HomeMy WebLinkAboutApplications, WC and Licenses � ,NE
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` 2 `:�R�o TOWN OF YARMOUTH BOARD OF BE��,a;` ;���rn � �
F , �,;� APPLICATION FOR LICENSE/PERMIT-2007:;' � N O V � � Q 6 I L
* Please complete form and attach a11 necessaryy doc�rrients by D �ep� n �` ^�^^
Failure to do so will result in the r e t u rn o� o u r `` ���'T•
y applicatio
NAME OF ESTABLISHMENT: �y�u(-�� ` ' TEL. #������j�,(��l
LOCATION ADDRESS: � � G� �y
MAILING ADDRESS: �' - o • , ��G "
OWNER NAME: -. � � T IN r
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL. # � ' .� �
MAILING ADDRESS: P�0. / , yL �, aa��
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. �� 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Comrnunity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifica,tions to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishmen�
1. A�/�- 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CER'I'iFICATIQNS:
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-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1' 2.
3. 4.
RESTAURANT SEATING: TOTAL#
LODGING:
OI+'FICE U5E ONLY
LICENSE REQUIItED FEE PERMIT# LICENSE TtEQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERIvIIT#
_B&B $50 _CABIN $50 �MOTEL $50 Q�0(?C(
_� $50 _CAMP $50 _SWIIvI1�RNG POOL$75ea.
_LODGE $50 _TRAII,ERPARK $100 _WHIItLpppL $75ea.
FOOD SERVICE:
LICENSE REQUII2ED FEE pERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
i
_0-100 SEATS $75 _CONTINENT,AI, $3p _NON-PROFIT S25 �
; _>100 SEATS $150 _COMMON VIC. $50 _yVHpLEgAT•F �'75
RETAIL SERVICE:
--RESID.KITCHEN $75
i LICENSE REQUII2ED FEg PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� <50 sq_ft. $45 _>25,000 sq.8. $200
VENDING-FOOD $20
_45,OOOsq.R. $75 _.FROZENDESSERT $35 TOBACCO $SQ
NAME CHANGE: $10 AMOIJNT DUE _ $ � ,�
""'•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
at!k f�!k h
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ADMINISTRATION
Under Cha.pter 152, Section 25C, Subsection 6,the Town of Yarrnouth is now required to hold issuance or renewal j
af any license or permit to operate a business if a person or company does not have a Certificate of Worker's �
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUS�BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES l/ NO
f
._. ......... .. . .. . _._ . ,
_.- _ .__.___ _ _
___. ... .___.___-.---"__ ..___.
_ . _ __-._. __ �
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must ha.ve and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an
aggregate of not more than ninety(90) days witlun 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, sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Degartment prior to opening. Contact the Health Department ta schedule the inspection five(5�days
pnor to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing. __ _ _ - - - ,.
FOOD SERVICE '
CATERIlYG POLICY:
Anyone who caters within the Town of Yarmouth must notify the�armouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pemuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBTLITY TO RETURN
'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIEENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIpMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
' _ .
DATE: I L ( SIGNATURE: � �
PRINT NAME&TITLE: i.v� v`f
10/17/06
�,,: 1
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The Commonwealth of Massachusetxs
Departeeent of Industrial Accidenls
> N�f/fi�IM�i
600 Woshington Stree� 7`�`Floor
Bos�,Mass. 02111
-- wurkers'com ho'Ias�asee Affiai.�ic:s.it - a,.�lEi�cAl cu�aaerors
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name: `t'
acldress_ 1 dL I D� (a 1t-�..�.� � e -" �; G r /��1�l"��
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❑ I am a homeowner perfoaning all wo�ic myself. Project Type: ❑New Co�trudioc��R�nodel
' I am a sole ' and�ve no�e w ' in an ' . ❑Buil ' Addition
❑ I am an e�nployer prmiding wa�s'compensation fos my empioyee.s woiking a�►this job.
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j the following workexs'compensa�on polices:
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�l^a�'�f as wea u dW patitla i�tl�e fira��f a STO!WORK ORDEA ud a A�e d31i0.N a dap ap6ut ie. 1 nders�d det a
c�py of f6i�eh�m�t my 6e firwardcd�tLe OIDoe u[1re�atMas of tYe DIA for c�verage v�er�alis�.
!�o J� by ce rnider die p�alns swApes of tlYtt the u��forMadow prov�de�iabore ia true awd oarrert
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Print aame �- � � � �G Y' Phonc#���' � �r�d Q �C� ,
e�l ose esiy da aot write b t�s ara ta be a�p�ed bY eil9 K'�own s�cjai
cily or te�vu: Pe�t�o�e�! u`�De�rt�mt
❑ekeck if ime�ale re,apene is req�'ved �s O�ffioe
esaact perssat phele#� ��t
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THE COMMONW.EALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #07-009 FEE: $50.00
�
Tlus is to Certify that Betty J. Stewart d/bla Knotty Pine Motel
: 24 Vinevard 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 terms and conditions,and to the rules and regulations in regard to said Motels so licensed as adapted
by the Board of Health,and expires December 31,2007 unless sooner suspended or revoked
January 24,2Q07 BOARD OF HEALTH: B +c���ru�rt�r. o�or�,/��., .
' a�elea Slu�i, �.IV., ?/ice G�ls�vr�,rG,si
Number of Units: 5 Rt�JI�`�B�orwt, �
P��1��
�I.t.�(f , R.IV. .
ce G. Murp ,MP .,CHO
Director of Health
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' . . ' �� K�►ot►y Fj�►E
��'=YqR TOWN OF YARMOUTH BOARD OF HEALTH ��
a �' o � do L� �S :� +'� ,' ,� _s'",--'
�•. -�S APPLICATION FOR LICENSE/PER',�VII�:�OA6 � r � J
�� ���� * Please complete form and attach all necessary documents by Dece er�i,�z�0�. 2005
Failure to do so will result in the return o£your application p 1qe�q�rH �E�T
NAME OF ESTABLISHIVIVIEEN'T: ` Ch TEL. )���q�UF'S'�G
LOCATION ADDRESS: � � , a�G
MAII.,ING ADDRE S: P.O � Co
OWNER NAME: (U�. TAX ID r •
CORPORATION N (IF APPLICABLE): �-
MANAGER'S NAME: � � TEL. # � '!�'
MAILING ADDRESS: Q , S�
PQOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list th�designated
Pool Operatar(s)and attach a copy of the certification to this form.
1. ;`�� 2.
Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food 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 provic�e new copies and maintain a fde at your establishment.
l. �� 2-
PERSON IN CHAR�E: _ - _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlbf��eH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-chokuig procedures below and
at�ae�i eopies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERNIIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 CABIN $50 LMOT'EL $50 �O6"Oo�Y
INN �50 CAMP $50 _SWIlvIlvIIl1G POOL$75ea.
LODGE $50 TRAII,ER PARK $50 WHI12I.POOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQtJIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 �COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMT"P# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_�50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_QS,OOQsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ S�.00
A fe R R/1pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""
i� r r �., '�.
ADIVIINISTRATION ;
Under Chapter 152, Seetion 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 WORI�ER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ',
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: � l
YES �/ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPUNSIBILITY TO RETIJRN
TI�COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLIS�IlVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- '
10 DAYS PRIOR TO OPENING FOR THE SEASON. "
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMI��NCEMENT. RENOVATIONS MAY REQITIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENII�TG: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 graund 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 Serviee Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
Fmzen desserts must i�e tested on a monthly basis�y a Stat�eertifiec�lab. �'est results-must be sent-t�the�ealth
Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparatioq or display of any food product by a retail or food service establishtnent is prohibited.
DATE: �'���ll�/�� SIGNATURE: ` �
PRINT NAME&TITLE: C�7� �`�
09l28/OS
`�"'�� The Cominonwealth of Massacl+uset��
��---�--� Depart�nent of Indas�ial Accidents
-- = N�.'Ilfrlrlf�
- = 6II0 R'ashington Stree� �"'Floor
` Boston,Mass. 02111
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Worlc�s'Com�a�tios Iaa�rawee Affid�vit:B�ildi I�m lecdncal CoihacMrs
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❑ I am a homeowna perfoaaing all adc myself. 'ect Type: ❑ Ca�sln�cti �Reanodel
I am a sole 'exor a�have no o�e wo � in any ' Buil ' Addition
� .s �,
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❑ I am an eanpMyer providing warkers°compensarion for my empbyees wo�cing o�n this job.
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� ❑ I am a sole proprietor,geseral costractor,or�omeewnr(cirde oae)and have hirad the contracta�s listed below who have
the following workecs'compensation polices:
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Faive a xcm�e a�raase a.reqdroe ouer s«u.a 2Sw si MGL ls2 ean Ina a u�e isp.in...tainial pna�n.r a��a t1,sKM a.al.r
�e yeats'Imptbo'eeat aa wr9 as dv�pmltles ie t6e fsrn ot a 3TOt WORK ORDER aid a Au�t S16S.OS a day�aMt me. 1 aedaahaod t6at a
wpy�f thia shh�me�msy be fonvardcd oo the Omce ef lave�tleas of tbe DIA tor toverage verMnlie�.
; I 10 Aenby ce ' xnder H�e patws sa n ' of perjrmy that NYe iwfor�nalloh provide�obo►�e is lrue awd uomcR
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� Ptint name �a� Phone# G]v d `� ! ,��6 �
officiat nse onFy do not�vr#e ia this area to 6e cempk�ted by dly or fo�vn e�cial
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i dty or tawn• permifNceffie# ❑BoidinE Departmeat
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i ❑chcch if immedjale rapeme is reqmred ❑Sdat�es's O�ee
❑HealtY De�ardent
� mntact person: phone#; �
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-024 FEE: $50.00
This is to Certify that Bettv 7. Stewart dlbia KnottX Pine Motel
' 24 Vinevard Street. South Yarmouth MA
HAS BEEN GRAlVTED 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 e�ires December 31,2006 unless sooner suspended ar revoked.
; Janu�y a6,Zoo6 so�oF�ai,�: B �`h. �o�o�,ibl.�., •
� ���s�, .�v., v����
� Number of Units: 5 /2�G},Bht�[wt, (�
i /��/ylc�5�ott
� � � t4��j , R.N.
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ruce G.Murphy, H, .,CHO
i � Director of Health
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�� .�. ;�o TO �TN OF YARMOUTH
0N ' +''j ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
� " MATTACMEES � � �
��'Oqp���fp�6���� Telephone (508) 398-2231,Ext. 241 — F� (508) 760-3472
B OARD O F HEALTH G � � C 'I' ��'; I� !�
�1�+`� `�• � lf)i�'�
To: All 2005 Yarmouth Board of Health License/Permit Holde H�ALTH L3����.
From: Yar3nouth Health Department
Re: Tax Identification Numbers
Date: March 22, 2005
' The Massachusetts Depa.rtment 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 tax identification number, whether it be an establishment's Federal
Employer ldentification Number (FEIl� or, in the case of an individual's license, a Social
�
Security Number (SSlv}. This informatiori will be used by the Health Department purely for
administrative purposes only.
",
� Would you plea.se 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 l�ours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The
telephone number is(508) 398-2231, e�. 241.
�
� Establishmen . F �Yl.Q, ��Z�- FEIN or SSN: 0�-�- f���0���
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Location Address: '��, � � � �
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Signature:
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Print: -.f { rT Title:
. . �� Printed
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02•O`:AR o TOWN OF YARMOUTH BOA �.TH � L� C� I� " M L� D
_. -'y APPLICATTON FOR LI S ' �2005 �I
� . ,is ,.
4: A =� ` NOV I 7 2004
r �
* Please complete form and attach all neces ��° ocuinents by Decemb 3�1 004.
Failwe to do so will result in the return ofyour applicataon pack H�LTH DEPT.
NAME OF ESTABLISHIVIENT. v ;vta-- TEL. � � d
LOCATION ADDRESS: 1/ `
MAILING ADDRESS: �a •i3
OWNER/CORPORATION NAME: �SetF� X'avt� Sf art
MANA ER'S NAME: TEL. # ��! -G d
MAILING ADDRESS: �G• G 2G� �
i
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
l. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standazd First Aid
and Community Cardiopulmonary Resuscitation �CPR). Please list these employces 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.
�
i 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 CNiR 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.
I
j PERSON�1V CHAIt�E: -- - - —----- ---- -- _--_ __
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIlVILICH CERTIFICATIONS: �
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your place of business.
l. 2,
; 3• 4-
i
� RESTAURANT SEATING: TOTAL#
� OFFICE USE ONLY
� LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 I MOTEL $50 S�
i _INN $50 CAMP $50 _SWIIviNNIIlJG POOL$75ea.
I _LODGE $50 _TRAII,ER PARK $50 WEIIRLPOOL $?Sea.
