HomeMy WebLinkAboutApplication and WC �
- � TOWN OF YARMOUTH BOARD OF HEALTH �'�
APPLICATION FOR LICENSE/PERMIT-2017
*Please complete forrn and attach all necessary documents by Decemb r 16.2Q16.
Failure to do so wili result in the return of your applicahon pac et.
i ESTABLISHMENT NAME: GG C6�J �
� ' LOCATION ADDRESS: � /1�c�r� TEL.#: - - OS"7J�
MAILING ADDRE • U� ll-��. v
E-MAIL ADDRESS: "
OWNER NAMEc
CORPORATION NAME(IF APPL,ICABLE): ,c��Ge �.'� C
i MANAGER'S NAME: • ` TEL.#: L — DS�Jr
; MAILiNG ADDRESS: D o� ��
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.
1. 2,
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at atl times. Please list the
employees below and attach copies of their certifications to this form.The Healt6 Department will not use pasY
years'recorda You must prnvide new copies and maintain a file at your place of busiaess.
1. 2.
3. 4,
� �OOD PROTECTION MANAGERS-CERTIP'ICATIONS:
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 Saniiary Code for Food 3ervice Establishments,105 CMR 590.Q00. �
Please attach copies of certification to this applicarion. The Health Department will not use past years'records, _ ;� �
You must provide new copies and maintain a file at your establishment. � -�: �
1. 2. � _�^p Rl
0 ��
PERSON IN CHARGE: � 4� �
Each faod establishment must have at least one Person In Charge(PIC)on site during hours of operation. -� � v
1. 2,
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(Gx3�a). Please attach
copies of certification to this appiication. The Health Department w�iii not use past years'records. You must
provide�ew copies afld�naiatain a file at your establishment. .�,a;
��
1. 2. r,
HEIMLICH CERTIFICATIONS: ��'�
All food service establishments with 25 seats or more rnust have at least one empioyee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anri-choleing procadures below and
attach copies of employee certifications to this form. T6e Heslth Department will not nse paatyeara'records.
You must provide new copies�nd maintain a file at your place of business.
l. 2
3. 4.
RESTAURANT SEATING: TOTAL#
LODGING:
OirFICE USE ONLY
LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIkED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT#
—�B S33 CAAIN S55 _MOTEL SIIO
���E SSS =T1tAi[,ER PARK Ss05 —SWIMMING POOL Sl l(ka.
_WHIRLPOOL S110ea.
ROOD SERVICE:
LICENSE REQ UIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE RE�UIRED FEE PERMIT#
0.100 SEATS Si25 _CONfINEN!'pL S35 NON-PRO IT S30
>100 SEATS s200 _COMMON VIC. S60 =WHOLESALE S8Q
RETAIL SERVICE: —RESFD.KITGFIEN S80
1LICENSE REQUIItED FEE P IT# LICENSE REQUIREp FEE pERM[T# LICENSE REQUIRED FEE PERMIT#
<50sq� VENDING-F�D SZS
�23,OW sq•ft. SISO Z` �ROZ�EN�ESSERTS840 �['OBACCO 5110
NAME CHANGE: $15 AMOUNT DUE _ $�Q,QO
'*"*`PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•'•+
�o�F_�y-a566-03
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ADMIrTISTRATION
Under Chapter 152,Section 25C,Subsecrion 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 WORKE�'S COMI'�NSa'fIQN I1�iSURANGE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarnmuttr taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CI-�E�K
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitstions 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.
Transienf o��upants must have arid be able to demonstrate that they maintain a principal pia�e of resid�nce
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest uait 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.a 64G or 830 CMR 64G,as amended,shall generally be considered Transient.
POOLS
POOL OPEIVING: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 inapection three(3)
days prior to opeuing.PLEASE NO'TE:People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,and submitted to the Heatth Department tluee(3}days prioz ta 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
SEASQNAL FOOD SERVICE OPENING:
AIl food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Departmentto schedule the inspection ttixee(3)days prior to opening.
