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Home My WebLink AboutApplications/Licenses . ' j� �� ^� � TOWN OF YARMOUTH BOARD O � � APPLICATION FOR LICENSE/PERNIIT-2009,�� L� � * Please complete form and attach all necessary documents by Dece� S 2"008.� � � Failure to do so will result in the return ofyour application packet HEALTH PT. NAME OF ESTABLISHMENT: TEL. # g rI�Q�'I�O� LOCATION ADDRESS: MAILING ADDRESS: OWNER NAME: � TAX ID FEIN or SSN : CORPORATION NAME AP LICABLE): MANAGER'S NAME: �� TEL. # - IOO� MAILING ADDRESS: 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 cun•ently certified in basic water safety,standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach wpies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your piace of business. 1. 2. 3. 4. / FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze requn•ed 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 estabfishment. l.l�z�lll![I�2c��Y'g✓'Pnlcll'� 2• .�}i�npl/ �ivr^ns PERSON IN CHARGE: _ ___ _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1.��l��[/X2=��4rli f' 2. ��f�Qu �d,�OiL HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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. �.�ICatlr4 (.��' l�� z. 3. 4. RESTAURANT SEATING: TOTAL # I I�� OFFICE USE ONLY LODGLtiG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUQ2ED FEE PERNIIT� _B&B S55 CABIN S55 MOTEL S55 _[NN S55 CAMP S55 SWIMI�4INGPOOL 580ea. _LODGE S55 IRAII.ERPARK 5105 WfIIItI,POOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI# LICENSE REQUIRED FEE PERMI'I# _0-100 SEA7S SSS _CONI'INEN'IAL S35 NON-PROFIT S30 �>1005EATS SI60 ��–QQy 1GOMMONVIC. $60 �09 DO ! _WHOLESALE 580 RETAIL SER�7CE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMI'I# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _a50 sq.ft. S50 _>25,000 sq.ft. 5225� VENDING-FOOD S25 QS,OOOsq.fl. 580 _FROZENDESSERT S40 TOBACCO 555 va�E c�vcE: sio AMOUNT DUE _ $ 220•ob ""•«"pLEASE TURV OVER.4ND CO�LETE OTHER SIDE OF FORM***** . ... . . ,-. �.. .� �._., �..�.,: .. . ..._..._r .:.. ._ . .. '! . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not haue a Certificate of Worker's Compensation Inswance. 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 Yazrnouth talces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGIIV"G ESTABLISHNIENTS TRANS7ENT 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 haue and be able to demonsuate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 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. a 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 ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days pnor to opening. PLEASE N01'E:People are NOT allowed to s�t m the pool area untii 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, 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 CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered evern. These forms can be obtained at the Health Departrnent. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Heakh. OUTDOOR COOHING: Outdoor woidng preparatio�or display of any food product by a retail or food service establishmem is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII,TTY TO RETURN THE COIVIPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �^, � DATE: 'J-� 0� O D SIGNATURE: PRINT NAME&TTTLE: - CcJ�! ioizvos � The Cominonwealth ofMassachusetts Uepartment oflndu�TrialAccidentc �� 600 Washington Street, 7`"'Floor Boston,Mass. 02111 Workers'Compeasatioo Iaaaraoce Atfldavk:Boildiog/plambing/Eleetrica�Coatractora �t�irm�tM�: P'kase PRtN'1'k�61� name: address: ciri � state� zio� ohone# work site location ffull addressl: -- � ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑R�odel ❑ I�a sole�proprie[or and have uo one working in m�y capacity. ❑Bwlding Addition � ❑ I am an employer providing workecs'compensation f�my employces wodcing on tLis job. � . camosev wmr. � . . .. . . . _ - � � � ad�ess• . . . . � . . cits: � oYaaell- . laemaxeea odkvM XL�� (`�O�fOG7i ..., .,. . , , .. .,. .,,.+�:'s�� n ..G-,=�t ❑ I am a sole proprietor,geaerai eoah�actor,or Yomeowa�(drdc ane)and have hiced the�co�acWcs�listed below who have the following wotkeis'cotnpensalion pplices: 9�awv iane• � . . . . . . . . . . addrps" � . . � . dry' . . . � � . . � . nya�e 8. � . . . � . Mva�ee oo. - � ��g � � � � . . . .<.. . . , . , �,. < , u.;;o . �ra.e.. �r ame• ad�eas: �ra,�eo� � p�icy g -. : v;,: Failms Y xeoe wverage n rtqeGid udQ S[etlw iSA a[MCL LS2 na kW b Ihe I�pdtlw N'ai�tW pnape d a��oe�b f13M.M aNer . . ••�rn�+'�nr`•••�••wa,.aw�..n�.mu�hrm.r.srorwowcortue�e..a.ee�.rsias.ee.a.y.�.n.r. ��w�, dpy�[1tl6 MaieieY my be fww�MM b Ise Omec�IaveMiqtlen K IYe DIA fer a�v�age verlpntlw. � � . !do hmeby rnd rnder NYe nd a anl pene&tea ofperJi 16 � dJon pre�i6el eboae Lc trre a�C corirct � \ D �� D , ..� -- d -- D PriM name� �L✓� .L�� Phone# D O oBdal ox anly de nof wrife Y tYis aRa to he aoRkYM 69.d�Y w bwe a�cial . � dlyortowu• . . permiNGc�ei fIRvYA1w p�p�� ❑chetk if ama�6e mpeme b rcqd'ed . � . ��B Board ❑Selee�'a O�m . ceMad paaou: Phwe d; ��t c�a s�c mm� . NOTfCE NV7It;t TO TO EMPLOYEES EMPLOYEES The Commonweaith of Massachusetts m DEPARTMENT OF INDUSTRiAL ACCIDENTS � � � 600 Washington Street. Boston, Masaachusetts 02111 � 617-727-4900—httpJ/www.stale.maus/dia � As required by Massachu�tts General Law,Chap�er 152, Secfions 21,22, &30,this will give you � notice that i(we)ha�re provided for payment to our injured employees under U�e above � menNoned d�apt�by Insuring vrlth: a z m o HARTAC)Rn FTRR TNf.RiRnN[`F. (`AMPAH7V � ��E�� .��A� O �CGl IQ�i SLSRi�I' A01D� yiD liQGR � �If mRTlC�D �nr 13413 � ADDRESS OF HiSURANCE�Al1Y �oe WSC NL4H12 06lO1/OS �POLICY IiUMBER EFFECi1VE DATES � � �NAME OF M�URANCE AQEM ADDRESS PHONE � �zDOM, INC. �1329 Rnirt�x 28 �imcr vnuurnirnu �is� n�FEd � �EIIPLOYER ADDRE,SS � � � :ENPLOYER'S WORKERH COI�ENSJl1'ION OFFICER(IF ANY) DATE � : � MEDICAL TREATMENT �ifi..bovs r�emea i�..r is r.quirsa in e�s of P� ��aut d.�a in u�. soua. of «�IoymeM to �fionieh �d�qwM and nasonabk hospi� and m�al a�rvkes h� aecad�e wAh 1he Provisiora d 1M Waia�rss �CAmpaa�on Acf. A copy of 1M Flrat ReporR d i�ry mwt b� gMn b tlw InJ�nd�ployM. Th�wpW� mhl �sNkt tds or her orrn pfrysiN�t� 7}»�nabis�wst of U�a aarvlces Provid�d bY�tr�tln9 plysi�wIM es Pdd b� �tlM bw�y if tlN trermaM is n�o�pary md rwon�bly eanNc�d 101M work role�d in�vy. In wsp requting i hoap�el a�ntlon.�np�byws an Iwn6y noUlbd tlrR tl»k�w�rr has an'ang�d for auch al1YlMlon at Uis � � �NAYE OF HOSF+RAL ADDRFSS : � TO BE POSTED BY EMPLOYER Form WC 86 20 07 C Printed in U.SA _ � . THE COMMOi�WEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-004 FEE: S60.00 This is to Certify that Z Dom d/b/a Doyle's Restaurant 1329 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respectin¢ the licensing of common victuallers. This license is issued in conformity with the authority eranted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .n�EQe_le��ne-S- l�rla�R�, `J2..N., C'Roa�bu►qta�tt� SEAIItiG:165 lTH4�G�o JG. .��C�[�tP��,G,} V,l,CR l.![lilXlitQK J�O�BPI[t `.�.�KOIUfL� I.CPI[2 Q�'�f�t,l,pt��„IP.Q/2Br�'C[,l,l�l�i�t��..lv. "..`^"d" �• "`^`�""" November 14. 2008 Bruce G.Muiphy, , .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-004 FEE: S I60.00 In accordance�rith regulations promulgated under authoritp of Chapter 94,Section 30�A and Chapter 11 I, Section >of the General Laws,a penni[is hereb��granted to: Z Dom 1329 Route 28 South Yazmouth MA Whose place ofbusiness is: Dovle's Restaurant Type of business: Food Seivice I To operate a food establishment in: Town of Yarmouth i Permit expires: December 31. 2009 BOARD OF HEALTH: 3qf�e�ee��n�.�S� /fraf��,�7J�Z�.7JeYQ., C'Prela�iw►t/c�uQt� SE.a71\G: 165 l.lLCIMGD .7G. ./LCCL(R4lL VLfR l.lLNl�lfil.CCIL � `J2oPex1 s. �J3acowac, Cpx�tl# , ' Eaef�c��a.�Eayeo JZ.N ', :. I \ocemberl4 2008 Bruce G. Murphy, M ,R.S., CHO Director of Health '�. �a� °` """ TOWN OF YARMOUTH BOARD OF HEALTH ry�� = APPLICATION FOR LICENSE/PERMIT-2008 �{`��(jo `'�� L `' �u�:' * Please complete form and attach all necessary documenEs bya`D'�cember 31, 2007. Failwe to do so will result in the retum of youc application packet. NAMEOFESTABLISHMENT:�� ( ��ari,rjr�Q�1,.NTTEL. # �SS��OI�� LOCATION ADDRESS:_1�'o�Q � Z,��l�p,.(L,M01lTI�.1 11�1 'i� na,l � t.�' MAILING ADDRESS: OWNER NAME:1�(U.1 A M S 1 R�R tAf�IT TfLX ID (FEIN or SSNI�� ' CORPORATION NAME (IF APPLICABLE):�,�M 1 N� MANAGER'S NAME: ��1�,�a A.M SU�PRQj�MI"� TEL. #�p$�(v0 f00� MAILING ADDRESS:J_3�9 P�. 'f,4 5•yA�2.M,lN"!"1-1 AA K} 0�o(o�{ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee eertificarions to this form. The Health Department wi0 not use past vears' records. You must provide neK� copies and maintain a file at your place of business. 1- 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. �he Health Department witl not use past years'records. You must provide aew copies and rosintain a file at your establishment. i. (�,ZI �.LI t�l ,SU12P�,EVJfl�N� 2. PERS9N IN CHARGE: - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. W I(.L I A�1 �$UR P6Z�7�(� 2. �►Z.1 A-ni LblJ�si HEIMLICH CERTffICATIONS: All food service estabGshments with 25 seats or more must have at least one employee traiped 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 cartifications to tivs form. The Health DeparYment will noY use past years' records. You must provide new copies and maintain a file at your place of business. �. �P�� RRA�u�.� rT z. �a�.rN a- ��_r.�k , 3.c(7nl N L} 4. �.',g��-I A.I.N D�l R�t RESTAURANT SEATING: TOTAL # ��O OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'oflT 4 LICENSE REQUIRED FEE PERYIIT= LICENSE REQL'IRED FEE PERbIIT= _B&B S50 _CABIN S50 _MOTEL S50 _INN S50 CAI�IP S�0 SNMVIINGPOOLS75ea � _LODGE SSO _TRAILERPARK SIO(1 R73IRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT a LICENSE REQIIIRED FEE PEIt:\117= LICENSE REQtiIRED FEE PER4IIT= _0.100 SEATS S75 _CONTINENTAL . S?0 NON-PROFIT S25 I >100SEATS 5150 bH�l7 /CO:�LbIONV[C S50 OS� I� _��7-IOLESALE 575 RE'tA1L SERVICE: —RESID.KITCHEN S7i LICENSE REQiJIRED FEE PERMII= LICENSE REQC7RED FEE PERWT= LICE:QSE REQtiIRED FEE PER�IIT= _<SOsq.ft. S45 >?i,000sq.d. 5200 VENDItiG-FOOD 5'_'0 _<25,000 sq.ft. S75 _FROZEN DESSERT S3i TOBACCO S50 vn:�C�yGE: sio AMOUI�TDUE _ $ ao0.00 •w*"*pLEASE 1'L1l.Y O<'ER A.\D CO�IPLEI'E OTHER SIDE OF FOR]f*"**• g^^'^'^� m�� a - -----._.....-..,,. .` , 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es 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 ofMotel or Hotel use,Transient ocwpancy 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 thaa ninety(90) days witlrin 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 Transiem. * 1�OTE: En�tosed Motel Census must be completed and returned witt,ct�iis�P�i�ar�on. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Aeaith Departrnent to schedule the inspection five(�days pnor to opemng. POOL WA'I'ER 1'ESTING: The water mus[be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 CATERING POLICI': Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Departrnent by fiting the requir�ed , Temporary Food Service Application form 72 hours prior to the cmtered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspens�on or revocarion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board ofHeahh OUTDOOR COOKING: Outdoor cooking;prepara6oq oi�isplay of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TP IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISfIlv1ENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�ICEME�IT. REVOVATIONS MAY REQUIRE A SITE PLAN. DATE:� � G SIGNATURE:,,�JI! � ,.