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Home My WebLink AboutApplications, WC, Licenses . , . ., � K Ea G�R. � � p � nrri, c TTo oxuL g soaxn o�ai.z�a �� ,? � = � � � • NOV 1_ ! cu08 * Please complete form and attach all necessary c�p�Gm ts.by' ece er I S 2008. Failure to do so will result in the return of.your a�pplicahon pac � r. ��;r ;i. NAME OF ESTABLISHMENT: �Z �I� ln (,� TEL. #�� 1 LOCATION ADDRESS: MAILING ADDRESS: V W � S � OWNER NAME: - TAX ID FEIN or S N : CORFORATION NAME (I APPLICA LE): `T�A7,�',{/` C— MANAGER'S NAME: �ai TEL. # Ck�-3J • MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimwn of two employees cunently 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 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 aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l.s��(`CX 2. <� _ PERSON IN CHARGE: Each food establishment must ha e at least one Person In Charge (PIC) on site during hours of operation. Ls�C?�Pa/) C�.mr 2.�o(�J'Fi A'�� 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 tlris form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of businessc� l. Iti� '�C 2. 3.S'p�lZe Gf� 4. L 5' RESTAURANT SEATING: TOTAL # I�� OFFICE USE ONLY � . LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQTJIItED FEE PERMIl�ik LICENSE REQUIRED FEE PERMI"I# _B&B 555 CABIN S55 _MOTEL S55 _INN S55 _CAMP S55 _SWIIvIIvIINGPOOL SSOea. _LODGE S55 _T"RAILER PARK 5105 _WfiIRLPOOL $80ea. � FOOD 5ERVICE: _ ._ _. . _ _ . _ __ ---- - -- . . _. . ___ _ LICENSE REQT.JIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI"I# _0-]00 SEA7S S85 _CONI'[NENI�AL S35 NON-PROFIT 530 I >I00 SEA'IS 5160 �0 � �L I COIvIMON VIC. 560 �611-6�J� _WHOLESALE 580 RE'IAIL SERVICE: —RESID.ffiTCHEN S80 LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _<jOsq.B. SSO _>25,OOOsq.ft. S22i VENDING-FOOD 525 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 I'OBACCO S55 ra�7Ec�.�cE: sio AMOiJNTDUE _ $ 22a.00 `*"*'�PLEASE TUR�OVER.4�\'D C011-II'LETE OTHER SIDE OF FORitiI*^^** f � ' � ADMINIS'I'RATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemtit to operate a business if a person or company does not haue a Certificate of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SICy�lED AND ATTACHED / Town of Yannouth ta�ces and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISffiVI�NTS 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. Transiem occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dweliing 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 haue been closed for the season must be ins ected by the Health Departmern prior to operung. Contact the Health De�artment to schedule the inspection five(�days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area unril the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departmem. FROZEN DESSERTS: Frozen desserts must be tested on a monttily basis by a State certified lab. Test results must be sent to the Heakh Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII.TI'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO t1ND APPRO Y OF HEALTH PRIOR TO COMIvIENCEMENT. RENOVATIONS SITE PL . - � DATE: ``` U✓• �(/ SIGNATURE: PRINT NAME&TITL . o io zuos �\ The Commonwealth ofMassachusett.s Department ofindustriolAccidents NMe�Nb� 600 Woshington StreeK 7`"Floor Boston,Mass. 011ll Worlcers'Compeasatioe Ios�sace AtTidavit:Baildiog/Plembiag/Ekctrical Coatraetors name: �� Y. � CX1�� ..�i cl/�,�:. �1Klll�� . .� � /t/lJ�. address:�v V� �1J4 i/*V"�-�S � �M . ciN �� M�1/`-i" � slate� �� 1.� .. �Zl9KJ�ohone# � �� / K/ ` � . wark site locatiwi(full addtessl: - . . ❑ I am a homeowner perfomung all work myself. Project Type: ❑New Consrtuctium QRemodel ❑ I am a le�proprietor and Lave uo one wodcing in any capxity. ❑Birilding Addition am an employer provi ' workecs'compensati�f�my employees wo�cing�this job. . . � ,^ com � me• / � � ✓�I � . . � addre�s' W . . . d : � e#: (J(/ �.,�.a�. r�icx . 12�,L IVl�2 c�� (h2aS 1� � fll`I n�SD3� c�.Sb l � � � .�.,e ��.�.� ,,� ❑ I am a sole proprietor,geaersl eeatractor,or bomeow.�(circle one)and have hiied the con�actois listed below wLo have the following workers•coivpensaataon polices: � �4mowv�ane• � � . . . . . add�na'. � . . � . . ds• . , . . � oiwe S• . . - � . � . . ineaw:c ea . . . �� . . . _ � . . . .. .. . ' - - - � f ... . emm.