. CATERING POLICY:
Anyone who caters witAin the Town of Yarmouth must notify the Yarmouth Health Begart4[tent by ftting the
� reqwred Tempotary Food Service Application form 72 hours prior to the catered event. These forms can be
' obtained at the Health Depa�rtment,or from the Town's website at www.Xannouth.ma.us under Health Department,
Downlaadable Forms.
.� �R��EN�ESSERTS: _ _
Fmzen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with saznple results
submitted to the Health Department, Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above tem►s have been met.
QUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior apgroval from the Board of Health.
OUTDOOR COOI�ING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibite�.
� NOTICE:Permits run annually&om January 1 to December 31. IT IS YOUR RESPONSIBILiTY TO RET(JRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
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 MA REQUIRE A SIT LAN. `
,� DATE: C�//Y/�G SIGNATURE: ^ C.°.
PRiNT NAME&TITL • C� ; �� ✓'eS'i`4����
Rev.l0/12/t6
' ' ' ` � The Commonwealth ofMassarhuset[s
Department af�ndustrial Accidents
D,f,�`ice of Investigations
' 1 Congress Street,Suite 1 DO
Boston,MA 02114-2017
, www mass.gov/dia
Workers' G�ompensation Insurance Affidavit: General Businesses
A licant Information Please Print Le 'bl
Business/Organization Name:��,�,��- � _�.�..
Address: ��' �U � /�?� ��
City/State/Zip: �a ► hone#: C�k�-�-���'xS`�'c�
Are you an employer?Check the apgropriate 6oz: Bu�ingss Type(required):
1.❑ I am a employer with employees(full and/ 5. (�Retail
or part-time).* 6. ❑RestaurantYBar/Eating Establishment
2.❑ I am a sole proprietor or parinership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] g• ❑Non-profit
3.� We aze a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.�Manufacturing
no employees. [No workers'comp.insurance requiredJ*
4.❑ We are a non-profit organizaxion,staffed by valunteers, 11.(]Health Care
with na employees. [No workers'comp.insurance req.] 12•�Othe�'
iAnY a�plic�t that chedcs box#1 must al�fili out the sectian below showing their workeis'aompensation policy information.
"'If the corporate of�cers have exem�ed themselves,but the corporation has othes employees,a workers'compensarian policy is iequi�ed and such an
organization shouid chedc box#1.
I am an employer that�s pmviding workers'compensatinn insurance for my employee� Belaw is the polfcy informatlon.
Insurance Company Name:
Insurer's Address: � � �j4��0
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation palicy declaralion page(showing the policy nnmber and egpiration dste).
Failure to secure coverage as required under Secrion 25A of MGL c. 152 can tead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against ihe violator. Be advised that a copy of this statement may be forwazded to the Office of
Inve$tigations of the DIA for insurance coverage verifccation.
I do kereby fy,under the ns and penalties of perjury that the lnforneatiore provided above is true and correc�
.-- �J `..
i � / --- � i �
Phone#: ��D �— �%5�--��'7.,�
D,fj`'icial use only. Do Kot write in this arera,to be completed by clty or town officiaL
City or Town: Permit/License#
Issaing Anthority(circle one):
1.Board of Health 2.Building Department 3.Ci#y/Town Clerk 4.Licensing$oard 5.Selectmen's Office
6.4ther .
Contact Person• Phoae#•
www.mass.gov/dia
Hov 11,2816 11:46:91 EST FROM: F2M/17628876456 MSG# 1532587689-886-1 PAGE 691 OF 6B5
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FAX COVER PAGE
To:
Fax Number: 5083982365
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From: "Services, Agency (Comm Lines, San Antonio/SCIC)"
<Agency.S ervice(a�thehartford.com>
Date: 11/l li 16 11:45:17 AA�
Subject: 76WEGNZ1661-�ANKEE CRAFTERS INC
Total Pages: 5 including cover page
PRIVILEGED AND CONFIDENTIAL:This eledronic communication,including attachments,is for the exdusive use of addre�ee and may
contain proprietary,confidential and/or privileged information. If you are not the intended recipient,any use,copying,disdosure,
dissemination or distribution is strictly prohibited. If you are not the intended reapieni,please notity sender immediately by phone,destroy this
communication and all copies.
