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Home My WebLink AboutApplications, WC, Licenses , ry�j G rge,D�No s ' ' a TOWN OF YARMOUTH BOARD OF HEALT$. , ° , � ;ti I� C � ' fl �S"^ �:�; I�r �� APPLICATION FOR LICENSE/P�RIVIIT q�AO$�� Nov i a 2oos �I * Please complete form and attach all necessary documents by ecember I S 2008. Failure to do so will result in the return of your applicanon pac cet. HEALTN Ci�PT. NAME OF ESTABLISHMENT: G/ft'/�/NO � F9.�!/��1 I�4/TA✓�a.�.vTr'EL. #S�P'�� LOCATION ADDRESS: o��d- �/1%^� T a� MAILING ADDRESS: .25`a2 fls�ii.�+ a OWNER NAME: TAX ID �,FEIN or SSNI: " CORFORATION NAME IF APPLIGABLE):r / 20/iuD�/ t u'�� MANAGER'SNAME: �D G.i¢it0/.vD TEL. y _ MAILING ADDRESS: SAff,P R.r fi��0liP POOL CERTIFICATIONS: The pool supervisor must be cerrified as a Pool Operator,as required by State law. Please list the designated - - P-ao�Dperator(sl and 3ttach a cony of the c�rtificarion to this form. 1. �• Pool operators must list a minimum oftwo employees cwrently certified in basic water safety, standazd Fnst Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofexnployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a 51e at your place of business. 1. �� 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establistunents are required to have at least one full-time employee who is certified as a Food Protection Manaeer, 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 wiil not use past years' records. You must provide new copies and maintain a Cle at your establishment. 1.�� //f/l/�/NJ 2. �� C1r�/tOl.vL PERSON P.�T CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.��:L---��J✓7J 2. �`/ �i/f-iz0/A�u Qo O �i�a 0/•v iJ HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Heixnlich 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. 1. ,�,� �,y..f/1�/n.d 2. 70 'y C.1=''9'�,p/� 3. 4. RESTAURANT SEATING: TOTAL # �9O OFFICE USE ONLY � LODGItiG: LICENSE REQUIRED FEE PERMI"I# LICENSE REQiARED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B S55 CABIN 555 _MOTEL S55 INN SS.i �CAMP S55 _SR'Bvti��GFOOi 580ea. LODGE S55 TRAILERPAI2K SI05 _ - _WI-IIItLPOOL SSOen. FOOD SERVICE: LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMCI# LICENSE REQiJIItED FEE PERMI�I# 0-100 SEATS 585 _CON"I'INENTAL S35 NON-PROFIT S30 �>700 SEATS 5160 �-03� I COMMON VIC. S60 �a' _�FIOLESALE SSO RETAIL SERVICE: —RESID.KI'ICHEN 580 LICENSE REQL�IRED FEE PE&bIIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.B. . �SSO � _>25,OOO�sq.ft. �� S225 VENDING-FOOD $25 _QS,OOOsq.B. S80 _FROZENDESSERT S40 _?OBACCO 5i5 �a:�cxnvcE: sio AMOIJNTDUE _ $ 220 .00 ""*""PLEASE TIIR\OVER A1VD COA3PLETE OTHER SIDE OF FOR�i'"•" ADMINISTRA'I'ION . ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemut 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 INSi1RANCE AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Aotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transiern 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 De�artment to schedule the inspection five(�days pnor to opening.PLEASE NO'I'E: People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered witMn seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Depaztmern 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 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 ofHeatth. OUTDOOR COOHING: Outdoor cooking,prepazation, 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. IT IS YOUR RESPONSIBILITY TO RETIJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 15, 2008. ALL 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �� /�" D � SIGNATURE: � PRINT NAME&TITLE: ,�D/.�/1�20 /�. �rJ.�i'20✓tio �n- P2�J/,oC,✓ I — `r��D/.�I J -�'.v� �oizvos . � i� NATIdNAL UNiON FiRE INSURANCE COMpANY OF PfTTSBURGN, PA. b9194-0040 WC bs?-3�-�� - -•-------------------------_.---.. �3072 ----� - oa3•82-0808-00 GIAROiNO'S 7A5TEE TQWEk tNC MemberCompanies a` wE&'iMYARM6UR�ET�RT�2�73 �aQ4 �� American tnternatianal Group � E%ECUTIVE OFxICEB� 1 70 %NE STREET, NEW VORK, N.Y. 1021U $EE FXTENSION OF 17EM 1. C1F THE iNFORMATiON pAGB � WC4B0810 � pC MA `Y(� ,�. _.. TPA lN5URANCE AGENCY, ING. WORKERS COMPEN&A7iON At4D EMPi.OY�FtB i0 NEW ENGLAND BGS CTR i7R ,481LITYP4�ICYlNFORMATION PAlSE AkClQVER, MA 0181C•1096 _..._ _..__ . ---.----------_.—__._____ _ _—_. �_------�,,_�___.___ . ____.._.___._�___._. ikSURE0IS PRE'v�OU..PULiGrNUMB R CORPORATtON RENEWAL 40�$ 6 50 p7t#ER WGR4CPtACE3 N4T S7t4WN A8046: SEE EXTFNSION OF !�'EM 1. O� THE INFORMATION PAQfi • WC940610 ITEN Y nOUCr PERI00 R�A�w M.�ta�qa�G ema sf tb�inwntl'� ��.m�a.aa.<.s raoM 4�/91 /0�} *0 0�lO1/09 �rer a p. Worken Compansatibn Inturenca: Pprt OM cf tM policy apptias to the Workars Compansation iaw oi ths states iistad h4re: I �1A I � 6. EmR�aYeta tiapilitq Insurance: Part Two ai tha puiicy ap#7lits to tha wofk in aach stata riste6 +n itam 3.A. The limifa of our lla4iliry undar Vart 7wo mre: godily In/4ry by Accitlent S 1�0.��10 each accldsnt � Bod�ly i�j�ry by Dise6se S S{�O.00f3 po�;ry F�mit 9odity injury by DitiMs+ 5 1Q0.Q40 racn empiayse C. Other States tnsux�anee: PtrR Thrse ef tha policy appises to tAe nlMes, �f any, 6sced here� AK AL AR AZ CO CT DC DE Fi. GA H 1 i A t d !t i N KS KY LA MD ME M 1 MN ri0 MS riT NC NE NH iV.! NM NV NY QK OR PA RI SC 5D TN TX UT VA VT WI WY D. Thls policy iocluaas tMeet SEE FXT€fiS#ON OF tTEi6t 3.4. 4F TtiE I1tFORMATiON PAGE - WC48461T ,rer+ The p+amium ror ibte poliry wili be d•termined by our Manuale oF Rulps, Clmssifioations, RMea and Rpting Plant. Ail mformatipn raqu�nd beiaw �s suDjaM ta writVca#ian mC #sange hy au8it. ( . � Es:�mateu?ora� w�.v,� si�ma:eo (789sriirq'Wns ._.._ __ !c11tl8 Nurvne' � �t'-iusPrdGW . ft694f.M.. . R'tlm:u � Anoua' �Yea' munrrattan �( qnr�¢; �3 Yt SEE EXTENSION D� ITEM A, Oi iHE lNFORMAT�ON PAGE • WC7954 I TAXES/ASSESSMENTS/SURCHARGES � ( $14 i � ! �i r E%V6wgEC'vN41A!rT�EXGEPIWNEftEAVPLKAp�<BYB�ATE! � � P�A MI�iMUMPRBMIi:M $`(1Q MJ+, iOTA.ESTiYtATEOPREN�UM �� . ..:-.fl!aiaf e,+�w� �.-co�n acdsfinents o/yert^-um 3Y+ei�74 rraae:. � $girrc,Hcr�„a-y � G:dr!9tly � MGOIMy DEVOSI?VREM:4M �_.._—...___ _. ... _ ....i ._.___.. .___.. 06/?2/OS PRRS i PPANY 82 ��-� � ^.' T �aS ��5 �tcuf Wto _�— +iw�np Otr:it _.—J_�— Aumo+iud AaPnu�i�,'�e �X,;pC x. ;kHC' .''i.'e-; :;-0�'::8'. TOWN OF YA,RMOUTH B{}ARD OF HEALTII PERMIT TO OPERATE A FOOD E5TABL15HMENT PERMIT NtiMBER: #04-022 FEE: $160.40 In accordauce with regu3ations promulgated under authotiry of Chapter 44,Section 305A and Chapter l l l,Section 5 ofthe Cieneral Laws,a pemtit is hereby ganted to: Giard'ma's Tastee Tower 242 Route 28, West Yarmouth, MA Whose place of business is: Giazdino's Familv Restaurant Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31 20Q9 floARA Of HEALTH: :�fel.'etc S� J�!"».�Y., 'C.�"xettatt sEat7Mc: 241 total (94-bar&c lounge; �QheCO :�. ��Af v[CC ��lXlNBtIYIL 58-rear diniug roam;84-front dining room) ��.�� Q��I,d,,yE,�,�If!"Gtdt�'l7,l�l,B,„6��.JV. 1"'�`g•`J�• """d`'" November 14.200& r��<!K""' "' Bruce G.MurpLy,MP , . .,CHO T}irector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTR PERMIT NUMBEIt: #09-012 FEE: $60.00 T'his is ta Certify that Giardino"s Tastee Tower d/b/a Giardino's Family Restawant 242 Route 28 West Yazmouth MA IS HEREBY GRA,NTED A C{}MM{}N VICTUALLER'S LICEIVSE 1n said Town of Yarmauth and at that place only and expires December thirty-first 2009 unless saoner suspended ar revoked for violatian of ihe laws of the Commonwealth respecting the licensing of cammon victuallers. This license is issued in conformiry with the authprity granted to the licenstng authorities by General Laws, Chapter 144, and aznendments thereto. In Testimony Whereof, the undersigned have hereunto aflixed their of6cial signahues. BOARD OF [-IEALTH: .lEelea SllalE�,.,9tn.-✓Y., C.l�tixntt�rt sEArINc: 243total (94-baz&launge; ��,�tl1t�.¢8 .`�. :lC¢i(,lhE,K,,g ��1Ce��ti7ttrti[tlf. S8-rear dining room;89-front dining mom) �o�¢Afl�..BAtOIttf6� l.�P�YIt Q�„it,,f/L,��,,X4'4.It�l1l[Ilty �.✓V. t"""'d"'�'.':�R�jYb Novemberl9 200R ' Bruce G.Mucphy, P ,R.S.,CHO I7irectoc of Health , ` 4 r �.�Ci��D�NOS �� ""1�s TOWN OF YARMOUTH BOARD OF HEALTH S APPLICATION FOR LICENSE/PERMTT-2008 �app - r ; ��sr? �, ' Please complete form and attach all necessary document,�hy.��cember 1, 2D3h� `s ' F a i lure to do so will result in the return of your application packet� E D i. i NAME OF ESTABLISHMENT: rR-�4p�rov � �jf,�j�-.p �pu.t�nTEL. #3D�=�`JT-�33,3 LOCATIONADDRESS: oP�fJ,Fn„ _('f T �,F. /y.� ; v,��d�,�,,�y� � 7� MAILING ADDRESS: S ' OWNER NAM€:_ TAX ID (FFII•I or Nl- � -� CORPORATION NAME (IF APPLICABLE):_�'rr//f22Di.�v� _��7�c� f-vw�,,,� �- � MANAGER'S NAME:� G.�FR.Oi,,,� � TEL. #�v��9J—0333 MAILING ADDRESS: // C"�,�.9� �,,,p !<,e�j//�pu1�1�14 D,2/o'j7 � ,� , . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi¢nated Pool Operator(s) and attach a copy of the certification to tlus 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 ofemployee certifications to this form. The Health Department will not use past vears' records. You mast provide ne�� copies and maintain a file at your place of business. I- 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: „ All food service establistunents are required to have at least one full-tnne employee who is cenified 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 applieation. 3'he Health Department will not nse p�st years'records. You must provide new copies and maintain a file at your establishment 1. �D �.��ar,�%fl 2. 7v�r l.i�ao�,�� PERS9N IN��IAAGE: __ __ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operarion. 1. �D/3 �-�/th Di.�0 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all tnnes. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to tlus form. The Health Department will noi use past years' records. You must provide new copies and maintain a file at your place of business. i. �D �,�r-�or.�.v 2. 7��r G,�-�o�.�v 3. 4. RESTAURANT SEATING: TOTAL # �OD OFFICE USE ONLY LODGIl�TG: LICENSE REQUIRED FEE PER'�IIT!� LICENSE REQL'IRF.D FEE PER4II7 # LICENSE REQtiIRED FEE PERYIIi= B&B S50 CABIN S50 MOTEL SSO � � INN S50 CAU4P Si0� � �� S\i'IYI:bIING POOL S75ea.- � _LODGE S50 _TRAILERPARK S10(1 _R7-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT ii LICENSE REQL7RED FEE PER14t7= LICEtiSE REQti IRED FEE PERVIIT= 0.100 SEA'IS S75 _COMINENTAL 530 NON-PROFIT S?i 1>100SEAI'S SI50 0 �O�j�J I CO:�L4IONVIC S50 �o3-bo � _RI-IOLESALE S7i RETAIL SERVICE: —RESID.KITCHEN 57i LICENSE REQUIRED FEE PERMIT= LICENSE REQliIRED FEE � PER�IIT= L[CENSE REQti[RED FEE PER�iI'I r _<50 sq.8. S45 _>25.000 sq.ft. 5200 _VENDING-FOOD S?0 _<25,000 sq.ft. S75 _FROZEN DESSERT S35 _TOBACCO S50 �1AD�CHeLVGE: S10 AMOUl\T DUE _ $0200 •�O *"+«'pLEASE'ICRY O�'ER A\D CO�fPLEiE OiHER SIDE OF FORJi""�'•" y • 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 dces 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 V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Towri of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRiATELY IF PAID: � / YES V NO MOTELS AND OTI3ER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a princapal place ofresidence elsewhere. Transiem occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ainety(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. * NOTE: Ea�losea Motel Census must be completed and returned w�tn ct�is apP�icat�on. � rooLs POOL OPENING: All swimming,wading and whidpoois which have been closed for the season must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certifieci 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 Yarmouth must notify the Yazmouth Health Deparhneirt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departmeni. 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 urnil the above terms have been mei. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board ofHeahh. OUTDOOR COOKING: - Outdoor cool�ieg,preparaEion;or display of any food pro�uct by a retxil er foed serviee establisimientisprotribite� NO'ITCE:Pernuts run annually from January 1 to December 31. Tl'IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL 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 COMME_VCEME�IT. REVOVATIO�TS MAY REQUIRE A SITE PLAN. DATE:f� �d' � � SIG�IATURE: � PRINT NAME&TITLE: �f/ w �o c.�/fiiz.rJ i�. �r.�20�it.o �%n-- iosom io�ai��oo� 10:15 FA% 508�285088 c�.a�vt rrstrx.�.v� �oos p /�../.�.[j/� y.. 1 ^' 1 �.M1'. : 4F ��`".) . i��/�+w }��^�� ,�t�.. ' � d � Y"�^e�� x . �'� -' t t ..QA?E 41MMlDOlYY? i; •' , � b 5,.s.9 .,e\'c�? ��ru��a ii EL. in. ' ' �� {. a, C `5' uy� i�� c��'y c� SI2512�07 �F iROOUGER IS CER ICA 1$ IS A$ A M�N�S�IiMA AF QERAAANI MSURANCE AG6NCY �.Y AND caN�ER9 NO RIGH7S UPON THE CERTiFlCATB HQLD�R. TH18 CERTIRICqT@ OOES NOT AMEND, EX7END OR 908 MAtN STReE7 7e v s w 03TERVILLE,MA 02665 � __ ,_COMpANIE3 AFFORDIN43 COVERAGE ( ��AA'�Y A1G MEMBERS�6MP.OF AMERiCA W7.6ROUP —• —� — —� -- ...� __ ..._. _ . ._.. .._ i .._. .� _ .__._ ._..__ _... . . _ . ... _. . inauRea � ��Y ' flCA,RDINO`5 TAS'T6E TOWER{NC. � B � 242 MAIN ST,iiT.26 F'—� -- — � — —'"' — _. ..__. ..,.. ... __.. WcST YARMQU3H.MA 026T3 � ca�urt �' _.�.. __� .._....._ ... . __. . .. . —. COFWA^1Y _ i p � r,'.� K ) t '}°s ; � } bkv iv ka.31 .''_`ti t ':�y. k�� ,s",: tirM ! `-�:-: �� `� '.- v�. . Y ��t ..�. .��,a.