lach Occurreneo S
iONn+ara&Cantraotors � I Firs Dama9e I S
Protoctiv� + � Medinal Exprrrso ;
Autp�rfobile L1a61)ity ' ComWteee!$InBts $
Any-Aato `�m�t
All-Owned Aatos Bodlly Injary �
N1r�d Autos (PQr P�rson)
Non-0wnad Au1as Bodily I��uy $
Garago Llabfllty (Por Acalde�rt)
Sch�dulod Aulos X Prop9rty oam�1 s $
�xcess Llabltlty Eaah Oecurrence �
�Umbrella Form
a.,Dtha��'ban-- -- _ -------- _ _- -- - -..,_ --
_ _ --
— I
- .--- -- __ Apyrapate �
Umbrolis
$ Wortcera Compensation �v 6-3-02 8•3•03 Statutory Limi4s
And 3002145 i '
j �ach Accfdant s100,00D �
Empioyera Lfablltty Poticy Limit �Jflp,00D �
Eaeh�rnploY� 5100,d00
Prap•rty Quliding
Ail Risk Raplwcem�n! D�ductlble
DESCRI97TION OF ppERATi0N5/LOCATION NEHICL�S/SPECIA�.I7EMS:
OPBRA710115 PERFORMlD SY NAAAS IidSURED AS PROVIdED II��R 8Y THE 7ERM8&CONDITIONa IN
TNE�Oi.ICY. 60$-g88-3480
GERTTfFiCATE�[01.081� CANCELLATION: SHJUI,D ANY OF 7H�ASOVE DESCRIBED POLlCIES
BE CANCELLED BEFQF;E THE EXPiRATIOW OA?E THEREOF,THE �
TOWN vF YARMOUTH ISSUING COMPANY WII.I,EIVDEAVOR Tp MAI[.30 DAYS iIURlTTEN �
NOTiCE TQ THE CERTII=ICA7E HOLDER IvAMED TO THE LEF'f,BUT �
� FAILUR�TO MAIL SUCti NOTICE SHAIL IMPOSE NO OBL;C3ATlON OR
�IA611lTY QF ANY KINCi 11PON THE COMPANY,ITS A�,ENTS OR
REP S AT�
���1��:�� '��i,�"Z V L�AM '
ACCARD 2S8(7•90) --
i
i
� 'd QEE a so zo c.o ��a
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-024 FEE: $50.00
This is to Certify that Attiyue A. Siddiqui d/b/a Captain Jona.than Motel
1237 Route 28, South Yarmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealdi of Massachuseris relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted
by the Board ofHealth,and expires December 31,2003 unless sooner suspended or revoked.
January 9 ,2003 BOARD OF HEALTH: �a�cled'r� i�e�, �radr�xa.t
_---_ ._. �' cAc D. - '�D., �l/1ce
���. �n�c, el�k
�a8rtck�leD�
�fele�c Skak. ,�72.
ruce G.Murp ,MP ., O
Director of Health
TOWN OF YARMOUTH �
BOARD OF HEALTH
�
PERMIT TO OPERATE A FOOD ESTABLISHMENT ;
I
PERMIT NUMBER: #03-092 FEE: $30.00 i
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: �
Attique A. Siddiqui, 1237 Route 28, South Yarmouth, MA
Whose place of business is: Captain Jonathan Motel
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31. 2003 Bo�oF�,�,'rH: ���. xelP�i, �at�r«ra�c
�'e.tfa�cur?�. C%aado�c. �Z�., `ll�ee �
,�o�ait�. �r�c. �
�a.�ttck�el�ar�rcot�
�f �, :
,
January 9 ,2003 '
ruce G.Murphy,MPH, .,
Director of Health '
�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NLIMBER: #03-047 FEE: $75.00
This is to Certify that Attic�ue A. Siddiqui d/b/a Caatain Jonathan Motel
1237 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Captain Jonathan Motel - OUTDOOR POOL
1237 Route 28
South Yarmouth. MA
This permit is ganted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2003 unless sooner suspended or revoked.
January 9 ,2003 BOARD OF HEALTH: ���i�. �`efli�t. (�a�a
�urfasrr�c D. G��ido.c, �llC.�.. �l/ie:e '
,�o�it�. �, (,�f,ack
�a�tte��C��
'�f �c. .�
�u�G.NtUm y, H,
Director of Health
j
j
I
" � c.qP'r.�Ton,a'c�aN �
TO BOARD OF HEALTH �� � �{� �;:, Q �1!J [� ['D� ;
AP C ENSE/PERMIT -2002 �}N ,�
�J`�7/ /30 -� ��� � � ����
* Please complete form and attach all necessary documents by December 31, 2001. Fai u�t�,oAc�a��a�sul in
the return of your application packet.
NAME OF ESTABLISHMENT' CAPTAIN JONATHAN MnTFI TEL. #- 3q8-3��0
T nrATION AI�DRESS• 1237 ROUTE 28 So Yarmouth, MA 0 .�h4
MAILING ADDRES S• S.A.A.
OWNER/CORPORATION Nt�1VIE• ATTz�uE A ST1�1�T(�i1T
MANAGER'SN�ME' ATTIQUE A SIDDIQUI TEL # �Ag_�ag�
MAILING ADDRESS• S.A.A.
