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APPLICATIOA I"OR LICENSEJPERNIIT-2817
'Please cc�mpleie#oc��x�ttd attacte all:iecessary documec�ts by Iles.rri er 16 38Id.
Failure to do so c�711 rest�tE In the relum ofyour applica�taa pa cet.
�;STARF,TSK�vlF.NTNA1tiTE: �va.
' Lt)c:A�11U[�Al)llRE`35: +iM� '�s.�l4a�1 �l.�t, 5.`�ar+wvwl�� MA �%6LyTEL.f�: f,��„o��,�' $-`�33�
�t11LILING 1lDDRESS: Sa+µ-
E-M?�II..�DI)RtSS: t�a�s.N. '�.`�e A W'sy.dwQ�,�� _ _ .
fl1�4'N£R NA_�iE:_ _�1�•��v.�., tw�a�t..r; .�
CflRPt)RAITDN NA,:�IE�IF AY:'LlCAt31.�.j: (�.k.�ti.. t n�C �T aL. = G �;
M��GER'S N�iNiE: �''�-� t�klt,�r.. TEL.�: o► �1.'l�b�33 �n n �,t
�I.+�II,ING ADDRL•SS: 1�_/��Q y,� (,1�t, �. �'o�n•`a.'l.� �''�A t 9 2 b 7 3 c rD— � C'�
.�_ �� —� ,°v
rc�or.c���c��ri�vs: s a' <
The�I supervnRor mos#be certiSeci as a Paol Upcxator,as reqnired bv State Isw. Plrase Iist the designated � �
P�I O�peratc�r(s)and attach a copy af the certification tv this form. � � �
-� c�a
1. 2.
Pool operatofi,must list a minimum nf tun empMyae.s curremiy certified in stm�dard Fir.��.id and C.ommuniry
(;atdiopultnonary Resuscitalion(�PR),having uct��rttlsetl ewpla}ee tm pzt�riisca at a1) times. Plc�a�list Lh-;
c=nployces bs,low and at#ach copies of their certifications to t�sis farn►.The liealth Department w�ilt not use past
years'r�sords. You mus#pravide new oopie�s and ma�t�in A ii[e ax your plaee of bnsiness.
1. ?• ----_ __._----_-- ___..___ _.-- --
3. 4.
r'O�ll Pl��'I'Et:3TUt�MANAGER3-C'ERTIFI�ATIC3_VS: �
AI?lixcyd sc�uicx eslablislm�ents are recEui�c[iv huve at Icasi w�fu�]-t�:ne empioyc�whc,is ce:titied� a F�c�d $
Prolact�un Mana;�r,as defined in ihe State S�anitary Ccxlr Tvr Fefcl:i Serviue EsEahli�ueents,]{15 CMR 540.{?t70. r�,. �
�l�attach copies ofcertification to this�Iicarion. The HcattM D�partm�t��l n�t use pastycars'rccaa�3s.
Ynu metst�ro�ide new cnp�es a�m�inrein a#'�e at}aur est�blishln�t. T ���
l. 2.
PERSQV IN CI�IRGE:
Each food establishment mast tmve at leet�st nne P�n in t'harge(PiC)on site during ho�rs nf orerutiart. Q
� o
Y. �- -�'1 1�i
:�.LLERGE�I CERTlFICE1TIflNS: ,��,. r.
411 fuad seavi�establishme.nts are raquired to have at tea�t one fult time employee whn ha3 A il crgcn L�rititi cmion, vt �
as de�in the Sfiat�Snnitary Code dar��od Service F_gtahlishments, 105 CA�R 59�.{l{l�(CT�3}{e)_ Pteasc�tt�6 �. p
copies of cerr�fication tn this ag�iicatirnl_ The Hes�th 1?epartarest sviN�i�se puat pears'recards. �'�a es�.st � N
ptvwide new eo�ies aad maintain a f�e at yonr establishmcnt. �
� (
1- 2, p
�
HFJMI.ICH�EItTIFdCA'rlONS:
Att fcial senice esia�tishm�nts with Z5 seais or rnore must have at least one�iny�e irair�ed in the i�eimiich
Maneuver on ttte pt+emiscs at all times. Piease iisi�rota-empl�yees traiued in anti-chokic�g proc�s briow and
attach copies af employ�e t;ertificfltions tn this ft�rm. The Heatth Dep�rtmeat vn"ll no�ns�past years'recQrds,
1'ou must provide itca�i�s�ud mxint�a�'iie at ynur platx of bRsiaess.
1. 2.
_ _..w�.�
3. �.
