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Home My WebLink AboutApplications, WC and Licenses �� > ''��•s_. ._..,"�AlZ. Lo y�GE�f 2z7o � .: ' � TOWN OF YARMOUTH BOARD OF HEALT$ r � � APPLICATION FOR LICENSE/PE 0 �� D 4 �oO �• * Please complete form and attach all necessary � e�,� ecer► �I�20�8 $ Failure to do so will result in the return of . r apphcation pa e�EALTH DEPT. NAME OF ESTABLISHMENT: ✓��,�►10�... I`i/��,• C.�o Ic.,�� -�27v TEL. # 5�� -34y'—S—�S'/ LOCATIONADDRESS: �3`f 12�I' �2g, , LScz 4�q��kt.`, /K,� t»r,.��/ MAILING ADDRESS: o � e� �Zb� OWNER NAME: TAX ID (FEIN or SSNI: b�f2-(o�ZI o COR.ROR.ATION NAME (IF APPLICABLE): MANAGER'S NAME: v�� S N�r�� TEL. #�'�O��39�/-b�5'I MAILING ADDRESS: /�� 3flx- � g(o , So S'�ae--r►lo�:k.•, P►'�� c7 Z.l�� 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 form. l. 2. Pool operators must list a minimum of two emp loyees cunently certified in basic water safety,standa�d First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these empioyees below and attach copies of employee certifications to this form. The Health Department �vill not use past years' records. Yau must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one full-time employee who is cei-tified 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 applicatian. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1.__ �cJ4� s�e�c�z--� 2. PER�ON IN CI3A�ZGE: — --- _ — ____ __ __ Each food establishment must have at least one Personln Charge (PIC) on site during hours of operation. 1. /�c1C'� s�1e��✓� 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-chokuig procedures below and attach copies of empioyee certifications to this form. The Health Department will not use past years' records. You must pravide new copies and maintain a file at your place of business. l. L7`tfi� S�e,-� �cil 2. _.�o��.� if✓l vc-��h.� 3. �-en e-� �7n�-c.�.� L l 4 _ �.S'�cr.�� .� ��l� RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER.NIIT# LICENSE REQUIRED FEE PERNII7# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN $55 _MOTEL �55 _INN S55 _GAMP S5� _SWIMMINGPOOL �SOea. _LODGE S55 _TRAILERPARK �105 WHIRLPOOL �80ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S8� _CONTINENTAL �35 f NON-PROFIT �30 �� _>1Q0 SEATS �160 �COMMON VIC. �60 VNHOLESALE S80 RETAIL SER��ICE: —RESID.KITCHEN �80 LICENSE REQLTIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<�0 sq.f�. �50 _>25,000 sq.ft. �225 VENDING-FOOD �25 _<25,000 sq.ft. S80 _FROZEN DESSERT $40 TOBACCO �a55 ��-z�c��cE: sio AMOUNT DUE = S �30.00 *'***PLEASE TUR1Y OVER Ai�TD C0�4IPLETE UTHER SIDE OF FOR�VI****• i ; _�1"*._ �� " . � � y' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS AND O�iER LODG�TG ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 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 Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days pnor to opening.PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been mspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7) days of closing. FOOD SERVICE ' CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern 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 until the above terms ha.ve been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking, rp eparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETLIRN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I � // (�� SIGNATURE: PRINTNAME&TITLE: / � Lt� She�-� �zn — l�c�r►1 ►�n �s �s�� io.�zzros . , ACORD,M CERTIFICATE OF LIABILITY INSURANCE °"� PRODUCER I 0 3-2 4-2 0 0 8 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NdT AMEND, EXTEND OR 5 5112 9 P: {g 6 6)4 6 7-8 7 3 0 F: (7 0 4) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 29611 CHARLOTTE NC 28229 INSURERS AFFORDING COVERAGE INSURED INSURERA:TW111 Clt Fire Ins CO INSURER& #2270 MOOSE LODGE ,INSURERC: . pO $�X ,-�� INSURER D: j � S4UTH YARMOUTH MA 0 2 6 6 4 j in,suRFR E: I ; COVERAGES � THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ! ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY Bf ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGA7E LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXMRATION � _ �Tp TYPE OF INSUHANCE POL�CY NUMBEfl DATE MM/DD/YY DATE MMlDD/YY LIMITS . OENEpAI LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY FIRE DAMAGE tAny one firel S CLAIMS MADE U OCCUR MED EXP IAny one person) S , I �PERSONAL d�AD'J iNJURY S i GENERALAGGREGATE S � GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG � S POLICY PR� LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BO�ILY INJURY S SCHEDULED AUTOS (� Per person) �_ HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ I IPer accidentl 6ARAGE LIABILITY I AUTO ONLY-EA ACqDENT I 5 . ANY AUTO - - OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS LIABILITY EACH OCCURRENCE S OCCUR u CLAIMS MADE AGGREGATE g S DEDUCTIBLE � $ RETENTION S $ WOHKERS COMPENSA110N AND X ORY LIM TS �ER A EMPLOYERS'LIABILITY 8 3 WBG AY 1016 0 5/01/0 8 0 5/O 1/0 9 E.L.EACH ACCIDENT S 1.�� 0 I E.L.DISEASE-EA EMPLOYEE� 8 Z O O � O O Q E.L.�ISEASE-POLICY LIMIT S rJ O l7� O O O OTHER I DESCRIPTION OF OPERATIONS/LOCATIONSNEHtCLES/EXCLUSIONS ADDED BY ENDOflSEMENT/SPECIAL PROYISIONS Those usual to the Insured' s Operations . � � � � i CERTIFICATE HOLDER i ADDITIONAL INSURED;INSURER LETTER: CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE iSSU1NG INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE !Donal d Sul1 ivan HOLDER NAMED TO THE LEFT, BUT FAIUIRE TO DO SO SHAI_L IMPOSE NO i OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSUHER, ITS AGENTS OR PO BOX $ REPRESENTATIVES. Bass River, MA 02664 A ORI D R ESEN ATflC�_ I M�3\\� BE p' s �- Itl<< �� L� y "+r'-- ..—� ACORD 25-5 17/97) �'ACORD CORPORATION 1988 � . ' ACORDTM CERTIFICATE OF LIABILITY INSURANCE °"� 03-23-2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION� ARS IL — MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6) 4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 29611 ' CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDING COVERAGE 1 � INSUHED � INSURERA:TW111 C1t Fire Ins C� INSURER B: #2270 MOOSE LODCE APR U 2 2009 INSURERC: Po sox 1 s 6 HEALTH DEPT. �NSURER D: SOUTH YARMOUTH MA 02 6 64 INSURER E: ' COVERAGES ' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �NSR POLICY EFPECTIVE POLICY EXPIRATION �Tq TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/VY DATE MM/DD/Ylf LIMITS • GENERAL LIABIl1TY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY I FIRE DAMAGE fAny one fire) I S CLAIMS MADE u OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY S i I GENERAL AGGREGATE I S ' GEN'L AGGREGATE LIMIT APP�IES PER: PRODUCTS-COMP/OP AGG 5 � PRO- POLICY JECT LOC � AUTOMOBILE LIABILITV i COMBINED SINGLE LIMIT S � ANY AUTO . � (Ea accident) . i , All OWNED AUTOS BODILY INJURV SCHEDULED AUTOS (Per person) S HIRED AUTOS , � BODILY INJURY s NON-OWNED AUTOS (Per aeeidenH r PROPERTY DAMAGE $ (Per accident) { GAHAGE LIABILITY AUTO ONLY-EA ACCIDENT S ' ANY AUTO OTHER THAN EA ACC S � AUTO ONLY: qGG S EXCESS LIABILITY EACH OCCURRENCE S OCCUR u CLAIMS MADE AGGREGATE S � s DEDUCTIBLE S RETENTION S $ .. WOHKERS COMPENSATION AND X WC STATU- OTH- � TORY L�MITS R A EMPLOYERS'LIABILITY 8 3 WBG AY1016 0 5/01/0 9 O S�O 1�1 O E.L.EACH ACCIDENT S 1 O O� O O O E.L.DISEASE-EA EMPLOYEE S 1 O O� O Q O : �-- — --- __ -`--__ _ __ ! E.L.DISEASE-POLICV LIMIT S`J O O� O O O � orH�at j ! DESCflIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCWSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Those usual to the Insured' s Operations. CERTIFICATE HOLDER ADDITIONAL INSURED;wsurten�erren: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town Of Yarmouth 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Board Of HealtYl HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL iMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR I.14 6 Rout e 2 S REPRESENTATIVES. SOuth Yc�r'mOUth, MA 02664 auTHon D E �seNTarne �v�jw //� u`�� Gt_(�L�(�t ACORD 25-S (7/971 °ACORD CORPORATION 1988 . • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT , PERMIT NUMBER: #09-013 FEE: 30.OU In accordance with regulations promulgated under authority of Chapxer 94,Section 305A and Chapter 111,Section S ofthe General Laws,a permit is hereby granted to: Lova1 Order of Moose, 834 Route 28, South Yarmouth, MA Whose place of business is: Yarmouth Lad�e#227Q Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 3 l, 2009 BOARD OF HEALTH: .