�/�� PRINT:VAME&TITLE:l,(J 1 LL I A�1 �S URPiP�t/A-n f i DGL//�I� io:oo� , : � ACORD�, CERTIFICATE C!F �IABILITY INSURANCE n�"''» wmaw�e THIS CERT6�CATE 641SSUED AS A MATTER OF MFORIIp7WN DOwBng 8 OTieil� Ot�Y AM!t�ERS#ND ftlCiNiS liROti TFIE Cf-R7IFICA'f'� ��GY �S'�1lERAOE AFFQI�ED�POL.ldC�8E1.OYIt. 973�Y�+�, PO 9tnt 4�4 HYan�is.YA 02601 1NS1MBt.4AFFORDMGS�AC,E MAIC3 � �w TheHarNa�rd mpM,lr�pB/A Ilbyle`a Res�uraM ��$ .._. .— 1328 Ro�e 28 �� "— .�"—" SaMYarmouth.YA 02664 .—..—..—..—.—..—....—.—... r�n: �RtxE... __...._...._....---.._ .._ COVERA6E$ 'f1�E PotN�EB�l�IV10E LIS1H/BB.pW t1AYE 9�'!6&�D 70 TFE M�NlIM�AdoVE WR 7FIE POUCY PBLOD rtJ�l(',A7ID NotVV7TtfsrAi�BJu�ICA ANY�iHti.lBi►i OftCONDI'RON#AXY OONTRACf OR 6Tt6200d141�iT WITH RESPCGTFONRRCW'TttfS t`�HiiiRCJITE MAY��Sf,�OR MAY PERTAMI�iHE KiSI1RMICEAFFf�BY THE POLK'.I�C�N�l118�C1'70lW.YIE'f6iM8.�MN?GdbRiON80F 9UCfi POIICIE3.A6QtEdATE 11M/fS 9HW'YH1.Yl1Y HAVE 8�1�9Y PADCAAtldB. 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NIfOON.V' Ai�G X /�R�I�U1t3+ielLiiT El4f7tOCf9lfCiR10E i OCCIIq �QIIWSIMOE A�UE ,� S _.... � O�IIL'�IBIE f PEiBit10N S 5��•—•��— A waiamracar��uo OBWECNLA642 QBfOlAT 88N7lQB X "� aN' �� rxa+�aa�r s1 000 �wr ar�re�o�wmz �.�-�, s19fl,6� r a.u�eosu�ax � �oreEneE-vaicrurr QQO onwa� umcw�rwx aFareu�ass�uoutawe ivec�ioop.uao�a�wam ereoa�rrr�aanvimais Na�ce oa�rerage is�d to d�e tetms,�.e�iusM�en.oH�et Ilmifatlons autd�ffi. f�lotl�g�i�!the CettilkeEa� �Buranas sheM be daMnad to hat�e albered,rraivqd,or ex�an�d fhe �P�ided bY�P�Y P�• (Sae A1�eh4nl�) CE4tl1F'ICAIE FIOI.�I� TtON � - �outfl�wr oR n��eovE arxoue�ra�ee s�s�u�ne�uwNn� ZDOMk�c. aaicn�.n�esua�oa�auq�w�.tenuwrtmw. _1.�� wrsw�arre+ 1529�28 �m��areenne�c�mnn�e�r.evre�moonas�w.� SouthYannoutlr�MA 02884 rwaae�or.w�nowaeu�aanvoFan�oxnuroxn+esro�e.mne�rsae �. 4 . .. . � � ... a"vcs _ a�m�omtm vx�sn�rwrne �' � ...�,...�� c ACDRD 1'S(�'U08)1 of 3 a49899 ..-.---- . ... ._. ... . (,$4 9 IICORD CORPORAFION 1�8 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�INIENT PERMIT NUMBER: #08-017 FEE: $150.00 In acwrdance with re�u(arions promulgated undet authoriry of Chapter 94,Section 305A and Chapter 111,Sec[ion 5 of[he�eneral Laws,a perntit is hereby ganted to: . Z Dom Inc., 1329 Route 2&, South Yarmouth, MA Whose place ofbusiness is: D�le's Restauraut Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD OF HEALTH: .�Eefen SIFa�, .�J2..N., C'f�patixina�z SEATING:165 �.�pXeQd ,�.��C�I�PlL V(CQ�p',l�l(1{p/y `J2adext s. `.�(i�run, C,�(� Qnrcc (a'xeen6aum., J2..�V. November 21_2007 Bruce G.Murp y, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NiJMBER: #08-014 FEE: $50.00 This is to Certify that Z Dom Inc. d/b/a Doyle's Restaurant 1329 Route 28, South Yarmouth, MA IS HEREBY GRANTED A ' COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-fust 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to \ I the licensing authoriries by General Laws, Chapter 14Q and amendments thereto. i In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 53en.jami2�t�`�� . ,�j .Mq.�2.�, . SEATING:165 . - ,�EQPRIL S![(iIL� ��UICC l.![lllXflt(YIL ` 3.J`3�[oaut, (.eexl� :!'ahdc�.Nic`�e�u►wtt Qruz , `J2..N. November 21.2007 Bruce G.Murphy, H .S.,CHO Director of Health r � .-; � f �ay� o�r Ry TOWN OF YARMOUTH BOARD OF REALTH r��i? ° APPLICAT[O1V FOR LICENSE(PERII�TT-2407 � z � ;.m�; � �� 2007 \`"J * Piease complete form antl attach all necessary documents by Decem�r 31, 2006. Failure to do so will result in the return of your application packet. NAME OF ESTABLIS��MENT� T�. #�� z.ocATzorrAnn��ss: i3�a Q� 2R c, �mcru�-h �rn,A oa-�.ncQ� MAiL.ING ADDRES3: �,ayv�.� 4WNER NANfE:�`�- Sc1t�P n(#�S i TAX ID(�IN ar SS,j��, � CORPORATION NAME{g' APPLICABLE}: MAIdAGER'S NAME: (A,��1.,1.lA�Mlh �1 R P 2�A.I.�y� TEL. # - � Q(� 3VIAiLING A[3DRESS:�,'?y�"-�.t rr L ^>� c �..f Gt.X 11f'lfllt}l-Zt , VY��1 POOL CERTIFICATIONS: The paoi supervisor must be eertified xs a Poo1 Uperator,as required by 5t�te taw. 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 oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please tist these erapioyees below and attach capies of employee certificatians to this form. The He�1th Department will not use past years' records. You must provide new copies and maint�in a file at your place of business. l. z. 3. `� FOOD PRQTECTI4N MANAGERS - CERTIFICATIOI�FS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the 3tate Sanitary Code far Food Service Establishments, 105 CMR 590.�0. Piease attach copies of cert'sficarion to this application. T6e Health Department wil!not use past yea�'s' records• You must pravide new copies and maintain a file at your estublishment 1.�1J-lS.A.�{-�-� l l��(`� � _ 2. PERSON IN CHARG�: Each food establishment must have at least one Person In Charge (PIC) on site during hours of aperation. -.-- �. r.l�� ► a� �C��ene� r�..,4,�,�".. z ��a� ��la�e��,,r�,r a HEIMLICH CERTIFICATIONS: All food service establishments with 2S seats or more must have at least one employee trained in the FIeimlich Maneuver on the premises at a1]times. Flease list your employees trained in anti-cholang procedures belaw and attach copies of ernplopee certifications to this form. The Health Departmenk wip noi use past years' recards. Xou must provide new capies �nd maint�in a fle at yaur place of business. 1. ��`�� a� �_ 3. rf 4. 1 4 t4 t ,(�.,� RESTAt.JRA'.NT SEATINC"i: TOTAL# 1�A� OFFICE USE ONLY toncuvc: LTCENSE RkiQUITtED FEE PF,RMIT# I.ICENSE REQCJIRE27 FEE PF..RMIT# LICENSE REQUIRED FEE PERMII'N B�B S50 _.... .._CAB1N SSp _MOTEI, $50 �...._._ `INN S50 _^CAMP $50 _ ,_SWIIvIIvIItdG�P001..$7Sca. � _..—LODGE S50 _..... ..._"L[tAI[,ERPA.RK SId4 --- —WHtRI.POUL S'15ea. �.._ FOOD SERVI£E: LICINSE REQLJIl2ED FEE PEItMft'# TdCENSE XEQUTRED FEE PF.RMI'f# LICENSE REQL7IRF..L) FEE 1'ERMf'I# 0.100 SEATS $'75 �CONTINENI`AL S30 _. _N'ON-PROFIT S25 _ ... 1>1QOSEATS $150 �67-r',..,�r �COMMONVIC. $50 O�'O _WHOLESAI..B E75 _ RETAQ.SBRVICE: .—RESID.KITCHEN $75 LtCII3SE RE;i2t31RF..D FEE PF.RMPI'# LICENSE REQi.JIRED FEE Pf?RMSST# LICENSE TtEQL7IRF.t� FEE PERMIT t! _<50 sq.H. $45 >25,000 sq.ft. $200 ,._ _VINI>1NG-POOD S24 .. __Q5,OOOsq.R. $75 _ _FItOZENDESSERT S35 _TOBACCO S50 NAME CAANGE: S10 AMOUNT I1UE _ $ Z.04.00 ••'"^PLEASE TUItIY OVER MiD COMPLETE OTH6R SID$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 ATTACHEI7 Town of Yarmouth ta2ces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHNICNTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shatl 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 ofresidence 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 ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspecrion five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme�rt 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health DepaRment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preg�ration,or display of any food product by a retail or food service establishmem is prohibited. NOTICE:Permits run annually from January 1 to December 31. Tl'IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN DATE: I sZ-�Z�-� SIGNAT'[J1tF� PRINT'NAME&TITLE: I L �4A-t�J'UICP /1.{.f�11� iomio6 � >�. .; fiF. �RMATION PAGE (Continued) Policy Number: OB WEC rn.4eiz `' 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 ttem 3.A. The limits of our liability under Part Two are: Bodily injury by Accident 5100,000 each accident Bodiiy injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee � C. Other States Insurance: Part Three of the policy appiies to the states, if any , listed here: � � � ALL STATES E%CEPT ND, OH, PIA, WV, WY, AND STATES DESIQ�TED IN ITBM 3.A. OF Tf� INFORMATION PAGE. � � D. This policy includes these endorsemeMs and schedule: c�.� WC 00 O1 13 WC 20 03 03B 1G2240 2D WC 00 04 14 WC 20 03 O1 m P)C 20 03 02 WC 20 04 O1 PIC 20 04 OS WC 20 06 O1 �n � 4. The premium for this policy will be determined by our Ma�uals of Rules, Class�cations, Rates and Rating o Plans. All i�ormation required below is subjed to verification aod change by audit o Premium Basis ::a Classificafioos Total Estimated Rates Per Estimated � Code Number and Annual 5100 of Annual � Description Remuneration Remuneration Premium � 8910 32,800 .15 49 � CLERICA;, �."�� 3IAYESS 1�C � � 90795 215,700 1.60 3,451 � RESTAURANT NOC � � � MA RATE DEVIATION PREMIUM CREDIT ( .10? t9037) -350 = TOTAL ESTIMATED AI�IId[7AL STANDARD PR�St7*S 3,150 � E%PENSB CONSTANT (0900) 284 � MASSACHUSSTTS DIA ASSESSM��PP 4.895 PERCENT 154 � FORBIC,N TERRORISM (9740) 248,500 .030 75 ��— TOTAI, ESTIMATED ATII�lJAI, PRBMIUM 3,663 � � � � � � � � � � � — Total F_stimated Annual Premium: $3,663 � Deposit Premium: � � Policy Minimum Premium: 5218 MA � In�rsfate/Intrastate Idernification Number. - NAICS: r... ,,.i.. _._ . Labor CoM►actors Policy Number. g�C: 5812 _.__ _ _ _ ---- UIN: —_ _ NO. OF El+�: 000027 Form WC 00 00 01 A (1) PriMed in U.S.A. Page 2 Process Date: 04/22/06 Policy F�piration Date: 06/Ol/07 —_.;,�t�tGY{SI6tiS: ,�... ..,, ,.., v. 'a; h y - �r��o��nAr�o� �ACE �� WORK�RS COMPENSATION AND EMPLQYERS LtAB1�fTY PO�IGY �Nsuft�tt: �xm�axn FSKa nvsu[�cs co�arrr HARTF4RD PLAZA. HAI2TPORD, CONNECTICUT 06_15 NCGI Company Number. 13269 Campany Code: � �'H� HARTFORD � � � � � ,� �x a �nas �Nevuai. � � POUCYNtlMBER: OS idEC 23L4812____ Ol m Previous Policy Number: OS WSC NL4812 �' xausa�c co��: rna z 1. �^�-��^ _ ' �5z +�g Address: ZDOM. INC. o� �� ''�� °---�` -_ ^� =;�Cud4) (SEE II�iD'P) ro c c 1329 ROUTE 28 � � ��a�r�.TM��*- _:___ . SOT7TA YARI+tC}UTH. MA 026SA ��.. j.`�c"`-.� �?3,'_'d`�..�r- xla��:3F"'Si: � � .� .�i3 � The Nattsecf fnsetred is. =-==�-=-'� � Busi►re�ss af Natned fnsured: ==``=-*! S�`YLE RESTAt1RAN.P - FRAN � OEher workpiaces not shawn above: -'-29 ROt3TS 28 � S:,u'�'H Y�xMOtlTx t48 02bfi4 � 2. Policy Period: From 06/01/06 To 06/01/07 � 12:D1 a.m., Standard fime at the insured's maiiing address. � �: PraducersName: �a7G & 4`NIiIL IRTS AGCY, FNClPFIS � � � 4401 MIDDLH SL�2'PT•�N'�' RD � NEW F�ARRTE'QRD, NY 13413 � Praducer's Code: 088233 � Issuing Office: � �'�� 4441 AiIDDLS SE2'PLBME+NT R4AD, 2ND FLOOR � NEW T�7ARTFORD NY 13413 � (86b} 467-$730 � � Total Estimated Annua!Premium: S3.663 � Deposit Premium: � � Palicy Minimurn Premium: $21$ MA � Aud'R Period: �7� lnsfallment Term: � � The palicy is no#binding uNess countersigned by our authoriz�represerKative. � _ �� K � Authorized Representative �: .a - - Farm WC 00 00 09 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: �4122l06 paiPcp F�cpiratian Date� 06141t4? ORIGINAL TOWN OF YARMOUTH BOARD OF HEAL1`H PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-131 F'EE: $150.00 In accordance rvith regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a petmit is hereby granted to: Z Dom Inc., 1329 Route 28, South Yazmouth, MA Whose piace of business is: Dovle's Restawant Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit e�ires: December 31_ 2007 BOARD OF HEALTH: B p� $�. A� �1�M.