�. ,Fit:'%�. .�,�,,.:, d5 �i,.:.�t.��. 1n:.i .i'_�... ��. i :,:%�l iNIS IS TO CERYiFYTNRTTHE PO4�C1F6 OF tN9URANCB LISTEO BE10W HAVE BEEN 19StlEOYO 7HE INSUAEO NApqED AoOVE FOP YHE POLfCYPERi00 � IM��C,PubED,NpTNA7k$TAµ(fIN{`i pNY REQVIRLMEA'T,i¢qY,OR `S.�NGtTIDN QF AkY CiJNTetAC.7 f7R(Y�}{Eft DDCUMENT WRN RESPEGT TO WNlCH Tii15 GERT3f1�ATE M4Y 8H ISSUBp OR kLAY PERTAUt,YHE{N5t7RANCE qRfOROF,6 9 Y TFi�FOLM_iP.$DESGRI6ED HER�N IS$UBJECT Tp ALL THF,7ERM$, E7(ClUSI0N6 AND CDNOITI6N5 oF$UCFI PDt,�,`IES.iJMIT9 SNOwN qWY FWVE 66FN RB W CEp BY PAID GLANdS. .-,_. _._ � __ . �_. ._ -. _ _ ..__. 1,_„_ __ �__ _. .�..__. _ �� TVFEOrINSURANCE i aDi.iC`rHu�te��e roucr�grreerrvE vpucriX�wnow� uaein � WY[IMM/OW�Y� M1L(NMIC07YY) ' tiENlR/3.�-�k67liTY '� � OENERw�PGGRE6A7E �f � CUMMENGIAt GENEJLaI U�&uTY j rPROD4CY&`CIXNPfoP ARG�s � � �. ..». ._._ ._ _ ��1cv�asawe i.�'x'a.s�� eesoHn�anwwauar �s.__ _� I ONMEq'6 a Co�:U1�TtlR'6�RQT f � (EACH OCCUR�NCE � E F� � � � FIRE'31MpGE �Aqarotl�6J d � �_J. _ �. . I . _. . � . . � � � uKOEXP tM+Xaqwnvr} S j A1170MOe1LE�NBiLiTY - � � i � Y'kNYAUYQ ' , i � CONflIN6051N�1S:'M'IT ! s �� i1iREGAI(TOS I � F- ... __._ .� � . .._ � t 1 r'4LLOWNEDAUT05 � � ' �gqp�ypy�uqy 5 � SCHEPU�EJAW7P8 j . � j �f�F+r�i_. . � .._. _._ . _ I �.� .. �i � � �80pRY WJVRY �� r�on-owuEcavros ; I ,z�+'•�+nr . _1 .- - �--�- �- -- —� I � I � j � nsareirn cww;ac .x �GARA6ELIKBIUTY M1700NLv_r.pqpCuSNT s ! � I �i ANYAUTO : ; i OTHENTHPNk1fO0Nl�':� _ _ _ i L � � i � 4ACHACCOENT j t �'� .__ .,_ ._' � , _' "' ' __� .'_ i � AWdlR(3A'E �i �6XCE8S 1U191U7Y ' [ACMpfptlflRlNCQ F j ( r ; J UMBRELtA tOliM i � � I�GGpEMTE �I s .... __ . �OTMERTNqryVMBRELL4FQNM I j � f .� . —. . .. ; ._... �— WOR�fIlR'lCOMplMSATIDNANO � I � �jy��p i �Fp_ A j ��oy�,��„ (W�678360 � 08/J1/07 p8/01t08 - — � E Etru,xaCCm�r 5 T 9�Opp.. f nea�tawnsrar I I�� j ! aareFnse.ra�cv��r+�iT�� s �500.4p0 �o-,�m�eHtWFVECuriue � { -._'--„_ . i o�asxa.r�: ��exu.1 ' i gmecnse�Fa cew�ovee s 1(YO,OPD �: PTFI[R ! ` � i � f � i � i � DCSCRIPTION 0�OPERA7KW8140CATi0NSNEMCLE9/SpqGULL 17EM8 i � ,t ft �.�.�� S�sa -li;-f M ... a, u f . - _ �� n n*Ff ,, ^I'M i r � � 1 L -�� > .. .._ . ,.v .:.. ._ ..,... ,n '.. 4t,. ... , ae�mun...: ,.a...nJ..s,..,1h,�e.,.a.iw.3t ,......�. -.. , ..., m.a,...ifi�.c�r..:u...s t.i�_L-a'.L> „ ._ ��,..:, . .,. u .�..� .�,.a: W3U10 11NYOF TNE ABPM OG9CWI160 POLICES BE CW�ELLEO BEFGRE Ii16 O''�i1lflt DRTB FNEREbF. 'f}�{�tNG CAINPiHY hN�L YNCFAYQR TO NNL ��DRVA WMTEN N{}TICENa TM!GERIIPICATi MOLY6{W�MEDTO TM8 LlFf. 5UT fBY.VlFET4MWLS1lCX N6TICEENAttIM9066 NO�itXN`AT16N 6RURattTY F g p�MTp v p 8 A1�7#fO�f� ATlV,�/� � a� w � �Jh�f�� '4�� 64 � �f ( t P Y f +✓t M '��. a, -_'tk'.�* ��. a �;.�.::�' a�.�Y..:'dG i.n.p`t'`. .'k�1 .�i. rt.�i'-+^"'Frc n�'' �{h;.i � �.ii�''��1Rn"./{RC��Rl1«. ..�.��-. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMITNUMBER: #08-033 FEE: $150.00 In accordance with reQulations promulgeted under authority of Chapter 94,Section 305A and Chapter I I 1,Sec[ion 5 of the�ieneral Laws,a pemtit is hereby granted ta Giardino's Tastee Tower Inc., 242 Route 28, West Yarmouth, MA Whose place of business is: Giardino°s Tastee Tower Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit e�cpires: December 31. 2007 BOARn OF HEnt,Tt-I: ,�c SR�aIf��C�awW►eart sEnru�rc: 241 total (946ar&lounge; C�.¢a ,`� vjt¢ �!�!/1t(!fy 58-rear dining room;89-front dining room) ��.�Y(Vt � Qftft�y�Neeft�ll'lqlt��.Jv. November 27.2007 Bruce G. utphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLTMBER #08-029 FEE: $50.00 This is to Certify that Criardino's Tastee Tower Inc. d/b/a Giardino's Tastee Tower 242 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMNfON 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 violation of the laws of the Commonwealth respecting the licensing of common victuallers. Tlris license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a�'ixed their official signatures. BOARD OF HEALTH: .�EePxrt SliuPi, `J2..N., C'ha�naut SEarQrG: 241 tetal (946ar&l.ounge; (,RQy�¢d ,`�,� QJ� ��y 58-rear dining room;89-front dining room) �p�S�p�, � Qltlt � �.,lY. November 27.2007 Bmce G.Mmphy, , .5.,CHO Director of Health �' � � �J71�MLCfl�oS i v'iR � .- �y TOWN OF YARMOUTH BOARD OF HEALTH \�� 3�� APPLICATION FOR LICENSE/PERMIT- 200'�,,Q( � � t�� r� s �. y� �� * Please complete form and attach all necessary documents by Dece ber 31, �,6.1 2 2006 Failure to do so will result in the return of your application packet! NAME OF ESTABLISFIIvIENT: G / F}2�i,v.' `✓ �ipr/�CP �Gir�iL TEL. #S'D�F'- �77J -D,.333 LOCATIONADDRESS: o?`f Sr,,.- 1>- T d MAILING ADDRESS: OWNER NAME: TAX ID (FEIN or SSNI: - CORPORATION NAME(IF'APPLICABLE): G1RsLD.nla� T�T� P T��/L��_'^� ' ��- MANAGER'SNAME: � �i �a�� TEL. #S�d'-�f% 1`� ' MAII..ING ADDRESS: t 2 --� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cudiopulmonary Resuscitation(CPR). Please list these employees be(ow and attach copies of employee certifications to this form. T6e Healt6 Department will not use past years' records. You must provide new copies and maintain a fite 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 Maoager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 540.000. Please attach copies of certification to this application. T6e Heaith Department will not use past years' rewrds. You must provide new copies and maintain a file at your establishment 1. �✓ C�'i�f/C�J�v� 2.� (>'i�/L.�/,va PERSON IN CHARGE: _ __ - ---- -_ ____— _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.�1� �r, f}� 17 i G�D 2.�D�1 �s r�-n.�.n- d 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. i. �D ��9n0i�-� 2. �4�'( �i/��O�.�v 3. 4. RESTAURANT SEATING: TOTAL# a �.J OFFICE USE ONLY LODGING: LICENSE REQilIItED FEE PERMIT k LICENSE REQUIItED FEE PERMI1'It LICINSE REQUIltED FEE PERMIT# BBcB S50 CABIN S50 � _MOTEL S50 INN $50 CAMI' $50 _SWIIvfhIlNGPOOL$75ee. LODGE $50 1'RAII.ERPARK $100 WfIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQiIIItED FEE PERMTC# LICENSE REQi7IItED FEE PERMIT'# LICENSE REQUIItED FEE PIItMfI# 0-100 SEATS $95 _CON1'INENTAL $30 NON-PROFIT $25 �>100SEATS S150 0�7�D�GI �COMMONVIC. $50 G� �cI _�OLESALE S75 RETAIL SERVICE: —RESID.KTTCHHN $75 LICENSE REQiJIItED FEE PERMfI'# LICENSE REQIlII2ED FEE PERMIT'# LICENSE REQUIItED FEE PIItMIT N _<50 sq.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. S75 _FROZINDESSERT S35 _TOBACCO S50 NAME CNANGE: S10 AMOUNT DUE _ $ 20�.o0 •'••'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"'"' : . , nnmmvis'r�'rtox Under Chapter 152, Section 25C, Snbs�tian b,the Tawn of Xarmouth is now required to hold issuance or renewal af any license or permit Yo operate a business if a person ar campany does not have a Certificate of Worker's Compensatian Insurance. THE A'TT'ACHED STATE W4RICER'S COMPENSATION INSURA.NCE AFFIDAVIT MUST BE CCIIVIP'LETED AND SIGNED,OR CERT. OF INSUitANCE ATTACHEL► � QR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens mast be paid priar to renewai or issvance of yanr permits. PLEASE C�CI� APPRQFRtATELY]F PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRAIYSIENT OCCUPANCY: Far pucposes of the limitatians af Mote3 or Hotei use,Transieni occupanc.y s,hall l� limited ia the temporary and short term ocoupancy, ordinarily and customarily assaciated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principat place ofresidence elsewhere. Transient occupancy shall generally refer to cantinuous occupancy of nat mare than thart}= (30} days, and an aggregate of not rnore than ninety(90)days witfun any six(6)month period. Use of a guest unit as a residence ar dwelling unit shail not be considered transient. Occupancy that is subject to the collection of Room Qccupancy Excise, as defina) in M.G.L. c. 64G or 83d CMR 64G, as amended, shall generally be cansidered Transrent. POOLS PQOL OPENING: All swimming,wadin�and whirlpools which have been closed fo€the season must be ins ed by the Heatth Department prior to opening. Contact the Health Department to schedule the inspectian Sve(S�days prior to opening. POtJL WATER'TESTING. The water must be tested for pseudomonas,total coliform and standard plate couctt by a State certified lab,prior ta opening, and quarterly thereafter. POOL CLOSING:Every outdoar in ground swimming gool Fnust be drained or cuvered within seven(7)days of closing. FOqD SERVICE CA'i'ERIlYG PQLI{;Y: Anyane wha caters witlin the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Apptication form 72 hours prior to the caxered event. These forms can be obtained at the Health Deparkment. FRQZEN DESSERTS: Frozen desserts must be tested on a manthly basis by a State certified tab. Test results must be sent to the Health Department. Failure to do sa will result in the suspension ar revocation of your Frozen Dessert Permit until the above terms have been met. OITTSIDE CAFES: Outside cafes(i.e.,outdoar seating with waitertwaitress service},must have prior appravalfromtt�Boaa-d ofHeahh. OUTDQOR COOKING: Outdoor coaldng,.prepazation,or display of any Food praduct by a retai]or foodservir.e establishment is prnhibited. NOTICE:Permits run annually from January I to December 31. IT IS YfJUR RESPCINSIBIL;ITY TO RE1'C.TRN fiHE COMPLETBD APPLICATION(S)AND REQUIltED F`EE(S)BY D�CEMBER 31, 20Q6. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR P�OL (i.e., PAIN'TING, NEW EQT3IPIv1ENT, ETC.),MtJST BE REPORTED TO AND APPROVED BY THE BOtLRD OF HEALTH PRIOR TO COD�4IENCEMENT. RENdVATIONS MAY REQLJIttE A SITE PLAN. DATE: .�o� "�.S �O � SIGNAT'URE: PRIN1'NAME&TITLE: r�A ft lJ �} • �. /f2,�/,�a T/L ��°/%0��7 1on7ros . � 11/07/Y008 il:a8 FA% 80842&3068 GERYANI INSURANCE 1�001 � W...... . _. _ . .__ �. ..� , -�,::-. - - - � . A .�'-. . : . . . ... .,. . .. �: �......_ .. ri L'ORQ ' ' : ,T4,� ;�, � r�n '� i�ano� ( ��.,w..,�.�,.k: .:�. .. �. _ '. � .; PitOGUCeR FICAT IS iUE� A MA7TGR F INFORMA � GERMANI INBURANCE A6ENCY � �1LY AND CONFERS NO RIGt175 UPON iNE CERTIFICATE i. HOLDER. TIi18 CERTIFICATE pOEB NOT AMEND, EXiE►�ID OR 90B MAIN STREET ..TFl� COVERAOE nFPORDEO BY TH& PUUGIES BiLOW. I 08TERVILLE,MA 028$5 --.COMPANIES AFFORDIN6 COVERAGE. ._. . .. ��""r AIG MEMBERS COMP. qF AMEftICA INT.GROUP .. _ ._ . ._.. . . .. . �� . . INSURlD __..._.- _ _ '_. ...'_ G�RDINO'S TA$TEE 701NER INC. 8 - 242NWINSLRT.28 � -- ..—...—..-_.._....'-- _.___. _ _.. ... WEST YARMOUTM,MA 02873 � I a�.wellr _ .. .___ . ._ . . _._. .. . I caim.wv .—.. . D „.. i� :�:14 .:i]Y•:? .1.. .� ...u.�I 'h.: �f!L'-ii$.+i�i..5.� +4L.ii�e � Yi3'.tf M �LL4414"S:�i'.a'•�M��:_i.«�.T.�.F.u"�! .c... TMIfi 19 TO CEP{T1f1'THAT THE POLICIES�INSURANCE LLRTEU BELOW FNVE BEEN�BUED TO TNE INBURED NMACO ABOVE FOR 7H6 POLIGY PERI00 .. xvDK'.A7ED.NOTNfliki3RWON6 aVY RE�URBJENi.TERM OR CONDRIDN OR ANY CONTRACT OR OTXER UOCl�EN7'Wrtli RESCECT 70 WNIGtI TH�S CEWTIFlCA7E hY+Y BE p3UED OR MRV PERTAW,T11E CISURANCB ARFORDE�8 Y THE pOUCIES OESCR19E0 MEREIN 1S 9UBJECT'f0 AL�-TNE TERMS, HXCLUSIOH5�WO CONORIONS�SUCH POI.�IFS.IIARS 6MOWN 1l4Y HAVE BfHN REDUCED 8V PAID CtAAe6. .., _— ... _ .._—. .. ..__...._" . . . �T__ ��;�E__ i �� l �, °��, ' �� ENBw4Lt.we�uiv � celEwuAG(�Eanh �s �� ;� � I ��s,��,��`s ..___ _ __. ow�xs��wmw,�ron•sweor ' �c�+oc�� . _..--- -- Fweav.wae wq�«a�> � . ..----� . ►EoawtAm«rw�san7 s pu an ��u�� I CMI&MEb 9RNitE LW i I 8 ANYAU70 . . _. .._._l . ._...__ . .'_ �AIIOWNEDAUTQS �pyY��y __j� SCHEOULEDAUTOS I�PM�1. ._.. ..._. (� N�NOWNEDAUTOS � ��d� .,. _ ..._ . � . . ..-'"" I PA�PERTYOMtqCE s � I GARA6ELI�BIL�7Y �AUTOdar.EAnCGlDENf 5 ! I nM'AUTO i OnffRTMAN4UT00NLV: . ..._ EPCHACC104NT.�$ ._. .__ _.._ _ . .._ I -�GGRfOAYE i— . lXCE88LV�BIl17Y EM.+,�CCIYtRBiCE i UMBREILAFORM . I AGfJREWYE . �- �� 'i .— � 6 �O'MFR THRrv taieREUAfOitlA � .—_. _�.6 ..— A � a "'°�,�,��' wc ees-ez-oe osro�ros oero�roi ��„�M '�'-�, '-. ioo:000 +�c� �u+�xi �eto�.aawrurr s— 50�000_ ; �rae. b�. erio '�-Er.eawr.av� s � 100,004 ,oniert i i � i oescsmrwr+oF oreruno�ac►�eau.tte� ry` " _ .�'.•..�9':''.Sa MqUW ANYa TM6 A60VE 0�lW i�E9 @ C�t�EI.tC�BEFORE Yf1E 1ElffQ 6'lIW1 OnTE THEPEOF. 7XE 166UCNi WNPANV M7LL tltlOPAYOrt TO pWL �eavs vmrr� xoneem Tnee�e�ureeninrnrure+ro n��ec�r, eur K�rornRwa xoncawnu.�.osF xooeuoa� on�ueiux w un rrs rrev ��A7N5 , ,��K rvr' �" ':1 1 Towrr aF�A�aur� san� o�H��,�H PERMT'F T4 CIPERATE A F4dD ESTABLISffiVIENT PERMIT NiJMBER: #07-091 FEE: $I50.00 In accordance with re ahons promaigated under nuthariry of Chapter 44,Sa:tion 305A and Chapter 111,Section 5 of the�erel Laws,a peimrt is hereby granted to: Giardinds Tastee Tower Ine. 242 Route 28,West Yarmozath,MA WhQse piace af business is: Giardino's Tastee Tower Type of basiness: Food Service Ta operate a faod establishment in: Tawn of Yarmouth Permit eacpires: December 31 2007 BOARD oF I��A.t,'rA: B '-7s. (io+�c, �`15., ' s1EA71rt�_ 241 toGil (94-baz&louage; cr!�e�c��ir'+li'i ��./Y.r vics l�•lrvi�aut 58-rear dining ronm;89-front dining room) nco�eh+��iotwci �eh+� /�atidc�a 1��5e�smo� �i.�.