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. ATTIOUE A_ STDDT(Z TT 2. IRTIKA E�. SIDDTOUT '
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 Aealth Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. ATTIOUE A. SIDDIOi1T 2• ����.�A ,�}, ��_
3. 4•
- , ;
FOOD PROTECTION MANAGERS - CERTIFICATIONS: ,
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
_ PERSDN TN CI-��i�ZG�: _ __ ___ _
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 a11 times. Please list your employees trained in anti-chokuig 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 I MOTEL $50 �OI
INN $50 _CAMP $50 I SWIMMING POOL$SOea da'O �
LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEL"o,PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 � '��. �CONTINENTAL $30 f�C�� NON-PROFIT $25
_>100 SEATS $150 � _COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 � _<25,000 sq.ft. $75 _TOBACCO $20
<50 sq.ft. �. ' $45 �>�,5,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $io AMOUNT DUE _ $ I,3O.O(�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
f
f
� r
ADMINISTRATION �
Uncler 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 �
i
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES ✓ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. '
SEASONAL ESTABLIS��NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ,
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. !
�
ADDITIONAL REGULATIONS
i
_ POOLS
POOL OPEI�TING: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. �
f
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of �
closing. i
FOOD SERVICE
CONSUMER ADVISORY:
Each food esta.blishment which serves or selis 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. ;
E
_ - -- - - - ---__ _— -_ . ;
- - -------- .
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: I
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ;
OUTDOOR COOKING: c
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
��— �
��
DATE:/���o/ SIGNATURE: i;���d,,�i
PRINT NAME & TITLE: ��i � v E . ��eDi�j_ �Tl��.��,� '
09/11/Ol ;
•.. , � '
The Commonwealth ojMassachusetts ',
` � � Department of Industrial.-�ccidents '
; Olflceal/�vest/OstJiis '
600 Washington S�reet
' •� Bnston. �lass. 02111 ''
�'" '��y Vb'orkers' Compensation (nsurance Affidavit '
Annlicant information: Pleas�PRiNTTed.'�
namr� ATTTQiTF. A GT1�1lT(�TiT 1�13A APTATN .Tc)NAmHAN MOTEL
location: 1 �'�7 RfIiTTF �R
cic� cn vAutvtnrTmu, M 02664 �neu 398-3480
� I am a homeowner pzrt�rmin;all w�ork myself. ',
� ( am a sole proprieror �-,', h��e no one ��orkin_ in an�•capaciri� ',
��t�m an empioyer pro��dins w�orkers' compensation for my�empioyees w•orkine on this job. ;
comnanv name: A TATN .TnNATHAN MnTF.T. DBA CAPE COMFORT TRUST
address: 1 2�7 Rni1TF. 2RSn_ �armo � h�,
citv: �C�� �����,�T�+�T_�q� 02664 DhoneH• �nR_�aR_�aRn
insurance co. F.ASTF.RN CAGiiAT.TY polity+# WCV 30021 45
- . _ ,_ a sole proprietor. Qenerai contractor, or homeowner(circle onel and ha��e hired the contractors listed beloµ ��ho ha�e
the follo��in� ��orkzr �ompensation polices:
com a{Lnv name•
address• '
cit��: ohone f!•
insurancc co. polic�•# '
com a�ny name: '
address•
,�y: phoee M•
insuraece co. �s,y if '
i
Faiture to secure covera�e as requ�red under Secdoo 25A of MGL IS2 n�lead to the iopaidoa of erisi�d pt�dtla of a d�e op to S1.SOO.00 a�dJor
oae yean'imprisoement�s w•clt as eivil penalda io the form of a STOP WORK ORDER asd a Ifae of SI00.00 a day apinst ma I�•dena.d e��e a
eopy of thh satement mav be fonvarded to the 011iee of Inve�tig�tioa�of tbe DIA for eoven�e veriBatio�.
I do hrreby cerrijy�under the Pains and penalties ojperjury tbat!he i�jorniation providtd abovt is tnte and eorreet
��p� —
Signature �%°T�Ll�� Date 1 2/18/01
Printname ATTIQUE A. SIDDIQUI Phonel! 508-398-3480
.. o(Ticial use onl. do not+.rite in this area to be completed by citv or town oAfeial
city or town: YA��IIT$ _ permitAieease k nBuildiog Department
�Lieeasiog Bo��d
�cheek if immediate response is required 261 �Seleetmen'�OlTice
(508) 398--?.Z31 eat. �H���tA Department
contact person: phone 1f:_ __. _ nOther
i
i
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-019 FEE: $50.00
This is to Certify that Atti�ue A. Siddiaui dlb/a Captain Jonathan Motel
1237 Route 28. South Yarmouth.MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confornuty with the authority granted to the Boazd of Health,by Chapter 140,Sections 32A,
32B, 32C, 32D and 32E as amended, and is subject to the provisions of the Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and condirions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended ar
revoked.
