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HomeMy WebLinkAboutApp-Permit-Compliance The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-21-1885-01 Issue Date: 1/1/2022 Mailing Address: Location Address: BAXTER INNKEEPING LLC 277 ROUTE 6A CHAPTER HOUSE YARMOUTH PORT, MA 02675 P.O. BOX 1503 EAST DENNIS, MA 02641 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Continental Breakfast; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . Bruce G. Murphy M , R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $55.00 Lodging License Number: BOHL-21-1883-01 Issue Date: 1/1/2022 Mailing Address: Location Address: BAXTER INNKEEPING LLC 277 ROUTE 6A CHAPTER HOUSE YARMOUTH PORT, MA 02675 P. O. BOX 1503 EAST DENNIS, MA 02641 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Innholder This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions INN: 2ND FL- 6 BEDROOMS 3RD FL- 5 BEDROOMS CARRIAGE HOUSE- 1ST FL- 6 BEDROOMS 2ND FL-4 BEDROOMS Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy MPH,R . CHO Health Director The Commonwealth of Massachusetts Department of Industrial Accidents -- —� 1,=5- Office of Investigations 1 _��;_ � NOV 2 3 202. ._.i.- 1 Congress Street,Suite 100 Boston,MA 02114-2017 HEALTH DEPT. Noe, www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly i) e.,;714-7,rA-2. (4-./tJ 5 F Business/Organization Name: 4-Kr-eta (AINKteA,iv'6 C L C 64-p it CP,) Address: 2.7 7 /2 o✓7-6 C. 4- 2—(,,7T City/State/Zip: ) 4-11.K o POT '¢"Phone #: 3' 0 S 7 T ri b �F Are you an employer?Check the appropriate box: Business Type(required): 1.ErI am a employer with 3 employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are 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 required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: nyloc rA re 7) til pc.of,`2S 05'v:-Z 4-EtreE I.i p.4iv'7' Insurer's Address: S-1-7 7 ,s 4v Afv,r4 City/State/Zip: /7v A L.ltV 6-i' , "14- '9 is 3 —O f 7 0 Policy#or Self-ins. Lic.# WCC- s- 14.5 o3 TO 2-t 4 Expiration Date: L (// /r /20 1-1- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 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 the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,unde the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1` //7 /2" Phone#: .l'i ° g '17 6 1F Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC-500-5024303-2021A PRIOR NO. NEW ITEM 1. The Insured: Baxter Inkeeping LLC DBA: Chapter House Cape Code a/o Baxter YarmouthportMailing address: PO Box 1503 FEIN:**-***0520 — " East Dennis, MA 02641 NOV 23 2021 Legal Entity Type: Limited Liability Company HEALTH DEPT. Other workplaces not shown above: See Location 2. The policy period is from 02/11/2021 to 02/11/2022 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 111111111 INTER SEE CLASS CODE SCHEDU_E Minimum Premium $276 Total Estimated Annual Premium $3,331 GOV GOV Deposit Premium $858 STATE CLASS MA 9052 State Assessments/Surcharges $2,878.00 x 3.5100% $101 This policy, including all endorsements, is hereby countersigned by " 01/29/2021 Authorized Signature Date Service Office: Dowling and 0 Neil Ins Agcy 54 Third Avenue 973 lyannough Road Burlington MA 01803 Hyannis, MA 02601 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: "-"'0520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included in this policy: Form No. Form Description Applicable States Policy Effective Date WC 00 00 00 C Policy Conditions 02/11/2021 WC 00 03 10 Sole Proprietors, Partners, Officers and Others 02/11/2021 WC 00 03 11 A Voluntary Compensation and Employers Liability 02/11/2021 WC 00 04 04 Pending Rate Change End. MA 02/11/2021 WC 00 04 14 Notification of Change in Ownership 02/11/2021 WC 00 04 22 C MA TERRORISM RISK INSURANCE PROGRAM MA 02/11/2021 WC 20 03 01 MA Limits of Liability Endorsement MA 02/11/2021 WC 20 03 02 A MA Assessment Charge MA 02/11/2021 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 02/11/2021 WC 20 03 06 B MA Limited Other States Insurance Endorsement MA 02/11/2021 WC 20 04 05 MA Premium Due Date Endorsement MA 02/11/2021 WC 20 06 01 A MA Cancellation Endorsement MA 02/11/2021 WC 20 06 04 MA Policy Definition Endorsement MA 02/11/2021 NOV 2 3 2021 HEALTH DEPT. EndorsementSch(04/11) Associated