Loading...
HomeMy WebLinkAboutApp-License-Certifications 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. � LOCATION ADDRESS: 4171 rf Z 9' w t S t _Yokr".4a.a4,Mil 016.I3TEL.#: `f --7-1 5 11 l MAILING ADDRESS: 1 LOYbaa Lsw.c . SOwtli Ywio.+- !Mp e2C6e/ E-MAIL ADDRESS: OWNER NAME: IN D1/44.41.ff� CORPORATION NAME(IF APPLICABLE): SS b A F I h a(v MANAGER'S NAME: ?p r<P DA•44./'1 a TEL.#: 171-2t -4146 MAILING ADDRESS: '7 t^wl.dtAA /o+.v.p . Y16 P'1/j ez aG y 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 Department will not use past years'records. You must provide new copies and maintain a file at your establishment. �� ► �u.0.1r�e. 2. N i I. co I e- Vo - PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. " 1. 1 skew 2. NICOl e Vo(V—— 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 copiesand maintain a file at your establishment. `� +/ - ► 1. t 1'-( 1-�LtAt / T P, 2. NI Iiia t 1 V+�f W - rOvt:LirlL� 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. 11 1. 1-Tei U Q 2. it/cGo e Vo i1L — r;n-1 a tam 3. Lt.Li.1 t1:Csv 4. RESTAURANT SEATING: TOTAL# 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 >I00 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***** 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 prio 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 REQU 'i A SIT Pi DATE: 3-10 -71- SIGNATURE: J PRINT NAME&TITLE: T Gw Rev.10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-22-3612 Issue Date: 03/30/2022 Mailing Address: Location Address: TYLER DUARTE 471 ROUTE 28 ANN& FRAN'S KITCHEN WEST YARMOUTH, MA 02673 7 LABAN LANE • SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler 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. Mu shy, PH,R.S., CHO Health Director The Commonwealth of Massachusetts Print Form Department of Industrial Accidents It ,— , '! Office of Investigations _ 1 1 Congress Street, Suite 100 VT Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: A V1in a t.{ 4-Ta."' l,[;'It e_to Address: `'I'I 'Ls vie c, City/State/Zip: V1cL;t Ic.A.Amc7iAA l/J14 6149Phone #: 'c e - i i c- /711 Are ypu an employer?Check the appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. EiRestaurant/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. El 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]** 1 L❑ 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: OIL;1/1e1A- In 5tMtv✓r1(� Insurer's Address: 11,4 5 5 rel City/State/Zip: C e 46,v;(I e � 6 2-43 Z Policy#or Self-ins.Lic.# - Expiration Date: 3 l 3"/-b--1--5 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 d penalties of perjury that the information provided above is true and correct. Signature: Date: 3 - Z ' sz2. Phone#: `1 - "Da ( c>t(L, 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 ACO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/30/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C:ON NAME; Joseph Dupuis McShea Insurance Agency, Inc a/c N.EXU: (508)420-0011 FAX (508)420-9010 1645 Falmouth Road, Rt 28 BLDG D EADDRE—MAIL , joe@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAICO INSURER A: Norfolk and Dedham Mutual Fire Isurance INSURED SSDAF Inc INSURER B: DBA Ann &Frans INSURER C: 7 Laban Lane INSURER D: South Yarmouth, MA 02664 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 00011812-0 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADL SUER POLICY EFF POLICY EXP LIMITS LTR INSD VND POLICY NUMBER (MMIDDIYYYY) (MMIDOIYYYY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY _ $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ PRO- JECT _ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ _ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A ANND ND WE226999A 03/30/2022 03/3012023 X I STATUTE I I OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under _DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Restaurant CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Health Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 - South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE (JFD) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by JFD on 03/30/2022 at 01:34PM �F \\ I / trJF ` \ '9 §\ ( k I-p ; ! a & S � R. a1111 \ f m / / { � \ / ,.. H alrn/ ® � / o % (uuuIƒ o_ /% /\ / -4 / � § _ -< \ \ \/ $ 0 / c . <D -0-0 � 0 01 q E r- 5 / L ii / II ,aƒ\ ƒ{ i miiim / » 11 } » co ® � / , e / 3 " \/ §. { INI 414 / / Z ) ƒ ) Z $ F / / E } \ Q / G > 41011 F, 7 2 « y 43. 0 .-4 1.11 0 . o 0 a F $ / m ( 5 . /i $ « 0 MP) I ` \ o 0 > A * k \ , e 7 > Z 0 Z m 2 < Q 2 \ § / 7 LI m § \\ X 4\ \ ƒ7 0 co / / co Z 70 - i 6 U.- 0. k = m 0. n § - —. / ƒ/ } a , -.¥B ® £ a I Uaac Z W8 m Z O ® 10 ) I 3 nZ Z `� Q O - Qx 141.1CII) o G 0 4 _s, { t 'Q J tA o - 2 r� $ O 1 °` 6 W f 1 z 3. z1 l T .11 4� � _ x, " 0 r� Q a W1 " 5 _ a _� O LL N o ` ii. '-' "" - -'-'--- in U -A f� y } Ai 1 5. i i t i a s�g- °s 41) G i� �-- A ll') r 7 ' . ao 0 5 bs 1 c Is 1 05: LW 4 tUa 4$ z �Y,tA'} 1,21 }��Y� 1,1,,1 T�-s-.Yi.C' to �.x.-C til '"'`,rc't �1 IX ,-,- s, I1• t .!L -,\N. 3 Y n t -.eh T,lw ' b n t t A!<- n t./:i",,w ' Z. n � t ',.=s\-N... ' Y n 437 1 co :-....i." • • J� � A VCN�I-. A m o i.A tl Q C 2 441)7 ,..... „, , ...,• PoiliN t". X*' :E3.M � ti - o cC+.E4--: _,..kkvle) Th,, b V, ,i, 61v 4 z re) 4f)7 pg „ ,, 0 Co h ' (p rD 1y -E3.„�' --‘C'�, s• 0 3 �C„e..-•; \''.(' A .-ton �, �'' CD n.> O � � m (7 0 .v% 1 I I il IL 17:i Pto g1 .1 4427 czt ..".`"" 2) 0 .. �. C Jl c� _n Y -* c it i Z 61Vi, 3J Q ,s C7 tt 1' IV 0 CA MI N iv :-F3..OV ;a, r ^ �� .E+-•: ' CD O �!, N N 5 Zi� '%1 N p Zi limillil .11 LA. .014 9. fil tl: ,n7 Als, R 2 E3'MJ ?: - �CHC-4 aw m et yi ...bk....* 64 1 Z 44, F...1 :"E2,NJ� �C.,Jr..-:i C ) .., 6r;‘, .‘k\� � -..es .... .n ., 0.4„ U4. i ,..,k' 'J.,' ) U i v\tx:I; i U lir i -,.„• -,- i U i 'A'//' } .U, 4 , -iiy7' y N. ii '•,.e..., 1 J�' ,• L /\, .L 1/\rte •T• 12 7 '� r• -07 P e,)7 ilt NOCIV q ..�/(c 1• ► ti �, ^r. whill 4 •1> • , - aN `0 CM) m n Atmll &;,, '' ► L„a '' `•� Z 'fel 11'' J o4 yCI) A it o o '' z a, 0 v Z .',..k..) - o • a. Do r* 2 es ` qve h A 6n ,• n 61V 4- - sa27 '.'.:-.. ..., � • ••p C) �• — .,, .. ._ > 6'y .,,...