��ett SR.IXI�, J2.JV., C'�rauur►tatt C'�ayceeo .� .7�eP�e�,c� `U�ice Cf�avururn *RESTRICTIONS—Outdoor cooking approved by Board of Health on J� `�.��GOlttft� �:CXJ[lt September 19,200�: QJLtt �(Ytlth� �..1�(. i)There can be unrestricted cooking of hot dogs,hatnburgers,ribs,chops and �;Af�tL�. .i� steaks;2)Chicken and roasts can be cooked six times per year;3)Anv cooking of additional items�vill require notification and a�pproval oi"the Healtfi Director; 4)All cooking�c�ill,be supen-ised by a State certif"ied food handler who holds a food Sen•SaTe certiticate. 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THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6) 4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 2 9 611 INSURERS AFFORDING COVERAGE ' CHARLOTTE NC 28229 . INSURED . INSURERA:TW111 Clt Fire Ins C� INSURER B: #2 2 7 0 MOOSE LODGE INSURER C: P� B�X �-8� ' iNSUflEfi D: � �SOUTH YARMOUTH MA 0 2 6 6 4 �INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR � POLICY EPFECTIVE POLICY EXPIRATION �Tp TYPE OF INSURANCE POLICY NUMBER DATE MM/DDlYY DATE MM/DD/YY � LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCfAL GENERAL LIABILITY FIRE DAMAGE lAny one firel S CLAIMS MADE U OCCUR ME�EXP(Any one person) S PERSONAL&ADV INJURY S GENERAL AGGREGATE S i GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COMP/OP AGG S POLICY PR� LOC JECT AUTOMO&LE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accidentl ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS IPer personl HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accidentl PROPERTY DAMAGE $ IPer accidentl GARAGE LIABIUTY AUTO ONLY-EA ACCIDENT S I ANY AUTO OTHER THAN EA ACC $ i AUTO ONLY: qGG S i EXCESS LIABILITV EACH OCCUflRENCE S ' OCCUR u CLAIMS MADE AGGREGATE 5 S DEDUCTIBLE S RETENTION S 5 WORKEflS COMPENSATION AND X WC STATU- OTH- T RY LI ITS ER A EMPLOYERS'LIABILITY 8 3 WBG AY�.Q�E� O�J�O�/O 7 0 5/01/0 8 E.L.EACH ACCIDENT S 1 O O� Q O Q E.L.DISEASE-EA EMPLOYEE S 1 O O� O O O E.L.DISEASE-POLICY LIMIT SS O O� O O O ' OTHER � i , DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Those usual to the Insured' s Operations . CERTIFICATE HOLDER ADDITIONAL INSURED;�Nsueee�rren: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE!10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE DOTI�IC� SUl11Va11 HOLQER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR PO BOX H REPRESENTATIVES. BaSS R1v@r', MA 02664 A aRi DR es�u nri� ACORD 25-S (7/971 S ACORD CORPORATION 1988 i TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-042 FEE: 525.00 In accordance with regulations promulgated under authoritv of Chapter 94, Section 30�A and Chapter 11 i, Section 5 of the General Law•s,a perniit is herebv gsanted to: Loyal Order of Moose, 834 Route 28, South Yarmouth, MA Whose place of business is: Yarmouth Lodse#2270 Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2008 BOARD OF HEALTH: ��Eeeeft SPtal.f�, J2..lV., C.'Hur�cntan C`�icrx�ee .�. 9G�'ei�r.ex,� `U�ice C'Peaixnuui *RESrRICTIONS—Outdoor cooking approeed by Board of Health on J� �. �K(tl(lfL� �:C�J�tt September 19,?005: �Zti/t �i�Rtti►t.� ✓�„lv. 1)There can be unrestricted cooking of hot dogs,hainburgers,ribs,chops and t:l�`".�.r..�. �� steaks;2)Chicken and roasts can be cooked su tixne�per vear;3)Anv cooking of additional items�i�ill require notiTication and approval o£the Healtfi Director; d)All cooking��ill,be super�•ised by a State certified food handler�ti�ho holds a food Sen�Sate certiticate. December 1 �008 Bruce G.Murphy PH,R.S., CHO Director of Health � , ACORD,M CERTIFICATE OF LIABILITY INSURANCE I DATE ; � ; 03-24-2008 i i PRODUCER i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION � �ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPQN THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6? 4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POUCIES BEL�W. ; � PO BOX 29611 � INSURERS AFFORDING COVERAGE '; iCHARLOTTE NC 28229 � r INSURED � -� INSURERA:`I'W111 Clty 'I''lY'e I11 ---a-----�-�-..m..� j � `?- ,--��-•-.�—� � lNSURER B: -' - �-= = �.�. ,� 9 — 1 I #2 2 7 0 P�IOOS E LODGE �wsuReR c: � }�``'��__I � I PO BOX �H6 INSURERD: _��_� "' `� � _`�"C°`� � SOUTH YARMOUTH MA 02664 ; ;NSURERE: i : COVERAGES ��_.._ �°`�� THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD�NDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH i POLICIES. AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. � � �LTH I TMPE OF�NSU(iANCE I POLICY NUMBER I DA E MMFDDTYYE I DA EY1 M�DD/YYN I LIMITS � � � GENERAL LIABILITY I I EACH OCCURRENCE I S I COMMERCIAL GENERAL LIABILITY I FIRE DAMAGE IAny one firel � S ii CLAIMS MADE u OCCUR I MED EXP(Any one personl � 5 I i i i I �� I PERSONAL&ADV INJURY � S —j t � � I GENERAI AGGfiEGATE � S i i GEN'L AGGREGATE LIMIT APPLIES PER: I I PRODUCTS-COMP/OP AGG j S � j r—j POLICY � PECT LOC I I ` � , '�. I AUTOMOBILE LIABILITY COMBtNED SINGLE LIMIT � � '' �i ANY AUTO i � (Ea accidenq $ j I �ALL OWNED AUTOS I i BODILY INJURY i � SCHEDULED AUTOS I (Per personi $ — � i , � HIRED AUTOS I i I I � I � I I BODI�Y INJURY ; $ i NON-OWNED AUTOS I I(Per accidenq I r-; � , � � �- � j_ --_1 ; � I �--� i I I PROPERTY�AMAGE i I I � � (Per accidentl j 5 i GAflAGE LIABILITY �--�-� --t � I i I � I AUTO ONLY-EA ACCI�ENT I S � j — _ _ " �� I I j ANY AUTO � I � I OTHER THAN _EA ACC�S _ � �-i iI I I � { I I AUTO ONLY: pGG i 5 � j EXCESS LIA&LITY i I EACH OCCURRENCE I $ I � OCCUR u CLAIMS MADE I i I AGGREGATE j S �� I � S i � � DEDUCTIBLE � I I S ___t RETENTION 5 � S i �. I WOpKERS COMPENSATION AND X WC STATU- � I OTH- —+ I i I TORY LIMITS ER A EMPLOYERS'LIABILITY I f � 8 3 WBG AYl 016 0 5 �1 �8 ��J �1 Q 9 E.L EACH ACCIDENT / / / / s100, OOJ - i I_ I E.L.OISFASE-EA EMPLOYEE�S�.O O , O O O � I I i E L DISEASE-POLICY LIMIT � S rJ O O � O O C� i I OTNER � I i . --� I I I ' � i i DESCHIPTION OF OPEIiAT10NS1LOCAT10N5/VEHICLES/EXCLUSIONS AODED BY ENDORSEMENT/SPECIAL PROVISIONS � � Those usual to the Insured' s Operations . i i i � � I CERTIFICATE HOLDER noorcwNa,��Nsueeo;�NsunEn�rreR: CANCELLpTION � i — — � SHOULD ANY OF T'HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I I. EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I � Town Of Yarmouth 3Q�AYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE ; Board Of Hed�.tYl HOLDER NAlWED TO THE LEFT, BUT FAILURE TO DO SQ SHAIL IMPOSE NO � OBLIGATION OR LIABILITV OF ASVY KIND UPON THE INSURER, ITS AGENTS OR 1.1.4 6 Rout e 2$ REPRESENTATIVES. i , South Yarmouth, MA 02664 - A OHI D RE)RESEN ATI� �� I � i ACORD 25-S 17l971 �'ACORD CORPORATION 1 ggg ' �' : A �#"�13g-a..