HomeMy WebLinkAboutApplications, WC and Licenses�
� , -TvEs �T 28 D�Nc1Z
' r TOWN OF YARMOUTH BOARD OF HEALTH�?�, �
� � _ � �3 I=,��C[l �;�l�i�?
� APPLICATTON FOR LICENSE/PERM ' �` ,.
0...o �° ��'�;.` ' ��F� � �.
* Please complete form and attach all necessary do�u � t � ecembe IS �82 � 1U09
Failure to do so will result in the return of yoti�app ication pac . ���L�-� ��P1 .
NAME OF ESTABLISHMENT: O� �� a?� /�l.I�� TEL. # �5��' �� � `�l�fGf
LOCATION ADDRESS: �� � r
MAILING ADDRESS:
OWNER NAME: %Cc :�� ��. C� TAX ID (FEIN or SSN)• ��il-��/ -22�1
CC)RRORATION NAME (IF APPLLICABLE): --
MANAGER'S NAME: C� T7 G TEL. # o - / ��J
MAILING ADDRESS: a Cr i t9 �i
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Uperatar,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two emplayees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee
cert�cations to this form. The Health Department �vill not use past years' records. You must provide new
copies and maintain a file at your place of bu;iness.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitaiy Cod� for Foad Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will nat use past years'records.
You must provide new copies and maintain a file �t your establishment.
1. 2.
PERSON 1N CHARGE:
--- --— -- --- --- --- - - --_ ___— _ --------
Each food establishment must have at least ane 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 Heunlich
Maneuver on the premises at all times. Please list your einployees trained in anti-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new eopies and maintain a file at your place of business.
1. 2.
3• 4.
RESTAURANT SEATING: TOTAL # y 5 6 N �i�5 E
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
_B&B S55 _CABIN $55 MOTEL S55
_1NN S5� _CAMP �55 _SWIMMING POOL �80ea.
_LODGE �55 _TRAILERPARK �105 WHIRLPOOL �80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRBD FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
� 0-100 SEATS �85 �6�-(S.� _CONfINEIVTAL �35 NON-PROFIT �30
_>100 SEATS $160 �COMMON VIC. �60 ��� �IHOLESALE �80
RETAIL SERVICE: —RESID.KITCHEN �80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQITIRED FEE PERMIT#
_<50 sq.ft. 550 _>25,000 sq.ft. $225 VENDING-FOOD �,25
_<25,000 sq.ft. S80 _FROZEN DESSERT �4Q TOBACCO $55
�a�7�cxAvcE: �1 o AMOUNT DUE _ $ /y5.a d
"****PLEASE TUR\OVER AiVD CO.'VIPLETE OTHER SIDE OF FORM"****
� �
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 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
MOTEI,S AND OTIIER LODGING ESTABLIS�liZENTS
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 ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggegate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days
pnor to opening. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER T'ES7'ING: 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 CLOSINGs Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern 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 Pernut until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOI�NNG:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RE5PONSIBILI'TY TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: ���� I Q � SIGNATURE:
�-----r.
PRINT NAME&TITLE: �� G 77 G I'!Ct VV I G /L( �91:19 h.Q b'
io-ziros
,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-155 FEE: S85.00
In accordance with regulations promuigated�mder authorin�of Chapter 94, Section 305A and Chapter
111, Section 5 of the General La�es,a pennit is hereUy grailted to:
___ Tatiana K. Malone, 928 Route 28, South Yarmouth, MA
Whose place of business is: Joe's Rt. 28 Diner
i Type of business: Food Service
;
i To operate a food establishment in: Town af Y�rmouth
�
Permit expires: December 31. 2009 BOARD OF HEALTH: .�f.e�e.rt S�, J�..IV., �"�a�nuut
C'.fiicrx�ea .3�. 9G�'�.ifE�x, `Uiee C'lfavtrrtart
SEATING: 45 �� ��y�((�f�y� �„/�I,
t:�ve�e�rt�' ��fcu�eo
Februarti�27,2009
Bruce G. M hy, ,R.S., CHO
Director pf Heal
THE COMMONWEALTH UF MASSACHUSETTS "
TOWN OF YARMOUTH
PERMIT NUMBER: #09-098 FEE_ 560.00
This is to Certify that Tatiana K. Malone dlb/a Joe's Rt. 28 Diner
928 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authonty granted to
the licensing autho�ities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto af�ed their official signatures.
BOARD OF HEALTH: .�Ee�en SR�a�, J2..IV., C.'lfacixntan
sE.aTt�G: 4� ���lUie¢0 .�. .��+e1�l�J1G, �(Ce ��i�itt
QItIZ �L�Q/t�ullflt, �..lV.
�. .�1�Q0
Febn►an�27,?009
� ruce G. Murphy, .S., CHO
Director of Healt
R iJf:-.Ak.� TOWN OF YARMOUTH BOARD OF HF,�,�`�<�i� � � � � d M C� D
$ � ' APPLICATION FOR LICEN � �008
° "� ��� � � � ,, ��� JAN 3 � 2008
r <, �a ..,
- *Please complete form and attach all nece�s�d��n�"'by Decem er 7.
Failure to do so will resul�in the ret�i of your application pa .��� ��PT.
NAME OF ESTABLISHMENT: ,�o��s 2i a 8 �1��lZ TEL.# 548 3 a0,_
LOCATION ADDRE5S: �a� hlain 5 2E's.'� .5' • yA,�7�9pUTN- �-I�'-1- Oa,(o� y
MAILING ADDRESS: �i�HF �
OWN�R NAME: Ti��-iq�!/� /C• 1-'1/3�.0�1� TAX ID (F�IN or SSNI����'��I1 a`;��
GORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: %/-�1�i/�y/-}- . 1�-�ig�,p,V� TEL. # 9� �-5300
MAILING ADDRESS: 2� i'1�i _ _ �Q c�t /y,q 0� 6 t�.