$., ' SEA1'ING 165 � �e�O/fG{y� ./�,� V[46�p�J//KGIL /�� fQ�r�s (�'3e�tG�u�xr /l./�. March 30.2007 B G. �uphy; , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #07-087 FEE: $50.00 This is to Certify that Z Dom Inc. d/b/a Doyle's Restaurant 1329 Route 28, South Yazmouth, MA I IS HEREBY GRt1NTED A COMNION VICTUALLER'S LICENSE ;; I In said Town of Yarmouth and at that place only and e�cpires December thirty-first 200'7 unless ! sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing ' ' ofcommon victuallers. This Gcense is issued in confornuty with the authority gramed to the ° I licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: BI, p� $�. '� M.`�l., ' SEATING:165 � OfBe�s7KfNl, �v., v� e� f�'QI'��C.lJP/il�l(//(�LA� . � fYKIY��lM'i K✓I. March 30 2007 Bruce G. Murphy,MP , .,CHO Director of Health -E�o9c8'/ � o��a,yo TOWN OF YARMOUTH BOARD OF HEA TH.�✓ �y�� e ��s APPLICATION FOR LICENSE/PEItA'IIT-2006 �•, ;Y �7 €. LJuS �l * Please com lete form and attach all neces p sary�ocumegts by December 31, 2005 Failure to do so will result in the reEuin o your applicahon pa�cket. NAME OF ESTABLIS��iENT:�'�.�]b,,��r �,�f �p u � ,� �, �,o:;� , TEL. # 5 O�S- '?kab-I��o LOCATIONADDRESS: f3 :� -�1 2i c �5;- 5�. i,1�a�il'N r�i1f1 ��,7lo(n�/ MAII,ING ADDRESS: r 3 � �j 2i-c- ��r 50_ �%vr'it-i�i>.� mn rD A.�v� OWNER NAME: u�;t l'I�c! �vL 5 �p/�•tiur�� TAX ID (FEIN or SSNI � CORPORATION NAME(IF APPLICABLE): 2. :7! mYv1,� T�� MANAGER'S NAME: t�, t l l'�vk JVL � ✓PlL�,yy rr/�` TEL. # -i�Ir-'7�d - /�O MAII,ING ADDRESS: �3 ��/ nTti �ro 5�� y/r��mo ✓>/f f�i�- a3Ca�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pooi Operator(s)and attacha cop�of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these empioyees 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 61e at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one fiill-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 fde at your establishment. 1. C,lf-1/Lc�� A- �/? 2. /�a'/!/�/� �iZ✓ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. !i1/t /�i�XY✓I"L ��+fJ2�Gi'J.+�'/"� 2. HEIlF�EECH 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 Gst your employees trained in anti-choking procedures below and atfae}i copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. i.,l/,�,�!h-�•� (�,.�vir� a. -i��•�� .�k 3. i41��a�n�s 4.�a.:fH 19i1�.�1. ,zas' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODCING: LICENSE REQUII2ED FEE PERMI1'# LICENSE REQiJIRED FEE PERMI'I'# LICENSE REQUII2ED FEE PFRMI'I'# _B1�B $50 _CABIN $50 _MOTEL $50 _INN S50 _CAMP $50 _SWIIvfhIlNGPOOLS75ea. _LODGE $50 _TRAII,ERpARK $50 _WI-IIRLPOOL S75ea. FOOD SERV[CE: LICINSE REQiJII2ED FEE PERM['P# LICENSE REQUQtED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# _0-100 SEATS $75 CONTINENI'AL $30 NON-PROFIT $25 I >ioosFaTs a�so #Ob-03/ � COMMONVIC. $50 06- 6 _wxor.Esar.E s�s RETAIL SERVICE: " LICINSE R&QUIRED FEE PERMI'I"# LICENSE REQUIl2ED FEE PF.RMIT# LICENSE REQiJII2ED FEE PERMIT N _<SOsq.ft. $45 >25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 200•00 """•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FOR�M*".•"�� " �� " � � AD1I�IINISTRATION 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 Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACI-IED � OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yaimouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PI,EASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annuaily from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RETCTRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT"I'I�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. Ai.i. RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS 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. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standazd plate count by a State certified lab, 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 CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CA1'ERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food 3ervice Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen�esserts must be tested en a monttily bssis by a State cerEified lab. Test results musi besent to the Heaith 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 CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmern is prohibited. DATE:�/�y'�� SIGNATiJRE PRINT NAME&TITLE: �/Jl�lt�Q/J'J 5,o,e�r��ni C /2�i�-i�%e12� ovnsios � 77re Comn►onwealtk of Mossechusetts --. --_-� � - Depart�xent ojlnd�sfrial Accidents = Nfeldiw�s -== 60o wosti;��,�� "'Fr�. - so�,ar�. oziil ,v Wo�lcas'Compe�sadoe I�m�a A�davik Bdl 6i�g/Eketrrcal Coatraet�rs . ...,-�� - � - � . ,w�... . ... . ... . ... , ' '°�� ' -;,..., '�� .�_�,�..,.. ; _, � .. . . .. ... : r� ,� e� � �: � ��,K� �.�� 7i 6 R �y I�s s i z.��,�-�rr+n% adm�: /3�,9 /C T..c_ ,�,€ 1� �.ry .Se . ia.9�rno �,��7�- sare• ivt ry- zin� On?�0��./ nhme# Td�- 7(o0 � �da() work site locati�rrvu addrasl: � ❑ I am a homeowna perfoxming a11 waak myaelf. Pcojact Type: ❑New Cmsavc.tion❑Ronadel I mm a sole 'etor aad have no�e w in an Buil ' Addition . . � .. ... .. .. _ . . . am an�pbyer�xovidi�wakecs'compeavati�f�my�pbyces wodcing oa Fhis job. mmuv roc• addres• � . . ckv . � sYreN• . �ea. ❑ I am a sole propcie[oy ge�eral e�traeter,or Yomeew�er(cirde owe)�d have hiind ihe�[as listed below wlw have the following wo�cas'compensabnn Polices: . �aoe: r�� suv: o��/: B ��: addrer dlr. � �reA� . . _. _ . . . . .. . _ _ - - - N Faivel�seene even�e n�eqdrtd odQ SaW�2SA dMGL 132 en led b 1Ye h�pMtlr da1�YY peafMe�ta�e�bS1+tM.M aNl�r eoc yean'�prbnweet n wd a�eM pmltln A tYe f�Na S'fOr WORC ORIIER aM��dS1M.M a dry a�et�e. 1 odeshW tht• npy Htlb Naaaal ry 6e fiewaMM b IOe Omee KLvndptlw rNe DIA far avaaee veNpnlM. ��ti�eey �„�ar..M� pcnalrtea ojperJrry tAu Me infon�etlon proddel ebove 6 trre ad csrmt �;�"°R��a��,:�, �u��-�� l-a9-� . Printname ��_j� �,a c,t �.f- Phone# emd�i.x ee�y aa e.c.rrke r w,,.r�b 6e t�erplMd 6r dlr.r w...�dd dtyortswu: �p - p�� ❑eYeek iff�mc�t�qeae b mqdred ��R Bmrd ❑SdxUraY O�ce ❑NnMh D4a�t caehel Peiaoe: pYwe 8: � l�es�mwl 12 (Poiiq+Prrn+isi4�s: WC 00 00 d0 Al 48 ivs, INFORMATION PAG� wsc Wt}RiCERS Ci�MP�►TiOfil AND EMPC,OYEFiS UABIIJTY POLiCY INSURER: HARTFORU FIRE INSURANCE C4tg'ANY HRitTFORD PLAZA. HARTFORTt, CC)HI3F�TICC74' 06115 ��: 1�� •--� TxE ��ARTFORD Compariy Coae: 1 � � a h O Sllflb[ �I.^Aq�B H-E��WA4 ~ !__!_QA-1 � P4LICYNUTABER: wRn vrr.4&11 c".� Prevkwa�Po�iep'Mun6�x' �.___._._.— m Ht?USING CODE: DW � 1, Named 4�u►ad a�td lAsNing AuWrsss: ZllOM, INC. o (tdo.,Streat,Taem.State,TrP�) (SEE ENnT) N O Z324 ROUT�>� �49 �+ FEIN Nwnbar: 043563537 SOUTR YARM6t3TFi, MA 02664 � � a5tats idan�on Number(a). � � � � � � '11M NBtINd k�f�lyd�: CGTRPQItPaTIQN � $wiiMlaas at Nwned Nroured: FAMILY STYLE RESTALT[t�N't' - FRAN OtlMrlNorl�sossnotaholNnalwva: 1329 1tOUTE 28 SOTJTH YARDSOUTH, MA 02664 � x. �yw►�od: �rom osralros ro osfo�.�os � 12:01 a.m.,Standard�ai the ins�xed's r�ii�g�. � � � #�qQyqp'��: DOWLING & 0'NEIL AJS AGCY, INC/PHS � � � � � 4401 MIDDLE SETTLE�Fd�PP ROAD � NEW HARTPOEtD. NX 13413 � Praduoer'sCods: 088233 � kHuYg Olfiq: THE HAItTFpRD � 4dfll MZDS}LS SETTLEL�+1'P ROAI}, 2ND FIAOR � t+T�6 HBR'EgpRD NY 134I3 � [866} 969-8?3Q � ToW E�ien�d Arr�wl P►emMm: S3.818 � D�posR P�arniun: � Policy�Yr1YntMn lhwnius: $21? MA � /1ud�Psnbd: ANNtiAL h�mwdTam: � Ths poiicy is,not i�nc�ng u�iess cnurdersignad by our aulhorized representativ � �-�I�--�� E �I�� Avthorized Rep�tative , , , -, ,Date �.. ._.,. ,.�______.____-._._.-- TOWN OF YARMOUTH BOARD OF HEALTH PERMTl' TO OPERATE A FOOD ESTABLISHMENT _ _ -- — __ _— ----- PERMIT NUMBER: #06-031 FEE: $150.00 In accordance with reaulations promulgated under authonry of Chap[er 94,Section 305A and Chapter 1]1,Section 5 of the�ieneral Laws,a peimit is hereby grmmted to: Z Dome Inc., 1329 Route 28, South Yarmouth, MA Whose place ofbusiness is: Doyle's Restaurant Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut e�ires: December 31 2006 BOARD OF HEALTH: L/��e�c�w�x/iwch`.?5. (�'autw�1�r,/19n.`11., ' SEATAIG:165 p6tPJi//�C.lJPJflKO�� V%C6`"i�fG�l3/1M4K � d�fi�. K✓,� ��j� R.N. ��mt�s.zoos Bmce G. M hy, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-026 FEE: 50.00 This is to Certify that Z Dome Inc. d/b/a Doyle's Restaurant 1329 Route 28, South Yarmouth,MA i I IS HFREBY GRANl'ED A � COMMON VICTUALLER'S LICENSE ' i Y In said Town of Yazmouth and at that place only and expires December thirty-first 2006 unless ° � sooner suspended or revoked for violation of the laws of the Commonwealth respecring the � � licensing of common victuallers. This license is issued in confornvty with the authority granted fo ' � the licensing authoriries by General Laws, Chapter 140, and amendments thereto. ' i In Testimony Whereof, the undersigned have hereunto affrxed their official signatures. ''� BOARD OF HEALTH: B/�e�r�r��' u�cl�a`�1. '�sso/1��s, �19.`.�5., SEATING:165 � . /�e[P/i M6JJPJtlXO[fy V[CB�i�l�!/M4K Rod�t�. !3� U�,k � �, R.N. �4.f.��j�.:d�.,�, R.N. December 5,2005 Bruce G. Murphy, S.,CHO Dir�tor of Health ,. _; , .,... __ - _ _ ..; . �BtQo �200'° o°`��o TOWN OF YARMOUTH BOARD OF HEALTH �— _ � s r, � � ,z APPLICATION FOR LICENSElPE$MIT-2U05 1 ' ` = ' � =- J' � n S 2004 * Please complete form and attach a1l necessary' Ocu�pt�s-�y�ecemb r 3 r��0�. Failure to do so will result in the retum��our appiication pack �HEALTH DEPT. NAME OF ESTABLISfIMENT:7 r�.�Q i.n f_ + 3i4 oyIRS tiZQ3+_ TEL. #,S''c�S-9C�D/Q`�) LOCATIONADDRESS:/3�`3 �%'� d'� S� t�Ai"MDv�f �ti7A- Cc�J�S< MAILING ADDRESS: ✓�T� � �'I.� ��o' OWNER/CORPORATION NAME: o wt-� in r� c7c .r 5 1�p=�i� MANAGER'S NAME: 1.13 t 1 i �4 rl� Sca � i^�2✓l �9 Y!l TEL. #5�8-7�� `I�' MAII.INGADDRESS: /3��i 2i�e o?' � S' �h1-I`/no�lT�/ ✓1�¢J ��(�,los/ POOL CERTIFICATIONS: T6e 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. l. 2. Pool operators must list a minimum of two emplo ees currendy certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department wiil not use past years' records. You must provide new copies and maintain a t'de 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 Pmtection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this appGcation. The Health Department will uot use past years' records. You must provide new copies and maintain a fde at your establishment. 1. �1/�%��-/Y! �PLL�jrL�N�i1! 2. PERSON IN C�IARGE: _ - _ — -- - - - _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1.�� rf/,�l'/ 2. �J��/1 .Jt4c24 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 fde at your place of business. l.f��t�/'�i✓2 Gfr�D �'O 2. ��iN vL��.•P.i s2oS 3.�1�✓ r"3�r�lj�C,�[ i% 4.�/.rEnc�✓ ,Jmr�-e � RESTAURANT SEATING: TOTAL#�(p� LoncINc: OFFICE USE ONLY LICENSE REQUIItED FEE PF.RMIT# LICENSE REQUIltED FEE PERMI'P# LICENSE REQL7II2ED FEE PERMI'L# _B&B $50 CABIN a50 MOTEL $50 _INN $50 CAMP $50 SWIIvIIv1II1GPOOL$75ea. _LODGE $50 7'RAII,F.RPARK S50 WIIIRI,POOL $75ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMI1"# LICENSE REQiJIl2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0.100 SEATS E75 _CONTINENTAL $30 NON-PROFIT $25 1»oosEnTs ��so - O6 1 co�oxvccT. sso fl'oS-�074 _c�o�s�u,s sn RETAIL SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICINSE REQUIl2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT p _<SOsq.ft $45 >25,OOOsq.ft. $200 VINDING-FOOD $20 _Q5,000 sq.ft. S75 _FROZEN DESSERT S35 TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ o�oo AO '"""•PLEASE TURIY OVER AND COMPLETE OTHER SmE OF FORM""••=. — ,._.._,...._. ..:.. ..........._, .