March 25 ,2002 BOARD OF HEALTH: e�Ca�rlem`s�, xe�i�i. �iufir�xau
�ea1a.Mci.�D. G�ia�r�. 7�?�., �/ice
,�o�ct? �ia�, L�
�ct�tlek��
s ��t
ruce G.Murphy, H, . .,CHO
Director of Health
;TOWN OF YARMOUTH
BOARD OF HEALTH '
PERMIT TO OPERATE A FOOD ESTABLISHMENT :
PERMIT NUMBER: #02-095 FEE: $30.00
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:
Atti4ue A_ Siddiaui, 1237 Route 28,South Ya_rmoLth, MA ,
Whose place of business is: Captain Jonathan Motel �
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31.2002 BOARD OF HEALTH: ��� xd�i. ���a�,ra.�
�c�D. G�imid°k. '!�D.. `l/�ee
,�a�ct jl �aoaMc, Lf�
�a�rtck'I1lc�e zM ca t�"
�� s� ��
March 22 ,2002
ruce G. urphy, H, . .,CHO
Director of Health
. , .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-034 FEE: $50.00
This is to Certify that Atti�ue A. Siddi�ui d/b/a Captain Jonathan Motel
1237 Route 28, South Yarmouth. MA
IS HEREBY GRANTED A PERNIIT
To Operate a Public,Semi-Public Swimming or Wading Pool
At tain Jona.than Mot 1 - OUTDOOR P L
12 7 Route 28
South Yarmouth.MA
'This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31,2002 unless sooner suspended or revoked.
March 25 ,2002 BOARD OF HEALTH: s� �eP�l�i, ��
' D. C�m�d,o�. 7 D.. 2/�re
��i 3 �. L?e�
�aauck�cDe�xa�
� .S .72.
ruce . urP Y> > •�
Director of Health
C�1�i��rL�I�K�Y� Y��D�el �.
f 4 �, � 1:ti .Y1 � �.`,'Jti' ,1 � !bD
TOWN OF YARMOUTH BOARD OF HEAIy'T$
APPLICATION FOR LICENSE/PERMIT-2000 ; F E B O �} ZOOO
�,
�°��� ~: TN PT.
* Please complete form and attach a11 necessary documents by De�en�ib�r��,d 1999. Fail
the return of your application packet. � ✓
---------------------------------------------------------__-----------------------�'--—�--�-��a__�1�----------------------------------� :
NAME OF ESTABLIS�� _lyT� ApmA-rtv TnNATHAN M(�TFT TEL # 398-3480
LO ATIQN , DRESS;._, 1 2 3 7 ROUTE 28 SOUTH YARMOUTH MA 0 2 6 6 4
MA�IN� ADDRESS� s SAA '
OWNER/CORPORATIONNAME� ATTIQUE A. SIDDIQUI
MANAGER'S�A1V�: ATTIQUE SIDDIQUI (SI1� � TEL. #398-3480
MAILING ADDRESS' , ..s,p,n,
�OOL CERTIFICATI�NS:
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tlus form.
1. ATTIOUE SIDDIOUI 2. IRTI�,w TDDTQLTT
Pool operators must list a minimum of two employees cunently 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. The Health Dep�ranent will not use past years' records. You must provide '
new capies and maintain a file at your place of business. '
1. ATTIOI,7E SIDDIOUI 2 IRTIKA_ SIDDIQUI
3. 4. �
HE�� I., CH 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 yc�ur employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department witl not use past years' records.
You must provide new copies and maintain a fite at your place of business.
1. 2.
3. 4. :
RESTALJRt�N�' SEA'��TG:_ TQTAi.,# - - NON-�MQKIN�SEATS_.TQTA,I��___ _---- _
------------------------------ ------------------------------- -------------�---------------------------------------------------------- - `
OFFICE U,�E t�NLY
�,,ODGING:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# '
B&B $50 CABIN $50
INN �50 CAMP $50 ',
LODGE $50 TRAII.,ER PARK $50 ;
I MOTEL $50 �?,IG.-�,Z I SWIlVIlVIIlVG POOL $SOea. .��=—�-_' ��j
WHIRLPDUL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# '
0-100 SEATS $75 I CONTINENTAL $30 Z� 1��� I
— --�i—"y'—
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
�ETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $45 TOBACCO $20 '
_<25,000 sq.ft. $75 FROZEN DESSERT $35 �
>25,000 sq.ft. $200
�TAME CHANGE: �10
AMOUNT DUE = $ ��D"
"•x•"PLEASE TUR1�T OVER AND COMPLETE OTHER SIDE OF FORM""""'
'� _____
t.s� .�! nyl li iy� ;`.: +� .ls� . . �- d . y li
j ! ADMINISTRATION ',
ER CHAP'�'ER 15 �, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED '
O OR RENEWAL OF ANY LICENSE QR PERMIT TO OPERATE A BUSINESS IF A
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 TA7�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK AP ROPRIATELY 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, 1998. '�I
SEASONAL ESTABLISHIVV�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 ��'��
DAYS PRIOR T4 OPEI�TING FOR THE SEASON. '
I
ALL RENOVATIONS TO ANY FOOD ESTABLISF�VVIEENT', MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMI��IENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�DITIONAL REGULATIONS
PUOLS
POOL OPENING: ALL SVV'�IlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE WATER TESTED FOR '
PSEUDOMONAS,TQTAL COLIFDRM AND STANDARD PLATE COUNT B�A S'FA'�E�R?'�IE��;AB,
PRIOR TO OPEl�tING, AND QUARTERLY THEREAFTER.
