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Home My WebLink AboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-20-0490-02 Issue Date: 1/1/2022 Mailing Address: Location Address: 1078 YARMOUTH INC. 1070 &1074 ROUTE 28 DAGGETT'S LIQUORS SOUTH YARMOUTH, MA 02664 1078 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE 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. Murph , MP ,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $50.00 Food Establishment License Number: BOHF-20-0492-02 Issue Date: 1/1/2022 Mailing Address: Location Address: 1078 YARMOUTH INC. 1070 &1074 ROUTE 28 DAGGETT'S LIQUORS SOUTH YARMOUTH, MA 02664 1078 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Retail; 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, PH,R.S., CHO Health Director The Commonwealth of Massachusetts Print Form Department of Industrial Accidents --Art Office of Investigations •: 1_ >ix .'r: 1 Congress Street,Suite 100 4 Boston,MA 02114-2017 �='►,;,1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Oct3 eJ+ I j u o r h r-e J Iv yup mobi-/ Pu( Address: I a'7 t- c.q 2 c City/State/Zip: S ref rr a M126'6 Phone#: 5,9S" 6 6 Are you an employer?Check the appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. 1.21 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. 11]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.] 12.0 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: 6 a 1 d g 0 u f f o ad y)s 6 j Insurer's Address: j 6-T 50N ill R tYC% Po) Sfi' [d City/State/Zip: &&d esrc t N , 03110 Policy#or Self-ins.Lic.# Sf 2f2 3 13 Expiration Date: / Iloq ) .2 2 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,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 NOV 1 ,20?1 The Commonwealth ofMassachusetts 6-PiklLFornt , _______i —.— t m,,--= y Department of Industrial Accidents =_ ''T z Office of investigations 1 Congress Street,Suite 100 t 9 Boston,.11L4 02114-1017 u. www.muss govidta Workers'Compensation Insurance Affidavit:General Businesses Applicant Information __ Please Print I.egibis Business/Organization Name: !OP, f{ct yo r '`-1-d r-e t a 1 ...ate_... : g- �..�,1: a r,„ Address: 10711 ', 0, 2'" City/State/Zip: S YQY.•n a v,vt,ri a'2CC , Phone#: e;c if — 81 f— i Are you an employer?Check the appropriate box: Business Type(required): 1 1.p 1 am a employer with employees(full and/ 5. C3 Retail 2.0 or part-time).* 6. 0 Rctatirant/Bar/Eating Establishment: 1 am a sole proprietor or partnership and have no employees working for mein any capacity.' 7. ❑Office and/or Sales(inti.mal estate,auto,etc) [No workers'comp.insurance required] 8• ❑Nora-profit 3,❑ We are a corporation and its officers have exercised 9. Ell Entertainment } their right of exemption per c.152,§I(4),and we have 10 C]Man ufacturin no employees.[No workers'comp.insurance required]* g 4.0 We are a non-profir organization,staffed by volunteers 11 Health e , with no employees [No workers'comp.insurance req.' I 12.❑Other ' ',Any applicant that checks box#I must alsofill out the;action below showing hen workers compenution policy information. .. _ -_ '•[f the corporate officers have exempted themselves bin the corpomtion has other ervpte ccs.a workers'compensation policy is required and such an organization should check box NI. I am en employer that is providing workers'compensation hesnrance jar my employees. Below is the policy Information. fo Insurance Company Name: G7°I ° u fD 3•i� - Insurer's Address ' PI 11 City/State/Zip: f=or N • C �Cd cl i Q f _ Policy#or Self-ins.Lic.n __ 'II- a_ 'z--' Expiration Date: .t t,a a�' ,22 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 1 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 curty,unde(r}the rains and penalties of perjury that the in,jormadon provided above is true and correct Sinange.: .,l'ille a++Y Phone ft. __5_6C-:. 79,1-- 44 5 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# l r ssuing Authority(circle one); f' .Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office .Other Contact Person: Phone p: II www mass.QovPoia `.'" NOV 182O21 HEA!