HomeMy WebLinkAboutApplications, WC and Licenses r . ,. ���.,Y C�wrArN
� " � � • TOWN OF YARMOUTH BOARD OF HEALTH '
� APPLICATION FOR LICENSE/PERMIT- 2009 :`�. �• � � � � � �� � °'
�,::
�. '�`' � 0 1 2008
*Please complete form and atta.ch all necessary documents�y" mber S �8�8.
Failure to do so will result in the return of your ap�cation pac et.
HEALT�I C��PT.
NAME OF ESTABLISHMENT: p' � � S TEL. .�D� - �S
LOCATION ADDRESS: — , �
MAILING ADDRESS: � �
OWNER NAME� 3'AX ID FEIN or SSN : — �
CORFORATION NA E ( APPLICABLE):
MANAGER'S NAME: � � TEL. # � "
MAILING ADDRESS: , � � , a _
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed 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-�/�.�z�n .���.�f.�.�2� (� 2.
Pool operators must list a minimum of two employees cui7 ently certified in basic water safety,standard First Aid and
Community Ca�diopulmonary Resuscitation(CPR). Please list these employees below and attach capies ofemployee
certifications to this form. The Health Department will nat use past years' records. You must provide new
copies and maintain a file at your place of business.
1.- ��-.�u �Ok�e.�,�� '--�
2. o
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 capies of certification to this applicatian. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2
_ P_ERSON_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 employee trained in tlie Heimlich
Maneuver on the premises at all tunes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certificatians to this foi7n. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1.
3. 2-
4.
RESTAURANT SEATING: TOTAL #
Lonci�vc: OFFICE USE ONLY
LICENSE REQUIRED FEE PERMIT# LIGENSE RE
QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S55
CABIN
_11VN S55 �55 -------- ._MOTEL �55
—CAMP �55 ` �Q '�7 a"'
_LODGE �Sg --------- _L._S�MMINGPOOL �80ea.
_TRAILER PARg �105 _W�,pOOL $80ea.
FOOD 5ERVICE:
LICENSE REQUII�ED FEE PERMIT# LICENSE RE U
Q IRED FEE PERMIT# LICENSE REQUIREj) FEE PERMIT#
____0-100 SEATS S85 _CONTINENTAI;
>100 SEA7S '�35 NON-PROFIT �30
— S 160 _COMMON VIC. �64 ---
RETAIL SER��ICE: ------ ____�OLESALE �gp
LICENSE REQUIREI} FEE PERMIT#. —�SID.KITCHEN �80
LICENSE REQUIRED FEE PERMIT#
_<�0 sq.n. �50 LICENSE REQUIRED FEE PERMIT#,
>>25,000 sq.ft. �22j
�<25,000 sq.ft. �gp ---- _VENDING-FOOD �25
---- ._FItOZEN DESSERT �40 -------
�A�IE CHANGE: �10 ---- _TOBACCO �55
-- AMOUNT DUE _ $ga,�
'"'�"**pLEASE TUR�O
VER AND CO�IpLETE OTI�ER SIDE OF FORVI"w***
��
.
—\
_� * ' -, ,
ADMINISTRATION
Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yasmouth 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 5TATE WORKER'S COMPENSATION INSURANCE f
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ;
;
Y
CERT. OF INSURANCE ATTACHED '
OR /
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED �J
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: ` �
YES �/ NO
MUTELS 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 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 Transient.
l
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(�days ;
prior to opening.PLEASE NOTE:People are NOT allowed to srt 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 must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY: ep the r uired
Anyone who caters within the Town o f�2 hours nor to hee a e ed even e The�se for�ms can be ob ained at the
Temporary Food Servlce Apphcation P
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis b ensson or r voca on of youreFrozen Dessert Permit unt 1 he
Dep a rtmen t. F a i l u r e t o d o s o w i ll r e s u l t i n t h e s u s p
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE•Permits run annually from January 1 to December 31. TT IS Y�OU�R�B�DE�N1BER lO5 0018 N
THE COMPLETED RENEWAL A�'PLICATION(S)AND REQU�E � � TING NEW
AI,L RENOVATIONS TO ANY F�OD ESTABLISHME p M�D BY��B������ pgjOR
EQ�IVIENT,ETC.),M�ST BE REPORTED TO ANll AP
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �� / O SIGNATURE: _
��v
�� „��-L �%�j� %1°U.S7T��
pRINT NAME&`TITLE: ,
io�zi!os �
. ti r
�'\ The Commonwealth of Massachusetts
Department of Industrial Accid'ents
> �COlf�fl�
600 Washington Street, 7`"'Floor
Boston,Mass. 02111
Wor�ers'Compensation Iffiuraeee AHidavih Baildiag/PlambinglElectricat Contractors
r . . . �--��
name: ,,._-°��1 �, r
address: �`�.� 1J�Q/?���' S'���'"7�T
city �v'i H �A-�LI�'T_"N state: �A zio_ f�7��l� oha�e# l��/ /!D�`�C�75F'.�
work site location(fnll ad�ress)_ `
❑ I am a hom�wner performing all work myself. Project Type: ❑New Cons(ruclion�Remodel
❑ I am a sole proprietor and have no one working in anY capacity• ❑Building Addition
'�I am an employer providing wo;kers'compensation4for my employees worlcing on this job. .
/\ � . r—'
com eame: � : �- � � ' l/� �"
�aa�- /:3'7 /�Ri�� .�7'.��'r
c; #: �� d'�� J
i
iBs ca � � # O �� O oZC�D$�
, < ,::�, ,. .a;a�z;«� .'*�a�+.�.::�,� v.. .
.;. ..,. ... . . . .;�:: � , _�. � „ __ .-- .::,. �, . ., ,< ,-.� . ,.:::,.,, �,..:;. ::a,- ;�,
❑ I am a sole proprietor,geDeral coatractor,or 6omeowaer(circle owe)and have hirad tbe coatractors listed below who have
the following workets'compensation polices:
commtv�ane:
address:
citv: o4o�e#: _
ies co. !�
_ ,. .�.x �..•." .,
so�nwav�ame• ,
address•
citr ukoae#•
. ;: . , ' .,
#
.. ���� .. _ - . . z�; . .. a ��-.> �s�.'t� .e:* r„ _
FaYare be xcQt owerase u reqaf�ed uder Sa�fon 2SA�f MGL 1S2 cu lead b t4e idp�Wa e[e�ioal pmaNia�a�ne�p b t1,3M.N ud/or.
oae yats'Ie�pti�oa�mt aa we8 as e1vY pe'allies in the fore��t a STOr WORK ORDER and a 6ne et f166.M a day agaimt me. 1 aedaalard tiat a
eopy af fhis�a�emeat�ay be for�varded�o tAe OIDce d l,r�of the DIA for coverage verl6aUe■.
I do leereby ctrd'fy xede e pai�es an�pe ' of perjrr thet tbe I�forwrwNon provided aboae is bue and corrrct
s�� �_ �te f�" z-y�- o�
Ptint natne ���B�T �r2�. Uii4-4.�'.e� Phone# — � ��
•fficial ax osly do not�vrite�t�is area te be cempkted 6y clty or�ra o�ial
dty ar te�v¢: permifl�eene A Q❑Ba�id�Department
Beard
❑eheck if imme�a�e mpeme is reqaircd QSdeetmea's O�oe
�liealtk Deparbaeat
, coatact persoa: ph�ee#; �Ot4er
�,�.�a s�c 2om)
�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD UF HEALTH
PERMIT NUMBER: #09-032 FEE: 580.00
rt,is is to cemfy t�ar ll ' M t r Lod e Cond minium Trust
, 1 ���, Y rmou ,�,
IS HEREBY GRANTED A PERMIT
To Operate a PubGc, Semi-Public Swimming or Wading Pool
At Jolly Ca�tain Motor Lodge Condo. Trust- OUTDOOR POOL .
1376 Bndge Street _
South Yarmouth MA
This pemiit is granted in confornuty with Article VI of the Sanitarv Code of The Commonwealth of Massachusetts,and
expires December 31,2009 unless sooner suspended or revoked.�
: December 17,2008 BOARD OF HEALTH: .�¢�t S�Af�� �..lv.� ��Q�lJlttlLtXIL
, C!lfa�c�eO �. 3Ce�ifli:ex `l�ice �'f�avrtrtcut
� ✓�a8.�xt �.53�rocrsn, e�
tl�uz C�xeerz6Eacum, J2..iU.
Bruce . y, . .,
Director of Health
1 ; � ,.. '` �Tv��y ��.F�-P-r.
Jt��Y�'� � TOWN OF YARMOUTH BOARD OF,H�A'�'H �6`� � � � � o � � o
� r
APPLICATION FOR LICENSE/PERMIT, "��`8 ,, �
rt • -�►-s :��� t
�- *Please com lete form and attach all neces ' �'� ` � � C 1 3 2 0 0 7
p sary documents by Decem er , 2 0�7.
Failure to do so will result in the return of your application packet. HEALTH DEPT.
NAME OF ESTABLISHMENT: ' o-� l.r,� u� �v �TTEL. .S��S 6D-oZ.3�f�
LOCATION ADDRESS: 3 T • Sour —
MAILING ADDRESS: P. D. ,�OX ��G � �'„�� ��s4,.L,uo��s� /L�A o�6��
OWN�R NAM�:� ,�fl� �a.of�,'. �C�(„fo,e LO?�66 n�,� .:.,,;,M�n:�'AX ID (FEIN or SSNI� n� �/„Z389�
CORPORATION NAME (IF APPLICABLE): /U A
MANAGER'S NAME: G'E E ` -- TEL. #CS ' 6a- ��
MAILING ADDRESS: o � , vT
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
�
1._�0�,� (,cJ���,�� � �rz� PDo C��, 2.
Poal 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 ofemployee
eertifieations to this form. T#te Ii�ealth Dep�rtfnent will not use past years' reeords. 'You r��st provide new
copies and maintain � file at your place of business.
1. P�bG V �i4�SO�t(� 2. �
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required fo 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�tl not nse past years'records.
You must provide new copies and maintain a file at your establishment.
l. 2.
PE�S9I�1 IN��A�RGE:
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 beiow 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 PER'vIIT� LICENSE REQUIRED FEE PER'�II7# LICENSE REQL'II2ED FEE PER�IIT z
,B&B 550 _CABIN SSO ,_„LMOTEL S50 �6g-Oa-y
�INN S50 _CA:�fP S�0 I S�VI'_��MING POOL S75ea. Q �OS7
_LODGE �50 _TRAILERPARK S100 _W�iIRLPOOL S75ea.
FOOD SERVICE:
LICEI�ISE ItEQUIRED FEE PERMIT# LICENS£REQUII�ED FEE PER��11T tt LICENSE REQL'IR£D FEE PEit:'�11T=
_0-100 SEATS S75 J..CON7INENTAL S30 ��'�cg _NON-PROFI? S?5
>100 SEATS S150 C0:4L'�fON VIC. S50 �L�iOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S75
LICENSE REQUIRED FEE PERMIT* LICENSE REQL�IRED FEE PER�rIII'� LICENSE REQOIRED FEE PER\RIT�
_<50 sq.f3. 545 _>25,000 sq.f3. S200 _VEI`'DIivG-FOOD S20
<25,000 sq.ft. �75 _FROZEN DESSERT S3� _TOBACCO S50
NAME CHANGE: sio AMOUNT DUE _ $ l 55.�o
*****PLEASE TL'R\OVER�\D CO�iPLETE OTHER SIDE OF FORJZ**x**
�
T
•
ADIVIINISTRATION
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 pernuts. FLEASE CHECK
APPROPRIATELY IF PAID: /
YES V NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRAN�IENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocrupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel us�:
Transient occupants must have and be able to demonstrate thax they maintain a principal pla�ce 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 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, shall generally be considered Transient.
* NOTE: Enclosed Motel Census must be completed and returned with this appiication.
POOLS
POOL OPENII�TG:All swimming,wading and whirlpools which have been closed for the season rnust be ins
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( da.ys
pnor to apenu�g.
POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total coliform and standa.rd plate count
by a State certified lab, prior to openin�, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE �
CATERING POLICY:
Anyone who caters within the Town of Yazrnouth must notify the Yarmouth Health DepartmeYrt by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the ;
Health Department. �
�
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit uirtil 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:
Outdoar cooking,preparation,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 RESPONSIBII�ITY TO RETURN `
THE COMPLETED APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER�;2007.