FOOD SERVICE:
LICENSE REQiTiRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIIZED FEE PERNIIT#
0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIl2ED FEE PfiRMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
_<50 sq.ft $45 _>25,000 sq.ft. $200 VENDING-FOOD $20
_Q5,000 sq.ft. �75 �FROZENDESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE = S c�O -O�
'"'••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*••*
� � - .
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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'5 COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE�TTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY TF PAID:
YES NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII,ITY TO RETLTRN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. '
SEASONAL ESTABLISHMENTS ARE TO CONTACT TFiE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-�VIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.}, MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COIVIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POQL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of
closing.
FOOD SERVICE
CONSUMER ADVIS�RY:
Each food estab ishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone 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.
FRO��N DESSEitTS:_ _ _ _ __
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
� __�_ � � .,
DATE: �� (/ SIGNATLJRE: �
PRINT NAME& TITLE: �G � @ �,tl d ✓
10/22/04
i
�
�
_---=�� The Commonwealth of Massachusetts
-=- - - Departmest of IAdustrial Accidenls
__ — N�1/irlrl�'�
-_ -- � 600 WashiAgton Stree� 7"�`Floor
i �„�,,, Bostox,Mass. 02111
Workers'Com�aahoa Iasm�ee Affi�vi� �iecdrical Co�lraetors
, ,,„ . . ._ � ., �_. ,_ ,
, � ., � . ��� ,
; name• l�),��'✓i �.1 a�.(a �'�Q.lA�ciJ�,{
' �s- �6 � 1���� �/�J � �
� a� — l9 08�G
; ��s��i«��r �s�-
� ❑ I am a homoownea performing all wadc my�eif. Prajed Type: ❑New Co�a��Rernodel
� � o
I am a sole ' and have no a�e w ' in an ' . ' ' p��
❑ I�ffi�P�Y�T P���W'�kers'comp�satia�fa�my employ�s wo�cing a�this job.
�•
I
� ��
! ,�; ��.
j
;
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; ❑ I am a sole proprietor,gs�eral ca�tracter,or�omeowt�r(iarc,fi owt)and have hirsd tbe co�actois listeci below who have
j the following workeas'compe�a�on polices:
I
,
��:
' �:
�' ni�e�E-
�
I
�•
s1�r: ��
: �
Fa�m^e to sccan e�e as,ey.lrea�sec�a zS�A.tt1�G1.Lu ea.laa h uK i�p�eitly.!'eri.iai pnalKa.ri�e.p a s1,sN�M,�d/.r
ese yean'impr6a�aeat as wr8 n dvi pmkfa ia tLe fira�of a STO!WORK ORDER a�d a 16�e dS1M.N a day ataidt oe. I asdnslud ti�a
c�y�f tib Nale�eet my be firwa�ded M He O�ce otlrnaf�atlys�ttlie DIA fire�v�rage v�iatlw
!do b�eby xeder Nre ' o perjrrry tl Fet dre beforiu�low providel ebovr ia leare aad onmcR
_ -- �L -�f
Signatute 1 �C.C.�� �n ///,6 f(/y
P�,� � � P��#�J 8 °s3 9 y .�/ �Ya
effieial we s'ly do aot wiite ta thi�area te 6e asepided bp ctly ar wwn�ial
city or tews: �# �����
t
❑e6M[if i�iale rdpsme is req�ed �,s Offi
(es�ad�ei'lsB: ph9�t#� ��t�t
,
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
S(JARD OF HEALTH
PERMIT NUMBER: #OS-006 FEE: $50.00
This is to certify that Bettv Jane Stewart d/b/a Knotty Pine Motel
24 Vinevard Street South Yarmout MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
Ttris 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 Massachuselts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Motels�licensed as adopted
by the Board of Health,and expires December 31,2005 unless sooner suspended ar revoked.
December 1 2004 BOARD OF HEALTH: ,B�t�st.�. (��,/�j,�. '
�����, v�e�-�
�st�a�v�
�v.�r , a.�!
ruce G.Murphy, R.S.,CHO
Director af Health
, I
i
1
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i
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�
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I . . �2�� �5d� k�m1 P��
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f_�'A
2 �.R.�o TOWN OF YARMOUTH BOARD O�LAI,T
j � ''�� APPLICATION FOR LICEN /�� �20 � �(�`""'"'~
� � � � b��
°��•. •�� ,,,,� ��
�� +�% yr �3.. .`V.
* Please complete form and attach all necess ` oc nts by D em��3� �0�
Failure to do so will result in the return " our a licatio cket. �o�
Y PP
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A
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• O• �
O N t
A ER' N rf .O 0
P� 6 la .
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 cop1�of the certification t�thas form.
1._� � 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records, You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFIC T�1 IQNS:
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 esta6lishment.
1. �� 2.
,
Ir �E1�SaIyV IIQ CHAffGE: ---___---- _ _ _ -_ . _ _ -—------- __ __ _ --
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. 2•
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
ust rovide new co ies and maintain a file at our lace of business.
You m p p Y P
1. 2.
� �
3.
4.
RF.4TA �ANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM(T# LICENSE REQU[RED FEE PERM[T#
_B&B $50 _CABIN S50 �MOTEL $50 ��'` '�"
_INN $50 _CAMP S50 _SWIMMiNG POOL$75ea.
_LODGE SSO TRAILER PARK S50 _
WHIRLPOOL S75ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS S75 _CONTINENTAL �3Q NON-PROFIT S25
_>100 SEATS 5150 _COMMON VICT. S50 �WHOLESALE S75
I RETAIL SERVICE:
i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM(T# L[CENSE REQUIRED FEE PERM(T#
�
<50 sq.ft. $45 _>25,000 sq.R. $200 _VENDING-FOOD $20
<25,000 sq.ft. S75 _FR07..EN DF..SSI:RT S35 _TOBACCO �25
NAME CHANGE. $to AMOUNT DUE = S 5 a •��
**"•*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 ',
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE '
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSIIRANCE ATTACHED
� �WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY T4 RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHIVI�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 '
DAYS PRIOR TO OPENING FOR THE SEASON. i
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIFMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL RFGULATION
POOLS
POOL OPE1�tING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening,and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered withm seven(7)days of
closing.
FOOD SERVICE
CONSLTMFR AI�VISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERi_NG 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.