�'� �yoosF' o� °f YaR TOWN OF YARMOUTH BOA�`°f��EALT�� ? � � APPLICATION FOR LICENSE/PE�MIT-2006 { N�� 005 -�� Y ` ..••"/� .. �_ , . * Please complete form and attach all necessa.ry documents by December 31, 2005. Failure to do so will result in the return of your application packet. NAME OF ESTABLIS b4��v� '�f� S�" � Z71�TEL. # 3� �69 I LOCATION ADDRESS: �L v � 2 MAII.,ING ADDRES : D l (o OWNER NAME: v�1G V S� � 2 Z7 T ID r ' Z- Z� CORPORATION N (IF APPLICABLE): MANAGER'S NAME: TEL. # MAII,ING ADDRESS: POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pt�ol Operator(s}�and atta��opy 6f�re c�rtifi�io�t��t�irs�ortn. _ __ _- - _ � 1. 2. � � Pool operators must list a minimum oftwo employees currently certiSed 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. 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 Protectivn Manager, as defined in the State Sanitary Code for Faod 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 ne c ies and maintain a file at your establishment. 1. � �u�r� � ZL v�9 � 2. j _ P�O�i�i CHARGE: ------------ -- --_ _ — : _ __-- _--------- - --- _ _ _ - - _ � Each food establis n st have at least one Person In Charge(PIC) on site during hours of operation. � � l. �� L1 vz ,v� 2. �b�L 6Z � HEIlb�T�H CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and at�a.e�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. l .;.•r�+w�z r� �L t.��^'L 2. - 4 L { 3. (/�-+-z u Y(�U�'�?-�k 4. �- 3�1 tv �4�cA--tv�t L RESTAURANT SEATING: TOTAL# � , i OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $SO _MOTEL $50 iINN $50 CAMP $50 _SWIIvfl1+IING POOL�75ea. LODGE $50 _TRAII,ER PARK $50 WI�KI,pppL $�Sea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 CONIINENTAL $30 ( NON-PROFIT $25 ��ZS >100 SEATS $150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMTP# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 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 _ $ 2S•00 RRflR�lpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••"� � � , � � � �� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V 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 3 L IT IS YOUR RESPONSIBII.ITY TO RETLJRN TI-� COMPLETED APPLICATION(S)AND REQUIKED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO ' COl��IlV�NCEMENT. 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 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 aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: • .�+� ......��.,. � ..,.,-,. �b Hexl�l. __. _ ��'6�er3 �essel�s ��' ,. ..�,.a .._a iTiot3�hly-bRs�s�3y-�-��a.�e�efttfie�-�:-��aiCs,=iasr o��rr�.�v��n, - , 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: 'y� Outside cafes(i.e.,outdoor seating with waiter/waitress rvice),must have p�or approval from the Board of Health. OUTDOOR COOKING: �� Outdoor cooking,preparation,or display of any food�produ y a retail o food service establishment is prohibited. I DATE: � �� 11.0��S SIGNATURE: PRINT NAME&TITLE: L �� AD �1,��s��a� 09/28lOS i4 I - —...�., �-�.� _ _ .a..� i�-_ - i . ACORDTM CERTIFICATE OF LIABILITY INSURANCE U022 08-25AT2005 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 551129 P: (866) 467-8730 F: (704) 921-4658 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ' P. O. BOX 29611 INSURERS AFFORDING COVERAGE � CHARLOTTE NC 28229 1NSURED INSURERA:TWIT1 Cit Fire Iris Co INSURER B: #2270 MOOSE LODGE INSURERC: IP.�. BOX �-8 6 INSURER D: SOUTH YARMOUTH MA 0 2 6 6 4 INSUREH E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR , MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - WSR POL/CYEfi�CTNE POLICYEXP/RAT/ON � LTR TVPE OF/NSUR,qNCE PoLICY NUMBER DATE MM DD Y/ DATE MM/DD � LlM?S GENER.4L LlABIL/TY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY ' FIRE DAMAGE(Any or:s fire) 5 CLAIMS MADE �OCCUR MED EXP(Any one personl S PERSONAL&ADV INJURY S GENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S POLICY PRO- JECT LOC AUTOMOB/LEL/AB/LITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accidentl ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S IPer accidenti GARAGE[/ABIL/TY AUTO ONLY-EA ACCIDENT 9 ANY AUTO EA ACC S OTHERTHAN AUTO ONLY: AGG S EXCESSL/AB/LITY EACH OCCURRENCE S OCCUR �CLAIMS MADE AGGREGATE $ s DEDUC?IBLE g RETENTION S g WORKERSCOMPENSAT/ONAND X WC STATU- OTH- A EMPLOYERS'L/AB/L/TY 8 3 WBG AY1016 0 5 f 01/0 5 0 5/01/0 6 E.L.EACH ACCIDENT S1�Q� �� E.L.DISEASE-EA EMPLOYEE $1 O O� O O O E.L.DISEASE-POLICY LIMIT S'rJ O O� O O O OTHER DfSCA/PTION OF OPERATlONS/LOCATIONSNEH/CLfS/EXCLUS/ONS ADDED BV ENDORSEMENT/SPEC/AL PROV/S/ONS � Those usual to the Insured' s Operations. CERTIFICATE HOLDER ADD/TlONAL/NSURED;/NSURERLETT£R: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WIIL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE U 0 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Donald Sul1 ivan HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR PO BOX 8 REPRESENTATIVES. Bass River, MA 02664 ��o�� ACORD 25-5 (7/97) �ACORD CORPORATION 1988 fi� —, I _ .�` � , � _ ._ _ _ —=�._ _ _ _ _ _ — , _ . . ,,, ,. i . .. ,.,< w,. _ .,� _ :_ . � . . � :. : ,: TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO QPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-015 FEE: $25_00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the(�eneral Laws,a permit is hereby-granted to: Lo al Order of Moose, 834 Route 28, South Yarmout MA ' _ _Whose place of business is: Yarmouth Lo e#2270 - _ Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth ; Pernut expires: December 31, 2006 BOARD OF HEALTH: Be�t�ts�t�S, fj''a�,o«,1L1..11. • ; P��tt, v�e�� a�`�.B�, '� �s�, �.n�. �.��.��, R.�v. November 22_2005 Bruce G.Murphy, S.,CHO Director of Health a i i I i DATE ACORDTM CERTIFICATE OF LIABILITY INSURANCE 03-28-2006 rnouuceR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL — MOOSE INTL�PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6) 4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 29611 CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDING COVERAGE INSURED INSURER A:TW111 Cit Fire Ins Co INSURER B: #2270 MOOSE LODGE �r,suaERc: PO BOX 1 H F) INSURER D: SOUTH YARMOUTH MA 0 2 6 64 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � 'TR TYPE OF INSUNANCE POLICY NUMBER POLICY EFFECTIVE POLICV EXPIRATION � DATE MM/DDIYY) DATE MM/DDIYY LIMRS jGENERAL LIABILITY EACH OCCURRENCE S � COMMERCIAL GENERAL LIABILITY FIRE DAMAGE IAny one fire) S � � CLAIMS MADE � OCCUR MED EXP(Any one person) S � PERSONAL&ADV INJURY 5 GENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ � POLICY PR� LOC � JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ! ANY AUTO IEa accidentl S ALL OWNED AUTOS BODILY INJURY � 1Per person) $ SCHEDULED AUTOS � HIRED AUTOS BODILY INJURY (Per accidentl S � NON-OWNED AUTOS � PROPERTY DAMAGE $ j (Per accident) i i GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5 , ANY AUTO OTHER THAN EA ACC 5 AUTO ONLY: pGG S EXCESS LIABIIITY EACH OCCURRENCE S � OCCUR u CLAIMS MADE AGGREGATE S S � DEDUCTIBLE $ RETENTION $ $ � WORKERS COMPENSATION AND . � X ORY IMITS �ER � EMPLOVERS'UABILITY ; A_ ___ - _ _ _ 83 WB� AY1016 _ _ 0�/O1/0Fi 05/A�/07 -��.