�C�� R.N. Febrnazy 28.2007 _ � Br�e G. urPhY, , Z.S.,CRO Director of Heal THE CQMMONWEALTH OF MASSACHUSETTS TOWN CMF YARMOUTH PFRMIT NUMBER: #07-061 FF.E: SO.OQ This is to Certify that Giazdino's Tastee Tower Inc. dtbla Giardino's Tastee Tower 242 Route 28,West Yarmouths MA IS HEREBY C>RAN'1'Ei,,D A COMMON VICTUAId.ER'S LICEIVSE In said Town af Yazmauth and at that place only and expires December thirty-first 2007 unless soonex suspended or revoked for viofa#ion o£the laws ofthe Commonwealth respecting the licensing af common victuallers. This license is issued in conformity with the autharity granied to the licensing authorities by Generat I,aws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto aHixed their official signatures. BOARD C?F HEAL`TFI: 8 y 4}. �(�,,�'�, 11�`�l., . sEa'1'wc: 241 total (94-bar&lounge; ayBl,�eQ�ta�i� �C✓I., 7/�tee G��x�C 5$-rear dining room;89-fraitt dming robm} Rt�u��. �?otws, � Qo-bitc+(a/�o�e✓�� ,4.� R.N. Febniazy 28.2007 r -MnTFhY> > S.,CHQ Directac of HeaIth �" (,F'�'�� C+IARblN6S f o e R,s TOWN QF YARMOITTH BQARI?pF HEALfiH �! 3 � APPLICATION FCIR LICENSE/PERMTT- �-� ..� Y�� . � �>ti � � * Please compleie form and attach a!1 necessary do , ., c°'�embe 31,2005. 4 Failure to do sa will result in the retum af y , p ion pack . ' �' NAME C?F ESTABLISHMENT: V"��r �O /�v % TEL. # "" LOCATION ADDRESS: �`!'>^> � �J �� 3 MAII.lIYG ADDRE9S: �`A�r '� QWNER NAME: TAX ID(FEIN or S+N} CORPORATION NAME (IF APPLICABLE): ivfANAGER'S NAME: /c 2 /n�� R TEL. # 3 ' '�,� l4fAILINGADDRESS: 2crv/.32/Q �3' G(/�"✓ D � � � _ � POCiL CERTIFICATIONS: The pool supervisor must be certified as a Paol Qperator,as required by 5tate law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. i. �� Pool operators must list a minirnum of Ywo employees currently certified in basio water safety, staaadazd First Aid and Cammunity Cardiopntcnonary Resuscitarian(CPR)_ Piease list these emg3ayees�law and attach copies of esflployee certifications to this farm. The Health Department wil1 not use past years' records. You must provide new copies and m$intain x file at yoar place oE business. 7. 2. 3. 4. POOD PROTECTION MANAGERS - CERTIFICATIONS: All food sen+ice establishrnents are required to have at least one full-time empioyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Estabiishments, 105 CMR 590.004. Please attach copies of certification to this application. The Health Department will nat use past years' reeards, You must provide new copies and maintain a File at your estabiishment. r. l`1 f12 UJ �i.�2D/Na 2. PEItSON IN CHARGE: Each food establishment must have at Ieast one Person In Charge(PIC) on site during hours of operation. 1.� 0�3 C��r ��/rr+-,/I/� � 2.�%7`r�1/�.i ..�s-i /�sc.,J//rc�c� HEEA�ECH GERTIFICATIONS: All food service establishments with 2S seats pr mare must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please iist your employees trained in anti-choku�g procedures below and attae}i eopies of emplayee certifications to this form. The Health Department will not use past years' records. Yau must provide new copies�nd maintain a f�(e at yoar piace af business. l.. � Gt/1f � �l. /ti'� 2. ✓ '�1r-/9`/ C�-/fl/!�/�-'L- 3. �. !.�/ r R�/211/�v c� 4. RESTALIRANT SEATIlVG: TQT'AL# ��"� Oi�FICE USE ONI,Y LODGING: I,ICENSE REQUA2ED FEE PERM['I'N LICENSE REQUIRED FEF. PP.RMI l'# LICENSE I2EQ(IIItE.T7 FEE PF12Ml'I fS _BBcB $50 �.,_ _CABIhT $50 _MOTF,'L $SO i _ _.,R�IDi $50 _.,�„ .._CAMf' $50 `� _SWIMbIING�POOY$75ra. L4DGE S50 7'RAII.ERPARK S50 WIIIRt.POOL S�Sca. FOOD SERIrICE: L,ICENSE RF^.QUIRED FEE PF,12MIT N L.ICSNSE REQIlII2ED FEE PF.RMIT N LICf�.NSE REQLTIIt&L7 FF.E PERMIT# 0-100 SEATS $75 CON1'INENTAL $30 NON-PROFIT $25 — —.......—..— ._ .. �>IOOSEATS $ISO �06-�iJa � COMMONVTC. SSp Ob""�� _WHOI:ESALE S7S RETAIL SERVICE: LICE23SE RI.iQI7Il2ED FEE PERMPf# LICENSE KEQUIRED FEE PF�iRMIT# LICENSE REQUIITED FEL' P6RM1'f tt <Spsq.ft. $45 >2S,OOQsq.fi. S2(!0 VEAIDING-FOOD $20 _QS,OOOsq.ft. $75 �.. _ _FTLOZENDESSERT $35 _T'OBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ 200.�1 ""*""pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•"""" F , � ADMINIS'T1tATION �� • � Under Chagter 152, Sectian 25C, Subsection 6,the Town of Yarcnouth is now required ta hold issuacc�e or r�ewal of any license or pemilt to operate a business if a person or company does not have a Certifioate of Worker's Compensation Insurance. T}tE ATT'ACHED STAfiE WOTtKEit'S COMPENSATION INSURANCE AFFIT}AVTI'lY1ITST BE COMPI:ETED AND SIGNEI/,Qit CERT. OF INStJRANCE ATTACHED �'� t7R � WORKER'S COMP. AFFIDAVIT SIGNED ANU ATTACHED Town af Yarmauth taxes and liens must be paid priar ta renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: �~ YES 1.� NO _ NOTICE:Pernuts run annually from January i to December 31. IT IS YOUR RESPONSIBQ.1'1'Y TO RETUILN T[� COMPLETED APPLICATION(S) AND REQi.7IRED FEE(S)BY DECEMBER 31, 2005. SEASQNAL BSTABLISHMENTS ARE TO CQNTACT THE HEALTH DEPARI'l1�NT FOR INSPECTION 7- 10 DAYS PRiOR TO OPENING FOR THE SEASON. ALL REN4VATT4N5 TO ANY FQOD ESTABLISHMElYT, MOTEL flR POQL (i.e., PAINTING, NEW EQUIPMENI,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARU OF HEALTH PRIOR TO COMIv�NCEMENT. RENOVATIONS MAY REQUIlZE A SI'TE PLAN. ADDITIONAL REG[TLATIQNS P(}OLS POOL OPENIlYG:Atl swimming,wading and whirlpools which have been closed for the seasam m�st be inspected by the Health Department prior to opening. PQOL WATER T'ESTING: The water must be tested far pseudomonas,total coliform and standard plate caunt by a State certified lab, prinr to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days of clasing. FQOD SERVICE CONSUMER ADVISORY. Each food establishment wMich serves or setis ready-to-eat,raw or undercooked animal products are required to post Cansumer Advisories. CATERIl�G POLICY: Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Departrnent by filin�the required Temporary Foad Service Apglication form 72 hours priar to the catered event. These forms can be abtained at the Health Departrnent. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be sent to the Health Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Pernvt until the above terms have been met. OUTSIDE CAFES: Outside cafes�.e.,outdoor seating with waiterlwaitress service},must have prior approva!from the Boarcl ofHealth. OU'['llOfJR COCiKING: Qutdoor cooking,preparatian, ar display of any food product by a retail or faod service establ'rshment is prohibited. DATE:�/'� ' 4 S� SIGNATCTRE:_G�r�i—t,�Y _ /r��,�, PTtINT NAME&TITLE: f�"-rY�l�v 1 �Ow�2� �� rf/�O.-N� �/U� 09128/p5 �� . �. � p�tTlr{lAMN� '� 11/14/2QQ6 AC�2RD �w�. . ., s .,,<<r._ :�.,�,. . . . .,,��'�`� � � ,.., . � '; � ',� naoeVc�l . . . . �R ,... MB4�E1�`7��'1"tgdt� AT�ON� ONLY ANp CONFER� MO RNiHTS UAWI TME CWitIFIGAi! . CsERMAN!#1$URANG£AGEFICY NQLpER. T}ili ClATi/ICATfi DOii NOT AMEND, EXTI!ND OR I 940 MAtN�TRL'L�'T ! OS'[l�RYILtl�MA 4xi66 � __T.. �GMPAtiNCS A�RQiNG COV,�NAGE� . __�___ � � `�i1°� AMERICAN NOME AS9URANCE COMPANI' ♦ .__... _._._. ._.._ . ..._.�,.._. ._. .r.__ ... ......._..�. __.__�____.. . riqy�lb c4w��' GIpROlNO'97AS7GETOWERlNC. � ._.��.. ...,_,...,._._- . ....__. 242 MAIN&7.R4UTE 28 �'�. -� - WE57 YAGiMOUTH,MA{120T9 � �µr �.._. . _. . . . __. _._. __�... .._.._ _ ! COMiNlM 8 .�;.'�,i;. . v,�Stl.IMl!` ��i^�IC.:.rv�� ,e.. II�..!'. �, . .�:.: �1 L^i � .;. i � <: '-; ._.. `hitB�aTOCER'nF`�TIU4T7liEPOttCESOFMBUMNCELi8�E68��OWIWVEBE8N198lJiDTO NEiqYURiEDi�AMEDA0C7VEFQRfHfPDL�GYP£FI00 �NGCATE4.NOTMTN91'AMpH6 ANY R64U1Rl41�lT.TE1W OR COf10�TIpN OF ANY COkrilA,.70R OTHER D4C�WNt riRX REBPECT TO rift WM TFMS CERTIFtW T!NAY BE�39UL0 Ult MRY PERTAIN.TiE INB4MMOE AFFORREp 0 Y TME P41M.fE5 DEBCRIDED hEliE1N i$41lNtt7 T6 At.L'+tE'RRMB. E%CW9i0M6 AND COkDI71pN90r 9U^.N PbL1CtE8,41Mfi=�MOWN M0.Y HAVE�UN REOUC&D Bv Pn10,CUM6.� .__._._. ._. . .._._. ... ._ . , ......_ ° _. UMR� � ou,Miairr+; ��u.� rnE aF ww�n�s �. roucr Murl�t ��N�Twa� E r nr�� , E OiNENALUAl1{,1TY I ��"��fi'_.....y-Y ,_.��._. ' ICOWAE9CM1.6t�iaux.r*r � '� ��OIMlC'�,5,�-LY1MPao�36�i . , ', ..__�—r�.... .. �fANM�MMf L^IX.1?�M � � t ,hil/ONK�JiD4klklAX iII � j i.. �_ ._ . .___._.__ _. awnrroaooNrMera�evnor� � � ar�ta:CVRPEf+ct ��._._.. _ +•� '. � ii ,'N�',�,dl�lW�tNam�,iM'�i ."__ �.,,�.__._�.. . �.. � '. �4EGOtfWharPrMrsl i♦ �Auf0�l7�1i�N�17Y �" � r } wAN'YMdLQ � � - � 4OMYNEDlWCleunttT IY .�. __ F.�....�._._� . �Ail4wMEDAU'RJ6 �� .. r,.� � !BQGIIr WJ1l0.Y _�0 __, licMEpUtEDAUTOS �� r'�Y0"7 .._.._� . .-- �HNREO RUi9B :� � �p�, r~NONiWAIEDAUt09 : ' �,iPv�eqYri�1! . !._ i,` �.__�.__ i '�1 . . I �. ! .nop�+�wv.cc i� �GAAAGltM�K+TY - i�umo�n.r.+'a�C4tlNrt '' � i .._._.. i ....��._._._ ._.. !FNYAVTO � �.QTNCRTlMNAV�O�NlY. L. ... � . I .� � HGM�GCwlM^ T�{i_ . �,..... ...�__. _. _ j i—�� GOVd1T! 'i "'" � ' EACKp W�4TY j �sAGtOOGM�NCl . .� .. ,_� � ! _ _.___ � ! U11BFElU frJRM : ' � �'Mi0lIRQFT! ��i ! i �..�.� _. _..�.._r. _.._..__.._ �...� dMr�TWNIAIORlILAFOMI i.•- _ � ' Y►WMWO'l1�LIN �O j��'�Q6"� �Q/QSro3 � �8/Q�� .. V __:_ . . _. i � c�ucxuc�em �s iGo,oOII +++�� ;v� j Iei.aewe�vcucr�viT rte� SOO,QDO .� �orn� �cxctl � 'aa�uaa-G ewi.ovte i� 100.000 �oniR i , I � � � �i t oE d7RAr10Mb+1 A Ct[arsv6cul Ms : � -,: ,�, „ i , . . . ...... "t 9',r. ,''.:r< , a.Y�:_ett.u�..�. �) .j?..0 .... _., n . �iE:�: &�L' , i::�1.,, . Tb'Xdninw... � bte0�71n AItIYOF iil[ll/OVF ¢tlp�Q�QLiO� N�Cfi116t1111L yfOM TME 1u �. 'i OMMf10N W71 iMENfQF. TiH pMYY/0 QdMMMT Ml4 tN0►AV011 TO Wll. � ��CAVR WMi�t MG�ICl7G Tn{OM71MIG1�NOLOl�NAM�O t9 TN! �.uT. suf I,vtW7PNNi.�VOn NOnPEMw.�uArON NDW4a4TMI01ltYWIAw WTM9��[NTA�iA7f� +�' [ M1 r�'i ":n 56!�{ .�, r ' i r m �y+,rx q ri.� .4x� 't�"frKd{'�' ••�'-�i t., �.irrv i'q . q a�f �i�'��}�'�� h� d �,WtV �y}� TOWN 4F YARMOUTH BOARD OF HEALTH PEi2MIT TQ CIPERATE A F04D ESTABLISHt�'NT — — __ __ - --. — —_ PERMIT NITMBER: #Ob-010 FEE: �150.d0 In accor�azice with regulations promulgated under authority of Chapter 94,Sec;tion 305A and Chapter 11 l,Section 5 of tha General Laws,a permit is hereby granted to: Giazdino's Tastee Tawer Inc. 242 Route 28 West Yarsnouth MA Whose place of business is: Giardino's Type of business: Food Service To operate a foad establishment in: Town of Yarmonth Pemut expires: Decamber 31 2�6 BOAIZD oF��nI.TH: b'ersjarai�a `�l. t'jo�orc,�`�5., . ssa'rIDrC+: 241 total (94-ber&lounge, n��i vk� ��a�xsa�C sR-rear c3init,$roam;s9-fi-onr ain;ng ioom> Rod�� B3t�u�, G'!e� d�rle�r,3�s�lsi !l./Y. A.�Cj�L�..� RJY. November 18 2005 ' � Bruc�G.MurPhX S.,CHp Dir�tor of Health TIIE COMM4NWEALTI3 OF MASSACHUSETTS TOWN dF XARMOUTH PERMIT 1VLTMBEIt: #06-U09 FEE: 54.04 This is to Certify that Criardino's Tastee Towar Inc. dlbla Giardino's 242 Route 28, West Yarmouth,MA IS HEREBY fiRr1NTED A COMbION VICT[7ALLER'S LICENSE In said Town af Yarmouth and at that�lace only and expires December tlrirty-first 20�6 unless saoner suspended ar revoked for vialahon of the Iaws of the Cammonwealth respecting the licensing of common victuallers. This license is issued in conformity weth the aut�ority gran2ed to the ticensing authozities by General Laws, Chapter 140, and amendments thereta. In Testimony Whereof, the undersigned haYe hereunto affnced their official signatures. BC?ARD OF IiEAL,TH: Bera�rrsra `11. !�''e�rc$asg 11�1._`?>. ' sxA1'[rtc,: 241 total (94-bar�lounge; n�/iie�t Mv�Se/[mo�, ?/:�e L'�aiR.,�,,�.� 5$-rear dining rooxtt;84-front d'ming raom} Rddwls�� 3ott+vt, �rlx� d� �'�r R./�! i9�r.i Q'+u�, ll.N. November 18.2005 l Bruce,G.Murphy,NII' , ,CHQ ,-- Direettor of Heatth � �.�.-� _ _ 1 Fcroe� Svc . � O��Y`9R �� '�� TOWN OF YARMOUTH � -,;�� y 1146 ROUTE 2S SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTqCHEES �'aa„a,"�„«fl� Telephone (508) 398-2231, Ext 241 — Faac (50S) 760-3472 B O A R D O F H E A L T H To: Yannouth Board of Health Pernvt Holders -`"' � ��-- � ��;,"t �� '� j r From: David D. Flaherty h., R.S. ;�D r APR 2 5 2005 F Health Inspector � Town of Yarmouth HEALTH DEPT. Re: Federal Tas ID Number Daie: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regazding all permits and licenses that we issue. One of the details that they require we send to them is every establishmenYs Federal Employer ldentification Number(FEII�otberwise Imown as your"Ta�c ID Number". This is purely for administrative purposes only. So� businesses use the ow�r's Social Security Number (SSl� for this purpose. If this is the case for your establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and retum this letter to Yazmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding this matter, please do not hssitate to call. The of�ce hous are Menday to Friday, &30 am to 430 p.m The telepho�number is(508) 398-2231,ext. 241. �' �+ /�pcuB/( Establishment ( Z�A/LDiu.9� /�Tc� / FEIN or SSN: ��- � o� / %1 ` /�i/�l, y�� 7• o2v Locarion Address. �� e✓' 7� �/�2�ok�`� /l� .� Signature• �/ l Print:�� ' C�9'/�/N� V � Title: ,��/�.��3.�,� �� Prin[ed on � � Peacycled �'� , �,�-4O�Fa� $200 , � �°f�"a TOWN OF YARMOUTH BOARD OF � G3 I� � C � 's fo; o�y APPLICATION FOR LICEN E �� D E C 1 4 2004 ��-s , � • , �, * Please complete form and attach all necess�y�o�ents by Dece �1p��flE PT. Failure to do so will result in the retu af your applicat�on p NAME OF ESTABLISHMENT: <.4k-O>.v» ,/ � T.4u�+1`TEL. # �7 LocaTTON Avv�ss: a � ,rJ�%� �(3� , a� c,�Evr� �vv7;l MnII.nvG avvxEss: _f'i3�-r � OWNER/CORPORATION NAME: :�vvr� ✓ �-'�/C- MANAGER'S NAME: �� .��t.Oii� TEL. #� ^ � MAILING ADDRESS: �,�r rYJ P s�✓ �.