FR(3�1'+I-:�F�ERTS: _ — _ _ _
Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE C�1+'F:�:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOOR COOI N�
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prnhibited.
pA�:_�G� (/` SIGNATURE: — ��
PRINT NAME&TITLE: ; �f�vt� S —
10/22/03
. �- �
The Contmonwealth of Massachusetts
� � Department ojlndustrial,-�ccidents
� ; olflceoll�►es�l�s�iis
I + 600 Washington S�reet
' ,,= Boston,Mass. 02111
'' �" �� W'orkers' Compensation Insurance Affidavit
;
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� n m•� Q.l-C1C_ LU�Y
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- , v��it . Q �� �5 �39 -d� �
� 1 am a homecwn r pertormin,all �ork myself.
� I am a sole proprieror�-,�, ha�e no one���orkin_ in anv capacit�•
� I am an emplover pro�i�in�w�orkers' compensation for m��employees w�orkine on this job.
�
m an • n
S � . /
dre.s: T
� ' C./
a�i r��/ f/�.�%LL.�.G,�I7 /'� /'� � �C/�/S�- 7'
�Ul1 ' � � - � �
i�surance co. policy!�
� I am a sole proprietor. generai contractor, or homeow�ner(circle oneJ and ha�•e hired the contractors listed below ��ho ha�e
the follo��in_ ��orkzr�� �ompensation polices:
somQanv�ame•
address•
�i�y: ohone k•
insurancc co. polic}#
com�ny name: -- - -- — __
address•
t►h'r nhone i�•
insurance co. �iier if
�
Failu�e to sccure coverage as required under Secnoo 25A of MGL 1S2 ea�lad to tre iopaidoe of trioi�d pe�dtles of a O�e ap to S1�00.00 a�d/or
one vears'imprisonment as w�ell aa eiril penaide�io the form of a STOP WORK ORDER aed a Aae of SI00.00 a day apin�t ma I a�dersn�d that a
copy ot th'n statement mav be fonv�rded to the ORice of Imatig�tioos of the DIA tor eoveraae veritipdo�.
!do hrreby certif}�un rhe poins and enal�ies ojperj "/�rrn nration rovided abovt is true aad evrr�et
Signature � ��/ d�/�
Printname oneK;���I"��1 ��U ��
.. ofTicia! use onl. do not write in this area to be completed by citv or towa oAleial
eity or town: YA��IIT$ _ permitAieenx M n8uiidiog Departmeot
QLicensipe Board
�check if immediate response i�required 261 �Stleetmen'�Oliitt
�HesitA Depanmeat
contact person: p�o��p;_ (508� 398�2231 eat. nOther
.. ._� .< �,,:
e
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #04-002 FEE: $50.00
This is to Certify that Betty Jane Stewart d/b/a Knotty Pine Motel
24 Vineyard Street, South Yarmouth,MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This License is issued in conformity with the authority granted to the Board of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisioas ofthe Laws ofthe Commonwealth ofMassachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations itt regard to said Motels so licensed as adopted
by the Board ofHealth,and expires December 31,2004 unless sooner suspended or revoked.
November 4.2003 BOARD OF HEALTH: �i�c�ctNrlwc�. �l°ad°u. �.�., �al�ttirci�c
�adriek 7XdDrn.,�ot'�, 2/iee ,(�,haar.�ca.�
,�odr�t�. �roe�, ,(,�lar�e
_ _ ._�ele�c-S�� .7Z. ___.
� ruce G.Murphy,MP ,CHO
; Director of Health
;
�
a
;
;
�
i
�
,
� + kn�oTr4 P�NE
" ���aR.�o TOWN OF YARMOUTH BOARD OF HEALTH
�: ,�'a APPLICATION FOR LICENSE/PERMIT-� 3� �� � � [, � � � [�
* Please complete form and attach all necessary doc t�`. yb�ce� er��OQ2$ Za��
Failure to do so will result in the return of o lication ac et.
Y : P
° NEALTN D�PT
S
A I S •
P 4. IG — �
C T N
�
�-✓ T 8- 9 -OB'S�G
D ,--
POOL CFRTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
' Pool Ope�ator(s}a�attach a eopy of the certifieatio�to�his form:
l. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION 1VLANAGERS - CERTIFICATIONS•
All food service establishments are required to have at least one full-time em�loyee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Esta.blishments, 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,
; -- AF�n�AT�I l��'i�_._
_ _ — _ - - - - _
' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2,
�]Y�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 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.
�
E
' 1• 2.
;
i 3• 4.
� RF TA RA1vT SEATIN : TOTAL#
,
OFFICE ITCF'ONLy
�.ODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT#
_s&B $so c�n�r $so I Mo�r. $so �Q3-a6/
�I1�1N $50 _CAMP $50 _SWIl�IMING POOL$SOea.
_LODGE $50 _TRAILER PARK $50 _WHIRLPOOL �25ea
�OOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $I50 _COMMON VICT. $50 _WHOLESALE $75
�TAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 <25,ppp sc�,ft. $75 �TOBACCO $20
_<50 sq.ft. $45 _,>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: �io AMOUNT DUE _ $ 50•00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'�***
f
_ ,,
� � y .
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHEB
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 RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2002.
SE�ISONAL ESTABLIS��IENTS 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 OPEI�TING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of :
closing.
FOOD SERVICE
CONSUMER ADVISORY•
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
------—
- Frozen desserts must�e t��te$o�-a inonth�y�asis by a Sfa�e certified Iab: Test resuIts must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
:�
��o��z� �
DATE: � � SIGNATURE: �
PR1NT NAME & TITLE: Vf — ��
10/18/02
i
. �\
. .. The Coin�onweafth of Massachasetrs
- _ `� � Department ojlnd�tstriQ/.�cciden�s
. _ _ _
_ • o �t►I�s�/ir�►osd� __
; 6b0 Wusbington Slreet
,' Boston.Mass. 02111
" Workers' Compens9tion Insur9nce Aftidavit
c.0 v f .
����: l�l (�J��'� h �- I�-�� �, r!�G r/l U
� c� �
. � .
�
� I am a homeou er pertorming aU wo myself.
(� I am a solz proprietor_r.� ha�e no one ti.•orkine in am•capacin
� I am an employ r pro�idins workers' compensacioo for m�employees working on this job.
m ' Y� U � (J 1/(�QI�
� • p� � •
. � �� � ` �a�� -d� �
r �- � �- — �• CJ
! � I am a sole proprietor. �enera!contractor,or homeowner(circle onel and ha�e hircd the contractors listed below• Nho ha��
thr follua�in_«orkers' �ompensation polices:
�omoatnv name•
address•
I ,
� .