i
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIIlVG POOL MUST BE DRAINED OR COVERED i
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE '
CATERING POLICY
ANYONE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH
DEPARTMENT BY FII,ING THE REQtJIItED TEMPORARY FOOD SERVICE APPLICATION FORM ?2
HOURS PRIOR TQ TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH
DEPAR.TMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTI4�NT. FAILURE TO DO SO WII.,L RESULT IN THE
SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,TI-�ABO�TERMS HAVE "
BEEN MET. _ . _ _ . _. _ _ _ - :_ __ _ ,
OUTSIDE CAFES:
OtJTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR
APPROVAL FROM TI�BOARD 4F HEALTH.
QUTDOOR COOI�ING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD ;
SERVICE ESTABLISHIVIENT IS PROHIBITED. ;
DATE: �� _ �-o�rfl SIGNATURE: -��,—�'�� �
C�'� �r�L�1!
PRINT NAME& TITLE: ��ia�'• /E ��t��u� ��t��.r G�cZ�.
11/12/99
;
_ r
�
' � ' The Commonwealth of Massachusetts
� � Department ojlndustrial.-�ccidents
� ; Olflce oll�st/ostliis
; 600 Washington S�reet
' ` Boston.Mass 02111
��'~ ��y' V4'orkers' Compensation lnsurance Atfidavit
A.Rnlicant informallon: PlessePR�'T'Te�7�r
n�mr� CAPTAIN JONATHAN MOTEL
1237 ROUTE 28 SOUTH YARMOUTH MA 02664
location�
��� phone� 398-3480
� I am a homeow�ner pert�rming all u�ork my�self.
� ( am a sole proprieror�r.,�. ha�e no one ��orkin� in am•capacin•
�I am an empioyer pro�idin� workers' compensation for my employees w�orkine on this job.
company name: CAPE COMFORT TRUST
atldress: � ��7 ROiiTF. 7R SCli1TH YARMni1TH MA n2tiFi4
cit�•: ehonet�• 398-3480
insur:►nce co. EASTERN CASUALTY INSURANCE CO. o���y� WCV 30021 45
� i am a sole proprietor. :enerai contractor, or homeowner(circle onel and ha�•e hired the contracton listed below ��ho ha�e
the follu��in_ «orker�� �ompensation polices:
companv name•
address
city: phone#•
insur�ncc co. oelic}#
s4mgany name•
tddress: . .
tiiy: nboee M•
insurance co. �liev N
a
F�ilure to secure coverage as required under Sectioo 2SA of MGL 1S2 a�lad to tbe i�paitioa of crisi�al peadtles o(a 6�e op to 51�00.00 a�d/or
one years'imprisonment a�w•elt»eivil penddes io the form of a STOY WORK ORDER aed a A'e of SI00.00�day Kainst ma I a�dersta�d tsat�
topy of tAis statement mav be fonwrded to tdt 0flice of lnve�tig�don�of t6e DIA for eovenge verifiatio�.
I do hrreby cerrif}�under t6e Pains a�ties ojperjury that tht injornration providtd ebovt is true and eontd
Signature _•,i Dau 02/02/00
Printname ATTIQUE A. SIDDIQUI Phonell 508-398-3480
., o(Ticial use onl� do not..rite in this area ro be completed by ciry or towa oAleial
ciry or town: y�M�IIT� _ periniNieease N nBuildiog Department
OLiceosioe Board
�eheck if immediate response ie required 261 ❑Selectmen'�ORee
pHnith Departmeot ,
contact person: phone 11:_ �508� 398�?231 ext. nOther
. ._� � �„,
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-80 FEE: $50.00
't'his is to Certify that Attique A Siddiaui d/b/a Cantain Jonathan Motel
1237 Route 28 South Yannouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At C�tain Jonathan Motel -OUTDOOR POOL '
1237 Route 28
South Yarmouth �
This permit is granted in conformiry with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
Februarv 8 ,2000 BOARD OF HEALTH: Gc� ///. �e#�, �`iairma�
�oa.n.G. �u�divan, �//, Vics C,�ai�man
Kobar�� 9�rown
a6rie�le�a�ol��rr�-�ooPs�
haa[ � o h(.ia
fl1C@ . UCp }r, , .