ALL RENOVATIDNS TO ANY FOOD ESTABLIS��VIVIEENT, MOTEL OR POOL (i.e., PAT�TING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF I-�EALTH PRIOR
TO COMMENCEME�TT. REVOVATIONS MAY REQUIRE A SITE PLAN.
�
DATE: ��- /pZ- Q'J SIGNATURE: �'
PRINT NAME&TITLE: � �"
io:��o%
� �
�
�
� ' � The Com�nonwealtti of Massac%usetts
Departwsent of Industnial Accidents
N�aMiw�Iwl9MMi
60o w����,�s� �`"F�o.
Boston,Ma�s. 02111
-_ Worlc�'Com tio�I�swa�a Affidavih B�il bi�g/F.lectrical Cootractors
,., �r,- � .. �,. .. , _ ,« � .,a� ,.. �,�,,{;:
�•..-. „ , �, .i. _ , .a�+�T;�`�;' � �
,. . ..:.
,�•, ,
� r,� c..�. ''�-
�� �Ta//Y L'���a;,v ,/�r 7� L��e �'d,,v�s1,ti�,�.�-� T6.7`
��g� /3 7L /�.P�`�✓d r �'f pP�
�y�+ stI /�RM�vj/1 stat�. �� ziR. �Z�4:4 p�<s��� ���-Z3�/s—
work site locatiao(fiil addressl•
❑ I am a homeowner perfo�ming all wadc myself. Projed Type: ❑New Cansiructioa��Remodel
I am a sole 'dAr and have no o�e w in an Buil ' Addition
�I am an e�ployer proviciing wadceas'o�tion fa my empbyees wo�cing an this job.
� �.,..o...... .T��y ��,l�7�d�`ti� /�'fc7d� ��✓� C.vo%�ti�t/rv.�-r Ti�57�
addras• �� 7�i G ip i`r,�o E' �iP�°P�
�.- �.so . y,�,�oG� �� oz 6 6 y �..��: c�8� 7� � -Z 3 ys-
/ Sv �r' � 7l�/.�06.30!Z 00
❑ I am a sole proprietor,�al eo�tractor,or iiomeewoer(drde ow�)and have hirod the cornractas listed below wbo have
the following workers'�pe�on Polioes:
m".��..�'
.aa.,�•
d,�y oYo�e�:
s�nut�me•
�C'�'
citr. d�o�e�:
PaYve a secve a+era�c.s req�raa oaer seew.2SA.t 11lGL 1S2 w laa ta Ire irp.itb..taid.d pe..Mb.t a e�e.p a s1,sM.M aaN.r
..e y�n'Ispr�t n wd as dH pe�tMia�tYe br�K a STOt WORlC OBDSIt ud a Awe K ti�e.».a.r�.e. i.�sa.a n�c.
npy�[fib�tal�eat��be t�rwarded M Ne O�ce�[Lvwtlpli�n�[t�e DU 1Yr a�vera=e wrfaatlw
J ro benby c uwder NYe pwi�a� olPM+�'!'NY�t dYs iwjonMs�ow pro►�i�id ebore ls tnrs ew�t oorn�c�
Sigtoatu�+e i �o�� �cZ'O �
Prun name �C c5 r�N f !�✓� �d/P�1 L"� Phone# �7��/ Z���' I 9n8
ofaci�l aae aaly de Nt wAte`thb area b 6e c�Plefed by eNy�r M�a�ehl
city or t�wa: p�eede i! f lB�Depart�eat
❑eYect Kismedfale �Beard
rapse�e B reqoired �'s Omee
Q�ak�u�par�est
cestad penoo: ph�e�; QpILQ
t���)
r _ ' ���68 �t5'SaO T,,.�,�,
r e �`�AR.� TOWN OF YARMOUTH BOARD OF TH ���- �u � "�' (_ [�
' � - - -,o ,� �� '��-, _, �J �i
G �� ��
'�� A P P L i C A T I O N F O R L I C E N S E E � 0 3
�_. -,� � � ;"�� ���� 1 � ����
•«..�...; <<-,� .:�
* Please complete form and attach alt nec ��� Y Decemb 31 200?
Failure to do so will result in the ret` of ` application pack t. ��F���-_...� ��� �����
I�IAME OF ESTABLISHMENT:Vo�/u C�AAiA�� ,,�����,�,c.�,o r�/ TEL. #�.�����3
I DRE ST �'a
: > � f�" ' ei�
N aG
MANAGER'S NAME: C��.S��.�l X--���/ti` �vP S.�/o,,/i TEL. #. 1`_l�� ��� /�y�
M�ILING ADDRESS: ,/ �;s-,.00n; R���c�q.1��Lf 0�7�7
' POOL CERTIFICATIONS:
The pool s�pervisor must be cert_ified as a Pool Operator, as required by State law. Please list the des�gnated
i Paol Op�rat�r(�)arid attach a copy of the certiticatian-to tt-,ts furnr.
.� - &
i. C I ��� �r �,� �� z.
�,r�•�.��/ /J, ���, ��-.
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
emp,loyee certifications to this form. The Health Department will not use past years' records. You must
provide�ew copies and maintain a file at your piace of business.
1. '� � 2. �
3. 4.
s�� G��.�•�Q.�� 11���
i
; 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 copies of certification to this application. The Heatth Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
� _ _ ..��_ .�.__.�.. w: _
' �'EI'ca�i�iiv �n�I��-_ _ __ _ - _ __ _ —- __ __- — _ — - -
�
Each food�stablishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 2.
�-IEIMLICH 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-chokin� 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 ptace of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
� LICENSE REQUIRED FEE PERMIT# I,ICENSE RI:QUIRED PGi; PERMIT k LICENSE REQUIRED FEE PERMIT�
`isBi.B $50 _C�IRIIV �50 �MOTEL $50 �D���
_INN $50 _CAMP $50 �SWIMMING POOL$?Sea.�n3-O�f�j
LODGE $50 TRAfLER PARK S50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 �CONTINENTAL $30 �0 Ib0 _NON-PROFIT ^�25
_>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75
�TA1L SERVICE• •
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.n. $200 VENDING-FOOB $20 ~
_<25,000 sq.ft. $75 _FR07.,GN DESSF.RT $35 7'OBACCO $25
NAMECHANGE: $io AMOUNT DUE _ $ /55.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
S
3
g + _,
ADMINISTRATION 4 �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
2
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�_ N4
--------_ _- -
--- --� _
NOTICE:Permits run annually from January l to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEF,(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT T�IE 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, N�W
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PR�IOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
- - - _ __ POOLS_ _ _ .
POOL OPE1vING: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 colifortn 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
('nN4iTMFR ADVISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
C'ATERNG 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.
FROtiEN DESSERTS• _ _____ __ ___ ----_---___ ,
F�roze�esserts must be tested-on a manthly basis by a State certified lab. Test results must t�e sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ,
� �
DA :�,� .,.c� � - 4 a� SIGNAT •
PRINT NAME& TITLE: '�0�i Q�-k. � d � ��l� �'�"���e-
10/18/02
r
• „ � �
� ' The Coinmonwealth of Massachusetts
� � Department ojlndustrial,�ccidents
� o Olflce o/I�es�lostJyis
' 600 Washington Street
' •` Bnston.Mass. 02111
V� .. .. � . . . . .
' ~ �• w'orkers' Compensation Insurance Affidavit
Anoticant intormallon• p��«pg -�.
o�m� /D��y �f,I/p/�?�`Ai' /701?.P �c✓G �t/N�.�lii(//O,Gj �OL����id�/
Islcation: I.� �iQi`CVa� ��
sit� •�. /r�/p��U� �� OZ 6�� phone� (.���J �7�'" ��6
� t am a homecwner pertormmg all w�ork myself.
� I am a sole proprieror��� ha�e no one ��orkin_ in am•capaciry
�am an employer ro�i�ino µ�orkecs'com ensation fnr mv em loyees w•orking on this job.
_ R._— _--- - P . P
s4m na n v n a m e: �./0�/� �/�/t9�`/'/ /'"/l? � LidG e l Difi�i���f/W/!?/1 s�5`���lJ�/[l//sO.P!
�ddress• �� �/!G� ///P/NO' �� ,
sitv• �o_ ��7�P�9ov7�,� /I/�- 02/6� ho� • ..�'O�'� `�'�cs' 1�Z,6
is�ur�nce co /�PB��sil�/d�LJ�6:l��.�'.v�'v/P � a`� �lMe.�i`Cc7 A9�lSy# l�'e z ocr���r9
� I am a sole proprietor. :enerai contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the follu�.in_ ��orker�� :ompensation polices:
sQmnanv namr
address
titv• Rhone t!•
insur�nce co. Felis••#
�m�anv namr
-�--- �— --
__ _-
______. _ --__ - ----
address• — - _ ____�_
�'� ohoee#•
insurance co. �g�.,�
a
Faiiure to secure coverage as required under Seenoo 25A of MG4 1S2 ea�lad to tbe ieporitioa oterioi�i peadtles o(a O�e op to 51.500.00 a�d/or
oae yean'imprisonment��w•ell aa civil pen�lda io the form of a STOP WORK ORDER aad a Aae of 5100.00 a day apio�t ma I a�dersta�d t6at a
copy of thy statement may be fonvfrded to the Otiiee of Inve�tig�tion�of tbe DIA for eovenae veri8atia.
I do hrreby cerrif}•un r the parns and penalti�s perjury that tht injorn�otion provided obovt is true and eorred
Signamre ' , „�/ �/ � � — z — �
� at� f I �
Print name fi�O�C-�Q�` � ��/{��QC—'7f PhoneM ���7J �����'�
�
.. olTicial use only do not write in this area to be completed by ciry or town o1lltial
ciry or town: YARMO�T$ _ permitAieenu N nBuildiog Department
pLiceasiog Board
�check if immediate response i�required 261 OSdettmen's ORtt
(�HealtA Departmeot
contact person: pAoneN;_ �508� 398�?231 ext. nOther
.. .�. <a,,:
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-025 FEE: $50.00
This is to certity wat Jolly Captain Motor Lodge Condo Assn. d/b/a Jolly Cantain Condo Assn.
' 1376 Bridge Street, 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 ofthe Laws ofthe Commonwealth ofMassachusetts relating
thereto,and upon such terms and conditions,and to the rules and regula6ons in regazd to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2003 unless sooner suspended or revoked.
January 17,2003 BOARD OF HEALTH: (�� i���t. �;�aua�
__-._ f�'u�D. G�imialoec. �11.?�:, tiu;e •
,�eder�t�. �zo�C, (,�l.ack
�a�ric��ar.xott
`r�dut Slr.a�. �.?2.
ruce G.M y, .5.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS.
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-049 FEE: $75.00
This is to certify that Jolly Ca tain Motor Lodge Condo Assn. d/b/a Jolly Captain Condo Assn.
137 Bridge Street, South Yarmouth.MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Jollv Captain Condo Association - OUTDOOR POOL
1376 Bnd�e Street
South Yarmouth. MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cp'ves December 31.2003 unless sooner suspended or revoked.
J�n�,�y i�.2003 soaRn oF�a�r.�: ��� x�, �4a�
��a.n�D. C�,arda.�, 71L D., `l/icc
,�o�it�. �oa�u�, �k
�a�cie��cDea�xott
s`�eleu Slrak. ,�'�l.
ruce G.M hy,MP . .,CH
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-100 FEE:_$30.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section S ofthe General Laws,a permit is hereby granted to:
Jolly Captain Motor Lodge Condo Association, 1376 Bridge Street, South Yarmouth,MA
Whose place of business is: Jolly Captain Condo Association
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2003 soAttn oF��.1�: ekanfea� �eflu�en, ekauuua.�
�a�ar�, b`'naaa•c�'o�calowc�9.. 2/Ecc '
�
�a�ue�'nle?��
� S .�1.
January 17.2003 � +
ruce G.M hy,MP .,CHO
Director of Hea1th
T
�
� ��i�' Tn�a�1 CAPY��IJ
� �oF�R o TOWN OF YARMOUTH B A� :�ILALTH �� �� 5 �� j y� , ;L,;...' i
a - -,� � APPLICATION FOR Ll�t��'PE � `���29�4 ��� � � 2004 �
;r �': .. � ..,��;�
r; ; �,' ,
•.. ..�'
* Please complete form and attach all necess'� documents by Decem e�A��.��PT.