-.,y ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR IiESPONSIBILITl'TO RETURN Tf� COMFLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISffivIENT5 ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTiON 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONII�IENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and wlurlpools which have been closed for the season must be inspected by the Health Depaztment prior to opening. POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, 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 CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DE�SE1�3'S• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishment is prohibited. � T-_ na�: �a- a6-m y s�GrrA�:�/j�� ° PRINT NAME& TITLE: W i 1�I A n'I. S�pr�e r�9'"n�'i 1-t vk S v f-tr 10/22/04 y �� I�rr. WORKfRS CdMPENSATtBN AND �� St Paul Fire and Marire Nsurance Compan4 EMPLOYERS LlABIlIiY INSU!{ANCE 3&�,Wasningron sneet POLICY � St.Paul,Minneso[a 55102 � RICCi COh/FaNY N0. aatos NJTIN INFORMATION PAGE r POLICY NUMBEP 8om POLICY PFRIOD ro. PREV.COVEAAGE AGENCY A/C MO BV�S811772 t3�tOi/d10d 06R)7t2005 WYA7727636 20Dffi5 4�9 '" NAMED INSIN�D ANO ADpflESS AGEM tTEM 1. � DQ11ES NESCAURANT ZDOA61t�DBA WWLIhG&4'NEIt INS A6C1'tt� ... � 1329 BOt1TE 28 7?2 W MPJN ST S Y:4RMOUIN,WA O2�'rt NYANNIS.MA 02£ttt-3753 � � m � � PEIN atsrisas3� Risk I.D.No. 435a Customer Num6er. sz�#saa51� � � INSURE015 C,aporation � p OTHER WOBY�I.ACfS N0T StM1WN ABOVE: No Add'�fimai ta:ations m lTEM 2 eaucv estiau:fltoen asrouzoon to os�a�lmr� �" 1T:49 AM STAN�ARD 71ME AT1HE INSURE�'S MAILING ADDAESS. p ITEM 3. A WORCENS Cp6�fWSATiON INSURAt�E:PAR70t��Tt�POL�Y hPPltfS i0 Tt#WORKERS CON�ENSATf4N tAW OF TI#STAifS � LISTEU HEflE: MA - m £ B.EMPLOYEAS LIABILITY INSUflANCE:PAAT 1W0 OF THE POLICY APKIES TO WOAK IN EACH STATE LISTED IN ffEM 3.0.THE LIMRS OF OtMi EIAB�.ITY UNDER PANT TWO A(tE: � BODILYINJI1flYBYACCIDEN! E ��.� EACHACCIDENT � BOOILY IttJtqiY BY DISEA''.�E # SOD,000 PDLICY LIMiT B�DILY INJURY BY OISFASE S t00,q0U EP.CH EMPLQYEE � s C.OT7ffR STATES INSURANt�:PMT'fHNEE OF7HE POLIGY APpI.�ES TO TF�-STAlES USTED HEAE:Alt STAiES EXCEPT iHOSE DESIGNATEp i � tN ITEM3A AB41�AND ND.ON.WAVN.WY, A � D.THIS PQL�'f INClUDES THE�fNDORSEAEMS AND SGHEDULfS:SEE IXTEt�N OF ik#flRMAT10N PA6f fQRMiNf PNiT OFSNIS s POiIGY. � 1TEN4 4. Ttff PI�lMUM FOR TtNS P�LICY Wlii BE DETfBMINEU BY OtBi MANUALS Qf RWfS.CtASSiF1CA.T10►i$RATES,ANQ RATiNG PEANS.AEL � INFIXiMATION REQUNtEO BELOW IS SUBJEC7 TO VEflIHCA't10N AND CHANGE BY AUDR. - � � CEASSIHCATION dF OPERATIONS � PHM-BASIS NATE EST STt�CODET(P TOT-EST - PE,RS100 l�IUAL : NO RSK ANN-AEMUN fl�MUN PREMIUM � � Sff EXiH/SION 4F It�Q�A7N3N Pl16E � MINIMUMPREMIUM 52i7 TOTALESTIMATEDTfRItORiSMCASi $67 � TOTAL ESTIMAIED COST $3,970 . � � DEPOS[� $3,970 � . PIIBAINMM.IUSiMBiTSWET0AWI1'WW.BEMADEUPONPOl1CYEXMItA710N , � fAUMOSSIGHED THIS DAY�F � Q�� AUfHOfl¢EpflEPflESEMATNE � &ALDMQBE CAS � —.... ..... .....--- --- ... e � ST PAUt FlAE AND MARINE INS CO � � P.O.B4Xii38-G#A�.00��31 � DOWiI[1�8�Q'NB�i . BALTIMORE,MO 272IXi�t�3B insurance Agency,l�e. 222 wesi hAsin Streat i-SB&227-8134 P.O.Box 1990 . - t�OZ601 rr re (r.�sas)ns-rs2o __-_.....�.- Fau:tso8)ne-12ss .._-----�-..," „n,.,� Y�OOODotA (NSt1flE0 f..,.,,.._._:< ' ..- .. ISSUE DA7E 09/07/2009 . . ;�5.�. OF��R ��' /y�j'�� T {J �XTN {� F YARMOUTH o , 31 `'3 1146 ROUTE 28 S()UTH YARMOUTI-I MASSACITUSI'TTS 026644451 � "`��"`"`r � Tele horxe a08 39$-2`Z31,Ext. 241 — Pas >08 760-34'11 �6]� xow.��o� � P �� 7 ' ' � �"� � � B OARB CtF H EALT13 ��—__._____________._ � Ta: Yarmouth Board of Health Permit I Iolders � ! From: David D. FiaherCy Jr., RS. ;� � � � Heahh Inspector ✓�� L. HEALTH a��pT. Town of Yarmouth Re: Federal Ttix ID Number llate: March 22,2fl05 "1't�Rlassachctseits Departt�nt af Revenue is t�w requiring that we fianish deiailed informatian to them regarding all permits and licenscs that we issue. Qne of the details thaY they require we send to them is every establishmern's Federal Empioycr ldentification Number(FEIN} othecwise lmown as your"Ta�c ID Number". This is purely for aduiinistrative purposes oniy. Some businesses use the owner's Social Sec;urity Number (SSN} for this purpose. If this is the case far yaur establishment, be assared that we wi2l nat altow this information to be public record Fiease fi!1 out ihe fields 1>e�w and return this tetter ta Yazmouffi Health Depaziuient 1146 Raute 28 Souih Yarmouth, MA,02664 'Thaz�tc you far your anticigaTed complia�e. If you have auy quescions regard'rug this matter, please do nat hesitate Lo ca:l. Tte office hours�ra i�fonday to Friday, $.30 a.m to 4:30 p.m The teiephone number is(508} 398-223T, ext. 241. Establishment:��l� � —x-✓ir �t�,fi'� ��FFIN ar SS'N: d��'iJ� c��J�' Locafion Address: I �`a � ��.� o`l c� so � y�!'lJ2!�l.1 t /'� l�•t ,/'� ��'� Signature: �-"��4��,�� Print: 4Nt.._�l (F, {Nl �U{7!'�P�}12 � Title: _,��15U?L� /R..._ ,.+ ��. f--. r. ... . ,. � Prin[ed o "°" :'� j Recyc ��.,y Pa " TOWN fJF YARMO[J'I'Ii BOABD 4F HEALTH PET{MI'T TO dPERATE A FOQD ESTABLISTIMENT PERMITNUMSER: #�OS-107 FEE: $lSQ.04 In accordsncc with arions promutgated im�awhoziry af Ciwpter 94,Secti�305A and Chapter 1 I 1,Section 5 of the Iaws,a permit is hereby granted to: Z Dame Inc 1329 Route 28 South Yarmouth, MA Whose place of business is: Dovle's Restaurant Type of bnsiness: Food Servsce To operate a food estabGshment in: Town of Yazmouth Pernut eacpires: Dacember 31 2045 BOARD QF FIEALTH:Bea�o�rtltic `.?1. i�o+tr/aar�`.b., SEATING:165 �� v��`� e��tei6MG SNa�ffy��y f7/WL gR�1iPG4{NL� K�. February 2.2005 ruce G. Mamhy, , S.,CHQ Llireetor af I�eaith THE COMMQNVVEALT,ti OF MASSACIIUSETTS TOWN fJF YARMOUTH PERMIT NUMBER: #OS-074 FEE: 50.00 Tfris is to Certify that Z Dome Inc. d/bla Dovle's Restaurant � � 1329 Route 2$ South Yarmouth,MA IS I�,IBREBY GRAN'I'ED A � COMMON VIC'TUALLER'S LICENSE , � ; In said Town of Yarmouth and at that place onty and expires D�ber thirty-first 2005 ruiless � i sooner suspended or revaked for violarion af the laws of the Commo�we�ith res�t ucg the licensing af cornmon victuallers. This liaense is issued in confarmity with the autliority$ranted to the lioensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed iheir officsa( signatures. BqARD OF IiEALTH: Bf}e-r�i-y_a,rrrlrt `.�. �ne,11��5., . SSA1'ING:Ib5 M��i V�'��' �t�� iot�vt, �e/�a � Sl�k, R.N. flr�¢�, RrY. ��z,zoos Bruce G.Murphy,MP .,CHO Director af Health .� � ��yg� 'Oi oav�.Es ' o��_�R � i� �� 3 � �c TOWN OF YARMOUTH BO �F HEALT a l`; CN O 1�/J i� � ,��., APPLICATION FOR LIC��RMIT -200 � a r •t ��. � , L � t��J , ' * Please complete form and attach all necessary doCuments by Dec tt�rf��-�(�pT Failure to do so will result in the retunt bf your application p Cket:----- _ �66 b LOCATIONADDRFSS• I �vZQ -VAYlrYI �'�/ V� ��Cn�! I � • ._. R/C T E: Z G ER' NAME• + 1S�"�'� U ( (�n n T -7�1d L AD S • CV10 (1� /j7 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 ariach a eopy-ef t#�e cerfificais�n to t#�is form. - 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. FOOD PROTECTION MANAGERS - CERTIPICATIONS: 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. � � i. (,�l�� !i �r�� . SUr�r��ar� � a. Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1._ �,Il��m �S .ji,�r�X-rY�T �= 2. KA4L�N L I��e�.(1 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. L �l�bflf�a �L'1,�,� 2. �,i i �� l�rtD�ZY�o�i 3. 1�`�YL�N �Y�'✓��1 4. f2UB f r2Y V-�2Y��lt �i r RESTAURANT SEATING: TOTAL#�� OFFICE USE ONLY LODG(NG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN - S50 _MOTBL S50 _INN S50 _CAMP S50 _SWIMMMG POOL S75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL S75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LtCGNSE REQUIRED FBE PBRMIT# LICENSE REQU(RED FEE PERMIT# _0-100 SEATS S75 _CONTINENTAL $30 NON-PROFIT S25 � >I00 SEATS $I50 I COMMON VICT. S50 _WHOLESALE $75 RETAIL SERVICE: LICENSE RGQUIRED FEE PERMIT# LICENSE RGQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $45 >25,000 sq.it. E200 VENDING-�OOD S20 _Q5,000 sq.ft. S75 _FROZ.EN DI:SSIiR"I' S35 TOBACCO S25 NAME CHANGE: S10 AMOUNT DUE _ $ 2.00.00 **«•*pLEASE TURN OVER AND COMPLETE OTHER SIpE QF FQRM*«:.. ADMINISTRATION . Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or r�newal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensafion Insurance. THE A'I"I'ACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pr}or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � / YES V NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILiT'1'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPAR'TMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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. RENOVATtONS MAY REQUIRE A SITE PLAN. AnD1TIONA F U ATION _ POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Hea7th Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, prior to opening, and quar[erly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE CONSUMER A1�VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. GATERING 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. Thses forms can be obtained at the Health Department. FROZEN EE�SER3'3: - - _ Frozen desserts must be tested on a monihly basis by a State certified lab. Test results must be sent to the Health DepaRment. Faiture to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board of Health. OUTDOOR COO iN .: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ��.��,�-- DAT'E: I �� SIGNATUTtE: PRINT NAME &TITLE: l,�i� �I�t� � � a(•��7 r� 10/22/03 � ' The Commonweallk ojMassachusetts ' : Department of Industria/.-1 ccidexu ; Ol11ce01/eresl/Osali�s 600 Washington Streer Baston,Mass. 01111 '��•` W'orkers' Comprnsation Insunnce Aftidavit Anolicant informaHon: PlessePRIIV7"TerGidi� oamc� �,�,��i 1�{�YY\ � � �/�V� 1J��C( l� � L�ali�� li� � CJ Cfi� �J"�I�V� ��, �'� . �� ehone k �� " l��i� ��(.i-V � I am a h meouner ptrt�rming all work mysdf. � I am a solz proprieror_-,', ha�z no one��orkine in any capacity � am an emplo}er pro�idins wor4/:e�rs' compensation for my empio}ees Korkine on thisjob. tomnanv name: .l .O1��--� I A��-� � aJAress: ��-L � �CJ [itv�: �� l��lY��.�� Y !�. �� ( i� � � �� ehoee Mc �� - C �� - 1 �U� insurance to. �h��. �. J � `I`� I �� — policv tl (��I �� Zo�� I am a sole proprietor. general eontractor, or homeowner Icircle ontl and hace hired the contractors listed below «ho ha�e thr follu��in_ �corkar, ,ompensation policas: tomnanv name• � address: cip;: ohone M• insurencc co. politv p _ eom�anv name• ___ address• eiri: phoee M• insuranee co. eeBev M � Failure to�ceure coven=e as requfred ueder Seenoo 23A of MGL 152 u�Ind m tAa iepnidw o(crid�l peultln of�ae ap to 51300.00 a�d/or oae yean'imprisonmeot�s wdl ae eivii peeaiNe�ia the form of i StOI WORK ORDER�ed�6ne ofSt00.00 a d�y K�imt s� 1��denh�d Hat a rnpy of thh antement may be lorw�arded ro�Ae Olfiee of(oveuipUom of Me DG tor eoven�e veri6utioa /do-hrreby ctrtij}•under the paint arte penaUies ojptry'ury thm�ht rnjormation praridtd a6ovt is due ond cerrtet Signaturc � ( � �� _� Print name 1� �� ''[ Y I�l ( one M J�TJ ��v� " �(�lj C� oRcial use only do not.