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-158 FEE: $30.00
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:
Attiaru,e A Siddi�»i, 1 �7 o rte 28, Cnnth Yarmnnth_ MA
Whose place of business is: Captain Jonathan Motel
Type of business: Continental Breal�a`�
To operate a food establishment in: Town of Yarmouth
Perrnit expires: December 31., 2000 BOARD OF HEALTH: �d�1l• �it�ea. ��a�c
� �. Sk�c. �?Z ?/Eec L''�Fa�caK
,�a�B�ct� �►'nou�, L�
S —�lFo�ed
d '
Februarv 8 ,2000
Bruce G.Murphy,MPH, S.,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-47 FEE: $50.00
Tt►is is to Certify that Attiaue A Siddiaui d/b/a Ca�tain Jonathan Motel
1237 Route 28 South Yazmouth MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked.
February 8 ,2000 BOARD OF HEALTH: �aG� �etted. �raGr�xa*c
l�oa�c � .S�a�ltva.a. �'.�l.. ?/iee C�au
�o��tt� �'aou�
. .Sa��i�ry"s��
d'
Bruce G.Murphy,MP R.S. O
Director of Health
� Ca�.rn .�or+a-t'►�O�n
� t . TOWN OF YARMOUTH BOARD OF HEALTH
} w � � APPLICATION FOR LICENSE�I',E�M�,- 1�999�-����� Gi� C� C� I� li Q0 (� �
; �` 'g p
� * Please complete form and attach all necessary documents by D�c�mb�r�1.�1�98�,F ' ' re�o do so�Sf�Yesu in
' the return of your application packet. �
i ----------------------------------------------------- _C��t.�!_ ;_��ALTi-� pFPT.
-------------- -------------------------- ---
' �1�ME OF ESTA.BLI IiMFN'r�
; �n nm�-�-�G1AT.1�'��i�111i �i�.T�L T #�a A$—��l,g �-g,g
'� L.00ATION ADDRESS: � ��� unrTmF �R �nrTmu vAumnrTmu MA p?ti6a
M�iLINCi ADDR�SS� �.amo a s ahov� �
RPORATION N MF' ATTT[)IIF A STl�1�T(�UT
1VLANAGER�S NAME: ATTT�[lF A_ STDDTQLTT TEi._ # 508-760-��5ti
i
�AILING ADDRESS• Same as above �
� POOL CERTIFICATIONS• M��� ------�'----__�_�_____�_:________________________
;' The poot supervisor must be certiGed as a Pool Operator, as rec�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tlus forin.
1. ATTTQIJF A_ �TDDT� 1T Z,. TRTTTCA ST1�I�TQLIT
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Commuruty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not uae past years' r�corda. You must provide new
� copies and maintain a 61e at your place of businesa.� .
1 �•--�'�'"�Qid�--l4: ��-B��$I�� 2. �t'-�'-�� ,S��}s�^��T•�
3. q
, HEIlViL,ICH CERTIFI ATION�•
� 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 wii!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# NON-SMOKING SEATS: TOTAL#
; _______�----------------�__� . .
----------------------------------------------------------------------
OFFICE USE OIy�Y
LODG NG:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 CABIN $50
i —� $50
CAMP . $50
_LODGE $50 TRAII,ER PARK $50
I MOTEL $50 - SVVI[1VIlI�IING POOL $SOea.
FOOD S�RVICE• .�P�OL $ZSea,
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE pgRMIT#
_0-100 SEATS $75 �CONTINENTpI, $30 l�C�
____>100 SEATS $150 NON PROFIT $2g
COMMON VICT. $50 WHOLESALE $75
� , ,.
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT#
_<50 sq.ft. $45 TOBACCO
$20
_<25,000 sq.ft. $75 FROZEN DESSERT $ZS
>25,000 sq,ft. $200 .
' '' $10
AMOUNT DUE _ $ �—
"""""pLEASE TURN OVER A1�ID Cp1YIpI,L+Tg pTHER SIDE OF FOItM
.....
i
F
4�`� , _ , ,_ L� �- ! ADMINISTRATION � ' '
UNDER�I�APTER 152, SECTION 25C, SUBSECTION 6,TF�TOWN OF YARMOLTTH IS NOW REQUIRED►
TO HOL� ISSUA�VCE`OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BU5INESS 1F A
PERSON' OR,:,�O1�IPAAIY: :D�ES NOT HAVE A CERTIFICATE OF WORKER'5 COMPENSATION
INSURAlVCE. ��'fi`�E ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR. �
CERT. OF INSURANCE ATTACHED
.�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID:
YES NO
NOTICE: PERNIITS RUN ANNUALLY FROM JANiJARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLIS�IMENTS ARE TO CONTACT TI-�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISFiIViViENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS � � � � '
POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT,AND THE WATER TESTED FOR
PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENIIIIG, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIIVIlVIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN (7) DAYS OF CLOSING.
�
. � f
�
FOOD SERVICE
�ATERING POLICY:
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH ,
HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD S�RVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT TI-�
HEALTH DEPARTMENT. �
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN
THE SUSPENSION OR REVOCATION OF YOUR FROZEl�i DESSERT PERMIT UNTIL T'HE ABOVE TERMS
HAVE BEEN MET.
OUTSIDE CAFES:
OLTTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITEIt/WAITRESS SERVICE),�'t HAVE PRIOR �
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COO�G:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD � 'E
SERVICE ESTABLISHHIVIENT IS PROHIBITED. j
l
�
DATE: �° 23 � SIGNATURE: ;���r �t
PRINT NAME&TITLE: ATTzQ�E A. SIDDIQUI
._ � � .. _ .-..�+.i-.�. 1,.. . _ __�
�
i
� �
a The Co�naronwealth oJMassachusetts
� � � Department ojlndustrial.-lccidents
� o Olflcao!/erastl0stliis
: 600 Washington Street
�, ,•` Bnston.Mass. 02111
�'" '��y V4'orkers' Compensation Insurance Affidavit
Aonlicant information: FleasePRiNT'�e�"hta
. _ - �.
n�mr� ATTIOUE A_ STDDTOUT
location� CAPTAIN JONATHAN MOTEL 1237 ROUTE 28 SOUTH YARMOUTI� MA 02664
���� pbone� 508 398— 3480
� [ am a homeowner pzrt�ormin,all w�ork my�self.