-EncHnccioEn�r -- s��-0-,��J�-- - E.L.DISEASE-EA EMPLOYEE SZ O O� O O O E.L.DISEASE-POLICY LIMIT SS O O� O O O OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Those usual to the znsured' s Operations . APR U 6 2006 HEALTH D�PT. ' CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town Of Yarmouth 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Board Of Health HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 114 6 Rout e 2 8 REPRESENTATIVES. South Yarmouth, MA 02664 �1LE�� . AlIS1,{ORI� D�_ RF�RESEN AT}`J;�� 1!V'«" ACORD 25-S (7l971 �ACORD CORPORATION 1988 w � �„ . _ - V ...�.IARIO�I�IO��S�I�H.LO�.L�'Idy1i0�MId?I�AO ARIf1,L�SY�'Id..... . ao• � _ �na iNnor�� o�$ ��v� SZ$ 0��'gOZ S£$ .L2I�SS�Q td�'Z0213 SL$ 'ki'�000`ST? 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THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6)4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. BOX 29611 CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDING COYERAGE INSURED INSURERA:TW111 Clt Fire 1115 C� INSURER B: #�2 7 0 MOOSE LODGE INSURER C: Q Q BQ�{ �,8 6 INSURER D: S YARMOUTH MA 0 2 6 6 4 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE fNSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ' MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR �ypE OF INSURANCE POLICY NUMBER I �UCY EFfECTIVE POLICY EXPINATION �Tp DATE MMlpDlYY DATE MM/DD/YY LIMITS QENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY I FIRE DAMAGE(Any one firei I $ CLAIMS MADE u OCCUR MED EXP(Any one person) 5 P[RSONAL&ADV INJURY 5 GENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PEFi: PRODUCTS-COMPIOP AGG S POLICY PR� LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) g HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) S PROPERTYbAMAGE $ � � tPer accidentl GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S I EXCESS LIABILITY �EACH OCCUHRENCE S � OCCUR u CLAIMS MADE �AGGREGATE S I S I DEDUCTIBLE $ II RETENTION $ g WOHKERS COMPENSATION AND X OCY IMIT �TR A EMPLOYERS'LIABILITY 8 3 WBG AY1016 0 5/O 1/04 0 5/O 1/0 5 E.L.EACH ACCIDENT S10�� Q�� ( E.L�ISEASE-EA ENIPLOYEE SZ O O� O O O � _�_ _ E.L.DISEASE-P011CY LiM1T S'rJ O�j O O O OTHER DESCRIPTION OF OPERATIONS/LQCATIONSNEHICLES/EX4WSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Those usual to the Insured' s Operations . CERTIFlCATE HOLDER � �ADDITWNAL INSURED;wsunen�n: GANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE , EXPIRATION DA7E THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTcN NOTICE(10 DAYS FOR NON-PAYMENT►TO THE CERTIFICATE ' DOI1d�C� SUI.11VEi71 HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR PO BOX H REPRESENTATIVES. B a.S".�"> R iv e r, MA 0 2 6 6 4 AUTHOR(IZ'�ED REPRESENT1�� . � �,C..-+.?�e�...c��'� � ACORD 25-S (7J97) °ACORD CORPORATION 1988 1 ; . - ,� - . TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NLJMBER: #OS-036 FEE: $25_00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 af the General Laws,a permit is hereby granted to: Loya1 Order of Moose, 834 Route 28, South Yarmouth,MA Whose place of business is: Yarmouth Lod�e#2270 Type of business: Non-Profit Food Service To o erate a food establishment in: Town of Yarmouth P Pemut expires: December 31, 2005 BOARD OF HEALTH: Eesr�a�u�c `.�. (�''o�,oa,/�`n. ' nc�i�ic�a/19c`.he�u,r�, ?/ice G�vu,u�� d�ele��'�li,�� R.N. � i � J��i i.2oos ' Bnice G.Murphy, ,R S.,CHO ; Director of Heatth i � I ; � � i ' . _ •, ,� C. � . '� � � °`;�R�. TOWN OF YARMOUTH BOARD OF�E' �� y � � � � � � � � �} _ o z. -�� APPLICATION FOR LICENSE�PERIV��'�00 � . .;� � NOV 2 2 2006 ; ' * Please complete form and attach all necessary✓documents by Decembe 3 } ' Failure to do so will result in the return of our a hcation acke . ��H_DEP e : � � Y Pp P � z I NAME OF ESTABLISHIVIENT:. � t},��,.► ,�i-�� 1,�1c�� c-� ,c� ��'Z'� � TEL. # �y >��.- LOCATION ADDRESS: � �c�t r z '� ' MAILING ADDRESS: f'' u . ' '(� � OWNERNAME: � �' r� w�e�vi-w ��L1G^t�5r �.�' '�E � Z77G� T EIN r �� " Z.. ��z. �J�;e_ 3 3 CORPORATION N APPLIC �,E): ; MANAGER'S NAME: �. c��v�� t� �'e� �z�v��1�� TEL. # �'�r' /��''S � MAII,ING ADDRESS: � i ^� � �.,� � POOL CERTIFICATIONS: The pool supervisor must be certified as a Poal Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. � l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and � Community Cardiopulmonary Resuscitation(CPR). Please list these employees 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 m�intain a file at your place of business. � � � l. 2. ' 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: � All food service establishments aze required to have at least one full-time employee who is certified as a Food � Protectian 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 Heatt6 Department will not use past years'records. You must provide new copies and maintain a fite at your establishment. ' � i � 1. �. c�::.:,:� i.� � t�P t iv�� 2. � � PE�SON�N£�RG�:-- -- __ . . __ _ __ _ _ _ _ - ---- - ---- ____ — - � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. r�� i l. J�z" � €;vrc �wt,� �'E�L c:. 2. 1 �I HEIlVILICH CER'I`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 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. ��i��%� 2. I 3 4 RESTAURANT SEATING: TOTAL# OF`FICE U5E ONLY LODGING: � LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B S50 CABIN �50 MOT`EL $50 INN $50 CAMP $50 _SWIlvIlvIINGPOOL$75ea. LODGE $50 _TRAII,ER PARK $100 WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTP# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL $30 I NON-PROFIT $25 � �Ol _>100 SEATS $I50 COMMON VIC. $50 WHOLESALE $75 RETAII.SERVICE: —RESID.KiTCHEN $75 LICENSE REQUIRED FEE PERMtT# LICENSE REQUII2ED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# T<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $'15 _.FROZENDESSERT $35 TOBACCO $50 NAME CHANGE: $10 AMOUNT DUE = S ZS.00 •""'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""' d , 4 r �I , ADMINISTRATION ' Under Cha.pter 152, Section 25C, Subsection 6,the Tawn 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 INSURA►NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED '''�r 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 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 afresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an aggre�ate of not more than ninety(90}days within any six(6)month period. Use of a guest unit as a residence or dwelling urut 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 genera.11y be considered Transient. PUOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to 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�nust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required ' Temporary Food Service Application form?2 hours prior to the catered event. These forms can be obtauied at the ' Health Department. FROZEN DESSERTS: Froaen 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 t1�e Board of Health. OUTD40R COOKING: _ �utduor cookin�preparation,ardispi�af�f�d prod�et�a ret�il flr€oocl-ser�se establ�s�xi�nt i�prehibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILdTY TO RETURN TI�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY k'OOD ESTABLIS�-IlViENT, 1ViOTEL OR PO�L (i.e., PAINTING, NEW EQIJIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMII�NCEMENT. RENOVATIONS MAY REQLJ�RE A SITE PLAN. . . �� ,; v-�._._.