�te in�his�rea to be completed by eiry or lawa ollltial cirv or rown: Y�M�DTQ permiNieee�M _ .� � . .. :; .. �...-..r�8uildine Dep�rtmmt ❑Lieeasie�Board �eheck if immediate response i�required - -�- -� - ---flSdeetmm•a ORce . �61 �HoItE Departmmt � coniac: ptrson: pfia��N:_ �SOS� 398�2231 eat. �Ot�er \ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHII�IENT PERMIT NLTMBER: #04-0029 FEE: $150.00 In accordance with re ons promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of t��al Laws,a permit is hereby granted to: ZDOM Inc., 1329 Route 28, South Yarmouth, MA Whose place of business is: Dovle's Restaurant Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemvt expires: December 31 2004 BOARD OF HEALTH: B/��cfa�i�l1�$. (�'a+ada�r, M.,$, ., ' SEATING 165 /�g}db�pJJ9qNlp�� vfCg�:IfQ�3NlG�K � ��✓,� November 25.2003 ruce G.M hy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-019 FEE: $50.00 Tlus is to Certify that ZDOM Inc. d/b/a Doyle's Restaurant 1329 Route 28, South Yazmouth, MA IS HEREBY GRANT'ED A 5�� COMMON VICTUALLER'S LICENSE ' `-� - a In said Town of Yarmouth and at that place only and eacpues December thirty-first 2004 unless ': ; sooner suspended or revoked for violabon of the Iaws of the Commonwealth respecting the x; I licensing of common victualler's. This license is issued in conformity with the authority ganted <' � to the licensing authorities by General Laws, Chapter 14Q and amendments thereta ,< � I In Testimony Whereof, the undersigned have hereunto affixed their official signatures. � BOARD OF HEALTH: Be�a�f, `.D. (�'aadox, M/�.`.,b., . "� SEATING 165 p6��'6�l�./`/76�/� 3/NO��/�v�K�� 4NpHNypK ROPNL�. 030[fIlE�4(i{6/(A �. , November 25.2003 Bruce G.Murphy,MP , ,CHO Director of Health ' pee R.y TOWN OF YARMOUTH BOARD OF Doyt.ES + o 3 `� APPLICATION FOR LICENSE/P - �: 1� T � rt�` � '? _�, �, ' � � c� a. � � ' * Please complete form and attach a11 necessary doc�u}nenf�b�D em er 31,'�,�0� f � C��? Failure to do so will result in the return Of y8ur,application packe . rj��t -. : � - - s i es an # � - �- Ma1LnvG aDDxEss: �rm e OWNER/CORPORATION NAME: ZLYSIM �ISCr G ° s m.�lan= # -� MAILINGADDRESS: �n�f `3- VA-2h'tOcJW1 ie. AMY� YYLYa- D�(y;3f3 POOL CERTIFICATIONS: The pool supervisor must be certiTed as a Pool Operator,as required by State law. Please list the designated Pool Opeiator(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 basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificafions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time emgloyee 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 Aealth Department will not use past years' records. You must provide new copies and maintaiu a file at your establishment. �. �,��,� s _ S��p��-z- 2. K� L �� PER ON IN C AR(',F.� _ __ _ __ _ _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. �A)��G�A�'Y� � . �U Y'(J(r'�?IlO�n l 2. �14Y2��1..5 L �m(��e.� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must haue at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking pmcedures below and attach copies of empioyee certifica6ons 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. L �((ct� 5 � (�n—' 2. `�16r�na �Pr� 3. F� 4. RESTAiJRANT SEATING: TOTAL#�� OF'FICE USE ONLY [�DGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&.B $50 _CABIN $50 _MOTEL $50 _INN S50 _CAMP SSO _SWIlVIhffNG POOL$SOea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-I00 SEATS $75 _CON'I7NENTAL $30 _NON-PROFIT a25 �>I00SEATS 5150 �02✓�0 0 ( COMMONVICT. $50 0?i�db�' _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO S20 _<25,000 sq.ft $75 _TOBACCO $20 _<50 sq.ft. S45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAMECHANGE: $10 AMOUNTDUE _ $ ZOO.Op *"'*'PLEASE TURN OVER AND COMPLEI'E OTHER SIDE OF FORM""*e* -� . ` '. '"�� ' � .�._.. -_..., _, ��. .. ._.: .._:.:.:� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 ATTACHEB � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMFsNTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOL5 POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 CONSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �/�� - DATE: � SIGNATURE: PRINT NAME&TITLE: I�� f I I� �'n'1 � - S lX lO r?11 C�X� � f'IQY�J�A Q�l� 10/18/02 �� .. , � The Cummonwealth af MrLssachusetts : Departmenl ojlndustrial.-lrcidents ; Ol//CAO//OYOStlyldlli' 6Q0 Washixgtox Street Bosron.Mass. OZlll " '"' '` W'orkers' Compens�tion Insurance Amdavit 6i„4:"""• ;we'�•""„«. PieAuPBIl�lTIs�i1t � m. 1�. 'n -�-�,v r�c�x->; tion G'i � ( \� �U+ �, , 5 �t Flt�.mc�� YY1� t��v� �ho��p `7Ce D � 1 odo � I am a home wner pzrforming atl work m}sdf. � I am a sotz proprittor _-� ha�e no one��orkine in any capacin� �I am an emploc r pro�idins workers' compensacion far my employees workin¢on this job. SS�,�� aame l�,�l1C,f `�''R/ J` �� ucirca� I l)� Cen �-r-al �. I v � ��VCJ �� CJ�rf � � �n�11G,Im Y?'1�} Oa1�3(�� b�l��„ �7�l= ��'l - /�?6 insurance ro °°�F�Y� � { am a sofe proprietor_ aenerai contractor. or homeowner{rirete oar� and hace hired the contracian lis�ed befou who ha�e thz follu�cin; ��orkzr> ,ompensation polices: � C� vn v ` e . �Cl( c�f!'J � '�d7C � m #� ;n a � �a addr . _ __.... __. .. .. .......___... . . _ _.._. . . �, � �,hoee M• � � aeliet ft — f Faiivre to sccarc covers;t aa reqvirM uodtr&eAe¢25A ot MGL 152 na ind tn abt iepp�itiaa ot titiai�tl Qealltes of�SI�e ap tn S1,SU4.00 aidiw oec ynn'imprisonment��wxll a�ciril peodHn io the form of a STOP WORK ORDER aad�Qee of2100.00�da�apimt m� 1 a�denn�d th�t a roA7 af thia stilemmt mar 6e tonratdM to tAe 4tlice ot Invtrttg�tiom aCtbe DiA tor eavert�t veri6qUe�. !do hrreby cenifp urtder!hr pcins nd pr�raltirs o rJury that rhe ieformatiorr provided a6ave is tmr a++d enrreet sgnacuce �.,��.�1�?��/A�cs�� o� l l— � —C�o7 Print name � � �M otttK It dt /�f V�� .. aRcial use onl.� do no��rite ie this�rn to be rompltted b�cily w town ollleiil � . . .. . s... cirv or town: Y��IIT� _ permiNiecp�e M _ nBuildiog DtDlrtmm� ' "'� -� C3Liceasio;Swrd []cherk if immrdiate response ia requircd Z61 �]Seltetmrn'e Olifee OHa�ltb Department � comaot person: Dbone N:_ t�d$} 398-2231 CEt. nOther i2/OSl02 FRI 13:3? FA% 608 778 1218 AO�LING & 0'NEIL C�002 �� CARRIERNAME: AMERICAN MOTORIST5 INSURANCE COMPANY NCCI CARRIER NO. 10065 WORKERS COMPENSATIUN AND EMPL(7Y�RS LIABILI'[Y PQI.ICY INFORMATtON PAGE ni�cT str,z, Issueoate o7�zs�zooz Palicy No, 7BG i 17679-00 RenewaURewri6e oF Palicy No, Status NSW item 1. NAM6t7INSUREpAMD MpILWG ApDRESS Federal Employer I.U.No. 043563537 DOYI,E�S RESTA[T&ANT. ZD�F, INC, bBA 1329 RO[7TE 2S Risk I.D.Nn. BARi�IST�BLE COI}NT4 5 YARMOUTH, �fA 02664-4453 Entity oP tnsured CORPOAATIDN LOCAT10N5 —AA usuaf work places aF tlte Insured at w from which operations cavered 6y tt�r� poiic.y are r�nductec! w Iocated at 1he aboNe address untess otl�e�wise sCaled herein. SEE EXTENSZON OF Tt� ItIFORtlB.TION PAGE FQR ABDITIpNAL IhiSi3�EDS At,IDJOR S,OCATIONS. Item 2. POUCY PERIOL); FRO�q O8/Ol/2002 ro aa/oa/zoo3 1Zp1 AM.Slandard Time at fhe Address nf the Insured stated herein. 16em 3.A.WORKERS CUNi�tfJSqT10N WSIIRANCE: Pah I,�e aF the poliry appfies to Uie Wwb�s Comperrsation law d the states listed Nece: MA. 11em3.8. E7iAPtOYERSlW8g3IYW'S1A2ANCE: PmtTwoofihepdicyappiiestovaoctch�h�3§�d��ern3A. The limits of our fea6ility unriar Part Two are: Bodily Injury by Accident $lOd,000 each accideM �dilY hW+tY bY Qisease $100,000 each ernWoyae Bodily Injuty by Disease $500,OOD pol�y Gmit I6e�n 3.C. OTHER STATES Q�LSURAPICE: Part Three of fha policy applies to the states,iF amr,listed here: ALL EXCEPT 1RUSS LISTEo SN ITEM 3A AND ND, dA, WA, WY 9ND WV. !�n 3.0. This pattt�y ir�des�en�rsemenfs and schedules_ SEE EX1'ENSIp1V QF TAE INFORlfATIDN PAGE FOR ENDqRS$MENTS FpRHING PA1tT OF 7HE P4LICY. Item d. 'the pr�+tiian fortl�is paicyv�6e determined byr our Manuals of Rules.CL�ssifications,�and Ratirg Plxns. N!iwformation req�i belaw is svDjed to ve�ificat+«+and change by aurlt SEE E7[1ZNSION pF TRE INFORhATION PAGE �`OR SCHEDiTLE OPERATIONS. $3,986 SEE F•XTENSIt�t OF TNE INFORHATION �.� IIS StTRCHARGES. $189 R .7Ut � ° Z462 ��c��s �z� Ta�l Estimated Cpst $4,419 MinunumPtcvn�m� $248 (24A) � DerAositAmaurrt $4,419 Adjusfinent of Premium sl�all be r�de: AHIYUALL iNS.AGENCY.WG. PRODUGERINFORMATION 061-OT084 �/ �tr.zr�c � a't�zL zrts a.�� 7� •� INC � CAUNTERSIGNATUftE: � � PO $OX 1990 �cat�n�xs ate o2�,01 Telephone: 508-775-1620 Uate; SERViGING 4FfNGE:1�EB INStTRh1dGE COMPANIES/6TPN : TEAl4 MANAGER v . _ � 301 PI,AINFIEI,D RQAD: St7I1� 300 SY�AGtJSfi, NY 23212 . __ . _ _..� CapyngM 1�7 Natiunal CounCil on Ctxnpensation Ipsut�;e WC o0 00 o1A(Ed OS s8y Page 1 of 5 Printed�n U.S.A. Ancf1T nnn�r � i2i08/02 FRI 13:37 PA% 508 778 1228 DOVPLING & 9"NEIL t¢�043 �('��"��:.., WORKERS CfJNlPENSATiON AND EMPLt3YER5 LIABILITY POLtCY INFORMATION PAGE EXTENSlON SCHEDULE -- kem 1.Continued PolicyNo. 7BG 117679-00 RenewallRewriteofPolicyNo. Status [Q£1d Named Msured DdYL,E'3 RESTAIJRAIyT, ZDOM, INC, DBA Issue Date 07/,�S/2002 LOCATIONS Location Addness E��y Numl�r Num6er 0001 1329 ROUTE 28 001 BARNSTABLE c0UN1Y S YARMDLITTi, MA QZ664-lt4.53 CapyrigM iS87 National Gamral on Compensafian Insurancae WC 90 00 OtA Page 2 af S ptinted in t!_S.A. TOR'N OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #03-090 FEE: $150.00 In accordance witli regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 ofthe Genera]Laws,a permit is hereby granted to: ZDOM Inc., 1329 Route 28, South Yannouth, MA Whose place ofbusinessis: Doyle's Restautant Type of business: Food Service To operate a food establishment in_ Town of Yarmouth __ _ ___ Permit expires: December 31, 2003 BOARD OF HEALTH: �fanlea� zellG4a, eka0uxa,o san�ru�rc:ies _ _ _ �a«�t.c D. rjmedea. 7A,!D.. ?/ru_ __ �e6iat?. $�eadc, �lark �et��et�ratt if�du .SkarE. ��Z. Jauuary 9 ,2003 ruce G.Mwphy, S.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-062 F'EE: $50.00 This is to Certify that ZDOM I�. d/b/a Doyle's Restaurant R } I 1329 Route 28, South Yarmouth, MA IS HEREBY GRANTED A � COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that plac.e only and eacpires December thirty-first 2Q03 unless � — soorier suspe—nde�evoked fo�violatioa of the hws sf tt�Ea�onwealth resg�tug-th� - licensing of common victualler's. This license is issued 'm confomrity with the authority granted to " i the licensing suthorities by General Laws, Chapter 140, and amendments thereto. : � In Testimony Whereo�the iwdersigned haue hereunto affixed their official signatures. BOARD OF HEALTH: ekazfic r?�. zdlG(ec. � SEATING:165 � D. �OSdOq/l�� ., �1CC �E�. ��10QPK. (icvw �des�ar«rett �elu S ,��l. January 9 ,2003 ruce G.Miuphy, ,CHO Director of Health . � � F�'� �� , DoY�Es � ` F � Y TOWN OF YARMOUTH BOARD OF HEALTH - " "' �� APPLICATION FOR LICENSE/PERMIT -2002 t ; a� 1�1��5 �' ' ��,, � 5 ��1 • Please complete form and attach all necessary documents by December 31, 2001. Failure to do so will result t� the return of your application packet. � AME OF EST LISHMENT: S RZf1 TEL # � b O LOCATION ADDRESS: 13 oZ Gl } �' Q> ,�`j.�(�{2,171orJ�'1 Y11A Do1Ce(Q�/ MAILING ADDRESS: �{�-rnf� ON : Z 17 �vaGEu°s rraME: t�J�i I�r�m u rnr�x,at�� TEL. # 3 .5�� a MAILINGADDRESS: 1D4 y- VY�t2mdv�h YL0 '�Qf1T11� 1'YI(� daCo3$ POOL CERTIFICATIONS: The pool supervisor must be certitied 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 basic water safety, standazd First Aid and CommuniTy Cardiopulmonary Resuscitation(CPR). Please list these employees 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 fde at your place of business. L 2. 