� I am a sole proprizror�^� ha�e no one norkin_ in anv capacin•
�� am an emplover pro�idino µ�orkers' compensation for my employees u•orkine on this job.
comnan�• name: r'gpE C.(1M,�G13?.�S ' iTcm
address: 1237 route 28 SOUTH YARMOUTH MA 02664
�it�•: phonetl: �nR_�qu_�zaRn
insu�ance co. EASTERN CASUALTY TNS C'n_ Qo i a w�v �nn�� a 5
� I �m a sole proprietor. :enerai contracror, or homeowner(circle onel and ha�•e hired the conttactors listed below �tho ha�e
the foilu��in� ��orker�� �ompensation polices:
companv n�me•
ad d ress�
ci�}: nhone�!•
insur�ncc co. nolicv#
comq�ny name: '
addrcss:
c�: ehoet M•
insurance co. �y M
t
Failurt to secure coverage as�equired uuder Seetioo 25A of MGL 152 a�lad to tbt iepaitioa of crioi�d pesdtla of a Ooe ap to 51,500.00 a�dlor
one years'imprisonmeat as w•efl as civil penaltia in the torm of a STOP WORK ORDER aed a line otS100.00 a d�y apiost ma [a�dersa.d mac a
copy of thH statemen[may be for.varded to the Ofiiee of Invatigatiom of tbe DIA(or eovenge veri8eadoa.
I do hrreby cerriJj•under rhe poins and ptnalties ojperjury rhat the injornratio�provrdtd abovt is uue and eorrtet
Signature �,�� Date 1 (l[2�f 9 9
Print name ATTI � UE A. SIDDIOUI Phone�l SOFi-39A-34R� '
., otTiciat use only do not r►rite in this area to bt tompleted by eity or town ofllcial
ciry or town: YA�O� _ permitAicease q nBuildiog Department
pLicensiag Board ,
� check if immediate response is required 261 QSdectmen'e OtTiee
(508} 398�2231 ext, �Healt6 Departmeat
contact person: phone p:_ _,_ _ nOther
.
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: 99-60 � FEE: $50.00
This is to Certify that Atti�ue A. Siddiqui d/b/a Ca�tain Jonathan Motel
1237 Route 28, South Yarmouth�MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
-This License is-issued in-confomuty with the authority.granted to the Bc�ard of Health,_by CZ�apter 140,Sections 32A,-
32B,32C,32D and 32E as amended,and is subject to tl�prwisions a�tbe Laws of tbe CommonwealW of Massachusetts
relating thereto,and u�on such terms and conditions,and to tt�e niles a�d regulations in regard to said Cabins so licensed
as adopted by the Board of Health,and expires December 31, 1999 unless sooner svspended or revoked.
October 26 , 1999 BOARD OF HEALTH: Eal�G. �i�, ��a.a
�c$. S�lllaa.�. �12.. Q/lee ��a�c
,�o�t� ��u�c
Sa���y-�
0'
Bruce G. Miuphy, MP . , CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 99-197 FEE: $30.00
In accordance with re ations promulgated under authority of Chapter 94, Section 305A and
Chapter 111,Section�f the�eneral Laws,a permit is hereby granted to:
Atti�ue A 4iddi��, 12'�7 R�nte 28, Cn„th Yarmnuth�MA
Whose place of business is: Ca�tain Jonathan Mot 1
Type of business: Continental Breal� �
To operate a food establishment in: Town of Y *�o�th
Permit expires: December 31 1999 BOARD OF HEALTH: Fd�'JlG. ��. ��
� $. Salllu�c. ��l. �f/�ee eiFat�r.r�a.�
?�rt� �iocwr. ��
� • s -�
�
October 26 , 19 99
ruce G. Murphy,MP ,R .,CHO
Director of Health
-�, . ��� ��� C'c�pfu,rnJona�haF� �`t�ad�i
.
� TOWN OF YARMOUTH BOARD OF F��ALTH C�� �' �N f,� �j M � �
APPLICATION FOR LIC�'�E/Pp „ - 1999 d�� 2 2 ��9$
. � A �� # t �, �� , F .�
* Please complete form and attach all necessary documents by�D�cern�ie�31;�1998. Fai�lure'to�do��.`.� ult in
the return of your application packet. � ��
--------=---------------------------------------------�ltp�'�i���H�-ib�E�Ei�---------------------------------------------
NAME OF ESTABLIS�-�NT� �2��RnuTF�� TEL. #3�'-34r4'G�
�QCATION ADDRES S: 80UTH YARMOUTH,MA 0266ti
Q�FR(CORPORATION NAME� L B/L/9 ��'� .���
MANAGER'S NAME� � � � TEL. # � �
MAILING ADDRESS� � .ri� �s f��vX}� '
POOL CERTIFICATI�NS:
The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the .
des�gnated Pool Operator(s) and attach a copy of the certification to tlus form. ',
1. ' , 2. _
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First A.id and '
Commwuty Cardio�ulmonary Resuscitation(CPR). Please li�t these employe�s below and attach copies of employee
cerrifications to tlus form. The He�lth Department will not use past years' records. You must provide new
copies and maintain a tile at your ptace of business.
l. 2.