------_ DATE: j 1 -2 +--�� G� SIGNATURE: � PRINT NAME&TITLE:,� ,1��,��z��-� ;1 r�� v�'J� ��vr�,v,S f>2�;j'�vc 10/17/06 � � ACQRDT� CERTIFICATE OF LIABILITY INSURANCE DATE I03 28 2006 I reouucee THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE r 5 5112 9 P: (8 6 6) 4 6 7-8 7 3 0 F: (7 0 4) 9 21-4 6 5 8 ALTER THE COVERAGE AFF RDED BY THE POLDICIES BE OW. � PO BOX 29611 � CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDFNG COVERAGE � INSURED ; INSURERA:TW111 Cit Fire Ins Co � INSURER B: ' #2 2 7 0 MOOSE LODGE INSURER C: • j P� B�X �-8 6 INSURER D: I j SOUTH YARMOUTH MA 0 2 6 64 j irusuaER E� � � COVERAGES a THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ' ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR j MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR � POLICY EFFECTIVE POLICY EXPIRATION LTR .TYPE UF MSUqANCE POLICY NUMBER DATE MM/DD/YY) DATE(MM/DD/VY LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one firel $ CLAIMS MADE U OCCUR MED EXP(Any one person) S I PERSONAL&ADV INJURY S �GENERAL AGGREGATE I S � GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 ; POLICY PRO- - JECT LOC � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accidentl $ ALL OWNED AUTOS BODILY INJURY $ i SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS IPer accidentl PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLV: AGG S EXCESS LIABILITY EACH OCCURRENCE $ OCCUR u CLAIMS MADE AGGREGATE g g DEDUCTIBLE $ RETENTION $ S WOpKERS COMPENSATION AND � X ORY LIATTS �E H A EMPLOYEHS'LIABILITY 8 3 WBG AYl 016 0 5/O l/0 6 �5,0 1/�7 E.L.EACH ACCIDENT S�..Q� �.�Q� E.L.DISEASE-EA EMPLOYEE S�.O O� O O O E.L.DISEASE-POLICY LIMIT SS O O� O O O OTHEfl DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS � Those usual to the Insured' s Operations . CERTIFICATE HOLDER ADDRIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEILED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town CSf Yd1"TTIOU'trl 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Board Of Health HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO 114 6 Route 2$ dBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. South Yarmouth, MA 02664 A ORI D RE ESEN ATI ACORD 25-S (7/97) °ACORD CORPORATION 1988 i • TOWN OF YARMOUTH ; BOARD OF HEALTH � PERNIIT TO�PERATE A FOOD ESTABLISHMENT � PERNIIT NIJMBER: #07-013 FEE: $25.04 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter t 111,Section 5 of the General Laws,a permit is hereby granted to: I � Loyal Order of Moose, 834 Route 28, South�armouth, MA i ' Whose place of business is: Yarmouth Lod�e#2270 ; � ' Type of business: Non-Profit Food Service � � To operate a food establishment in: Town of Yarmouth ; Permit expires: December 3 l, 2007 Bo�oF HEALTH: Be��a�. ��/�`n., . ; � .� s�, .�., v�e�� e�t�.a�, e�,� ' A�k�NN�:��t �4.��j�.tdr�, R.N. NoV��Zs.aoo6 Bruce G.Murphy, ,RS.,CHO Director of Health � i I « -;- �'-�8� �LS�� LZ7d � �� C� � � �JL� o ��°`:�'R�o TOWN OF YARMOUTH BOARD OF H�A�TH o,: �,s APPLICATION FOR L10EN��E�� 2Q04� NOV O 3 Z003 . ..•� �; , � � - ' * Please complete form and attach all necessary� �;um��""by�Dece EPT. Failure to do so will result in the return o�our application packet. NAME OF ESTARi i�HMFNT• �4��:.�u�=- ls�� iz�v T i # � y5��t/' LOCATI9N ADDRES : �3�I ��v��Z�- �VIAILING 1�D F��• � t �� WNER/C RAT N � A ER'S NAME: �� ;� .> �.[>v�� T 7,r�� MA�I�ING ADDRESS• �-� r� C 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 cop�of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1• 2. 3. 4. FOOD PROTECT�ON MANA ER CERTII'I ATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. , i.- �f:cv�kL� � cizl��'�� 2. , __ �R�c�N-IlV-�Fi� ��• _ ---- -- - .. _ . Each food establislunent must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2 HFIMLICH CERTIFICATION�• ; 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. � 1._ '�t 1��[`H�� 2. � 3• 4. RFSTAURAI�IT SEATTN(�t: TOTAL#�_ LODGING: 9FFICE USE ONLY LICENSE REQUIRED FEE PERMTT# LtCENSE REQUIRED f EE PERM►T# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MUTEL $50 _11dN $50 _CAMP $50 _SWIMMING P(JOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL �75ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS $75 _CONTINENTAL a30 �NON-PROFIT �25 �� >100 SEATS $I50 _COMMON VICT. S50 _WHOLESALE $75 RFTAIL SERVICE• LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLARED FEE PERMIT# _<50 sq.ft. �45 _>25,000 sq.ft. $200 _VGNDING-FOOD $20 _<25,000 sq.ft. �75 _FRO7.EN DI3SSI;R'f a35 _Tn[3ACC0 S25 I�IAM�CNANCF• a�o AMOUNT DUE = S ZS.o� i **"'**PLEASE TUI2N O�ER AND COMPLETE OTHER SIDE OF FORM**�'** ` i,:• � I � 1 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 ''� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES '� NO NOTICE:Permits rurt annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED AFPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PR10R TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL. RF.GULATIONS ` 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 �ONSIJMFR ADY,.�,SORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ("AT�Ri_NG POLICY: � Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the , required Temporaty Food Service Application form 72 hours pnor to the catered event. Thses forms can be ; obtained at the Health Department. �un��T nr�crr.r�T�. _ _ - ____ __ ----- � ---��Y`�IiJl'J�\ Ll/UA71�/1\1►lY -. 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. i OUTSIDE CAFES: i Outside cafes(i.e.,outdoor seating with waiter/waitress service), �Cave�prior appmval from the Boazd of Health. i OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food pr ct ,,�retail or food service establishment is prohibited. �> DATE: 1�' � i- �� SIGNATURE: ---- _. . PRINT NAME&TITLE: . o+��z,� �_ �� ,�',a,�,� � t�Ybt +�v�� t+2� �74� 10l22/03 � . /f . ., ' �ACORD,� CERTIFICATE OF LIABILITY INSURANCE JDH °",� P4SA 09-11-2003 , PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 551129 P: (888) 253-4940 F: (704) 921-4658 A�ERT ECOVERAGEAFFORDEDB�THEPODCEESBE OW. P. O. BOX 29611 � CHARLOTTE NC 28229 INSURERSAFFORDINGCOVERAGE /NSl�ED INSURERA:TW111 Cit Fire Ins Co INSURER B: #2270 MOOSE LODGE INSURERC: P O BOX 1 8 6 INSURER D: S YARMOLTTH MA 0 2 6 6 4 INSURER E: COVERAGES I THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING i ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER.DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ' MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO AL�THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH i POUCIES.AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � �� POUCYEI�ECTNE PoL/CYEXP/R4T/ON LTR TYPf Of INSURANCE POL/CY AH/MBER DATE MM Y DATE MM/OD/YY L/MlTS GENERAL L/ABILITY EACH OCCURRENCE 8 COMMERCIAL GENERAI LIABILITY � FIRE DAMAGE(Any one firel 8 CLAIMS MADE n OCCUR � MED EXP(My one personl 9 PERSONAL&ADV INJURY S GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 8 POLICY PRO- � T LOC AUTOMOB/Lf UAB/UTY COMBINED SINGLE LIMIT � ANY AUTO � �Ea accident) $ ALL OWNED AUTOS BODILY INJURY s SCHEDULEO AUTOS �Per personl HIRED AUTOS - 80DILV�NJURY $ NON-OWNED AUTOS (Per accidentl ' PROPERTY DAMAGE $ IPer accidentl GARAGE L/AB/L/TY AUTO ONLY-EA ACCIDENT S ANY AUTO O.THER THAN �ACC S AUTO ONLY: qGG S EXCESS[/AB/UTy EACH OCCURpENCE S IOCCUR u CLAIMS MADE AGGREGATE g � g DEDUCTIBLE S RETENTION & s WORKERS COMPENSAT/ONAND X WC1STATU- OTH- A EMPLOYERS'1/AB/L/TY 8 3 WBG AY 1016 • 0 5/01/0 3 0 5/01/0 4 E.L.EACH ACC�DEN7 S�.0�� Q E.L.DISEASE-EA EMPLOYEE S 1 O O� O O O E.L.DISEASE-POLICY LIMIT S'rJ O O� O O O OTHER DESCR/PT/ON OF OPERAT/ONS/LOCAT/ONSNEHICCES/EXCLUS/ONS ADDED BY ENDORSfMEM/SPEGAL PROV/S/ONS Those usual to the Insured's Operations . CERTIFICATE HOLDER ADD/T/ONAL/NSURED;/NSURERLETfER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDfAVOR TO MAIL 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Donald Sul l ivan HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO PO BOX 8 OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Bass River, MA 02664 AUTHOR/ZfD REPRESENTA `��,..