Failure to do so will result in the return of your application pa . -
f
NAME OF ESTABLISHM��1T �Tv ll� C a�t r��n► GaHAv A$SoG iat�o a TEL #So�- 398-�s3
LOCATION ADDRESS i 3'76 "F�r i���. �_�Ar �e 4��. t"�r�• � a G 6� �
MAILING ADDRESS• I l�t�i s ci 1,1a�. 'Rd- r'1��► w,��, I�'1p - oaoS3 e/a �=N ' � ��� �� ;
OWNER/CORPORATION NA._ME J'o«Y C��'P{ pi a 'Motor �-.oelae C o Nlo A SsBG tqt toe�c
MANAGER'SNAME �Zo�e.P�n ��N�► 'fru►s�a 'Q����d�w�t- TEL #a��g'�1'�g /�a�
MAILING ADDRESS � �,i n�e t►� `� �e�►� d A�e h'�-+�- � �h ��
POOL CERTIFICATIONS: ;
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ;
_Pes�L��erater{s}and���.c�i a�c+;�y nf x�-s�:�-e�if s:a�.�'a:ta tl�is f��rc�. _ ;
1. ��1�,.t�1 �C S �e+fZ 2•
S P 1.c►3� �o o ls �C'Nc.-
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. �A�R t e W1 Q d�i 2. �eg t�._ ` ti A r So �1S
3. 4'
FOOD PROTECTION MA�IAG�RS - 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'
- _ __
-- _---_ _ _—.
- - _.
----�`�N-TI�`v CHA��:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 2'
HFII��LICH 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 empioyees trained in anti-chok�ng 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' '
RF_STAUR�INT SEATING: TOTAL#
�
QFFICE USE ONL� '�
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# y
B&� $50 _CABIN $50 _L_.MOTEL $50 �t'u�'O 3
� $50 _CAMP $50 �SWIMMING POOL$75ea. O�'���
LODGE $50 �TRAiLER PARK S50 _WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUII�ED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEAT'$ S75 I CONTINENTAL S30 O�{� O NON-PROEIT S25
>100 SEATS $150 _COMMON VIC"T. S50 _WHOLESALE $75
RFTAIL SERVICE•
LICENSE REQUIRED FEE PERMIT# LlCENSE REQUIRED FEE PERMIT# LICENSE REQl11RED FEE PGRMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $2Q0 _VENDiNG-FOOD $20
_<25>000 sq.ft. S75 _FRO'1..EN Df:SS1:R'I' S35 _T�E3ACC0 S25
NAMECHANGE: $to AMOUNT DUE _ $ 155 -06
**"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***""
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
Campensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
.AFFIDAVIT MUST BE COMP'LETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
� � /�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �V
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 annuall from Jan
y uary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEAL,TH DEpqRTMENT 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 FRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�DDITION RFGULATIOIy�
POOLS
POOL OPEI�IING: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
CONC�IIM.F.R ADVI�ORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
�
CA'�'EIZiNC�POI,ICY•
�; Anyone who caters within the Town of Yarmoulh must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
. _
Frozen desserts 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.
9UTSIDE C F'FS•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR�QO iN •
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishrnent is prohibited.
DATE. , ! . _0 3 SIGNATU ; � �, _
� ,
�'RINT NAME& TITLE: c'����'k �.�. D Q��I `1('h u�t ee,
10/22/03
' L �
� The Co�nmonwealth oJ'Massachusetts
� � Department of Industrial,-1 ccidenrs
� ; 011lceo/%s�IDs�iis
600 Washington Street
' ` Bosron.Mass. 02111
�'" ��y V4'orkers' Compe�sation Insurance Affidavit
Agnlicant information: PlessePRifp7"Ti�."i�a
n�m`�� -�6�-�L/v �i7/)�Ai.f/ f'"/ /d/P L.rJ�ON /A�fil�a f9i�!/fOL�I �� f/�/ iOD
L�cati�n; �.3 7�i .CS/Pi`do� �,
�it� J� /�RMUU�i / �� % Z.lo6� Fhoneuu/�,� �?�—�7?�
� I am a homecwner pert�rmin,all work myself.
� I am a sole proprieror �r.� h��e no one ��ori�in� in am•capacit��
�am an emplo�er,pro�idin� w�orkers' compensation for my employ�ees w•orkine on thisjob. ____
- --- - - .
`_ ___
_ _. __-— --- -
comnan?" name•�f���5i �f�/C��ii!/ O�� L�d�`i� L�.�ido/y�.�//O.� �I��°/d�iO•G
8(�(��C55: /� �14' Y �1 �`I ��`' Jj:
�it��: .�6 I�PE'l�U Th J /-!� l'J 2�o�c�- nhonetl• ��t�� 7 �!�' / ��
insurance co. �� �vl����l��!l�dPa'.�iil�"N L O_ olicy# �' �� ��`�s�.�
� I am�a sole proprietor. general contractor, or homeowner(circle one/ and ha�•e hired t�te contractors listed below �tiho ha�e
the follu��in_ ��orkzr �ompensation polices:
companv name•
address•
city: nhone q•
insurancc co. �olic�#
s9mpany namr
address:
tiri: nhoee 11•
insurance co. noBey 1f
•
Failu�e to seeure covera;e as required under Secnoo ZSA of MGL IS2 n�lad to tbe iepaitioe of erioi�ti pesdtla of a O�e ap to S1�00.00 a�d/or
one yean'imprisonment as w�ell a�eivil penalde�io the form of a STOP WORK ORDER aad a fise of SIOOAO a dar a��io�t me. i r�dersta�d tbat�
copy of th'n statement mav be fonwrded to the OtTiee of Inveatig�tion�of tAe DU tor eoven�t veri8eatio�.
/do hrreby certij}•under r�e poins and pertalti s of perjury that tht injornration provided abovt is due and conect
Signature �c.�-i- /2- �/ �D�
Print name �[ OC G��J � �, ��/P/pL=Tf Phone Il 1���� -�� 2 —�'f7c�
.. olTicia! use onl� do not..rite in this area to be compieted by citv or town oAleial
city or town: YA��IITQ _ permilAieense N nBuilding Dcpartment
�Liceasiog Boa�d
�eheek if immediate response is required 261 [�Seleetmen'�ORice
pHealte Departmeot
contact person: phone N;_ �508� 398-�2231 ezt. nOther
,.. .< ��4; �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #04-043 FEE: $50.00
'rhis is to certify that Jo�Cantain Motor Lodge Condo Assn. d/b/a Jolly Captain Condo Assn.
1376 Bridge Street, South Yannouth. 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 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 31,2004 unless sooner suspended or revoked.
February 10,2004 BOARD OF HEALTH: Bs�tstt�. �j� /y�. '
p����t, v�ef�.�
��R.N.�
ruce G. Murphy, ,RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMUUTH
BOARD OF HEALTH
PERMIT NLTIVIBER: #04-070 FEE: $75.00
'rhis is to certify wat Jolly Captain Motor Lodge Condo Assn. d/b/a Jolly Ca�tain Condo Assn.
1376 Brid�e Stree, South Yarmouth, MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, 5emi-Public Swimming or Wading Pool
At Jollv Cantain Condo Association - OUTDOOR POOL
137b Bnd�e Street
South Yarmouth, MA
This pe�it isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2004 unless sooner suspended or revoked.
February 10,2004 BOARD OF HEALTH: BeKy��tsit.�. (�dlc�at, /N�. '
p���� v� e��
R�t� B�, e�,�
� S!� R.N.
Directar o He�alth� p �'
. � `
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #04-140 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:
Jolly Captain Motor Lodge Condo Association, 1376 Bridge Street, South Yarmouth, MA
� Whose place of business is: Jolly Ca�tain Condo Association
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2004 BOARD oF HEAI,TH: Be�r�c .`n. �a�us,/6f.`n. '
��a����tt, v� e��
R�t� ��, e�,�
� �1�, R.N.
February 10,2004
Bruce G.Murphy ,R.S.,CHO
Director of Heal
o�.°�q� ��,�fz '
�� �: ,,.�'o TC) � N F YARM � UTH
�(� '� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451
• MATTACMEES ��7 �
� 4��A�OR�If0�6�'� (O Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472
��
B O A R � O F H E A I. T H
� � !r" '� � �-'' - ,'�
� - i
To: A112005 Yarmouth Board of Health LicenselPermit Holders � MAY 2 5 2005 '
� : i
From: Yarmouth Health Department �-- ���='�_ .._. �-`�� �
Re: Tax Identification Numbers
Date: March 22, 2005
The Massachusetts Department of Revenue is now requiring that the Health Department furnish
to them detailed information regarding all permits and licenses that we issue. One of the required
details is to provide a t� identification number, whether it be an establishment's Federal
Employer ldentification Number (FE1N) or, in the case of an individual's license, a Social
Security Number (SSN). This information will be used by the Health Department purely for
administrative purposes only.
Would you please fill out the fields below and return this letter to:
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
Thank you for your anticipated compliance. If you have any questions regarding this matter,
please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The
telephone number is(508) 398-2231, e�rt. 241.
,%o/l �'a�'fa,ii//�'lofaiP Lc�f�
Establishment: C�.c%v ,�ss.rr� F°EIN o�,�'� d y -3 /Z, 3 �� �
i 3 7C /�Q,�/ e Sf (/Pf Z�)
Location Address: Se Ya�e�+vyi-�. �`1� o z�6�
Signature:
Print: ���'G� �/, ��✓P/�� Title: �P�S�/t��✓�
,,:;':�
�� Pri�.ed on
cied
� �r
S 1
' •� :��R� TOWN OF YARMOUTH BOARD OF $��-�'H �"���r��s !�
2 ,�
APPLICATION FOR LICEN�E '-2QQ5
° ' y � .IAN 0 7 2005
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* Please complete form and attach a11 necessazy do t � �ecemb ��O�H D E PT.
F a il u r e t o d o s o w i ll r e s u l t i n t h e r e t u�n o f y o u r a p p li c a t i o n p a c k .
NAME OF ESTABLISHMENT: .�o/t, itv ,(yI� � d nc�,9�soc TEL. #����� ����
LOCATION ADDRESS:/3�� ���Sf �f�� ��/.¢,f'/�od�� �j� G�G G y�
MATT"ING ADDRESS: �¢�.�_
OWNER/CORPORATION NAME:
MANAGER'S NEiME: _:►oS��t /J�cc,(/`i� TEL. # 77y�S�F�!�2_3
MAILING ADDRESS:,J13/�T�rt.t 1Sr. /�/ovedR/t /�%g o��S�7
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.
i.����-s,� �ov/s. ...�'�v� - Dl'/�A�s, rn� 2, _
Pool operators must list a minimum of two emplo ees currently certified in ba,sic water safety, standard First Aid
and Commuruty Cardiopulmonary Resuscitation (yCPR). 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. ��f3��Cr .��i� % 2. ���'l'q Y �iiy�'Sd/7.S
3. ��C I�i► �//i e�G �"r•�j 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 atta.ch copies of certification to this application. The Healt6 Department will not use past years'records.
You must provide new copies and maintain a fde at your establishment.
1. 2.
��RSO�Il�I E�if1R�E: __ - _ _ _ _ _
Each food establishment must have at least one Person In Chaxge(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 employe� e trained in the Heimlich
Maneuver on the premises at a11 times. Please list your e�ployees 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.
RESTAURt�NT SEATING: TOTAL#
OFFICE USE ONLY �
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT#
B&B $50 CABIN $50 I MOTEL �50 �0�-OZ9
_INN $50 _ _CAMP $50 I SWIlvIlVIIlVGPOOL$75ea. �06�'�'
LODGE $50 TRAILER PARK $50 WF�RLPOfJL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 / CONTINENTAL $30 �t'Q �(3� NON-PROFIT $25
>100 SEATS $1S0 COMMON VICT. $50 WHOLBSALE $75
RETAIL SERVICE:
�'�I6$�TSE REQUIRED FEE PERMIT# I,ICENSE REQUIItED FEE PERMtP# LICENSE REQtTIl2F.D FEE PERMIT#
'_<50 sq.ft. $45 _>25,000 sq.8. $200 �VENDING-FOOD $20
_Q5,000 sq.ft. $75 FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: �10 AMOUNT DUE _ $ /SS^�OO
'•'�'�•PLEASE TURN OVER A1VD COMPLETE OTHER SIDE OF FORM�RRRA
i
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ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or 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 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 RESFONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONALESTABLISHMENTSARETOCONTACTTI�HEALTHDEPARTMENTFORINSPECTION7-10 '
DAYS PRIOR TO OPENING FOR THE SEAS4N. ;
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�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 Depa.rtment prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd 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 Yannouth 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.