•••.. A)J wC) CD X11 tilill Or- �' o N en 0 O G rVJ el, Dr . '-' V IF (.0 (414.114)azo1(,,V il yfrk -A 0 1:6 r 00 r ;rcitk_ !.) .37 rz. 4 L, '.:1 :4 7” 1 C r C1. ' 4 m 7; co zI..r �. ...e74c".. 4 Z 4 .1>, (t:1' - -1.k j Z (,)' 4 n el, { vl`.Zry y C '1/4\''of%1'Y y L ,a,1'..,' y : v','1 ,`.,..'l,,,-- y l r z Ir y m c o pp o y "" gcE 0 OC U r O .� C w on N E L s v c N 0 W 3 ai m Of N p a Q Z T m ' m aim W U > > C > E -o E "1"1 « E u v co O a c bOA z J ra Z H in o n 1 2 OL a0 w o' ° d Y 0 y s oz co Q (O 7 N U J LL 0 V 'O fo J. CN > CV:.. IIIIIIIIII 4.) C 4c C i,NCN o a O6 N V W � tU M Z a UasN U o Ug C 1.1' E o3 . o0cU Z .' orVJ }�L O4,N N U _ yc > X 1 in Et m ▪ U E « u N _U Ro s r (34 Z 1.1 c CO E E0 in .12m N m mco o E A 0 - C•MI N0 doEUo o c C c- E # ancumCumCo• z1-▪ Yo ID 411 CO O co w w w .F. - Emo gOZa o o2 ' Nc0aW 0 r0 W � c ON N o Z CD rts C `_ oN y to UM O • N ^ -o T +a L g1. V Q 4'dWa `W = C / i C TJ ! • F'- Vl N E cNVm Z 0C! } u O o c NN N• o ^ Et -o cco • > U U . 1111 E 01 —C V oa > r a o . friS (...) W. cao ce • "'C0,5 L u agi LUG1 � ci Vy L ° `— o urEf c_ iLgy13 Y OS N(p c p111X VC co 44— 0 v �+0 7Z O 7n � ,,r, V ONd C dG QL. VTW coV3 N C NO O CO `7 N }i f V fl.m v G. ' Y O C CD C c N o rQ T WE H IA JW oy E E y Ou▪ d w U ' a m w :1.2' C. L E 'n r n 0 '0 o c6 c VL ;S a) o z u U OE Z u0j -° N coou L 0 >". _c ti tz U • 0 3 W H H > s H E O c Z U o `°a� 72 V o _0 c U a) H L S ILLIy Q Y ,-,.:.-- -.- H 0) y o CO 0 = w uo (112 S a E - as y a; E W c C[ E a c `c Y' 90 ce 0 'a u a E. o 0 0 c Z L c U y _ o 'Y W N a7 o a c a ++ u o - C d tc 0 . O a) ns E u +' c a� o 12 c., 0 W c o oz) u ...... Q m W > 0 U a`) o W U `) Y Er) ua �® L,n O c o rp aW I 7 m vm v� WZ 03-4 oa cV m 3 3,,q ? ; zNZa g aW F 33 D 6J GJ QLL •L ' Q U oTo u-1 N W H S +�+ o N a Li) E d 5 nim i a 2 N u CO 2 23 1- L0 w U g w !!�!.°t! aFilm 0 C 2 a) 3 CC m o a V °oma Z (c:_15 U ° Q a N cc d O LD O p ~ O O. > O 4.0 7 > V U 0'47 p1 L N I ! 1 ) U Illu. o COC n r E = E 44!t 1 MM C u c c c c E 7i E ro CO D Z o w 5' 0 0 0 2 ° p_ O Q c c c - o c _, O O O O O U-O O COW 1 y N N M0 7 j L V O_ _! O 7 7 7 Y Y H N CO y N W W W < < W s !cal; �. to y ti) o A. C m 4: mom /w��, t No C O7 d UNI C W V N p Z r m D Y stN ICCi6 `• !Vcu • C :ii.. 4t;', ~ CG C I6 -13lip NC till • 016 0 o UJ o 7 E - o Q Y eAa p_ N 43 K CCO c U W OI 03i.-at Cod a/ ro n3 Li e . . so E ._. , C c L MI ++ 7 C O c a c U N 0 0_ .c C Y N O Clelilzi Z N u, L d L d N • o V d n N U V Y 01 V N C c cn' 3 O y N - O' Q ♦�02) d N O O O Y -O •'y Y E L E L co J A d r -C o C Q m d W O N V N as c n � 'c v C a `r L x '12 tin v E i 0N N r• W 7 V fl. d t E M 4., o . �^ w o I. L co ao C 3 U W u CD ` o _c W 0 co s uE >1.1 H �' W ti � � V U • VVIc Z UE 2 co c W O w + N u _oc 03 LU C N m nj Y ON o(ID CC Was c c -E ; E w CD 4 -O LL -p m f LU III CU U o dXba1)U U U Y +� m C 0 o ®L W ' U O .