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Register today at www.thehartford.com/servicecenter and discover the ease of paying your bill,
enrolling in AutoPay,requesting certificates of insurance,viewing documents or Going Paperless.
We care about meeting your service expectations.Did I provide you with a great Hartford�7cperrence?Please eel ree to
sendarryfeedbackon myservice to Vivian.Buzako@thehartford.com ��������
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HEALTH DEPT.
Nov 11,2816 11:49:17 EST FRUM: F2M/17628878456 MSG# 1532587669-686-1 PAGE 961 OF B65
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The Hartford
FAX COVER PAGE
To:
Fax Number: 5083982365
Company:
From: "Services, Agency (Comm Lines, San Antonio/SCIC)"
<Agency.S ervice(-?a,thehartfo rd.com>
Date: 11/11/16 11:45:17 AM
Subject: 76WEGNZ1661-YANKEE CRAFTERS INC
Total Pages: 5 including cover page
PRIVILEGED AND CONFIDENTIAL:This eledronic communication,inGuding attachments,is for the exdusive use of addre�ee and may
contain proprietary,confidentiai and/or privileged information. If you are not the intended recipient,any use,copying,disdosure,
dissemination or distribution is stricfly prohibited. If you are not the intended reapient,please notify sender immediately by phone,destroy this
communication and all copies.
Memo:
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Register today at www.thehartford.com/servicecenter and discover the ease of paying your bill,
enrolling in AutoPay,requesting certificates of insurance,viewing documents or Going Paperless.
YVe care about meetingyour service expectations.Didlpmvide you with a great Hartford�cperience?Please feel free to
send anyfeedbackon myservice to Vivian.Buzako@thehartford.com
Nov 11, 2816 11:49:47 EST FROM: F2M/17626878456 MSG# 1532587699-866-1 PAGE B63 OF 8e5
PAYCHEX INSURJ►NCfi AGENCY INC
PO SOX 33015
BAN ANTONIO TX 7B2fi5
Town Of Yarmouth Health Departtnent
Attn: Sruce Murphy
1146 ROUTE 28
5QUTH YARMOUTH MA 026b4
ACORD 15(2016108)
Kov 11,2616 11;49:53 EST FROM: F2M/1762e878456 MSG# 1532587689-866-1 PAGE e64 OF ee5
p�'�� UI<G D�rn,�nrM.vo rYw�
��"� CERTIFICATE OF LIABILITY INSURANCE Rooz 11/11/2016
TH18 CERTIFICATEI8188UED A6 A MATTER OF INFORMATION ONLY AND CONFERB NO RIGHTB UPON THE CERTIF�CATE HOLDER,TH18
CERTIFICATE DOEB NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER TNE COVERAGE AFFORDED BY TNE POLICIES
BELOW. THI9 CERTIFICATE CF INSURANCE DOES NOT CON8TITUTE A CONTRACT BETWEEN THE 133UIN0 IN3URER�3),AUTHORI2ED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORT4NT:H the csRlficate holder Is an ADDITIONAL IN$URED,the policy(lea)muat havs ADDITIONAL INBURED provlslons or be endorssd.
If SUBROGATION IS WA�1/ED,suhJect to the terms and condltlnna of the pellcy,certaln pollcles may requlre an endor6ement, A statemem on thla
certifioete doea not confer ri hta to the certifioate holder in lieu of auch endor�ement a.