��e• � � addrw• � � : . . � . . � oYa�elf' . . � imua�oed. . . . �y� . . . . �` . .. .. _ . . ,- ,,g S �.,.._ ,c.y,F.�. _ F, Fa9mei�xe n 2SA�MCLLS2neladbHeispnHWKaiN�YpeaNin�fa9�eq�bS1,3M.ManNw:�; � tn ndN Nb Netm�da37'OrWORK06DBRud�OeedSlM.Madayapiort�e, Imdnaaedf4ta e�pp �tlbWhaM tonra tYe d dIkDlAfire�ver�gevc+isnlfn. � � � . !10 ereby .� ofPP�HN�Y Md Me infonndlon proviAel abotr b we and corrrct� . � �� /2d- 6 0� r P�M� ��d �3f� ��9 �ea�w.x.wy aoow..�`m�.raNa�oo.q«eaey.�y.r�..n.m� etry or t.wn: . . . . . permkl5ttne g Og�Od�a Dm�o� ❑tYuk Him.editle`eapeeae h rcq�M � . � O�¢ . mWct pvwu: �#. ❑IWMh Depa�O°mt t2.:ea s�mw) �e T4W�F 4F YARNIOIiTH BQARD OF HEALTH PERMIT TO CIPERATE A FOOD ESTABLISHME�iT PERMIT NUMBER: #09-046 FEE: S160.00 Iu accqrdance«•ith reeulatipns pmnmlgated under euthtirih�of Chaptzr 94,54ction 305A and Chapter i 1 1, Section 5 of the Geciecal Larvs,a pennit is herebp grantad ta: Santhside Tavem LLC 81 Kia 's Circuit Yannouthport MA Whose place ofbusiness is: Ardeo GritTe at Rin�'s Wav Type ofbusiness: Food Service To operate a food establishment in: Town of Ya�mouth Fermit expires: December 31, 2009 BOARI?OF HEALTH: .`�EePRft SPUC�t, J2.✓V., C�iabemcut sEA7tN�: 41 seats-dinin�roam �.t[�iG�¢8 .`�. .`��t�tYli �ttE�tnftttttt 32 sents-bar and lounge �4�� • ✓3'�w�x� � (Ztttt C�'lEwat�pttlri, `JZ,N. �� December�2.'OOf3 —` mce . urp y, , . > D'uector of Heaith THE COMMdNWEALTH L}F MASSACHUSETTS TOWN QF YARMOIITH PERMIT NUMBER: #Q9-431 FEE: Sbd.60 ?his is ta Certify ihat Southside Tavem C,LC dlb/a Ardeo Grille at Kin�'s Wav S i King's Circuit, Yarmouthport, MA IS HEREBY GRANTED A COMMQi1' VICTUALLER'S LICENSE In said Tativn of Yarmouth and at that place only and expires t�ecember thirty-fvst 2004 uriless sooner suspended or revoked for�tiolation of the laws of the Commonwealth respectin� the licensing of cammon victualiers. This 2icense is issued in conformiry with the authority eranted to the licensing authorities by General Laws, Chapter 1�40, and arnendments thereto. In Testimony Whereof, the undersi¢ned hava hereunto affuced the'rr okTicial signatures. BdARD OF HEALTH: .�Ee�za SllaPe3.`J,2.,N., ('�c+ciaunun sE.�it,�'c 9! seats-dinu�e roona ��Q-0G�¢4 .`�. :tiY�l�C1G �tCC�.��ti4ltJttXtt 32 seats-bar and loungz ,�QXl �. �NO[Uft� � fltttt ti'XEetL�t[tCttt, J2..JV. Deceanber 4 ?OQ8 __�� Bruce G. Murp�iy,MP , R. , HO Director of HealFh , , . � ARDc-c� GfUc.CE' �t "^N� TOWN UF YARMC?U'TH B4ARD t?F HEALTTi ,„, �Qy _ s� � = APPLICATIONFQRLICENSE/PERMI3'-i2� � , h30V 2 7 2t7�71 �c �-?' -.: b° , , • Piease camplete form and ai#ach a!1 necessary document�1��° � er$1; 2007. Faiture to do so will result in the retum of you�'appTication packet.v NAME OP ESTABLISHMEN`£:�-�D� Co'�i��E' � �� L,J�1� TEL� # SZtS�Q4�-f�U�-(SJ LOCATIQN ADDRESS: MAILING ADDRESS: \I L�� ,y� . {7WNER NAME: �` + ^� CORPORATI(JN'NAME (TF APPLICABLE): k'"� �-- MANAGER'S NAME: �e�. TEL. #�h'c `�9Y C17Xlq` MAILING ADDRESS: FOOL CERTIFICATIC7N5: The poo!xapervisor must be certified as a Pop! Operatar,as reqaired by Skate Iaw. Please list the desienated Pool Operator{s} andatta�h a_cQgy.nf the certificatianro Yhis fonn. - - - 1. 2. Fool aperators must list a minimum of two ernployees currentiy cenified in basic water safety, standard First Aid and Communiiy Cardiopu3monaiy Resuscitation{CPR}. Please list these employees below and attach capies of emgioyee certificatians to this form. The IIealth Depart�ent will not use past 3•ears' records. Yau must provide new copies and maintain a 61e at your place of busiuess. 1. 2. 3. `�� FOOI}PROTECTION MANAGERS - CERTIFTCATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protectian Manag�r, as defined in ihe State Sanitary Code far Food Service Estahlishments, 145 CMR 590.004. Please attach copies of certification to this applieation, 'i'he Health Deparkment wiil nat ase past years'records. You must pravide new copies and maintain a file at your establishment. 5��'-� �. r�� s��_____ 2..��'1�- P�RS4N IN CI�ARGE: Each food establishmcnt mixst have at least ane Persan In Charge (PIC) on site during h rs of operation. L � (� 2.