��� ehens�•
(
j insur�ncc co. F�Y�
tomeanv nAme•
i
�
��dress•
eitsr: A�IIA��; .., _.�...�___...__ .
insur�nce ce. ' ��
r ,.
�, .�,� .,
Fsilure tu xcure coren�e.:s rtqyirrd uadtr Seetioa 2SA of MGL IS2 n�le�d to tre i�oitKp�i�i�d pe�Iqe�o�i A�e sp te s�,SppAO ud/or n
ane yean'isprisos�neat as well'a�eivil pesalttp j�tAe fons�a STOT WORK ORDER'aN`�AfE sf 519�.N s A�y qdat s� t��deesra�d t�at a
� copY of thh sntemcnt m�r be tarrardcd to Me OQice of lavatl�atiom o�f�e DU for eovera�sreriAqdN,
/do•hereb ctnifj• dtr�he poins ond ptealtits ojp ' ry rhat tbe injonmdow p�nvidal oboMe is�rae awd eorms
Signature • �.._ _ ���� _
�
Print name � �Q�� 9� �(��0
_ _ . _
. officiaf ux onh do not w►ite in tbis ares ro be eompleted by dty or Ww�ollkhl
eiry or town: Y��T�i _ . . persitAieeax N nBuildio;Deparnneot
pUeeosio�Bo�rd
�ehtck if immcdi�te response i�required 261 �Seleetmee'a Olfiee
p P��M;_ (508) 398-2231 ext. �Ot6erh Departmeot
con�act enoa•
un�,eo;�c VIM - .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #03-001 FEE: $50.00
This is to Certify that Bettv Stewart dJbJa Knotty Pine Motel
24 Vineyazd Street, South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This Lic�se is issued in confvrmity with the aufhority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B,
32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of�e Commonwealth ofMassachusetts relating
thereto,and upon such terms and conditio�,and to the rules and regulations in regard to said Cabins so liceT►sed as adopted
by the Boazd of Health,and expires December 31,2003 unless sooner suspended or revoked.
November 8 ,2002 BOARD OF HEALTH: �a�tlee.'�, i��, ��ra�c
_ _ __ _ -_
�e.�cfa�D. Gio�d�. �9JC.D::�iee- �
�a�rt�, b�raacac, L�
�a�zf��e�aaMcot'r
��s�. ��t
�
�
;
� ruce G.Murphy, .S.,CHO
j �� � � Director of Health
�
;
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a
� _ - :=
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,
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* � KNo`f7t{ PtNE
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TOWN _ RD OF HEALTH ` Y,,r, _ _ _,_.�
APPLIG ' IO E/PERMIT-2002 � �'; � '� � �'
,t��� i r �8`50• 6 O t ' �; `� �.� ����;
* Please complete form and attach all necessary documents by December 31, 2001. F ilure to do so wi re lt in
the return of your application packet. I-i EAl_�t � i i��i:.
AME ESTABLISHMENT: �' TEL. # ► �
IO `
MAILING ADDRESS: . �
WN R/ O E:
E 'S NAME: `- � ►^ ' TEL. # ��J �O
! MAILING ADDRESS: ��� � I��t/� �Jb � cS o� V�r YIllo c�� �a� ����n� �
�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
ii Pool Operator(s) and attach a copy of the certification to this form. ��.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a fde at your place of business.
l. 2.
i
3. 4.
1
i
�
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.
�
I
; PERSON IN CHARGE: __ .. --- --- ---- _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service esta.blishments 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-cholcing 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.
�
;
I RESTAURANT SEATING: TOTAL#
I
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_BBcB $50 _CABIN $50 I MOTEL $50 �O a���O
_INN $50 _CE1MP $50 _SWIMMING POOL$SOea.
_LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75
�tETAIL SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 <25,000 sq.ft. $75 _TOBACCO $20
_<50 sq.ft. $45 >25,000 sq.ft. $200 FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ �Sp.n n
. *****PLEASE TLJRN OVER AND COMPLETE OTHER SIDE OF FORM*****
��
�___ _ . _
��. _ ��.���� <`�' � _ �
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
�
V�JORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY 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
C'ONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
("ATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. T'hses forms can be
obtamed at the Health Department.
- - — -- - -- ---------- _ _ _
FRn7FN DESSERTS•
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus 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: SIGNATURE:
PR1NT NAME&TITLE:
09/11/O1 -
;
, . �. �
The Commonwealth ojMassQchusetts
i � � Department ojlndustrial.-�ccidents
� � a 011lceo/%st/�stliis
� 600 Washington Slreet
' � Boston,Mass. 02111
�~ ��y W'orkers' Compensation Insurance Affidavit
A�nlicant information• ples«pR -�•
n�m� �ZY^��! Y V� � ���1:(]� ✓T
locati�n: fo�� � C6`GJZLi �!-Lcp , �./�� �0����
tit� �u `��i A1/n� !,r 1 Y \CL- i ��(O� 7' nhone� . U�`�%�v 0 d�Q
�I am a homeow er pert�rmin,a w�ork myself.
� I am a sole proprieror=-,', ha�e no one ��orkine in am•capacin�
� I am an emplo�er pro���ins w�orkers' compensation for my employ�ees w•orking on this job.
�omnam• name: !�/' ,� _ -
�ddress•
citv: 2hons q•
�
i�surance ca oolicy#
� l am a sole proprietor. generai contractor, or homeowner(circle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu�cin_ «orker� ,ompensation polices:
sQmoanv n�me• �I l
address
titti'• nhone k•
insurance co. ooli f•#
comoanv namr.
-- — ----- _ ___-
ad d resr.
�ri� ohoee+�•
insurance co. 2�n,�
•
Failu�e to seeure coverage as required under Seenon SSA of MGL 152 a�Ipd to tbt iopaiboe of crioi�al pesaitlef of a A�e op to 31,500.00 a�d/or
one yean'imprisonment as w�cll aa eivil penaitits io the form of a STOP WORK ORDER aad a tiae otSI00.00 a day apio�t ma [a■dena.d c6a�a
copy of thie statement mav be forrvarded to tht OlTice of Inveetigttioru of tbe DU for eoven�e veriflutio�.