_TE-1 DEPT. The Commonwealth of Massachusetts Fee Town of Yarmouth $50.00 Food Establishment License Number: BOHF-20-0492-01 Issue Date: 1/1/2021 Mailing Address: Location Address: 1078 YARMOUTH INC 1070 &1074 ROUTE 28 DAGGETT'S LIQUORS SOUTH YARMOUTH. MA 02664 1078 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Retail This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 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 • ruce G. Murphy,MPH, R. ., Cnb/Mallory R. Langler,R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Town of Yarmouth $110.00 Tobacco Product Sales License Fee Number: BOHTP-20-0490-01 Issue Date: 1/1/2021 Mailing Address: Location Address: 1078 YARMOUTH INC 1070 &1074 ROUTE 28 DAGGETT'S LIQUORS SOUTH YARMOUTH, MA 02664 1070 & 1074 ROUTE 28 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE This-license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 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 4 truce G. Murphy, "PH,R.S., -SHO/ allory R.Langley, R.S. Health Director/Assistant Health Director ` l UTICA NATIONAL INSURANCE GROUP we 000001A 180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica National Insurance Company of Texas MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page Policy Number: 5482313 1. The Insured and Mailing Address: Prior Policy Number: 1078 Yarmouth Inc DBA Daggetts Liquors 1078 MA-28 Producer: Boyd & Boufford Ins Agy 167 South River Rd Ste 10 SOUTH YARMOUTH MA 02421 I3edford, NH 03110 Entity of Insured: Corporation Producer Number: 70548 Other workplaces not shown above: SIC#: 5921 Insured's I.D. Number: 852165907 NCCI Company Number: 17973 Risk I.D.Number: 2. The policy period is from 11/04/2021 to 11/04/2022 12:01 AM 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: M/-\ B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Policy Limit Bodily Injury by Disease $1,000,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: All States except those listed in Item 3.A., ND, OH,WA,WY D. This policy includes these endorsements and schedules: 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. Premium Basis Rate Per$100 ❑See Extension of Information Page Code Total est.Annual of Estimated Annual Classifications No. Remuneration Remuneration Premium Minimum Premium: $ 208 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 1,901 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 1,901 Issuing Office: New Hartford, NY 13413 Date of Issue: 10-25-2021 Countersigned by C PJB., 8-D-WC Ed.08-2008 Copyright 1988 National Council of Compensation Insurance BILLING NO. 205113976 WC 0000018 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EXTENSION OF INFORMATION PAGE Item 4. Continued Page: 1 NCCI Company Number: 17973 Policy Number: 5482313 Code Premium Basis Rate Estimated Classifications Total Est.Annual Per$100 of Annual No. Remuneration Remuneration Premium State: MA Location #:1 Beer And Ale Dealers-Retail (8017) 8017 8017 200,000 0.84 $1,680 Term: ( 11/04/21-11/04/22 ) Term: ( 11/04/21-11/04/22 ) Manual Premium $1,680 Rate Deviation 9037 -.15 -$252 Employers Liability 9812 2% $29 Employers Liability to Minimum 9848 $46 Subject Premium $1,503 Standard Premium $1,503 Expense Constant 0900 $338 Certified Acts of Terrorism (CAOT) 9740 .0300 $60 Total State Premium $1,901 8-D-WC (Supp) Ed. 08-2008 Copyright 1987 National Council on Compensation Insurance ENDORSEMENT SCHEDULE State(s) Number Edition Description 7A454 Ed. 09-07 Commercial Edge Cover Sheet MA 7A455 Ed. 02-16 Commercial Edge Cover Letter MA 8DWC Ed. 08-08 Information Page MA 8DWCSUPP Ed. 08-08 Extension Of Information Page MA WC990603 Ed. 04-84 Endorsement Schedule MA WC990603 Ed. 04-84 Locations Of Operations MA WC990603 Ed. 04-84 Schedule Of Named Insured MA 8L937 Ed. 04-05 Prescribed Wording For Utica National Insurance Company Of Texas MA 8L1834 Ed. 05-02 Important Notice About Your Premium Audit MA 8L1763 Ed. 12-12 Privacy Notice MA 8L1543S Ed. 02-01 Important Notice To Report Workers Compensation Claim (Spanish Version) MA 8L1543 Ed. 03-96 Important Notice To Report Workers Compensation Claim MA 8L1911 Ed. 06-03 Important Notice Regarding Calculation Of Your Workers Compensation Assessment Charge MA 8L870 Ed. 07-86 Policyholder Notice Massachusetts Assessment Charge MA WC000414 Ed. 07-90 Notification Of Change In Ownership Endorsement This endorsement,when countersigned by a duly authorized representative,shall form a part of Policy No. Issued by W 5482313 