�a v-( POOL CERTIFICATIONS: The poot 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 emplo ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please Gst 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 -CERTIFICATIONS: All food service establistunents aze required to have at least one full-rime 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 appGcaxion. The Health Departmeut will not use past years' records. You must provide new copie�and maintain a fde at your establishment. 1. I • �12 Cri �✓ � 2. PERSE}N IN C CrE: — - _ — — - --- --- -- - - __ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �. f��e2r G��-ti.v,� 2. .� G, � ' �IM�ICH��RTIF�(;ATIONS: �� '� �`�� 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 Heelth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � 1. �OwA �.O C./�a0i,�� 2.��i ��/��Di.+r'v 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMIT# LICINSE REQUII2ED FEE PERMIT tl LICENSE REQLJIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 INN $50 CAMP $50 SWIIvIIvIQJGPOOLS75ea _LODGE $50 _TRAII.ERPARK $50 WIIIRI.POOL $75ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PF.RMIT# LICENSE REQUIItED FEE PERMIT t! 0.100 SEATS $75 CON'PINENTAL $30 NON-PROFIT $25 �>100 SEATS $150 S�OB� / COMMON VICT. S50 �k65-060 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQiJIl2ED FEE PERMIT N LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMI"P# <SOsq.R $45 >25,OOOsq.ft. 5200 _VENDING-FOOD S20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ a�O.00 •""*"pLEASE TURIV OVER AND COMPLETF OTAER SIDE OF FORM"•"•• � �A. . � � • 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 COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and Gens must be pvd pnor o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITl'TO RETURN Tf�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COIvIMENCEMENT. RENOVATIONS MAY REQUIRE 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 Department prior to opening. POOL WAT'ER TEST'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 estabGshment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters witivn the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service AppGcation 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 resuks 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 ofHealth. OUTDOOR COOHING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishment is pro6ibited. DATE:/ � SIGNATURE: PR1NT NAME& TITLE: �2CU,f<t jJ �• �ill2/,Ji.`.,� V ti 10/22/04 �2 eJ/��ir/� , t Pa9� 1 of 2 BRANITE STATE SNSURANCE WMGANY WORKER8' COMPENSATION INSURANCE AUDIT ADVICE 70 PIt+tE STREET • EXECUTIVE OFFICES, NEW YORK, NY 14270 INSURED �IARDINO'S TASTEE TOMER INC POLICY PERIOD FROM: os/oe/oa TO: oe/ot/os 942 MAIH STRECT RT 48 MEST YNIMOL7TH, MA 02673-0000 AUDIT PERIOD FRC)M: 08/otl0� TO: oe/o1/oa CANCELIED: PRO-RATA PRODUCER ncenCr Resouaces iNc. SHORT RATE es �ms��owaRooK slv� MAYNE, NJ 07470-7007 BUREAU !D: 00018�479 nuD+r rvPE: vouurraev FOR STATE O�: wssac�wws�tts ISSUE DATE: tt/9o/oa DIVISION: BRANCH: P LICY No TYPE OF ADJUSTMENT: 013 VARSIPPANY � 784-33-18 __ _ FINAL- -------"-"'---_-'-"' .—' _ 013-84-9803-00 --- DESCRIP710N CODE EXPOSURE RATE PREMIUM ----- �--- PERIOD: 06/O1/03 - 08/01/04 ranr:Nc oRouP: 000i-oa �oc No 000� GIARDIND'S TASTEE 70MER INC 2�3 MAIN STREET RT 28 ME5T YARMOUTH, MA 02673-0000 CLERICAL OFFSCE EMPLOYEES NDC 8810 81,500 0. 19 747 � RESTAURANT NOC Y07Y 293,233 4. 15 4,588 TOTAL CLASSIFICATION PREMIUM ♦,7g2 TOTAL FOR fiPLIT PERI00: 08/C7/03 - 08/01/04 TOTAL CLASSIFICA4YOIJ PREMIINA 4,732 TOTAL UNADDIfIED PREMIUM 4,7gg EXPERIENCE PREMIUM (ACTUAL) 0.88 88Y8 -521 IIOOSFYED 5TAIOARD PREM2UM ♦,�� THI$ IS N17T A BILL WC990613 (Ed. 4-97) INRI)RFf1'S COPV TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #OS-089 FEE: $150.00 Iu accordance with reQulations promulgated tmder authority of Chspter 94,Section 305A and Chapter 111,Section 5 of the�ieneral Laws,a permit is hereby gianted to: Giardino's Tastee Tower Inc. 242 Route 28 West Yazmou MA Whose place of business is: Giazdinds Familv Restaurant Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit e�cpires: December 31 2005 BOARD oF I IF.nI.TH: Bwcfaari�c `.?5. (�'oarloa,�$,, SEA1'ING: 241 t0181 (94-bar&lounge; �1¢t¢ry/f7�� 7/�e1� 58-rear dining room;89-front dinin8 room) /lo�� B�oawg �e3� �l�c Sl�i R./{�. y4.u� lf�u�. RrV. January27.2005 Bruce G. Mucphy, ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-060 FEE: $50.00. This is to Certify that Giardino's Tastee Tower Inc. d/b/a Giazdinds Familv Restaurant _ _ 242 Route 28 West Yarmouth,MA IS HEREBY GRANT'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-Srst 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecring the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Be�ywxi�s `15. (�'o+�do�,/19`.IS. ' sEq7�i�tc: 241 total (94-bar&lounge; p�,��f+ff�� Q/��yuk 58-rear dining room;89-front dining room) /jp�k�. B�y� � � � R.M. ��j , R.N. January 27,2005 Bmce G.M�uphy H,RS.,CHO Director of Health '' '' �'Rc83 .. �'i��D�___�s.-"1 ,;�r o`'Yr°ay T/JWN OF YAIiMOUTH BO�2 TH 3r = APPLICAT'ION Ft?R LICEiVSE7P T-2004 Na V � � 2Q03 rC��;s , * Please camplete farm and attach a1i necessary docurnents by Dece � , ��'T• Failure to do so will result in the return of your agplication packet. NAMF. (7FRfiTARt,tSHMF.NT_ lA-l�,bi�. o ,s f'FF�+n � L IQ�ST_ T�L. # .S'0�- 7750333 1 (1(' TION ADDRFSS• 25�Z M:A�i n� c i i,� .�/�}2�u�Trt 1!- n 21.,7 3 MAI IN DRF R• SA-r^ t-c OWNERICORPC?RATION NAME• t i /d-n..A t n's �yLnNAG R°�S NAME• TEL # Sa$-7�S-a333 MAit IN r A DRFSS� , , �..�,�� POOL CERTIIICATIONS: The pool supervisor mast be certified �s a Poal Operatar,as required by State law. Please list the designated Pool Operator(s)and attach a copy�f the ceriification to ih:s focm. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiapulmonary Resuscitation (CI'R}. Please Lst these employees below and attach copies of amployee certifications to this forzn. The Health Department wif! not uss past years' records, You must provide new copies and maintain a Cle at your place of business. 1. 2. 3. 4• FOOb PRO"TGCTION MANAGERS - CERTIFICATIONS• All food service establishmenis aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the Skate Sanitary Code for Food Service Establishments, 105 CMR 590.000, Please attach capies of certificatian to this application. T'he Health t}epartment wiIt not use past years' records. You musk provide new copies and mainkain a file at your establishmenk. 1. 14/J'2.r' .�, G a fi-2 �t� 0 2. PERSON IN�HARGE: _ ._ _ _ _ _ _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2• H�L,Mj,ICH CERTL�"ICATiON4- All food service establishments with 25 seats or more must have ai least one employee trained in the l�Ieimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokrng procedures below and attach copies af emptoyce certifications to this form. The Health Department wili nat nse past years' recards. You must provide aew cppies and maintain a file at ynur place of business. 1./6m (�r� /ka�+� �1 0 2. 3.�`DwRat� A-� frr /+�. r) in16 4. RFSTAURANT S_�ATING: TOTAL # OFFICE USE QNLY LUDG[NG: LICENSE REQUIRED FEE PERMIT# LICHNSE REQUIRGD PEE PBRMIT M LICENSE REQUIREU FEE PERMIT N _B&B $50 _CARIN S50 _MOTEL S50 _INN S56 _CAMP Si0 _ _SWIMMING POGi,S75ea. _LODGE $SQ �TRAiLERPARK S50 �WHtRL.POpi. S75ea FpOD SERVICE: LICENSE REQUIRED PEE PEAMIT# UCENSE REQUIRED FEE PGRMIT k LICENSE REQ(JIRED FEF, P6RM(T H __0-IWSEATS E75 _CONTINENTAL $30 _ ,NUN-PROFIT S25 �>I00 SEATS $l50 '1I Dy-08S LCOMM4N ViCT. S50 6'{-ba$ _WHOLESALE S75 RETAIL SERV(CE� LtCENSE REQUIRED F8E PERMIT# LICENSE RGQUIRED FEE PERM17'# L[CGNSE REQUtRGD FEE PERMiT f! _<50 sq.ft. $q5 �>25,000 sy.Il. $200 ` _VGNDlNG-F(�D S20 _<Z5,000 sq.ft. S75 �PROZEN DIiSS1iR'1' S35 _TqUACCO $25 � rvamE cHatv� : Sio AMOUNT DUE _ $ ZA6.00 *•«"*pLEASE TURN OVER AND CUMPI,ETE OTHER SIpE OF 1�ORM"•""" 't. y i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now requireci 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 Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � V WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS 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 r POOLS �___ _. __. POOL OPEIYING: All swimming,wading and whirlpools which have been closed for the season must be inspeeted 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 CONS iMF.R VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF.RNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Heaith Department. �RQ��F 33ESS�RT5:_ _ — Frozen desserts must be tested on a monthly basis by a State ceRified 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. OiJTSIDE Cr�FEC• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE:�/��G ' a � SIGNATURL: i��'�� PRINT NAME&TITLE: /L�.C< � ur R f�- lr 2,�i"'� �` i 10/22/03 ti S � ' � • • � � GRANITE. STATE INSURANCE COMPANY 73619-0000 WC 13102• ,� 782-43-i ------------------------------------------- 013-82-0803-00 . PENNSYLVANIA . • . ...• . . . GIARDINO'S TASTEE TOWER INC 242 MA I N STREET RT 28 �� Member Companies of WEST YARMOUTH, MA 02673-0000 American International Group ' � EXECUTNE OFFICES: 70 PINE STREET, NEW VORK N.Y. 70270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# � , -t;v. -: �,�y� . '� `. WORKERS COMPENSATION AND EMPLOYERS �# � �� E� LIABILITY POLICY INFORMATION PAGE �� 1� INSURED IS aREV10U5 POLICY�NUMBER CORPORATION RENEWAL 00 36 140 OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRE55 SCHEDULE - WC 0610 ffEM 7 POLICV PEHIOD 72:01 AM.standard lime at the Insure0's e mallingadd�asa fNOM QO��3 TO� �8��0�{ rr�M3 p. Workers Compensatioo Insurance: Part One of the policy applies to the Workers Compensation Law of the statas listed here: .. .,r._ . .. . . . . :.Mk. ' ' . . _. ,- _ 8. Employen Lisbility InBunnce:�Part Two��of the policy applies to the work In each stete,listed in item 3Ar � , ; � -- Tho limits.of�.our liabbily under,Pak Two bre: � � �Bodily In�ury�by Aceident S - � 100.000 eacfi 8ccident -� Bodily In�ury by Diseese S 500.000 poticy Iimit Bodily Injury by Diseasa S 100.000 each employee C. Other States Insuronee: Part Three of the policy applies to the atates, if any, IisMtl hare: AK AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI i�M a The premium for this policy will be detarmined by our Manuals of Rules, Classiflcatlons, Rates and Rating Plans. Ali fnformaHon �equired below is subject to ve�ificaUon and change bV audit. - EstlmaleC Total pete Ver Estimatatl qaesliiptions � CotleNumber pomunawtlon =�OOOFNtr Premium � ❑� Mnual ❑3 Yaar munentbn� �M��e ❑3 Yw SEE El(TENSION Of INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $212 IXPENSECON$TAMaIXCEPTWHENEAVPLICABLEBYSTAiE) $zI�IF M/� . MINIMUM PNEMIUM - SZ f�' M(� � ' �• � ' � Tp7qLFbillpq7ED PNEMIUM 54 8(��i II indiu�eE below,mterim adjustments of premium shall bc matle: ' � � '� �-� . .. . . .... . .. . . . . � S�mi-Annually � Quarterly � Monthly DEPOSR VREMIUM ENOORSEMENTS�FOIBANUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 06/1 1/03 PARS I PPANY $Z ' A � c� � lasue Date luying OHbe �Native yy�pp 00 0 38967 TOWN OF YARMdIITH BQARD QF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NCTMBER: #Q4-038 FEE: 154.OQ In accordance wiih re ations gromttlgated uncler suthority of Chapter 94,Sectiou 305A and ChapTer I I I,Sectioa 5 of the Laws,e penmt is hereby granted to: Giardino's Tastee Tower Inc. 242 Route 28 West Yarmouth MA Whose piace of business is: Giardinds Familv Restaurant Type of business: Food Service To operate a foad estabGshment in: Town ofYarmouth Pernut expires: December 31 20Q4 aonrcn aF�u.1�: 8��.6. lj�,da�,M.�., • sEa'tnac3: 2di Wtai (94-bar 8c Iounge; l�d`e3/�i�o�ls3ixo� �/fc�es e�iupwl�►iwrc+c 58-rear dining room;89-frant din'sng room? R��IDoavr., ��1r�a � a�v. Llecember 2,20p3 ��.��, s.,cxa ��o�x�rn 'THE COMMONWEALTH OF MASSACHiTSETT5 TOWN OT� YARMOUTH PE;RMIT'NtIMBER: #Q4-028 FEE: $50.00 This is to Certify that Giazdinds Tastee Tower Lnc. d/b/a Giardino's Family Restaurant 242 Ronte 2$, West Yarmouth, MA IS HERF.BY GRAN1'F.D A COMMf3N VICT€TALLEl2'S LICEIYSE In said Town of Xarmouth and at that p3a.ce only andexpires December thirty-first 200A unless sooner suspended or revoked for violation nf the laws of the Commonwealth respecking the licensing of camman vichaaller's. This ficense is issued in conforiruty with the authority granted to the licensing authorities by General Laws, Chagter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their offici�l signatures. BOARn oF HEAAI.:TH: ,8�Z',. Cfw�darr,M.2. • SEn7TNc: 241 total (94-bar c�lovnge; Q�J�a.�a3#NA�� licts��f6��YI►[G�L 58-rear diniog room;89-&ont dining room) Rodra��. B3�+uwty �.,(i�b� �./y. Deceuit�a 2� G. M , .,CHO " [3irector of Heat {r � G1HR�IN05 . of f a.� rawiv oF Y�ovTx soa��Tx t-- _, wv 3; � APPLICATION FOR LICENSE/P '� 003 � � ' " � J ��'� ;; * 6 � �'� '��0i 2 - 2CO2 * Please complete form and attach all necessary� s by Decem 31, 2QQ2. FaiIure to do so will result in the reNcun a your application pack t.HE�`r�; C:=i'?, NAME OF ST i FNT• A a D t..a =�f O - � -^O 3.T� LO[�ATIOI�T DD F S o�,�>z. /7'A .�i �T' o� � �.t/��Ly/�•t+4!Ju/i��d".�'_j J 9u{ OWNER1Cf7R�,'ORATION NAME• G/A.�lJi�+�` �9-rtc'P � �'/r/ �- T��A TA,C' ,.RI',,,�,� 'S I�?AA�F.: ,Q w /�� /�. �r 9QD/.�✓J T.�l „_ TEL. #.�P��Sl<-�I S`�� AtArrrt�rn_ Anr�u�GS' --- - pooL c�xTlFrcATtoNs: The poal supervisor muet be certitied as a Pool Oper�tor,as required by State law. Please list the designated Poat �perator{s}and-attach a copy af the certification to this form. 1. �. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Cammunity Cardiopulmonary Resusciiatian(CFR). Please list these emptoyees below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. You must provide aew copies aad maintain a fiie at yanr ptace af business. I. 2. 3. `�• FOOD PROTE�TION MANAt'�PRS -t'FRTLFICATTONS� All food service establishments are required ta have at least one full-tirne emplayee who is certified as a Food Pratecdon Manager, as defined in the State Sanitary Code for Food Service Establishznents, ]OS CNiR 540.Od0. Please attach copies of certification to this application. The Health Department will not use past years' rec+ards. Yoa must provide aew copies and maintain a file at your establishment. 1. ��2 .�- �9-i/�/L C)d n.a 2. _._ _ • _.. _ Each food establishment must haue at least one Person In Charge (PIC) on site during hours of operatian. 1. ��Gva-n.-�f �-�.9ri /�i.�•� 2. �1,il.r�7� ��,r1'�9�rc a, � DN�J" �r�/}�D n.�,9 ��Yn� G,��nOrv I IICH EC RTI�'ICATi�OIVS All food service establishments with 25 seats or more must haue at least one employee trained in the Heirnlich Manenver on the premises at all times. Please list yaur empioyees trained in anti-chakmg pracedures below and attach capies of ernployee certifications to this form. The Health Deparhnent wiil not use past years° records. You must provide new copi+es and maintain s file at yonr place of business. 1. �Orr��.D 6�. (!�/��.WJNC� 2. /`?,f,,��t/ ,� t�ri�+�d?i*.va 3. �'tlatrn.r n` .pa0i�a 4. RRRTAU ANT SEATIlVG: TOTAL# OFFICE USE ONLY T OD('IN(�: LICENSE REQUtREll FEE PERMtT# LICF,NSE REQUIREII FEE PERMIT ti LICENSE REQUtRBD fEE PERMIT# B&& S30 CABIN $4Q _MQTEL S30 INN $50 CAMP 5S0 _SWR4MING POUL$S�a _I,ODGE $50 _'1'RAILER PARK $SO _WII[ItI.P()OL $25ea FOOD SERVICE: LICENSE REQLIIRELi FEE PERMIT# LiCENSE REQtJIRBD FF.E PERMIT# LICENSE REQUIRLD FEE PERMIT# _0-(00 SEATS $7S __ _CON'I'INENTAL $30 , `NON-PRQFIT $25 4 >100SEATS Si54 �'a3-ygy 1 C'OMMONViC2'. S50 �'� _WHOLESALE $?5 �FT,� RVICE: LICENSE REQUIREp FEE PERMIT# LIC6NSE REQUIREll FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _{25,000 sq.1�. $75 _TOBACCO $20 <50 sq.ft. $45 _>25,600 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $EO AMOUNT DUE _ $ 2.a0��O •**'*PLEASE TURN O'VER AND COMPLETE OTHER SIDE OF FORM*`k'* . . 'r'ti.Y . . � lw i . ADMINISTRATION ' Under Chapter 152, Section 25C, Suhsection 6,the Town of I'armouth is now required to hold issuance or renewal of any license or permit to operate a bnsiness if a person or campany does not have a Certifieate of Worker's Compensation Insurance. TIIE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETEI3 AND SIGiVED, OR CERT. OF INSURANCE ATTACHEL' � � WORKER'3 CC?MP. AFFII�AVIT SICZNED AND ATTACHED Town of Yannouth taxes and tians must be paid pnor to renewal or issuance of your permits. PLEASE CHECK APPFCOPRIATELY IF PAID: YES � NO NOTICE:Permits run annuaily fmm January i to December 31. IT iS Y4UR RESPONSIBILITY TO RETI3RN THE COMPLETED APPLICATION(S)AND REQUIREI7 FEE(S)BY DBCEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TQ CONTACT THE HEALTH DEPARTM}:iNT F012 INSPEGTTt}N 7-14 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIC7NS TO ANY FQOI3 ESTABL3SHMENT, MQTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD QF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RFGLJLATIOrTS POOLS POOL OPENING;All swimming,wading and whirlpools which have been closed for the season rnust be inspected by the Fiealth L)epartment priar ta apensng. POOL WATER TESTING: The water must be tested far pseudomanas,taEai oaliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL GLOSING: Every outdoor in ground swirnming pool must be drained or covered within seven(7) days of elosing. FOOD SERVICE C4N'�UMER A1�VISt3RY- Each f`ood establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �ATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. 1'hses forms can be obtained at the Health Department. I�RQZEN DESSEBT5: Frozen ctesserts mu�t be tested on a monthly basis by a State certified lab. Test results musi be sent to the Health Departmeni. Failure to do so 4vill result in the suspension or revocarion af your Frozen Dessert Permit untii the above terms have been rnet. �7UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. OUTDO4R COOHING: Qutdoor caaking,pregaratian,or dispiay of any food product by a retail ar faad service establishment is prohibited. �A�r�:/1-��r-- D ,2 SI�NATU�:__��,�.��:��1/ /��%�;� Y�- . PRINT NAME 8t TI7'LE: �q��i�jr�lio„a �7/t-- P2�1,O�,,JI 14118l02 GRANISE STATE INSURANCE COMPANY � 736�9-000o WC 536-51-4p ' 13102 � ---------------------------____._--------- , � 013-82-0802-00 PENNSYLYANIA G I ARD I NO'5 TASTE E Tp�IER I NC � �g�et��5 Qf 242 MAfN STREET RT 2i� WEST YARMOUTH, MA 02073-o0p0 Americ8n Intematlonal Group EXECU7NE dFFlCE6: 70 %NE STREET. NEW YORK, N,Y. 50270 SEE NAME ANd AOpRF55 SCHEDULE - NC990b10 I.D;Y ' ..,,__ _.,BTFiEET E : W{tRKERS C014{PENSATiON At�D EMPLOYERS �£-� . �„�� LIA8iLl1'Y POUCY INFORMATIdIN PAGE ►�< " ,�� tORuPORAT$i0N .,vvV,V_�.;,iiE�� — OTHER WORKpLACE8 Np7 SNOWM AaQYE:SE NAME AND ADDRESS SCNEDULE - NC 0614 Rdt Y P4i.iCV POFIOD tY:6t AM.Mt�nAMM qms�t tM Inwr+dY """'"O+d°'°" F�o►+ 0810�Jo2 �o a8ta�to3 �+' A. Worlun Compensetion Inw�ancs: Part On� oi tfie poliry applfq to tha Workara GompsnsaUon Lew of ths stetss lisntl h�M: MA �. Eropioyrn Li�bility Inourmca: Part?wp of Ms pDlfcV appll�s to the work In eylch s#ats Ilsbd in Hpm 3.A. Ths limtn ot our 1ia411tty unMr Part Two ue; Opd��Y Mjury by AcCidsnt f 180{OOd wch udd�nt ladlly InJury by DlsNss • 500.Q00 pollcy llmR 6odily in�ury by DltMse t 100.000 yCh amployM C. trtpar Strta Msurance: sart Three ot ths po�iry tppiim to ths siatsc. N NnV. Iistad here: AK AL AR AZ CO CT QC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NG NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI �< Ths promWm for tAis policy will be daarrnbrod by pur M�rtu�ls ot RuMs, Cfasslfl+ertians. RMes and 11�tkey� Plses. AN ioformeNan regutrod bsiow is suis�sct to vaiRc�tion md cha�s by audk. EotlrtM/fETatat Rata4ar Eftimatatl Classllic�tionc Cotl�Numb�r ��^0^�� on j��pe. Rsmlum � AnrtY�t 3 Ypr muMMtbn x AnnuN 3 Yqr SEE fXTEN510N QP ItIfQRMA71pN PAGE - WG7754 TAXES/ASSESSMENTS/5URCHARGES $238 E%PEN6E CpNSTANT(E%CBiT WHERE APPLICABLE BY STATl) 244 hA wima�uaevxeexw+ $219 MA rora.esnFa�nn�w� �5.435 It ivdic�t�tl bplow, ints�im adjuc�m�nts ol O�emium ab�ll 6�m�dl: � S�.nr-Fnnu��ry � Gu�tlarty � Montnry DEip61T RIRMIVM ENDORSH111EM'$(FpqMINUMBEP) 5EE ATTAGH£U fQRM SCNEDUIE - WC990612 p$/12/Q2 PARSIPPANY 82 �..��o,�. iuui�w amw rwteauad newe�•macnre wc oo tw o� auas� 1NSURED'S COPY • r PAGE 1 - ENDORSEMENT This endorsement, sffective t2:07 AM 08/Oi/2002 Forms a pert of poliCy no.: NC 536-5�-40 tssued ta: G�ARD i NO'S 7ASTE E TOWf R t NC By: GRANITE STATE INSURANCE CO�iPANY lOC NO. NAME AND ADDRESS SCFMEDULE FEIN UI # �001 GIARDtNO`S TASTEE TO ER INC 242 riAlk STREET RT 2� Wf5T YpRMOUTH, nn oa673-aooa lssue Qats: 48/T 2l02 Authorized Rspresentative WC9g46t4(Ed �•87} 1NSURED'S COPV TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #03-068 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 ofthe General Laws,a permit is 6ereby granted to: Giardino's Tastee Tower, 242 Route 28, West Yarmouth, MA Whose place of business is: Giardino's Tastee Tower Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�ires: December 31. 2003 aonxn oF�n[.'['x: �a�lia:f� zdU�Ea�, � SEATING: 241 tOt81 (94-bar&lounge; �a�D. �.��ilC.D.. ?/rce 58-rear dining room;89-front dining room) R '�. �reaew, � �tt��ctnretE �fe[e Sk � ,�7Z. December 18 ,2002 ruce G.Murp y, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NZJMBER: #03-044 FEE: $50.00 This is to Certify that Giardino's Tastee Tower Ina d/b/a Giardino's Tastee Tower 242 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only andexpires December thirty-first 2003 unless . -- sooner suspended br�evoked for vialatiasafth�laws ofthe Goum►o�vealth respecting th� — - _- licensing of common victualler's. Tlvs license is issued in conformity with the authority granted to the Hcensing authorities by Ge�ra1 Laws, Chapter 140, and amemdments thereto. In Testimony Whereo�the undersigned have hereunto affixed theu official signatures. BOARD OF YEALTH: (�a3lea'ri�. ,'��G4a�, �kaa�a.r Ssa'r¢�rG: 241 tofal (94-bar 8c lounge; �u ya.,�D. � �1C.D.. 9/ue 58-rear dining raom;89-fronk d'wing room) �aBext'�. �teaMc, (,l�at� �adKek�DauxotY � � December 18 ,2002 ruce . Y, A, • Director of Health • 1 �� G�Q2DiNo s TOWN� ARD OF HEALTA APPLIC;�, I � SE/PERMIT-2002 � �, ,ti ��, I 4 " �j � G� C� C_ * Please complete form and attach all necessary documents by December 31, 2001. Failu e tc�►�scQ�ll�plt i the return of your application packet. � �,�aa y�r2ao- o v ME ESTABLISHMENT: -r � v-wrti TEL. # 9 —O� LOCATION ADD FSS: a�foL. 2ac. y'C oZ� wc�T /✓92.�euT/t /JA �yl6 J� MAILING ADDRESS� ��^� l ' WN H� MANAGER'S NAME• /�1/1 /�/) �siR20i.�J lT� TEL # � �.?�� I�AILINGADDRESS• I:oM�P POO RT FI ATION�: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safery, standazd First Aid and Community Cazdiopulmonary 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 - 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 applicarion. The Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your establishment. 1. �� rAa/liNd 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1��'1 G, �tit�/�-'J 2. �O� �ri 9nQ/,t,t7 HEIMLICH CERTIFICATION : 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 yow employees trained in anti-choking procedures below and attach copies of employee certificafions to this form. The Health Department will not use past years' records. Yo ust provide new copi and maintain a file at your place of business. 1 Sfl �fAti�,�� z. , 4. RESTAURANT SEATIN : TOTAL#�L Lonc�xc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN S50 _MOTEL $50 _INN $50� _CAMP $50 _SW[MMING POOL$SOea _LODGE $50 _TRAILER PARK �50 _WHIRLPOOL $25ea FOOD SERVI('F. LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 I >100 SEATS $150 �'Q�-D�j,s I COMMON VICT. $50 0 -0 _WHOLESALE $75 RETAIL RVI LICENSE REQUIRED FEE PERM[T# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<Z5,000 sq.ft. $75 _TOBACCO $20 _�50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANCF� g�p AMOUNTDUE _ $ 200.00 ":*•"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM «..:. .# ._ ADMINISTI2ATION Under Chapter 152, Seotion 25C, Subsection 6,the Town af 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. TfIE ATTACHED STATE WOI2KER'S C4MPENSATION INSU12A1�CE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSLTRANCE ATTACHED� � WORKER'S Ct�MP. AFFIDAVIT SIGNED A1VB AT'I'ACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuancc of your pertnits. PLEASE CHECK APPROPRIA'I'ELY IF PAID: YES NO NOTICE:Pernuts run annually from January 1 to December 3 3. IT IS YOUR RESPONSIBILTI'Y TO I2ETIJRN THE COMPLETED APPLICA'TIQN{S)AND RFQUIRED FEE{S}BY DECBMBER 31,20Q1, SEASONAL BSTABLISHMEN`T'S ARE TO CONTACT'I'[-IE HEALTH DEPAR`I'MENT POR INSPBCTION 7-10 I7AI'S PRIdR TQ{JPENING FC7R THE SEASC3N. ALL RENOVATIONS Tp ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MUST BE REPORTED`I'd AND APPROVEI7 BX THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. I2ENQVATTONS MAY REQUIRE A SITE PLAN. AI}DITICf11iAL REGULATI4IYS POOLS POQL OPENIPTG:All swimming,wading and whirlpools which have been closed far the sea+on must be inspected by tha 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 quarteriy thereafter. POOL CLOSING: Every outdoor in ground switnming gool must be cirained or covered within seven{7}days of closing. FOOD SERVICE CONSUMER ADVISORY: Each foad establishment which serves or seils ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmauth must natify the Yazmouth Health I}eparUnent by filing the reyuired Temporary Food Service Application form 72 hours prior to the catered event. Thses farms can be obtained at the Health I�epartment. - — _ _ __ __ __ FROZEN DESSERTS: Frazen desserts must be tested on a monthly basis by a State certified lab. Test results tnust be sent to the Health Department. Failure ta do so will result in the suspensian or revocation af your Frozen DesserC Permit until the above terms have been met. OUTSIDE CAF�S: (Jutside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior approval&om the Board of Health. QUTDOOR COOKING• Qutdaor cooking,preparation,or display of any food prodnct by a retaii or food service eskablishment is prohibited. DATE:��SIGNATCJRE: PRINT NAME& TITLE: -� G� n ..��i�i a ,� n 09/11/Ol � The Commonwea/th ojMassachusetls � Depar�ment ojlndusiria/.-lccidexls o OJllte o/ler�rstl�stlsrs " 6Qo washingron srrerr > Baston,Maxs. 02111 " W'orkers' Compensation insurance Affidavit Agplicant information: Ple�seFR�� „ms G,�� o .� J :. 7`f,-� .� ,�`o�.-.�.,-� it,�,,;�,n �y� Rv,,c7�n _ v��f- Gc��.�i"" /.>�. ..�'�u�`id�, '7/� d"�6�_l -� t� �� oi+one a / ?J ��,.