3. 4. FOOD PR9TECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 applicafion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �. l�J`�I1��t�-m :S• Sf�rt,Yenc�nT 2. PERSON�CHIIRUE:- _ _- - - - _ _ _ _ -- — -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. u), Ilir�n �. �Ur,��na�i 2. Kt�.v�s c� ��rnc��en 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 anfi-choking procedures below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. f��"�IU L-/Sl-N(7Klt�� 2. 3? 4. RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&.B $50 CABIN $50 _MOTEL $50 _INN � $50 _CAMP $50 _SWIMMING POOL$SOea _LODGE $SO TRA[LER PARK $50 WHIRLPOOL �25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM}T N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $'75 _CONTINENTAL S30 NON-PROFIT $25 �>I00 SEATS 5150 � a-n{�'7 .. I COMMON VICT. S50 �f,�j _WHOLESALE $75 F.TAIi RVICE: LICENSE REQUIRED FEE PERMIT# LICEN$E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N _TOBACCO S20 _<25,OOO,sq.ft. $75 TOBACCO $20 � _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 xnrtE cxpSIGE: g�o AMOUNT DUE _ $ 2 00.o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF I�S�tIN'#*** � � � " � � �- �' v�.✓�f,u.... �.. �.o _..._.._. } --- , , f , 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 t� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED r� Town of Yannouth taaces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILI'I'Y TO RET'IJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-IE HEALTH DEPARTMFiNT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. 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 REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab,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 CONSUM R VISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked aziimal products aze required to post Consumer Advisories. ('ATF. ING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yannouth Health Depattment by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Deparhnent. -- — _ _ _ _ _ FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of yow Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES_ Outside cafes(i.e.,outdoor seating with waiter/waitress service),m�S have prior approval from the Board of Health. oiTTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is pro6ibited. DATE: !� J �� SIGNATURE: Wu'/rlJ V) �� _. ( PRINT NAME&TITLE: �'(ZrC�U C� �n �11�f�1 /' ! eIV 09/I 1/Ol • • C � / �'Qd�C//'/2�L�1f . 325 Donald J. Lynch Boulevard, Marlborough,-Massachusetts 01752-4729 (NCCI Carrier�16942) AMENDED DECLARATIONS ENDORSEMENT Policy#: WC01 695108 Effective date of Endorsement: 8!1/2001 Effective: 8/112001 to 811l2002 Issued to: ZDOM,Inc. Doyle's Restaurant 9329 Route 28 South Yamrouth.MA 02664 t. To be used for premiwn transactions In consideraCron ef premium af S subjed otherwise to aud'R it is agreed tliat Hem 3 of fhe poliay is amended as folloxrs Classificati0n Ptemium BasiS Rate Per Es�nnated ; Ciass 7ntah�stitimaped j00 of Annual s D�cription Code Annual Remuneration Premiums ' Remuneration Massachusett�Rating Restaurant-Nac �79 :S 739.657 $ 2:08 $ 2.905 ClericalOFficeErtq�I�leesNoc 8$1Q S 24.066 $ ' 0.18 $ 43 Coverage B-100l500/106 98d5 5 0 Standard Premium` $ 2,948 Expense Constant 214 Division ollndusUial,Acadents.Assessmeni 139 Total Estimated Mmial Premium ' $ 3,301' The minimum premium appiicable to this policy is $200 2. To be used for non-premium transadions Chan�d inwred Name from IDOM,Inc.and DYKER Ina to ZDOM,Inc. Charged DBA from DB/F Doyle's ReStBtifaM M�Uoyle's�.ReStawaM - . . Name was wpposed to be added to CP poliq onty-art��ed,but not mailed. � � Atl otlier terms of thLs pplicy remain unchangetl. �,. . __ , _-_�,.d.._ Agency: Dowling&O'Neil Insurance Agency 222 West Main Street countersigned ny Hyannis, MA 02601 695 utnor¢ed Representative JS 10/11/2001 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #02-017 FEE: $150.00 In accordance with regulations promulgated imder authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby granted to: 7.nOM inc 1329 Route 2R_ South Yarmnuth_ MA Whose place of business is: Doyle's Restaurant Type of business: Food Service To operate a food establishment in: Town of Yannouth , Permit expires: December 31.2002 BOARD OF HEALTH: �efrazlea�. ZdfJea, ekaGu�a.s SEATPIG: 165 S�Gc�QdItG�D. �o7�a/�/t,�� `�., �/iCC ��iO�iO[t� �7.O�rt. [�sm r8t02� OrC Januarv 28 _2001 ruce G.Murphy, H, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTA PERMIT NUMBER: #02-013 FEE: $50.00 This is to Certify that � ZDOM Inc. d/b/a Doyle's Restaurant 1329 Rnute 2R Snuth Yarmnuth_ MA i IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violafion of the laws of the Commonwealth respecting the licensing of common victualler's. 1'his license is issued in conformity w�th the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto �xed their official signatures. ;;; I BOARD OF HEALTH: L/ka,rlea'�f. xdfrlrec. �/Fadurra/c SEATAIG:165 �pt/�_�Jrail`n�.f �a�o�C �D.. �/lCC �O!/�L� �, pR0[pK. �9F� P � � January 25 , 2002 ce G. Murphy,MP , . , CHO Director of Health � n . _`�'o �1� UWN Ur YAxMuu 1 n ro�na � C COLLECiOR P.O.BOX 1150 SO[TITi YARMOU'[N MASSAC[IUSETIS 02664-7150 N nwnwcnc s� � �.,,��oR� /a' Telephone(SOti139R-2?31,Ext.232,233 — Fax(SOR)39H- 6" 6�� REC � IVED � �c.-„ AUG - 6 2001 AUG 0 7 2001 TOWN OF YARMOUTH HEALTy DEPT. � � � TOWN COLLECTOR � TO WHOM IT MAY CONCERN: To assare Wat t6e "NEW OWNERS"get their b�ls in x timdy manner,�ronld yoa please have them complete the information bdow and get this form back to us as soon as possibla T6ank you for yoar coopention. DATE OF SALE 08/03/Ol NEW OWNERS NAME �*+ T*TM' MAILING ADDRESS 1329 A�ute 28. South Yarneuth, MA 02664 (Doyc�S REST,> �— PROPERTY LOCAITON 1329 Route 28 �p�p��,L 060.163 �-� , ,�r. _,.�.wd r �_ � , ,-, �-^ . . , . ' ...�� r-->, , Gti � � `'. � TOWN OF YARMOUTH BO�QF HEALTH �.- 3 �� O 5 YOOO APPLICATION FOR LICEN�'PE�Ml"I'-2001�,1p�� ' ti HEALTy DEPT. * Please complete form and attach all necessary documents by December 31, 2000. �ailure to do so will result in the return:of your apphcat�on packet � ---------- - - - ----- --- -----r�- - •- - �..a;.�.--- , y M 11.IN ADD F : , L . n 5 ' ------------------------------------------------------------------ ------------------------------------------------ POOr. RTIFI ATION • The pool supervisor must be certified as a Pool Operator, as reyuired by new State iaw. 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 basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees 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. iTFT_Mi I H C R FI ATION : 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 empioyee 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. i. �i��,�s, E ��o%s� a.��-t� r� i ,� 1�� 3.-5�,��F_n��1 a. �—� RESTAURANT SEATING: TOTAL# l.S NON-SMQKING SEATS: TOTAL# �L L �I'��/�� ------------..___"------�---------- ----------- ----___._ea_�.--- -------- _----- --------- ------ -------------- OFFICE USE ONL.Y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 TRAILER PARK $50 _MOTEL $50 SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: — NO'I'E: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAI, $30 / >100 SEATS $150 �nl -008 _NON-PROFIT $25 I COMMON VICT. $50 (–0 _WHOLESALE $75 RFTAii. .RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 N MF.(' AN �• $10 AMOUNT DUE _ $ 200.o0 kiill(f .... .�, ..•.. PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**""* � �� . � " ' � � - c... . . . . . ... .. .. :. -- - _ .. _. .. _ �.._ .. . . . ��-__ . - ,� ADMINISTRATICEN Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewai of any license or permit to operate a business if a �rsan or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOI2KER'S COMPENSATION INSUI2ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, QR CER'T. OF INSLJR.ANCE ATTACHEb ti� � WORKFiR'S COtU1P.AFFIDAVIT SIGNEI}AND A"i'TACHED Town of Yazmouth ta�ces attd liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPRflPRIATELY IF PAID: YES� NO N{YFICE:Pernuts nrn annuaily from January 1 ta December 31. IT IS YOUR RESP{}NSIBILTTY TO RETURN THE COMPLETED APPLICATION{S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASQNAL ESTABLISHtv�2VT5 ARE TQ CONTACT THE HEALTH DF,PARTMENT FOR INSPECTION�-10 DAYS PRI012 TC!OPENING FOR THE SEASON. ALL RENQVATIONS TO ANY FOOD ESTtIBLISHMERTT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MCJST BE REPORTEB TO AND AP'PROVED BY THE BOARD G1F HEALTH PRIQR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADI}ITICIN.�RFCiTi ATiC1NS POOLS POOL OPENiNG:All swimming,wading and whirlpools which have been closed for the sr,�son rnust be inspected bY the Hez�lth DeP�rtrnent, aztd the water tested for pseudomonas,tatal califozm and stanndard plate count by a State certified lab,prior to opening, and yuarterly thereafter. POdi,CLOSING: Every outdoor in ground swinuning pool rnus#be drained ar cavered within seven(?) days of closing. FOQL!SERVICE NE�'S�,ATE SANITt�RY Ct}DE FOR FQOD EST LISHM NTS• The effectiue date for foad protectian manager certifieation is Uctaber l, 2001. As stated in 105 CMR 590.003(A)(2), food establishrnents must have at least ane person-in-charge who is a certified food protection manager. Tlus provision is effective one yeaz from the date of promulgation of 305 CMI2 S90AOt}. The effective date for consumer advisory is January 1,20(Ii. As stated in 1 p5 CMR 590.000(K),enforcemenC af Consumer advisory,Fooci Cade 3-6Q3.11,wili be u' np lemented January 1,2401. C?nly establisl�ments which sell or serve ready-to-eat, raw or undercooked animal products are required to have consumer advisories. CA��g—TIvG POLIC'_V: Anyone who caters within the Town of Yarmquth must notify the Yaimouth Health Department by filing the requu�ed Temporaty Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Hea(th Department. FRO F,N D . .RT • Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be sent to the Health T3epartment. Failure to do so wiil result in the suspension or revocation af your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAT�. • Outside cafes(i.e.,outdoar seating with waiterlwaitress service),�have prior approval from the Board af Health. OUTIIaOR COOI�ING: Chztdoor eooking,pregazatian,or disglay of any faod product by a retail ar foad service establishment is pmhibited. DATE: / Z� —< �C�� SIGIVATURE: ,7��1r �sJ'r �' .' PRINT NAME&TITLB: F`S� "�" t, �� ` G �' I1116{00 -�-��AR D� Workers' Comoensation and Emulover's Liabilitv Policv jj� AmGUARD Insurance Company � INSURANC� PolicyNumberDOWC124414 �r G R Q U P Renewal of DOWCO21935 NCCI No. [21873] �.�---- ---1 � [1] Named Insured and Mailing Address Agenry ( f DOYLE'S RESTAURANT DOWLING &O'NEIL INS AGY ' � DYKER, INC. D/S/A/ 222 West Main Street � 1 1329 Route 28 P.O. Box 1990 i South Yarmoafh, MA 02664 Hyannis, MA 02601 � � AgEncy Gode: MADOWLIO � � ; Federal Employer's ID 04-3175292 Insured is Corporation ! � Risk ID Number ; [2] Policy Period - -._._..