1�[:STAUit�+sl�T SEATTN{3: T[}TAI.#
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oF�ie�us�o�rL��
1,!{:�I�;E 12ttjUfRLD FT?T: P1'RMiT�i LIC6IVSk 1tEi1..�(�t[!} f'�f� 1'ERM1T�f L1tFNSfi R.-Q�'[REt) FEE PFRI.tiT�
-� S5= C'AB(�1 S53 WC7TEL 51IC±
SS° �4MP S55 � —S1iY[r1,LItNG°t?Qt,SI I[�ea�
�..O:Xi� S5; �PIt11lL[RPARi� 5103 ,,�„ --- ,WHIRI.Pt}t?t SIIA�t
RlSQD$ERYIC E:
LIGEY�E Ft�Q(,i}iEU t'tE PER411T if L[CENSk KEQL1}�}1J f'lE Pf:NMft� UCGI�ST•.Rlit1(iiREp FEF; PERMI'f�
D-1�C�SE,0.'�S S115 �CO VTIA`EAI['A[, S13 1�ON-PRCI�[T f30
>lOtl SEaTS �20U C'OA4MON ViC. 5+4�] --- --WIKk.e3AI.E S80
— .�. __..��_._ ,.�.RE:SfF�.KtT['tiF.N � .
RE't'A1L SERVICE:
L(CFTfSF.REQU)REI) FEE P�Rh4Pf'A� I.ICF.NSE ftEQU1REt3 FEE FERta11T Y LICENSE REQUIRED FE� PERS�ttT�
<sos�.s. 8so �2s,�� $. a2� vr-.r�mn�-�aon s2s
T�S,tXa),q:ft 5174 ��fb =F?i�E���S�tT:�i --�-7UL3A�:;:1 3l:J �$
NAIVF£c'.TiAIYf,'F'� f i s AMO�."1PT UUE _ �.�`�i{"�tX�
«i+.eaFLEi1SE 7UB!1i OVER A�iD C0�9PLETf OTHER SIRE OF FOR111�*asa
�,DMINI5TRATION
ilnder Ghapter 152,Section�SG,3uba�ectivn 6.the Tawn of Yarmo�ih is nnw rsquired to hold isst�ace vrrene�ral
af ttny license or permit to operAtc a husittess if a person or coripany does nat hare a Ceriifi�vE'�'vrker's
Compensation lusurance. THE 4TTACNED STAT� WORk"ER'S C:OMPF,NSATION IVSURA�iCE
AFFIDAT�'IT Mi15T BF CC)MPI.E'C'LD A�-D SIGNED,(71t
CERT.(}F 1iv�URAVt;F.ATTAC�iEp
Ult —--
W URK�R'3 COA4P.AFFIDt11iIT SIGNE�rLVD ATTAC`HF.T1
?oun of 4'azmuuth;a�cec aud lie.js musi be pxid pr'sor iv re,n�wal Dr issuttr�ce af 3�-�ur J��snits. Pi.EASE CFi�K
APPIZOFRLATELY 1F PAIi}�
Y�S NQ
MO'IT:LS tllYD OTHF.R LC?M:TVG FSTABLI6E[M�A'TS
TR.ANSIElV�1'�C`CIJYANCY: F�pur�oses ofihe limitations ofi�lotel arHatsi u5c,Trans�nt nc.ci�asncy sfiall be
limited to the t�mparary and shQrt term c,ccv�ancy,cxdinariiy and customariiy assvciabed with niotei�hc�tel u�.
'I'rAnsicnt occ:upants miist have and be abie 6o deinaustrate ilust they maintain a prircipat place nf residenoe
elsetivhere.TraQsie�i occ�tpancy s2�s11 genetnl ly rcfcr tn�tinuot�s ncca�tncy of not mtxt ti�t thirt}�(30)d�ys,�d
an a�gre,�ate ofnoi more than ninety{9U}days within anv six(6}iuvuth��ri�d. Use ofa gttest unit asa ra�idence or
dw�lling unil shall not be consider�d tran�ient. t'�upancy that is subjec.t ta the�ca�lection of Room Uccupancy
�xcise,as def ned in A�I.G.L,e.G4Ci or 83U C1dR b4G,as a.-nended,shall gt�er�lly be considered Trans�en�.
PtH7L�S
P1JOL OPEI�IIYC::A l i 4u7mmin�,wading and tshirlpc�ols wlnch haye been riosed for the seasuu mtat l�msp�cted
by the Ht�[fh Depantment prior to ogeain�g. t;cx►iact the f-Iralth��riment to schedu�e#he m on three(3)
dA3s(1T10��O 9�CIIlII�.PL�:�S�NL)IE:P�ple�re N4T allowetl t0 slt tR t�iC��atCS tiniil��E haa becn
inspecied and ope�ed.