/do hrreby cer�ij}•under rbe pains and prnalties of perju thet rhe injorneation provedtd abovt ts tnre end coneet
Signatur � I�/ �� �
Print name�.�Y' '1�� � ���(� a. 1r� PhoneN�,���13 ' � l! `''60 ��
.. o(Ticial use onl. do not+.rite in this area to be completed by eiry or town oAkia!
city or town: YA��DT� _ permitAieease q nBuilding Departmeot
�Liceasiog Board
�check i(immediate response i�required 261 �Selectmen's Ofrce
�HeaitA Depanment
contact person: p�o��p;_ (508) 398�2231 ezt. nOther
v
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #02-040 FEE: $50.00
This is to Certify that Carleton J Beriy Stewart d/b/a Knottv Pine Motel
24 VineYazd 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 tlie Laws of the Commonwealth of
Massachusetts relating thereto,and upon such terms and conditions,and to the rules and regulations in regard to sa.id
Cabins so licensed as adopted by the Board of Health,and expires December 31,2002 unless sooner suspended or
revoked.
May 16 ,2002 BOARD OF HEALTH: � zeP,ll�c,
��D. G�ardo�. .�iee
�o�t� �c, elr�rk
�a�itek'�ar«rot�'
� S . �
�
ti
' ruce G.Murphy, S.,CHO
Director of Health
i � �
;
1
;
I
;
�
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_ ,-. � ` � a o r� l�i�vE Mo�
w '.� � �i l+� ' (..
�� E
�°�� �._ o rL �� r- %� �� D
(� _ ,
TOWN OF YARMOUTH BOARD OF HEALT D E C 0 6 2000
APPLICATION FOR LICENSE/PERMIT-2001
' '-��::.'�.i._,�:.i �;EPT.
* Please complete form and attach all necessary documents by December 31, 2000. Failure��tcs'c��"s'�'v�i�i�
the return of your application packet.
, -------------------------------------------- -- ------------ ------- -------------- ------------------------------------------------------
.� � � ,D
� Q
N
. � rt n s? r �Q
;
�C/r /lJ� �s -�/
�OOL CERTIF�CA��ONS:
; The pool aupervisor must be certified as a Pool Operator, �s rec�uired by new State law. Please list the
; designated Pool Operator(s)and attach a copy of the certification to this form.
; l. 2.
,
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscita.tion(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. Yoa must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
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
i attach copies of employee certifications to this form. The Health Department will not a�e past years' records.
You must prnvide new copies and maintain a file at your place of business.
1. 2.
3. 4.
;
i RESTAURANT SEATING: TOTAL# NON-SM4KING SEATS: TOTAL#
,
� - --- - - ----- - -- ----------------------------------------- -
---------------- --- -------- ---- -------- ---
--------- ---------- ---------- ----------
' QFFICE USE ONLY
' LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT#
B&B $50 CABIN $50
; _INN $50 lCAMP $50
i
LODGE $50 TRAILER PARK $50
i / MOTEL $50 – �p �SWIMMING POOL $SOea.
� —
i WHIRLP40L $25ea.
j FOOD SERVICE: �
; NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for
food protection manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAI., $30
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETA L S RVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
_<25,000 sq.ft. $75 ____FROZEN DESSERT $35
!>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ 50.00
***k*PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM*****
.,_._ ...
� �I
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLIS�-IlvIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGUL T,�A IONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State
certified lab,prior to opemng,and quarterly thereafter.
_ _
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
NF,�,�T,ATE SANITARY CODE FOR FOOD ESTABLISHMENTS�
The effective date for food protection manager certification is October 1, 2Q01. As stated in 105 CMR
590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection
manager. This provision is effective one year from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement
of Consumer advisory,Food Code 3-603.1 l,will be implemented January 1,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
requued Temporary Food Service Application form 72 hours prior to the catered event. T'hses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
QUTSIDE 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: l o'Z a`7 ��C�i SIGNATU ' ��C�
PRINT NAME&TITL � �(l�a✓ — Dl� K��'
11/16/00
, A �
, _ The Commonwealth of Massachusetts
� � W Department ojlndustrial Accidents
^ o Of1/C001/OY@S��f�Ilt
� 600 Waskington Street
, �,�` Boston,Mass. 02111
" "• W'orkers' Compensation Insurance Affidavit
A�olicant information: P`IeasePR�I'�
�.���
� �n m•:
` � � r e�
cit� ,� � �Y � Q L(���1. , �,�-� V �(�(l phone# b�0��c3�J "U�/
� I am a homeowner pertorming all work myself.
�I am a sole proprietor�:;� ha�e no one ���orkin� in am•capaciry
� I am an employer pro�idino workers' compensation for my employees working on this job.
com�n�� name•
address:
ciri•• phone#• _
ins�r�nce co policy#
� I am a sole proprietor. ;eneral contractor, or homeowner{circle one/ and ha��e hired the contractors listed below «ho ha�e
the follu��in���orl:er' �ompensation polices:
�QmP�nv name• --
address•
�y• Fhone#• _
i�sur�ncc co poli�,y:#
company name•
--- — -
-------___ _
---- -
_ __ __------ —
addr ss• - _ ___----
�y: - - Fhone 1�•
insnranr��n_ ROIi,,
Failure to secure coverage as required under Secrioo 25A of MGL 1S2 eae lad to tbe imposidon oterioi�fl peaaltia of a tioe ap to SI�00.00 a�d/or
oae yean'imprisonment as w•ell a�civil penaltia io t6e[orm of a STOP WORK ORDER aed a tine of 5100.00 a day a�aiost ma [a�dersta�d t6at a
copy of thi�statement may be forwarded to the OfTiee of Inve�tigatioa�of tbe DU for eovenge verilieatio�.
I do hrreby certi �under rhe parns and enalties of perjury tha�!he rnjornwtion providtd ebovt is true and eorrtet
Signature � su �a„1 Q 7/�G d �
Print nam � 1 ��c�-� � Phone#���d=� ��7(J
., otTicial use onh• do not w rite in this are�to be completed by city or town otlicial
ciry or town: Y�M�IITQ _ permit/lieeese q nBuilding Department
pLiceasiog Board
�check if immediate response is required 261 QSdectmen's OfTiee
�H-alth Departmeet
contact person: phone q;_ �508} 398--2231 egt. nOther
(recised i;95 P1A1 �
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' TOWN OF YARMOUTH BOARD OF HEALTH � � � � � � � �
� :� .,
APPLICATION FOR LICENSE/PERMIT-2000 N 0 V 1 6 1999
� __
* Please complete form and attach all necessary documents by�De�ember�31,�1999. F ' t in
the return of your application packet. - �� f � � °- -' ��
------------------------------------------- ---- ---- ----- --- ---------------����---�--------- - •
F E S u � -- ;� - ---- T -- -_��---��- --
L ATI � �U�
L D v
�
r t' # ` : �
D � /
� ��5� �� (��. _ � 2(�6� �
` POOL CERTIFICATi�NS- � -------------------------------------------------------------------------------�
� The pool s�ervissr must �E cerf'if'i�tl�s � Paol O�erator,_as ret�aired by new State law, Please list the
desi�nated Pool Operator(s) and attach a copy of the certification to tlus form. ��
.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Dep�rtment will not use past years' records. You must provide
new copies and maintain a file at your place of business.