�1�U��l�S�'�_�� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maueuver on the premises at all rimes. Flease list your employees trained in anti-chokwg procedures helow and attach copies af employee certifications to this farm. The Health Department will no# use past years' records, You must rovide new capies and maintain a file a#yaur place o#basiness. �. r� z. Yi�t,� �Q s 3. 4. RESTAURANT SEATING: TOTAL#�� OFFICE IISE O�LY LODGING: LICENSE REQUIRED FEE PERtif17# LICENSE REQL'IRED FEF PER�i1T� LICENSE REQUIREll FEE PERW I= B&B S50 _CABItv' S50 _MOTEI: SSp (NN S50 ,�CA.VIP S50 _ ._S�"[YT�IINGPOOLS75ea. vLODGE S50 �TRARERPfiRK 5106 _ti�tI1RI.POOL S15ea. Fp4D SERYICE: 210ENSE REQUIRED FEE PERMI]'� T.ICENSE REQL7RED FEE PER�417= LICEtiSE R�QtilRED FEF. PER�ll7= 0-100 SEA7S S75 _Cl1N7INENTAL S30 ,_NON-PROFIT S2> 1 >1pOSEATS S1i0 �i" -��t . IC<?:�fONVIC. S50 ��0�_:;��"i �«-FIOLESALE 575 �„� RETAlLSERVICE: —RESA7.KI7CHEN S15 LiCENSE R£Qi7IRED FEE PER.kiTi= LiCENSE REQLnRED FEE PER4tIT= LICE:v`SE REQLIRED FEE PER.l3lT= Y<SOsq.Yt. S45 >25,OOOsq.ft. S?OQ ,— —1'E\DIivG-fOt)I? S?Q v<2S.00Osq.it. 575 TFROZENDESSERTS3i _IOBACCO Si0 ' va:�c�vice: sio AMOU\T DUE _ $ �oo,o0 •*•"*PLEASE iCR.\OV'ER,�\D CO�iPLETE OTHEIt SIDE Ofi FOR\t•^*"* a � } ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any Gcense 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid p or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES • NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pwposes ofthe limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewheae. Transient occupancy shall generally refer to conrinuous 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 shaii not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as deSned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be wnsidered Transient. * NOTE: Er,��osed Motel Census must be completed and returned W;tb t�is appuoacion. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the sea.qon must be ins ected by the Health Department prior to opemng. Contact the Health Department to schedule the inspection five(�days 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 thereaRer. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closin�. FOOD SERVICE CA'I'ERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Departmern by fiting 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 haue prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking preparatinnror display ofany food prod�bya retail or food seruicc establishment is prahi6ite�. NOTICE:Pernuts run annually from 7anuary 1 to December 31. I'I'IS YOUR RESPONSIBIIITY TO RETIJRN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2007. Ai i RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROV ' BOARD OF HEALTH PRIOR TO COMMENCEME�IT. RE�IOVATIO�IS M E ITE PLA . DATE: II•7 � ' � ` SIGNA URE: PRINT iVA1�1E&T E: � � io;o o- �'\ The Commonwealth of Massachusetts DePartmertt of IndusZria!Accidents NLqN� 600 Washington Stree� �'F[oor Boston,Masc 021I1 Workers'Compeaaation l�m�aace ASdavk:Boildi�g/Plambi■glEketrical Co�trxton !'lar E'Ri[�P le�ih oa�ne: add�ess: siN smte� zio• ohone# vrork site location(fiull addressl: ❑ I am a hom�w�r perfoxmaig all w�k myself. Project Type: ❑New Consunrcd��Reanodel ❑ I am a sole pco�ttietor and have no one wocking in any capecity. ❑B�rilding Addition ❑ I am an employer prov'ding wotkers'compensati�for my employees woiking o�ihis job. _ . .. :. _. _ . .__- ----. ._ __. _.__ _. . . .. . _ .. . con �ane: - - � —.. WNes: � a : �-, Pq2 U . (�2(vf_o �: � �I � ��.�/l.S C� i !I � D I�t 6'OS`0,3��5�7 CXn - _ �,. , , ❑ I am a sole proprie[or,geaerai eo�tractor,or homeow�er(cirdt owe)and have hiced the contractas li&ed below who have the following worke�s'compensa[ion polices: wnmav me• a_d_d�ss: . cih': nha�r M� iqeaeee eo. � � �y � oosouv�e• �: �: o�eee M� . ._ _ . . _. _. . . . . . imeuee eo. . .. poLh M . .._ .. - . LdaiFii�Y1il�t��YYr��.