_ �R+E}Z�i�1-B�SS�R�S: ____ _ _ _ _ _ __ -- ------ ____
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
4UTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: SIGNATURE:
PR1NT NAME& TITLE:
10/22/04
V __ _�' The Commonwealth of Massachusetts
��� -� Departme�rt of Industrial Accidents
=- = N�ieiNiw�
� _- -= 60t1 Washingto�e Stree� 7`�`Floor
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= o Bos�on,Mass. 02111
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Workers'Com�essatioa I�s�aee Affidavit:Bd ' b�/Eleedrical Cootraet+�s
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name: '�[B��v �/.Z,:r/ /7aT�/�' Lodl� L�.�/�l'd f1iA/iu.r9 f7�sS'vl��a/7`oG
aaa�s: _/.3 76 ip�` �� .S7`. �v7'�� 2t�
��y sa ,�.Q..�raaJ� �: /�� a�_ d z 6 6 5� r,�#1s08� `f?a'- %7Z�
worlc site locati�(fnll addressl:
❑ I am a homeowaer perfom�ing all wozk myseif. Project Type: ❑New Ca�structi��Rsrnodel
I am a sole 'etor and have no a�e w in an Buil ' Addition
_
[�am an eanployer pmoviding wackeas'compensatioa f�my employees wo�cing�this job.
, �%a��r �x.�/�,`.v /7oT�iP G��� Q /�.d n/v�/�;t�iv.�i�so�.a .a�
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❑ I am a sole praprietor,ge�eral ce�tractor,or�omea�vaer(esrcti oiu)and have hired the cartractors listed below who have
the following workets'compensation polices:
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addre�
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Failm�c a secere�everase a�reqai�ed.�er Secl�ZS�A.f MGL iS2 na Ind a tl�e irpaki�.f ai.iai pe�aMia.f a 8�e�p a ti,SM.N aadhr
eme yeus'in�riwnmmt as wU as dv�pe�ltia ia the br�of a 3T0!WORK ORDER asd a�ne a[S1M.OS a day a�t�e.I udezsbod t6at a
capy ef t6is etalea�e�my 6e forwarded 1a the Omce dlsva�ef fMe DIA tat eev�erase veHAeatly.
I ro ber�eby ce n r tJYe pein�and nelties of per,�irry tlYot the h�forsro�eloe provided abov�e is Ir�s mid on�
Si¢natan�'/I � , �ti�iv � �i V p� ��— � 2 —O ''�
Prim name_�f��l�i T li1/; /�f}��t C� Phone# ,���'/J Z 3S—/94�
e�cial ase only de aot wrke is t6is area ta 6e eemPkfed 6Y ei�'�lwre sfficid
city ar ts�vn: per�t/�ieeese# �lB�Depubment
❑chect if i�1e rdpeme is rtqaQed OSd� O�ee
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centaet Pcrson: P�e#; QOt6a'
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-029 FEE: $50.00
This is to Cemfy that Jolly Captain Motor Lodge Condo Assn.
1376 Bridge Street_ 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 pmvisions of the Laws of the Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Motels so licensed as ado�ted
by the Board of Health,and e�cpires December 31,2�5 unless sooner suspended or revoked.
February 3,2005 BOARD OF HEALTH: Be�t�tut�. �o?�ut,J��. '
p����, v����
Ro6vrt`�. B�, G''le�
��, R.N.
�����, R./N
ruce G. urphy, S.,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�NT
PERMIT NUMBER: #OS-135 FEE: $30.00
In accordance with regulations promulgated under suthority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a peimit is hereby granted to:
Jolly Captain Motor Lodge Condo Association, 1376 Brid�e Street, South Yarmouth, MA
Whose place of business is: Jollv Captain Motor Lodge Condo Association
Type of business: Continental Breal�ast
To operate a food establis}unent in: Town of Yannouth
Permit expires: December 31, 2005 BOARD OF HEALTH: Bes�r�sirc$. �'°�,o�/y1.�. '
����� v�e�.�-�
���R.%V.�
�!��n��, R.N.
February 3,2005
. ruce G.Murphy, S.,CHO
Director of Health
v . �
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-052 FEE: $75.00
This is to Certify that Jollv Captain Motor Lodge Condo Assn.
' __ 1376 Bridge S�reet, SoLth Ya_rn,oLth MA
;
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
' At Jolly Cantain Motor Lodge Condo Assn -OUTDOOR POOL
i 1376 Bndge Street
South Yarmouth, MA
This pemut 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.
:; February 3_2005 BOARD OF HEALTH: Be�list�. �o�art,/��. '
� ������, v�e��
��t�8� et�
' �� s!� R.N.
�1�!�' , R.1V.
�
Bruce .Murphy, .,
Dire�tor of Health
�
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„
1
' THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #08-029 FEE: $SQ.00
This is to Certify that Jollv Cantain Motor Lod�e Condominium Trust
1376 Bridge Street 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 ofthe Laws ofthe Commonwealth ofMassachuseUs relating
thereto,and upon such terms and condirions,and to the rules and regulations in regard to said Motels so lieensed as adopted
by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked.
December 19.2007 BOARD OF HEALTH: ��¢�¢tt S�q,�� ✓�,,,1�(.� (��
�� .`�.��iP��I�RJ,IG� ��ICC ���[/Itlllt
� S..�i��[QUJ./L��(:C�Jl�t
�
Bruce G.Murphy,MPH,R.S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #08-057 FEE: $75.00
This is to Certify that Joll Ca tain Motor Lod e Condominium Trust
1 76 Bnd P �trQP , Y rmn»t , j`�s
IS HEREBY GRANTED A PERMIT
To Operate a PubGc, Semi-Pabtic Swimming or Wading Pool
At Jollv Cantain Motor Lod�e Condo Trust OUTDOOR POOL
1376 Bnd�e Street
South Yarmouth MA
This permit isgranted in eonformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2008 unless sooner suspended or revoked.
December 19.2007 BOARD OF HEALTH: .`��¢ft$/�Y�� ✓�,J�(,, ��XlttQiL
�� .�. �.¢�l�G ��CC��LIYR
J`f�ad�e�rt�.�B�ca�cu�, C!�
Urr�rc C��ceerr�aum, J2..N.
Bruce .Miup y,MPH,R. .,
Director of Health
�
� ` TOWN OF YARMpUTH
� BOARD OF�ALTH
I PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #08-078 FEE: $30.00
In accordance with re�ations promulgated under authority of Chapter 94,Secrion 305A and Chapter
ll 1,Section 5 of the neral Laws,a permit is hereby granted to:
Jolly Captain Motor Lodge Condominium Trust, 1376 Bridge Street, South Yarmouth, MA
Wliose place of business is: Jollv Cavtain Motor Lodge Candominium Trust
Type of business: Continental Breakfast
To operate a food establishment in: Town of Y rmouth
Perm�it expires: December 3I, 2008 BOARD oF HEALTH: „�f,¢�e,a$f�� J�,,.I�I.� (!�h��
��r.�E�L (,'�tce C'�avrntQft
Clnxi C�cee�r�uum,�` '..N.
December 19_2007
Bruce G.Murphy,MPH,R.S.,CHO
Director of Health
�
, F_Ya �I�� �_ � r� 3
�° .._R�.o TOWN OF YARMOUTH BOARD O�II�4 .A,L`'�'$ '�� , i
o� -�y APPLICATION FOR LICENSE/PERMI'�'-�7}. � � �: ,�' NOV 2 7 2006
� r . ,.�s ��t;� �� �
�
* Please com lete form and attach all necess documents b December 1 ' �'�==��
P �'Y Y ��T'-. _ti;._; 1�.
Failure to do so will result in the feturn of your application packet.
NAl1�OF ESTABLIS�IlVIENT:��„��c� �,�st�,�r��To ��n6� ,�m,z.�:�r�.r1 j TEL. .So� S"
LOCATION ADDRESS: �
MAII,ING ADDRES :
OWNER NAME: a iLa � `f ID IN r - U — � '`J
CORPORATION N (IF APPLICABLE):
MANAGER'S NAME: TEL. # Sb�' 60_d,�3��
MAILING ADDRESS: 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.
l. �� � ���� ��h.► �o� -�'t�• 2.
Pool operators must list a minimum aftwo employees cunently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these emplayees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must prnvide new
copies and maintain a fde at your place of business.
1. �EGI v ��liPso.t�S 2. \�os�A� �iPB ct
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
Pratection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.OU0.
Please attach copies of certification to this application. The Health Department will not use past years' rccords.
You must provide new copies and maintain a file at your establishmen�
L 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlVILICH CERT`IFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at 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 fde at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OF'FICE U5E ONLY
LODGING:
LICENSE REQtJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
_B&B �50 _CABIN �50 I MOTEL $50 07�007
_INN $50 CAMP $50 �SWIlVIlvII�tG POOL$75ea. Q,� ?-O l b
_LODGE $50 TRAII,ERPARK $100 WHIRLPOOL $75ea.
FOOD SEItYI�E: _ __ _
LICENSfi REQUIRED FEE PERNIlT# LICENSE REQUIRED FEE PERMfP# LICENSE REQiItRED FEE PERMIT#
0-100 SEATS $75 �CONTINENTAL $30 �O'�-6 ( NON-PROFIT $25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE: ____12ESID.KITCH�N $75
LICENSE REQUIRED FEE PERMTP# LICENS�REQUIRED FEE PERMI'P# LICENSE REQUIl2ED FEE PERMTT#
,<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.ft. $75 +,FROZEN DESSERT $35 TOBACCO $50
NAME CHANGE: $10 AMOITNT DUE _ $_/�S,OO
••'"'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'••""
�� .
ADMIl�TISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requireti to hald issuance or renewal i
af any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensatian 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
APPROPRIATEL�IF PAID:
YES � NO
_ . -- --
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an '
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wadin�and whirlpools which have been closed for the season must be ins ect�l
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days
pnor to opening.
POQL 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 '
- elQsi�g. _____ __
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 obtauied at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a montiily 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 frorn the Board ofHealth.
OUTDOUR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN
TI-�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATI4NS TO ANY FOOD ESTABLIS�-IlViENT, MOTEL OR POOL (i.e., PAINTING, NEW :
EQUIl'MENT,ETC.), MUST BE REPORTED TQ AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�..
DATE: /�6��g�� a.7.z,00� SIGNATURE: ',
�—T—
PRINT NAME&TITLE: - L3G�4i ��i2us
1O/17/06
1
s
, � The Commonwealtb o Massachusetxs
f
Departineent of Industrial Accidents
N�riNiw�
606 R'ashington Stree� 7t"'Floor
Boston,Mas� 02111
---— - worlce.rs'Com hoa I�m�awee A�davi�Bn'1 • bio�fElectricat co'haeMrs
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name: y d��� ����i.I/ ✓7cTJ/4 ���o� [�d.t/d0�9��f✓i!!�'I /if'!'S/ _
�s_ /3 7� .e.`�d c� Sf��P7`
��e� �S'�. y.�r�rcv�i ��: /�� g»: Qz��4 ,�#<�o�) ��0�35ES—
worlc site loc�ti�(rutl addressl_
❑ I am a Iwmeowner performing all wo�lc myself. Project Type: ❑New C�structio��Remodei
I am a sole 'etar and have no�w in an ca ❑Buil ' Addition
�I am an employer pmviding workas'compea�ati�fa�r my employces working a�n this job.
c�nvv��/d/(Y C-c�'e��d�`N �'"(1i�/� Ld�/!r�' L2it/da�1/�f/lU,vl T!!Sl
_ ���_��'��, .�'��7�
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./ sv � 0/.���.��f z Oo�
❑ I am a sole proprietor,g�ersl costractor,or gomeo�r�er(earde owe)and have hinad the contractors listed below who have
the following worke�s'compe�ation polices:
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Faparc a�ee�e a�ma�e n rey�irea.�der seatl.a 2SA.tMG1.152 ea.lna a uK�M..tcriwt�l pe..we.t:�e�a s1,sM.a,adl.r
o,e�us't�prl�amtan wes as eHi�adtla h tre E�r�of a S1'A!WORIC OBDEH a�d a 11re dS1�N a dry a6a6ut�e. 1�dasmd tY�a
oapq si RYb afa�my be ferwarded b Ne O�ce oll�we�tl�Wam�tbe DIA ter c�vera�e ve�atlsa.