And shall be effective from Standard Time at the address of the named insured. M., Countersigned at Date By ibtit4t40,- C PieJ Authorized Representative NAME AND ADDRESS OF INSURED r � PRODUCER: PRODUCER NO. L J WC 99 06 03 ED.4/84 ENDORSEMENT SCHEDULE State(s) Number Edition Description MA WC000000C Ed. 01-15 Workers Compensation and Employers Liability Insurance Policy MA WC000422C Ed. 01-21 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement MA WC200301 Ed. 04-84 Massachusetts Limits Of Liability Endorsement MA WC200302A Ed. 09-08 Massachusetts Assessment Charge MA WC200405 Ed. 06-01 Massachusetts Premium Due Date Endorsement MA WC200601A Ed. 07-08 Massachusetts Cancellation Endorsement MA WC200303D Ed. 08-10 Massachusetts Notice To Policyholder Endorsement MA WC7506J Ed. 09-19 Notice To Employees Medical Treatment MA WC9249C Ed. 09-19 Notice To Employees Medical Treatment This endorsement,when countersigned by a duly authorized representative,shall form a part of Policy No. Issued by W 5482313 And shall be effective from Standard Time at the address of the named insured. M., Countersigned at Date By iSktUtir., C PecL Authorized Representative NAME AND ADDRESS OF INSURED r � PRODUCER: PRODUCER NO. L J WC 99 06 03 ED.4/84 LOCATIONS OF OPERATIONS Location Address Average Number Number of Employees 1 1078 MA-28 7 SOUTH YARMOUTH, MA 02664 Term:(11/04/21-11/04/22) This endorsement,when countersigned by a duly authorized representative,shall form a part of Policy No. w 5482313 Issued by And shall be effective from Standard Time at the address of the named insured. A M., Countersigned at Date 2021-10-25 By C PIC )�—Authorized Representative NAME AND ADDRESS OF INSURED r 1 PRODUCER: PRODUCER NO. L I WC 99 06 03 ED.4/84 SCHEDULE OF NAMED INSURED LOCATION(S)# NAME INSURED ID# Tax ID# 1 1078 Yarmouth Inc DBA 852165907 Daggetts Liquors Term: ( 11/04/21-11/04/22 ) This endorsement,when countersigned by a duly authorized representative,shall form a part of Policy No. Issued by W 5482313 And shall be effective from Standard Time at the address of the named insured. M., Countersigned at Date By jblg4ti‘0, C PJeL Authorized Representative NAME AND ADDRESS OF INSURED r 1 PRODUCER: PRODUCER NO. L WC 99 06 03 ED.4/84 • THIS NOTICE WITH THE COVERAGE FORM(S), DECLARATIONS PAGE AND ENDORSEMENT(S), IF ANY, COMPLETES YOUR POLICY. UTICA NATIONAL INSURANCE COMPANY OF TEXAS DIVIDEND PROVISION- PARTICIPATING COMPANIES: The named insured shall be entitled to participate in a distribution of the surplus of the Company, as determined by its Board of Directors from time to time, after approval in accordance with the provisions of the Texas Insurance Code, of 1951, as amended. IN WITNESS WHEREOF, the Utica National Insurance Company of Texas has caused this policy to be signed by its president and secretary at Richardson, Texas, and countersigned on the declarations page by a duly authorized representative of the company. b141474 1/*/ Secretary#1 President 8-L-937 Ed. 04-2005 - TOWN OF YARMOUTH BOARD OF HEALTH - APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: l.�ccy 445 I ,j q zi r 5 .9 iv--C TAX ID: LOCATION ADDRESS: /0 7 Y 1 o UJe 2-F S ye.,y rvN earikAia 2GGt} TEL.#: 9O k- 39 - CCM MAILING ADDRESS: i o l`6 0.0.4-4-t2 2 K S vcA, +�o:tlmtrio 2 G 6"ii- E-MAIL ADDRESS: f a yy p F. 9 IriN CV> e Cowl Cci S.1• ,C t OWNER NAME: /Vc4 v)i /— -0 CORPORATION NAME (IF APPLICABLE): 10121 Val-m o v-1-1,, N MANAGER'S NAME: Iva yr o pU -efi TEL.#: -7 Yr 956 - I L12 MAILING ADDRESS: SP-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 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 2. — 3. 4. - . . FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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. E._ 1. 2. 3. 4. TO t $ u - RESTAURANT SEATING: TOTAL# HEALTH DEPT. OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $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 _RESID.WH LESALE $80 _ 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. t. $150 FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 1 CO •D e *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance 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 RES � A SITE PLAN. DATE: 1li/�l21 SIGNATURE: tr PRINT NAME & TITLE: /2qj,n;bh.N' Rev. 10/15/19