�-� 0 I am a homeoµner pznorming all work m}self. 0 I am a spiz proprieror =cd ha�e no one��orkin� in am' capacitc �am an emplo�er pro�idins µorkers' compensation for my employees workine on this job. coL�an� na�nr �/��°'�^'N C. �� -. .. aJdrecS: �� "� "`✓�'f) G- h /� yIl/C// /S lY�G L'�/9/1^ - / "�;/�/ Sj,i,y:;�/4��oIZ d� (Y y ' '/� ehone q• i ran e N �/�' �'� � W � � �� `� ( � I am a sole proprietor. qmeral convactor.or homeoµner f irrle arrU and hace hired the contractore listed 6elow l�ho ha�e the (oilo«in2 «ori:er> compensation polices: companv n mr � — addres«� ��• ohone N• ins r�ncc co Ji��t�'� comnanv name• - � . . __ . .. . . __ . . _..._ . . ...-- -- �--.— _ . . . .._._ - __ _--. ._ . addre � �y: ohoee M� iII3' " oolierM t Failurc ro secure coven�t u�rqulrtd un4v Secaoe 25A af MGL IS2 a�iatd to Me inporitlw ottridW!pe�dtla af a pae ap to S1,SOO.AD tullw oee years'imprisortment ie xdi as ririi pco�itla io t6e form of�STOP WORK ORDER�ad�iiet of SI00.00 M d�r Kaimt ma 1��denn�d bat a eopy of tAia sneemem mty be lonv�rded ro the ORce ot Iorc�tig�tlum otMe DIA Cor eorera6t rerilfutfe�, /da�hrreby ceni p under rhe parn a ptey�res ojperjary t�{rhe rnjarenatlon pravidtd above is 7ne and carrtcY. s�gn�cure ��w`��;��Q,r' m� �1 `�l' �� Print name � 1.C/�/t-/7 � CJ�/+9sc d/Mt �'� Phmx N / 'T�>� .. alTicia!use ont. do not+.�itr in this fm ta tx tompkted by city ar town oflftial airy ar town: ��Q� permivTiernu a nBuiidiog Oepartmeo� [�Lieemieg Board Q chrek if immrdiitt respanx is required Z61 pSe�a�mrn'�Oflfce {5�8 pHealm Depenmeat conrsct psrson: phone M;_ �� 3g��31 eat. nOther � N(JTICE NOTICE TO TO EMPLOYEES ` �MPLOYEES The Cammonwealth of l�iassachusetts DEPARTMENT fJF INDUSTRIAL A�+CIUENTS 64Q Washington Street, Bast+�n Massachusetts 02111 617-'727-4900 ,4s required by Massachusetts General Law, Chapter 152, Sections 21,22 3p,this will g�ve yau notice that 1 (we}ha�e provided for paymemt to our injured emplo}ees under t�e atwve mentianed chapter by insuring with: Eastern Casaalty Insurance Company (Name of Insurance Campany) 32S Danald J, Lynch Blvd., Msriborough, MA 01752 (Address of Insurance Company) WC79 3143fli 08-41-20Qi TO 48-01-20!}2 (Palicy Number) (E£fective Dates) Germani Iusarance Agency 908 Main Street,Qstervilie, MA U2655 {S08} 428-9194 (Name of Insurance Age�t,Address,Phone} Giardino's Tastee Tower, Inc. 242 Main Street, Roure 28, West Yarmouth,MA Q2673 (Ernpioyar,Address) Emplo��ets tiYorker's ComgensaCiQn Of1'ecer(If Any) (L7ate) MEDI AL TREATMENT Thc above uamed insurer is reqaired ia cases of personal ia}nrzes arising ont of and in t6e course of emplayment to fnrnish adequate and reasonable hosp3tal and medical services irx aecordance with the pravisions of the Worker's Compensation Act. A capy of the First Repart of Inquiry must be given to the injured empiayee.The emgloyee most select his or her own physician.The reasonabie cost of the services provided by the treating physician will be paid by insurer,if the treatment is necessary and reasonablv cannected to the work related injury. In cases reguiring hospital attention,employecs are hereby notified t6at the insurer 6as arranged for socb attention af tiee (Name ufHospi4al��^ (�lddress) Tt3 BE P(�STED BY EMPLOYER WC 750tie(Ed, I-$4} . . . TOWN OF YARMOUTH B(7ARD OF HEALTH PERMIT TO CIPERATE A FCIOD ESTABLISHMEIVT PERMITNtJMB�R: #02-035 FEE: $ISO.Op In accordance wiih regulationspromulgated imder attthority of Chapter 94,Section 305A and Chapter 1 f I,Section 5 of tlre Gc�eral Laws,a permik is hereby granted ta: ('.iardinn's'j'astee Tow�, ?4? R� in �tr IM in 4treet u7P�e Ya,�.,,nnt(y MA Whose place of business is: aardinda Tasree'1'ower 'Type of business: Food Se^�ice To operate a food establishment in: Town of Yannouth Permit expires: Decpmber 31. 2002 BonRD oF HEAI.TH: �,lu�rlea'r"3�• Z'e�el. �at�uxa� sca�t�tc: 241 total (94-baz&lounge; `z�j`��D• �1�� •• '�� 58-rear dining roum;89-front dining room) +��"+'�� '�- � �d�t�c�ounwt8 '7fePe�c .Skak, r'�.�1 Februazv 20 ,2002 _ Bruce G.Marphy,MP R. ,CRO Llirector af Health T�con�nvzarlwEai..zz�aF lvussAc�s��r�rs TOW1H OF YAItMQUTH PERA�IIT NUMBER: #d2-018 �� This is to Certify that Gi�rdino's Tastee Tower 24 Main 4tree1/Route 2R West Yarmouth MA IS HEREBY GRANTED A COMMOIY VIG i'UALLER'S LICENS� In said Town of Yarmauth and at that place anly and expires I?ecember thirry-first 2002 unless sooner suspended or revoked for violation of the laws of the Comrnonwealth respecting the licen.sing of cammon victuatler's. 'Phis ticense is issued in conformity with the authanty granted to the licernsing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �,kwrEes'r3� x'eP�eic. �iFatnmxaw s�r,r,�: 2a 1 cow� (Qn-bar��ow,ge; �e+C�z�C D. �da+�. 71L.D.. `��ce 58-reaz dining runm;89-frant dining room) �o�art� S�roawr, (�,faxk �at7tic�'�.�a�ouoLl .S' �� Februatv 20 ,20Q2 -. Etruce G. Murph ,MP . HO Directar of HeatHr . . ; � ,, . . �� . �. Tawiv o�Y��ourx so ��,�Tx DEC 2 6 Z000 APPLICATIOTV FOR LICEA��I�IZMIT:-2001 HEALTH DEPT. • Please complete form and attach a!1 necessary documents by December 31,244U. Fa+lure to da so will result in tha return of yoixr application packet. _____________.._________.__________aM---__�__________________-_---_`--______ ----------__.._____________---__ t. .0 '.77J=0s'�� J'^ ,�Z IYI�ii ING ADj�RF� C�.¢,a r MANAGEIt'�N MF- ,,,f'�!1 ��stn0in�� TF�. # f'- Y � M,4ii�i D F4S• �Y 7"/I<l v a n at' .�'�T/� w �/ 2 -- _ ----------------------------^-------------------^----------- � PQOL S"�,,'�'jCATIONS: The pool supervisor mast be certixied as a Pool Operator, as required by new State Iaw. Piease list the designated Pov2 Operatar(s}and attach a eopy of the cectifieation to this form. ---._ _- -- -- — -- _ _ i. 2. Pool operatars must Iist a minimum of two eraployees currenUy certified in basic water safety, staudard First Aid and Comm�nity Cardiopulmanary Resuscitation(CPR}. Please list these emgloyees below and attach cogies of employee certificatians to this form. T6e Health Depariment will not use past years' records. You must provide new eopies and maintain a fite at your piace af business. T. 2• 3. 4. . i.ICFi .ERTIFIGATIOj�S: All food service establishments with 25 seats or more rnust have at least one employee t�rained in the Heirnlich A�faneuver an the premises at a1i times. Please tist your employees tcained in anti-chokrng procedures below and attach copies of employee certificationa to this form. The Health Deparlment will not uae Qast y�ars' reeorda, You must provide new copies and m$intain a file at your place of business. 1. T d G��ri a�' 2. �'al , L��2�:.Y.�; 3. 4• REBTAfJRAI�T SEATING: TdTAL#� NdN-SMCIKING SEATS: TOTAL# ;�i �-�-� -------------------------------------------------------------_--__._--------------------------_._____------------------------ LODGING: G�CE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQLIIIZEI} FEE PERMIT# B&H $50 CABIN $54 _INN $50 �CAMP $50 �L4DGE $50 �'TRAILER PARK $50 �MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. �OOD 5ERVICE: � NOTE: Per khe new 105 CMR 590.I100 State Sanitary Code for Food Establishments, the effective date for food prnteetioa man�ger certificatiao is OcWber 1,2diF3. LICENSE REQUIRED FEE PERMIT# LICENSE REQt7IRED FEE PERMIT# _„0-100 SEATS $?5 �CONTINENTAI, $30 ! �100 SEATS $154 � NON-PROFIT $25 / COMMON VICT. $50 �Qj-OS'7 �WHOLESALE $75 BE_T�.� •R� LICENSE REQUIRED FEE PERMIT# I.ICBIVSE REQUIREU FEE PERMIT# ��50 sq.ft. $45 �TOBACCO $24 T<25,000 sc�.ft, $75 _FROZEN DESSERT $35 T>25,000 sq.ft. $20p NAMF.C�N�,� $14 AMOUNT DUE = S 2.�.Oo x""*pLEASE TURN OVER AIVD COMPLETE OTHER 3IbE OF FORM*«wR• �-___._..__ ., _ _ , . . . , E I ", ADMINISTRATION � ; ��,�-,_. •;_ , , ., ; �, UA�'�Gh�p`te�'#-5�;S€Etion 25C, Subsection 6,the Tawn of Yannouih is naw required ta hold issuance ar renewal af any license or permit to operate a basiness if a person or company does not have a Certificate of Worker's Compensation tnsurance. THE ATTACHED STATE WORKER'S COMPENSATION INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEI?,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFPIDAVTC SIGNED AiVD ATTACHED Town af Yacmouth ianes and tiens must be 'd priar ta renewai or issuance of your permits. PLEASE CHECK AP'PROPRIATELY IF PAID: �S NO N01'ICE:Permits run annually from January 1 to December 31. IT IS YOtTR RESPONSIBILITY TO RE'I'[JRN THE COMPLE"I'ED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,20(74. SEASONAL ESTABLISHMENI'S ARE TO CON'TACT THE HEALTH DEPAR17v1E;]VT pOR INSPECTION 7-10 DAY3 PRIOR TO QPEIVII�tG FC?R THE SEASt}N. ALL ItENOVAITQNS TO t1NY FOOD ESTEIBLISHMENT, MOT'EL OR POQL {i.e., PAIN'1'ING, I,TEW EQUIPMENT, BTC.}, MUST BE REPt3RTED TO ANI7 APPROVED BY TI-fE BOARI3 t3F HBALTH PRiOR TO COMMENCEMENT. RENQVATIONS MAY RF,QUIRE A SITE PLAN. ADDITION i F ITi qTIONS POOLS POOL OPENING:Ail swimming,wading and whirlpools which have been closed far the season must be inspected bY the Healtt►Department,and the water tested for pseudomonas,total coliform and standard plate count by a State certified lab,priar to o enin and quarterly thereafter. POOL CLOSING: Every outdoar in ground swimming pool rnust be drained or covered within seven(7) days of clasing. FOOD SERVICE Ni'W�TATF SANTT'ARY['nilj,' FnD �ppi�ERT CiCNMFrd'1 c The effective date for food protection manager certi5cation is October 1, 2001. As statefl in 105 CMR 590.Q43{A) 2), food establishments must have at least one person-in-charge who is a certified food protectian manager. �s pmvisian is effective one year from the date of promulgation of l OS CMR 590.000. T6e eff,ective date for consamer advisary is J$nuary i,20Q1. As stated in 145 CMR 594.OQ4(K},enfarcement af Consumer advisory,Food Code 3-Gt33.1 t,wiil be implemented January l,2Q01. Only establisl�ments which sell or serve ready-to-eat,raw or undercooked animal pmducts are required to have constunec advisories. ATFRnv� vnraCy Anyone who caters within the Town of Yarmauth must notify tha Yazmouth Health Department by fitin� the required Temporaty Food Service Application form 72 hours prior to the catered event. T'hses forcns can be abtatned at the Health Department. _ _ _ _ � •.�N DF"SSERT,S: __ -- __ _ _ . Frazen d�sserts must be tested on�monthty�asis hy a Siate certi��eci lab: Tesi results must be seni to the-Heaith Department. Failure to do so wiiT result in the suspensian or revocation of yaur Frazen Dessert Fermit until the above terms have been met. S�L-Tsill a�� Outside o es(i.e.,outdoor seating with w�aiter/waitress service),must have prior approval from the Board of Health. OC1TL100R C�C�: 4utdoar eooksng,preparaYion,or disglay of any food produat by a retail or food service establislunent is pmhibited. DATE:J� '1�-� �� SIGNATURE: Y --�G2G„�-�� PRINT NAME&TITLE:�,�1(J�A�/ �. �i/t2,�i�0 V 2 11116/00 �i2clr��,u � _ __ _ . _�.�, _.. --.._ _ __ - . � � 1 � � � The Commonwea[th nf'Mossac/rusetts s" Department of Ixdustrial rfccfdents ; Omcea//�ost/i�s d00 Washingtox Street Bosron, Masx. 02111 ` Wbrkers' Compensation Insurance Aftidavi[ Anoiicant ittformation- PitaseYRtl4TTi.�d.'hFa �7- 7—� . .,�, aamr� �t/,tr2/f/NJ i //�Ift�L'� /�`�'��'�- � IoCSlion' tX T.� l'J��K� t3,1. ""-�'��r2�x'�"L�'/ �. ...- sit�� ohone p /�/ ''�.�3� 0 1 am a homeowaer pert"orming a{t wark myself. � � I am a sole propriemr �cd harz no one «orking in am capacity [J I am an employer pro�iding workers' compensation for my employees workin¢on this job. ,.^ -�_ _..-��_ ___._ _.__ _ _ _ comnanv namr. 1 �`h �-P __ _._.._ _ ___ asldress� �tt'� ehone q• inSurance co, ooli y N � � I am a sole propriecor. oeneral contractor,or homeowner{clrcle aael and hare hired the contracion listed below u ho ha�e the follo��in�! «orkzr_�;ompensacion polices: comQanv name: addres : siiy: ohone#^ tnsuraqcc ro. pofiet�M eompany name: . ._. .- addres_c; . . ...._. _ .. _ ._. . . . .___ . . ..— _. _.. . _.__-- s1jy: phooe N: jpsuranee cp. _p.pJjty N F�ilure�o setore covengt as rcquirtd under Setnoo 25A oC MGL 152 raa Wd to tYe i�paitloa of orisiul padtla of�dee op Ro SI,500.00 a�dlor oat yeaes'imprisoamrnt n w�e0 as civiF pendtla in the form ot�SCOP WOBK ORItER a�s tine uti296.9@ a dar qaiwt�. t a�dtnta�d Nat s copy of lh'n saument msy be farw�rded to the ORce of lavarigr��am ott6a DU for eoveraga verilieario�. /do�hrreby ceriij}�under thr pains and penafties pjperjury that�ht injormallon provided abovt is twe and corred Signaturc Dme Print�ame �+one# .- o#Tiriai ust onl� do not a ritt in tt�ia arn ta 6e compttttd bp city ar towa oltieiai � tity or town: y�ODT$ _ permfVlicepx k Buildiug DeQartment � (]Liasosing Bo�rd [�ebtek it immrdiste«sponx is rcquirtd � Z61 OSdcctmen'�OtJice pHcait6 pepartment contactpersox: ppaMp�_ (SOH} 348�2231 ext. nOthcr Irane4 iA5 PMI THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O1-OS'7 FEE: $50.00 This is to Certify that Giardino's Tastee Tower 24� Main Street/Rnntr 2R West Yarmonth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirry-first 2001 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 with 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. BOARD OF HEALTH: $d�1L, �etlea, �iabr�ux searwc: 241 total (94-bar&lounge; �ta�t�P.d�, i�effil�, �/r,ce �a6toxaac 58-rear dining mom;89-front dining room) �� , �t,� �� ix March 2 ,2001 � ruce G.Murphy, H, . , O Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #O1-098 FEE: $150.00 In accordance with tegulations promul�ated under authority of Chapter 94,Section 305A and Chapter 11 I,Section 5 of the General Laws,a permit is hereby ganted to: ('.iardino'c T c Tow r 242 A�ain 4treet/A�ain 4tre CsJect Y rmnn h A�A Whose place of business is: Giazdinds Tastee Tower Type of business: Food ervice To opente a food establishment in: _ Town of Yarmouth Permit expires: December 31 2001 BOARD OF HEALTH: �d�lZ. �etl'ea, (�uor SEa.