-s�_�.�--�-�� ACORD 25-S 17/97) m ACORD CORPORATION 1988 i fl ACORD,� CERTIFICATE OF LIABILITY INSURANCE UOBB °"� 03-24-2004 wto�ucex THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL�PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6)4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFQRDED BY THE POLICIES BELOW. : P. O. BOX 29611 CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDING COVERAGE INSURED INSUREflA:TWlIl Clt Fire Ins C� INSURER B: #2 2 7 0 MOOSE LODGE iNsu c: ❑ � � P � BOX 1 8 6 INSURER D: ~ � ` S YARMOUTH MA O 2 6 6 4 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO C 1�'bT ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCUMENT WITH RESPECT TO WHIC UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH i POLICIES.AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !� �LTR TYPE OF INSURANCE POUCY NUMBFA ��Y EFFECTIVE POLICY EXPIpATION ; DATE MMlDD/VY DATE MM/DD/YY LIMITS ? ��&VTM EACH OCCURRENCE g COMMERCIAL GENERAL UABIUTY �FIRE DAMAGE(Any one firel I 8 CLAIMS MADE U OCCUR I MED EXP(Any orre person) I 5 I PERSONAL&ADV INJURY � S I GENERAL AGGREGATE I S : GEN'L AGGREGATE LtMIT APPLIES PER: I PRODUCTS-COMP/OP A�G I S � POLICY JECT LOC i ,� AUTOMO&LE LIABILITy COMBINED SINGLE LIMIT � ANY AUTO {Ea accidant) $ ALL OWNED AUTOS � SCHEDULED AUTOS BODILYINJURY g (Per person) � HtRED AUTOS JNON-OWNED AUTOS BODILY INJURY $ 1 (Per eccidantl ( PROPERTY DAMAGE $ IPer accident) ��E��m AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS UABIUTY EACH OCCURRENCE S OCCUR u CLAIMS MADE I AGGREGATE I g $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND X WC STATU- OTH- A ��YE"$ `��"� 83 WBG AY1016 05/01/04 05/01/05 E.L.EACHACCIDENT s100, 000 E.L.DISEASE-EA EMPLOYEE S Z O O� O O O on��t _ E.L GISEASE-POLICY LIMIT SS O�� O O O DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BV ENOORSEMENT/SPECWL PROV1810NS Those usual to the Insured� s Operations . CERTIHCATE HOLDER � �ADDITIONAL INSUpED•INSURER LETTEp• CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWIl Of YaY"[ROUtYl EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE i10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE Board of Health HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO �-�.4 6 Route 2 H OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. South Yarmouth, MA 02664 AUTHORIZED pEpRESFJyT E ��....s�..��e.-��c� ACORD 25-S 17/97) o ACORD CORPORATION 1988 r� , . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-004 FEE: $25.00 ' In accordance with regulations promulgated under anthority of Chapter 94,Section 305A and Chapter , 111,Section 5 of the General Laws,a permit is hereby granted to: Loya1 Order of Moose, 834 Route 28, South Yarmouth, MA ; � Whose place of business is: Yarmouth Moose Lodge#2270 1 Type of business: Non-Profit Food Service ! To operate a food establishment in: Town of�armouth , ! Pernut expires: December 31. 2004 Bo,�oF��.�: �e��u,c D. C�a�do�c 711.D. ��aur„�c 1 �3aar�ek'�1ldD�, ?/u;e ��.uanc " �o�tt�. S��raacr,a, (��.oz� � �elu� S ��l. � � November 4.2003 ' � Bruce G.Murphy, .S.,CHO � Director of Health ; I , ; �/11/'LUU:i 11 :41AM '1'H� HAti'1't''Utill 1�A(ir: ;3 Ur' ;i ACORD� CERTIFICATE OF LIABILITY INSURANCE P4 A 09-11 TZoos PAODUCF3t THIS CERTIFICATE IS ISSUED AS A MATT OF INFORMATIOId ARS IL — MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE �TIFICATE HOLDER. THIS CERTIFICATE DOES NOT , EXTEND OR 1 5 5112 9 P S (8 8 8)2 5 3—4 9 4 0 'I'' : (7 0 4) 9 21—4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE LI CIES BELOW. ° P. O. BOX 29611 � g , CHARLOTTE NC 2 S 2 2 9 INSURERS AFFORDING COVE GE��W� =ps"'�° �5� A�Twin Cit Fire Ins C C�'� ;�-,_ •........, INSQAIDi 8� #2 2 7 0 MOOSE LODGE nasm� �, P O BOX 18 6 n,s� o, S YARMOUTH MA 02 6 6 4 INS� e: COVERAGES THPs POLICIES OF INSURANCfi LISTED HSLOW HAVS BEBN ISSUED TO THE INSURED NAMED ABOVS FOA THE POLICY PERIOD INDICATED. NOTWITHSTANDIN ANY RBQUIREMENT� TSRM OA CONDITION OF ANY CONTRACT DR OTHSA �OC[7A�NT WITH AESPECT TO WHICH THIS CERTIFICATH MAY BE ISSUSD OR MAY PSRTAIN, THE INSUAANCE AFFORD&D BY THS POLICIES DESCRIBSD HBASIN IS SUBJECT TD ALL THE T&RMS� SRCLUSIONS AND CONDITIONS OF SUC � POLICI85. AGGREGATS LIMITS SHOWN MAY HAVE BEBN REDUCED BY PAID CLAIMS. � Lp� � POI.ICY EPFECTIVE P07.LCY EXPIRATIOP yqg TYPE OF IPSURANCE � POLICY PUMBQt DATE NM DD Y DATE NA�1 DD 7.IMITS GIIiERN.I.IABIyITY BACH OCCQRA6NCE $ . COA4f�iCIAL GEN�tAL LIABIZITY PIAB �AMAGB (Any one fi $ CI,AIMS MADE �OCCOA MEO E7[P �Any one person) $ P6RSONA7. 6 ADV IPJOAY - $ � � G6NEAAI, AGGA86ATS $ j G6N'I. AGGAEGAT6 LIMIT APPLIES P � PAODUCTS - COHP/OP AGG $ � POLICY g�T LOC AUPOMOBII,E S.IABILITY COMBIN&D SINGI,B I,IMIP ANY AUTO (6a accident) $ � ATT OWNSD AOTOS BODII.Y INJQAY $ � -� SCH6DOI,ED�AOT05 (Pea pezson) HIRED AOTOS � � BODII,Y INJDAY $ . � NON-OWNED AOTOS (Pez accident) � � PROPEATY DAMAG6 5 - (Pec accident) GARAGE S.IABILITY AUTO ON7.Y - BA ACCIUBNP $ ANY AOTO OTH6A THAN �ACC $ � AUTO ONS.y� A� $ I E%CE86 LIABII.ITY S jEACN OCCUAAENC6 � OCCOA ❑ CLAIMS MADB A6GAEGATB $ , D6DUCTIB7,S $ t $ � R6TBNTION $ WOARERS COMPE9SATION A9U V WC STATO- OTH- $ � A E[�LOYEAS' ELABILITY g3 WBG AY1016 05/01/03 05/O1/04 E.L. EACN ACCIDHNf s100� 000 � je.z. oiseass _ em m�rzo s 1 0 0,0 0 0 B.L. DISEASB - POLZCY L $TJ O O O O O . oTFIEEt OFSCRLPTIOP OF OPERATIOt7S/I.00ATEOtiS/VEHIQ.ES/EXQ,llSIONS AD�ED BY ENDORSEMEPT/SPECIAT.PAOVISIOIPS Those usual to the Insured' s Operations. CERTIFICATE HOLDER ADDITIONAL INSUAm; IHSUAIIt I,EPTEA: CANCELLATION SHOULD ANY OF TH& ABOVE �SSCRIBE� POLICIES BL CANCSLLSD B&FORE THB t BXPIPATION DATS THSRSOF, TH& ISSUING INSURSR WILL SNDSAVOR TO hiAIL TOWIZ O1 Yarmouth 30 DAYS WRITTSN NOTICE (10 DAYS FOR NDN-PAYMENT) TO THE CSRTIFICAT Board Of Health HOL�ER NANfED TO THE LEFT, BUT FAILUAS TO DO 50 SHALL IMPOSS NO 1 1 4 6 Route 2 S OBLIGATION DR LIABILITY OF ANY RIND UPON THS INSURSR, ITS AGENTS 0 RBPRESENTATIVBS. South Yarmouth, MA 02664 AUTHORI(E'E-D��REPRESENTA €�-+�`*��.�'�t�a.r�.asaa.�cR+Q., ACORD 25-5 (7/97) m ACORD CORPORATION 1988 : .... . . _ . ._---_;_..aa� _ _. � . .. . . . -,., �- ��:. f- .,�� \ _ � s«�rsl�li2lOrI 30�4IS�I�H.LO�J.�'IdNiO�Mt�'ZI�AO 1�t2IIId.�5��'Ids�� o•sz s = �na iuno�� oi$ ��—�� s�$sxassaa x�zo� DOZ$ '8'bs 000`sz< sv$ �u��os> oz$ o��dgoi—" scs �u��000`sz>— oz$ o��dgoi—' #,LTJ�I2I�d ��3 Q�If1a�2I�S1�I��I'I #.LIY�I2I�d ��3 Q�2IIf1a�I�S1�I��I'I #.LIY�I?I�d ��3 Q�IIf1a�I�SI�I��I'I � � A SL$ �'IHS3'IOHM OS$ '.L�IA I�IOY�iY�tO� OSI$ S.L�'3S OOI< �aQ� SZ$ ZIdO�Id-I�IO1�I� 0£$ 'Id.L1�I�l�II.L1�I0� SL$ S.Ld�S OOI-0 #.LIW?I�d ��d Q�II11��I�S1�I��I'I #.LIb�RI�d ��3 Q�IIf1�i2I�S1�I��I'I #.LIY�RI�d ��d Q�IIIa�I�S1�I��I'I •� A�db� . '�aSZ$ 'IOOd'I�tIHM OS$ ?I�Idd�I�'II�.L` OS$ �tJQO'I 'BaOS$'IOOd rJi�IIWYQIMS OS$ dY�'� OS$ NI1I OS$ 'I�.LONi OS$ 1�II�'� OS$ . 