I do 6eneby ce xrder dbe paPws owd pawhiea ofPerJ+r�'tNat dre nrforpre�ioe provided obov�e ia trxe and onnrct
�s� � � ,�f- z 7-�J6
Pr;rn„a�_�m b P�t]'G Gf/, a�p/1't'�` PhOne# �`78// 23v� /9D8
efficiN ase salq ao aet�rrite lo this arra a be o�pleted 6Y dly�/nvn effidai
�'°r t°�v°' Perd�c�se# f-lRaiMi�Depudrent
. Ql.ioee�Bsard
❑c4eek K�1e*�sse�rdl� �Sdecfo�'s O�ee
(��o� pkNe i�'
�Q �t
THE COMMONWEALTH QF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-007 FEE: $50.00
a
�his is to certify that Jolly Captain Motor Lodge Condominium Trust
13�6 Bridg;e Street South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
T}us License is issued in confomuty with the suthority 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 conditions,and to the rules and regulations in regard to said Motels so licensed as adapted
by the Board of Healttl,and expires December 31,2007 unless sooner suspended or revoked.
January 23_20d'� BOARD OF HEALTH: Q �. oRc�o�t,/��., .
��t�, �t�v., v�e��
R�t�. B�, et�
a��r��
� �v.,�r��, a.n�.
_ _ ruce G.Murphy, ,R S.,CHO.
Director of Health
_ _ _ __ __
_ _ _
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: #07-031 FEE: 30.00
In accordance with regu1ations promulgated under authoriry of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a perrrut is hereby granted to:
Jolly Captain Motor Lodge Condominium Trust, 1376 Bridge Street, South Yarmouth, MA
Whose place of business is: Jollv C�tain Motor Lod�e Condominium Trust
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2007 BOARD oF HEALTx: B `n. ,/l�.?S., '
d�e .�lu�i, �u�G'lravu,ic.i
Rad�t 4. B�, G'!�k
� A��1��`
����„�, R.�v.
January 23.2W7
ruce G. urphy H,RS.,CHO
Director of Heal
f
TH� COMMONWEALTH OF MASSACHUSETTS
TOWN QF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-016 FEE: $75.00
�
This is to certify that Jolly Captain Motor Lod,ge Condominium Trust
1376 Bridge �tree,.South Yarm�uth,MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Pubtic Swimming or Wading Pool
�
� At Jolly Ca.�tain Motor Lodge Condo. Trust-OUTDOOR PO4L
1376 Bndge Street
South Yarmouth,NiA
This permit isgranted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�ires December 31.2007 unless sooner suspended or revoked.
January 23.2007 Boaxn oF�.�: Be .��5. ¢�,Arl.�., .
����`s�, R.�, v�e��
R�t� B� Gl�
� P�A�1��
�4� , R ,
ruce G. urp , H,R. •,
Director of He
j
� . � �TO tGY CiFP�I�
of;;�R.� TOWN OF YARMOUTH BOARD OF HEAL q
a �� ��t2$ 5.�%
� ;'� APPLICATION FOR LICEN��I7��'�QOG ��
�;- !x '- .
� � _F. s�
. . .� -
* Please complete form and attach all necessai�y d�o�cuments by Deceml�er 3l,2005.
Failure to do so will result in the retum of your application p ket.
NAME OF EST.ABLIS��VIEENT: O/I ,L � � - -
LOCATION ADDRESS: �, �
MAII,ING ADDRESS: 3 �`id -
OWNER NAME: ' �s T ID r S : ' 3�
CORPORATION NAME IF APPLIC E):
MANAGER'S NAME: GP� TEL. #V Odr 71oC1 �3y,S'
MAILING ADDRESS_P — !�
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 ta this forEn.
i. S�/�3.s�i �v/s . ;��'/c.�,vs, /�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 N 2. -��..�.5� ���
3. G' %/�/h 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fiall-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.Q00.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHAI�C'rE: __. _ _ _ _ _ . _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
L 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-chokmg proc�dures below and
at�t�i cnpies 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 REQUIItED FEE PERMTI'# LICEN5E REQUIItED FEE PERMIT#
B&B $50 CABIN $50 �MOTEL $50 ��6"6�B
IIvrr $so _ca� $so ! swnvflvm�GPooL��s�. �66-0�0
LODGE $50 TRAII,ER PARK $50 WHIIZLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
0-100 SEATS $75 I CONTINENTAL $30 (j�e-'I � NON-PROFIT' �25
>100 SEATS $150 COMMON VIC. $50 WHOLESALE $7S
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_QS,QO(?sq.ft. , $75 _FROZENDESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ ISS.OO
"•"•"PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•*•*"
_ �'^�' 1
�, � � �
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal
of any license or permit to operate a business if a person or company does nat 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
VVORKER'S COMP. AFFIDAVIT SIGNED ANU 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 RESPONSIBILTTY TO RETURN
TI� COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�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 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 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 obtauied at the
Health Department.
FROZEN DESSERTS:
- �e�ea�esser�s mtrs�k�e tes�e��n���hl�basis b�a State eertified-lab. '�es�r�ts�nust be sent to t13e I�ealth
Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Pernut until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishme�t is prohibited.
; r-
DATE: �A/yl /D_ D b SIGNATURE: '
,
PR1NT NAME&TITLE: D/�,gG�b�� G'QDiL� G•F�R/R
09/28/OS �� � �/ � �
I//G.
S � �'� D����
. ' `�
---� The Commonwealth of Massachusetts
� � Depart�ne�et of Industrial Accidenls
= - N/feaN�ws�
- _ = � 600 A'oshington S'tree� 7`"'Floor
�-_�,•,�` Boston,MQss. 02111
_
Workeis'Com�aatioe I�s�a�ce Affidsvi�B�il lecdrical Co�tractors
. .:._. .. �_.,�._ �� �. �u�`� ' � �� ����,, �����'",� �''.
, �M , �, _��
,.. ; �,..:.
,: __.
¢ zu �
�:..
nalue'
address-
ci�+ state: zip: ohane#
work site locati�(fitll addcessr
❑ I am a homeowner perfomning all wa�lc myself. Ptojed Type: ❑New Co�a�QRemodel
I am a sole 'etor and have no one w ' m any cap� Buil ' Addition
'E .,,
«�����'�- �.�,.. .>..: , _
❑ I am an empbyer pmviding warkeis'compensatio�for my e,mployees wo�cing on this job.
ao�o�ame•
a�-
dtv- . olte�#k:
❑ I am a sole pra�prietor,ge'eral eottmMr,or�omeo��(circle oue)and have}rirad the contr�ctors listsd below wlw have
tlie following wotkecs'compensation polices:
eo�ouv m�r-
ad�rm:
c�y: uio�e At:
#
� ��
'� , ..s�'�z�''S r`«x..a-�,., .ix» .ri .�;t�`z-: x >�xa� ..-�'v �.�>.,,,.�'*�^,�h�: s .�..;�� , ��:.,. �� '.., E ....., . _ . . . _ ..., r_ ..... _ .. . .
11911111i�Q�!' .
i�Ylf'
CIIY' D�6�!�'
— -— —— --- �y �
f
- �l.fi��= __ _ � -- — ----- # - .__ _ _ �` _c��} C7��__ _
„- ,- ,.- . .� �
.
. . .. .. ':�:,,l,'` :�`.;.. , .,.=.:: , � ��.;° , kk,.�l",s 't�t*��', x �-Ep�i�,..�'�� . ���.'s.� e Y;�cx ...
. �.� �..��� .
Fai�te 10 seearc oeveraae at reqdred udv Satloi 2SA ef MGL 1S2 aa lad b tYe�w.t�rt.�..i pndua.ta�e.p a t�..m.r
oa ye,r�°��c�.�.:a.�a.�m c�e ro�or�s�ror wonic oxu�x�.a a e�.tsieo.ae a a,�y��.�. i ona��a�c.
cepy of tYia stalese�my be f.nvarded/o He O�x�lave�atlons af t6e DIA[or tovenge veripatlee.
I do 6er+eby cerafy urder tbe paihr�s aad peneltres ojperJwry t6at tbe iwforsretlon provlAed oboNe is true awd rnrr+e�ct
Signature Date � �—��'
Print name LG��r Phone# 8 398 �-33
of5cial ase only do not write i�this area to 6e compk�ted by dly or�wn o�ciai
city or ta�vn• permiNlicense# �Baidi�g Depatmest
�l.iceea�8 Board
❑ehedc if immedia�e r�eapeme ia requi�ed �Sdeetmes's O�ae
❑���
mutsct peraon: pho�#; �Olher
lmiacd Scp-�)
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-038 FEE: $50.00
T1�iis is to Certify that 7olly Cavtain Motor Lod�e Condo Assaciation
1376 Brid e Street 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 Commonwealth of Massachusetts relating
thereto,and upon such teims and conditions,and to the rules and regulations in regard to said Motels so licensed as adopted
by the Board of Health,and eaLpires December 31,2006 unless sooner suspended or revoked.
February 9.2006 BOARD OF HEALTH: B tsst�. �1�,tut,/��., '
d���s�, R.�., v�e�.��
a�d�t�. B�, �l�
A��Ll��t
�4���.��, R.N.
ruce G. h , ,RS.,CHO
Director of He�alth
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISffiV�NT
PERMIT NUMBER: #06-148 FEE: $30.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pemut is hereby granted to:
Jolly Captain Motor Lodge Condo Associatioq 1376 Bridge Street, South Yarmouth, MA
Whose place of business is: 7ollv Ca�tain Motor Lod�e Condo Association
Type of business: Continental Breakfast �
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31�2006 BOARD oF HEALTH: 8 _`h. ,/yl.$•, '
���s�, �'�, v�e���
Rad�t�. B�, e�
- p����
�4��n�.�, R.1Y.
February 9.2006
ruce G. MurP Y, , S.,CFIO
Director of Health
. .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-070 FEE: $75.00
� This is to certify that 7olly Captain Motor Lodge Condo Association
1376 Bridge �tree , SoLth Yarmo�th, MA
IS HEREBY GRANTED A PERMTT
�
To Operate a Public, Semi-Public Swimming or Wading Pool
� At Jolly Cantain Motor Lodge Condo Assn. -OUTDOOR POOL
; 1376 Bnd�e Street
I South Yarmouth MA
�
:
! This pern►it is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachuseits,and
e�ires December 31.2006 unless sooner suspended or revoked.
February 9,2006 BOARD OF HEALTH: B �. �o?�o�t,/��., '
���"`s�, .�v., v�e�-�
a�t�. a�, �!�
�����
�v � , a.�v.
ruce G.
� Y� -�
Director of Health
! � � ,� `� �£
� . ;� � 4. � -� �"ou..Y CAPrx4rN
:! ,
� t �WN OF YARMOUTH BOARD OF HEALTH
� �'�,� °�/30��APPLICATION FOR LICENSE/PERMIT-2002
3 ,t ; '
'' * Please complete form and attach all necessary documents by December 31, 2001. Failure to�o so wil�resu�t in
� the return of your application packet.
O z353
AME OF ESTABLISHMENT. a!� ' ` T � L
�/e�✓ N D f.,�, �—
; �qddRPS�MAILING ADDRE S: � • iS° 6 � , . ,d i(�J�
R/C IO tr �' �
AG ' N E: � TE . - �6`
' ILING A D SS: / '
;
; POOL CERTIFICATIONS:
I The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
, Pool Operatar(s)and attach a co�y of the certification to this form.
1. e� � 2.
S�l�s� �a/s
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.��4h� /y��I - 2. /"�C�ca �C�'r�6 �S
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•
__ P�SON TN CHAI��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 a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at�your place of business.
l. 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 S50 {MOTEL $50 �'da��3�
_INN $50 _CAMP $50 �,SWIMMING POOL$SOea �aa-o�
LODGE $50 TRAILER PARK $50 _WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 �CONTINENTAL $30 �C�'��7 _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 �r_ _<25,000 sq.ft. $75 _TOBACCO $20
<50 sq.R. $45 �'� >25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $io AMOUNT DUE _ $ 1.30•00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�--,.�... _ -
S
`e �t
�
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 permit to operate a business if a person or company does not have a Certificate of Work�r's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
4 . vi�
WORKER'S COMF. AFFIDAVIT SIGNED AND ATTACHED�
Town of Yarmouth taxes and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2001.
SEASONAL ESTABLISH�VIENTS ARE TO CONTACT'TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 �
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW `
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
(''ONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Deparhnent. _
- FRnZFN 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 untiT the
above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING: '
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �
DATE; ��� - � I SIGNATU .
� �
PRINT NAME &TITLE: ��c��ae r � �� � e,��� �'RusT�ec,�
09/11/Ol
i . .