1. 2,
3. 4.
� HEIlbII,ICH CERTiFTCATTnNS. �U�}-
� 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 yc�ur employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department wilt not use past years' records.
You must provide ne�v copies and maintain a fde at your place of business.
1. 2,
3. 4.
� RESTALrRAIVT SEATING: TOTAL,�# - ND�T-SM4I�I�TG S�AT�: '�A��#--
� ----------------------------------------•---------------UFFrCF IJ�S�NLY^�---------------------------------------------------------•
�
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERNIIT#
B&B $50 CABIN $50
' INN $50 CAMP $50
; —
T..ODGE $50 TRAII.,ER PARK $50
I MOTEL $50 Z C— _SWIMIVIING POOL $SOea.
� WI�LPOOL $25ea.
� FOOD SERVI .F:
i
� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 �CONTINENTAL $30
_>100 SEATS $150 NON-PROFIT $25
_COMM4N VICT. $50 � WHOLESALE $75
RETAII., 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. $200
NAME CHA�IGE• $10
AMOUNT DUE = $�C�_
*""""PLEASE T(JRN dVER AND COMPLETE OTf�R SIDE OF FORM""•"•
' : .. � ADMINISTRATTON �,
UNDER CHEIPTER 132, $ECTION 25C, SUBSECTION 6, 'THE T4WN OF YARMOUTH IS NOW REQ�J�kED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE QR PERMIT TO OPERATE A BUSINESS IF A
PER�.C�l�-�Ol��-�C���1�IY 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 ATTAC�D
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID►PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES � NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 3I. IT IS YOUR
RE5PONSIBILITY TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIRED FE�(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISFIaVIENTS ARE TO CONTACT THE HE.ALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR T4 OPENING FOR THE 5EASON.
ALL RENOVATIONS TO ANY F�OD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMNIENCEM�NT. RENOVATIONS MAY REQUIRE A SITE PLAN.
Ai�DITI4NAL_REGULATIONS
POOLS
POOL OPENING: ALL SVVIlVIlVIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CL4SED FOR
THE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTN�NT, AND T�3E WATER TESTED FOR
PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER.
POOL CLOSING:EVERY OUTDOOR iN GROUND SWIlVIlVIIlVG POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE '
C�TERING POLICY �(-�-
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIF'Y THE YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH
DEPARTMENT.
FROZEN DESSERTS�
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN TI-�E
SUSPENSION ORREVOCATION OF YOURFROZENDESSERT PERNIIT UNTIL THE ABOVE TERMS HAVE
_ --._ _
----- -- — —___ __
- - --- __
BEEN MET.
QUTSIDE CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),1_V([JST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
OtTT'�OOR COOKING�
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLIS��VIENT IS PROHIBITED.
DATE: � �� � _SIGNATURE: ����
i
PR1NT NAME& TITLE: ���� �S - ��UJ � v� �
11/12/99
i
�
��
The Conrmonwealth of Massachusetts
� Deparlmenl ojlndustrial,-�ccideats
� w J
_ o OfIICO 0//OrCS���dIlt
600 Washington S�reet
' ` Bnston.Mass. 02111
.
�~ ��y W'orkers' Compensation Insurance Affidavit
n�mr
location:
�it� ehone#
� ( am a homeow�ner pertormm�all work myself.
�, I am � sole proprieror�r.� ha�e no one ��orkin� in am•capacin�
� I am an �m�ta�erpro�r�i�-�vc�rkefs'-ee�er�satio�-fs�-���Emplw�ees_�orkin��n this job. -��' -
; comnan�• name•
address•
zitv-
ehone�
insurance co. ��Y�
� I am a sole proprietor. _eneral contractor, or homeowner(circle aneJ and ha�•e hired the contractors listed below ��ho ha�e
the follu�cin� ��orker_� ,ompensation polices:
i comoanv �ame•
i
�
�
�ddress•
;
� ���� rzhons M
i
s
� IIISUfBOCC C9. F��IC�'�
i
m n n
-- - - - — --- - --------
----- ---- -- _
a�dress:
ciLY: nh�ne_.+�
insurance co. ��y,*
t
Failure to secure coverage as�equ�red uoder Secnoo 25A of MGL 1S2 ea�lad to the iopo�idoa of erisi�al peaaltla of a ti�e op to 51.500.00 a�d/or
one years'imprisonment a�w•ell a�cirii peaalda io the form of�STOP WORK ORDER aad a Bse of 5100.00 a dar a�aio�t ma t r�dersta�d t�at a
eopy of thy statement may be fonvarded to the ORice of Iave�tig�tioos of the DtA tor eovenge veritiqtio�,
/do hrreby cert' •under the parns en at�i�s ojperjury that the injornration provid�d obovt is tnre and evneet
Signature � !1/�rO��y
Print nam -l. � �v� oneJl .'��l1 � ����sd��
•. a(Ticia! use only do not..�ite in this ares to bt completed by citr or town otlkial
ciry or town: Y�M�DTfI _ permit/Ilcense a nBuilding Departmeot
�Lieeosiog Board
❑eheek if immediate response i�required 261 �Selectmen'e ORee
pHealtb Departmeot
cont�ce person: phone N;_ t508� 398�2231 eat. nOther
.. < a,,:
:.. THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-1 FEE: $50.00
This is to Certify that Carleton J.Bettv Stewart d/b/a Knottv Pine Motel
24 Vinevard 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 ofthe Commonwealth of Massachusetts relating
thereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted
by the Board of Health,and expires December 31,2000 unless sooner suspended or revoked.