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A age Prepared: 04/17/02 For: #2270 Moose Lodge The Hartford (Affinity) P O Box 186 P.O. Box 29611 S Yarmouth, MA Charlotte, NC 02664 508-394-5091 28229 888-253-4940 � overage i mount ompany o�cy o xp ( Workers Compensation � Twin city F�re msurance �g3wscr�x1o16 OSi01/02 i OS/01/03 � i I, I I � Named States: MA I I Employer's Liability ' i Each Accident ioo,000 � � I Disease-Policy limit 500,000 ii i � Disease-Each Employee 100,000 , � ( �Other States: AL AZ AR CA CO! CT ' i I �Additional Coverage/Endorsements ', i ' 1 � � � ; � , � i : ; i � ; � � � � ; � i ! i I ; i I � : ; � � � i ; I i ' i � f � 1 � � � i � � � ; � ; i I ! , � i i I ; � � j i j � � � ! � � , ; ,, i ; � , ; j � � � � ' I ; � ; � � � � 12/03/2002 10:31AM THE HARTFORD PAGE 2 OF 2 � � �►�r� CERTIFICATE OF LIABILITY INSURANCE P4 D 12-03�=2ooz � nvL�viceF. � THIS CERTIFICATE IS ISS[7ED AS A MATTER OF INFORNATION .ARS IL - MOOSE INTL/SCIC ONLY AND CONFERG NO RIGHTG UPON THE CERTIFICATE HOLDEA. THIS CERTIFICATB DOES t�OT AMEND, BXTEND OR 5 5112 9 P: (S 8 8� 2 5 3-4 9 4 0 F'': (7 0 4) 9 21-4 6 5 8 FS,TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. BOX 29611 CHARLOTTE NC 2 8 2 2 9 IN6UAER6 AFFORDING COVERAGE =�L"�° I]d3UAGR e:Twin Cit Fire Ins Co �s� e� #2 2 7 0 MOOSE LODGE IP� �; P O BOX 1 B 6 IftSURER D: S YARMOUTH MA 0 2 6 6 4 INSWiER E: COVERAGES THE POLICIE:, ��F INSUAANC3 L=a^TBD BELOV7 HA�7E HEEV ISEUBD TO THE IV3CRBD NF�ISD ABOVE FOfi THfi POLICY ?ER=OD IKOICATED. N��T'ti=IflSTP.NDIN ANY ILQ7IR&ME[�T, TSRLS OA C�JP77ITI027 OF ANY CCti2R9CT ��R OTIIER DO��UMEKT WITII Il&F,?EC^_ ^_�� A'L7ICI] T[lIS CEZ^_IFICP.TE M?.Y DE IEo'U6D OR hU1Y P;A'lAI2�I, TH6 INSUELANCE BEF7RTE0 BY TH3 FOL=CIES DESCRIBEO �EREIt7 IS SUBJECI' ^� SLL THE TERMS� 3XCL'JSIOTS r1ND CONDITIONS OE SUC POLICIE�. AGGFE3ATE LIMITS S�ONTN MAY f3A'�lE BEEV REOU�ED BY PAID CCAIMS. IR� PVLLCI EPPECYIT POI�ICY EXPCRP.T=UP gt ^_YPE OF INSUREVC6 BJI.ICi'H9MBER DD Y' Y 1CKI^_S �EtlERAJ,�IABILLT� EB^} O�CUAAEN^9 � COPAfERCIAI, �EA3[tA1 7,=,1BIlI'fY PIAfl DAtUGE Ar �ne fiz � Q�AIPIS yAD3 n�CCUR MED E3P 'AnV �r_e peraoni : YER iONAL b F.DV IN7LIAY G GENHite1L AfAtS;ATS : �HA'L AGERE:,F1^_E lIMI7 APP�IES F PR�DOC1'S -COHY/OP A6G : P01ICT rg�� lOC �zz-vrxex�e YC+lEI1IYY ('.fINA-Nfill STNC.T.A "�7MiT AN7 AIIT:1 (S3 ac�iflent) AI.1 CKD7�a[IT03 dUU1L'� 1NJLLLY SCAECUI.EO aUT03 (Yaz parson) HIAfiC AUTOS BODIlZ IRJCkY NON CWN�1UT0� (Par a�cidentJ PA�P671PT DP14e1:H � �Par a�cident) ;PSIAC�E LCACII�PLY AQPQ ONLY - G9 AC�ID3N7 A21'l AQT� �A ACC ¢ OTHIIR PHAN &IIl'0 ONS,'l: AGG E%CES3 I,L9HI�ITY EA.�.} O�COAREN�6 OCCUR � CIAIMS LqADE hG�'iECATS nFD[7C.T TRT�F HG'CtD'P 1JN X N.^. 9TPTU- C7H- � N�3lCERS C]MDkR15L^_I[M xqD � A FS@I.OYERS' 1LAEIlI'fY' g3 WBG AY1016 05/Ol/02 D5/O1/03 E.L. E_ACH P��m� s 100, 000 E.L. DISF115E &1 EI�LOZ $ 1 O O O O O E.L. DISEIL.E POLICY Z $^_ S O O O O O �TIIEA ➢'SCRCPTIOV OF JPERATIO]TS/10:.P.TLJ25/✓EH=CLSS!E7.CLJSIOBS AD�D 3Y E9DOASP1:EflS/3PE�IP�FRO"JISIONE Those usual to the Insured' s Operations. CERTIFICATE HOLDER nnn[rxnnai, _psup.�; c�evaea x.�reu, CANCELLATION SEOCLU F:NY OF TAE 9BOVE D85CRIH� POLICIS£ HE t7F.NC3C,LEC BSFOkE TH3 SkP'fRP.T70N iIATT. THFAFOF, THR TA6ffTMG TNEfTFRR NT7�� ?N'iSAV7R T� MAT-� t 3f. f1AVS NRTTTF.N VOTTCS �10 pAYS Frp Tfr,N-PP.YAfRNT` Tt� 7RF �F.FT7F7t^.T, , TOWIL O1 Yarrnouth H��LGEP. NAM3D TO ZHE LEFT� BUT FAILURE T�� LO SO SHA�L =MP�SE r0 1146 Route 28 ObLIGP_TION OR �=9BILITY OL' ANY ZIW UFOr TFIIi INSIIRsR, I^S PGCNTS O R6PF.�EENTATSV�S. South Yarmouth, MA 02664 I.IITHrJALZED AEPA.iSEHTA �..�..-��-�-�� ACOR� 25-5 (;/97J � ACORD CORPORATION 1988 , . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #03-081 FEE: $25.00 In accordance witl�regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Loyal Order of Moose, 834 Route 28, South Yarmouth, MA Whose place of business is: Yarmouth Moose Lodge#2270 Type of business: Non-Profit Food Service ' To operate a food establishment in: Town of Yarmouth � j Permit e�cpires: December 31, 2003 Bo.�Rn oF��,Tx: ��f. �ellu(r�z. �ka�,ra.c b�e��D. ��.�G.D., ?/ie:e � i �o�ait�. �, L� ' � �a�tiek�Darix� i � `�fe�$�. �� i � December 19 ,2002 ruce G.Murphy,MPH,R .,C Director of Health t � 1 i ! � i � 1 � 1 � � � � � • � �. �; `�L}R- NtooS�l.OD6E'f�2�-'►� � '; TOWN OF HEALTH ' APPLIC IO E/PERMIT-2002 � � � � �� ,� �7�3a ,�`�5 �� * Please complete form and attach a11 necessary documents by December 31, 2001. Fail re t�� +�il�(��ult n the return of your application packet. AME ESTABLISHMENT: � +4�kco�ir 1M�oSC � v TEL. # 3 Sd I IO �}� 2-6 MAILING ADDRESS: � 1 �� IO E: +^�z � MANAGE ' N E: ��r-!+4 t p c�L L t vs4.�( TEL. # MAILING ADDRESS: '`EL+-�� 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 l. 2. � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. � � FOOD PROTECTION MANAGERS - CERTIFICATIONS: i � ; All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach 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. � ._ �'�R�flI�fi�i�i C�AR��:___ __ ____ __ -- -- _ _ _ - __ - - -- _ _ 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. 1. �� 2. n.(;U� 3. 4. RESTAURANT SEATING: TOTAL#�_ OFFICE USE ONLY LODGING• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 SWIMMING POOL$SOea _LODGE $50 _T`RAILER 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 aF a� 6 >l00 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 ItETAIL 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 _ $ 25.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** - - � � ___ _ � _ �-. �,..r.,._ � -� 4 • . . � . .> �+` k .. • • ADMINISTRATION � � Under Chapter 152, Sectibn 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or perniit_to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED v � 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 RETU�N THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2001. SEASONAL ESTABLISF�NTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION�-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. , , annITIONAL 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 (`�NSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. C'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. Thses forms can be obtained at the Health Department. —_ ---- ---- ---—____ . __ _ __ FRn7.FN 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. .�_£ <. . . , � � ,�� . ��'Y't1RE � � _ . , _ _ . . ,.�rx � .�. �� . �:: � : ,. �� ,, ��; - �� ! '�-,+'.,.'��i,. �x�' ,�,,�.`,f.�",,��..;�3��:��;�_i Y w�-t7'��-:.� ��',�-,+�'` �� 09/11/O1 � ' ACO'fiD�, CERT1�'ICATE OF LIABILITY INSURANC�,�� °Aos�o ioi' PqODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS I1 Moose I nternati onal ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 83-551129-AP-OC-XSA HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. BOX 29611 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Charl otte NC 28Z29 i INSURERS AFFORDING COVERAGE 888-253-4940 704-921-4658 �iNSURED INSURERA: TWltl City Fire Insurance � INSUFER B: ' � �2�74 MO�� Lodge INSURERC' � f�OX INSURER D: ; armou MA 02664 INSURER E: COVERAGES THE POIICiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ; ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB,IECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH PO�ICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �TR 1YPE OF INSURANCE � POUCY NUMBER DATE(MM/DO/YY) DATE(MM/DD/`lY) '� UMITS � GENERAI LtA81LITV j EACH OCCURRENCE S � ��COMMERGAL GENERAL LIABILITY i i FIRE DAMACaE(My one fire) $ 1 f �-;-i i ' � ; - ! I � CLAIMS MADE �OCCUR ! I � i MED EXP(Any one person) �$ ' � '� _ � ; j PERSONAL&ADV INJURY $ I I �GENERALAGGREGATE $ � GEN'l AGGREGATE LIMIT APPLIES PER:I I ; PRODUCTS-COMP/OP AGG $ � j POLICY jE a LOC I i j AUTOMOBIIE LIABILITV $ j COMBINED SINGLE LIMIT � � ANY AUTO (Ea accident) ALL OWNED AUTOS BODILV INJURY SCHEDULEDAUTOS (Perperson) $ HIRED AUTOS � BODILY INJURY $ NON-OWNED AUTOS (Per accident) ' PROPERTY DAMAGE $ � (Per accident) � i ( I GAHAGE LtABILITY AUTO ONLV-EA ACCIDENT $ � � ANY AUTO EA ACC $ OTHER THAN � 1 �AUTO ONLY: AGG S � EXCESS LIABILITY � ; EACH OCCURAENCE $ � ��j OCCUR � CLAIMS MADE I � 1 I,AGGFiEGATE �5 � , � --� �� DEDUCTIBLE ; � ; $ i � ', RETENTION $ I i $ � ; WORKERS COMPENSATION AND j � I ' i TORY UMITS ER I____ EiviPLOYERS'UABiLi'fY O'rJIO1�O1 I O�J�OZ/OZ iE.L.EACHACCIDENT �$lOO,OOO A i ! 