__i From July Ol, 2000 to July 01, 2001, 12:01 AM, standard time at the insured's mailing address. i �_____ � [3] Coverage � J �—v_� A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation � � Law of the foliowing states: Massachusetts I 1 B. Employer's Liability Insurance - Part Two of this pokicy applies to work in each of the states listed I in item [3]A. The Iimits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 � Bodily Injury by Disease - each employee $100,000 j Bodily Injury by Disease - polity'limit ' $500,000 ' C. Other States Insurance - Part Three of this poficy appiies to all states, except any state �isted in E ; item [3]A. and the states of North Dakota, Ohio,Washington, West Virginia, and Wyoming. ; � D. This policy includes these endorsements and schedules: ; j WC OOOOOOA - STANDARD POLICY � '� WC OOOOOlA - INFORMATIONPAGE ; WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR WC 2003U1 - MRSSACHUSETTS LIMITS OF LIABILITY ENDT. ; WC 200302 - MASSACHUSETTS-ASSESSMENT CHARGE i WC 2003036 - MASSACHUSETTS NOTICE TO POLICYHOLDER END � WC 20U401 - MASS. PENDING PREMIUM CHANGE ENDORSEMENT � WC 200601 - MASSACHUSEITS CANCELATION ENDORSEMENT ■ �-___-_ �_ _+ ; [4] Premium j ; The Premium Basis and, therefore, the premium will be determined by our Manuai of Rules, Classifications, Rates, and Rating Plans. All required information is subject [o verification and change by j � audit. (Continued on another page) A � _ � �� Total Estimated Policy Premium g 2,qqq � TotalSurcharges/Assessments $ 105 Total Estimated Cost 3 2,549 INTfRNAL USE �� Page- 1 - .Information Page MGA : DOWC12aa14 �WC OOOOOSA- Date ; 06/16/2000 -- -�_- - �� . � � MANOTE �� - , _ . --•-- �. .� 4�IeaH3o�o��anQ OH� ` . `HdY�I `�ycLny� •�aonig �* '� lOOZ` £Z� d� d �F� N��0 L��'l?p'1ly� �1'� 'k"'°L� "4 r--/°Q+ • 3'Y,l� '��I ��7rt�7� S9! �'JM1tl3S �+�j '�� y? �H.L�`d�H 30 Q2IF�Og IOOZ iaqLuaoa sandxa ituuad � �n ,13o umoZ :ui�uaun�s►Iqe�sa poo3 e a�siado oZ aoc,u o3 :ssauisnq3o acLiZ elsag s�a� Q si ssau�snq3o aoeid aso� :oa paaus��Cqaiaq s�l�uuad e°sme-I�eiaua�ayl;o S uo,y�aS`[I I iaidey� P�dSOE�o��as`qb ialdey�30,Cluoy�ne�apun pa�eSlnmoid suo�lejnSai ypm aouepa000e uI 00'OSI ��33 8�0=I #��2I3gY�if11�I,LIY�I2I�d .LAI�NiHSI'Iff�'.LS�Q003� �.L�'2I�d0 O,L.LIL1RI�d H.L'I��I 30 Q2I�'Og H.LIIONRIF A.30 AtMO.L THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMITNUMBER: #O1-005 FEE: $50.00 This is to Certify that D�er Inc d/F/a Doyle's Restaurant 1329 Rnute 2R South Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violahon of the laws of the Commonweaith respecting the licensing of common victualler's. This license is issued in confomuty vrnth the authonty granted to the licensing authorities by General Laws,Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto �xed their official signatures. BOARD OF HEALTH: �d�1L. jte�e¢. sEn,a.iG:�6s G/anlea• 2/iee ,�o�it�. �ou•k, elrnk �aeP 0'L' a.Kiwc D . 'yll . January 23 , 2001 ruce G.Murphy,MPH, .5., O Director of Health .�.�. . _ , lS.�.!C�',�lV, v- � � �„� � , � _. ______. _ . , t_�. __._��,� � . � � � ��'w,. �� ` , � ! � Z � � __ __.______�______�_----�-_�_��_____ y �' � � � � ° �.. �3 �., ,, ,---� � , � /��. �� ,. � .�~� ,� , �.�.�.... � _ . e ,,� ' � �. ,.� � � 1" U� a\ o ;?� � � g I ,�,o . . � _ � n ��_ '`�� . � � a i . � � t � � � � "7 � 5 y ..3 2_I �` � � T � � �� yo 1 � I I � �__.______� �_�___.___.�.. �' � u � �� i� �z- !3 J�+ l IG %7 J81' -, �> C C� �� f � � � � -------�.___. ., _. � APR 2 6 2040 .� Z„� �'�`,�� _____.._____r_-� _.-----�-....._ .. , ,�;,F �u.)e� �EazY:-3 ��P�` , � _.�f._____._._..._._._ �a'7�2�t. � {ys4 „ � 11� ��. �. �� _____- � _ : __�_.______�_ � �� ` � � ` � Z � �z � z j p � 1 '�-� j �� - � t � �,ro�,�, .____--__.ry � ..«J � � ( � i ,�' f ,> ' . . ' � ', , . I . �/'�Y' . . . I � � � . : '� � , �. �I, ,, � � �. . . , I i, I �'. i I '� i I . . . ., � �. . � . '�i �' i � i , ' � . � Q�� I ' . ,.� . . . : � �, � - � �� _'_ , . , . �� i . , i I I I � x _..,__ ___.. _ ' �� S��r � , ; � ___ __.a_ ._ —___._.._�.__.._r..,._._. ;-�_ � ' �— -- � � � � � � ! , � E.�c � � � , � ; r I � � � � Ii ' � I ; � � � � � � ! �� ; � � � , i � �j � � � � i I � � , � � � � , , � -----r-.--�-- t � ' i � � � � `"I � � � � � i , i i � � ; i ' � � � I i � � I � � � I I � � �, � � ' I � � �� j ' ! � i : � � � I � � - � � � � ; �� I i � �� i � � � i ' \ � I � � , i � � I N �� i i � i ' � ; i � -I f i � , . � � 1 � I � � � � ', ; .�0 1 es �� , i � � ', � � ; y �� , � � �, ! � � ; � � i2� l�/� 1� ; ' , , I ' � ! � �' , � —;� i � il ; ' ' � � ' , I I ; , '� , � ; � � � � � ; � � � i I , i : I � I , I ; I i i i f � , ' ' � , 3D S��-� ��1`�, i � � I i : � i I '� � � � � � /�� 3S s�s �� , , ,, � j � ' ' �y(,, I � ii i � ' � i Ij �� ' . ' l ��i IIi�V�� i i '�.., , I '�. � � �.`.�. : _--_..__ ; � � � � ; ; i i � i , �S�ii�� , , , � � � , , ' ' i � ; ' � �� ^ �� , �I ' ;I Gr^i$�N�-I i � ' ' � 1I _ �3�, � ! ,E __. _ ____. , i i � -- ____ , . - - -_ 36� - _ . _ : _ - - ' i ,. � ,� _ , , , . . . . . � � � 'n . . . . . , _, . , , � . . . � : ', .�q � : � , ' ri �.p...1. wl /'; � ]l�... . wl /�L �. �. ,. . . ', ., ! � , ii � � . -• � . , �� ,�io�� o IIM (� DD TOWN OF YARMOUT�$OARD OF HEALTH N 0 V 3 0 1999 � ` APPLICATION FOR T:IC�NSE/PERMIT-2000 HEALTH DEPT. * Please complete form and attach all necessary documents by December 31, 1999. Failure to do so will result in the retum of your application packet. -------------------------------------- - - ----- - --------------------------------------------------_ NAMEOFESTABLISHMENT �� rs �Ur9r�� T # 7G4- /00� LOCATION ADDitESS: /3 a� Ra�� ,. /r�,-m�r. aa G " L D � E �- ' o a s # � ADD _-___-----_�.._----------------------------------------------------____------------------------- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to t}us form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certiScations 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. HEIlI4LICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at teast one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this fonn. The Health Department will not use past years' records. You must provide new copies and maintain �file at your place of business. ` 1. fH l.s'� 2. .�/7q �el /� /� 3. � Ul 4. RE3TAURANT SEATING: TOTAL#��o NON-.SMOKING SEATS: T�TAL#- 6� ---------r_______----------------------------_______�__________________�_�W-------------�_� QFFICE USE ONLY I.ODGING: LICEN3E REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlVIl�IING POOL $SOea. _WHIltLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _0-100 SEATS $75 CONTINENTAL $30 � >100 SEATS $150 Y?.k' 2 NON-PROFIT $25 �COMMON VICT. $50 Y2K'Z) WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 Nr�ME CHANGE: $10 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 REQUIR�D TO IiOL,D'ISSi7ANC� 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 AFFIDAVTl' MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED ✓ .QB WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA3�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK AP�OPRIATELY IF PAID: YES l� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILITY TO RE'TC)RN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMNiENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIl�Il�IING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR _- PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY TI-�REAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SWIl�tI��NG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. TI-IESE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULT3 MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO 50 WiLL RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE _ _ _ _ BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APP1tOVAL FROM TF�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. n DATE: /��o� �� lJ� SIGNATURE: �y��"�' G~� PRINT NAME& TITLE: l 't{� lf/Q �� OUJ/1 P r' /1 ✓ 11/12/99 ' . . ; � The Commonwealth ojMassachusetls . s = Deparrmen! ojlndustrial.accidents _ o omceoner�sa�sw�s 600 Washington Slreet Bnstox, Mass. 02111 ` W'orkers' Compensation Insurance Affidavit Annlicant informaHon: pl *se� nimc� �1�� Il�'"--� location� � ��t� ehon p � I am a homeowner pen�rtning all work myselE � I am a sole proprieror �-,'. ha�e no one�corkine in am capaein� c� am an employer pro�iding workers' compensation for my emplo}'ees uorkin¢on this job. m an na e: S Lt�� dArccs• ��a� Q_� � (BL/�' [ �/ i u nnc / q l� !1 O` �q,�� I am a sole proprietor. general contractor. or homeowner(circle onel and have hired the contractors lisced below who ha�e thz follu�cin_ �corkzrs compensation polices: comP�v_namr. � ad d ress: cirv: phone k• insur�ncc co. poliev# com�n2me: tddress tiri: phoee X• insuranee co. eeflev M t Failure to securc covenet a�required uoder Seenoo 25A o(MGL 153 a�iud w Me i�paitioe of uiW�fl pudtln of�O�e op ro 51,500.00 a�d/or one ye�n' imprisonment n w�Nl n eivil peeNNa io the torm oh STOP WORK ORDER a�d a Ilae ofS109.00�df�qdnst s� 1 ndenb�d H�t� topy ot lhn sntemcnt m�y be forw��rded to the ORee of IaveetiQ�Gom of the DIA for eoven{t verillutfw. I do�hrreby cenij}' der the paint and pmal�ies ojnperjury that the injormolion providtd abovt fs we and contct Signature i�'�I_ _— "' — �"`v�" ��_ Date /i-�-9 - 99 Print name �I 't,� �.��Q. IJ � Phpne M �(J d — �d�v .. olTicial use onl. do no�.rite in�his�rn to be compleud by eity or towe oflltial —� _ ' �"�� ' " �_,.: �,.,, i<...,., ..... . _ _. eiry or town: Y�M�DTQ _ permiNieeme r n8uildiog D�arttnent ---��Liefofioc Bo�rd � cheek if immediate response ie required Z61 �Seleetmen'�Olfiee (508) 398�?231 pat, ❑HeiltA Dep�nmem contact person: phont M;_ _ nOther . kf��'� V . INSURANCE �� GR�} UP �t`1rsLh=:F-'.. 7.fi-:�s%.3i�2�=�i•d;_.E:.. �'::3r<<r.,�i:,;;r; . . . .. . . _ .. ,:.:, .. . di-ii�.Y _r� _i i;, (Ii C:.1 i=�F s e..'_..i >'_ ,� �" -i� 9 Ea � 1 •;.�? - . ...� _ t � ti.__Li_. � .., _ .:.4'`i�E .') - _`,:'«.t r- t_!j� � fx ' �-.=- _ , F`aiioy I*3i��k,ars UC3v7GC�F�.2�35 F,�T1�;z�1 ct�: i�Eui ( _ ; P3�me a� Inpure� ar,d Mail%n�, Addre:3g. A�ertc� : ��I`{E.E`� REfi1'r1Ukt�NT DCYILI2^IC- :� U"�lE�' `P;tcJ 4�=�^; �:Yd{ER, IHG. 27/p:Al :?22 'ne-.t i�airi �;t��..t: 1^a29 Route 2$ p. �, ��:: ;cc�;r, South Yarmouth. MA 0266? Hganrsis, T�� 2E�Q�I � �� 57c IL' l�iilii4Pr�: fA@OC�JfC��J�<,'t ��s;= �?'!t� ��?; C!=E—�.t _ . fC:i,^E'�P �CtCl@: F:[.�t�'J.�'.�F...)�t'_. :sqe'�ISCj` r:vu. .. ,,.. li � . .. I;,�+<zred iss t:arperataon � � ----------�-----------------------------__--:�____:�___��---,------_°___'---------=------------�--. ---•_---- _.--------'---------------- is r;,2,re��er.t �1 enang�� E%�'�tTF„N� �€}U:FiCk5I0�. Effect;ue 87/�111595. I Jttie; teras and condiiaons oi t�is go}i¢p reaain w�cSsa�i. _ �. � ... ��i _ t , f , N ,-�r;,_ ;��i '�'07'i`tf..._, , ,,., - , ,.., t '_, ,;: . .:..., -, � . � ,..: _ _._, . ! '.:: � ,. ,,,, : - - .i ,' �.t �:.r .�;r.� . . . , . �t .3:-�; �r:.� I '.,.._i� 1 1 ' -..'sSFf�C=_Ti: .. � �:::.i� � � � , ,.. . . . . . �' I :„t�:' � iit?, �•;r (}[ttia_l.�Y��;.rJ�-. T . - c ._. i:_ '; , �; . .. . ;:i.. i , 2:i;'` "' _ _ ..../. I�::..i �. ,-=c_tf � . ry} 1 leN- L � r, .:. ��t"t�<� ----� �.i_ .:`_5,` _ .y `^+Nfi1i9�&0 Nki(IttS42f�Ce ,,jpL,__--' _ � '.' :?'��;�Ur:Zc"7 :�Br1'ES,�tCd�i`:: � ; ` ;{°CRt ir_ __ . _..., , e: ±'j _ � '37�i:islS:t9_ � . w�.. ,_. . . .. . . � � - Pb RIIY>.w wuvicenann� ...