Employers Insurance Company - - - ------- Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: **-***0520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: LOCATION SCHEDULE Insured Unit:001 Workplace:001 Business Type: Limited Liability Company Business Type: Chapter House Cape Code a/o Baxter Yarmouthport 277 Route 6A Yarmouthport, MA 02675 TAX ID:854310520 NOV 2 3 2021 HEALTH DEPT, Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: (11/11)LocationSch Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: **-***0520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Unit State Code: MA Policy Unit Name: Baxter Inkeeping LLC Billing Plan:4 Equal Quarterly Payments Classification Class Payroll Rate Estimated Description Code No. Amount Per$100 Premium HOTEL: ALL OTHER EMPLOYEES & 9052 216,400 1.33 2,878 GSL'-Lu NOV 23 2021 HEALTH DEPT. Deviated Premium 2,878 Excess Employers Liability 1.00% 29 EEL Minimum Premium Adjustment 21 Premium Subject to Exp Mod 2,928 Standard Premium 2,928 Expense Constant 338 Terrorism Act Surcharge 65 Total Estimated Premium 3,331 DIA ASSESSMENT 3.51% 101 Total Estimated Premium & Surcharge(s) 3,432 ClassCodeSch(04/11) • Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: 854310520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: INSTALLMENT SCHEDULE Units Billed to this Unit:1 Policy Unit No: 001 Billing Plan: 4 Equal Quarterly Payments Policy Unit Name: Baxter Inkeeping LLC Installment/ DIA Total Amount Due Date Billed Endorsement No. Assessment Down Payment $25 $858 02/11/2021 Billed Installment 1 $25 $858 05/11/2021 Installment 2 $25 $858 08/11/2021 Installment 3 $26 $858 11/11/2021 Total $101 $3,432 NOV 2 3 2021 HEALTH DEPT. InstallmentSch(04/11) • Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: **-***0520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: POLICY RATING SUMMARY BY STATE Massachusetts Deviated Premium 2,878 Excess Employers Liability 1.00% 29 EEL Minimum Premium Adjustment 21 Premium Subject to Exp Mod 2,928 Standard Premium 2,928 Expense Constant 338 Terrorism Act Surcharge 65 Total Estimated Premium 3,331 DIA ASSESSMENT 3.51% 101 Total Estimated Premium & Surcharge(s) 3,432 NOV 2 3 20Z1 HEALTH DEPT. Total Estimated Premium & Surcharge(s) $3,432 RatingSum(01/12) Associated Employers Insurance Company Insured: 5024303 Producer: 10083-002-001 Baxter Inkeeping LLC Dowling and 0 Neil Ins Agcy PO Box 1503 973 lyannough Road East Dennis, MA 02641 Hyannis, MA 02601 Insured FEIN: **-***0520 Issue Date: 01/29/2021 Policy Number: WCC-500-5024303-2021A Endorsement Effective Date: 02/11/2021 Policy Period: 02/11/2021 -02/11/2022 Endorsement Number: NAMED INSURED SCHEDULE The following is a listing of additional entities or locations with a different name than the insured named in this policy: Insured Name DBA Name FEIN Business Type Baxter Inkeeping LLC DBA- Chapter House Cape Code a/o 854310520 Limited Liability Baxter Yarmouthport Company NOV 2 3 2021 HEALTH DEPT. NamedlnsuredSch(04/11) • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to PART ONE all terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE GENERAL SECTION A. How This Insurance Applies This workers compensation insurance applies to A. The Policy bodily injury by accident or bodily injury by disease. This policy includes at its effective date the Bodily injury includes resulting death. Information Page and all endorsements and 1. Bodily injury by accident must occur during the schedules listed there. It is a contract of insurance policy period. between you (the employer named in Item 1 of the 2. Bodily injury by disease must be caused or Information Page) and us (the insurer named on the aggravated by the conditions of your Information Page). The only agreements relating to employment. The employee's last day of last this insurance are stated in this policy. The terms of exposure to the conditions causing or this policy may not be changed or waived except by aggravating such bodily injury by disease must endorsement issued by us to be part of this policy. occur during the policy period. B. Who Is Insured B. We Will Pay You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a We will pay promptly when due the benefits partnership, and if you are one of its partners, you required of you by the workers compensation law. are insured, but only in your capacity as an employer of the partnership's employees. C. We Will Defend C. Workers Compensation Law We have the right and duty to defend at our Pe expense any claim, proceeding or suit against you Workers Compensation Law means the workers or for benefits payable by this insurance. We have the workmen's compensation law and occupational right to investigate and settle these claims, disease law of each state or territory named in Item proceedings or suits. 