83WBGAY1016 � -- ? , � j j E.L.OISEASE-EA EMPLOYE $ IOO,OOO � I I i i E.L.DISEASE-POLICY LIMIT $�jOO,OOO ; OTHEii ' , I , �.. '�, � , � , ; i 'DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENOORSEMENT/SPECIAL PROVISIONS � ' Those usual to insureds operations. ; � ; �CERTIFICATE HOLDER � N � ADDITIONAL INSURED;INSUHER LETfER: CANCELLATION DONS186 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO I DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL IO DAYS WRITTEN � NOTICE TO THE CERTIFlCATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL � DOII SU��1 Vaf1 IMPOSE NO OBLIGATION Op LIABILITY OF ANY KIND UPON THE INSURER,ITS ACaENTS OR PO BOX 186 REPRESENTATIVES. S Yarmouth MA 02664 ��, - K �� ACORD 25-S(7/97) " ACORD CORPORATION 1988 f � I , TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHIVVI�NT i PERMIT NLTMBER: #02-166 FEE: $25.00 , ; ; 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: ; T,nval (hder of Moose, 834 Route 28,South Yarm�uth, MA I ; Whose place of business is: Yarmouth Moose Lodge#2270 �--__ ____Type of busmess: �Von=Pro�it�od Service..-- _ ___ ___ _ _. , � � ° To operafe a fcwd`establishment in: �'own of Yarmouth ' ; _, j � - , � � `. . '.. � . ; Pernut��pires: December 31.2002 BOARD oF HEAI,'�'H: ��'s� xelltk�. Lka�xa�c � D. C�mrda�c. 'l11G.D.. `l/1ce � RESTRICTIONS:See reverse side. �u�I�� b��n. 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Box 2 9611 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Charlotte NC 28229 COMPANIES AFFORDING COVERAGE COMPANY PhoneNo. 888-253-4940 FaxNo.704-536-0278 A Hartford Fire 2nsurance INSURED COMPANY B COMPANY #2270 Moose Lodqe C P O Box 186 $ Y32'IROL1tZ1 MA O2GG4 COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDINCa ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CU11MS. CO TypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/Y`/) GENERAI UABILITY GENERAL AGGREGATE S COMMERCtAL GENERAL LIABILITY PRODUCTS•COMP/OP AGG S CWMS MADE �OCCUR PERSONAL&ADV INJURY S OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE S FIRE DAMAGE(Any ona flre) S MED EXP(Any one person) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE IIMIT S ALl OWNED AUTOS BODILY INJURY t � SCHEDULED AUTOS (Per person) i � HIRED AUTOS BODILY INJURY s � NON-0WNED AUTOS (Per accident) I PROPERTY DAMAGE S � GARAGE LIABILITY AUTO ONLY•EA ACCIDENT j � ANY AUTO OTHER THAN AUTO ONLY: i � i EACH ACCIDENT S ' AGGREGATE S ! ��E��TM EACH OCCURRENCE § UMBRELLA FORM AGGREGATE s i OTHER THAN UMBRELLA FORM s � WORKERS COMPENSATION AND WC STATU• OTH- I EMPLOYERS'LIABILITY TORY LIMITS ER � EL EACHACCIDENT S�.00�OOO A THE PROPRIETOR/ INCL 83WBGAY1016 ��j PARTNERS/EXECUTIVE /O1/99 OS�OZ�OO jELDISEASE•POLICYLIMIT SSOO�OOO OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE S 1 OO OOO OTHER I � DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS I Those usual to insureds operations. CERTIFICATE HOLDER CANCELLATION TOWNL�.4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN NOTICE TO THE CERTIFICATE NOLDER NAMEO TO THE LEFT, Town of Yarmouth Dept of Permi ts BUT FAILURE TO MAIL SUCH NOTICE SHALI IMPOSE NO OBLIGATION OR LIABILITY 114 6 Rt 2 8 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. $011t�'1 Yarmouth Mp, 02664 AUTHOJtjZEDREPRESENTATJV� �i�� K �� ACORD 25-5(1/95) " ACORD CORPORATION 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-38 FEE: $25.00 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: T.oval nrder�f Moose, 8�4 R�Lte 2R_ S� � h Y rmo � h, MA Whose place of business is: Yarmouth Lodge#2270 Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�� et��, C'�atr»��. RESTRICTIONS IF ANY: �oan� �ullivan, ��, Vice (,�r:rma Water usage is not to exceed 2000 gallons per day. Monthly records are l�o�ert� �rown, C�eer� to be maintained and reported to the Board of Health once a year, ad rie[[e�a�io[s� -../�oo a , D prior to December 1 of each renewal year. ic�i,a �[in December 7 , 19 99 � ruce G. Murphy, MP R. . 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THIS CERTIFICATE IS tSSUED AS A MATTER OF INFORMATION ARS I1 Moose Internati onal ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 83-551129-AP HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.0. Box 29611 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chal'l Ott2 NC 28229 COMPANIES AFFORDING COVERAGE ' COMPANY Pr,o�r,o. 888-253-4940 FeXNo.704-536-0278 A Twin City Fire Insurance INSURED COMPANY B COMPANY #2270 Moose Lodge � P 0 Box ZHC) COMPANY S Yarmouth MA 02664 p �i3VERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR'fHE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM Of1 CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VL'lTli RESP�CT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFQ�DED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITl�NS O�SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TypE OF INSURANCE POLICY NUMBER P�LICY EFFECTIVE POLICY EXPIRATION LTR DATE(MM/DDKY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE �OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(My one fire) $ i MED EXP(My one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ ' GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLAFORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND WC STATU- OTH- ' ; ; TOflY LIMITS ER ; _ ' � ffii�tOY@RS'-t1A6Y�TY � . _ _-.. . . .. _ _ . _--- . _ ... --. _ ._ .._._ _ ` -- - EL EACH ACCIDENT $IOO,OOO A THE PROPRIETOR/ �( INCL 83WBGAY1016 05/Ol/98 05/O1/99 EL DISEASE-POLICY LIMIT $ 'rjQO,QQQ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ ZOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Those �sual to insureds operation. Certificate holder is also additional insure . C�R7I�ICA't'�HOLb�R CAMC�LLA71pt�t ZZ7OMOO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL LO DAYS WRITTEN NOTICE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFf, #2270 Moose Lodge BUT FAILURE TO MAIL SUCH NOTiCE SHALL IMPOSE NO OBLIGATION OR LIABILITY Don Sullivan PO Box 186 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. S.Yarmouth MA 02664 AUTHQFtyZEDREP_RESENTA'pyE � ��(�a'X��. %� V A�C1R�25-5('tl95j ' AL:ORD CCTElP�31�k?'ION 1988. �; ! TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-17 FEE: $25.00 ' 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: i.oval Order of M�os ., 834 R�ute 28, S�uth Yarmo rth, MA Whose place of business is:_ Yarmouth Lod�e#2270 Type of business: Non-Profit Food Service To operate a food establishment in:_ 'Town of Yarmouth � ' Permit expires: December 31, 1999 BOARD OF.HEALTH:��/. �et�e, C'�irman � RESTRICTIONS IFANY: �oan. � �u[Livarc� K.�� Vice l.,hairman j Water usage is not to exceed 2000 gallons per day. Monthly records are Ko�ert� ��own, �ler� � to be maintained and reported to the Board of Health once a year, a�r��Ja�o��i�✓�ooP�e prior to December 1 of each renewal year. ic�e � hlt� December 15 , 19 98 ' ruce G. Murphy,MPH, S., O Director of Health i ; � i �