-...._........ TOWN OF YARMOUTH - BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: Y2K-32 FEE: $150.00 In accordance with regulations promulgazed under authoriry of Chapter 94, Section 305A and Chapter 11 t,Section 5 of the General Laws,a permit is hereby granted to: l�yker Tnc. 1't A Ronte 2R Snuth Yarmnuth_ MA Whose place of business is: Doyle's Restaurant Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 1999 BOARD OF HEALTH:�d �n/. .��7etp�g�, C'�(a�irqmqanq � /!/ SEATING: 165 oan C�. Jullioa% K.//.� Vica l,hairmarz o6/e.�p.g�pe�ro/wg,�,I c�/,'� abrisllap Jak/o�laky!-p✓�toopee ec l �do hlin December 6 ,19 99 �/ Bruce G. Murp PH, R.S.,CHO Director of Healt THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-21 FEE: $50.00 This is to Certify that Dyker Inc d/b/a Doyle's Restaurant -- 1� 9 RontP R 4onth Yarmnnth h�A IS HEREBY GRANTED A I COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity wrth the authority granted ' to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. ` i BOARD OF HEALTH: ��I. �antteQsg, Cl�ac(�.mqa�n � � /J � SEATAIG:(65 oan�c7Jullivar� Ke.//.� Vice l��iiman o�erf J. �inwn� �[er� a6,w/ l�0�a,Go��y-.pld�pe� ' haal �ou �lia , December 6 . 1929 ruce G. Murphy, MP , R.S, CHO Director of Health . , : bc•yt�s RFst�u.c+rz2 TOWN OF YARMOUTH BOARD QF HEALTH- �� '�' �� APPLICATIQN Ft312 LICENSE/PERMIT- 1949d,�,� �O � . * Please cornplete farm and attach all necessary dacuments by December 31, 1998. Failure dE�� tlie return of yaur applioation packet. ---------------------------------------------- ----:�-----�----------------�v-�--------------------#---------------j->s�rl � I N �� J /T"s"'�--� /#r� � yJ L,. # " - � POOL CERTII�ICATIO�,VS The poot supervisor must be certi�ed as a Pool Operator, as rec�aired by new State 1aw. Please list the designated Pool Opsratoz(s)and attaoh a oopy of ihe certification to ttus form. l. 2_ Pool aperators musk Gst a minimum of twaemployee.s cimentiy ceitified in basic water sa€eCy, standard First Aid and Cammumty Cazdio�ulmonary Resuscitsttion(CFR). Please list these employees below and attach copies of employee certifications to ttus fozm. The Aealth Department will not ase past ye�rs' rccords. Yau must pravide new copies and maintain a file at ypur place of business. l. 2. 3. 4. I�' I 1-1 CERTIFICATIONS� AIl faod sarvice establishments with 25 seats or more must have at least one empioyee trained in the HeimIich Maneuver on the premises at al! times. Please ]ist your employees trained in anti-cholnng pracedures below and attach copies o£employee certifications to this form. The Health Departmeat wiil pot use past years' records. You must provide new copies and maintain a file at your piace af besiness. �. �Fj-t� tc1 A��. 2.—�Xla G/�dl.s �. 3. ��'�i�p„ 'F/7�N 4. �� .-�c� �'�-P l� � � . RESTAURAN'I' SEATING: TOTAL#.,��0 NON-SMOKING SEATS: TOTAL#_�2� ��'�S �-i -----.—__—__---_—______----.— ____ __—_—___------------------------------------------------�--- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 rivzv $sa c� $so `LODGB $50 �TRAII,ER PARK $50 ! _MOTEL $SO _SW:�IMING POOL $SOea. \, _WIiIRI.POOL $25ea. �'40D SERVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQtJIltED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 I >I00 SEATS $I50 qq-3 NON-PROFTT $25 �COMM(JN VICT. $50 � WHOLESALE $75 F.TA .C .itVi LICENSB REQUIRED FEE PERMI'I'# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $4S TOBACCO $2p �<25,OOOsq.ft. $75 ^FRCIZENDESSERT $25 �>25,000 sq.ft. $200 1YA11�E CHANGE• S10 AMOUNT IlUE _ $ ZL��?' ••"••PLEASE'F[IRN QYEIt AIYD COMPLETE OTHER SIDE OF FORM*'i''"�"..�... .. .. ._ .. -. `� ,� w�.. . . . . _ ._._._... . � ..�'��-._.._�_--..�__.._._ ..,. ....� �~,_..__.__. _ __..� � F _ . ADMINISTRATIQN LJNDER CFIAPTER 152, SECTION 25C, SUB3ECTION 6,TI�TOWN OF YARMOUTl•I IS NOW REQUiKED TO HOLD ISSift�I�{CE OR RENEWAL OF ANY LICENSE (7R PERMIT TO OPERA"1B A BUSINESS IF A PEBSGIN OR COMPANY DOES I�tt1T HAVE A CBRTIFICATE 4F WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WQRKER'S COMPENSATION INS�RANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CE1tT. 4F iNStTRAI�tCE ATTACHED Q8 WORKER'S COM[?. AFFIDAVIT SIGNED ANL) ATTACHED TOWN QF YARMC?UTH TAXES AND LIENS MUST BE PAID PRIl7R TO RENEWAL Olt I3SUANCE OF YQTJR PEItMITS. PLEASE CHECIC APPROPRIATELY IF PAIl?: 'YES�_ NCY NOTICE: PE12MI'I"S RUN ANNUALLY FROM JANUAR.Y 1 TO DECEMBER 31. IT IS YOi7R RESPONSIBILTTX Tt3 RETURN THE CC3MPLETBD APPLICATIdN(S} AND REQtITRED FEE(S) BY DECEMBER 31, 1498. SEASCINAL ESTABLISFIlviENT'S ARE TO CONTACT THE HEALTH DEPARTMENT F4R INSPECTION 7-10 DAYS PRFQR TO OPENII'vTG FC}R TF3E SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POdL (i.e., PAINTING, NEW EQTTIPMEP+IT,ETC.}, MUS`1'BE REPORTED TQ ANI}APPROVEI3 BY'TI�BdART3 QF HEALTH PRIOR TO COMM.ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA�T. Al)DiTTONAi.RFGtn.ATIONS POQLS POOL OPENING: ALL SWIMI�IINCr, WADING ANI7 WT-IIRZ,POOLS WHICH HAVE BEEN CLOSEA FOR THE SEAS(7N MUST BE INSPECT`ED BY THE HEALTH DEPAR'TMGI�3'I',ANIl THE WA`i"ER TES'TEI7 FOR - PSEFJD(3Mt?NLtS,TOTAL CQLffORM AND STANDARD PLATE COIJNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVIIVG, AND QL7ARTERLY TI�REAFTER. POOL CLOSING: EVERY O[3TDdOR IN GRC}UND SWIl1�IIvflNG PQOL MUST BE DRAINF.,D C7R CQVERED WI'THIN SBVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERING PQLICY: A1VYLINE WHO CATERS WITHIN THE TOWN 4F YATtM(7IJTI3 MUST NQTIFY THE YAKM(7UTI� HEALTf� DEFAR'T'MENT BY FII,ING TI-IE REQUTRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BS OBTAINED AT THE HEAL'TH DEPARI'MENT. �(tOZEN LIESSERTS: FROZEN DESSERTS MUST BE T'ES`i`ED ON A MONTEILY BASIS BY A STATE CBRTIFIEI}LAB. TEST RESLTLTS MUST$E 3ENT TC}TF�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.;L RESULT IN Tf3E SUSPEIVSION OR REVOCATION OF YOUR FROZEN DESSERT PF..RMIT UNTII,TEIE ABOVE TERMS - --- _ _ _�AVE BEENMET._ __---- - OUTSIT?B Ct�FES� OUTSIDE CAF'ES(i.e., OUTDOUR SEA'TING WITH WAITERlWAITRESS SERVTCE), ll ,[Z$�HAVE PRIOR APPROVAL FROM THE EtOARD{JF HEALTH. Q�TT.DOOR COOKING� pT�TpppR CppKINGr,pREPAtiATION, OR DISPLAY OF ANY F�D PR4AUGT BY A RETAIL QR FOClD . SERVICE ESTABLISFIMENT IS PItOHI�ITED. DATE:�1�/�� SIGNATI.TRE:,`�� '�'L`�'�''�� P�urrr N�� TrrL,E: �1 -ft� t�r119 l�� a�t� l�r�'t-" ... _ _ . . ' � The Commonwealth ojMassachusetls _ : Department ojlndustrial.-Iccidents s ; OMCo01//YESUyfUIIi 600 Washington Slreet � Boston, Mass. 01111 W'orkers' Compensation Insurance Affidavit Aoolicant informafion: P(easePRllaTTesGi.F: � � name Location: � . cit�- phonc a 0 I am a homeowner pzrt�rtnin�all work myself. � I am a sole propriecor_rd hace no one ��orkin_ in any capacih� �I am an employer pro�idino workers' compensation for my employees workine on this job. m n . n . !3 �' ��C STA � . ._ _ � . . address: �3�� P �V . . citv: � 7�I'/y'Q(,�vY�. phonep: �Q^ 161! �/ insuranceco. �/Y! � oolicyk �GB- ��Q��Q� '—T � I am a solz proprietor. oeneral contractor, or homeowner(circle ortel and have hired[he contractors lis[ed below uho ha�e thz follu�cin� �sorkar_ ,ompensation polices: companv name: address: �j�y: phone N: insurancc co. polie��# tem a�ny name• addresr � [�: ,yhoee M• inanren�w m ppR�y N � . f�ilure to secure covenge as required uoder Seenoo 25A of MGL IS2 n�Ind to tYe i�paido�oferisiW pndtln ot�e�e op to f1,500.00�W/or one ytan'imprisonment a�w�ell a�civil pen�IHn io the form of�STOP WORK ORDER aed a liee of f100-09�d�y q�inst mt 1 eWenta�d t��t■ topy ot thy statemcat may be forw�rded to the Olifte ot Invertigatlom of IAe DIA for emeraLe veriButlw. . /do hrreby cenijy nder rhe paint and penalties aJperjury 1ha1 the injorrrmtinn providtd abovt is trrt and ronrd Signamrc �� d�/J� _ Date �/.7�� Print name ��'/� (N 1'��—.� � Phone N��/�'��J ., olTicial use onk do not write in this arta ro be tompk�rd by eih or low�n oflltitl � ' "' - �� ;.� � 4 ... ....�. .r .,,.. .,.... -:_... city or rown: Y��TQ _ permiMieenu N nBuildio�.l�epartmeol _ _ _ . ----. "..... �Litensiog Board �check if immedi�ic response ie rtquired 261 �Sdectmto'�011fte �Hcilth Dep�rtmeet con�actperson: phoncM:_ �508� 398�2231 eat. nO�Aer � IrenMi;95P1AI .. - I�� CARRIER NAME: AMERICAN M[1NUI'ACTURGRS MUTUAL INSURANCE COMPANY NCCI CARRIER NO. 17116 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE ENDORSEMENT DIRECT BILL Issuc Date o6/25/1998 Poliry No. 7CQ 140418-03 Policy Change Endorsement No. 003 NAMED INSURED _ Fedcral Employcr I.D. No. 043175292 DOYLE'S RESTAURANT � (DYKER, INC. DBA) POLICY PERIOD: FROM 07/O.1/1998 TO 07/O1/1999 EHective Dace of Change 07/O1/1998 ` 12:01 A.M. Standard Time at thc Address of the Insurcd statcd on thc Policy. TOTAI SCHEDULE OF OFC:".ATIONS PREMIUM AMENDED $2,755 TOTAL SURCHARGES AND TAXES AMENDED-SEE SCHEDUL� OP MISC. SURCIfARG�S $130 EXPENSE CONSTANT $200 TOTAL ESTIMATED COST AMENDED $3,085 MINIMUM PREMIUM $179 (MA) DEPOSIT AMOUNT AI�ND�D $3,085 TfiIS CHANGE RESULTS IN A RETURN PREMIUM OF $320 i PREMIUM TO BE RETURNED NOW (BASED ON AUDIT FREQUENCY) . $320 THE FOLLOWING SCHEDULES REFLECT THE CHANGES TO YOUR POLICY: FII,ING/STATE ID NUMBERS SCHEDULE OF OPERATIONS SCHEDULE OF MISCELLANEOUS SURCHARGES SUMMARY OF CHANGES: EXPERIENCE MODIFICATION: ADDED - MA rJ /j_ `�; . � , PRODUCER INFORMATION 061-07084 G I��,,� .�n DOWLING & 0'NEIL INS AGCY � �� INC COUNTERSIGNATURE: PO SOX 1990 �nWllnp 4 No l l Inauranco Agancy, Ina, FIYANNIS MA b2601 ( I�� (/ Telephone: 508-775-1620 Date: (o ��1, � n SERVICING OFFICE: KEMPER INSURANCE COMPANIES/KSA CE ER � 1 WORLD TRADE C1R 35TH FLR NEW YORK, NY 10048-3500 �� ._. . WC 99 06 61 (Ed. Ot 94) Page 1 of 4 _ Printed in U.S.A. INSURED __— T4WN OF YARMOUTH BOARD OF HEALTH ' PERMIT TO CIPERATE A FOOD ESTABLISHMENT PERMIT NL11vIBER: 99- FEE: $150 00 In accordance with regulations pmmul�+ated under authority of Chapter 94, Section 30SA aad Chaptzr 111,Section 5 af thc Generat I,aws,a permit is hereby granted to: Dyker Tnc t'i29 Ro�rte?R„$g�,jth Y rmo i h MA Whose place afbusiness is: Do, le's Restaur nt � Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31 1999 BQAFtll dP HEALTH:��/n. .�nattQpDs, G'/�(�t.,,q�/�n� / /3/ SEATING:165(65 Nm-smoka�p,.J oJan G. Jy�ulGivan��7Kg.t/(•� Vke l.-huinman �b/or� �(9��rowpn� t,.,te/r/h . (Y/,,/��7�ajbn/ia�.Ju�Z/a7[a�rf/-e�IYooPe6 /F/ic/uze dou�hlin� i ��b�� ia iv 9s �'� ��G. M,,�,ny,ivrnx s.> o Director of Health -- - � THE COMMONWEALTH OF MASSACgi7SETTS TOWN UF YARMUUTH PERMIT NLIMBER: g9-3 FEE: $54.00 This is to Certify that .,pyker Ino d/�/a Doyle's Recta�rant 1"i29 Route z$„ 4n rth_ Y�arm�uth_ MA � � IS HEREBY GRANTED A can�orr vic~�vni.��c�s z,ic�Ns� In said Town of Yazmouth and at that place only and e�ires Deaember thirty-first I9�9 unless I sooner suspended ar revoked for vialation of Yhe laws af the Commonwealth respecting fhe } licensing of cammon victualler's. Tlus Gcense is issued in conformity with the authority granted to the licensutg authorities by General Laws, Chagter 14D, and amendments thereto. In Testimony Whereof,the undersigned have hereunto aff�zed their o�aiai signattues. �o� QF��.�: �d mn.�(e��6�pI c�[��,��//Ary� /�/ SEAI7NG:16S(65 Nw-smokmgJ � oaJn G�.'Jj }u�lkvan�/K7y.///.� Vice l„hairman �. 1 �obaif J'. /�rown, l�leMt l:� I �d.��.�a��y-.��Q ��e�0'aC' �� December 10 . 1928 ce G.MurPhY, H,R.S., O r af Health