� - �� �
' { The Commonwealth ojMossachusetts
� � Department ojlndustrial.-lccidents
J
> O�ce oll�stl�stJiis
a
600 Washin ton Str
S
eet
, ;`
� Bnston. Mass. 02111
�'~ '��y NWorkers' Compensation Insurance Affidavit
�Rnlcant information: p►essepRil'aTTi�ihiv
n�m� Vo��v �s�� i!/ /"/aTbR .�.Ddnr� �.�/d�.�1i �j/i Dl�i�Z�7'Od
Is�c�tion• /�7l f3��do S7�
J
�t� � So . � o��P/�OU� /y D2�/SF �one q��88���8� /22 6
a I am a homeoµner pertormin,all w�ork myself. "
� I am a sole proprieror ��,'. ha�e no one��ori�in= in am•capacit��
�am an empio�er pro�idino w�orkers' compensation for my employees w•orkine on this job.
s4mnanv namr (TO��Si Cd�/d/A/ /"!>�/'i �doP .G�ld�l/�!/%U�1 /`/�'B Lr%2'�d.t/ .
acldress' �✓ / � �i�/U'4 .�/ •� '—
s�t,�: S. Ya��vo��/ //� rthone tl•�8 /�7� ��Z6
�
s�ra n c e c o. L�Q'/Uit/ ,L�vS'v�d /Y'p C�d,�/�a�,(/X p,Q�Y!t l�(/� � - O D 2 7 d 9 Z
� I am a sole proprietor. ;enerai contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the foilo��in_ ��orkzr_ �ompensation polices:
s4mnanv name•
address•.
citr: ohone q•
insurancc co. olic}•#
s4mn�nv name• -
_ _--- --- --—_---
address•
�t'�': ehoee 1!•
insurance co. olieY�f
i
Failure to secure coverage as requ�red uoder Secnoo 25A of MGL 152 cs�lad to t6e iopo�itioa ottrioi�al pesaltles of a d�e op to 51.500.00 a�d/or
one yean'imprisonment a�w�ell as civil penaidea io the form of a STOP WO[UC ORDER aad a Aae otS100.00 a day apiost me. I a�derata�d t6at a
copy of thh statemen[may be fonvarded to the ORice of Investig�tiom of tbe DU for eovera;e veritiatio�.
I do_hereby cenif}•under t/�e pains and pertallies ojperjary lhat t/rt i�jorniation providtd above is trut and eonect
Signature � ���� � .s�r �� /2—/3—O/
.
Print name �I 4BC7i'1`!�f/ ,B�'I�P.P�l`1"" Phone M�6/7�,3,3 2 —���'�
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city or town: YARMOIIT$ _ pennitAieeau N nBuilding Department
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nRoouc�+ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
� PROCTOR AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
NOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR
� PO BOX 429 ALTER THE COVERA�iE AFFORDED BY TIiE POLICIES BELOW.
� 15 MAIN ST COMPANIES AFFORDfN(i COVERAGE
�
WILTON NH 03086 CpMp�y
; A MERRIMACK
�upE� COMPANY p D
DANIEL F HARRINGTON e
& LORI A HARRINGTON COMPMIY
� 60 OLD ENGLISH ROAD �
BEDFOR.D NH 03110 ppMPANY _
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C S O SU CE S O E E ISSU O SU O OR E OLICY�PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICM THIS
CERTIFICATE MAY BE ISSt1ED OR MAY PERTAIN,THE iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TFIE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClA1MS.
i CO POLICY EFFEC7IVE POLICY EXPIRA710N
LTR TYPE OF�URANCE POIJCY NUMBER DATE(MMJDD/Y1� DATE(II�MIDDNY) ��
'I c�n�u�e�m HP 2 0 9 7 5 71 6 2 3 O I 6 2 3 0 2 CaENERAL AGGREGATE $
COMMERCIAL GENERAL LIABIIJTY PRODUCT3-COMP/OP AGG $
CLAIMS MADE �OCCUR PERSONAL 3 ADV INJURY $ _
' OWNER'3&CONTRACTOR'S PROT EACH OCCURRENCE S 3 O O� O O O
FIRE DAMAGE(My one fire) $
MEo exP Wy one oarson) S 1� O O O
AUTOMOMIE W161LITY
MIY AUTO COMBINED s�NGLE UMiT $
ALL OWNED AUTOS BODILY INJURY
SCHEDUL�AUTOS (�Pe�) $
HIRED AUTOS BODILY INJURY
NON-0WN@ AUTOS (p��M) :
PROPERTV DAMAGE $
SARAGE LIABLLRY AUTO OWIY-EA ACCIDENT S
�'A�T� OTHER THAN AUTO ONLY: :
�nccro�nrr s
AGGREGATE E
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UMBRELLA FORM AGC3REGATE S
OTHER THAN UA�RH.LA FOFWI g
won�s coM�sw�ao '
EMPLOY'e1fiS'W1BBJfY TORY LJMITS __ ER : _ �_.
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OTIER
DESCR�l10N OF OPERATIOIIS/LOCA CIAL 11EM$
LIABILITY FOR 2000 REGAL 27' HULL S#RGMWD256E001 WITH 2O00 REGAL 200HP MOTOR
ADDITIONAL INSURED IS JOLLY CAPTAIN CONDO ASSN, 1376 BRIDGE ST, SO YARMOUTH,
MA 02664
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SFIOULD ANY OF T!E ABOVE DESCR�ED POLK�S BE CANCELLED BEFORE iT�
JOLLY CAPTAIN CONDO ASSN EXPIRATION DA7E 7HEREOF, n� issu� co�a�r wiu eno�►voa ro Mna.
1 O DAYS YVR1TiEN NOTICE TO TFE 7E MOLDER TO TF�LEFT,
13 7 6 BRIDGE ST BUT FA�URE TO MNL$UCN NO710E SNALL No N oR wueiun,
S O YARMOUTH MA 0 2 6 6 4 pp pNy pNp UPON TFE COMPANY AG R EPRESENTA7ryE$.
AUTHOA�D REPRESENTA7IVE
�:............................................... ........... DAVID....E....PROCTOR ' � VK A
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-031 FEE: $50.00
'rhis is to Certify that Jolly Captain Motor Lodge Condo Assn. d/b/a Jolly Captain Condo Assn.
1376 Brid�e Street South Yarmouth,MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity 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 conditions,and to the rules and regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or
revoked.
Apri130 ,2002 BOARD OF HEALTH: s�{�, i�e�i�,
fa�ct�D. CFordo�c. .�iee
�a�a�� �• (�'r,�
�e�tie�'�eznrot�
s
�ruce G.Murphy, .5.,CHO
Director of Healt�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�IlVIENT
PERMIT NiJMBER: #02-117 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:
Tollv Ca=�in MotorT.odge.Gondo Assoc_, 1376 Brid .e ��eet, So� h Y rm�� h,MA
Whose place of business is: Joll�Captain Condo Association
Type of business: Continental Breakfast
To operate a food esta.blishment in: Town of Yarmouth
Permit expires: December 31,2002 BOARD OF HEALTH: Lkanled r�l�, zelltlrcx, ��uwc
��c�c D. (�arda�. 7�D., ?/�ce
,�a�t� �c. L�
�a�uc��er.xa�
S�Fak �72.
Apri130 ,2002
ruce G.Murphy, .S.,CHO
Director of Heal
w
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
� BOARD OF HEALTH
PERMIT NUMBER: #02-056 FEE: $50.00
This is to Certify that Jolly Captai.n Motor Lod�e Condo Assn. d/b/a Jolly Captain Condo Assn.
1376 Bridge Stree South Yarmouth,MA
IS HEREBY GRANTED A PERMIT
To Operate a Public,Semi-Public Swimming or Wading Pool
�
At Jolly Cantain Condo Association -OiTTDOOR POOL
1376 Bndge Street
South Yarmouth.. MA
This permit is granted in conformity with Arkicle VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2002 unless sooner suspended or revoked.
� Apri130 ,2002 BOARD OF HEALTH: ���'s� z�. ���a�ur�rra.c
�a�arl.ic D. C�r°'rd°"c, 7 D.. `l/ice
,�o�iert� ��ro�aMc, (�
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T a Of/Ice ol/erest/ostliis
� 600 Washington Street
.� Boston,Mass. 02111
�' ��y W'orkers' Compensation Insurance Affidavit
Aqnlicant information: PIe���pBIHT'Ie��
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mmc: )LL!iJ ��4�7�97/✓"' �'dy✓1) c7 �'/pU�r
J�cation: / � 7 � �OL/D.�� ��
�� .�_ "/ l�I'1- �(3��'� j'�6� �Z�o�o� R�one fi( f��� -�.�9 i��dy
� I am a homeowner pertormin�all work myself. �
� I am a sole proprietor�r� have no one���orkine in am�capaciry
�m an empioyer pro�idin�workers' compensation for my employees workin2 on this job.
�2��2' name• :��/LL�' �l�i�l�/�/ �G�ti'� U �SSI�C�'
�����ss• /3 76 �i�P/O�f .57`
��.. s0 ��/P/�Q�71`/� /�1f� phone R: l.S��'�_���_ -Jc�D�
r-
insur�nce co L����1�{/ //�/SU/P�i(.�L�� C��/�iv� policy# ��-'� '0�z7��2
� I am a sole proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed below «ho ha�e
the follo��in� ��orker�' �ompensation polices:
com a{�nv name• --
^�dress
�y• phone!l�
insur�ncc co poli�y#
sompanv namr ---
_ _ - _ __ _ __ _ _
. _
'ddress• _ _ .
c��.+• ntioee l�•
insurance co p�y�
Failure to seeure coverage as required under Seetioo 25A of MGL 152 eae lad to t6e iopailioo olerisi�tl peodlia of a tf�e op to 51,500.00 a�d/or
one yean'imprisonment as w•ell as civil penalda io the[orm of a STOP WORK OItDER aod a tine of 5100.00 a day apiost ma I a�denta�d t6at�
eopy of thH statement may be forwarded to the OlTiee of Inve�tigations of t6e DU for eovenge veritiutio�.
/do hrreby cerlij}�under the pnins nd penalties ojperjury th !ht injorniation provided above is true and eonect
Signaturc ' ` �,,�� �2� /`j` .Zd�l O
Printname ✓�•�✓/"� U � � n�/S dI� Phone� ( �O� � ���'"��iDL/Y
., o(Ticial use only do not M rite in this're�to be completed by city or town otlicial
city ar town: Y�MO� _ permit/license p nBuildiag Departmeet
pLicensiog Board
p check if immediate response is required 261 ❑Selectmen's ORee
�H-alth pepartmeat
contact person: phone 11;_ �508� 398t2231 egt. nOther
Im-ised 3;95 P1A1 .
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHIVVI�NT
PERMIT NUMBER: #01-111 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 pernut is hereby granted to:
Jolly('aY tain Cond� Assoc ,..] 76 Brid��,t, �oL h Y rmo�th,MA
Whose place of business is: Jollv Cantai�Condos
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31,2001 BOARD OF HEALTH: �d� �e#ed, ���
el���f. �e��. `�/ice L��
�o�� �'�v�c, L'�
��� d '.C'
�D.
March 2 ,2001
ruce G.Murphy, H, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #01-035 FEE: $50.00
'rhis is to Certify that Joll,y Ca�tain Condo Assoc d/b/a Joll�Ca�tain Condos
1376 Bridge Street South Yazmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in confomvty with the authority granted to the Board of Health,by Chapter 140,Secrions 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 regulations in regard to said
Cabins so licensed as adopted by the Board of Health,and expires December 31,2001 unless sooner suspended or
revoked.
March Z ,2001 BOARD OF HEALTH: �� �e�ed, C��ut�t
�ia�rled�, xa�. �l/ice �?�iavro,r.a�
�o�it�. �arouW,c. L�
J'?�icl,cae� d �.L�a�
� D. . ?� .
Bruce G. Murphy,MPH, .5., O
Director of Health
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� TOWN OF YARMOUTH BOARD OF HEALTH , `c��, Q C� C� C� � M i� D
APPLICATION FOR LICENSE/PERMIT-=`2000
• � „�,, ��� �,���� D E C 2 7 1999
* P,lease complete form and attach all necessary documents by DecernU�r 31, 1999. Failure o��}�����n
thc return of your applica.tion packet. � ��a
------------F EST---------------N---------_-L----------------��------ -----------------------T-L#-----------------------•
L T 37 Sa a�tHa�
L 6 �.�ro w�v ��v ` A �
N • �! � C r 2r/s oy
MANAG�R'S NAME: �C�-r�,✓ C7 /P'.�/ ?!A u ST�r� TEL. # �'o P' ��9�'
MAII.ING ADDRESS: �-(��,�T`C'L !N�— 1Z7��1'��r� .�n r-� v 2o Lf�
POOL CERTIFICATIONS:
The poot supervisor must be certified as a Pool Operator, as rer�aired by new State law. Please list the
desi�nated Pool Operator(s) and attach a copy of the certification to_tlus form., C��� ( , �,��-- �'pc��
1. ��'�l �__���c �—'�`. _��O d-/n� � t��b'�S T!�"1�.