November 23 , 1999 BOARD OF HEALTH: �c`� �atfee, (..�rairman
�oan� �u6[iwar�, K.//, Vice (_.�irman
�o�srE.}. /�rown
a�rielle�ako[el�y✓�tooPe�
��10�0��1,�
Bruce G.Murphy,MPH, .5., HO
Director of Health
T
� . Q � , �`�y�\ �Yl ' �M'l� �(��
TOWN OF YARMOUTH BOARD OF HEALTH � � � � l� ��`� « �
APPLICATION FOR LIC���PERMIT- 1� j�t�; � � ���g
� rt� ,,
* Please complete form and attach all necessary documents�y De�eem�b�r��, �19'8: F ' � � ! �c��H�Fes t in
the return of your application packet.
' --------------------------------------------------------------------------------------------------------------------------------------�--
TAB : �v�-0 i Y�C- # -D O
� A I N D S: `� � � . l
M •O�
RAT N N
� ER' N � `� �� L. #
j MAILING ADDRESS: �.U PJ�rG y�!
!. -----------------------------------------------------------------------------------------------------------------------------------------
,
; 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 tlus form.
1. � �}' 2. (" f '
Pool operators must list a minimum of two emp loyees currently 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 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. 2.
3. 4.
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 all times. Please list your employees trained in anti-chokuig procedures below and
� attach copies of employee certifications to this form. The Health Department witt not use past years' records.
� Yau must provide new copies and maintain a f�le at your place of business.
I
L 2.
3. 4.
I
�
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
----------- - ----- ---- --------------------- -- -� _ __ _-- _ _ _ _
_ _ _ _ . _ flF���-�7SE O��.Y _ _ _ _
a LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
B&B $50 CABIN $50
� _INN $50 _CAMP $50
LODGE $50 TRAII,ER PARK $50
i �MOTEL $50 ����^� _SVVIMMING PQOL $SOea.
WHIIi,LPOpL $25ea.
FOQD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT #
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 N('IN-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAII.SE�tVICE:
LICENSE REQUIRED FEE �ERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $25
>25,000 sq.ft. $200
�iAME CHANGE: $10
AMOUNT DUE _ $�
*""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""""
_. _ . _.., j � �
ADMINISTRATION
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED
TO'HOLD TSSiTAATGE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PERSON OR COMPANY DOES I�TOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. THE ATTACHED STA'Y'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 1..�� NO
NOTICE: PERMITS RUN ANN[JALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 L?AYS PRIOR TO OPENING FOR TI-� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISF�VIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQilIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO COMIV�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENII�TG: ALL SVVIlVIlVIING, WADING AND WHIltLPOOL5 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 OPENII�tG, AND QUARTERLY TF-�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SVVIlVIl�IING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOUD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN TI-� 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 DEPARTMENT.
�N 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 WII,L RESLJLT IN
TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DES 5ERT PERMIT UNTIL TI-�ABOVE TERMS
- -- — —-- _ - -- - --
- -
_ _ . --------------— __
HAVE BEEN 1V�T. __ _ -
OUTSIDE CAFES:
OIITSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
�UTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD
SERVICE ESTABLISHIVIENT IS PROHIBITED.
DATE: / SIGNATURE� .�--�--'��-��-�-����'� ,
,
PRINT NAME& TITLE: �V I'�'�7JV] S •' �-}1"�-tx-� a-�.-t ��/ti��
k
1 ,
� , , �
_ The Common wealth of Massach usetts
;
� W Department ojlndustria/.accidents
i � a Of/Ice ol/�st/oslJ�is
! � 600 Washington Street
� ' y\�y Boston,Mass. 02111
1 �,
? '�� W'orkers' Compensation Insurance Affidavit
,
� Aoolicant information: PlessePR�'I'T�d.'h�
� -
� n�m•: CllZ,`�'
3 � a 'o : � � � ��� �
� � L fLc q �� .
� � I am a homeo er pertorming ali �ork myself.
� �I am a sole proprietor��� ha�e no ne ��orkin� in am•capacity
� � I am an empiover pro�idin�workers' compensation for my employees w•orking on this job.
� : -- ___ _ _
C � _: . ___ . . _ _ _ .'._
m o • n
address: �Y' d,(t�l.� �.
� � � • �.J�� � �i 7'�-i
i i
� insur:►nce co. � li #
i
� I am a sole proprietor. _eneral contractor, or homeowner(circle onel and ha��e hired the contractors listed below «ho Ma�e
the follo��in� ��orker�� �ompensation polices:
companv name•
address•
ci�y: phone#•
insurancc co. Qolicy#
�'i sQm a�ny name:
_ _ _— -----
--_ __ - ----
-
a dress: ----
�: phoee i{•
' iesurance co. p�y it
Failure to secure coverage as�equired under Secdoo 25A of MGL iS2 e��lad to tYe iopai000 oterisi�l pe�altla of a O�e op to Sl*500.00 a�d/or
one yean'imprisonment a�w�ell aa civil penalde�io the form of s STOP WORK ORDER and a fiee of 5100.00 a day apiest ma I a�dersa�d ma�a
eopy of thi�statement may be fonvarded to the OtTice of Inve�tig�tion�ottbe DU for eovente veritiatia.
/do hrreby cerrij}�under�he pains and penalties ojpery'ury that the rnjornwtion provided abovt is tnre and eorr�et
Signaturc Dau �Z///�/I
Print name���P T� -S - ���\A� �Y� �" Phone# �� U d ' c"� 7 7'' d��
.- o(Ticial use only do not write in this ara to be completed by ciry or town otficial
ciry or town: Y��IIT� _ permit/lieense k nBuildiog Departmeot
�Lictasing Board
p eheck if immediate response is required 261 ❑Seleetmen's Otliee
(508) 398�2231 egt. �Healtb Department
contact person: phone N;_ _� nOther
Ue��ised i;o5 P1A1
f , ' ' . _ .
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
� PERMIT NUMBER: 99-9 ' FEE: $50.00
This is to cerafy that Carleton J.Bett,y Stewart d/b/a Knottv Pine Motel
24 Vine,yard Street, South Yarmouth. MA
HAS BEEN GRANTED A LICENSE TO
OPERATE MOTELS
This Licease is issued'm conformity witl�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 regazd to said Cabins so licensed as adopted
by the Board of Health,and eapires December 31, 1999 unless sooner suspended or revoked. '
December 17 , 1998 BOARD OF HEALTH: �c`� �af,f.e�, ��i.airmare
�oan� �ullivan�/�.�� Vice l.hairmaic
Kobert}. �rowrc
a�riel[e Jahof��cf-�htooPee
• �6�0' ��.�.
�
� ruce G. Murphy,MPH,RS., HO
Director of Health
�
I
�
�
;
i