�� .. � . � . . . . .. . FaYve U a[eae wmqe n xeq�N oda Sa�2SA d MGL 13S w kW b tYe t�pnMY�daidW peapn da O�s�b f1.lf�lM aNNr�: ax ynn'p�prMwt as we��s b h tse[ars af a 37O!WORIC ORDER ud�6e ef S1M.N�day gWit.e. 1 odnshed 16at a npydtlh y4e � 1oeOmcedlne�tlgatlw�ft6eDlAfirt�vengev�pe�tlx. I lo ereby cera s d6e Ferjery Mat the iwfonwallon provided abore is trre a6 cerrtct � Date ��'�� ' f I p � ,r '� Phone# ��F�J ��7 VU 7 � e�l me anly de eaf wrke lu tYis ura fo he cavpkfed DY d!Y er Ywn e�il eNyarta�vv: ��p �g��p��'� ❑eheek ifimmed6ie n�epeme h�ouM ��Bsard �Sdxtm'a O�ce ❑da11Y Dep�E�at tial�cl pus°' PYa�e 8: ❑Ome la.'sd 5�yt mm) ACORD CERTIFICATE OF LIABILITY lNSURANCE C3R �T °"'�`"""°°""`"' AAD80-1 08 11 06 PR�� THIS CERTIFICATE IS ISSUED AS A MATTER OF MIFORMqT10N Thomas F. Reefe Ine. Agcy. Inc ONLY AND CONFERS NO PoGHTS UPON THE CERTFICATE 51 WeSt Cantral Street HOIDER.7H15 CERTIFICATE DOES NOTAMEND,EXTEND OR P. 0. Box R ALTER THE COVERAGE AFPORDED BY THE POUCIES BELOW, Franklin MA 02038 Phoae; 508-528-3310 8ax:508-526-3887 INSURERSAFFORUfNGCOVERA6E NAICiI INSUREO INSUNERA: F1LSt CdLdlfldl South Side Tavern LLC iHsur�ne: Trumbull Ins. Co. DHA Ardeo DHA Ardao Crille at &ings Way �NSURERC: 23V 9Phitea Path ��wsuaeRo: South Yarmouth M1► 02664 INSURER E: COVERAGES THE POIKIE$OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TME INSUREO NAMEU NBOYE FOfi TME POLICY PElilO�NJOICqiEO.NOTWI7HSTANOWG ANV REOINREMENT.TERM OR LONOIiION OF ANV CONT(tpCT OR 07HEN OOCUMENT NqTry RESPECT TO N4iN�1 THIS GERTIFIGTE M4Y BE ISSUED OR MAY PERTAIN.TME INSURANCE AFFORDED BV TNE FOUCIES OESCRIBED NFREM!IS SIIBJECT T0 aLL THE lERM3.EXCLUSKINS AND CONOITpNS OF SULH POLICIES.AGGHEGATE LIMITS SHOWN IAAY NAVE BEEN REUUCFD BY PAIO CUIMS. �TR NSA TYPEpFINBURANCE POLICYNUMBER DpTE MMIDWYY DGTE ��n GENERALUA&LITY �HpCC�qpENCE s COMMERCIALGENERALLIR9ILITV PREAMSES Eaoca2noe) i _ CWMSMAOE ❑OLCUR MEDIXP(MYoneDersonl f FERSONALBADVIWURY S GENEMIAGGqEfi�TE f GEN'LAGGRECATEUMITPPVLIESPER' PROplICjS-COMP/OPAGG f POLICY PRO- JECT L� AUTOMOBILE W1&LIN ANVAUTO �MBa�EcnDu1NGLEUMIT = ALl OwNED AUTOS BODILY IWUM SCMEOULEO AUTOS (�P«) i HIREDAUTOS BOOILV INJURY s NON-0WNED F1R05 (Pd M��^O . PROPERTY WMAGE s (GxeaiCea) GARAGELM&LITY i AUTOONLY-FAACCWEM f 1 I ANYMf�O on�Eanwru �•ncc s AUTOONLV: �� _ EXCEBlIUMBRELULIABILT' EALHOLLURRENCE S OCIX1R �CWMS MADE AGGRE6ATE E 9 oEWCnBIE S RETENTION S S Y/ORI(ERSCOLIPEN311TiONANO X TORYLIMITS ER EM►LOYER511AMU7V 1 A ANYVROVRIETORIPRf1TNER/E%ECUTNE I 014005030285106 �1�01�07 Q1�Q1�Q$ E.LEACHACCIOENT j§QQQQQ OFFICEWMEMBERE%CLUOED? E.L.OISEASE-EAEMPIOVE f SOOOOO x� ��"�r EIDISFABE-POLICVLttA1T SSOOOOO :SPECIAL PROVISIONS bAow �OTHER B Liquor Liability VQ0004517 06/14/07 06/14/08 Liability $1,000,000 DESCpIPfION Oi OPERATG191 LOGATIONS/VEMClEB/OfCLU510N5 ADDEO BY ENOORSEMENT I SPECUL v�t0V�510N5 Restaurante at 23V Whitea Path South Yarmouth and 81 Kinga Circuit Yazmouthport FAX 508-394-3049 CERTIFICATE HOLDER CANCELLATION 1.�0_1 SIqULO ANY OF TME ABOVE OESCRIBEO iOLIGIC3 BE CANCELIED OEFORE THE E%%RATION MTE iMEREOF,THE ISSUING IN3URER WILL ENDEAV00.TO MNL __ ppyg yyp�N NOTICE TO TXE GERTIFICATE/qlOER NANED TO TNE LEFf,BUT F1y WRE TO 00 SO SHALL Town of Yarmouth - dS3�II SCLBC't IMPOSENOOBL OR 11TVOfANYlUNOUPoNTHE1N3UliEp,lT3qGENTSOR Yarmouth MA 02664 �PRE$EM Es. AUTHORQ REP EN A Thoma f i s. c .Iac ACORD 25(2001I08) mACORO CORPORATION 1988 TOTRL P.01 i-mrt-1•i-C✓JG6 it•.�i Ktt�-t 1NSURRNCE 15085283687 P.01/01 ACORD CERTIFICATE OF LIABILITY INSURANCE �sR � �TE(MMIDD/YWV� ARDEO-1 03 13/OB PRODUCER THIS CERTIFICATE IS 135UED AS A MATTER OF INFORMATION Thosae F. Reefe ias. Agcy. Inc ONLYANDCONFERSNORIGHTSUPONTHECERTIFICATE 51 �Cest Central Street HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR P. O. Box R � ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fraaklin DIA 01038 Phona: 508-528-3310 Faxs508-526-3887 � INSURERSAFFORDINGCOVERAGE � � NNC# �Nsurseo iusurs�rtn �.'First Cardiaal - - �,-: ;�,� - South Side Tavera LLC msuneRa��. r.Trumbull Ins. Ca. c� �� DHA Arfleo � --� . DHA Ardeo Grille at Rings �Pay � iNwRERc: � - . 23V Whitea Peth " � � � � �� - South Yarmouth MA OZGG4 INSURERO: msuREke .