PUDL V�'A`I'�R TF_ST1Nl�� 'T1��vuater must be tested for pseudor�onas,tatal califorct�ai�sta�lardplaU�wunt
by a State certitierl lab, a►�ci submitted to dte Heaith Department[hree(3}�isiys rrior tn�pcning,a�d quarlerlv
therc�ftcr.
�'OOL GL(fSI�iG:E�ery outcia�r ui�rau�►cl sw;mminF;puvl must be drained ar cavered within�ven{7j duys af
closing.
1�[H}ll���1'ICE
SEASU�tA1.,FO(1I3 SERVICE�PENIIV�:
11I1 faod service est�btishment4 mugc l�in�pccrcd b3�tl�Hcalth Ucpar-tment pr�r to o�ening. Plcasc cantact tlae
Health lle�ari�c►t tv sa:l�edule tt�e ixzs�pec:livn three{3)days prior tc>�gening.
CATERIN�PULICY:
Anyo�wha caters wethin the"i'own vf`�arrnauth znu�t�fil�y the Yarmvuth H�alth Deparkment by filittg dte
requtred Temporary Food Se�vicc A�plicatir►n frnm 72 hc�urs Prior fo the catered eveat: ll�ese fomis cau be
obtained at tl�Healtn lle�ncnt,or fttr�tEie Tvwn's wehbite al wu�w.�t�ttautlt.ma.ug ua�der Hesieh Depachment,
�OWR�flC�IItI�CC FDTTi1.4.
TROZEI\IIESSEI�i'S:
Fccrcen cles-serts must be#esi�ti W a Sta#c cextihed lah�rit�rtn a�ening�md mnnthly t�t�eaftcr,writh s�mple re�[ts
subtnitbcct to tt►e IIcalth Depa�nen� F`ailure to�o so will€�sull in ihe�uspension ur ievocation vf yut,tr Ptozen
Dess�ert Fermit until the ubove terms havc lsccn mct.
OiJTSIDE�A�S.
Uutside cates{i.e.,e>utdoor seating witte waifer,�waitress service),must have prioraFspmvat fmm the Aaard af Health.
QUTDaOR COObINC:
Clirtdoor eaoking,prepmtafioc�,�r display of any food prcxtuct b}•a retail or fi�od aervic:e fatablishment is prvhibited.
TTOTICE:Permifis run�nually from Januery t m T)�anher 31_ IT i5 YOiTt RESPONSIBII.ITY 1'O ItL1Z.TR.�1
r1i�con�rr��zD�wA,z.��Lic�,�rlvv�sl�v�t�t��IxED F�E{s)BY DE�EMBER i�,2ots.
ALL RENOYA110N� '1�U ANY Ft3(}D EST�IiLLSHI�fEV`i', A�I��'FI� aR P40L �t.e., PAINTiNC, NEW
EQUIPMENT,ETC.j,MUST BF RF,Pt7RTFJ,i?Td A.N�APPIt��r'ED BY TI IL'IIC}ARU UF IIL•'r1LTH 4'ltiUK
TO CC7MMEVCEh�1�1�1'. it�VOVA7'EOI�S MAY RE(�(� A SITE PLAN.
D,�'rE: I�1�-2 q 1(� Slcrt�:lv�: ,. •
F�t�r��v,��r����,�t.�: mG h�,,, Gk k.��. -- t7�.�
Rev.]0;1?'tt
� Tk�Cor�mr�nwea�tb nf.tl�furs�+chusetts
.a�eparr�Rt of Ihdustr�tal Accirierrts
Ufftce v}'fn�estig�€o�s
1 Cvngress S�tree� 5rci�e Il�
Bestrrn, �IA @ZII4-10I7
www.�as�gavfdira
Workers' �ampensaiion Iasuranae Affi�da�vit: G�neral Bu�inesses
Annlicant Inforrnafinn Ple,�tse�'rint Le�`blv
Businessl�r�anization�ame: '5���•� iQ,�- �,\\
Address: �1'16 S���•• .�1,�.