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attacli copies of employee
eertifications to this forrn. T�te �Iealth Dep�rtroent will not use past years' reeort�s. 1'0� �ust provide ne��
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification co this applieation. �he Health Department�vill not ase p�st years'rP�ords.
You must provide new copies and maintain a file at your establishment.
I. 2.
_ - - - - :
_P���9I�IN���'sE:— _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. Z.
HEIMLICH CERTIFICATIONS:
All food service establishtnents with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employ�e certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE Ol�LY
LQDGING:
LICENSE REQUIRED FEE PER'vIIT* LICENSE REQL'IRED FEE PER'�r11I'� LICENSE REQLTIRED FEE PER�IIT=
_B&B 550 _CABIN S50 _MOTEL S50
INN S50 CA1�IP S50 TSV4II�LVIINGPOOLS75ea.
LODGE S50 TRAILERPARK S100 _V4�iIRLPOUL S75ea.
FOOD SERVICE:
LICENS£REQUIItED FE£ PERMIT� LICEI�iSE REQL?IItED FEE P£ItA<iIT� LICENSE REQtiIRED FEE PER'�1IT=
�0-100 SEATS �75 6 8'�� _CONTINENTAL S30 NON-PROFIT S35
_>100 SEATS 5150 _[__C0:4L'�ION VIC S50 �"6��O � _�'�'HOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIItED FEE PERMIT� LICENSE REQUIRED FEE PERyfIT� LICE:�'SE REQL'Il2ED FEE PER'4IIT-
_<50 sq.i�. �45 _>35.000 sq.ft. 5200 _VENDIIv'G-FOOD S20
_<25,000 sq.8. S75 _FROZEN DESSERT S3� _TOBACCO SSO
NA,'1�fECHANGE: s�o AMOUNT DUE _ $ /�S -00
'�****PLEASE TL'R\OVER A\D C0�IPLETE OTHER SIDE OF FORJZ**"•"
�
a
� ,
ADNiINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: ,/
YES v 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 terrn occupancy, ordinarily and customarily associated with motel and hotel us�.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhe�e.
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)mQnth period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be consider�Transient.
* NOTE: Enclosed Motel Census must be com�leted and returned with tlus application.
POOLS
POOL OPENIlVG: All swimming,wading and whirlpools which have been closed for the season must be ins ected
'` by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days
pnor to opening.
POOL WATER TEST�TG: The�vaxer must be tested for pseudomonas,total coliform and-standa�d plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmetrt by filin�the required
Temporary Food Service Application form?2 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 hy 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 afHealth. �
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETLJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COMMENCEME�IT. RE�tOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �/ o� $�0� SIGNAT'URE: � G�'�"c-�
PRINT NAME&TITLE: T-�`i���t1A I`���-4/�(�
lo��)�)7
-- _- --
_ _ _ __ _ <
+ � The Commonwealth of Massachusetts
Deparhnent of Industrial Accidents
Nllf��i�1�i
60o washiRgtos stree� f�'Froor
Boston,Mass. 02111
Workers'CompeHsatioe I��nce Affidavih Baitdiag/Plambi�giElectrical Costractors
A�nHc�t��f�: P�a�oe PRINT I�bh
name: 6) rh '� S � t �. 'e-s
addtess• c^�.�1 2� 1�'�� ��
citv�o o �c�.✓' ✓�L C7 V�� state: �''��.,�-s Z1p: a�,�v�� nh�e# S-c5�"-�3�'&�S�3 aa
work sfte locatiN�,rfiiu addreSsY
0�,ann a hom�wner performing all work myself: Project Type: ❑New Canstructiaa�QRemodel
0"I am a sole pro�xietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing wodcers'compensation for my employees working on this job.
comwnv eame•
address:
citv: o4oee#:
im ca. #
. •'.. . . };. : � . :: ' ,. .;�., _ ._. ...;.:� , oi; ,,.. u..�: a� .;:,;- . .,r.,:.:�.,. , .�.«�ea...Stv,:a+.: �a.ak .r`.:.
❑ I am a sole praprietor,geeeral coatractor,or lameowaer(cn c�fe owe/and have]rired the co�actats listed below who have
the following workers'compensation polices:
cumuuv rame•
sddress:
citv n6ore#:
iesm^aace co. #
_:- s .
csnouv�mu•
addre�•
_ _ _ _
- -- -- ___ _--- —_ __.____------ —--
citv: . d�e#:
i�s�w. #
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Fa�u�e b xeme eu�vera�e as neq�ral»der 3ee�a 2SA�f MGL 1S2 cu Ind b tYe�t�edsial peaaWa�f a iae�p b Sl,SN�M aid/o�r x
one yars'ImprNoveat u w�as dH peeakia in t6e form of a STOr WORK ORDER�ed a 5ne e[f196.0�a day agaimt me. 1 aadeestaad tht a
cepy et tYb sfa6�e�t my be firwarded�n the O�ce of IYve�Isas of the DIA ter avera=e veriAatlse.
!�o bereby cerlrjy xeder tJre pe and Iha of perjxry tNat tl�s infonwelion provided abov�e fs true med cor►+�cx
s�� � � nat� �.�� �C � �
Print name � !���- ��l. l o �'l Plwne#�d � �� �^ -�. � �
e�eiai�ealy do not wiite�thb area to 6e ooapleted by cily er�ov►a afficial
eity or tewn: pern�ioe�se# �Baid�E DePartmeH�
��.ieee�ie8 Bsard
❑check Kimmt�a�e nspeme is ra��mred �Selxtmen's A�ee
�Depar�t
centact person: phene#; �Olhe
c+�s��)
� THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NIJMBER: #08-099 FEE: $50.00 _
This is to Certify that Tatiana K. Malone d/b/a Joe's Rt. 28 Diner
928 Raute 28, South Yarmouth, MA
� —
IS HEREBY GRANTED A
; COlVIMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authonty granted to
? the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
; In Testimony Whereof, the undersigned have hereunto af�xed their official signatures.
BOARD OF HEALTH: .�e�ett S�, `J�...IV., C�awr,n:att
sEartrrG: 45 C��uaX�Ri3 �.J��e��x, �iCe ��►talt
� i�'(ir.�.ex��.53�tlWrt, C'�e�r�
� � � � � Cln�(�xeer�a�c,rn, .12..At.
.�Ear�,e�
February 7,2008
h .S. CHO
ru e G.MmP Y, , ,
_ H 1
Director of ea th
TOWN OF YARMOIITH
BOA1tD OF HEALTH
PERNIIT TO OPERATE A FO�D ESTABLISIiMENT
PERMIT NUMBER: #08-159 FEE: $75.00
In accordance with re�ations promulgated under authority of Chapter 94,Section 305A and Chapter
I 11,Sectian S of the eneral Laws,a permit is hereby granted to:
' Tariana K. Maione, 928 Route 28, South Yarmouth, MA
Whose place of business is: Joe's Rt. 28 Diner
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31�2008 BOARD oF HE��,TH: .�'fe�ett SRtaf�, J`Z.JV., C�ai�cnuuz
�'P�i�aQur_�� s ��.9�i�'�i�ie���`,tJiee (',R,cwuricrx�
SEATING: 45 �Ilw�s�3�✓,�Q�tlfiL� t.�.�a�L
C���., �.�v'.
�,�e��- .�i�
� Febivary 7,2008
Bruce G.Murphy,] , .S„CHO
Director of Health
r
` - � r �°T,`� `7'�s I�T; Zg ��lRZ
' .°`,�R�. TOWN OF YARMOUTH BOARD QF�A�,'�'$
? o
������ APPLICATION FOR LICENSLII�E��1'" ��7``�-��� �
� � Q 2007
.. ...• � , -
* Please complete form and attach a11 necessary documents by Dece�mber 31�,2006
Failure to do so will result in the return of your application packet.
NAME OF ESTABLISFIlVIENT: ,�)bE S fZ.�2?� i�I�UET�, TEL. #�6o8��c1���1�1�
LOCATION ADDRESS: ��$IZ�t"rl�SrfZ�Er ��5- �i�,P�`10�r1� /yp- 07�6��
MAILING ADDRESS: �!-1M�
�WNER NAME: T/�i iA�l� ,�C. M/a�A�cJ� TAX T�(FEIN or SSN�Q�����y
CORPORATION NAME{IF APPLICABLE):
MANAGER'S NAME: TEL. #
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s)and attach a copy of the certificataon to this form.
l. 2.
Fool operatars must list a minimum of two employees cunently certified in basic water safety,standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach 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.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
i All food service establishments aze required to have at least one full-time employee who is certified as a Food
' Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishmen�
1. 2.
FER�O�V IN CHtLRFE: _ _ __ _ _ - _ �,
Each food establishment must have at lea.st one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlVILICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
i 3. ,"_ 4.
RESTAURANT SEATING: TOTAL#
CE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIt�D FEE PERMIT#
B&B $50 _CABIN $50 _MOTEL $50
INN $50 CAMP $50 SWIIvIM1NG POOL$75ea.
_LODGE $50 _TRAII,ERPARIC $100 WI-IIRI,POOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMI'P#
LO-100 SEATS $75 O�Saj _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 �COMMON VIC. $50 �07�0 � _WHOLESALE $75
RETAll.SERVICE: �RESID.KITCHEN $75
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_45,000 sq.ft. $75 ,.FROZEN DESSERT $35 TOBACGO $50
NAME CHANGE: �10 AMOUN'T DUE _ $ �2�.OQ
••"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""'°•
,
,
AD1VlINISTRATION
Under Chapter 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 MUS�'BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prio to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: �
YES NO
MUTELS ANp 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 terrn occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must ha.ve and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of nat 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, sha.11 generally be considered Transient.
POQLS
POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(S�days
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 Fnust be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERiNG POLICY:
Anyone who caters within the Town of Yarmauth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Applicatian form 72 hours prior to the catered event. These forms can be obta.med at the
Health Department.
FROZEN DESSERTS:
Fro2en 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 Pernut until the
above terms have been rnet.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service},must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor c�kin�nrep�tionror display_of a.ny faod prQciuct by a retail ar foad serv�ce esta.l�lishmentis�rohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET[JRN
TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY POOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO CONIlV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: Oi D�I �'j�- SIGNATURE: li'��'�
� �-�
PRINT NAME&TITLE: I A7-�RNx1 �� !`�f l3�.0�1� ,�(9�c1�2�
�
10/17/06
�
r
�
� The Cor�monwealth of Massachusetts
Depart�ne�rt of Indastrial Accidents
> �a�i�/Mi■i
6(� Washengton Sh+ee� 7`�`Floor
.