PRODUCEF CONTACT
PAYCHEX INSURANCE AGENCY INC (A�Nu,�d�: (Alc,Nu7 �888� 943-6112
210705 P: F: (888) 443-6112 .o"�0a:
P� BQx 3 3 0 1 5 INBl1RER(8)!FFGROIN3 GGVERAOE NN�
SAN ANTONIO TX 782E5 IN6Ufi�FA: TW111 C�LY F�PC �n,� co �»59
INfiURED
IN9URER6:
�NBURERC:
YANKEE CRAFTERS INC INBUtiEFO:
PQ BQ� 296 IN6URERE�
50UTH YARMOUTH MA 02669 INBURERF:
COVERAGES CEaTIFICATE NUMBER; REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE� NAMED ABOVE FOR THE POLICY PERIOP
IN�ICATE�, NpTVJ�TH$TANDING ANY REOUIREMENT, TERM OR CON01710N OF ANY CONTRAC"f OR OTHER DOCUMENT 1h�TH RESPECT TO WHICH TH�S
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE �NSURANCE AFFORDED BY THE POL�CIES DESCR�BE� HEREIN IS SUB,IECT TO ALL THE
TERMS,EXCLUSIONS AND COND�TIONS OF SUCH POLICIES.LIMfTS SHOWN MAY HAVE BEEN REDUCE�BY PAID CWMS.
ln'Sn TYARr7F7,Wf:7t�V!'E .�SG� Pq7.J('YNl'MflF.N WII,II:YF.FF YU[.u'Yrv� l.IMIT.P
77MiU»
CONMERqALGENERALL�AB�L�TY EACN OCCURRENCE s.
CLAIMBab1ADE ❑OCCLIR DAM.4GETORENTEO
PREM�6E8 Eaaeeun��m
MED EXP(Any onP pProom
PER&ONAL a ADV INJl1RY
GEN'L AGGREGATE LIMIT APPLIES PER: DENERAL AGGRE�3ATE
POLICY❑J CT❑LOC PRpOUCT6•CC�PIOPA00
OTHER:
ALITOMOBILE LIaBILITV COMB�NED 6�NOLE L�MIT
� (Ea acddent}
ANY AUTO 90�ILV�NJUaV(pr pusori)
OWNE� SCNEDLILED BODILYINJURY(Pe�eccidenq
� AUTOS ONLY AUTOS
HIRED NON-OVvNED PROPERTrD�na�oE
A11T03 ONLY ALfT09 ONLY (P�i eccld�nt)
UMBRELLAIJAB OGCUR EACN OCCURRENCE
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DEO RETENTIJN 8
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aivnr.�rrr.nrr.ec��✓�nn.rn Y 6TATUTE EN
ANV PROPRIETORIPARTNER+E7fECIJTIVE YIN EL EACM ACCIDENT . �],O O�O O O
OFFICERfMEMBER EXCLUDED7
A f►4andatorylnNNJ ❑ N�A �G �aEG N2_bbl 45/06/2�16 �75/06/2D17 EL019EA3EEAEMPLOYEE 'ZOO�000
K yce,drsvi6e under E,L,b16EA6E•PDL�CY IJM�T 2 5 Q Q Q Q Q
DEBCRIPTION oF oPERAT1oN8 belrnv �
DESCRIPTION OF OPERAT/ONS/LOCATIONS/VENICLES(AGORD 1U1,Additiond Ramarlw 6chedile,mey ba eQxhad if mora avace ie roduirad�
Those usual to the Insured's Operations.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLE�
Town pf YaYmouth Hea1Lh De aY�tment BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
� DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
Attl'1: Br'l1C@ MllTj�11y AUTHORISEDREPRE9ENTATYVE `
119 5 ROUTE 2 8 '"7�,� "�'�'���
SOUTH YARMOUTH� MA a2b64 ''�
�1988•2D16 ACORD CORPORATION.All�Ight9 reaerved.