Pool operators must l�st a minimum of two employees currently certified in basic water safety, standard First Aid
at�d Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. 'Ifie Health Department will not use past ye�rs' records. You must provide
new copies and maintain �file at your ptace of business.
i. ���ei ,�L'l�� 3�`�- � 3��' 2. ,��v�,� c� `n/�-��-�
� 3• .k���'A��IV��Li 4.� G�.ot�� CJ'/�/�IL�
� HEIMLICH�ERTIFICATIONS:
All food service establishments with 25 seats or more must have at teast 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.
3. 4.
-__--�ST-��'�AVC�: T-Q�AL## _ _ __ __�TQDI-SMOKING SEATS� TOTAI.�__ _ __ _ . __ _
--------_---__--------------------------------------------------------------------------------_-------------------_----_--------------___.
OFFICE USE C�NLY
LODGING•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 �TRAILER PARK $50
�MOTEL $50 �-Z7 ✓SWII\�IlVIING POOL�Ol $SOea. ?.k-
WHIRLP�OL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 �CONTINENTAL $30 ��I IJ�
>�04 SEA"F�--- -_- --���9 _ _ _- -- -- - _ _�FO�-P�BF��=----- __��3 _ ___ _
COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35
_>25,000 sq.ft.�-�.�, � '. $2Q0:�
NAME CHAN�E: �10* _��,:,
� � , _ AMOUNT DUE - $ l•3D, 0(�
-� � u ,r t. �. .,a 'a
"""""PLEASE TiTRN OVER AND COMPLETE OTHER SIDE OF FORM���R k
. T_ ,
� .
:
� � � . . ADMINISTRATION
? LTNDER CHAPTER�152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIRED `
`. TO HOLD ISSUAI�CE OR RENEWAL OF ANY LICENSE UR PERMIT TO OPERATE A BUSINES5 IF A '
� PEI��Q11t�I;�OR CONIl'ANY DOES NQT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
` ""INSI7�1�fiCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAV�IT
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 PRIQR TO RENEWAL OR ISSUANCE OF
Y4UR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES t� NO
NOTICE: PERMITS RUN ANNLJALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPOI�FSIBII.ITY TO RETUR�i THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S} B�
DECEMBER 31, 1998.
SEASONAL ESTABLISHN�NTS ARE TO C�NTACT THE HEALTH DEFARTM�'NT FOR INSPECTION 7-10
DAYS PRIOR TO OPENTNG FOR THE 5EASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTINCr, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEAI;T�i PRIOR TO •
CONIlV�NCENI�NT. RENOVATIONS MAY REQUIItE A SITE PLArT. �
�DITIONAL REGULATIONS
POOLS
POOL OPEN�NG: ALL SV'V:IaViMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
TI�SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND'I'�-�WATER TESTED FOR
PSEUDOMONAS, TQTAL�QLIFORM AND STANUARD PLA,TE_CULJNT_BY_A STATE CERTIFIED LABs______
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(?)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN TI-�TOWN OF YARMOUTH MUST NOTIFY TI�YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM ?2
HOURS PRIOR TO TI� CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT TI� HEALTH
DEPARTMENT.
FROZEN DE SS ERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTrv�NT. FAILURE TO DO SO WII,L RESULT IN THE
SUSFENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,THE ABOVE TERMS HAVE
__ _ __ _ _ _
_ BEEN MET. _ _ _
OIJTSIDE CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
�UTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII.,OR FOOD
SERVICE ESTABLISHMENT IS PROHIBITED.
_ � ' �- _
DATE: �e 2—!�S � SIGNATURE:
PRINT NAME& TITLE: �����,�i/� CJ /?h�l�L . 1�dSJ'er,�
11/12/99
,: � . �
The Corr�monwealth of MassQchusetts
` � � Department ojlndustrial.-�ccidents
" ; 0J11COO1JOYCSII���IIs
: 600 Wirshington Street
� ' �` Boston.Mass. 02111
�'" ��y V4'orkers' Compensation I�surance Atfidavit
ARnlicant information• p►easepltIl'�TTe�'s•�
namr: JOZL�1 �/�-�Y�'m�� �'c�iJO� 1�Z!/C' T
�
Is�cation: �.� � -� 2� � �-/fZ,�y�r
�� so. '��}'1'L 1'h�il/7-� _ �A- 0 z t G `�' phone��'v�"J �3c7�,�60�
� I am a homeow�ner pert�rmin,al w�ork myself. �
� f am a sole proprieror �r..'. ha�e no one��ori:in_ in am•capacin�
�am an employer pro�idino workers' compensation for my employees w•orking on this job.
.�. - ___ ,
vcTZZ,!/I _��-�1'6J�N L OND d �5�2C' - --_- _. � _
como�nv namr _- -- --
address• �3 �/� �OLJD�� �'�'
sitv: �(J ��lL)'Ylc�t�i}� I� l� nhone#������ ��f� (T�U�
iosuranceco. �.�f�ON /NSU/P�'�/G'E �p�yPA,,VX' Rolicy# 1/1/C�--ODz �^D92
� I �m a sole proprietor. general contractor. or homeowner(circle oneJ and ha�•e hired the contractors listed beloµ �tiho ha�e
the follu��in_ ��orkzr �ompensation polices:
s4mpanv name:
address•
��n'� ohone t!•
iosur�ncc co. ooli }•#
s�m�2nv namr.
____ __ _ --- --- -
_ _ _ ----- ---- - _- _
a�dress: _ __ .__ _ __ _ --- -
sitv: ehoee M•
insurance co. _��+{�
t
� Failure to seeure coverage as required uoder Seedoo 2SA of MGL 1S2 tas Iad to tht i�po�idon o(eriaiYl ptaaitla of a O�e op to SI,500.00 a�d/or
one yean'imprisonment a�w•ell a�eivil pendtla io the form of a STOY WORK ORDER aed a Ifae of 5100.00 a dar apin�t ma t a�dersta�d tbat a
eopy of th'n satement may be fonvarded to the Otlice of Inve�tiguion�of t6e DIA tor eoven;e veri�fatia.
/do hrreby cenif}•under rh�pains and penaltia ojpery'ury thm tht injormation providtd abovt is urre and eorrect
Signature C o.rw �Q A ,��--� �.l.��t1�, Date / Z-- �l�r� /
d�T
Print name 1�• l��n/n./ �0 ��l L� Phone 1�� _�G't�� 3�cl' =�i���
.. atTici�l use onl� do not..�ite in this ara to be compieted by ciry or towa otfleial
city or town: Y�M�IIT� _ pennitAieeAse N nBuildiog Department
�Lieeasiog Board
�check if immediate response i�required 261 ❑Selectmen'e Olfiee
�HealtA Depanment
contact person: phone p;_ �508� 398t?231 ext. nOther
.. ._� < �,,.
TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-112 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:
Toll, C' pYain Cond� Tru��, 1376 Bridge Street, Sn��th Yarm� � h_ MA
Whose place of business is: Jolly Cantain Condo
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�d� �et��, C'�t�,na�
�oan G. Ju6livan� K./1.� Vice C.�irma
�o6erf.1. �rown, �fer�
abriel��a�Zo(,��ty-JdooPe�
�oCou lin
� J�.n�ua�v�0 s�00(1 - — -� -
Bruce G. Murphy P .S.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
- TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-27 FEE: $50.00
This is to Certify that Jol Cantain Condo Trust d/b/a Joll�Cantain Condo
1376 Brid�e Street South Yarmouth A
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 Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked.
Januarv 20 _,2000 BOARD OF HEALTH: �c`///. �efte�, ��aairinaa
�oan� �u[�a�, �//., Vice C,hai�man
�obert� 9�row�, C,ler�
a�ried�e�a�o(.��y-.�l�ooPe�
• ��O�Co��l�
Bruce G. Murphy,MPH, . .,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
. TOWN OF YARMOUTH
BOARD OF HEALTH
. PERMIT NUMBER: Y2K-44 FEE: $50.00
This is to Certify that J 11 Ca tain Co 1 t � C
1376 Bri ge Street. South Yarmouth. MA
IS HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Jolly_Cantain Condo - OUTDOOR POOL
1376 Bnd�e Street
South Yarmouth. MA
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
7anUary 20 ,2000 BOARD OF HEALTH: �cl� �elte�� ��xairman
�oan� �ullivan., K.//., Vice C,hairman
KoberE,}. �rown, �fer�
a�rielle�a�rolo�y-✓�tooPe�
' �l � o hlirt
fUC@ . U1P Ye �
Director of Health
� ��:,� � _ .�c�I ���,p�zii�Cc��i�
�:.
A ;'T'
: �
TOWN OF YARMOUTH �' � �OF HEALTH Q � � � O NI � D
� APPLICATION FOR LIC E/��II�- �'
� JAN 1 5 1999
�'� l�
* Please complete form and attach a11 necessary documents by December 1, 1998. Fail yd-tC,@l�'�M�g��ult
the return of your application packet.
-------------------T�---------------------�o�L---------------:A�J�---------------------------------L-#--------------------
i.nC'ATION ADDRESS� 13 7 � 13 R-�n�� STT
MAILING ADDRE S S� �6 Pi%�r� l�l r�-� ,j'�')/�,�s�� rz,D lyi A O�.o�-8'
� T N v L�- TA,,J .✓ !7s
1VLANAGER'S NAME' ��i/i,.� O '!�/g LL , 12usrdi� TEL. � S�s 33�-So5'.�
MATT,TNG ADDRESS' �.-(� P..�Tv G.ir��•, I7'Il3NS�i�L D /ri�t c'��O�/�
i .
; -----------------------------------------------------------^-----------------------------------------------------------------------------
1 POOL CERTIFICATIONS:
! The pool supervisor must be certified 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 this form.
� 1. �P.�FJS,�'/ �(�`��.5 2.
,—,.
Pool operators must list a minimum of two employees currerrtly certified in basic water safety, standard First Aid and
Commusuty Cazdio�ulmonary Resuscitation(CPR). Please li�t 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 tile at your place of business.
1. L'�A 1�1� � �1'V 1{I L L 2. • j��Yn�/ C7 � o►'I L Z
3. Y�'!r�n-i� j'�'1 r�7✓;��� 4. o[�zr O'�v����
� S. j oay� yrJ� /�27"/�/v 2
' HEIlVILICH CERTIFICA I',�ONS:
; , 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.
Yau must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
� ----------------------------___________-------------------------------------------- -------------------------------------------
. _ _ QFFICE U�� O�TLY __
{ -- -
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERNIIT#
B&B $50 CABIN $50
INN $50 CAMP $50
' LODGE $50 TRAII,ER PARK $50
; �MOTEL $50 �_ _1__SV'VIMMING POOL $SOea. - �
1
; WHIRI,POOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT # LICENSE REQUIRED FEE PERNIIT#
_0-100 SEATS $75 I CONTINENTAL $30 q '�l_��7
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
, I.�TAIL SE�VICE:
LICENSE REQUIRED FEE �'ERMIT# LICEN5E REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
^<25,000 sq.ft. $75 FROZEN DESSERT $25
>25,000 sq.ft. $200
' �tAME CHA,NGE: $10
AMOUNT DUE = $ ��V`""'
""""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*R R b k
� _ . _ - - - _ _ --- —_ --- — ------ --_ __
I
�4. .
ADMINISTRATION � ' • ,
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,THE TOWN OF YARMOLTTH IS NOW REQUIRED
TO HO�L�I��aiJANCE 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 STA'�E 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 APPROPRIATELY IF PAID:
YES�/ NO
NOTICE: P�RMI'�S RIJ�T AN�UALLY FROM JANUARY 1 TO DECEMBER 31: IT :IS Y4UI�
RESPONSIBII.ITY TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLIS�-IlV.�NTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO CONIlv�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. t
ADDITIONAL REGLTLATIONS
POOLS
POOL OPENIlVG: ALL SWIlVIl��IING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
TI-� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND TI�WATER TESTED FOR
PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
_ PRIOR TO OPEI�TING,_AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIlVIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOUD SERVICE
CATERIl�TG POLICY:
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE 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
RESLTLTS MUST BE SE1�TT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN
THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS
- ----- _-- -- - -- -----___- --
_ _ - - -__-- ------ -- ------- _
_HAVE BEEN MET. _
OUTSIDE CAFES:
OUTSIDE CAFES(i.e.,OLJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING: :
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT$Y A RETAII,OR FOOD
SERVICE ESTABLIS��VVIEENT IS PROHIBITED.