� � _".i�T COVERAGES � . � THE POLICiE3 OF INSURANGE LISTED BELON/MAVE BEEN ISSUED TO TME INSUREO W1ME0 ABONE FOR TNE GOLICV PERIOD INOICATF-0.N07WIT13TANDING . ANV REqU1REMEM,TERM OR CON�ITION OF ANV COMRACT OR OTHER OOCUMENT WRH RESPECT TO Wi1iCN THIS LERTIFICAIE MAY BE I5SUED OR . MPY PERTAIN,THE INSURANCE AFFORDE�BV THE POLICIES OESCRIBEO HEREIN IS Sl1BJECT TO ALL THE 7ERM5.EXCLUSIONS MND CANDRIONS OF SUCH POLICIES.AGGREGRTE LIMITS SHOWN MAY HAVE BEEN REOUCED BV PAI�CLAIMS. � .LTR NS TYPEOFINSUR/WCE �4CYNUNBER pp MANDOM/ I DATE NWWNY I ��M� GENERpLLW11,IfY EACNOLCURRENCE S COMMERCIALGENERALLIFBILITV PREMISES Eaoaurence) S QAIMSMADE ❑ OCCl1R � MEDE%P(MyafepelaanJ S � PERSONqL 8 AOV INJURY S � GENERALAGGREGATE S I GEN'LAGGREGATELIMRAPPLIESPER ' � PROWCTS•COMP/OPAGG 5 POIICY ��7 I LOC :.. AUTONOBILE lJA&LITY COM&NEDSINGLELIMR s ANY AUTO I�eCtitlMl) PLL OWNED Al1TOS � BODILYIWURY $ � . SCHEDt1LEDAUT05 I � (PerOe�N I NIftEU AIJfO$ eooavu�uuav s � NON-OWNEDAUT03 � (PvactlEenq PROPER7YOAMAGE $ � (PMsxitlenlJ �GARAGELIABIUT/ AUTOON�Y-EAACCIOENT 5 ANYAUT� OTHERTHAN EAACC E nuro owiv: �c s EXCES9NYBRELLA LIA&LIiY ` EACM OCCURRENCE 3 oCCUR �CUIMSMAOE I AGGREGnTE f 5 DEDUCTIBLE 5 RETENTION S . . .. . S WORKERSCOMPENSAT�ONANU . X 70RVLIMITS ER A eMttorei+s•uneamr -014005030285108 Ol/Ol/08 � 01/01/09 E.L.EACHACCIOENT s500000 ANY PROPRIETOR/PFRTNER/EXECUfNE OFFICERIMEMBER EXCW DE�? E.LDISEASE-EREIIWLOYE s500000 Ayes tleuriDe untler SPECIALPROVISIONSbelow E.LDISEASE-POLICVLIMIT SSOOOOO 0T17ER 8 Liquor Liability VQ0004517 06/14/07 06/14/08 Liability $1,000,000 OESC W PTION OF OPEPATION51lOCA'f10N3/VEWCLE31 EXClU910N3110DED BY ENDOp$EMEM/SPECWL GROVISIONS Restaurant at 23V �Phites Path Yarmouth anfl 81 Riag's 9Pay Yarmouthport FAX to 508-398-0836 Attn: Linda Cipro CERTIFICATE HOLDER CANCELLATION YARMO-1 $HWLDANYOFTNEABWEDESCRIBEOPOLICICSlECANCELLEDBEFORETNEE%PIItqT10N DATETNEREOF.TXEISStpNGINSURERWILLEN0E11VORTOMAIL SO pAv3WRITfEN � - � NOTICETOTHECE XOLUERNAYEGTOTHELEFf,BUTFAILURET000SOSHe�� xown of Yarmouth Main S treet ��SE NO O LIT'OF ANV KINO UPON T1ff INSURER,ITS AGENTS OR Yarmouth MA 02664 � � AT� � A Th K Ins. .Ine ACORD 25(2001/08) �ACORD CORPORATfON 7988 TIITl1� O !]� TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-041 FEE: $150.00 In accordance with re�u1�[ions promulgated under authority of Cl�epter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a permit is herebygranted to: Southside Tavem LLC, 81 King's Circuit,Yarmouthport,MA Whose place of business is: Ardeo Grille at KinQ's Way Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31. 2008 BOaitD oF HEALTH: .�EePeet SRta�, ` .lY., C'R�aLu►ean sEnrING: 91 seats-dining room � ,�.�I�IP,J,IG� �„IC¢(��QlA(/fiQ/L 32 seats-bar and lounge J�O�PXt�.�KO[!)ft� I�.CPXR . . Qfttl � ✓�.JY November 28.2007 D ector of Health � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-034 FEE: $50.00 T1ris is to Certify that Southside Tavem LLC d/b/a Ardeo Grille at Kin�'s Wav 81 KinQ's Circuit, Yannouthport, MA IS HEREBY GRANTED A • COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confoimity 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: .q�f�e�ee�"r�a�S" I�qa�Rt,(7�`J�Z�.�.N��.,""C"'�na'u�[nqcaQa�� SEAITNG: 91 seaTs-dllllIIg LOOIri �.iLLViCC'p .7G. ✓I.GCLfIµ,�,F� V"(CC l.lLC{l3//�H, 32 seats-baz and lounge J�o�Pllt�.J�MmG/It (,GPJ[R . � . . '¢If.d'atlflt� ✓� . November 28.2007 Brnce G. Murphy ,R.S.,CHO Director of Health . �� {i� �-��r3Ro�a Gz�u� °`:=�-'P o TOWN OF YARMOUTH BOr4RII OF HEA�.�H � G3 ,2s C, I� fl ,'7 '` D o��y APPLICATION FOR LICENSE/PERMIT- �{0�17c ' N OV 2 0 2006 � . : t,e: ; � ��'' ; * Please complete form and attach all necessary documents by Dece er 31 2006 Failwe to do so will result in the retum of your application pa kb1��LTH C�EPT. NAME OF ESTABLISHI�IENT: �LA� �� (�S►n( 1`}y� TEL. #��• LOCATION ADDRESS: MAILING ADDRES S:�3 \/ W i�;h,�5 S• N(17LM• 'yY�A _ DZ�(n owrr�x NaME: �7,�,m4 T�ix ro �nv or � CORPORATION NAME( APPLICABLE): �`p� ci n p/Y� 1 I C' MANAGER'S NAME: �T�ilI� �i1rni TEL. #,9`.�?•�9 'D79/ / MAILING ADDRESS: POOL CERTIFICATIONS: 1'he pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Piease list these employees below and attach copies of employee certifications to this form. The Health DepaRment will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2_ 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wiil not use past years' records. You must provide new copies and maintain a£de at your establishment 1. c.JC�J�L- �� 2. v l.