�ru�G: 241 total (94-baz&lounge; �(��L, ��y eU� �t_�� (.:� 58-rear dining room;89-front dining room) �� ad d :� D. �K.D. March 2 ,2001 ruce G.Murphy, H, .,CHO Director of Health �i C<uC�l 61C,S I Gste� 7�� V � , . `��-. Clzit-Ivlbb �2ooQ . ' TOWN OF YARMOUTH"BOARD OF HEALTH p [s (� [� Q \VJ � pD � APPLICATION FQR LTCENSE/PERMTI'- 2000 - D E C 0 1 1999 • Please complete form and attach all necessary documents by December 31, 1999. F u�i�q�dp�op��+�su in ffie return of your application packet. -- ----------------------------------------___------------_----- -- -- ---- - - -- --------------------------------� NAME OF ESTABLI�HMENT ��.9s.v�, T�1�'ce,�Owe.� TEL # 7�.T�� CATION �D F.CR �?��' � .,�y_�,L /�7.4 a� �f'�- L.i1c--.rT lfAa.t�o�y`�' NN !_ i binA T�?C �we�.. �.� C. 1VIANAGER'SN MF ,1j _� s �v # 3 fd" � MAII.,INGADDRESS� �i ?iPo.�vBR�OGC pA-f7t w�� ti�ut�h�-----a��J _- ------___--------------------- -- ----------------------� POO RTIFI ATION ----___ 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 certiScation to this form. 1. 2, Pool operators must list a minimum of two employees cunently 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 maintaia a file at your place of business. l. 2. 3. 4. HEIMLICH� .RTIFI 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 employee certifications to this form. The Heait6 Department will not use past years' records. You must provide aew copies and maintain a file at your place of business. 1._�yn (!'�,�f1.4i�u 2. /�i�/L� Cri9nDir� 3._�p G,lyitD�,� 4. RESTAURANT SEATING: TOTAL#o��o� NQN-SMOKING SEATS.-�'OTAL# ��_ — __-------------__—_---------------------------•--------------------_____—_____-------___—_ OFFICE USE ONLY LODGING• LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 TRAII�ER PARK $50 _MOTEL $50 SWIMMING POOL $SOea. _WHIRI.POOL $25ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _0-100 SEATS $75 CONTINENTAL $30 I >100 SEA�'S $150 ZK• _NON-PROFIT $25 �COMMON VICT. $50 y ZK-�Z2. WHOLESALE $75 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ 2�— "`••"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••"• ' 1 ADMINISTRATION � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQUIR�`D TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON"OB.�OMI',ANY 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 INSiJRANCE ATTACHED ✓ � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES__E�_ NO NOTICE: PERMITS RUN ANNIJALLY FROM JANLJARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILTTY TO RETURN TF� COMI'LETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COn�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DITION T n ATIONS POOLS POOL OPEIVING: ALL SWIMR�IING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIviNTING 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 NOTIF'Y Tf�YARMOUTH HEALTH DEPARTMENT BY FILING Tf� REQUIltED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI-IESE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE BEEI�MET. O TT. IDE FFS: OiJTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), M[JST HAVE PRIOR APPROVAL 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. DATE: l�� °?� � �S SIGNATURE: � �1 . � PRINT NAME& TITLE: Cu.¢.�/� /T� �//f�0/n�a �/Z iinzi99 I��O��'Z� Towiv oF Yn�aurx � sanRn aF x�az.Tx PERMIT TO C}PERATE A FOOD ESTAEtLISHMENT PERMIT NUMBER: Y2K-34 FEE: $I50.00 In accordanca with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 af the General Laws,a permit is bereby granked to: Ctiardinn t Tasiee Tower inc 2"� �"� � cr«� */tvta;n CtrnPt Wect Yarmonth MA Whose plaee of business is: Giardina's Tastee Tow�r Type of business: Food Service To operate a food establishment in: Town of Yazrnou Permit expires: D�cember 31. 2000 BOARD OF HEAL1'H:�d ��/.+.�att�g�, C'�ayt��„q��an � j J 56ATMG: 241 total (94-bar&lounge; �t�oan C�. �ru�llivan� K.Y/., Vice �h.airma SR-rear dining room;89-frnnt dining room} J/e��a�p �}fOtf/t/� C��r/� �'�J/a/)drisCla�a�oUh�/-p.Jdoo eb ///ic O au�hlin t December 6 , 19 94 ruce G. Murphy,MP , R .,CHQ Director of Heai?h O1 TfIE COMMONWEALTH OF MASSACIIUSETTS TOWN OF YARMtJUTH PERMTI'NUMBER: Y2K-22 FEE: �56.00 This is to Certify that Giazdino's Tastee Tower Lnc dlb/a Gia_rdino's T;astee Tower 4 Main Street/Route 28 W»t Varmnnth_ MA I5 HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place on3y and expires December thirty-first 200d unIess saoner suspended or revoked far violation of the laws of the Commonwealth respecting the licensing of common victualler's. 'This license is issued in confamuty with the authonty granted to the licensing authorities by General I.aws, Chagter 14Q,and amendments thereto. In Testirnony Whsreof,the undersigned have hereunto affnted their official signatures. BOARD OF HEALTH: �d {�I�.e�Qtf�da, C'�.:.,�q�.. q � 5EA7'QJG: 241 [ot31 (94-bar&IoungB; oan G. �ta�lGivan, �//.� Vice ��iairman 58-rear dining roam;$9-front dining room} �o�rart p�0 �3rou,�R,/ �le/r,� a6rveC[e sa�r/O�f�k�-.JVoo�aa �� oCo 'n December 6 , 14„29 � nice G.MuTP y,MP R CHQ � Director of Health .. � , Gcar�li ��s �'a&�� Toy.�eY TOWN OF YARMOUT$ BOAItA OF H�AL'1'I3 p � � � 0 b C� D . APPLICATION FOR LICTNS�/kE�4I'I�- 1999 ' �,�'Od DEC 1 6 1998 • Please complete form and attach all necessary documerrts by December 31, 1998. Failure o�,p. 1�1�result in the return of your application packet. nC�� n DEPT. ------------------------------------ -------�---�– ---------------- -�----------------------- -------------- TAB � �0/ � � � ?e Pti # 7 .$�03.3-? t OCATION AT,DRESS oZ�'-o� /LI/� ^� sr �^ � h' 73 MAII,ING ADDRFSS S9M �P N a L 9� C� � iv L R' N �t � o.�� L. # –C� nv �o .l a9 ---------------------------__`"--� �-- —'�°- ---------------------------------------------------------- POOL CERTIFICATIONS� The pool supervisor must be certitied as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the cerGfication to tivs form. 1. 2. Pool operaxors must list a minimum of twoemp loyees currernly certified in basic water safery, standard First Aid and Community Cazdio�uimonazy Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tivs 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. HFIMLICH 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-cholang procedures below and attach copies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a fde at your place of business. �. �� G,g�.o�N� z. f-t.�� ,�,� � 3. fi� n G��aDi.�� 4. RESTAURANT SEATING: TOTAL�y� NON-SMOKING SEATS: TOTAL#�� ------- -------_��__�—��-------------------------- _ O�FI�E U4E QNLY — LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERNIIT# B&B $50 _CABIN $50 � $50 _CAMP $50 LODGE $50 _TRAILER PARK $50 MOTEL $50 _SWIlVIlvIINGPOOL $SOea. WHIIt,LPOOL $25ea. FOOD SERVICE• LICENSE REQUIltED FEE PERMIT# LICENSE REQUIltED FEE PERNIIT # 0-100 SEATS $75 _CONTINENTAL $30 �. >I00 SEATS $150 � Z NON-PROFIT $25 � COMMON VICT. $50 qg-2o WHOLESALE $"15 RFTAII.SERVICE• LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIItED FEE PERNIIT# _<50 sq.ft. $45 _TOBACCO $20 <25,000 sq.ft. $75 FROZEN DESSERT $25 >25,000 sq.ft. $200 NAMF CHA�iGE: $10 ` AMOUNT DUE _ $ 7/�� •^R""pLEASE TURN OVER A,ND COMPLETE OTHER SIDE OF FORM•"'"" O � ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQUIltED 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 AFFIDAVTI' MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� 2 WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA}LES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK tjF�PROPRIATELY IF PAID: YES 1/ NO NOTICE. PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IB YOUR RESPON5IBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISI-IMENTS ARE TO CONTACT TI-IE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISf�vvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIIvfENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL RE TT ATION POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR Tf� SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENf, AND THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIl�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CATE TN PO I Y� ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY Tf� YARMOUTH HEALTH DEPARTMENT BY FILING TF� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TF�SE FORMS CAN BE OBTAIIVED AT TI-iE HEALTH DEPARTMENT. �'ROZEN DECSERTC� FROZEN DESSERTS MCJST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN _ 'ruF cr Tcu�IQN pR RFyQ�A.�pH OF YOUR FROZEN DESSERT PERMIT UNIT[.,Tf�ABpVE TERMS -- HAVE BEEN MET. — ---- O 1T IDE FF4� OiJTSIDE CAFES (i.e., OiJ1'DOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE pRIOR APPROVAL FROM Tf�BOARD OF HEALTH. OUTDOOR OOKiN['� OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT$Y A RETAII,OR FOOD SERVICE ESTABLISfIMENT IS PROHIBTfED. DATE: ��f� SIGNATURE: �� O ,�j PRINT NAME& TITLE: `�G�9� /� �ifQ�i.� ,� 1�fL Piz�1,�� . � The Conrmonwealth of Massachusetu • = = Ueprrrtment of Industrial.-�cciderrts b OI//GOO//OY�dSUY,tlN�f 600 Washington Streel Bosrort,Mass. 011I1 � Wbrkers' Compensatio� lasuranee ACfidavit Anolicant information: p► AseNR � � nam� �� l��r_.l� Na `s � a6 tee� jaWc� �Ncr L�ic�tinn� G�Z, l��a`�r.r 5( .� i�`f`� a� � . .;r, Wes� �'ar Ma u�� Nj�., b��`73 .� phontU 77�=0�33 � 1 am a homeowner pzrtormin�aIl work myself. � f am a sole proprietar�r.d hace no one 4+orkin_ in anc capacity �Q I am an emplatier pro4 iding workers' compensation for my employees workine on this job. 7- tomoant� namr address• tift'• phanc#• ipsuranceco. �'�S�e �� -SU$..�`{'y ooiicytf vt,`1L^ �lq 3!'�{'Jff�f � f am a sole ptoprietor. oenera3 contractor,or homeawner(circle onel and ha�e hireC the connactors listed belaw �cho hase the follut+in� tiSorAer;' .ompensation polices: sompanv namt: �ddress• ci(q: � ghane M• � iosurancc co. oolicv it tomnany name: � _. _ . _.._ _ _ . _ . . _. ! tlS9: . . . -_"____' _._ _ '_ .__".__'_ . . � [f{y: ahaae M� insurenee co. _yQ,(�y N Faifurc to secure covengt ss rtquired uadtr Secries 25A at MGL 132 a�idd te tbe iapaition�tfiaiW pe�titln mf t 6�e�p to St,54Q.Qfl a�d/or oae ye�n'imprisonment n wdl a civil penddc�io ths form of�STOP WORK ORDER�od N 6ee of 5100.Os�dry�do�t ma 1��dsnnnd Wt� rnpy ofi this statement mav be fanvardeA to t6e 011icc ot taratigallom otrte DU[or tovera�e verillutlw. . t do trereh}eerriJ}�und the pains and pexalria ojperjury thm the injormwfoe provided above is tnee and arrKd ' /��/�� s�g�aNn r t � �rLr� Dau Printname � �—�l�c�1�lZs Pi�one# �7� a��✓� .. oRcial usa onh� do not wri�e in�his arey to be eompleted by cily or tpwn oi9ltiat ciry or town: Y�MQ� _ perwiNicaese M n8uiiding Drp�rtmept � �Lktesiog Bo�rd 0 theck if immedi�tt respanse ie required 261 QSeltrtmtn':OlTfte �HtdtA Dtp�rtment ronmct ptrson: phon�R:_ ��x} 398-2231 ext_ �OtSer finezetl i,4S PIAa � NOTICE NOTICE TQ TO EMPLCIYEES � El��''LQYEES The Commanwealth af 11�Iassachusetts DEPAI2Th�ENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Baston Massac6usetts 02111 61'7-727-0900 As required by Massachusetts Generai Law, Chagter 352, S�ectians 21, 22 & 3q, i63s will �ive yau notice that 1 {we) have provided for payment to our inJured employees under the above mentioned chapter by insaring with: Eastezn Casualty Insurance Company tx«me or Ia�nn«camp.ay> 325 Doaald J. Lynch Blvd., Mazlborough, MA Oi752 (Addrcas of lmunoce Compmy) WC79 3143Q1 08-01-98 Td 08-01-99 � {Poliey Number} (EPhdive D�ma) IOHIV R. GERMANI INS. AGY 14 PARKER RQA[3, P.Cf. BC}X 832, OSTERYILLE,MA 02655 StS8-428-9194 (N�me ot Inemance Agent.AMimas.PMm) GIARDtNO'S TASTEE TOWER, INC. 242 MAIN STREET, ROUTE 28,W. YARMOUTH, MA 02693 tEmploysr.Addxssi . . �P�aYda Wocicar's Compcnsat'an Off�er(It MY) (Daw) MEDICAL TREATMENT The above named lnsurer is required in cases of personal injuries arising out of and L► the course of employment to furnish adequate and reasonable hospitat and medical services ia accordance with the provfsions of the Worlcer's Compensatian Act. A copy of the First Report of Irnquiry must beg�ven to the injured employee. The employee may select his or her own p6ysician. The reasonabte cost af the services provided by the tresting physidan witl be paid by khe insurer, if the treatutent Ls necessdry and reasouably connected to t�te work related in,jury. In cases requiring hospital attention, employees are hereby aotified t6at the insurer has arranged Por such attention at the Ca e Cod Has ital H annis, MA (Nwrc of HospiaM) t�dass7 TO BE PO�TED BY EMPLOYER T4WN OF YAR�I�IQUTFi � BOARD OF HEALTH PERMIT TQ OPERATE A FOQD ESTABLISHMENT PERMIT 1VUMBER: 99-32 FEE: 5150.00 In accordance with regulations promulgated under authority af Chapter 94,Sectian 305A and Chapter 1 I t, Sectioa 5 af the Generai I,aws,a pertnit is hereby granted Ya: t'ri rdinn'e TacteP 'Tow r In 24 Main RtrertlMain 4tre,�j, Wect Yarmnirth MA Whose place ofbusiness is:_ Giardino's Tastee Tower Type af business: Food Service To operate a faod establishment in: Town of Yazrnouth Permit expires: Deeember 31 1999 BOART?QF HEAI..TH:�pd m ��ttga�a, �'�:�.J,/,/a}„ q / /�/ SEATING: �41 total (94-baz&lounge; ,.joan � �yu�llivan� �//.