Boston,Mas� DZlll
i __ Work�s'Com tioa Lsamaee Affidavfh B'it bi�/Ekcdricxl Coatnetors
�� �,�.: -�:-„ �. .„r.��.-�:� . , _.. �._,.,�. �:�.,�,� ��� ,;�
, 1
; name; ��O � S �t v�^2.rr-
�S: �2�L��-.� �S�
� �r �S� K,�.��� �-(,� �e_ �� . �;Q, c� 14��i�# S�� -3 9 r�y��o
��S,�i�a�rrnu�Sr.
p I am a�meo,�perfoaning all wo�k m,�lf. Pro;ect Type: p xew c,a�tia�pR�,«iel
I am a sole 'etor atd have na a�e w in an Buil ' Addition
am an e.mployer providing wake�rs'compensati�fa�r my employ�s wadcing on this job.
�� _ __ _ _ __ _ _
ai�ilr�ss;
c[t�r: � al�e�e ik:
.e� ��t-�
❑ I am a sole praprietor,g�eral ea�tractar,or komeaw�er(cirde ow�)and have hired the contr�ctas listed below who have
the following workers'compensation polices:
��
�
citY: �,�s,
��= � ..�.
�-
� ��
Failere��enae ov�e as reqi�ed�rder Sectl�a 2SA�f MGL 1S2 en lad b fie 6rpaMi��!'ai�d�al pefalKp�f a II�e�b SI,SM.N aadl�r
..e�°��c�w�a u aw��c�e�.sra sror woiuc oxu��.a a m�e.[sies.N s aay a�.imc.e. i naa�sa.a n�a
c�py ef tl�k�la�aest my be finnrdcd 1e the Onice�tl�vatlptl�a ot tlrc DIA far earerage veri�eatlse.
I 10 ba+eby cer�ify xnder dYe polws ewe1�of perjr�ry dYot�IIYe iufons�ton provided obore is lnre aud oaro+erx
S1�UPC I — !/-/� �81C �,�0 �
P,�;nt� T� J�--c� �a Pbo�#�o �'�`'r S�— `�9 0�
•fficiai ase on�y aa a�t..rtte�e�a are.ce ne a�pie�d br eltr or irw��clat
c�p or ts�vn: �� �t
❑e6eck if�h rdpeme b re4�'ed �Sdeclsm s O�oe
�DqratUeeet
��P�' P�we#; OO�
;��
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
RENEWAL QUOTATION
WORKERS' COMPENSATION
PLEASE MAKE REMITTANCE T
TEL.# (800)876-2765
A.I.M.Mutual Insurance Co
Date 12/28/2006 P.O.Box 4070
Burlington,MA 01803-0970
Michael Malone IMPORTANT: COVERAGE WILL NOT BECOME
dba Jce's Diner EFFECTIVE UNTIL YOUR POLICY EFFECTIVE
928 Main Street DATE.
South Yarmouth,MA 02664
PLEASE PAY THE TOTAL AMOUNT
DUE SHOWN BELOW NO LATER
THAN:
INSURED 02��7�2��7
Schlegel&Schlegel Insurance �
34 Main Street,Rte 28
West Yarmouth,MA 02673
� PRODUCER OF RECORD
Policy Effective Date 03/09/2007
Policy Number AWC 7018468012007
Rates Per
CODE Estimated Total $100 of Estimated Annuai Premiums
NO. Annual Remun- Subject to
Remuneration Ail Other
eration Modification
SEE EXTENSION OF INFORMATION PAGE
TOTAL ESTIMATED ANNUAL PREMIUM 1,z62
TOTAL MA ASSESSMENT
960 x 4.1920% 40
DEPOSIT PREMIUM 1,26z
DEPOSIT ASSESSMENT 40
sbindman
TOTALAMOUNTDUE l, 302
FOR COMPANY USE ONLY
Net Amount of Check
Initial&Date
placing office: 704
AP 4921 (9-89)
F . , . . .
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiVI�NT
PERMIT NUMBER: #07-153 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 345A and Chapter
111,Section 5 of the General Laws,a peimit is hereby granted ta
Tatiana K. Malone, 928 Route 28, South Yannouth, MA
Whose place of business is: Joe's Rt. 28 Diner
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit e�ires: December 31. 2007 BOARD oF HE1�,TH: B y�s `h. ,�1.�.��
dfe��l�e�s �'��i, ��/ _rc'�
SEATIlVG: 45 R�� B�lti!(�VL� (.LB�
n/�� ���/� �
' tY � r KJI.
Apri14�2007
� Bruce G.1Vlurphy,� , S.,CHO
Director of Health
THE CQMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #07-097 FEE: $50.00
This is to Certify that Tatiana K. Malone d/b/a Joe's Rt. 28 Diner
928 Route 28, South Yannouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: B j��,�y 21. �i�,�rs,�f._`h., .
SEATING: 45 c��eG� c7�� JI.� �U%Ce C:K!'sy!/1t�iL
� Rol,�ht�. B�, G�
nc�iscl�Z 1�a�1�
� � , R�v�
Apri14.2007
Bruce G.Murphy ,R.S.,CHO
Director of Health
' �,�,3`�a�./�-o�s 2T. 28 Dr�►E12
� ��'=-YAR TOWN OF YARMOUTH BOARD OF HEAL� �-�� �
a `'_ �. + �7 .i., p In3 !� C� I� �iMC� DD
� 3� ���� APPLICATION FOR LICENSE/P���0�6� � �
Y� �� ��� � FEB 0 9 �2006
* Please complete form and attach all necessary dqcurr�ents by Decemb 3l, 2005.
Failure to do so will result in the return af your application pack t.�{EA�7'H L��P�.
,
NAME OF EST.ABLISHIVIENT: JQE'S �ZT�8 �/�5/F,�, TEL. #�08 ' - Oa
LOCATION ADDRESS: F-' . A2. � NA O
MAII.,ING ADDRESS: U QL.E a� �S u,✓,�< <J O O
OWNER NAME: iCNAEti ,MR•�.o�l� T ID 1N r 1- -.2-25!