3.A. of the Information Page. It includes any We have no duty to defend a claim, proceeding or amendments to that law which are in effect during suit that is not covered by this insurance. the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions D. We Will Also Pay of any law that provide nonoccupational disability We will also pay these costs, in addition to other benefits. amounts payable under this insurance, as part of any claim, proceeding or suit we defend: D. State 1. reasonable expenses incurred at our request, State means any state of the United States of but not loss of earnings; America, and the District of Columbia. 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the E. Locations amount payable under this insurance; This policy covers all of your workplaces listed in 3. litigation costs taxed against you; Items 1 or 4 of the Information Page; and it covers 4. interest on a judgment as required by law until all other workplaces in Item 3.A. states unless you we offer the amount due under this insurance; have other insurance or are self-insured for such and workplaces. 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other Page 1of6 NOV 23 2021 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. HEALTH DEPT. TOWN OF YARMOUTH BOARD OF HEALTH O� 23 202 PPLICATION FOR LICENSE/PERMIT - 2022 N *nzItis- -+mplete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ' %f 2 l iA, ,E p /AJ6 `L e 4 ESTABLISHMENT NAME: CW.A—P re, h /4.0c-1St TAX ID: 81- '13/ o Wiz- 0 LOCATION ADDRESS: 11-1 1 /2mVTG-- 4 - / k/4-it 0-(o(JTht P0147 ; �P TEL.#: 3/a 8 77 5-3-‘ MAILING ADDRESS: Po 7301( /So3 . EH-Sr 2tv,Vi5 , 1-14- 02- G E-MAIL ADDRESS: -721("4- grixr./ FfofP '7744- /7-7 . �K OWNER NAME: 77‘4/4/ - 5-t 1-(//4- 5rf x 7 72, CORPORATION NAME (IF APPLICABLE): /3 A- 5'A-D,A-eo uT/-k ( /{o (iv 6J G e MANAGER'S NAME: -PH I 2 34--/le7e TEL.#: 3 r o 8 7 7 MAILING ADDRESS: ?o /�d 1c / 5-0 3 , / IVnr i F , q- p L- 6 ( 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. 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 all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Departmen . '11 not use 'ast ears' records. You must provide new copies and maintain a file at your establishment. Cg ./ 1. 2. p,r i`i PERSON IN CHARGE: HEALTH DEPT Each food establishment must have at least one Person In Charge (PIC) on site •uring ours o opera ion. 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(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55MOTEL $110 _ 'INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** L' IA• \`6%/ . 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 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 of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six (6) month period. Use of a guest unit as a residence or dwelling unit 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, shall generally be considered Transient. 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. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE: 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 Health Department three(3)days 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 SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. 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, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample 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 terms have been met. OUTSIDE CAFÉS: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 18, 2020. 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 REQ E A SITE PLAN. DATE: �1 74/2-0 2 ( SIGNATURE: PRINT NAME &TITLE: ffflc- /�� Rev. 10/15/19