3 4.
��1!II,ICH CERTIFICA'�IONS: ,
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '
Maneuver on the premises at all times. Please list your employees trained in anti-chokuig 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 f�e at your place of 6usiness.
l. 2. �
3. 4.
RESTAIJRANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# '
---------------------- ------ --------_______ - --- _ _
�FFI�� �SE 0�Y _ ----_ _ __ �
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
B&B $50 CABIN $50
INN $50 CAMP $50 '
LODGE $50 TRAILER PARK $50 �
� MOTEL $50 4�•� �SWIlVIlVIlNG POOL $SOea. � ;
WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT# �
0-100 SEATS $75 '�CONTINENTAL $30 Q�-/4��
>100 SEATS $150 NUN-PROFIT $25 '
COMMON VICT. $50 WHOLESALE $75 '
�
I�TAIL SE�VICE: � `
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# �
<50 sq.ft. $45 TOBACCO $20 �
_<25,�00 sq.ft. $75 FROZEN DESSERT $25 '
>25,000 sq.ft. $200 �
�
�TAME CHANGE: $10 �
AMOUNT DUE _ $ I� �
"*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""" '
�
� � �
_ �
• � � x �f
� 4
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 PERNIIT TO OPERATE A BUSINESS IF A
PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION '
INSURANCE. THE ATTACHED STAfiE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR. '
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK�PROPRIATELY IF PAID: �
YES NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN TI-� COMPLETED APPLICATION(S) AND RE(�UIRED FEE(S) BY �
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
I
I
ADDITIONAL REGULAT�ONS
POOLS
POOL OPENING: ALL SV'VIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
TI� SEASON MUST BE INSPECTED BY TI-�HEALTH DEPAR'TMENT,AND TI�WATER TESTED FOR
PSEUDOMONUS,TOTAL CQLIFORM AND �TANDARD PLATE COUNT BY A STATE CERTiFIED LAB,
PRIOR TO OPENI1�tG, AND QUARTERLY TF�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVBNG POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE j
CATERING POLICY: ;
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPART'MENT BY FILING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO TI-� CATERED EVENT. 'TI�SE FORMS CAN BE OBTAINED AT THE
HEALTH DEPARTMENT.
�RO�EN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI.Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII.,L RESULT IN
THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSER.T PERMIT UNTIL'THE ABOVE TERMS __ .
____-���EN 1V�T:- _. _
--- - ----- - — - --- _
_ _- — __
—---- -----
OUTSIDE CAF�
OUTSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),MUST HAVE PRIOR
� APPROVAL FROM TI-�BOARD OF HEALTH.
�
� OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.OR FOOD
� SERVICE ESTABLIS�IlVIENT IS PROHIBITED.
.
DATE:_/2�z-��� SIGNA ���
PRINT NAME& TITLE: f-, dGj�S ,��T��,�/�/,�- �„����it.��/��•��-
J'� a
�
� The Commoawealth of�IassQchusetts
4 W Department ojlndustria/.accidents
; Olflce ol/�rss�l�s�►iis
` 600 Washrngton Street
' „•� B�ston, Mass. 02111
� �� W'orkers' Compensation Insurance Affidavit
A.Rnlicant information: P`fessePRIIQTTed�Tir
n1m���S.r�''�l� -d--65'�E��i�-I �����iZ� ���, CAPTAINJONATHANMOTEL
�'z�s—
location: SOUTH YARMOUTH,MA 02664
�it� phone# .3������p
� I am a homeowner pertorming all work myself.
� f am a sole proprietor��,� ha�e no one��orking in am•capacin�
�am an emplo�er pro�idins workers' compensation for my employees w•orkine on this job.
m n • n
�
�ddress: 1237 F�Ot1TE�€�
i
citv: ehone�f• �f� �.3�� ,
insurance co.�/B�rY �It�f}'G- poli�y# /`' �� -�'✓�,� �l�v-3 ;
�
� I am a sole proprieror. ;eneral contractor, or homeowner(circle onel and ha��e hired the contractors listed below� �cho ha�e ,'
the follo�cin� ��orker' �ompensation polices: j
company name�
I
address• '
ci�: phone#• i
�
insurance_co. Qolicy#
tom�any name:
I
_-- — _ _----_
_ _ _-_ _
_- ------ _—_--
address: _ _ --- -
c�: ohone M•
insurance co. on(iey M '
Failurc to seeure coverage as required under Seetioo 2SA of MGL 152 ea�Ipd to t6e iopaitioe of trisi�fl pe�dtles of a A�e ap to 51�00.00 a�d/or �
oee yean•imprisonment a�w•ell ss civil penaltles io the(orm of a STOP WORK ORDER aed a lise of 5100.00 a day apiost s� I a�dersta�d trat a '
i
eopy of th'n statement may be forwarded to the OfTiee of lave�tigatiom of tbe DU tor eoven`e veri6eatb�.