CORPORATION NAME (IF APPLICABLE): n���
MANAGER'S NAME: ,,gqr/� TEL. # �9K�
MAILING ADDRESS: i�,q►1�
; POOL CERTIFICATIONS:
I The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list th�designated
; Poal Operator(s}and attach a copy of the certification to this form. -- -
i
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
' FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fizll-time employee who is certified as a Food
Protection Manager, as defined in the State Sarutary 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. �"�c� S�t Wtc=� � 2.
�' PE1tSON IN�HAI�GE:_
__ �-_ _ _ -- _ __ _ _ _ _. _ _ _ _ _
' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2. _
HEIlb��CH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
at�ae�i eopies of employee certifications to this form. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. ltilrcH,4FL i�'iAL.�L �1wt� 2.
3. 4.
RESTAURANT SEATING: TOTAL# �3'
OFFICE USE ONLY
LODGIIVG:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMTP# LICENSE REQUIItED FEE PERMIT#
B&B �50 CABIN $50 MOTEL $50
iINN $50 _CAMP $50 - _SWIlvIlvIIIJG POOL$75ea.
LODGE $50 TRAII�ER PARK �50 WHIItLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
�0-100 SEATS $?5 �O'� S CONTINENTAL $30 NON-PROFTT $25
>100 SEATS $150 /COMMON VIC. $50 OG-0�3 _WHOLESALE $7S
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQITIRED FEE PERMIT#
_<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20
_<25,OODsq.ft. $75 _FROZENDESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOiJNT DUE _ $ �2 S.O Q
""••'�PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*'�""
_ -� F
,�
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF 1NSURANCE ATTACHED
OR
WORKER'S COMI'. 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 RETiJRN
TI�COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLIS�IlVIEENTS ARE TO CONTACT T`HE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEIVING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMN�NCEMENT. RENOVATIONS MAY REQUDZE A SITE PLAN.
ADDTI'IONAL REGULATIONS
POOLS
� POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of .
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caxers 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:
__ F�eze��esserts 3nust be�ested on a r�on�hly h�sis b�a Sza�e c�t��ed lab.-T�st rgsults must b��nt to tl�-H�lih_ _
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited.
DATE: ��.3�0� SIGNATURE: � G�I �
PR1NT NAME&TITLE: ���--�r--� �2 4-�m� �
09/28/OS
,
,
,r._..____�'
WORKERS COMPENSATION AND EMPLOYERS UABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts NCCI NO 26158
(800) 876-2765
POLICY NO. AWC 7018468012005
PRIOR NO. NEW BUSINESS
ITEM
1. The Insured Michael Malone dba Joe's Diner
Mailing Address: g28 Main Street South Yarmouth MA 02664
(No. Street Town or City County State Zip Code
� Individual ❑ Partnership ❑ Corporation ❑ Other FEIN 06-1741224
Other workplaces not shown above:
2. The policy period is from03/09/2005 to 03/09/2006 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation insurance: Part One of the policy appiies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy appliss to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily injury by Accident $ 100,000 each accident
BodilyinjurybyDisease $ 500,000 policylimit
Bodily Injuryby Disease $ 100,000 eachemployee
C Other States Insurance:See Endorsement WC 20 03 06 A
D. T.his policy includes these endorsements and schedutes: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required betow is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Eslimated
Total Annual of Mnual �
No. Remuneration Remunerelion
Premium
INTRA 097035
SEE EXT NSION OF INFOR ATION PAGE
Minimum premium$ 217.00 Total Estimated Annual Premium $ 1,016.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 1,052.00
� Annuaily ❑ Semi Annually ❑ Quarterly ❑ Monthly
• MA Assessment Chg.
$740.00 x 4.9000% $36.00
This policy,inciuding all endorsements,is hereby countersigned by 03/21/2005
Authorized Signalure Dale
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Schlegei&Schlegei Insurance
MA 9079 2 704 98 Main Street,Rte 28
WC 00 00 01 A(11-88) West Yarmouth,MA 02673
Includes copyrighted material of the National Councii on Compensation Insurence,
used with ils permission. .
R
T"'" �'.
' __ _`�� The Commonwealtl�of Massachusetts
�---=.--3
_- - - _ Deparhnent of Industrial Accidents
_ _ -� M�ei/Ii�1M�
_ _ -= � 600 Woshington Stree� f"'Floor
- r
—-,, Bos�on,Mass. 02111
Worl��s'Com�aatios Ias�Affidavit;B�it
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r�i�+ �":,,, (� �+�,n,,_' state• '(�-�� aQ. �2,6�nhcne#�g'^ �'�"0 0-/�Q�
work site locatiam(full addressl:
❑ I am a homeowner performing a1I wa�k myseif. Ptoject Type: []New Coostrucaa�►�Remodel
I I am a sole 'etor and have no�e w ' in any cap�city Buil ' Addition
. � ���.�� . �;;���.���'-� ..» . _
. w� x,:; . ._ .. :
I am an e.mployer�xoviding worlcers'compensati�fa�r my eanploy�s wadcing oa this job.
aomouv m�e•
�:
t�: ��.
❑ I am a sole proprietor,ge'eral co�tractor,or�omeo�(czrcle owe)and have hirad tbe cantractars listed below who have
the following workers'compensation polices:
�«
dtr• ��.
: �F^a...,�fa�aa 3�.,�.::�� ....�� ��. �
� !.:��.y v. � ..
- . . ..fx:.1 Y .,p->]. iri..-m��i�.�`'.� h'n.._.ix. � .w.`'.,i .,Y"-';vd" . ., s
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�i
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-._ . . __.._� ..__..__.. . .___.-.---_____ ._—.-_.____._. .. . ._ ._ . .. . . _ . .