City�Siate,��ip: �. �/�..x.m�,�. , MA t��.66� I'hflr�e#: So� 3 �- 3
Are on as emplflyer?t�heck tLe appropri�te boz. B�in�'I�pe(req�ired):
I.� 1 am a�nployer with�emplayees{full and.r 5. ❑ R�teil
�r part-fima�.* fi. ❑ RestaurantJBarlEating Establislt�ment
2.❑ I am a sole proprietor or par�►ership and have nc� ,
employees warkin�for me in any eaPacitY- 7. ❑t3f�ice ar�d+vr Salcs(utcl.rea�estate,aubo,etc.}
[\o workers'comp.msurance requirtd] $. ❑ Mon-profrt
3.❑ We are a corpvration and its of�rce�s hsve exercised 9. � Entcrtainz�t
their r�e�hE af eaceurptio�t�er c. 152, §1{�},and we have �(}.Q Manu1'acturing
no empinyees. [ltio wc�rkz�'tximpr ins�an�e raquir�d�" I L�] Healdi�are
�.❑ ��e are s n�n-pmfit�rganizatian,ataffod by volunteer.�,
w'stla no employees. [No workers'cc�mp_i�surance req.] 12,[] Oth�r
"AA�r r�rlieanc that el�ecks i�nx i!l must atsa fii�c�it�he�cm l,etaw�owing rfieg rvorlceas'eompensmion golicy infamatiun.
s•lf tht caipaaate ofbaers haut exe�pted�tvcs,but the uapr�ration�as�ther e�r�Myees,s warkers'acsmpensati�po:i�r is required myd s�eh an
o�aeizatia�should chec�.box�I.
F asr a��npJn3�.er tfirr�is�vrravidiMg w�rkers'c�tpensaiuur�airanerr for»»tp�n�tt�yi�� l�elaw!s th��rrlicy i�,ft�rxrat�in.
Insural�ce Company Name: "T�.re.\u� �n u�c,s„ti �o+�.�a�:Y,S
Insurer'sAddtess: �,U. C3�� I�IS�
citylSt�lz�p: t�:dlal�bafc� MA n2�-+H
T
Pfllicy#or�elf-ins. I�ic.# UlQ>'�A9 �`���� Expirafron Date: � '�" /��1�
Atbch a c�opy of the workers' compensation pol�ep deelaration page{skowing the policy number and expiratian date).
Failure tc�secw�ct�verage as rEquir�u�der Se,ction 25A of A{GI.c. 1 S2 can ieaci�d�e im�nsitian of criminal penalties of a
fine up ta�Z,Stl4.t�aruUar ame-year imprisonment,as wel]as civil penaities in the form of a STOP W{3itI�QRDBR and a fine
crf up to S2S0.00 a day against the violator. Be advis�d that a copv of this statement ma.y be fcxu a,r�d to the C)ffice of
Inves#igations of the DIA for inst�ance ct�v�age verification.
I do�ereby cer ' under tlre pains a►id pen�rlties ofP�7�tY t�the inforn�rtiaie provicfed a6r�ve is m�ee and carr�
; — �u- 2�-2c�l6
Phnne#: C5"��'��8- 23'�7
OfJ�I gse oah. Jhi�rat�vri�e�x this erea,�ii be ca�pleted by c�y ar tr�wre o.ff�ct�
City nr Tawn• PermitlLieense#
issuing Aat6ority(carcle one):
1.Baard of Heatth 2. Bnilding�}epartmcst 3.Cityt7'own Cl�k +�.�.icensiag Baard _S.fielectmen's(�'fce
t.(3ther
Cdni�t Per3on• Y�oue fi�•
www.�s.govl�a
AC a� �r��'°°rxvrr�
�� CERTIFICAT� Df LIABItITY INSURA�iCE io�2�j�oY�
THIS CERi1FICA'i�iS 1$SUED AS A MATTER OF iNFORMATK}FI ONLY AND�NFERS Mp RiGHTS UPON TH€CERTiFiCATE MlOLDEii� THtS
GEltTIflCATE �OES NOT �F�!l�MAT11tELY (!R 1�1€GATNELY AMEN[7, EXTEl�ID OR ALTER THE GOYfRAL�E A�FF!?RDED BY THE POLICIES
BE�OW. 'tNl$ GERT1FtC�tTE DF iNSURANGE DQES NOT COkSTITUTE A C4NTRACT SETWEEN THE lSSUING lNStlRER(5), AUTHORIZZED
REPRESENTATiYE t3R PRODUCER„AND THE GERTtFtGATE HpL[lER.
iMPORTANT: If the certiflca#e holder�an ADDITIUNAL Ii�ISSURfQ,tt�paltcy(�s}must be endcrrsed. if S�IBROGATION IS WANEd,subject to
ttie�rms and condttions of the poNCy,Cer#a1n p4litMs may reqWe�8n endo�sement A statemer�oa lhi�Gartifilca�tlaes not eor�t8r righffi to tl�
certtf#cate hohfer ir�lieu of such er�do s.