� .0 C m w Y �'y v > E a 7 y L j w C m CI; U o al C) > �d O vrnC j m cc, O N O L.) W U (0 Z z f0 U c 6! C�i Z •N X • 7 E an w H E; 61mm C U L o) Q •° 0 4 S Q' Liz Z S Z O Z w R u, c .t. D ' L C Z d R C N g C 11111111. W C IAC ^ ^I nI ,ryS U@ a V d w o: (fitill O oO N « C a O a s m p U uN « 8L VN C��oZ 0 H Ccn o U E i E p v .waN w � C C a) i — N CyO V .c m W A 9 E 12 m Z O 0 7 0 0 0 Z CI o O Q O O O O O N C y O <1 4CD , 0 U V CO V 7 N V w: (a 7 7 7 ate+ i.,-, .y y t� N W W W C W y (o W44 W v ° E a, y _ O c �, �a °' C 1 N p Zco cr) >, a•3 ILI \/ 7 0 14 y O o 2 Nso c N L To o G) YY/// VC 4-ia, E L 0.) o 11141: 4-. ~ U N H ` N a. CL ■ E C (0 m c N O O VII E 3 O y E cni 01 a 0 d D aQ7 O j ] w E Clia 0 .... C +sv + aa °'5'.-,' c ._ s - a c 8 CU Ce Lim �I C N U CD O U « mw = Ctil T W OV _v °d a E ° w a .Nep U IIIX �~ O 4-1 n3 in; ++0 72 O (p O YUN m C O 7N U U r ma N v Q }L.N .47; II MI NC C N O o O Ly UN _v -CO_ Y C E aQ WN E- a+ E t a( W V ,..... . , •,, -,- 0 (1) = W C fl to v L all It' J dE O eo C L g . 3v -0 2 U g 3 w o _c - V (1) uW ;sU y uO o �+ W °ti Iii cl- y o c Z U o � O Y U 0 W co U _0 c o W y _c73Y Y y rn N t - c - O O 112 (1:1 to oa E al -p a-J 0 0 U a C O o U a_Ciec Z ii c U 0 rp ilit .., W N06 Oa c y � � 3 a as co U p m m E u 0 u o -tea R LI o a) o 2 a.� L Q ci W U m o W UU w< m c _c _c Y Y USC f pi,0-( o � TOWN OF YARMOUTH BUILDIN r RECEIVED DEPARTMENT �.... . . _ _... 1146 Route 28, South Yarmouth,MA, 02664 FEB 03 2022 (508)398-2231 ext. 1261 Fax: (508)398-083: BUILDING DEPARTMENT By: ZONING DETERNIINATION FOR BUSINESS CERTIFICATE APPLICATION The purpose this form is to determine if your business complies with the Town of Yarmouth Zoning Bylaw. The applicant shall complete the top section of this form and file it with the Building Department. Once the Building Department has made a deter.'nination,it will be forwarded to the Town Clerk.Please have your tax identification number and/or your social security number available when completing the application process with the Town Clerk. The Building Department will render a determination based on the following factors: (a) The business/use, activity, (b) The zoning district in which the business is to be located. Allowed uses are based on Zoning Bylaw Table 202.5 and(c)previous or new zoning relief from the Zoning Board of Appeals. Date: `4 y 3 ZZ Telephone: .1 - 0 9 c. Business Address: 971 Rf 2-8_ iN 2s`t! yU,ffrt.v 4-7i" RA 6-2-4;7 3 Name of Applicant: L DBA: 41,14 "t' 1 cwl s V1 4-Cin e,vl Mailing Address: 1 L,h LS"'a 74t1 r G*� �'G � -0,2G4.t/ Description of Business Activity: Reck-A.(4 r q.✓l-i- n g uv Own Qom' The applicant acknowledges that a determination will be made by the Building Department based on the information provided on this date. Any changes in the business use and/or activity will require additional approval. The applicant agrees to abide by all conditions referred to below. Failure to do so may result in the revocation of the Business Certificate and/or appropriate Zoning Enforcement, should it be dete • •ed that the changes are non-compliant. Applicant's Signature: Date: -Z-3 —Z'z_. Building Department Determination Approved: Comments and Conditions "—c_-v LA." .1 ElDisapproved: Comments and Conditions .4111}1" Building Official's Sign. _ -001111 Date: loh-Z .31 _