. ,.___ . --_.-.. .._—_.._. —__... .._ ._.�. _ . ..__
_ .__. _-____ .____. _ -.__ __.._.
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-.� , . ��-� ��,,,,,�r �' *��ri'� �.���` s,r?".��"���`���s�'�t� �',�',�� :
Fait�re�secare oe�vva�e a�neqaired�ader Sectloa 2SA sf MGL 1S2 aa Ind b tYe�i a!'crl�id pnaNks�f a Sne�p b S1,.SM.M aad/� .
o�Yan'�eptbeommt m we8 as dvi pe�aMks ie t6e fors ota 3T0t WORK ORDER aad a 6ae dS160.OS a day ag�t oe. 1 mdenh�d tEnt a
cepy of this staMmeat maq 6e forwarded�o the Omce e[lave�gatioss of the DlA for eoverage veMeeatlN.
I do 6enby cer(r;jy xeder Nie pains elties of perj tlirat tAie iwfor�,neflon provided above is true�d c»rn�ct
signature � �� Date e2— �—O 6
Print name l�t G l�2.o / �e�I o�� Phone# ���' ��� " �gG�'
official aae only do not w#e ia this are'to be compkted by dly or to�vn o�ial
city or te�vn: �����#
❑check if immedia6e r+e�peme is rcquired ❑�,s�ce t
❑Hnit6 Depardeat
rnutact petaon: p�oae#; �a.
Inviecd Sq�t-2�i1
,
. , ,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-155 ,,. FEE: $75.00
In accordance with re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pennit is hereby granted to:
Michael Malone, 928 Rou`te 28, South Yarmauth, MA
Whose place of business is: Joe's Rt. 28 Diner
Type of business: Food Service
i
To operate a food establishment in: Town of Yarmouth
; Permit expires: December 31, 2006 Bo�oF HE�,�: G `h. �o�o�,�19.`h., '
� d�������1�lsa�i, ./V.�,/?/�ic/e l�i�r�,r�rs
SEATING: 4S R/�G��, •[b't�.,/B�hLfJ�[t�fL�_(�SL1PlLIB
(/�G��RtC�/i'[Ci..t�@�lpl(M�
' fY/lIL � .
Februazy 13.2006
Bruce G.Murph� H,RS.,CHO
Director of Heal
�
THE COMMONWEALTH OF MASSACHUSETTS
� TOWN OF YARMOUTH
PERMIT NUMBER: #06-Q93 FEE: $50.00
This is to Certify that Michael Malone d!b/a Joe's Rt. 28 Diner
928 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confarnuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereta
In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures.
BOARD OF HEALTH: B `h. L��o�irt,�19.`n., .
sEa'rn�rG: 45 oy��t�i, ��.N., 'l/sce G���irx��s
Ro�eJl��.B�uiuwt, ��
/��L�uc�/yc$e�rito�
�4���-�� R.N.
February 13.2006
Bruce G.M y,MPH,RS.,CHO
Dir�tor of Health
� � .�
i
j � � ' ' � I
� i
�
� To: Date
a
� From:
p F0�2 YOUR COKAMENTS ❑RE.PLY&SEND ME COPY
❑FOR YOUR APPROVAL p FOR YOUR INFORMATION
i ❑TAKE APPROPRIATE ACTION ❑FOR YOUR SIGNATURE
� ❑CALL ME ❑
� ❑SEE ME
� 0 p�,,�,�Q �
COMMENTS: �p-T–
—� �
� �D�S � 2S t�Yl-- � �
�
(� C ' ��M I���Q. Insa� Co. �
T— �
� o000 � �1a3.s �
i , og oS
��1 �c�2�- l��
�vt�.-�—� ��N M.�l- 618cs� :
�'�0--��4� — ����"
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-159A FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
Michael Malone, 928 Route 28, South Yarmouth,MA
Whose place of business'is: Joe's Rt. 28 Diner
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2005 BOARD oF HEALTH: Be�aHri�s�. �'oadorr�/�$. '
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SEATING: 45 R��. B�l�#l(RfL� �"+fPJlR
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March 24,2005
Brucc;e G.Murphy, ,RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #OS-096A FEE: $50.00
This is to Certify that Michael Malone d/b/a Joe's Rt. 28 Diner
928 Route 28, South Yarmauth, MA
IS HEREBY GRANTED A
CO1ViMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2005 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the .
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto aff�ed their afficial signatures.
BOARD OF HEALTH: Ber�w,ass�`Yl. Cf'o3d,�+rs,/yl.`h., .
SEATIlVG: 45 n�ic�J�a�PJtyro� 7/sce e�isws
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March 24,2005 °
Bnice G.Murphy, H S.,CHO
Director of Health
__ _"�'"�� The Cominonwealth of Massachusetts
----_-__-�
�� __ � Depart�ent af Indrtstnial Accidenls
_--_ - - - �tNiNli�l'�R
- _ _- � 646 Washington Stree� f"`Floor
-=�,? Bos�ox,Mas� 02111
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❑ I am a homoownex perfaaning all wo�lc myself. Project Type: ❑New Caoslructi��R�nalei
I am a sole 'etor and have no a�e w in an ca B " ' Additian
an empioyer p�oviding w�keas'compensatian fa�r my emgloyees wo�cing on this job.
c�a�aurr�wae:
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. �NS 8o0�Z -�2.76 . 0006
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❑ I am a sole Proprietrn',ge�erai coitracMr,or homeew�er(cirde o�e)and have hired the c:ontractots listed below who have
the following wa�kecs'compensation polices:
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Failete p scc$e errera�e at reqaired uder Sa�a 2SA�f MGL 1S2 cu Ind b IYe�p�a�!'cr6d�a1 pe�aNia da�e�p b S1,SN.M aidl�r
one yan'imptbonmmt as weY as cM pmltles i�the fers•ta STO!WORIC OBDER a'd a Au dS160.N s day apd�t re. I adenh�d t6at a
apy�t fiis�ta6e�my 6e[�rwaeded 1s Ne Omce�f 1�veN�tlHs at tre DIA ter c�v�d�age veriAaliN.