-,Gi ""�_� PERSON IN CHARGE: - - --- Each food establishment must ave at least one Person In Charge(PIC) on site during hours of o eratip on. 1. CJC�S�� N'PY11 2. � IL i OI 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 Heelth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. l'.�i V1;�W1�G� �� 2. 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: L[CENSE REQi7IRED FEE PERMIT N LICENSE REQUIItED FEE PERMfP# LICINSE REQiJII2ED FEE PERMI1'# _B @B S50 _CABIN S50 _MOTEL $50 _1NN $50 _CAMP $50 _SWIIvIIvIINGPOOL$75ea. _LODGE $50 _1RAII,ERPARK 5100 WHIltI,pOOL $75ea. FOOD SERV[CE: LICINSE REQUIltF,D FEE PF.RMIT# LICENSE REQUIl2ED FEE PF.RMII'# LICINSE REQUII2ED FEE PEAMIT# � _0.100 SEATS $75 _CONTAIENTpL $30 NON-PROFIT $25 1>]00 SEATS E150 �6 —66 1COMMON VIC. $50 �' _WI-IpLEgpi,g S75 RETAII,SERVICE: —RESID.KTTCIIEN S75 LICENSE REQUIl2FD FEE PERMIT# LICENSE REQiJIRED FEE PERMI1'# I,ICENSE REQiJIItED FEE PF,RMIT# _60sq.ft. $45 _>25,WOsq.ft. 5200 _VENDING-FOOD S20 _QS,OOOaq.ft. $75 _FROZENDESSERT $35 _TOBACCO S50 NAME CHANGE: S10 AM�UNT DUE — $ Zp0 �� '•"`PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••^• ADNIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A'I"TACHED STATE WORKER'S COMPENSA'ITON INSURANCE AFFIDAVIT MUST BE COMPLE'I'ED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �/ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth t�es and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short teim occupancy, ordinazily and customarily associated with motei and hotel use. Transieirt occupants must have and be able to demonstrate that they maintain a principal place of residencc eLsewhere. Transient occupancy shall generaily 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 shali 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 aznended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the 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 certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool tnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yamiouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to t6e catered event. These forms can be obtamed 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 untd the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: _ Outdoor cooking,�reparation,or�isplay ofa�y food product by a retail or food service establishment is prohibitetl. NOTICE:Pennits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN TF� COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APP OVE Y THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY S PLAN. DATE: I�` ��"' SIGNA . � PRINT NAME&T � iomros �.: /� j . � t t . J t J Y �. fC�r_.��L� � ' l�rl I il. v I� � �:"�j� 9 ' � 1� V i ;7�CI_ � e /�l _ r � � �,�"=itc`�� i v i l •�y II � '� `-I +i � . 1 [ � : ti i , . . . . .... ..-. 3 :#... y'. tt >eiul ...� 'neEld✓f��ti+�o v�� 1� ��{ 1�•�� ] !l � �� .� � LA lL �� Y'. � �� " � � � � �l nlu � i.� �-i �a� . n � �w � � � ' �n ��.- � u : � �� r. n � ' � ■ :III : 1 ' 1' Il. wl :llll : '�I1 �.1 �� Ili 1 ' 1� y1� . � . � � � , .> � ^ ,. ' . :F. ... .:s :.^. ..>, ' 4. x ..,Fe „ .'iie .. . ,,: . , .. . , .Gw . . ... . .. . . . .. ._ . , , 7 i4 I( .III� t s 1 �' �i� �I � -i�w�� 1 �1 %�i� � t� II` ! ' � i � � � il u ,-�-: ir: �t� �rr�►► �Lt ,,, /G.�l( u � , � '�� ,�r- ,�� :,t _,. �':C. ___x l� ♦/ � ♦ i � i ■� .,�� : �, � ., � , � . , ,: � �� ., , .,,, � > � �„� , ,� a � , .,,,�, „ .� ... , .� � -- �� . . ,_,:. �. �:., � ,� ,>...: ��, ,_ � :r:_.�. :_ <.::, * � .�, -� , r�,r._ � — .r�!i�'�il� , . � ��'"�� _�� ' � ■ : � . ■. ■ ■. a � r . ■� , . , TQWN dF YARMOUTH BQARD OF IIEAL'TH PERMIT TO i?PERATE A FQOD ESTABLISHMENT PERMITNi)MBER #07-049 FEE: $ISQ.40 In acccudance with re�u1atians promutgated�uuler authoiity of Chagter 4A,Sedicm 345A and Chapter I 1 I,'",�ecction 5 of Yhe�reneral Laws,a pamit is hereby�ganted to: Southside Tauem LLC, 8l Kin�'s Circuit,:Yarmouthport,MA Whose place of business is: Ardeo Grille at Kin�;'s Way Type o£business: Food Service To operate a food establishment in: Town of Yannouth Pernut expires: December 31, 2007 BOARD oF HEALTH: Q i .2l. il9:`1t., ' sEn11Nc: 91 seats-dinuig room aygG�e��fe�ic, �le� �i�iAatr.h 32 seais-bar and lounge Rv�2t�. Btrocu�c, � P�M� rr��n�z�.zoo� � R . . . �� IIirector of H�ealY > > THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARM4UTH