� Vice l,,,hairman 5$-rear diniug room;89-front dining rcwm) Ko�orl� P,rowa, ��.�r as��s��, ��a�n� � �� December 16 , 19�8 Bruce G. Murphy,MPA,RS., Q I7irector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF XABMOUTH PERIVIIT IVLTMBBR: 99-20 FEE: �SO.Od This is to Certify that_ Criard'uro's Tastee Tower Ina. d/b/a Giazdino�s Tastee Tower 242 M in �trertt/Rnnt . 28� WeM Yarmouth MA IS HERF-BY C,RANTF.,D A COMMdN VIC"TUALLEB'S LICENSE In said Town of Yarmputh and at that place oniy and expires Deeember thirty-first 199�unless saoner suspended ar revoked far violaUon of the laws of the Comrnonweakh respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing autharities by Gene�ra(Laws, Chapter 144, and amendments thereto. In Testimony Wher�f, the undersigned have hereunto affixed the'u o�`icial signatures. EtOARD OF HEALTH: ��YYI. ��esttg�g�, C��y,�}�j/�nq{ t ( sEw'1'wG: 241 total (94-baz&loanga; d[P/o�a/n� Jut�l[ivan� Kp.//.� Vice �hairmaa $$-ie8i diRiIIg room:89-$OIIt dining SOom) KoberE p�p �Jro/tvpn,/ �ta/r/� � � a�rief(e�ako(ekt�r/d�oaPaA � • �.�0' � � � December 16 , 19,28 � ! rucc G.Murphy,MPH,RS., O � f H alth � ' _ , � • , ., . u c��, �` t , x � G3 � � `� � `�? 1� [�� TOWN OF YARMQUTH BC)'�AR.D��A�TH APPLICATIUN FOR LICENSE /PERMIT - 1998 �� -$ �� HE��T+-t {:)Er�T. •Piease Complete form anc2 attach all r�cessary documents by Uecember 31, 1997. Fai3ure to da so will resuk in the return of yow application packet. --------------------------------------------- ----------------;-------------------------------------------------- �I..p�MF QF STABLISFIMENT• ��C��/ti_�/L!.�'itia � L # NI.�J=17.�5"_? A171�RF S� r� �'/�2,. /`J.� ..1�.�� `� ��•tG ADD�SS ' ,�R.d n.u ' /� �' .2� mtli H ----------------------------------------- PO(7L CERTIFICATI{3NS: Pool Operatars must list a minurnun oPtwo employees currently certified in basic water safety, standard first aid and Connmunity Cardiopulmonary Resrzscitation(CPR).Please list these employees below and attach copiss of employee certificatians to this farm. The Heak!► Department will not use past years records. You must provide new copies apd maiatain a file at yonr place of business. 1. �• 3. 4. T�jML,IC"f��RTIFiCATTONS: All food service estabtisiunents with 25 seats or�re musE bave at least one employee trained in the Heimlich Maneuver on the premises at all tirnes. Piease list your employees trained in anti- choking procedures below and attach copies of employee certificatians ta this farm. The Fleatth Departmeot witl not use gast years records. Yau must provide new copics and maiotain a file at your place of business. 1. �a �%�4 i.� _.� 2.��!? ..rri�a�r.�� 3. ��F�a�... 4. RESAURANT SEATING: TOTAL # f J NO1V SMOKING SEATS: TOTAL #�� ---------------------------------------------__.�--------------------------- -- - OFFI TTSE ONLY I.QD . N .: LIC. REQIJIRED FEE PERNIIT# LIC. REQCJIRED FEE PERMI'T# B&B $S4 �CA$IN $SQ INN $54 _..._CAMI' $50 _.,_LODGE $50 _,._TRAILER FARK S50 MOTEL S50 _,,_SWIM POdL $Sdea. WHIRLPOOL $25ea. �'UOD SERVICE: LTC.REQZJIRED FEE PERMIT# LIC. REQIJIRED PEE PERNIIT# 0-140 SEATS �75 �CQN'I'INEN'1'AI. $30 �>l{}4 SEA'FS $I50 �� NON-PROFIT $25 f COM. ViCT. Sd 4g-� �WHt?LESALE $?5 BE�IL S.�'1i1.�� LIC.REQUIRED FEE PERMIT# LIC.REQUIRED FEE PERMIT# �,<SO sy. ft. $45 _„_TOBACCO $20 T<25,000 sr�. ft. $75 _,,,_FROZ. DESSERT $35 _>25,000 sq. ft. $200 Separate payment is rieedecl for A,MQUNT DUE = �� liquor or ernertaicunent�icenses ADMINISTRATION I1RTI}ER CHAF'TEIZ i S2, SECTION 25C, SL7BSBCTION 6, TFIE TOWN OF YAI2MOUTH IS NOW REQUIRED TO H�LD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANX DOES NOT HAVE A CERTIFICATE OF Wt}RKER'S CC?MPENSATI4N LNSLTRA.NCE. T�IE ATTACHEI} STATE WORKEIt'S COMPENSATION INSLTRANCE AF'FIDAVIT MU3T BE COMPLE'FED AND SIGIVED. 'I'C}WN OF YAIiMOU'L'H TAXES ANLl LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE{3F YOUR PERIviIT5. EASE CHEGK APPROPRIAT'EF.Y IF PAII): 'YES � 1'VO 1YQTTCE: PERMITS RUN ANNCIALLY FROM JANUARY i T4 DECEMI3BIt 31. IT 1S YOUR RESPONSIBILITY TO RETUTtN THE COMPLETED A,PPLICATIQN(3)AND REQUIREI}FEE(S}BX DECEibiBER 31, 194? SEASONA,L ESTABLISHMENTS ARF TO CONTACT THE HEALTH LIEPAR'TMEN'T'FOR IN3PECTi4N 7-1Q DAYS PItIOR TO OPENII�tG FtJR TF�E SEASCIN. ALL RENOVATIONS T�ANY F0C3D ESTABLIS�IlUiENT,MOTEL Oit PCX}L (i.e. , PAIN'TING,NEW EQLtIPMEIUT, ETC.),MUST B� REPORTED TQ AND APPROV�.D EtY THE BOARD OF HEALTH PRIOR TO CONIlvIENCEMENT. RENOVATIOb15 MAY REQUIRE A SITE PLAI�. AI3I}I IOI�F T RfiITT A1"Tf)NR POOLS POOL OPENTNG: ALL SWIIvIlbIING, WADINC3 AND WHIRLP04LS WHICH HAVE BBEAT CLOSED FOR TI� SBASON MUST BE INSPECTED BY "1'I�HEALTH DEPARTMENT, AND'[`HE WATETt fiESTF,D Fd8 BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO QPENING. POOL CLOSING: EVEI2Y OtITD04R iN GROUND SWIA9�+IING POOL MUST BE Dl2ATNEl7 DR CO�EREb YJITHIN SE��+t(7) DAYS OF CLQSING. FOOD SERVICE AT .RiNCs PO .I Y: ANYCINE WHO CATERS WITHIN THE TOWN Qk' Yt1RM0U"I'H MU�T NOTIFY'I'HE YARMOUTH HEALTH DEPARTMENT BY FILING Tt�REQUIRED TEMPORARY FOfJD SERVICE APPLICATIt}I�F4RM 72 HOUR3 PRIOR Tt}TI�E CATERED EVENT. THESE FORMS CAN BE OBTAINED AT '['E�HEALTH DEPARTMENT. FB�� -��.�iT�: FROZEN DESSEILTS MUST BE TESTED ON A MON'1'HI..Y BASIS B'Y A S'TATE CERTIFIED LAB. TEST RESULTS NNST BE SENT Tt}THE I-IEALTH DEPARTh+�NT. FAILURE TO DO 54 WILL RE3ULT 1N THE SUSPENSION pR REVOCATIdTJ dP YG1UR FROZEN DE9SERT PERMIT UNTIL 'I'HE ABOVE Tk:RMS HAVE BEEN MET. �SIDF CAF,��: OUTSIDE CAFES (i.e. , OUTUOQR SEATTNG WITH WAITER I WAI'fRESS SERVICE}, MUST HAVE PRTOR APP1tOVAL�RQM'TI�Bt?ARI7 OF HEALTH. dUTi)OOR�00[�C�: _ flUTDOOR C04KING,PREPARATICIN,OR I?I3PLAY OF ANY FOQL1 PRQDUCT BY A RETAIL OR POOD SERVICE ESTABLISTMIENT IS PROHIBITED. DAT'E: !� �,! � l J SIGNATURE: 4'� PRINT NAME & TITLE: f'�''-�� w�� jI. �}n�.�a t�'C- 10/97 page 2 of 2 , ��F.Yq��ti TOWN C1F YARMOUTH ll4( ROI:TE 2& SOIIT1[YARM(;7UTH b11SSAC:H{!SGTI'S C12669�4j] � HATTqCHEES � ��+ra,.o�rio,,9� 7'clephone Cj08) i9S 7�31, 1':x[. 241 — F�x (SOk3) 3)5-236;7 BOARD OF HEALTH . '~'^—r"-�-' n�/' ;y' '� 1,� L� ��-� L. u tr �_ �i� DEC 3 0 1997 ! i��.Ps4�_$..� !�!%�4'Z TO: r13iC�.lIlO'S —._....�__..._.._.__.._.d.._ From: Colleen E. Pelley Health Inspector Date: December 17, 1997 Subject: 199$ License Applicants As noted on the 1998 Application far Licensing, it is your responsibility ta return the completad applicatian(s}and required fee(s}. This appiication format must be eampleted in full, as required by the Baazd of Selectnien. Tha following checked question{s) were not answered on your application when you submitted your Application far LicenselPermit. A)„� Under Chapter 152, Sec. 25C, Subsection 6, the Town of Yarmauth is required to hold issuance ar renewal of any liaense or pernut to operate a business is a person or company does not have a certificate of worker's compensation insurance. As part of renewal or issuance of your pernuts the State Worker's Compensation insurance �davit must be completed and signed,. B)_ Town of Yannouth tazces and liens must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: Yes No C),J All fflod service establishments with 25 seats or Fnare must have at leasi one emplopee traaied in the F-Ieunlich maneuver on the premr.ses at all times. Please su6mit new copies of the ernplayee certifications. The Health Department will not use past years records. You must prvvide new copies and maintain a file at your place af business. Please be advised th�t your establishment cannot legally open until the State Required informatian is obtained by the Heatth Departmen# and a permit 6as been issued. Thank you for your anticip�ted cooperation in this matter. cc: File CEPJjrnp � r�;,�t�a oa �,.5 x�r��a � Paper �'� �C,rc(vw, 2N�- . . , , � The Commonwealth ojMassachusetts : Depar�ment of Industrial.-fccidents s Olflce ol/sresU�sayis 600 Washington Street Baston. Mass. OZlll Wbrkers' Compensation Insurance Affidavit Aoolicant information: PiesiePRlNT7e�Tt oam� �9"i i4/!,/�/.�<J ��'`r/Lta /�t4i /i9c/�'!�.-�. � location: a�� //��.�. ../�T / � ! �J �� C��/ % l��^-/%ot-[fl� �/'� �0�� `�� y�qneaSO� `�`7J=1�333 � I am a homeowner ptrf ing all uork myself. � I am a sole proprietor ar.d h�cz no one��orkin_ in am capacin �am an employer pro�idino workers' compensation for my employees µorkine on this job. m a n � n � y�t T�2 lti � �.r � .�� N.� � �'?..�c - C�/. �Jdress• J�� ON��/� � � /��i//��f .C�d1L.'�� citr G 7/�� /'=��(3l� �/� G�f %�� hene p• 5 O�'� �'.��GU o insur�nceco policyM �� / ��c� / � � I �m a sole proprieror. general contracmr, or homeowner(circle onel and hace hired the contractors listed beloH ��ho ha�e thr follu«in� ��orker ,ompensation polices: companv name• address� �� phone M• � insur�nce co yolie��# � comoanv name• addrea.• �jv � nhoee II• :.�.�..��.�� po�N Failure to secure covengt�s«quired uuder Secrioa 25A of MGL 153 u�lad to the i.paitloe oterisiW peultln of�6�e op to f1�00.00�W/or one ycan'impriaonment u w�ell n eivil peodNa io the form of�STOP WORK ORDER�od a Ifee otS100.09�dq�pimt me. 1 a�denta�d H�t■ topy of thie shtement m�y be fonnrded to the ORce of Invadg�dom otthe DU for eoven{e veritiutlw. I do�hrreby cer�ijy unde�rhe pains and pen/aJ/�ies ojperjury t/ha�l fhe injormalion provided abovt ir true end cor►tct SignaNrc��cr � ✓.�1C� �r Date �/ �v.'�� Prim name �✓�GC/�/t� �• Cl�'��l�i�"� �� '� Phone N.,f��'�/✓ �?J - oRcial use onh do no��rite in this area ro be tompleted by ciN or Po�vo olileial eity or town: Y�HO�� _ permiNicenu 1t nBuildiog Depirtment ❑Lieeosiog Board � thetk if immediatt response ie requirtd Z61 ❑Stie[tmen's Ofliee �Ht�lth Dep�rtmenl contact person: phone B:_ �508� 398-2231 eat. nOther Ire.rsxE iA}PIAI ( Easte�Casualty'Insu�nce Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY j INFORMATION PAGE �I i NCCI Carrier 16942 Risk I.D. # 1874 3 Policy No. WC 79 314301 Federal I.D. # 1. The Insured/Mailing address: � Individual � Pa�nership GIARDTNO'S TASTEE TOWER, INC. �X Corporationor� 242 MAIN STREET. ROUTE 28 W. YARMOUTH. MA 02673 Other workplaces not shown above: i 2. Policy Period: The policy period is from O8/01/47to 08/01/98 12:01 A.M. Standa�d Time, at the insured's mailingaddress. 3. Coverage: �, A. Worker's Compensation Insurance:Part One of the policy applies to tfie Workers Compensation Law of the sta�es listed here: Massachusetts I. B. Employers Liability InsuranGe: Par[Two of the poliCy applies to work in eaCh state listed in item 3.A. The limi4s of our liabiliry under Part Two are= Bodily Injury by Accident-` 500 s 004 each=acCident._' � � Bodil,Y InJury by Disease 500=044 policy limit ' ' -Bodily Injury by Disease SOA.OOD each employee C. Other States Insurance: Part Three,of=the policy applies to-the states, if any, listed here: All states except tt{ose listed above in;,item 3A ahd NV, ND,OH, WA, WV &WY. D. This policy includes these endorsements and schedules: WC122b, WC242, WC332, WC350, WC367, WC4�11. See InformaHon Page I!{ fpr ather applicable entlorsements. Total Estimated�!{nnual`Premiur�i �t �y= � �:D�+� � � Pro RaCa Premiurn (If Appli�sj�i � ��a � x � } � _ s� � � '� a�+ � 6 ';p . . . ` ` . `»;a. y "' y " '. " , .� . . , , - ,: ' �. _ . :. r. .,. . ' Countersigned J. R. GERMANI INSURANCE AGENCY I 14 PARKER ROAD OSTERVILLE� MA 02655 !, Date 07-11-97 By I AMP) . .. � RePresentaC � THIS INFORMATION PAGE WITH THE WORKERS CAMPENSATION AND EMPLOYERS LIABI SUflANCE POLICY A � . ENDORSEMENTS,IF ANV,ISSUED TO FORM A PART THEREOF CAMPLETES THE ABOVE NUMBERED POLICY. �I NSIIRED .APV � • / TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-99 FEE: $150.00 In accordance wiUt regulaUons promulgated under authority of Chap[er 94,Section 395A aud Chaptec 11 l,Section 5 of lhe General Laws,a permit is hereby granted to: �iardino's Tastee Tower Tnc �4 Main Str . /AiTain Street West Yarmouth_ MA Whose place of business is: Giazdino's Tastee Tower Inc Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31 1998 BOARD OF HEALTH: �� P/. �nett�pp�, C�a//i�rmqqanq � /� SEATING: 241 to181 (94-bar&loUnge; �/�oan G. Jnullivan�nK.//., Vice l,�iairman 58-reaz diniug room:89-front dining room) Ko6er��7�// O,rowpa, C.Pe/r'�x C.�(�a�driel[e �a�i/o�la�x�-JdooPe! ///{G�B� � o�.�q�yg��IL Jauuary 16 , 19 98 i-L,cx. � •�l-^ �:� Bnxce G. Murphy,MPH, R.S� CHQ Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-58 FEE: $50 00 This is to Certify that iardino's Tastee Tower Inc — 242 Main 4treet/Route 2A Wect Yarmoutlt MA IS HEREBY GRAN"I'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1998 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 with the authority granted to the licensing authorities by General Laws, Chapter 140, and atnendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �d ��I.+ ��e7�a��, C�(+�M�q/�n/� , /7 sEnT[Nc: 241 total (94-baz&lounge: �/�oan G. Jun[Civart�nK�.7/l.� Vice C.�tuirmaa 58-reaz dining room;89-tront dining room) Ko6srl/�/// 9,�o/u�0ro, l�[�/r/�i a6riellep�ah/o1G��r�-.phtooPxd � ic�el �oCou��fin. � X ,� January� 16 , 19 98 c ; / �"'r` ` Bruce G. Murphy, H, R. .,CHO D'uector of Health ,