I do he►�eby cer�fJ'y xnder dYe pai�s mid penahlas of perjury tbet tlYe i»fon��ion provdde�abovie fs texe osd on�
Signatute I�te
Ptint name��� `�c..JC�� Phone# 2 �
e�cial ex only da�t wrke Ia t�a am f�6e co'Pleted 6Y e3t7 er Mwn o�al
eity or tawn: �t �lBaidlnc D�nt
❑eheck if imme�aMe re�s�e b raq�u+ed ���
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�°f.�R o TOWN OF YARMOUTH BOARD OF �� rn -
� .: �
F: .�,;� APPLICATION FOR LICENSE/P �2�Q05' �F B 2 g 2 0 0 5
.� $�
�` �' , , s�
* Please complete form and attach all necessary do�in�s�'�y December 1 �TH DEPT.
Failwe to do so will result in the return ofypur apphcation packet.
NAME OF ESTABLISHMENT: �7'[� S f I�l� TEL #
LOCATIQN ADDRESS: 9�8�� �i R.��T" , �'ovr���A�M o��� h�} �26�c�.
MaII,nvG AnnxEss� �� v�e.�.� �oa% �� �,�,T� ,�N�� , Mr� oz:66 0
OWNER/CORPORATION NAME: �����
MANAGER'S NAME: MI��fAE� MA�-ONE TEL # ��0—l'80$
MAILING ADDRESS: �� v��e�.� �'s �4 y �ovr� �N,r3 � �1�4 0 2��
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1• 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
employee certifications to this form. The Healt6 Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1- 2.
; 3• 4.
�
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
I Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this applica.tion. The Health Department will not use past years' records.
; You must provide new copies and maintain a fde at your establishment.
i 1. ���OG'� 'e5�1-C�,(.,�1���Z. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employe� e trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedwes 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�le at your place of business.
1. �i CN�.� �-t�-z.enl�. 2.
3• 4.
RESTAURANT SEATING: TOTAL#��
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
_BBtB $50 _CABIN $50 MOTEL $50
_INN $50 _ CAMP $50 _SWIlvIlvID1G POOL$75ea.
_LODGE $50 _TRAII,ER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT#
�0-100 SEATS $75 6 �� _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS �150 1COMMON VICT. $50 O'S�OCf(o _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRBD FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $2t� VENDING-FOOD $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ �Z'�j . O O
""•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�R Rf!R
i` .
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
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
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL E STABLISHMENT S ARE TO CONTACT TF�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEAS4N.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HE.ALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 cavered within seven(7)days of
closing.
FOOD SERVICE
CQNSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours pnor ta the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is proMibited.
DATE: �-d��'�`� SIGNATLTRE: ���
PR1NT NAME& TITLE: �r�.��/ �G*�d�o•z� p,.�,a�s--
10/22/04
9
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- -_-� The Commoawealth o Massachusetxs
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�� _ _ Deparhnent of Industrial Accidents
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— ,,,�°�` Boston,Mas� 02111
. Workers'Com�eaaahoe I's leedrical Coatnctors
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; ❑ I am a homeownet performing all wadc myseif. � Ptoject Type: ❑Nevr Ca�structia��Remodel
I am a sole 'etor and have no one w ' in an ca " . Buil ' Addition
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I am an emP�Y�P�i�S W'��'��on fo�my e.mployees wodcing on this job.
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I ❑ I am a sole p�roprietor,geseral co�tracMr,or komeew�er(cude oAt)and have hired ihe�tors listed below wlw have
tl�following workers'crnnpensation polices:
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Faims r aecve owerase n reqeired udK SaWi 2SA�f MGL 152 n�lad b tYe irpailMa�t�l�al peatl�s�a�oe�p b t1,3M,N aadhr
�ae ya*':'I�SPtira�mmt as weY as dN pwdUes i�tbe Eara ota STO!WORK ORDER ud a Sue dfllS.N�day agaiest re. 1 ndastud t6at a
apy ef Hb rtaem�my 6e fennrded 10 tOe OAfce of lave�ptlys e[fb�DIA tor ew�age va'i�eatl�a.
I do be►�eby cerhfy xwder the pafns enApeaalties of pe�irry 1Net NYe iefonrreAto�prov�ied aboNe is trxe aud cornect
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P,�;m name ltit;�,L,�,o/ L•a�/r�,�.. Pbo,�e�,,�/?£f� ?�D- /8��
efficiai�se eely de Dot wrke i thi�un te be cypleted 6Y ek9 or lnva�1
cilY or tewn: �# ���
❑e4eck Kfie�a6tle napene b reqaired ,
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�INANCE f u*e�uu�r,uk��Ut a+.r.u.t�u�
� WORCESTER,MASSACHUSETTS 01613
{ �ViA�NA COMPANY� INC. TEL.(508)756-3067 FAX(508)752-8197
Cash Price ' �
Toral dollar amount of premium U ( S Y
$1,052.00 MICHAEL MALONE DBA JOE'S DINER
928 MAIN STREET
Down Payment S.YARMOUTH, MA 02664 50&760-1808
Your Cash Deposk
$368.00
SCHLEGEL b SCHLEGEL INSURANCE 88 MAIN STREEt W.YARMOWTH,MA 02673 MAG180
AMOUNT FINtANCEU FINANCE CHARGE TOTAL OF TOTAL SAIE ANNUAI sEcurt�n
PAYMENTS PRICE PERCENTAGE RATE Y����0 e Security k�tarest in pie MwraMx Pdfa4s
amount of cred'R provided Dollar amou�t the cred'R The amouM you will have The cost of your Premiums The cost of your credit as d���'�
co you on your behalf. wili cost you, paid after you have made on credit including your yearly rate LATE CHARGES:
all paymeMs as scheduled. dawn payment of Peisonal a Houaehold Accduds:Vau wiR be cherged
35.00 or 5�.af the PaYment,rfikhcHer M lese. C,anrrbrdal
5684.00 �47.09 $731.09 $368.00 , ^�: 5����►r o��
27.�3/o PREPAYMENT:
�f l�PaY�ear1Y.You wiN noE have to pay a peneqy.Yau
$1 099.09 ^18Y��od m a reflind of part d 1he Finar�ce Chsrge.