r+�oot�cEx �!��T Linda Cook
Ocea�+oint Insurance Aq�n�r � (401)847-5200 F� �;<so�tie+a-so��
5�t? 9test iKain Rd �gg.lGvok@viceazspointins.aom
w€��cov�w►cE �wc s
Middletawa RI 0��4� erstNt�tnaTravelers Casualt 6 Surs 1903$
t�surtm
nost��rt a:
_ . __
i�'#�d l��� 211C x+su�c:
1� i Sons Inc. nisur�a n:
�$� Statioa A•ren:te 'ut5ti�e:
'' SC�H �H 2�i C12664 f�
COVERAGE� CERTIFiCATE AlUMBER:CI.161Q2601605 R�Yt�1 NUMBER:
THi$IS T[5 CERTIFY THAT THE PCk_#CtES Qf INSi?RAt�1�E tISTEt�SELC�N NAYE BEEN tSSUED TO TIiE lNSURED hifiME()ABdVE�QR TF#€PUUGY P�it�3
lNDICATEd. t�TWfTNS7ANDING ANY RE(2U1F2EMENT,TERM OR G�+fE}ITK�+1 QF ANY CC7NTRACT OR OTHER UOCUhIEPlT iMTFfi RESPECT TO WHICH THIS
CERTtFIGAT€ �AY S�t�ED C3��aL4`f�42TAtN, THE tNSJRANCE A�FL)RDE�BY T#!€P�Jt..�lES LIESCR!$€� H�(E#�1 ES SU�,IEGT 7Q ALL TNE'��t�4E�,
EXGtUSiONS AND CQN[}ITtf7NS OF SUCN POLlGYES.[�IAd1fiS SNdWtJ lNAY!-lAVE BEEhi REDLlCED HY PAID CLAlMS.
LTit TYAE��ISU�JINCE �y�� POIiCY EFF PDUGY E7FP �
�cu�e,��eu�e,�urr �occtra��rx� s
� o���ro�im --
CLAlMS-MADE 4CCUR ' . . , p��ry ����� ?�
1�IXP a�e n S
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C�EML AGGREGATE LIMIT APPLfES PE#t_ G�NFRAL P�TE i
PUUGY�JEL`QT ��-QC P�TS-C�MPKSPAfG S
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At�i�BlLf tlABtf.lTf S
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,orarAurc� �rna,ntRvt�erper�,� s
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H�?£L'A�`'f� ! !�LtitR+f-0WNEQ PRC)PERTY DpMAGE $
s
��� c�cccua �+s�ccUr��n� s
occFss�a�a cEan�s.�aF ,�r�c�a� s
OF� RETENT� S
WQ(�tfRSCWlPE/1SAT1Wi x �7p�7 ER
AND B�^Lp]'ERS`LYI�EtTY Y I M "
�PdVY PR�RiETOWPARTNIEWEXECUTNE El.EACH A4'�lD�fT S 1 OQQ t1Q4
f?FfICERtMEA46ER E)CG(.U6ED9 �N 1 A
a ���m7�+a� a�s�a�o s��ao�s snt�� E��-�,�o,r s t oaa o00
[?�SSCRtPT1oN dF OPERaTtoNS bdnw E.�DiSFASE-P[}L.ICY L�IT S 1 iY00 flQ0
�ti�7�N CF�ERAi�N3 t CUGAi101tS/VEF�Nd_ES{RCOI�#tM,A�Ratmks SeUa�,mce�t ba ettaeFied N�Y sPia��W�1
CERTIFIGATE HtKDER CANCEi.LAT1QN
S1i0ULD AWY OF THE ABpVE dESCRIBED POLIClES BE CANCELLED BE�'ORE
'1`QWI! Of Y��ffiOLl#22 �3A 7FiE EJCPlRAT10N DA"TE THEREOP; WCYt'10E NRLL 8E OELIit�ff�0 IM
ACGOft[lAA10E Nt17H THE POLfGY PRqViStONS.
AUTNOKII�D I�FRESF/�tTATrif£
�i�r�� �cak/LL�^ Cd `t�.:s-�«.�Ce.,� C°.��-�e��fc._
�1988 2f)14 ACORD CQRPQRA7'ION. All tFig�hts r�setved.
acc��2s{2a�4ro�� tns Acot�na�and�es$o are r,��,�e�d mar�s ot aco�
INS02Sr�n,an4,