PERMIT NUNfBER: #07-00'7 FEE: $50.00 'I'his is to Certify that Sauthside Tavern LLC d/b/a Ardeo Grille at Kin�'s Wav 81 King's Circuit, Yannouthport, MA IS kIEREBY GRANTF,D A ca�ox vicrU�.L�x�s LTc�rrsE In said Tawn of Yarmouth and at that piace only and e�ires December thirty-first 200? unless sooner suepended or revoked for violation of the laws of the Couxnom�vealth resp g the licensing af cornmon victuallers. T6is licensa is issued in conformity with the sutYio ty�ranted to the licensing authorities by General Laws, Chapter 14Q, anfl ameadmeats thereta. In Testimony Whereof, the undersigned have hereunto at�'viced their official signatures. g BOARD QF k�ALTFI: d��&c��r�xf�c� �ioe L�lusi�.n sEn'rttac: 42 seats-dinin room �a 32 seats-bar and lounge /lp�J��, ��, e(g,g� /�r�iita�/�c�3¢�to� /�.1�! Novembet27 2006 Bruce G.M�rphy, , S.,CHO Dir�tor of Heatth ' (Ftxu�ca.ut A�rti�'�� ±�Fe�'+.y TOWN OF YARMOUTH BOARD OF HE � . � � ' � � d � �° �� APPLICATION FOR LICENSE/E�i�- �� Mi:iY 0 9 2006 � �`� * Please complete form and attach all necessary do Decem r Failure to do so will result in the return of your application pac ��-�� DEPT. NAME OF ESTABLISHI�IENT: �O ff �f !.J TEL. #�`� CO �l �LOCATION ADDRESS: � 8 MAII.ING ADDRESS: i �S- A�Y.PoI . f�Lfo6 OWNER NAME: o i T ID r CORPORATION NAME APPLICABLE): ` cuJ /1 / ! (' �/ MANAGER'S NAME: � i TEL. # ,7 MAILING ADDRESS: �LjGf_ Z(o� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum oftwo empioyees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofempioyee certifications to this form. T6e 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 certi8ed as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and ma'ntain a t"ile at your establishment� �. c`�� V� C7�lY�ii� 2. �o Q� (� PERSON IN C�IARGE: Each food establishment must have at t one Person In Chazge(PIC) on si e during hours of o eration. i. c�o�� r9?�'I i CJL a. vt�ic� LRci� HEIR�:FCH 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 attaeti 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. 1. / �'l�c�Y�C J`�-� 2. ��u�� — c�. �(,oc�� 3. 4. RESTAURANT SEATING: TOTAL# f Z� c ��_ OFFICE USE ONLY LODGRVG: LICENSE REQUII2ED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT tJ LICINSE REQUIl2ED FEE PERMI1'# _B&B $50 CABIN $50 MOTEL $50 _INN $50 CAMP $50 _SWIIvII�9NGPOOL$75ea. _LODGE $50 TRAII.ER PARK E50 WIIIRI,POOL $75ea. FOOD SERVICE: LICINSE REQUIItED FEE PERM[T N LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMI1'# _0-100 SEATS $95 CON1"INEN1'AL $30 NON-PROFTT E25 �>ioosEnTs siso (0—l7� Ico�oNvic. aso O6—(0� _u�oLEsni.E s�s RETAIL SERVICE: LICENSE REQi1IItED FEE PERMIT'# LICENSE REQi1Il2ED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# _dOsq.ft. $45 _>25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. . S75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ 2.00 . �� "••""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""""" � ., . ADNIINISTRATION ' . Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. 'I'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFP'IDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior t renewal or issuance of your pemvts. PLEASE CHECK /R APPROPRIATELY IF PAID: YES ✓ NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILiTY TO RETURN Tf� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31;2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf-IE BOARD OF HEALTH PRIOR TO COD�NCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been ciosed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. 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 Pemvt until the above terms have been met. -- ----------— _ --- _ _ _ _ __ OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must haue prior approval from the Boatd ofHeahh. OUTDOOR COOKING: Outdoor cooking preparatioq or display of any foo rodu b retai food rvice establishment is prohibited. DATE: 5� � '�l0 SIGNATLJRE: PRINT NAME&TITLE: cTo 1 09/28lOS . ' � The Coinmonwealth ofMassachusetis Departinent of Industrial Accidents Nf�c�N� 600 R'oskington StreeK 7`�'Floor Boston,Mas. 02111 workers•compeaaatiuun I.sera.ce n��vk:seilai�g/e�.me;.g/Ekctrical cu■eYetu.s nata: c)�17�'l ��I�� . a�tess: �� '1�.T l.