/do hrreby cer�ijj• nde��/ee poins and penalties ojperjury thw thr injornmtion provided abovt is true and conect ,
Signaturc ��/��/��
i
Print name � Phone N ._���'����
.. otTicial use onl� do not w�ite in this are�to be completed by tiN or town oAicial
i
�
ciry or town: y�M�� _ permiNicense k nBuildiog Departmeat ';
pLiceesing Board �
�check if immediate response is required 261 �Selectmen's Otiite �
pHealtA Departmeot i
contact person: phone q:_ �508� 398�2231 egt. nOther
1
;4
Ire.ned i,o5 P1A) I
VDAC LIBERTY
M�U�.• Workers Compensation and
ISSUING OFFICE BOl
INFORMATION PAGE Employers Liability Policy
ACCOUNT NO SUB ACCT NO. Liberty Mulu�l Insurance Group/Boston
1-417770 0000 LIBERTY MUTUAL FIRE INSURpiNCE CO. 16586
POLICY NO. /CD SALES OFFICE CODE LES REPRESENTATIVE CODEN/R ST YEAR
WC2-31S-417770-018 XX X STWOOD 101 ASSIGNED 3000 2 1983
Item 1.Name of LOUIS J.ANGELONE &SHEDDON W.ANGELONE, ��
Insured DBA CAPTAIN JONATIiAN MOTEL
Address 1237 ROUTE 28 �g ID 133630
S YARMOUTH,MA 02664-4456
Status 02 PAR7NERSNIP
Otherworkplaces not shown above: SEE ITEM 4
Mo. Day Year Mo. DaY Year
Item 2.Policy Period:From 12 014'� standard time at thed dress of the insured as stated herein.
Item 3.Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Warkers Compensation Law of the
states listed here:
MA
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3A.The limits
of our liability under Part'I�vo are:
Bodily Injury by Accident 100,000 each accident
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease 100,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states, if any,listed here:
. SEE END WC 20 03 06A :
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4.Premium - 'The Premiu�'f°r this p°licy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is subject toverification and change by audit.
�;�� � UNE 110
�;ro�a rer sioo ��a
Code TotalAnnnal of Re- Ammal
�8SS1f1Cdt10I1S No. Reman�atiom m�ceration Premi�s
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium $ 221 ( MA) Total Estimated Annual Premium $ 535
Interim adjustment of premium shall be made: ANNUAL
This policy,including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710
nwro.�a�m� n•� a6-so-9s
i.«.c� Term. oper. IN noaicB� r�rioa��P�oc �s� Poi.H.G. HomeState n;Y�a�a RENEWAL OF:
06-30-98 MA WC2-31S-417770-017
GP04030 Rl
�PY�ight 1987 Nationai Councii on Compensation Insurance WCoo 000i A
IN3UF�D COPY
i
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: 99-45 FEE: $50.00
This is to Certify that L � n 1 n e
1237 Route 28�Sout Yazmouth MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool '
At Cantain 7onathan Motel - OLTTDOOR POOL
1237 Route 28
�— South Yarmouth, MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31. 1999 unless sooner suspended or revoked.
Februarv 5 , 1992 BOARD OF HEALTH: Gi�� ..teltee, C��airman.
�oan� �u[livan�K.//.� Vice (�hairman
�obarE..t. /�rown.
a�rief�e�ukol�h�f-..J�too�ne�
' �60oC i++
Director of Health� � �
TOWN OF YARMOUTH
BOARD OF HEALTH �
PERMIT TO OPERATE A FOOD ESTABLISHIVV�NT '
PERMIT NUMBER: 99-106 FEE: $30.00
� In accordance with reg�lations promulgated under a�rthority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
T �nit& Sheddon Ang��, 1237 R�Lte 28, So� h Yarmo� h� MA
Whose place of business is: CaDtain 7onathan Motel -
Type of business: Continental Breakfast � —
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 1999 BOARD OF HEALTH:���/. �o��, C��n
' �oan� �ullivan,K./1., Vice Crhairman
• Ko�rE J'. Y�row►a� (�lev�
��qaq�ria��a�s/o�lek�-J�tooPed
'i/LCI2RB� dOK /LLNL ',.
February 5 ,19 99
_ � Bruce G.Murphy,MPH,RS. CHO '
Director of Health '
� ' THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-28 FEE: $50.00
This is to Cerafy that Louis& heddon Angelone d/b/a Captain T�nathan Motel
1237 Route 28, South Yarmouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
T1�is License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and u�on such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted
by the Board of Health,and expires December 31, 1929 unless sooner suspended or revoked.
February 5 , 1999 BOARD OF HEALTH: �c`� ,}ef�e�� ��uiirman
�oan C�. �u6[ivaa.� K.�, Vice (��irman �
�o�erE.}. �rown
abrieGle�a�ofa�e�-.�tooped
Fchae6 O� ou��[in
/
Bruce G. Murphy,MPH,R S. O
Director of Health
�
i
� I
;
�
' i