ACORD 26(20161D3) Tha ACORD name and lego are registered marks of ACORD
Nov 11,2816 11:58:14 EST FROM: F2M/17628878456 MSG# 1532587689-e86-1 PAGE BB5 OF B65
AGENCY CUSTOMER ID:
LOC#:
�� ADDITIONAL REMARKS SCHEDULE
Page_ of _
AOENCY NAMED�NBURED
PAYCHEX INSURP,NCE AGENCY INC
POL1CVNl1NBER YANKEE CR.AFTER5 INC
SEE ACORD 25 PO BOX 236
enawea N�uccooe SOUTH YARMOUTH MA 02664
SEE ACORD 25 EFFECTIVEDATE� SEE ACDRD 25
ADDRIONALREMARKS
THI8 A�DITIONAL REMARKB FORM IS A SCHEDULE TO ACOR�FORM
FaRMNUMBER: ACORD 25 FORMTITLE; CERTIFICATE OF LIABII,ITY INSURANCE
' Brian M, Heaslip A55t. Hedlth Agent
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ACORD 101 (2014101) �2014 ACORD CORPORATION.All riphte reserved.
The ACORD neme ehd logo are�eglatered ma�ka oi ACaRD
i
A�� DATE(MMIDD/YYYY) ..
CERTIFICATE OF LIABILITY INSURANCE 4/8/2017
THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE GERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIYELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT GONSTITUIE A CONTRACT BETWEEN THE 155UING INSURER(S),AUTHdRIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVEd,subject to the terms and conditions of the policy,certain policies may require an endorsemen�. A statcment on this
certificate does not confer ri hts to 1fie cerlificate hol�r in lieu of such endorsement s.
PRODUCQt CANTACT
NAME:
PAYCHEX INSURANCE AGENCY INC �",�°NN,��>: �.vc.No�: (888) 443-6112
210705 P: F: {888) 443-6112 E�"""
ADDRESS:
P� B�4 33015 INSURER(5)AFFOROINGCOVERAGE � NAICY! �
SAN ANTONIO TX 78265 INSURERA: TW1R City Fire Ins Co
INSURFlJ
INSURER B:
INSURER C:
YANKEE CRAFTERS INC INSURERD:
PO BOx 296 INSURERE: �./'1LTH P
SOUTH YARMOUTH MA 02664 ir+suaeaF:
GOVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NdTWITHSTANDING ANY REQUIREMENT, TERM OR CONDffION OF ANY CONTRACT OR dTHER DOCUMENT WffH 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 CLAIMS.
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GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE g
POLICY a PRO-❑LOC PRODUCTS-COMP/OP AGG g
JECT
OTHER: S
AUTOMOBILE W►BILRY COMBINED SINGLE LIMIT $
(Ea accident) .
ANY AUTO BODILY INJURY(Per person) g
OWNED SCHEDULED BODILY INJURY(Per accident) g
AUTOS ONLY AUTOS
HIRED NON-0WNED PROPERTY DAMAGE �
AUTOS ONLY AUTOS ONLY (Per accident) �
$
UMBRELLA LIAB OCCUR EACH QCCURRENCE g
EXCESS LIA9 CLAIMS-0AADE AGGREGATE g
DE RETENTION$ �
WO�EF5CONPEIVSATION PER OTH-
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ANY PROPRIETOR/PARTNERlEXECUTIVEY/N E.L EACH ACCIDENT $1 O O� O O O
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A (MandatoryinNH) ❑ �A 76 WEG NZ1661 05�06/2017 OS/06/2018 E.L.DISEASE-EAEMPLOYEE$�OO� ��0
�, If�es,descrit�a.4nd6�- . E.L DISEASE-POLICY LIMIT $�j 0�� Q�� �
DES�I21PT10N OF OPERATIONS below
DESCRMTION�OPERAT/ONS/LOCATIOMS/YEH/�RD 101,Additional Ramarks Sch¢dule,may be attaehed if more spaca is requirod)
Those usual to the Insured's Operations.
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CERTIFICATE HOLDER GANCELLATION =_
� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Town 0 f Yarmouth Health De artment BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
P DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Bruce Murphy auntotazEors�a�sFavrarrvE 4
114 6 ROUTE 2$ ��., ���,�„�,,,�
SOUTH YARMOUTH, MA 02664
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