-S . ciry U � �1 �1 Y�' '� � ctah• I��C'� , zio•Q C�tX nLone#� • J/ ! � vV l / work sih lacation(fvll addassl: � ❑ I am a Iwmeowna yerforming aIl work myself. Project Type: ❑New Camshuction❑R�odel ❑ I am a sole pro�ie[or avd have no one working in�y capacity. ❑B�rilding Addition �1 am an employer providing wo�ke�s'compensation for my employees wodcing�ihis job. . ��o��: . ,� _ ._ � - - �� ,q�cDfo �r�Il� � K��tr��`� � : �o �r� ' k � � f ud. d : l�. , . �.�1D �: �euo� 9Y8� 850 � �. 2 � 1 Ybt �s w� �r� � !`( 'D3o &�85I �o � � � � .,_ . s,._ . ,. � ❑ I am a sole proprie[or,ge�a�sl eontraetor,or Lomeow�(cude owe)aed have hired the co�ractas listed below who have the following workeis'com�em4ation polices: eaomv me• addrm: �" nhare#• ieoua�ce ca. oellev N eaomv nme• a�: d�' � Na�e M� 4p��. osliev# �i11WDItiiYirYrlili�tfFl�rrry*-- . . �. . ' � . "—. .. "' ��•_—... Fa9vt Y aecR a�enae o nq�trN ode Sarir 2SA�(MGL 15!eu kad b IYe I�MIM daf�iY pmNin�f�Le R b f1,3MM+�dbr� encynn'ImprYountaswe9ndNpeWtlnlstreNr'e[a3TOrWORK08DERud�BxdS1M.Madryapinc.a IudaeeWt6�ta upy Ntlh MatraM vy be farwaM[d b tAe O��e NLveatlplMn a[He DIA fir wYenge veeientl�e. !lo h y �eeeNiu n./'PRl+�Y dY�Me]wforwdlon proviJad ebnne is bve aiAcerv[cG �� n �5-�=Dlo PriM nanx \ P6one# �(l�' ��/� V�/ I 1 w�aid ex oaly do net wrke Is Uh�n to be eamPkied bY dlY or wirn a�eil dly ar fawc ��p �� ❑cYect HlmsaB�Be'e�eme 6�MM�� dMmn O�ce ❑HaMY De�atds� eeMaet penea: Pg�p: �Q tti.sw sm�.zam� TOWN OF YARME3i7'I`H BOARD t?F FIEALTH PERNIIT TO OPERATE A FQOD ESTABLISHMENT PER.MITN[.JMBER: #06-175 FF;E: $150.00 �n acuxdance with re uons pzamulgated unde�authonty of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of the enerai I.aws,a pema�t is hereby granted to: Southside Tavern LLC SI Kin�'s Circuit Yarmouthport MA __ Whose place of business is: Ardeo Grille at Ki 's Wa Type ofbusiness: Faod Service To aperate a food establishment in: Town af Yannouth Peanit expires:_December 3] 2006 }3oARD oF I1F,AI.TH: B��ei�� /l�`�., . .1Y. ?Ja�a Gf&ai.t�►ra,w SEn7'nvG: 91 seats-dining mom ({o�s+ft�• ��, ��T' 32 seets-bar�loua8� pa}hfa� c�Pltaro� � R.N Mav 9,2006 � � y g_ ., Director of Healdi THE COMMONWEALTH OF MASSACHUSETTS T4WN C}F YARMOUTH PERMIT NUMBER: #06-106 F`EE: 50.00 This is to Certifp that Southside Tavern LLC d/b/a Ardeo Giille at KinQ's Way 81 Kin�'s Circuit Yarmouthport MA IS HEREI3Y GRANTED A COMMON VICTUALLER'3 LICENSE In said Town of Yarmouth and at that placz on2y and e�cpires I}ecember thirty-first ZOOb unless sooner suspended ar revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensiqg anthorities by Creneral Laws, Chapter 140, and amendments thereto. In Testimony VI/hereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEAL'I'H: B p��2��. Cj'oulo�r M..`b., . SEr1CING: 91 SeatS-d�ritltg IOom <�Rp�o►u.+ei Ff.tY., ?/la�G�&r.�t�rcur. 32 seats-baz and lounge Rod�t 4. B�,o.�,.� l�l�k J1a�o�klcJie.:n�o# !jg �, R.N May 9.2�6 ruce G.M ,R.S.,CHO I}irc�ctor of H TOWN OF YARMOUTH 0`1 —+ O .- ""TH;o 1146 Route 28 South Yarmouth MASSACHUSETTS 02664-4492 _ c Telephone (S08) 398-22' 1, F.,xt. 268 267 -Fax (508) 3)8-2365 New Liquor License APPLICATION FOR: IDC, Inc. (at Kings Way) NAME OF APPLICANT: Joseph J. Jamiel, Jr., manager (508) 280-7333 Contact person: Leland J. Adams, Jr., Esq. 317 Scargo Hill Rd, Dennis, Ma (508) 385-7666 DBA: ADDRESS: 81 Kings Circuit, Yarmouth Port, Ma 02675 NAME OF PROPERTY OWNER: Kings Way Golf Club, Inc. Date of Selectmen Hearing Tuesday, May 23, 2006 * * Please provide the board of selectmen with the new occupancy based on the Proposed Expansion/Addition of the premises including deck or terrace. * * Board of Health Comments: 10 S ezt C2, r -t- do Cj �cttia.Yei� rL�aa ,'fit (�i ,E Signature: Accessibility: Front door ramp: —Yes—No Alternate door ramp Yes No Wheelchair accessible bathroom Male: Yes No Female Yes No )Need completed form by Thursday,May 18, 2006 Date: 5— 1"` A, r Rev. 5-06 golf cart storage area EXIT lockers employee bathroom employee bathroom sprinkler room hallway )rinkler room EXIT kitchen storage I kitchen storage walk-ins I stairs �ACOR- Vjs (MV CA cAJkx Row, P1i -kA- %efc NALLVW EXIT )INING zoom EXIT FKLDA AY FOYER FO) EXIT I MR1 EIV I' RS