� See yota Contraet DacumeM fo►any add[bnal�
about non-paymmt,defauM,airy rnquired peyrnent in iull
YOUR PAYMENT SCHEDULE WILL BE: betae tha scheduled date,and prepayment reiunds end
penaldes.e means an esthnate. •
Number of PaymeMs AmouM of Each PaymeM When PaymeMsare Due:
�5- $146.22 Mo�,� 04/01/2d05
y Beginniog
ITEMfZATiON OF AMOUNT FFNANCED: '{'t�e�nouM Gsted as Amourrt Finarx�d is being paid to your Insurance AgentlBrokerfCompany in your DehaN.
The Charge}br kstereat herein isnR in e�ess oi the charge authorized by regufffiions pursuant to the provisions of Massechusetts Generat Laws,Chapter 175,Section 162-B.
CASH PRICE(PREMIUN� CHECK# INSURANCE COMPANY AND POI.ICY TYPE OF INSURANCE EFF.DATE POLICY NUN�ER
WRITING AGENT IF DIFFERENT FIRE.AUTO,W.C.
H.O.PKG.
51,052.00 MASS HOMELAND AUTO 02/2812005
s1,052.00 GRANDFOTAL-CASHPRICE
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Aws u�as�nsA Pr�riiMns ncairaA Lo�r M inwar. .
T1�e�Mtlerdpimd�'�Ort t e^Y diedS Adt s ads fer Oeymert d n�ney whm�ed hylre uMeeegrd in acmMwkewlA riis apeprM b re0�nad urpeid or k mt hd�deA Ey rie ba�k ar etl�er dapoeilory,rie uMr.ysigned she�p0y e
�1 DO IVOT S�C;N THIS AGREEM NT!F ANY OF SPAC S I TENDED FOR THE AGRE D TERMS ARE I�FT BWNK.
2�YOU ARE ENTITLED TO A CO�Y OF THIS AGREEM�N�AT THE TIME YOU SIGN �
3 UNDER THE lAW YOU HAVE THE RIGHT TO PAY OFF IN ADVANCCE THE FULL AMDOUNT DUE AND UNDER CER7AIN
PORTON OF TTHE ADMINtSTRATNE FEE SHA�BE REFUNDED FUR ANY PR��AYMENT N FULLANO REFUND WILL BE
❑ MADE tF LESS THAN a1.00
S�cw►nx�oF Nsur�p�sz a►1E S�Eo
� y/ /'��Q..��z_--�_ �2/28�2�05
ASSKiNMENT WRWWITHOUT R�COURSE
Far w�lue►ecxived the�signed herehy se�.�.and transfets,v►ntl►out recourse,to MAGNA FINANCE COMPANY,INC.aq rigMs.Ulle�td interest in.to and under tlre v�hin
Premium Finance/k�ree�nent- The�oer6f�es�d W2rrants Ura4 U�e Pretrdum Finnrice Ag�eenrent�vaRd;thet to the best d fiis k
'desaibed and M force and ihai the above reoeived a oopy of the ag�eement;that there�rro defense to said Premium Finance Agreement th��Schedu���s)d the
canmissian to MAGNA,provided ihe ►epreseniatbns�e due Ni ap respects.The u�ed agree,g�on cancellaGon d any of the Scheduled policies to pay the uneemed
��^� to Pay U�e same to ihe Scheduled Insurance Comp�es or their agerits.
SpVGATURE�PRODUCER
DA7E SlGMED
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, . . � -
TOWN OF YARMOUTH
BOARD OF HEALTH
� PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NLJMBER: #OS-159 FEE: 75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted ta
Michael Malone, 928 Route 28, South�armouth,MA
Whose place of business is: Joe's Diner
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2005 BOARD oF HEALTH: Ber�ru�s`h. (�''u�icP,oss,ll9.$. •
p��/ �� ���n,' v_ ,�e�.�.�
SEATING: 4S R!O'�' � B�IfiWR1l�A'(iLP�/�
oY�B��� QJI.
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February 28.2005
Bruce G.Murp , ,R S.,CHO
Director of He
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBE&: #OS-096 FEE: $50.00
This is to Certify that Michael Malone d/b!a Joe's Diner
928 Route 28, South Yarmout MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2005 unless
sooner suspended or revoked for violation of the laws of the Cammonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authonty granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto aff�ed their official signatures.
BOARD OF HEALTH: Besy��$. ��°,�,���il.25., .
SEA�G: 45 Ar.#tic�/blc`��, ?/sce L��uiu�
RvdP�t 4 B�, Gl�
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_ February 28 2005
Bruce G.Murp , ,RS.,CHO
Director of He