!, /� , . `�
DATE:_ /- S- �I � SIGNATLTRE: ,U • /C�/ � ���
PRINT NAME& TITLE: ,L� . �z't�i�✓ (� ���� L J2 tJ J'S�.[�
r
i
r 's �
The Commonwealth of MassQchusetts
� ' M W Department ojlndustrial.-�ccidents
� o Ofl/ce ol/ev�s�l�sdiis
� 600 Washington Street
', •� Bnston, Mass 02111
� v'V
W'orkers' Compensation lnsurance Affidavit
A.Rplicant information: pleasePRi1�7'Ted�'i,�i��
n�mr� �`c�ZL vI CF} t�Tt�inJ C r/6�t� �c'c�C' -
i �
locati�n: /3 7� �R.-1 D�,-,� �T`
. �� . ri m �r 026G # $Q£s 33`�j-SnS"3
� I am a homeowner ertorming all work myself.
� f am a sole proprietor��� h��e no one��orkine in anv capaciry
�am an emplo�er pro�iding workers' compensation for my employees workine on this job.
_
com�an�• name: x JOL�- �l �/�'�r'?9'/,U �'Q�(/�Q �J-s,sp
address: .S�/��
S!IY� X ohone ti•
ir sur:►nce co. X L C�I�� �i�ISl�/P/f,�/(�C �O�l�/�.�/y policy u //�/C.3— �'1 G L?O 9Z
� I am a sole proprietor. _eneral contractor, or homeowner(circle onel and ha�•e hired the contractors listed belo� «ho ha�e
the follu��in� ��orker�� �ompensation polices:
com�anv name:
address•
c�y: �hone�•
insurancc co. policy#
comqany name:
__ address: - __ _ _ _ _ . _ _ _ _ ___ _ _ _— -- -----
�: nhoee 11•
ie�urtance co. po�M
F�ilu�e to secure coverage as required under Secdoo 25A of MGL 1S2 n�lad to t6e iopai0oo of erisi�l peealtla of a A�e ap to 51,500.00 a�d/or
one yean'imprisonment as w�ell as civil peaaldes io the fo�m of�STOP WORK ORDER asd a Oee of 5100.00 a day apimt sa I a�dersta�d that a
eopy of thy statement may be forwarded to the ORce of Inve�tigaUoo�of the DIA for eovenge veriAado�.
I do hrreby certij}•under the poins and pena/ties ojperjury tha�thr injormation providtd abovt is tnre and eon�e�
�
Signature � - �.-- �� �s� , /� Date �"� cl�
Print name � ° �dl�nJ 6 ���IG L %rz us7-d� Phone#�5��� 3 3 5 '��� 3
.. olTicial use only do not w rite in this area to be completed by city or town oflleial
ciry or town: Y��IIT� _ permitAiceese a nBuildiog Department
pLiceasiog Board
�check if immediste response is required 261 QSelectmen'�Ofliee
�Health Department
contact person: phone p;_ �508� 398�2231 egt. nOther
Irec�sed i;9t P)AI
m.��9�,:k ; _.. _ .�c�! C'�,pfi�,i r��vnd�
A T
� ,
TOWN OF YARMOUTH :,Al �OF�EALTH Q � � � � d � �
�� � APPLICATION FOR LIC �����E��I�- ��`'
F JAN 1 5 1999
�� t�
* Please complete form and attach a11 necessary documents by December 1, 1998. Fail r�-tE,@1�.�M�g��ult
the return of your application packet.
----------------------------------------------------,----------------------------------------------------
---------------------------- --
NAMF OF ESTABLIS��NT c�ocL� C�.p�'AnJ _or.Jf> a TEL. #
�OCATIONADDRESS� l37 � 13R-�D�� ST�
MAILING ADDRESS' �6 PI�r� �J�-� Yh►�r�S���tLD l�'1 �9 (O 2o�f-$'
C N v L�- r� �A��J ,✓ !�s
M�IVAGER'S NAME' l��r/i.-� O 'lv� L L J�u s r�� TEL � S�F's 33�-SoS'.3
MAILING ADDRESS' ��{�,�,,�rv l..ir�h �'I�n�s�ietL� /ri A ��o�/S%
,
� ----------------------------------------------------------------------------------------------------------------------------------------
i POOL CERTIFICATIONS:
i The pool supervisor must be certified 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 form.
i
1. _���FJ�,� ����5 2.
Pool operators must list a minimum of two emp loyees cwrently certified in basic water safety, standard First Aid and
' Commwuty Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
! certifications to tlus form. The Health Department will not use past years' records. You must provide new
copies and maintain a f le at your place of business.
1._ L'�A1�✓1� O �1'V 7�)L L 2. .C� • ��b'YnJ C7 ��1/n+')L L ,
3. Y�'1�3n-�� 1'��'1✓;�,', 4. �Q6�.r D'iv���L
S. j�vaNr� yr�� /�27�/v2
` HEIlVII,ICH CERTIFICATIONS:
� � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
� Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
� attach copies of employee certifications to this form. The Health Department will not use past years' records.
� You must provide new copies and maintain a file at your place of business.
,
` 1. 2. �
a 3. 4.
I
� RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
I ----------------------------------------___-----------------------------------------------------------------------------------------
� _ OFFI E-US�O�TLY _- -
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
� INN $50 CAMP $50
j LODGE $50 TRAII.ER PARK $50
�MOTEL �50 �_ �SV'VIlVIMING POOL $SOea. - �
WHIIt,LPOpL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT#
_0-100 SEATS $75 I CONTINENTAL $30 q '�l�
>100 SEATS $150 NUN-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
I�TAIL SE�tVIC�
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
�<25,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ ��C.�""'
•'"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""""
k
_;�, ,
ADMINISTRATION ` ' a ,
iJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI�TOWN OF YARMOUTH IS NOW REQUIRED
TO HOQ�i��aiJANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A
PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'5 COMPENSATION
INSURANCE. THE ATTACHED STA�E WORKER'S COMPENSATION INSUR,ANCE 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 APPROPRIATELY IF PAID:
YES� NO
NOTICE: P�RMI?'� Ri7�-AN�UALLY FROM JANUARY 1 TO DECEMBER 31: IT ,�S YfJUR
RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY ':
DECEMBER 31, 1998.
SEASONAL ESTABLIS�-iIVN�ENT'S ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�1VIENT, 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.
ADDITIONAL REGULAT�ONS
POOLS
POOL OPENING: ALL SVVIMMING, WADING AND VVHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND'THE WATER TESTED FOR
PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENTNG,AND QUARTERLY TI-�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIMIVIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
_ CATERII*TG POLICY:
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEPARTMENT BY FII,ING TI-� REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE
HEALTH DEPARTMENI'.
FRO�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. FAILURE TO DO SO WII,L RESULT IN
TI-iE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERNIIT UNTIL THE ABOVE TERMS
- - - ------ ---------— ---__ _____ _ -
HAVE BEEN MET. _ _ -___--- ----- ------------
OUTSIDE CAFES: '
OUTSIDE CAFES(i.e., OLJTDOOR SEATING WITH WAITER/WAITRESS SERVICE),1VIIJST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD
SERVICE ESTABLIS��VIENT IS PROHIBITED.
!, /� , • `�
DATE: /- S- �j � SIGNATURE: ,U � /CXY'�/ C7 I_����
PRINT NAME& TITLE: � . /�z r�i�✓ (' ��i 1- L I�z v,rr�.�
r
� r �' �
_ The Commonwealth of Massachusetts
� ' � W Department ojlndustrial,-lccidents
� o Ofllceol/�s�lostbis
� 600 Washington Street
y ,,,� Bnston, Mass. 02111
� V� ,
Vb'orkers' Compensation Insurance Affidavit
I �Rolicant information: P(easePRll�➢7'T�'�•
�
� namr� �OLL vI CF} t�T"l9�� T/�t� <<"c�iC .
� locati�n: �.3 7�-, �R-t D�,!{ ��
; . �.� . n ►�►-� �r OZ�G # $08 3.3`�'-Sn�"3
� I am a homeowner ertormin�all work my�self.
� 1 am a sole proprieror��� ha�e no one ��orkine in am•capacin�
�am an employer pro�iding workers' compensation for my employ�ees working on this job.
, --
X_ TOL(. � - __
s9moan�• name: � � �/�'���� CQ.�/�� /�'.SS�
address: .�/?'ME
�itt': X phone fi•
insurance co. 1[ L C�I�� �/�Svir/N/�C L�O,G!/��,�iJ� �olicy# !�v C.3— dG Z j�9Z
� I am a sole proprieror. ;eneral contraetor, or homeowner(circle onel and ha�•e hired the contcactors listed below «ho ha�e
the follo��in� ��orker� :ompensation polices:
�om�anv name•
address•
citv• nhone R�
insur�nce co. �olicy#
s�m�y"namr.
__ ---
re§sc ---- . _ _
�'� nhoee 1�•
insurance co. ���
Failure to secure coverage as�equired under Sectioo 25A of MGL 152 ne lad to t6e iopo�itioo oterisi�al pt�dtla of a 6�e op to Sl¢00.00 a�d/or
one yean'imprisonment as w•ell as eivil penaltiea io the form of a STOP WORK ORDER aod a lioe of 5100.00 a d�r at�iast ma I a�derstt�d ttiat a
eopy of thh sqtement may be fonvarded to the Ofrce ot Invatig�tiom of the DIA for eovenge verifiutia.
/do hrreby certij}•under rhe poins and pena/ties ojpery'ary thallht injornwtion provided abovt it trut and eo►►ect
.
Signaturc � - �—..— �� %n� Date �—� CI�
Print name �'-�. ° ���/,n/ 6 ���IL L %2 uss-d�f � O�) ,�'3] -f vs'" `Z
Phone# S
., o(Ticial use only do not�rite in this area to be completed by city or town oAicial
city or town: YA��IITQ _ permit/litense p nBuildiog Department
�Licensiog Board
�check if immediate respoese i�required 261 �Seleetmen's ORiee
�Healt6 Departmeot
contact person: phone q;_ �508� 398�2231 egt. nOther
� �rt��ued i,05 P1A1
. THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-41 FEE: $50.00
Th�is to cerefy that Jolly Captain Condo Assn d/b/a JollX Ca�tain Condo
1376 Bridge Street South Yannouth, MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in canformity with the authority granted to the Board of Health,by Chapter 140,S�tions 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 tern�s and conditions,and to We rules and regulations in regard to said Cabins so licensed as adopted
by the Board of Health,and earpires December 31, 1999 unless sooner suspended or revoked.
Febru ,aty 12 , 1999 BOARD OF HEALTH: �c`///. .}etfee� �`eairman
�oan. � Jul�ivam�fC.//•� Vice l.�irman
• Ko�rt.}. 9�rotvit� l..fer�
a�rie[[e�aholehef-�ooPee
O , �
� �e[ ou��lin
ruce G.Murphy,MP ,R ,CHO •
Director of Health
THE COMMONWEALTH OF MASSACHUSETT5
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-67 FEE: $50.00
This is to Cer6fy that J ll 'n /a Jollv Ca�tain Condo
1376 Bnd e Stree, Soi�th Yarmnnt MA
I5 HEREBY GRANTED A PERMIT
To Operate a Public, Semi-Public Swimming or Wading Pool
At Jolly Ca�t�n Condo -OL1Ti�nC)R pOOL
1376 Bndse Street
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.
February 12 , 1999 BOARD OF HEALTH: C�c`� .}eftee, ��riirmun
� �oan G. �aLlivan���s �/ice l.�crman
' Kobert.}. �rows� l,fer�
a�rief�e�a�ole�Z�ooPee
. �06 O� ou��lin
Director of He�alth � �'
. TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: 99-147 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:
Tolly�,ntain C',ons� Assn_, 1376 Bridge Street, S�uth Yarmouth, MA
Whose place of business is: Jolly Ca�tain Condo
Type of business: Continental Breakfast
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 1999 BOARD OF HEALTH:���/. �Bt�e, �'��.�z
oan � �ullivan.� ��� Vice lr�irman
KoberE� �rown� C�[er�
abriel�e�a�ofa�cf-.htooPe�
�'i/ic lOoCou �li.
�
February,l2 , 19 99
ruce G. Murphy, H,R .,CHO
Director of Health
�
