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Home My WebLink AboutApplications/Licenses/ � l.. - ;A • »� TOWN OF YARMOUTH BOr1RD OF HEALTH �, �� c� �ly�y� �� ` � APPLICAITON FOR LICENSE/PERMIT�2 00 � �- ��' � �� !G�l 2 ? L'U0� ~. * Please complete form and attach all necessuy �t �e�ts b�'�� I S 2008 Failure to do so will result in the retum o �ur a�pl`I`cahon pack . - � � � ' NAME OF ESTABLISHMENT: ' RS'7 TEL. # �/ — /�" J J y� LOCATION ADDRESS: � MAILING ADDRE : 4 S OWNER NAME: D FEIN or SSN : CORRORATION NA E �IF APPLTf e RLE): MANAGER'S NAME:_��(t � TEL. # Y e7 .0 MAILING ADDRESS:� ��p�g,/�,St "�f` POOL CERTIF'I�ATIONS: ��y The pooi supervisbr must be certified as a Pool Operator,as required by tate law. Please list the designated Pool Operator(s) and�attach a copy of the certification to tlus form. 1. 2. ��. Pool operators must list a mii�amum of two employees currently certified in basic water s ety,standard First Aid and Community Cardiopulmonuy$esuscitation(CPR). Please list these employees below an ach copies ofemployee certifications to this form. The`�Iealth Department will not use past years' records. must provide new copies and maintain a file at yaur place of business. �\ � L � � 2. A 3. \ 4. . FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. ��p'�� 7�}� 2. � �[j��if�� PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. l.�a �� l�,, ,r'�J.A 1�.� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list yow• employees n•ained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You m�si provi3e uew copies and maictain a file aY yone�la�e of basiness. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGL�iG: LICENSE REQUIRED FEE PERMIT# L(CENSE REQiIIRED FEE PERM[T# LICENSE REQUIltED FEE PERM[T# _B&B S55 _CABIN $55 _MOTEL 555 _I1V1V S55 _CAMP S55 _JWIMMINGYOOL SSUea. _LODGE S55 _1RAILERPARK 5105 WHIItI.POOL S80ea. � F�OD 5FRVICE: LICENSE REQUIRED FEE PPRMII'# LICENSE REQUIItED £EE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS 58> _CON"I"[NENTAL S35 � NON-PROFfI S30 �'O�l'O _>I00 SEATS S160 _COMMON VIC. 560 WHOLESALE S80 RE'IAIL 5ERVICE: —RESID.KITCHEN S80 LICENSE REQiJIRED FEE PERMIT# LICENSE REQUQtED FEE PERMIT# LICENSE REQUIRED FEE PERNRT# _bOsq.i't. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25 _QS,OOOsq.ft. S80 _FROZENDESSERT 540 IOBACCO 555 �AIZE CHA�GE: S10 AMOUNT DLTE _ $_,,30.Qp ****•PLEASE TURti OVER A1VD CO.'1�LETE OTHER SIDE OF FORM"••** � � . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue 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 Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transiem occupants must haue 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 � by the Health Department prior to opemng. Contact the Health Department to schedule the inspection five(5�days pnor to opening. PLEASE NOTE:People are NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CT.OSING: 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 norify the Yarmouth Health Departmern by Sling the required Temporary Food Service Application form 72 hours prior to the catered eyent These forms can be obtained at the Health Departmetit. _ - FROZEN DESSERTS: Frozen desserts must be tested on a monthiy 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 revocarion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHeahh. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILTI'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 EQUIPMEN'T,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. i� DATE: !1 ( � SIGNATURE: � PRINT NAME&TITLE: io zvos � � � Tl�e Commanweaith of Marsachusetts Degantmpet ojladustniat Acciu(entc �� 60b R'ashingJon Street, �k Floor Boston,Maas 02111 Workers'Compensation imwranee A�davk:Boildieg/Plambiag/Eleclrical Co.lnctors .,_.._�_.e..L�....v. Pleas PRfiNT 1�dbtY „�: i.v S �� .�.�`�.__ _ _ e: .r.r. �; . G 7 �� —� y`/��J,J'7�`' ��g�e�i�ti�r�u�sr ❑ I em a Iwmeowcer perfiYxming all wak mysdf. ProjectType: ❑New Consttuctiam�Remodel ❑ I am a sole�pxo�ietor and Lave no ane wozking in any ca�city. ❑Building Addition �am an employer providing workers'cclxnpensation for my employees wodciag on tltis job. � m asme: � j} ! r 3 � �a: � "�U�' 7 71� �I�f0-- '�jC��2/y ' t/fI v � ...- . . ., �. � :.. . '.�.c . ,s . ;,ce., , ,� � ._�W> a... wk�axa k�+v.�. .,f� (� I am a sole prc�ietor,geaerai eo■trsctor,or bomeawwer(cirde anej aad have Li�ed the coNracwcs lisWd below who 6ave t6e following wa�kers'eempensation oolices: mne�ay�aue• � � a+idrrra• . � - — � . fi� . . . � ��, . . . . � . i��eeta. ., . oeit�.# . . ., . � s .�.g, x.a,. �_ .�..� � . . � � � " � . yylite�• � . � � . . . . . � _ . _ _ —_. _ _. __' ___—_. - _ . . ... _. __. __.. . __ . .. .. $ �"�.��i. , e^y tY �?M. ,.'4+?' �. Fdvmaxemeavve�a6casraqd�edudes8eeriwssA�rMGLu2mkaas.ueisp�.Itlwdair6a�pnWin.taJf�e�past,SN.N,.at�r . mrm**'�w..e��,oa.�awa..xw�neterm.r:s�rorwowcotro�s.,.a.�.tsxw.ee.a.y.�.a ioar�r..eu.�. cepy.rW.Na�maNmy6er.r...MedbcecOmao[trve�tl.natl�nura�cavenger�a�w.. � /da Aerrby xnfer tM��Met dYs U.fmiwmtaa prowlded abaar�e d,�t»rrert: � . ��-=�"�" .. � . . 7 �P � Dare �n �P ` `" � '��}� P��._,�y �-}�(�6Af c�e�� eb��x d�f-. __ � O � .` o�l ese.uty eo ua wd�e is tels.rea lo de cow�kf*d bs.dlY er rwn.mrW . . . . aity or tewn: � . . �d �BoYdini Depatbment e Q��6� ❑cMat itimmeALee td@amt is tcq�red � �`+�R � � � �ki Dqatibt uWet¢qaw: �#„ � i�a su mm, a�rls.lt�� xa:ay �r�iz��i�ua - _ ca.e+itK ra�. v� ACDitl.? CE6tTIFiCATE �F LIAB{LITY INSURANCE � ""°g,`�' '��R �scErr�+cn��s�u�nsnewrs�taF�ar�w a�e.r ana coup�ts ao�s uaa�rMa csitr�ca� +�BS. �. Haxflek Z&6uxance Ager3c�* NOLD6lE7ti�t�7R�lCATE�ta01'AMiND.EX7END dt 31]. Plyaouth Strn�t . ,lU.TERiHBCOYERlYdEAlMCRD@U9YTf�'POLiCES6R.CAA1. 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S_.. _.._. �a�nnTnn s a . lwcyru�xs�xitnpteWro ; � � � S 8 `��-��,�� ;NICV0034640- �� i p6j30j08 d6J80/0$ P.i.G�cx�ccoda �i$OO.00D , � ea...nwune-s1 s 80Q OGD s�t��a�Wva�r,x.S�r � tea.�•oaacvwf t500 O80 �� r . ` t j � j � O�' f10NOROPatY4T10Wl�TCNSFYtlMClEB/E%CLWKM�BAMEC�1' il�IRL � � - G�� +g !Xp{k�DM1Y�T11@�OE .S�NBdA1�GLIC�S�CMIC9.L�lLR0116itiE C/1SOTtM1SE6F,Ti@�'6iRIAi@lYlN.46�IqYAWMtOLLN. SQ DAV5117itlTE! .'. XD7ICIK 70TNEtER�MMA16f�D�NR11EE70TNEA6RT.MIh FW.tN1Etd ti0 LPiMa4G RIFOBE YG OBU011YWM MS LNtQ4iiYCP A11YiW144U'Ok TM[�,f!$Mof[i dR � - q@N6581fA71YB8. 1 A1f[114N�Y '!M � t6sr . o t ,0.�E�RD 25(tCSttiGB} �1iG4XQ TiOPt 5886 TOWn OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-039 FEE: 530.00 In accordance«-ith reatdations promulgated under authoritp�of Chaprer 94, Section 30�A and Chapter 1]1, Section 5 of the �`General Laa•s,a pennit is l�ereby granted to: Cape Cod Child Development Proeram 367 Route 28 South Yarmouth MA Whose place ofbusiness is: West Yannouth Pre School Type of business: Non-Profit Food Sen�ce To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2009 BOARD OF HEALTH: .`�EeB¢fi SRaPt, JZ.✓V., CPaixnuat Restrictions I�o fwola�or: \o ecill. 52o6ent �xa�un, C�enPt`ce Clfawunaa ��J2.rV. V'ovember 26 2008 ruce G. Murphy,p ,R.S., CHO Director of Health ' ` . �� Gcc� Jt YAk TOWN OF YARMOUTH BOARD aF'HEAL�'H "�� ,`�(1 f ?� y�� s APPLICATION FOR LICENSE/PERMTT-2008 � �CA� , � � � 0 M L DD � � i ��.. '� Ptease complete form and attach all necessary documents by December 3 , ��C 1 4 2 0 0 7 F a i lure to do so w i ll resu lt in t he return o f your application packet. T. NAME OF ESTABLISHMENT: � TEL. # - 0� LOCATION ADDRESS: .� _ w , MAILING ADDRE S: OWNER NAME: � X F IN r SN - — � , CORPORATION N E F APPLICABLE): �- -- MANAGER'S NAME: N' TEL. # 5a�- 97s"-/.�,S�U MAILING ADDRESS: �� POOL CERTIFICATIONS: T6e pool supervisor must be cert�fied as a Pool Operator,as required by State law�. Please list the designated Pool Operator(s) and attach a copya the certiScation to this form. 1. 2. .-- . Pool operators must list a minimuxu of tcvo em oyees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation( ). Please lisy these employees below and attach copies ofemployee certiScarions to this form. The Heaith Departm t well rrbt use past years' records. You must provide nen� copies and maintain a file at your place of busin I. 2, 3. 4, FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time 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 certificaEion to this application. The Health Department rvitl not nse past ye�rs'records. You must provide new copies and maintain a file at your establishment. 1. G �Ci � ��2ff'2 2. PER�(9N IN CI�IAAGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.��4•a6� ��-� 2. HEIMLICA 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 yes►rs' records. You must provide new copies and maintain a File at your place of business. 1. _ 1� 9,�i J6}/FfZi�, 2. 3- 4. S AT G: TOTAL # OFFICE USE ONLY LqDGING: LICENSE REQUIRED FEE PER131T?� LICENSE REQtiIRED FEE PER�III'� LICENSE REQL'IRED FEE PERbi[7'_ _B&B S50 _CABIN S50 MOTEL S50 _INN S50 _CA.'4fP S50 _S\�7�LbIING POOL S7iea. _LODGE S50 _TRAILERPARK S(00 �i7-IIRLpOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQIIIRED FEE P£RA9T�� LICEtiSE REQtiIRED FEE PERbfli= _0-(OOSEATS S75 _CONTINENTAL S?0 LNON-PROFII' S25 �OS-�3'� _>1005EATS 5150 _CO:�I.YIONVIC. S50 �YHOLESALE S7> RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUQtED FEE PERMt7= LICENSE REQL7RED FEE PER\417= . LICENSE REQL7RED FEE PER4III'_ _<50 sq.R. S4i _>25,000 sq.8. 5300 VENDItiG-FOOD S?0 _QS,OOOsq.B. S75 _FROZENDESSERT S3i TOBACCO S50 �iA:�CHAVGE: S10 AMOUNT DUE _ $ ��'-S .00 *"*"'pLEASE TCR.Y O\'ER:1_\D COJiPLE'IE O?HER SiDE OF FOR�I'^^•* � • ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED O Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PI.EASE CHECK APPROPRTATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principa(place ofresidence elsewhere. Transient occupancy shall generally refer to conrinuous occupancy of not more than ttrirty (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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transiem. * NOTE: Enc�osed Motel Census must be completed and returned with this app�ication. POOLS POOL OPENING: All swimming,wading and whirlpools which have bee,n closed for the season must be ins by the Health Department prior to opening. Contact the Aealth Depaztment 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 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 Heakh Department by filing the required Temporary Food Service Applicarion form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heakh Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Pennit umil the - above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking preparafion, or display of any food prodnct by a retail or�'ood service establishment is prohibitcd. NOTICE:Permits run annually from January 1 to December 31. Tl'IS YOUR RESPONSIBII.ITY TO RET[JRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIStIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME:VCEMEVT. RE_VOVATIONS MAY REQUIRE A SITE PLAN. DATE: ! SIGYATURE: C�I PRINT NAME&TITLE: '(�fi�� "� �-�'b�� io:o o� ��''r�'� '�\ The Commonwealth ofMassachusettr DepaRment oflaahishial Accidents Mlfe�Niw� 600 R'ashirtgton Street, ��Floor Boston,Mass. 02I71 Worlcers'Compeesatioe I�svaace ABi�vih Bo�diag/PlambieglEketrical Co�tractors name: [,� PS t �/��/�j17 s 4� /�.SCQ!�l address: , J�-7 /C .f Y� � citv W,Q S(� ��A_� cta(c•�/� t ' zio� oo.(0 7�7 �hme# `��/O'�(p(p/� work site locati�ffvll addfessl: ❑ I�a 6omoowner perfoming all work myself. Project Type: ❑New Constructi��Remadel �❑ a sole proprietor aad have no ame wo�cing in any cap�ity. ❑Birilding Addition ��PbY�P�'iding wakeis'compeasati�for my employces wodcing�t6is job. com umr :��. ad�h'�eu' �3 �. S� ' . . � .,��'/t.�.o.o - D�tled 1 �a• �� 7?f��v��0 —b�cl-�I y j..�� /� l �h�t. �' ff1 w�s� f�tl�-✓o03� 6�U � _.,� . �.r . . .F _�.,--.�.�.�. .,;�. ❑ I am a sole proprieWr,ge�eral eaatraetor,or iomeoweer(endt oetj�d Lave hieed the contracWis listed below who have the following woik�s'compensation polices: �mnuv nme• � � . ad�ress•, �' �e/� iuea�ea � � natlev# �v ume• a_d_d�q- eiN: �..�p� � iuva�cete. - ��g - ._._.---- _ A�Eii��wR/flieYre� � - . ... _ �� Failve U xeae c�ea6e o�eqd�M oJv See1M 25A dMGL LS�n�Iwi M IYe h�pwitlr dari�Yal pnWp�f a eee�b f1.3M.M odhr.:�. oa r�+'�c�•oee�...b n dw��,m ue rw.eta sror wowc oxoea..e.e�.tste�.e�,a.y�ame.r. i ma�.sr,w eru. cepy o[tlN Weeoat yy be feewaMM b Ne O�.e atlweMieatl�m e[tk DIA flr twerage veri6atls�. /do Aa+�y ceiO'J'yy axder Me pst/ns awl penehka o.(Perj+/r}'Md Me iefora+eflva provl/el eborr 8 trae w�d rorre�et Sigoamm��1011' Q.1 'yjxi�D�� Date �Z�� Prim na� r . C . .. . . Phone#� 7 (O (� ��'o?�� e�da�ox..y ao na wrke m wh area m ee eomqMed Ds dtY or rwo e�sl � dty ar tewa: �p ❑ch[ek if�aoditle re�peme is req�ed ��e+�Board ❑Sd�'t O�ce �� ceehet P�� p6oae M: �Q 1��1 _..� :;'Rx"fje#elTim� _ A�G-13-2007(MON) 13�37 178129313� P. �1 , 88I1312007 13:18 178129313H0 BORF�K PAGE 81 s�ca.R_o_ CERTIFICATE OF LIABILITY IN�URANCE ��i °g�°a r�� 1HIS CERTfl7CA'PE IS�N1ED AS A MA77ER idF�ORMkTIqr � pNLYANO CONF'feR3 NO W6H7$UPON THE CER71FiCATE SPM. P_ Borhe# YnBuraaCe Agexiep HOlDfrR.TH1SC�RTffiCAT�ifOr.''4NOTAMEf�.EXTEN40R 3I3 Plymoath 3hreat pL7ER TX@ 6m/ERA6E AFFlaROEp BY 7HE pOLlCIES A@I,OW. 8alifax MA 62338 Phoae: ?$1-293-6331 Bax'e761-293-2171 y,{�U1��SqAF�pRp�NQ�py�p(;g �; rnsurreo � *�xn: atii7.ade]. bia lasurancm Cage Cod Ch32c1 Deoeiop�nt '�Re Atlantic Chazter Fro mmt Iac_ �c: IItica HaXioasl 2nanranca p 5976 83 �earl St. $�a�,,u� aw o2eaa "�a coveRacEs �� n�rouc�s aF��a�ow wv�ecs��To'n�r+e�s+�ww�oneovtwoKnrt ooucrv�aoo�rw,un:�r�r.sr� ANV REQYW&MEM�7FRHORd�YWiION�NNC COM[MCTOR4TNKROpClPB1i MS#I�CTTO WF9UITWBCCRlCIGITE WT�6947EV Wt I�ATPERTRkY.7�1ElV�NI�ARfqfq(iV HYIHEPOLK.'�BO�ii&�NiS�tI6iH.'TtOALITNHT6FNS.0[Q.UlON$#NO�OG M1t POL�IES.AOfiRE6F7E tIMR391W WNYAY w�V@ BFEHlS�II�DBY PW 4Y.aaQ. - TR 7YPE�9i�Rpi�E FOLKYIRi�BBt 7Lr IAYT8 6i�«�^�'+' �n+ocawaEr+a s 100Q004 A x w�o�uncutc,�antcweqmr pgggg7g267 �-06/25/D7 06/25/08 s100000 , CwuswoE $�Ccart ,. �sr� p� . s9060 a abnae & moleStati � � � �pwxcnww�v a 10000p0 � 66NetW.AC4�6ktlE i 30tl6808 ��'��T�� IPRDOIIC.TS•COWOPn66 53GDOOpO rocCr cac wro��e uaannv - L'" u++'�4 8AC 1$3$2$9 66JI4/0? O6/14/OS 1:�i°�'"y�� S1,O�O,C04 u�av�owms emcv�xnmv x scr+�ou�mnuroz �.a�•xrsen� . t � E �aawntnos . % NON�OytN�lAutO$ ��-W�ealae� S C !t�,"��°n""u� s cuw�cetraa¢rtr � �urrornav.��xr s �wrarro � �� i �� nec s " �i.uuawu[r . Su�tro� 3-� 400 D04 A % axw �annswwo� pg'pg064590 06/25/q7 06/Z5/OB n�� s 3,000,000 . Ofij25J6?- � 3 . � � 06/25/08 s �na� s s .�woa�R9 c�at'�s�Troe allo $ - & �� WC�/0834640- 06/30/07 66/30/49 6.i.�xcro�nr s5oo,ap0 a`R�'��4�d+ � e.�.daF�-nn i5G0,40D s+�'��w+o.�aa`�asmm. ¢�oa�.aoucr�a�rt s500,000 �� OHSCRIWTWN05OPERAiq!l67lOGATWN$lYBiCWESJ!'Xf'AWIqIPdA00ED 8Y b7WI�A8M7/BPECµ4 PROYq10118 ,{{ CER71FlGfl7E FiQ4UER ��Et�A'fipN . . , sHoui.owaos�rnE�ebve�Dvauc�98Ec�tEOaEFortEn+ee�niq oaret�.aff��sw�+dret�wn�owe� 30 o�rswwrrer �. _ ._ _ � � aarc�Tan+�c�ancicn��wnttxw�m»��.ar.mhrrm.�rouasoswu.� _.__. ._.......•.... .. ��OSEMOOYM�uM17CMORWW.I7YGFANYq1AUVONTNEW&1REN.17311GEMSOR AEPIlESPITATN@5. NifklOf�O REPRE�Ii'A'fNE --- -.. _.____.. ._ . .. .__._.____..._.. Merle D. Ott ACORp 25(2001J08} . . � ,, � �qCORp GORPORATION 1568 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISI��ENT PERMIT NUMBER: #08-084 FEE: $25.00 In accordance with reQulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 11 I,Secrion 5 of the�ieneral Laws,a pernut is hereby granted to: Cape Cod Chitd Development Program, 367 Route 28 South Yarmouth MA Whose place ofbusiness is: West Yarmouth Pre School Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD oF I-r�ni.1'[i: ,�EeP,en.SRtaRr., J2JV., C'haittmaa C�'dR��a��x��"e"�a��""��"�� ,j ?I,i,ce 'Ufnix�nan RestricRoas: No fryrolator; No gill. ,npfiGW,�',,/yµkU(L C,CPX�L Q�tn C�xcen6atutt,�`J2..lV. December 28.2007 _ Bruce .Murphy H,RS.,CHO Director of Heal � � . c�o55� �� r � � �- �'_ _' - �- ��R o TOWN OF YARMOUTH BOARD OF HEALTH `' �2��s APPLICA'I`ION FOR LICENSE/PERMIT-2007 f U E C 1 1 2006 �' . * Please complete form and attach all necessary documents by D e p,��F3Q�4PT• Failure to do so will result in the retum of your application e . NAME OF ESTABLISFIIvIENT: GU S TEL. # 5��'�TyU'7�J LOCATION ADDRESS: MAILING ADDRESS: OWNER NAME: T r CORPORATION NAME IF APPLICABLE) � ' E�rY�i MANAGER'S NAME: /IICc L. # MAII.ING ADDRESS: ,�/fima_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as requirect by State law. Please list the designated Pool Operator(s) and attac a copy of the certification to this form. 1. 2. Pool operators must list a ' um of two employees currently ified in basic water safety,standard First Aid and Community Cardiopulmonary esuscitation(CPR). Please list th se employees below and attach copies of employee certifications to this form. The ealth Department will not us past years' records. You must provide new copies and maintain a file at y ur ptace 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 Establistunents, 105 CMR 590.000. Please attach copies of certification to this appGcation. The Health Department wiil not use past years' records. You must provide new copies and maintain a fde at your establishmenG 1. 1 L�} �1,..�� X}L� 2-A�. 2. ' PERSON IN CHARGE: Each food establishment must have a one Person In Charge(PIC) o site during hours of operation. 1. 2. ft`f �d, . HEIIbiLICH 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-chokmg procedures below and attach copies of employee ceRifications to this form. The Health Depar[ment will not use past years' records. You must provide new copies and maintain a fde at your ptace of business. 1. ��'(�'�/°� 2. 3. 4. RESTAURANT SEATING: TOTAL# — /� �) l OFFICE USE ONLY LODGING: LICENSE REQIlIl2FD FEE PERMI7'# LICENSE REQiJIItED FEE PERMIT'# LICENSE REQUIItED FEE PERMI1'# _B&B S50 CABIN � E50 _MOTEL S50 _INN $50 _CAMP $50 _SWIIvIIvfII1G POOL$75ea. _LODGE $50 _TRAII,ERPARK $]00 WHIRI,POOL S75ea. FOOD SERVICE: LICENSE REQUII2F.D FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# _0-100 SEATS $75 _CON1'ININ1'AL $30 LNON-PROFIT E25 ;fr 0�7'OS� >100 SEATS $150 COMMON VIC. $50 WHOLESALE S75 RETAII.SERVICE: —RESID.KTTCIIEN $75 LICINSE REQUIRF.D FEE PF.RMIT# LICENSE REQUIl2ED FEE PERMI1'# LICINSE REQiJIItED FEE PERMI'L ii _dOsq.ft. $45 _>25,WOsq.ft. 5200 _VENDING-FOOD $20 _QS,OOOsq.ft. S75 _FROZINDESSERT S35 _TOBACCO S50 NAME CHANGE: $]0 AMOITNT DUE _ $ 25.00 ""•"pLEASE TURN OVER A1VD COMPLETE OTHER SIDE OF FORM'`•"" ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or 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 INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PL,EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTBER LODGING ESTABLISH1l�IENTS - TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motei and hotei use. Transiem occuparns must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generaily refer to continuous occupancy of not more than th'vty (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 coilection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be wnsidered 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 6ve(5�days pnor to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereatter. POOL CI.OSING: 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 Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Depa�tment. 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 Board ofHealth. OUTDOOR COOKING: Outdoer cooking�pr�par-atien,-or display ef any food grodust by a retail or food service-establishment isprehibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TI'Y TO RETURN Tf�COMPLETED APPLICATION(S) AND REQITIItED FEE(S) BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIl�IENCEMENT. RENOVATIONS MAY REQLJIRE A SITE PLAN. __ DATE: SIGNATURE: � T/ec Commomvealth ofMassachusetls Departneent of Industrial Accidentc �� 600 R'ashingme Streey f"Floor Baston,Masc. 02111 - Wo�icers'Com tio�Lsva�ee Affid�vik B�7 ' b��giEketrical �tractrrs .. . , ..Y�. . .��v� wrr��s.x e:r>§�ar � >.� v,;.'��,sr. .... ._ ._. . .� � �: / — .�� eaa�g: � S' ' u�� y/�'�-� �3 ' -' �a � - 7 S`lvd a �n�x i�a�r �Sr. / c XT.�-/f ❑ I mm a homeowar performiog all wak myself. Projecx Type: ❑New Caostiucti�ORanadel I am a sole and have m ome w in m ❑B ' ' Addition ❑ I am an e�ployer providing wa�keis'compeasation fce my�ployces wodcing on this job. . . . . ��• .��,i�I(1 k.S A�YJ:il.l. ',�_ � . . sditer�• � � � ��s - �� ❑ I am a sole propridor,gwenl co�tracter,or komeow�er(urcle awe)�d Lave hrtad ihe wntracwis lis[ed below wln have tlie followmg wakas�compe�sation Pulices: � . cffis• nlref: � N aaeorv�se: ad�: �: �r9: _. . _._ -__ .__.._ _. .__.. _--- ---- -._ __. . _-- _ .___. . _ .. . __ . . _ —_ .._----- ---_ .. . M FaNre i�aave erverqe u teqiN dv 8ce1M 2SA d MGL 1S2 m IM q Ne E�p�i1M da�iul psdtle d a 6e�bSI�M.M dl�r at yetn'IsptY�ant a wN a d�i penitln 1�t6e fir�af a 31'Or W08K OSDP,R ud a B�e sf S1BS.N a day�� 1 oderiad HH■ npy�lib Mai�eet ry he fi'waM[A r Ne 6mee stlaveMlptlwe KUe DIA flr e�rerage verNnWa !rn heroay ce.tljy r,.ae.Hie p.G�..eapen.rnra oppeywry ud M.;qja�wrbw y,ov7rer aboMe 6 ave nd mr.eet Sig�oee IMte /� / Prietname AF'�– CC�iC�� Phom# �d C �)��df �/1 � �ot� .ma�.xo.ry a..�..dr�rmx,.�roe�o.Wmanr�xr.rw...m�d cuy or tewa: per�kl6oeae i fl�e ucpndmt D�Yeeflm�Hsvd ❑�at Ki�eA�t mpsne h reqahal ❑Sdx�'s O�ee ❑�� nNaet Pensa: Plwe N: ❑OIYQ lrt+i�d Sqt 2�3) Rx Date/Time .JUL-12-2006(b�D) 09:47 7812931300 P.� 07/3Y/20�6 i0:17 FA% 78129a1300 BOAHER YNS. _ �005lOOJ ..ACORO CERT"IFICATE OF LIA�lLITY INSURANCE oaio s °°'E,^'�"°°�''� CAPEC-1 07 12 06 raooucErt TNIS CERTIFICATE f51SSUED AS A MATTER OF 1NFORMATION ONIY APiU CONPERS ND RIGHTS llPON THE CHRT�F�CATE WM. F. Borhek Inaurance AgenCy HOLDER.THIS GERTIPICATE DOES NOT AMEND,EXTEN�OR 311 P2ymouEh Street 11LTERTHECO`/ERAGEAfFORDEDBYTHEPOLICIE56ELOW. Hali£ax MA 03338 Phon0:�81-293-6331 Fax:781-393-2171 INSURERSAFPORDING COVERACaE NAICp . N/SUR60 M15URHiA Fhiladel hia insuranee �xsurssae: ,Atlantie Chartez Cape Cod Child Development ��. —""`-" Pr03x8m IRc_ � -- -- Hyannis1MAtU2601 - wsuaEaa: _ .. . -- - ws��rx e COVERAGES TH£POLICIES OF INSIIRANCE LISiE086lQW NAVE BFEN ISSUEO YOlME M511Rm NANEO ABOVE FORTXE POLCY FEiiIOD INWCATGO.NOTW RH£TANpWG ANY REGUIREM2Mi.TLRiM OR CONORION OF M!Y GOHTR4CT tkt OTHER OUCUMlM WITi1 ftESG2CT TO WXIGH Tl115 CERTIfiCATE MAY BE 63UE0 OR NqY PERAUN.THE IN^a11RMICE AFFON�EO eY iHE POLICIES 06�weE0 HER6W IS SU47�CT TO��TMfi TER/A$,WcCtV$�0�13 M�D COND�I'70N5 OF SUCH PoUGIES_AGGRfiGA7ELWR5 SHOWN MA'!MNVE BEEN REDUC�9YPAIDCWMS. LTR INSR ITPE OF WSURANCE pp�ICYNIJMBER pp��•E�� OwTfi� -"_' UpVTS G�� ' EncnoccuwzexcE '41000000 ._... A X COMM6HCMLGENEHALLIA91L17Y pFTP8175287 06/25/06 06/25/07 vqeauss�s�vzt �%100000 _ - ��u�n�ssen�Eaoecur¢. w�oEzr�nmarxoerwi �55�0� n� % abuse & moleetati P&RS@1PLdADVWJURY_ S1ODOOOD GEt+Ewu.n66REWrE S 3000000 GEN'IAGGP.EGAIELIMI7APPIJESPER: FiiODUCTS-001APlOPAG6 S�OOOOOQ GOLICY j� LOC AVfOM09dELWeM1RY COMBME�SIPiGLELIkR S (Ea acc+drnl! awYnyTO AtIOWpE0AUT05 BODILYp1JU� _ IPs PefwN L.CHEDULFDNROS � HiR60AUTOS B�OLLYWJtlRY S - fPe(2MOBM) .. NON-0WNEDAU705 '— - PR�PER7VDRIA0.GE f — . lPsrHccWmml � GnRnGEuae�ulY RUTODeILr.EnaCCWeNT 5 - �AUTO O'fNERTH+� �� 5 . At1TOONLY: qGG E Fxcess�urmrtELuu��rzr EACH oCCURRW+CE s 1,000.D 0 D A g occua ncuwsv,noe BHII8064590 Ofi/25/06 06/25/OT nacAecnTe ___ s1,000,000 s -- ' I �oEoucnai.s ' •-- S_..._..__.._ .. .- �FcfSENTION S � ' S WORIfFRSCONi6N5AT10NAND iORYLINfTS X ER 8 EM1�LOYERS'LIPBLL.fTY ry��y0034640- O6/30/06I 06/30/07 E.L,fJ�CMACCiOEM_ SSOOi000 NNY FROPRIEfOWF'AFiTHBFIEXEGUTNE . pp�K�yN�M6ERptC��pEp� E.L.0IS�ASE-EpEWP1.01'E i500,000 u}4!eexneaonne c�.asEnsE�ro�Kvw.�rt s500,000 gV��lAI,PRpV4410N8 Etlew OTHER � OESCRIP7�N OF OPERHTIONS i LOCATIDNS 7 V6wClE5!�tCLVStONS AOOED eY ENWRSEtlIENTI SPECIML.PROVISIONS CERTtFICATE HOLDER CANCEILATION gN0{/LO ANY OF TNE ABOVE 0lSCPo6ED GOLIC�ES BE CANCELLEO 9EFORE TNE EXqqat lpk ppTETHEREOF,THE IS54WG INSl1RER IMLL ENOEAYOR Tp MM 10 ONYS WRR i EN � NOTICETOTXECfRT�FiLAYfiXOLDERNAM5DTOT�LEFT.BUTFA1LURcTO0O505HALL � I�.ffOSE NO DBLIOAiIOu pRW�LRY Of nNY WNO UPON TH&INSII0.EH.RS AGENi:OR � REPRESENTATNES. AUTNOR2fA REFNESENTATNE . --_. . _-.__.. ._....___._ Mer1e n. oee ACORD 25{2001108) � �� - � BACOROCORPORATION �9C6 ��- TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHM�NT PERMIT NUMBER: #07-087 FEE: 25.00 Iu accoid�ce with regulations promulgated under authoriry of Chapter 94,Section 305A and Chaptrs 111,Section 5 of the General Laws,a peimrt is hereby granted to: � . , Cape Cod Clvld Developmeirt Pro�ram, 367 Route 28, South Yarmouth, MA Whose place ofbusiness is: Yarmouth Child Care Centei/Pre-school Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit eacpires: December 31_ 2006 BonRn oF�ni.�: B �. ��M.$., a��' -s�kr./s, K./Y.�,'U-io,s�� Rcstrictims: No&yolat� No gill. �� /I/6JJ�f1� ��i�«.. R.N. Febmary 27.2007 ce G. Mucp ry,A , .5.,CHO Director of Health � . ��K�'�V, C.C. �trt.D UEl/El• • • �R.� TOWN OF YARMOUTH BOARD OF HEA�TH + _ ,o ; "y APPLICATION FOR LICENSI�tlPERMIT-2006 r s , , ' Please complete form and attach all'�ieaes ,docaments by Decemb�,2LQ0�Q05 Failure to do so will result in tRe r�of yow application packet. y / NAME OF ESTABLISF�IE�IT: - L. # y�(ID" 7y0 � �/(0�0 LOCATIONADDRESS: �.� — 0 3S 0.�� 7 MAILING ADDRF,�SS: 5 OWNERNAME: ' c.o r — � CORPORATION N ( PLI ABLE): ' MANAGER'S NAME: /-�'� �Ct� �C; TEL. # � �b' '1 y0— �60 MAILINGADDRESS: — ss a�(� POOL CERTIF'ICATIONS: 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 miivmum oftwo employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new wpies 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 fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a t"ile at your establishment. 1. 2, PERS�I�I IN CHARGE:_ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2. 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 attaeii 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PF.RMIT# LICENSE REQIJIItED FEE PF.RMIT# LICINSE REQUII2ED FEE PERMIT# _B&B $50 _CABIN $50 MOTEL $50 _INN $50 _CAMP $50 - _SWIIvA9NGPOOL$75ea. _LODGE E50 _TRAII,ERPARK $50 WIIIRI,POOL S75ea. FOOD SERVICE: LICENSE REQUIltED FEE PERM[T# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQiTIItED FEE PERMIT# _0-100 SEATS $75 CONTINENTqL S30 / NON-PROFIT $25 �.�G-08d- _>700 SEATS S150 _COMMON VIC. $50 WHOLESALE $75 RETAIL SERV[CE: LICENSE REQUIItED FEE PERMI1'# LICENSE REQ[JIItED FEE PF.RMI1'# LICENSE REQUII2ED FEE PERMI"1'# _c50sq.ft. $45 � _>25,OOOsq.ft. $200 VE,'NDING-FOOD $20 _Q5,000 sq.ft. S75 _FROZEN DESSERT $35 TOBACCO $25 NAME CHAPiGE: E10 AMOUNT DiTE _ $ 25.00 "*""•PLEASE TURN OVER AND COMPLETE OTHER 5mE OF FORM"•""" . , . _ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernvt to operate a business if a person or company does not have a CertiBcate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSA'ITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSITRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIL,ITY TO RETIJRN Tf� COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPAR'I`MENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. AT"i" RENOVATIONS TO ANY FOOD ESTABLISIIIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COD�IlvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS - _ _ _ POOL OPENING: All swimming,wading and whirlpools wtrich have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories: CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departrnem 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 betested on a monthty basis by a State certified tab. 3'est resuhs�nust b�s�nCYta th�iea�[h Department. Failure to do so will result m 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 waiter/waitress service),must have prior approval from the Board ofAealth. OUTDOOR COOKING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishment is prohibited. DATE: Q / SIGNA'I'[JRE: ��e Cil�1`�^�"�GL'� PRINT NAME&1TTLE:��".e.� ��ti �n G� GG�� 09/28/OS —� The Comnronweahh of Massachusetis �__- _� - _ D�partweent oflndusdial Accidenls - = NbN� - - 60o wos/�ingtoe sr„ee; f"F/oo. ,,3� BosTat,Mass. 82I11 � Worlcen'Compe�saho�I�sQa�ee A�d�vS�B�il 6uglEleeh�cal Co�trxtars � L... � .. . . , . . , .., ... 3:"� �. ..:":�, .. :�::-- s �.. � rm..N ps=3 yr name. J � � i�`uWGM. ,. � � «n. � ..�,... F �- �� ad�ess: JCo ? ��e- d-8' � � �.� t� - �-�/�-� �� t A c s � ao� o a�� 3 �� -So�- �90 -��G o ��K��m�s,u�� 5�,�-�� ❑ I am a homaownet perfo�ing all wark myself. Projed Type: ❑New Consftucum❑Ranodd I - a sok and have m�e w in� B ' ' Addition ... _ . ,. ... ..� . I am an�ployer{roviditig w�cas'compe�sati�for mY�bY�W'�o8 thia job. �� v ' � r7- �e: �r f`�v d lJ �.o.. A�CliYl I,� GtJ✓ O 3�6 OQ ❑ I am a sole propridor,ge�a�al e�tractor,or�omeowaer(crrdi o�u)and have hrzed�co�actois lia[ad below wlw have the foilowing workess'comPensaGun Polices: ��e: �: d�" d�ae IF N addrer• Mts: �{. _ __ _ _ _ __ g _ Fa�aeYa[e�e . . .s . � �_. ... a..e.s� �yrn+urQse�r.�ts,��esct,uzo.waauet.pwr��ra�.epea��,.rai.e�asi.sn.Moarr ••�r�'dv�+a�•••�wod.��nue»�..r.srorwoa¢oxo�e..aae.�.tue�.w,a.�,�n.� isa�.w.amea dpy d Ws Wfmat ry 6e fanurded b Ne Omeee dl�ntlpWw KtYe DIA frewaa�e verNntlM. !/o hereby rnler MepeG�s owl pen�d�ojperjrry t/��Me ig(on��w�e�flo��n�re�dal abone 6 trrt pud cenect s;�an,m � ` /UC/ i=,.- Cr/GY�'+ ' l /// U/GJ/ r,�;�� e '-e ` C! �i.�it,��aa l-�P� 7��'-�.ZS6c� � ��f�iy .madoxe.y a.■�...irerws.rcae.ee�..pl�dusexrre.wn.m.w dly°TGwe: P�IBemeY ^- --• D�� ❑cheQ Himse�4 tespeme h teqoed �� QSd�'a O�ce ��. P�* �Deparhent tn+�s�maa� ,� F,?x Datel7ime �-26-2�5(TUE? �:4$ 7812931� P.�1 07/28/20p5 OS:10 FA% 78129S1a00 BORHER INS. @J001 /�CO_RD CERTIFICATE +DF LlABILITY lNSURANCE pp °"'g`""°°°"""'' CAPSe 3 0 26 45 PR�� THIS CERTRICATE IS 1$$UED AS A MATTER OR IIiFORMATION ONLYAND CONFERS NO RiCiHT$UhON TNE CER'lIR1CATE 7PM. F. 8orhek Iasnrance Ageacy HOLDER7HISCER7IFlC;ATEOOESNOTRMENO,EXTEIVDQR 311 Plymw�h StrB�t ALTER TiE COVERAGH AFFqtDEp BY 7HE POLICIES BELOw. Bal3fax MA Oz33s PhariE: 781-293-6331 Fax:781-393-27,71 INSURERSAFFORDINGf:OYERAGE NAIC# INSUR&G � INSURERq; BLiIAQ61 hia Tae. Co. +w�aERa� Utic tiaaal Snenraaae Gr u 5976 `'1�;3►MM�C �.� .::.F 01 . W+su�o: � . . .. . INSURER Et COYERA�iL'S � THE PouGES OF 1NSUPANCE LIS'fEn BEI.OW MqVE BE6N�SSUL°D TO YME NJ$URFD Nn1AEo nBOV6 FOQ�B PouCY pQ3l0O INDICpTEp.N07W�7NSTNNDIN6 ,wr wEou�t��t�r.taue orzweminaN a'urrewrrro�cr oRrn�nrfit oocuwe+rmrn aes�cr ro w�ar rt�c�anFr.sh raar eE rs�aort MnY PERTqIN,iM6 M13URqN�qFFORP�ZD ev THE YOUCIES D65CR�BEo MERFJN I&�UB�ECT TUALL TME TBRMS.E)dtU810N5 AND CqNOfIqNSOF S4C11 POUC�ES.pO�REf3RTE LMRS SIiQWN 1N0.Y XAVE BEEN REUIIt�OBY PAIO CW1AS. TR TYYE OF MSU CE Po�Y N��eR OAT�E TE �MT9 6Er�ntiA4Hrirer . EaGXOCCURREnCE S1,000e000 A 8 �MMERCIALGENERRLlV191lRY pgg�051613 06/25/05 06/25/Ob pp�r,�isss m�enm ElOtl,U00 wn�srxaoe .�occuR �oacatM+rmrea�+> s5,Q40 _ w�rssoru�saoviwwev s1,00a,000 GFr+Euw.acctt�r,niE s3.000,044 � cart�nnou�¢nni�uMrr�aar.iesrac FRODu07S•COA�IOt+AGG s3,000,000 ro��c+' �' wa 8en. 1,800,Oo0 �� S��E��T f1,004,000 H nr+vnvro HAC 1838254 06/14/05 06/14/06 �'�tl°'"� ALt OK'MEDAiRO$ 80�tY INJURY X SLN6WL6tlAVTU5 lPerDefson) g $ XiRfiO AUit'i$ � QQOILYMJURY ,� % rror�.OwNE4auras (Perxdaw) PROVEqTYOqMAGE s I�a�eaenq pnrtnceuaei�m auioOM.r.rwnccroErl7 S nxrnUra OTtlEanww �ux E aU1'O pW.r pGG S eXCESSNMBRsttaiweiurr �er�cttOCCURaF.�+cE 31:000.048 A X oct.UA �cu�Msawoe PHS18019428 O6/25/05 06/25/p6 nc�rseOntE x1,000,p00 x u6a�cnai.� a REYENTtON S 5 NWW A710MJYYY . � TaRRVt�RS ER e ��,n,�,E wvC003asaoo 06/30/O5 06/30/tl5 E.L.FACHACCIOEHT ssapao0 �ys�cGwa6Gx 5,�.asrvs�-naa�a �s Sd0004 �NiCI"i3Ee�ow� L'�.0�5EASE•PoucvUnul' S50000d GiNeR �E9CRIPnGf�)QFOP6RRi1CiN5!IOCATqNSlYENICtE9(8%CLUSWNS ADOED BY2NUORSEMExTl:%pEqN.PRDYISWMfi CERTIFICATE MOLDER CqNCELtATICiN 0000444 9NdULDAMYUFTNEA80ME0�'FCRIBEDI'01.1GIESBEGMCELLECBEFORETNEE%PIflAT10N � �uSE TNEREOF,7NE L4911M61N9UREit VMYdL ENOEAVOR TQ MnIL �_ OAYS WRII'THN M�TICElO7ME CERTIFlCATEtKA�t NA�D TO TtME LEFf�pyTFA�t/RE 7D OCSOSNALt pAP09E Np OBLICiAT10N OR W84fiY OF fW Y MNo UPON TME IN6UN8R fl3 Ac�tl15 OR RHpRESE7(A7lVE5. nUTMORIiEO REPNESENTA7IVE � 7d Se D. Ott ACORD 23(2007/OB) 0 ACORD CORPORA71pN 1988 �rowiv aF Yn�oU� BOARD O�HEALTH PERMI'C TI] QPERATE A FOQD ESTABL�LSHMENT PERMIT NUMBER: #Q6-482 FEE: 25.00 In accardance with regutations prarautgated tmder anthority of Chapter 94,Section 305A and Chapter 11],Sec:lion 5 of the Genaal Laws,a perttut is hereby granted to: Cape Cad Child Development Pragram, 367 Rnute 28, South Yarmouth, MA Whose place of business is; Cape Cod Child Development Program-Yarmouth Child Care Type of business: Non-Profit Food Service Ta operate a food establishment in: Town of Yazmouth Pennii eacgires: December 31 2046 BOARD oF�aL`rH: Bs sss$. �Yl.`.b., . ann+��Slialc, �kss G��s�C R�shictimis: No fryolatw; Na grill. �� lQrwc�ir�t�sra+r /1.N. January 12.2(�6 "�� ruce Ci.h+I , Tlirectar of H�eal�th� . CHO N�-R� � �,�� YA�'�� TOWN OF YARMOUTH � `� 1146 ROUTF. 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 H MATTACMEES � ,��e„�„�a,�r�� Telephone (508) 398-2231,Ext. 241 — Fax (508) 760.3472 G3 � t5 � 7 �9 .� �; B O A R D O F H E A L T H APR 1 �2 2005 To: Yarmouth Board of Health Permit Holders HEALTH DEPT. From: David D. Flaherty Jr., RS. �D r Heahh Inspector Town of Yarmouth Re: Federal Ta1c ID Number Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we fiunish detailed information to them regazding all permits and licenses tl�t we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIIV)otherwise laiown as yow"Tax ID Number". This is purely for aciministrative purposes onty. Some 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 return this letter to Yarmouth Health Department 1146 Route 28 South Yarniouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this �tter, please do not hesitate to call. The office hours are Monday ta Friday, 830 am to 436 p.m The telephone number is(508) 398-2231, e�ct.241. Establishment: ��b/i �i ��f7 «�'C FEIN or SSN: �� Location Address: �� GU •�'/72� , xl�- ��7� signature: _ Ptint: ��T ��lY Title: ��'1��"�J/1L� � Z�� Printed �"�� Recy Pa : `yl,.p--l�S � i°`:"R o TOWN OF YARMOIITH BOA gEA�;�JT� � � � ,�� -� � ' ��; APPLICATION FOR ? � �I�El��'�- 2TI05 � ' Please complete form and attach all nece��ents by Dec er 31,20��. Z004 Failure to do so will result in the r ofyow application pa k��ALT�H DEPT. NAME OF ESTABLISHMENT: ' TEL. #508-?90- LOCATIONADDRESS: 3�'1 Ra,�c a8� Lues�- rrb�, �L, MA- oaG73 MAILING ADDRESS: 5 ue OWNER/CORPORATIONNAME:L��e G��l� D�U�Ianm.on-1- MANAGER'S NAME: Anrn 5��-�- T'EL. #SU8�775-6a�,/d MAILING ADDRESS: A 3 PN�zY! St� }�wlnnis Mk d�/ab/ r— POOL CERTIFICATIONS: TLe pooi supervisor must be certified as a Pool Operator,as required by State Iaw. Piease 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, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PRO'I'ECTION MANAGERS - CERTIk'ICATIONS: All food service establistunents 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 certiScation to this appGcation. The Health Department will not use past years' records. You must provide new copies and roaintain a fde at your establishment. 1. f��J�-��. C��L�c.��ll 2. PERSON IN CHARGE: __ ____ __ __-- - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �i�,�- �� 2. /��ri SQ �dn�n Vic-ki 51�Nrto�r'r� 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 Departmeut will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. ��oDr�tf, �/'�sLv�(l 2. Po� /�l� 3. ' 4._Koi-�"� A�nd�?rs sy��it�. oarojinog Talsh� i-io k;m Uan /�lorrrr�, Kar�h �ic{�cv� son RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQLJIl2ED FEE PBRMIT tf LICINSE REQUIItED FEE PERMIT'H LICENSE REQi7IItED FEE PERMIT'# _B&B $50 CABIN $50 MOTEL E50 _INN $50 _CAMP $50 _SWIIvIIvIING POOL$75ea. _LODGE S50 _TRAII,ER PARK $50 WHIIZI.POOL $75ea. FOOD SERVICE: � � LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE pERMIT'# LICINSE REQiJIItED FEE PERMIT'N _0-]OOSEATS S75 _CONI7NENTAL $30 �NON-PROFIT $25 �p5-,p67 _>100 SEATS $150 COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[1'N LICENSE REQUII2F,D FEE PERM11'H LICENSE REQSJII2ED FEE PERM[T# _<SOsq.ft. $45 _>25,OOOsq.ft. 5200 VENDING-FOOD $20 _a5,000sq.ft. S75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 2S•OO ""•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM^•*•• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemvt 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 INSIiRANCE AFFIDAViT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth tasces 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 RESPONSIBII.ITI'TO RET[JRN THE COMPLETED APPLICATION(S) AND REQIJIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT TI-�HEALTH DEPARTMIIVT FORINSPECTiON 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMl�1ENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDTl'IONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparhnent prior to opemng. 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 estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Hea7th Department by filing the required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: - Frozen esserts 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 wili 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 Boud ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: /�`3'a/ SIGNATURE: �G�G�Gi/� PRINT NAME& TITLE�j�� i �I�Y.dn�ir' 10/22/04 . . —�� The Commonwealth of Mwssachusetxc �� _ Department of Indushial Accideefs � _ _ �M� - 600 R'ashington Stree; 7t6 F[oor = Bostwy Mass. 021II ,�, Worlcen C�Reaaho�t�sea�ee A�davk:Bo7 bi�glEleeurfeal Coitrxtws .._ .�: , t ._... �,.. _=�� ,,y�`... . D' . � g � - - „t�� °4�,'�°6s'��-s�.�zr�. . ., .._ . . nvuc��Ctoe �.r,-it',�,� Id �Pt.�[olJm��,-�- PlaArCu�,-, [ct�.,�fv Yi, (_��ilc� Cllr� �: 3G'� ,Pa�, a a£f s�r ��t�s� ?�a.rn,oi�,-l� �� MlF ao� a�G73 �a Sa$-79o- 7.✓� work site tocatim rTntt addressl: 52� nio ,2s 2b9U� o I am e h�O,+mer verro�ing eu wak myarat: rroj«x T,�pe: ❑rrew cros�ucdan pR�odel I am a sole 'dor and]mve no�e w in an Addition � I am an�PbY�Pro�idin8 watkeis'compeffiati�fa my emPbYces walcIDB au this job. . �..�,�: C2a�Cnc� �i� ��u��G r�� P✓n�s r� vr, �_�3 P�rr st-� s N � -77 - D i�a.oee�. �L° Q7'i-2C.rl ❑ I am a sole propiieWr,gaa�al ea�truter,or komeow�er(arde aweJ�have hired the contracto�listed below wla Lave the followinS wodcexs�compensation Polices: �: dh" � nia�e�: M �urc me_ sidreu• dh" orre/- � . _. _- __- ___- _._ __ . __ . _ _ _ __... . - __-__- .-.__—_ .._ . . _ . . _ . .___.__ . B . . _ . .. 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DorA�k Iwur �� • J, v (,�j� �Y U1D CONMiRi NO RKiMT!U�ON T11f CiRTNICAT{ �22 Pl �n �• HOco�R trNs GERTx�ICAlE OOEs ntoT 6MENQ,lX7�tiD 01t y�OtitII $ttNC � � � ALTERTNECOVENKikA►F4RDlDOYTNlMOL�C�tYlLOW. aliiau IY1 09i7• �haaa:?Ol•233-i331 auc:7il»i!l-1171 py��rp�pRp�p�pyE�p� �« � �w iAi�a4slnLia laa. Ca. � we�wEn� Utla� B+�tioa�l InMur�aa� lis S9'!� �!�zia�aa� 11r�wlnpr�►n! �rnwc Atlaatia Chaztws s�l tb Ol "�"� �e: COVEiMAIp � lnRWutr[fawruurrai»� iNMM►�MffMiNKflTQTMEfli�WOMIiifAMWiFORTIEOPLCfiPM�OLiNCCAT47MOt1MA�fTi� M�`k04�41iMT.�IM6RWMOr dMiYCpN7MCT0110?Nf�OCCUI�M►WflMRYQLTTOWMICHT1MiCORI/ICtTEWY�(IOW�pWI lNYr�M'Mi1MpMlMpC/Mf0 WTM!'OL�CI!!0!lCI11NDNlIItN�eN:NCRTOKLTMlnRW.IXC�W10NQuqC�IDaqtiOflUCI! 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IY►N4MTAAN�. �. � MR MIMWNTA7Ni ♦ 1Q7f�2W�/0!) f �. �Olb�k . i ACQRD CORKIRA110N l91� 'i Tawx oF Y�ouTa BOARD dF HEALTH PEIiMIT TC!OPERATE A ROOF ESTABLISH.MENF PERMIT AnJMBER: #OS-067 FEE. 25.Q0 In accoi�dance with re alions F>romtilgated tmder authority of Chaptcr 94,Sectioa 305A mid Chapter 111,Section 5 vf the�eral Laws,a petmit is hereby granted to: Cape Cod Child Development 367 Route 28 South Yarmouth, MA Whose place of business is: Cape Cod Child Development Pro�ram- Yarmputh Child Care Type of business: Non-Profit Food Service To operate a food establishment in: Tawn of Yarmouth Permit expires: Deosmber 3 L Z005 BOARD OF IIEAI."TH: Bev�ja�s�s$. l�So-3cfo+s,l�$. A�� v� e� x�n;�;�: x4 rry�t�«; xo�;u e� �'!ia&, 1T� A.,�.z tf�r� R.IY. Jan�21,zaos Bn�e G.Murphy, RS.,CHO Director of Heahh ; - �3�� . ,,;., .c. o�^R.y TOWN OF YARMOUTH BOARD QF t�A �a� _ � `��` �� APPLICATION FOR LICENS�ti'��2 D�E C 0 4 2003 * Please complete form and attach all necessary doc�n'ents by December 31w�3TH DEPT. Failure to do so will result in the return of your application packet L�(AME OF ESTABLISILMENT: �'!�-I�P Y��y �' � �+r T . #�hSC- b-? h LOCATION ADDRESS:.-�/)Rf o�`tf / . �i'lrmnre� MA' h�(o'1� R/C A A E ' NAME• — ADDRE • S i-� K POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operataa(s)ar.h 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 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 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. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. ��hnr�Ca�1,��,1 I 2. PEItSO�i IIv GFiARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1.�.��C��51�.1 � 2.�/1��'� pbY13�C] �t'icik- y V'�c.�'i� 5{��t,e»h HEIMLICH CERTIFICATIONS: Ail food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �CLS LsL�j 2. 3. A 1-_4. . �y U i�.. �[!'Da'U'�`�- �C�e97 7Q,<s�Ye 1�JID SY�P�Ydil� S�f"�c?,�� RESTAURANT"SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 11 B&S S50 CA31N S50 _MOTEL S50 INN $50 CAMP S50 _SWIMMING POOL S75ea _LODGE S50 _TRAILER PARK S50 _WHIRLPOOL S75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICBNSE REQUIRGD FEE PBRMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS 575 _CONTINENTAL S30 I NON-PROFIT S25 �D -O >100SEATS 5150 COMMON VICT. S50 WHOLESALE $75 BETAIL SERVICE: LICENSE REQUIRED PEE PERMIT k LICENSE RBQUIRED P68 PBRMIT H UCGNSE REQUIRED FEE PERMIT# _<50 sq.ft. S45 _>25.000 sq.ft. 5200 _V F.NDING-FOOD S20 _Q5,000 sq.ft. S75 _FRO'I.EN DIiSS1iR"P S35 _TO[1ACC0 S25 IYAMECHANGE: Sl0 AMOUNTDUE _ $ 25.00 a+«.:pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'"* � 5 � ADMINISTRATION Under Chapter 152, SecUon 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernvt to operate a business if a person or company does not have a Certificate of Worker's Compensation Insarance. THE A'I"I'ACHED STATE WORKER'S COMPENSA'I'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE 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 NO NOTICE:Permits run annual(y from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPAR'IMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVAT'IONS 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 F ATION _ POOLS POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and siandard 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 CONSU F.R VIRORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF. iN PO ICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Tempo Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the H�th Department. FRO •NI D . RTC• 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 wili result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUT ID F'N`'C• Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior appmval from the Boazd of Health. OUTDOOR COOHIN • Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: ��o��J3 SIGNATURG:�/�,Cyouf,� PRINT NAME& TITLG:�j�t.�' ��l�� yJ/� l,�O� ��n�j�' 10/22/03 . . � The Commonweallh ojMassachusetts s = Department ajlndustria/.-Iccidents ; 0/Jlceol/erestlysahis 600 Washington Streer Bosron. Mass. 02111 " w'orkers' Compensation Insurance Affidavit Anolicant information• P►�sePRINTTrraid� nam� L lIO�C.'b� �'1,�,)� t7��ng�rr�n� Yi1r�,� �'�i�l��>�'� loc�tion� .�.07 Qn/ oZ,� c�t� Lv� Y/�.�mnrp� /N�}' ��e�.3 ehoneN��-�]�b '-'�i�� I am a homecµner pertortning all work myself. � I am a sotz proprietor�c� ha�e no one��orkine in am capacin• (� I am an employerpro�idino workers' compensation for my employees workine on this job. comnan�� name: ( '�Ck/�hf,,��( 7.d �Flo - OYT� K�mnY� . .,_��.�.t. ndAress: �S� p�l r� �' v [ih�: � �hY115 ✓`t TT [� bb! ehone p• '��- 7��—�� insurance co, policv N � I am a solz proprietor. _eneral contractor. or homeowner(ciic/e onU and hace hired the contractors lis[ed beloµ �lho ha�e the follo«in_ �+orkzr ,ompensation polices: tompanv name: � address: citv: nhone p: insurancc co. yeliev# comoanv name: � - --address: ._ _... . _ __ _. . _ _ ____ - - _ . . _ �y: phoee M• iesurante co. �. eeRevK t F�iiure ro�ecure covenge�s requircd under Seenoo ZSA of MGL 152 u�Ind to tht ieporidw oterisiul pndtle of�O�e ap m f1300.00 a�d/or oae ye�n'imprisonmeet u w�dl a eivil penalHa io�hr torm of�STOP WORK ORDER�W i Il�t of SI00.00�My qtimt s��I��denta�d Mat i eopy of tAy ehtemrnt m�y be lonv�rded to the Otliee of Inrntlguiom of t6e DIA fw eoven`e reriflntlo�. �. /dn�hrrrby ' •under rhr pains and pena!!ia ajptrjury that 1ht injonnaNan provided above is p�e md corrcct Signatu ��-,7'''� U� Printname p�e/��[M �J7�� h� . aRcial use onh do not writr in tAis am ta be eomplercd by cih or towe ollleial eiry or town: y��DT$ _ permiNiteex M nBuildin'Departmem -- �Lieemiog Board �cheek if immediale response ie required 261 �Seleetmen'�Offiee (508} 398-2231 p�t. �He�IlhDepanmtet , conuct person: phone N:_ nOther , 01/17I2003 14: 50 5087715421 HEAR �TART PAGE 02 �. 02 10: a tlO�hlh Insurenee 78t293c^17Y . p. : .;A NAT�ONA INSURANC� G�::: ' PAGE i BAPNIC M75 UAI, YNS. C0. T7377 80 GENESEE 5 EE7 WII. F, 6QRHEK 7NS AGV INC aEW M4W7FONC, Y 13413 3t1 Pt,VMOUTH ST � W1L,iF/IX MA 02�3A i7EA9 ONE � (;81) 2�3•6�3� , POUCY NUMBEq: gq� 83E25a REN A� OF BAC 18�E2S4 NAMEDINSUpiO: E C00 CM2L0 OEVELOM�NT � ApOPESS: N PNELS MAR0260� " I PORM OF NAMEO IN$Ufi 'S BUSINESS: CO�P�M7ION � NAMEp INSUAEO°5 9U91 ESS: DAY CANE POLICX PEqipp: POL� VQRS FRpM 09-ta-Q2 70 Od-7a-03 12'O� A.M1A Stondard Timv at cna Nar+wd ln8y�9p'9 AOtlfa�L 9KOqC 7tOVe. � IN II�tUAN F011 TME MYM OF YME PREM�UW,At�O 7UBJEGT 70 A�L 7�5 iBqMS OF Tti�S POVC1°,wE a6REE wi'N V�u'O P414NOE 1ME � inSUMNCE�S S'ATEp IN 7M1 npt,K,w. � MA' USETTS GfCLARATiONS— BUSINESS AUTO COYERAGE FOqM ITEY TWO—SCMEDUI F COVERAG&S ANO COYEREO AUTOS 7ni�Pwq prariaa onM�M �p�s M.r� a ��rq� �:stqwn in th� pr�mium caumn t��ow. Earn oe th�u canrp.. wii� .pp�y oniy�v !no.. :.w:Of�' UNwn�t esYMW• •'�YtO�•Sf!7hO.M N CO'.'M�0'0yqb'tW�pi�WIY�Mipe �I M� MQ}�Ol ON� 01 R10/0 01.�0:}�IftOCli SMRI M� :OVEAEO AUTOS S�ctlan af e� Du�hna Mrto Ca�evsp�Fam n�xt i0 M�nwn�vl:h��ww�p�, ' COVERAGES CO`/EaEDAUT05 l9NIT PREMIUM � . �iiwyrww�durM��NnN�J7WMC0 T�f40{�VM Wy ►Mv /EN u.vOMC �OQ�OFM 9A ld5 . Oi�WM IPIi�OWM�LVI6CMM�MfMIIMM WvaU'wNI w MYwN'w1M C�uPvt90a+'BOO1lY tN,iUpv 7 0 8 t2e.000 EJ{cN t+EP50N S 8,531 � f�0,000 EAGMACG"�NT . . � /F�l9CXNL iNlUfA'►PO! 7 IiA00 i?AM r(R50N S 8�4 iqWLtiY t�IIWNCE � �T�WLLi60i6�+NJUW1' 7 8 9 t 9 �000,000 E1�.N,�A��NT S �9,837 oaoscarr a�wwe f EACH AC4MCEN7 �coa.uu�nr uM�r u. UTO MEOIG�PAYNENY$tN$ NPo@ 7 g $�OOO EA�M PEfiS'JN S 8S NtN$UNFA MqTOp1ST5 � � f 1 OO�OOO EqCM pEFu�ON :0�1WLSORv'�wti'9l2C, �000f S JOO,OOOE4CMaCCOEN' i iSJ NCEfYN8URE6 M6�OWSTS i 7 S t 00�OOQ g,qQH PEFlSON S 76S I ; 300,OOOEaGMpCC1�@NT Po1V5�Cpl D�N�GE�16U AC(tiAl Cw�Sii VAW:OA^�.J'St CF riEPIJN,WHICHEVER 13 i lE'a5,!A{NUS; CCNPAENENSNE" I E � f S0� 7oCvdiolOFOAE�CN:.�RED'R11T0' S �,a55 � 9P£qAEO GU9ES QF GOVEwWE �.a�oaD�ROA EiCH L�vEREO'aUTO' UhNTED OCLL'�.SIOK E �duvtfoN FOq EACH��RRED°AUTO" . G:7LLISION GOVEPAG"c � f SOO ;�ducGiqN:G5 FhCM v.?Jr�@0'AUTQ" S ��z� 70wnrXi xN0 Lt/OR i saen alwbem�n ol�?r�van pa�s�npa•a�:w'. FORNS AND ENDOASE MTS COtv7AIti'�0 �ZEMIVM FOR E�vi7l7RSEMENYS � 60.04 IN YM15 PCUCY Af ffS ! EPT10N; Si�&S•t019 --wrT�AE�TS�tGTAL APEMNm S 32,543.�" i Q� � � �krfq�� ,✓ •"�^'.� �.� �., . . � �AC rl4 a t83825a cw�wira�c«7/ —7'�=,.' . � B•OV-V;itM) £a. t-97 scxcur..nchar.��rn[cv,wow.a .c;,wr�aYa,uw,:..�.rxerne.w.Y.*�eauwwwc.;.a+ar��,�,e. COa[NO[f01M;JiaMtlC'100�ElN4'�'qPMr,l951.[Di0!RM��PM�� Tn{�pr.r�p.7('nEMqq NUYC�`11C0lOJCY, �'WY Ng�laMrv.y}a�.:�nwSwwc��:lAa��.�n�. PRODUC�d OF�r�7i`v.h9 n., r. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-099 FEE: 25.00 In accordance with re ations promulgated under auUtority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a permit is hereby granted to: Cape Cod Child Development, 367 Route 28, South Yarmouth, MA Whose place of business is: CCCDP Yarmouth Child Caze Type of business: Non-Profit Food Service To operate a food establishmem in: Town of Yarmouth Permit expires: December 31, 2004 BOARD oF HF.AI.TH: Be+r fa�ci�c $. lfo�wq ��. ' n�� sc�a��u, v� e�.� Restrictiaa�v: No&yolator; No gill. ROOi6�JE �p.�B��Mi(4IL� � � �i Q�. January 29,2004 Bruce G. Murphy,MP , .5., CHO Director of Health "'� C.C. CN��D 'D6VEloPM� ' �eAa,y TOWN OF YARMOUTH BO,r�RD OF�,, -IEALTI� _ o� ° APPLICATION FOR LI�ENSE/P� IT��O 3 � � ' �� _ , .� ��6��i . * Please complete form and attach all neqess, cuments by ece�bei-31; 2d(�Z �+ J Failure to do so will result in the ret�of your applicahon p�cket _ -ti�-;=t. NAME OF EST I MFNT• .L D � 1 .> ra TF.T.. # 50Pi-79b-7(/� LOCATION ADDRESS• �(o'� /4�" ag W• Y�vmn�,a-1, MYt La7�'7 3 A ss• a w � Q. � 7 3 OWNER/CORPORATION NAME• L� r� Uo n-I- *�ANAGER'S NAM .: An� � ni-1� TEL. #;SbSS-77:5-�a4b MAILINGADDRESS• g3 P�r� �t I��n�ni5a �119 Dal.,bl POOL CERTIFICATIONS: TLe pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool 9perator�s)�n�altach a�opy 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 certificarions to this form. T6e Health Department will not use past years' recorda. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MASIAGERS - CERTIFICATIONS• All food service establishments aze required to have at least one full-time emgloyee who is certified as a Food Protecdon Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 17�0�n��"� � [ '/.�C f .� �� _ 2. P-ERSnT.r rTv�uaR�E: - ---- -- __ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1._�)L'��W�1 2. �Qr t Sl�.. �b11 P�i-ri�i� N.a.�ty Vi ,i A�� 'r� �.TMi.T( H C'F.RTI�ICATIONS: All food service establishments with 25 seats or more must haue at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anri-chokmg procedures below and attach copies of empioyee certificarions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i.Y�a �r��, �... i�l 2. � �� I 3. ' 4. ' " R.I ' Shzran H%l er Sy vi� �'�� Sb /�n � ��s� �/'�' ,R�F TA ,RANT SEATING: TO AL# KG��-'' }f�i/�n{ii�� JS i», t/�n A)ti rvw'�--� OFFICE USE ONLY LODGING: LICENSE REQIIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _.. _INN $50 _CAMP $50 _SWA4A�IING POOL$SOea _LODGE $SO _TRAILERPARK S50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQIJIl2ED FEE PERMIT# LICENSE REQiJIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS $75 _CON'I'INENTAL $30 �NON-PROFIT S25 �AQ�O�� >10(1 SEATS $150 COMMON VTCT. S50 WHOLESALE $75 RF.'�'A1�RV[ :E LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 <25,000 sq.ft. S75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CIIANGE: $10 AMOUNT DUE _ $ 25.00 **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*••** _^ 1� - ADMINISTRATION ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEB .r � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �=—� NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO I2ETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHMFN"1'S ARE TO CONTACT THE HEALTH DEPAR'CMENT 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. �1DDITIONAL REGULATIONS POOLS POOL OPEPTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, priar 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 Yazmouth 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 Health Department. FROZEN DESSERTS: Frozen desserts must be fested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. 4UTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: /a -a`-d� SIGNATURE: PRINT NAME&TITLE:� � 10/18/02 . _ � . The Commonweo/th ojMassachusetls ' : Departmen! ojfndusrrial.-�ccidenrs ; Ofllce ol/mstlOsUiis 600 Washington Slreel ' Bnston, Mass. 02111 " W'orkers' Compensation Insurance Af6davit Aoolicant information: P►e*sePRINTTesGida l I � n�m_C-L_/Lf.+G. C_wl� ( Y11 �O 1A71�,pLnnvu �hY Y✓1Y.Ti`�2m 7�✓`yjp/ F� h VI � rD loc�tinn. _'��y 4 f�� a$ •us�_J�_S_f y�trmn�.�,, HA D�73 ono� a5bg-74 -`7( (b � I am a homecµner pzn�rtnin�all work myself. � I am a solz proprie[or�r.,', ha�e no one ��orking in am capaein• � I am an employer pro�iding workers' compensation For my employees uorkine on this job. tomnan�' name: ( "/.Z.iOl. C 'ISCY ��11� IJ101J-0�(MY�Dt� � adAress: 0 3 !'"f�� (1`POi' � c�c�hs I�IA- �.Y�,O/ yns��tl. ,'S� �'7�y/� UiSufance co. .JN_L� � 7"I�.-Ala,o� nnlie�i p �HE Q.�d � I am a sole proprietor. _eneral contractor. or homeoµner(circle onel and hace hired the contractors listed below �tiho ha�e thz follu��in_ aarkar> ,ompensation polices: comoanv name: address: cirv: phone p• insurnncc co. oelie��!! snmoany�.me: address: � --- ---- _ _ �y: ehoee M• insuranee co. neRn M t Failure to�eeure covenee�s repuired uoder Seenoo ZSA of MGL I52 u�Ind to tYe iepo�iow oteri�iul pndtlef of��e ap m 51300.00 aW/o� oae ynn'imprisoemrnt�a w�ell�n eivil prnNtlee io the form of�STOP WORK ORDER�ad a li�e of 5100.00�d�y mio�t me I��denh�d Hat� eopy of tAia staumcnt m�y be fonnrded to tAe 011iee of Inveatiptiom ot16e DIA for eoverqe verillntlo�. � � /do�hrreby cenij}•under the pains and pena!(in ojptrjury�hat tht injormation provided ubovt is true and corrcci Signaturc /lJ i'�^oZ�^(.�2 . Print name ' . � oneN�"ST1Q' �/J— `f'//6 � oRci�l use onh� da not..rite in�his ana to be completed by eih artmva ollltiil ciry or town: y�M�DT$ _ permiNieeox M nBuildiog Department � OLicemio6 Bo�rd p check if immediate response i�required 261 pSeiectmen's OtTiet (508} 398�2231 eat. �He■ItADep�rtmee� - con�act penon: phone N•_ � _ nOther � • � '� CERTIFICATE OF LIABILITY iNSURANC��q 01�"�;°N;; IN� � A O�MyLVy.W� 1tlOM1�YN1�MTM t.- _�� .y1 01��Y /FSMhiM�� r KTM .�A��R 7�1 �1 �litas 10 023ii ' li�M�lil•if3-f771 faft�7�1-=l�-�171 . �� '� �rll�r �� Q . � �IIIA!! � �u ��L .�+MG Qt�aa esai �i111L-09i01 «rMMa t�r � � www� �Iw�9rrww�rtirm�nMr�r wrwr�arrm m�r w�unrr�wdno��bucr�wmroiu�o.ia�anrruau .w�raiaaenawawrrarrre►ai enreooe�ww+w�wMlMet�ewweNnrawwranwrr�eoe �.IIW�TNL 11R�IIIIIMIq{ManOfOMM�eLRJY OOC111�fe WIIW ql11N�Cf TOALLM7/W�,CIG+yYI�MMCOMMipI�OI NCM MIY.Ir.�yrY�l�Wf1�101M�WY MMA��IIOIOi W MO CLAYL nw a wrrrie. .a�wwa um ar��ruw � �eeow�o�os s a • nw/Iw�YrM�i�wrnr �Y-�f3l0�41 Ot/1S/01 Of/�f/07 wMarW r t 1 iMr11w[ Q000YR Womwwwwwl t 000 �•1Nl1.f00.0 r�wrtulwwl�fp �l��MrMO awMit t � � t �euer �ao f y�ww��v �I�C 1�7�354 Oi/14/01 Oi/1�/0! �� 1.000,�00 �laoww�wna �� YI►M �marrww � . IAIqM�NM1101 Prr�Ml�rtl MO�I1�11�� - MYwWLLIPI � � Mlrodar.M�OC�M • NMYM pwr�yy 4YC { MIIOdLM � : M�1M�A� fACMOCi11� t POCIM �4AY{W�[ �Y�MMT{ � { � �IIfl11Lr � . . MI�rtqM t i 11��LO�I�I�NAII� a ""•''"'�""'"" wceesu�oo oc/�o/oa o�/�o/oa u.aw.oco.+� � ..�o..w•M �s �o LLOriW�•�IOYtM � �reewwawwmwwu woLOM x .me�..r.�nwraurne c�retuwna� GK9>�O YIOILOYI�alirY0M0001�Y�OHOYYCMIOW��tM Yar�oath Child Care C�ACYL °"TM"�"'0�'��"""'�'"R''��01"� —'—'�"�"��' 367 Yout� 2B w�wronraawca�Ma.owwir�omnfun.wrMwwwarMwri W�at Yar�outh MA 02677 ��0°�°��a""°'�"�°"OYT�� r�rrrt.ww. f�A7) . • O HM _ _ � _-.... . .,.... ,,,..,. �� ,�� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-072 FEE: $25.00 In accordance with regulations promulgated under aut6ority of C6apier 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Cape Cod Child Developmern, 367 Route 28, South Yazmouth, MA Whose place of business is: Cape Cod Child Develonment Program Yarmouth Child Care Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2003 sonxn oF�.a�.'['1i: �fa�rlia r�, z�, (�ar,�aw __ _ _ _ _ a a. � �x.D., v� . � R�slric[ioas: No&yolator; No�ill. �C��.y��i t�tOpK. � . �Q� �'Z-G[f/PldlAtOtt �� SRAK. �� . . . . Decemberl8 ,2002 ruce G. wphy .S,CHO Director of Heal � � �Cz,ti-t ►�Il� !'°. �.c. c.�trw vEVEE . ��1e(� TOWN OF YARMOUTH BOARD OF H �P ' , I ��j�DL �/ ec3m�� APPLICATION FOR LICENSE/PE � �++°/ _� 't7��v' z3f_�; � � �r�n� ' Please complete form and attach all necessary documents by Dec , r 31�, 2001. Fail�re to do so will'result in the return of your application packet. _._ NAME OF ESTABLISHMENT: ��I �Gu onmEn riv,,r,: v�-4'F,L. #�� 7�0-7�a(c0 LOCATION ADDRESS: .3�'� 2� aK f.,v 4/,�rmc��.+l� . '�1i.� b�b7� � , M LIN ADDRESS: � c� � O � C. � � F�IIE�l�nm�n-�- MANAGER'S NAME: u IZ2 �u-d� TEL. # �fr- 'J7�s=G2y6 �INGADDRESS: �.� PNc�rl 5t• 1-ludnnis �MA POOL CERTIFICATIONS: The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificaUon to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deparhnent 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 establishxnents 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 51e at your establishment. �. �� a,� G'-.� w.�l z. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of opera6on. �. (Je�hrih ('1c;��.11 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1.J`1�.u-isg'i(�rinz� 2. Pa� /11�J1�, 3. ::�i. ijc�O�,��anP_ r� �-��2 4.�',�,_ ,��tv� RVa:� Sa�obs . RESTAiJRANT SEATING: TOTAL# SYluic� parvj� na� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 INN $50 CAMP � $50 _SWIMMING POOL$SOea _LODGE $50 TRAILER PARK $50 WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# _0-t00SEATS $75 _CONTINENTAL S30 � NON-PROFIT $25 �6a..8aa- _>t00 SEATS $150 _COMMON VICT. $50 WHOLESALE S75 $ETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. $75 TOBACCO E20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 xaMEcaaxcE: s�o AMOLJNTDUE _ $ 26.00 *****PLEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM*'""' _ � ADMINISTRATION y 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 � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ,./ Town of Yatmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: , YES - NO NOTICE:Pemuts 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, 2001. SEASONAL ESTABLISIIlv1ENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR'I'HE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab,prior to opening, and quazterly thereafter. POOL CLOSING: Every outdoor in ground swinuning 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 are required to post Consumer Advisories. 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. Thses forms can be obtained at the Health Department. - - - --- — ----_ _ --- - - - FROZ .N DFC ,RTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: PItIhiT NsRME 8c TITLE: 09/11/Ol : - � . The Commonwealth ojMassachusetts = Department ojlndustria/.-lccidenrs ; O//IceaJ/sresUosdsis � 600 Washington Street Boston, Mass. 01111 " ��'` W'orkers' Compensation Insurance Affidavit Agplicant information: Plesse� �,m� �i; nr� (�n� CRtiid �G Mnmp�-� �r riiur, location: :3L al /P/.Ui�'N c�� ' ��, Lv Y.�rm ni�� M l� oa.!n� ehone p 'S(�SC'-��7C1-'�L��oD � I am a homeouner pzrt�rtning all work myself. � I am a solz propriecor�-,', ha�z no one norking in am capacin• [� I am an employerpro�iding workers' compensation for my employees uorkingon this job. comnaarname: CJ'.t..1 ^� C_.64 ��I� ��t)R�h�iMAY1� � address: �o� PNl1.P� �� ciri: Yill2J'�nIS i'`1�} ehon a• b$-77 -/ao7Y6 iosurance co. �iq ST�.�f(..�l �! G}S(A.�.W eolicv# n�o� Q�7 � I am a solz proprieror. general contractor. or homeowner(circle onel and hace hired the contractors listed belou ��ho ha�e thz follu�cin_ ��orker compensation polices: companv name: address• cin�: � phone a• insurancc to. eolic�•# tnmoany name: _ . .. --— - � — _ _ _ . _ .___ .. .. -- -- address: . tiM Qhoee�• � insurants to. neRev M t F�ilure to secure covenee as requlred uoder Stenoo 25A of MGL 152 u�lud to t0e i�paidoa o(erisiW peWtln oh O�e ap ro SI�00.00��d/or one yean'imprisonmrnt as w�ell af tivil peodHn io the form of a STOP WORK ORDER aed�Oet of S10D.00�dar q�imt me. 1 udeah�d th�t a eopy of thh sn�emem may be fonv�rded to the 011fee ot IevaN`�tiom of t6e DtA for eoven�e veriflntlx /do�hereby cenij}•under rhr p ns and pena/�ier ojperjury thallhe injormatinn providtd abavt is trnt and corxet Signature�., �� r �� r2/ lD � Print name �?'1✓I�Z- �1 • J (.,o � �oneN 5�&�775 —�i Z�1a .• oRcial use onh do not�rite in tAis area m be eompleud by eih or town ollleial city or�own: YARMO�T$ pemiNicenx M nBuildioe Departmtot pLietnsine Bovd �check if immediate response ie requirrd 261 �Selectmen9 ORce (508) 398�2231 eat. �HnItA Depanmmt contact ptrson: pAOnt M•_ __ _ f'IOther �J , Accpunt Number EC�lIGe/'/Z t✓CZGILL4LL�J Statement Due Date: fi6306T Ofi/30t24Q� Please write your policy �umber on your check and mail it to: Eastem Casualty insurancs Cor�pany 325 Donald Lynch Boulevard Mariborough MA 0 f 752 Cape Cod Child Devslopment Program, Inc Account Baiance: 580,832.d0 83 Pearl Street Hyann':s, MA 02601 Current Minimum Due: $14,031.00 Ptease dekach and send in with ypur payment You may pay efther the Current Mirtimum Due or the ACCount Baiance Statement Glosing date: OS/3dt2441 Biiti�g Statement Statement Due 4ate: 06t3012001 Policy InvaiceiCheck Transactia� 7ransacYian Period Number Type Date Amount 46134t2401 -0613Q12002 224655 WC Renewat Premium WC00 663067 Q5134l2001 $80,832.Qd Previous New Charges/ Accaunt �---- Baiance + Disbursements " Payments ' New Crediks " Balance Past Due $��0 � -30.06 --� ' ---584,832.00 � . §O.Op � {30.00} � ; S$Q,832.00 Minimum Due 514,031.00 Poiicy Hoidec Cape Cod Chiid development Progrem, inc Account Number. 663067 For biiling questions piease cail Eastem Casuaity insurance Company at 508-303-1000 For claims questions please calf Ciaims Customer Service at 800-89$-3242 For coverage queslions please call William F. Borhek Insurance Agency, Inc. at 781-293-6331 d513t2001 , � � �tl ' '� ` � �� ,''" � >, * ",N, �' R r� �_ ,,,, �, ,, _ �� ,��,�� ` �L'f7Zc..�t[OLLGt�` g � fi 325 Danakf J. i.ynch Boutevard, Ma�tborough, Massachusetts d1752-4729 (NCCI Carrier 16942) WdRKER3'COMPENSATION ANd EMPLOYERS'LIABILtTY INSURANCE P4LICY INFORMRTION PAGE �VEL�j� WCOQ 663�6T Federal!D#: 237324732 Cape Cod Child Development Program, Ina Legai Entity: Corporetlon 83 Pea�i Stsa�t Hyannis,MA 026Q1 Sea attached Schedule of Named Insureds and Locatlons ��e�t""_ The policy period is from 06/30/2000 to 06/30l2001 12:01 A.M. Standard Time, at the insured's maiiing address. �� A Workers'Compensadon�nsurance: PaR One of#he poiicy appiies to the Workers' Campensaiion Law af the shates fisied here: Nlassachusetts � + B. Employers' Liability insurance: Part Two of the pplicy applies to work in each state listed in item 3A The timifs of our Iiabilify under Part Two are: Bodiiy Injury by Accident SOO,OOd each accident Bodily injury by Disease 500,000 palicy timit Bodity Injury by Disease 5q0,000 each employee C. dther States insurance: Part Three of the policy appties to the states, if any, iisted here: All states eaccept those listed a6ove in item 3A and NV, ND, OH,WA,WV,_WY. D. This poiicy inciudes these endorsements and schedules: Refer to Attaehed Schedule Totai Estimated Annuai Premium; $68,876.00 Countersigned: William F. Bprhek Insurance Agency, Inc. 311 Plymouth Street P.O. Box 29 HaGfa�c, MA 02338 ��"=t �� { � By — Date: 06/23/2000 orized representatrve) KLR ,. . y�.,. . ,, , ...,.i S." .... �'.� rv.�.:�.:..�+r,��tY.ik�h�.�.�4:ira':; . . Y�+X:k�vl<.:.,�� . .y. � .9��5;`.`F: .�� s P�}(` �� ..'.''i`�1.�''�!..'::. TOR'N OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISFIlbIENT PERMIT NUMBER: #02-022 FEE: $25.00 In accordance with r�ations promulgated under authority of Chapter 94,Section 305A and Chapter 1 l 1,Section of the General Laws,a pennit is hereby ganted to: Cane Cod Child Develn men 367 Rnute 2R Snuth Yarmouth_ MA Whose place of business is: Cape Cod Cluld Development Program Type of business: Non-Profit Food Service To operaYe a food establishment in: Town of Yazmouth Pernut expires: December 31. 2002 BOARD oF HEALTH: /�elea s?�, xe!le�ec, �iFakarsn D. � �G D.. ?/� Restrictions: No&yolator: No grill. `3. �RO[aK, � �aatiek�rx.xofl :f�ele.� Skal. ,��l. Febivary 6 ,2002 ruce G.Murphy, , .5.,CHO Director of Health TOWN OF YARMOUTH BOARD OF �� APPLICATION FOR LICENSE/P 5� },.� APR � 6 �OQ� * Please complete form and attach all necessary documents by Dec r 31, 2 0. Fail c�qso will resuh the retum of your application packet. �/�LTH DEPT. --------------------------+-----------------------_----------�'� -------------------------------------------------- --------------- � � � ' - � MAILING ADDRESS: C�f31'Y1P� --------------------------------------------------------------------------------------------------------------- -- POOL CERTIFICATIONS: The pool aupervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certrfication 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 Cardiopu(monary Resuscita6on(CPR). Please List these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintain a file at your place of buainesa. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: � �'� ��- V_ o-- � ��" C �'� + �-�+ �,d e�r�hQd All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at atl rimes. Please list your employees mained in anti-choking procedures below and attach wpies of employee certifications to this forrn. The Healt6 Department will not uae past years' records. You must pmvide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---------------------------------------------------------------------------------------------------------------------------- OFFICE USE ONLY LODGING: LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMMING POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAI, $30 _>100 SEATS $150 �NON-PROFIT $25 -I67 COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE• LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ 2,��OO *•*•*pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM**•"• ,*'�'a . - � '� ,�y ADMINISTRATION � Under Chapter 152, Section 25C,yS�tion 6;�lhe Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a bus' ess if a person or company does not have a Certificate of Worker's Compensauon Insurance. THE ATTA�ED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your perxnits. PLEASE CHECK APPROPRIATELY IF PAID: — �n'►�YOFf-F' YES NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLISHIviEN'I'S ARE TO CONTACT TI-IE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVAITONS TO ANY FOOD ESTABLISIIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water 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 pcwl must be drained or covered within seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certificarion is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establishments must have at least one person-in-charge who is a certified food protection manager. �s pmvision is effective one yeaz from the date of promulgation of 105 CMR 590.000. T6e effective date for coasumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory, Food Code 3-603.1 l,will be unplemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporazy Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit unril the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior appmval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepardtion,or display of any food product by a retail or food service establishment is prohibited. DATE: I � ��1 SIGNATURE: , � ��/ �J�-�� (.�-�" PRINT NAME & TITLE:�l�1 i C1G�.�`'�QC��1Q�C� ' �I YPC'�CX 11/16/00 _ � � ` ' The Commonweo/th of Massachusem W Deparrment oj/ndustria/,-lcciden�s ; 0/llceol/eresdos� 600 Washington Slreet Boston,Mass. 02111 W'orkers' Compensation Insurance Affidavit Anolicant informafion: pfeasrPRllaTTesGi�e namc lucation: �� phone k � 1 am a homeowner pzrtorming all work myselE � I am a solz proprietor acd hace no one ��orkin_ in any capacin� �am an employer pro�idino workers' compensation for my employees working on this job. comnam� name: (�IA-(JO l:El� 1��/o� �t)Q-�0 0/l�t�l'—C �$U�� nC � ,aa��ss: �3 �j .ea.� ��— cih: ��I�M✓�vi r�/lo� d2C�01 phonek: �0&— rl'1�—�nZ4d insurance co. �a4'i�I'n l fy.Srio�7`-v�^S(iR �c+ _ policy k W� �� h [��a b ? � � I am a sole proprietor. _eneral eontracmr, or homeowner(cirde onel and hace hired the contractors listed below �cho ha�e thz follo�cin� «orker> compensation polices: companv name: addresr ci[y: � phone#: insurancc co. polic��# � 0 A address• � t�y: � Qhoee N: � insunnce co. portey N � failurc to secure covenge as required uoder Setrioo 25A of MGL 152 n�Ind to IYe i�paitloe of erisivl peWtln ot�Ou�p ro SI¢00.00 aWlor oae yean'imprisonment a�w�ell as civil pen�INn io the form ot�SfOP WORK ORDER�od t tioe of SI00.00 i d�y tpiott sa 1��denta�d tY�t a copy of thh shtement may be forw�rded to the ORee ot Inveftig�Uom ottbe DIA for eoveraLe veri6utio�. _ � 1 do�hereby certijy undei Iht pains penal�ies ojperjury thm tht rnjormallon providtd abovt is aue and rn et Signaturc a�� (�L /� Date � _ Print name�� .LC/it�, phone# T�7 V' lo o�� 'Q .. oTci�l use onk do not wri�e in�his area to be completed by ciN or tow�n ollfeial . ciry or rown: Y�HDIITQ _ permiNiteoae M nBuilding Dep�rtmem � � � �Litensiog Board �check if immediale response ia required . 261 �Sdeetmed�011iee (508) 398=2231 eat. �Health Depirtmeet contact person: phone M;_ _ _ nOther Iraned i,o5 PIAI 3V1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-167 FEE: $25.00 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a permit is hereby granted to: Caz e Cod Child Development Program, Inc., 367 Route 28, South Yarmouth_ MA Whose place of business is: Cape Cod Child Development Program Inc. Type of business: Non -Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2001 BOARD OF HEALTH: Ed X 574W, &4&m" &"nf'ed q,/�� `% a &a&m" Restrictions: No fryolator; No grill. 'Rok t` T • 86", eaz April 19 12001 ruce G. Murphy, MP , . ., RCHO 0 Director of Health i OF�Y'`��4 �� - `�� TOWN OF YARMOUTH � - � 1146 ROUTE ?8 SOUPH YARMOCTH MASSACHUSETTS 02664-44j1 �nwrr�cncu "�w,,,,,i,r*'�d' Telephone(508) 398-2231, Ext 241 — Fax (508) 398-2365 BOARD OF HEALTH April 11, 2001 Cape Cod Child Development 83 Pearl Street Hyannis, MA 02670 RE: Health Inspection, Cape Cod Child Development Rte 28, West Yarmouth Dear Sus, On April 10, 2001, this office conducted an inspecrion of the food preparation azea at the above address. The facility was approved for •reissuance of iYs Food Service Permit. When preparing the paperwork for the center it was noted that no application for the yeaz 2001 was submitted to the Health Department. Enclosed please find an application for your office to complete and return for review and to complete the file. If you have any questions please do not hesitate to contact this office. Thank you for your attention to this matter. Sincerely, ��2��,�: Peter J. �y Health Inspector Enc: � �«a� �� ^� ; �;i�� Cccl �blc1(1 Cc'v�a;�-„}cat� ��,,' ' f�3C � � OMt� Q � TOWN QF YARMOUTH BQARD O�HEALTH • APl'GICA3TIDN F{3R LiCEN$EIP�RMi�;�U00 D E C p 6 1999 �* Please complete form and attach all necessary documents by December 31,`1999. Failure t A�" � � �� the return of your application packet. -- --- -------- -------- --------- ------------------µ----_--_--_------ --------------------------------------------- ------ a& - 66G FE D � p rtL R, # � � 5-62 D o �v PdOL CFRT�'ICATtdNS� � The poo! sapervisor mnst be cert�ed as a Potti Qperator, as required by new State law. Please list the designated Paol Operator(s) and attach a capy of the certification to this farm: 1. a. Pool operators must list a minitnum of two employ�s currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR}. Ptease list these employees below and attach copies o£ employee certifications to this form. The Health Deparnnet►t wil!not uae past yexrs' records. You must provide new copies and maintain $file at your plxce af busmess. X. 2. 3. 4. �II��.I H ERTIFjCATIONS All foad service establishments with 25 seats or more must have at least one employee trained in the Heirrilich Maneuver on the premises at all times. Please Gst ypur employees trained in anti-chokrng procedures below and attach copies af emplayee certifications to#his farm. The Health i�partment wil3 not use p$st years' recor�ls, �Xou must provide new copies and maintain a file at your place of business. 1. 1 ' nrot � � �� ;�en 2. il !t �i ��onr 3. „� v��g� �n � a 4. �Cd RESTAL7RANT SEATING: TOTAL# NON-&MOT£�N6&EA'FS; 'f0'£P�#- ------- -- ----______-----------------___________-----------------------------____________.._______ 4FFIGE USE(7NLY 1�,ODGIlVG: LICENSE REQi7IltED FEE PERMIT# LICENSE REQUTRED FEE PERMIT # B&B $50 `CABIN $50 INN $50 _CAMP $50 Lt}DGE �50 _T`RAILER PARK $54 MQTEL $50 �SUJIMNIING POOL $54ea. Vi'HIRLPOOL �25ea. FOOD S�RVICE: � LICBNSE REQUIREI7 F'EE PERMIT # LICENSfi REQUIRF.D FEE PERMIT # 0-140 SEATS $75 �CONTINENrAL $30 >l44 SEATS $150 �NON-PROPIT $25 �G� COMMON VICT. $50 �WHCILESALE $75 KETAIL SE��E: LICENSE REQLItRED FEE PBRMIT# LICENSE REQUIREL7 FEE PERMIT # Y<50 sq.ft. $45 �TOBACCO $20 ,{25,000 sq.ft. $75 vFROZEN DESSERT $35 _?25,000 sq.ft. $200 Nx�1�E__GHANGE: $14 AMOUNT DUE = $ ZG��` ,••""pLEASE TURPI OVER AND COMPLIiTE OTHER SIDE OF FORM•'""" �� ; � . _ �,. ADMINISTRATION . UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQtJIRED• 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 Q$ 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: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIvv1EEIVTS ARE TO CONTACT TI-�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIlVG FOR TI-IE 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 Tf�BOARD OF HEALTH PRIOR TO COr�Il1�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DITION I F ATION POOLS POOL OPENING: ALL SWIbIl�IING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY'THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATS CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMNIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE ATR iNG POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOT'IFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS� FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN Tf� SUSPEN3ION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFfiS OLTTSIDE CAFES(i.e., Oi1TDOOR SEATING WITH WAIT'ER/WAITRESS SERVICE), ��HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OITTDOOR COOI�iNG� OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLIS NT IS PROHIBITED. DATE: / SIGNATURE: 1 "/��-�� - D ��- PRINT NAME& TITLE: l�V� � r l_ o �� ✓1 �e vn�e�- � i re c�-�o Ir 1 U12/99 , T4WN OF YA.RMOUTH BOARB OF HEALTH " PERMIT TO OPERATE A FOOD ESTABLISHMEIVT PERMIT NUM$ER: YZK-45 FEE: $25.OQ I�accordance with regufazions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby�anted to: C'ar �'od ('hild T7evelonment Prng�„m_ Tnc.. �67 Rrn�te 2R Sn�th Y rmo� h MA Whose place of business is: C',�pe Cod Child Devela�ment Pra�r.�m Inc Type of business: Non-Prafit Food Service To operate a faod estabtishment in: Toum of Yarmouth Permit expires: December 31. 2009 BOARD OF HEALTH: Fd� �etYea, jLkaor«rsk �.naa_.6c�G'.�. Sarfftc<an. /l�x.�'•�'fl�.. ?lice �(/Favr�ra+w ftestrictions: Nb fiyolatpr, No grill. �eave�w�� L�4oCtlK. {�cvw I� S Y�� O .C� L}ecember I6 , 24� Bmce G.Murphy,MPH,R. .,CH Director of Health " " TOWN OF YARMOUTH BOARD OF HEALTH � � � � � � � � � APPLICATION FOR LICENSE/PERMIT- 1999 �UG n 2 19�9 �, ' Please complete form and attach all necessary documents by December 31, 1998. Failure ' the return of your application packet. -------------------------------------------�- -I--- -- ------------------ -----------------------------._ N TAB I � C:f�P� �� L , Q�o � o- G�a ATI D CQ � � G� M LI 3 26ta( ZGp O RA N � � ER' N # - 2 Y� MAILING ADDRESS• sa,u— ------------------------------- ---------------______________--_------------- POOL CERTIFICATIONS� The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. 1. 2. Pool operators must list a minimum of two employees cxurently certified in basic water safety, standard First Aid and Community CardioQulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus form. The Health Department will not use past yeara' reeorda. Yon must provide new copies and maintain a file at your place of business. 1. 2. 3. q, HE Mi ICH 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 empioyee certifications to this form. The Health Department wiR not use past years' records. You must provide new copies and maintain a t'de at your place of business. �Ic� 1. �j � --- 2. Jo�; � �C. 3. Tu_2,..�c_ , 4.__ �i»ru.�- <S/�.Lc.� RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# —______— _ _—__—_----------------------------------------_—_------ OFFI E . ON .Y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIbIl�IING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE• — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ✓ 0-100 SEATS $75 _CONTIIVENTAL $30 _>]00 SEATS $I50 �NON-PROFTf $25 -�Q _COMMON VICT. $50 _WHOLESALE $75 RFTAn•SERVI F• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME . A �• $�p AMOUNT DUE _ $ pZ . � . ""•""PLEASE TURN OVER AND COMpLETE OTHER SIDF OF FORM ..... ADMINISTRATION � UNDER CHAPTER t 52, 3�CTlON 25C, SUBSECTIQiV b,THE T4WN OF YARMOUTH IS NOW iLEQLJTR�D TO HOLi7 ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR CQMPANY DOES NOT HAVE A CERTIFICATE OF WURK.ER'S COMPENSATION ITdSLIRANCF,. TRE ATTACHED STATE WOItKER'S CQR'EF'ENSATION INSURANCE AFFIDAViT MUST BE COMPLETED AND 9IGNED, OR CERT. OP INSURANCE ATTACHELI S2� WORKER'S COMP. AFFIDAVTf SIGNED AND ATTACHEI?�f TOWN OF YARM4UTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUAi3CE OF YOUR PERMITS. PLEASE CHECK APP1tOPRIATELY IF P � YES NO"� �G C�c_(�.e_.. NOTtCE: PERMITS RUN ANNUALLY FRQM JANUAR.Y 1 TO I7ECEMBER 3l. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION{S) AND REQUIItEI7 FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISf iMEIVTS ARE TO Ct?NTACT Tf� HEALTH DEPARTMENT FOR INSFECTIQI3 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENQVATiONS TQ ANY F40D BSTABLISIiMENT, MOTEL OR PC}4L {i.e., PAINTING, NEW EQUIPME.N'I', ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOIt TO COMMEI*10EMEIrIT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDIT�QN�-ItF�L� ATIdNS POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIItLPdt7LS WHICH HAVE BEEN CLOSED FOR THE SEAS4N MCJST BE INSPECTED BY THE HEALTH DEPARI'MENF,AND THE WATER TES'FEI7 FOR PSELJDOMONUS, TOTAL CdLIFORM AND STAIVDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIGR Tt3 OPENING, AND QUARTERLY'I'HEREAFTER. POOI.,CLOSING: EVERX OUTDOOR IN GROCJND SV�TIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAXS OF CLOSING. FOOD SERVICE CATERiNG POLiCY: ANY{7NE WHO CATERS WITHIN THE TQWN OF YARM4UTH MUST Nt?TIFY THE YARMOI7TH HEAI.TH DEPARTMENT BY FILING THE REQUIRED TEMPORA1tY POOD SERVICE APPLICATION FdRM 72 HOURS P1tIOlt TO THE CATBRED EVENT. TEIESE FORMS CAN BE OBTAINED AT THE HEALTH DEPART14fENT. FR02.EN DFSSERTS: FROZEN DESSERTS MUST BE TESTEB ON A MON'fHLY BASIS BY A STATE CERTIFIELI LAB. TEST RESULTS MUST BE SE1VT TO THE HEALTH DEPARTMENT. FAILURE TO I70 SO WII.L RESULT iN 1'I-IE SUSPENSION OR REVOCATION OF YOUR FRO�T DESSERT PERMIT UNTIL THE AEtOVE TERMS HAVE BEEN MET. OUTSLi�E CAFES: QUTSIDE CAFES(i.e., OL.ITDOOR SEATIIVG WITI�WAITEIt/WAITRESS SERVICE), �j�T HAVE P1tIOlt APPRdVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: CiUTDOOR C04ICING,PItEPARATION,4R Z3ISPLAY OF ANY FOOD PRODiJCT BY A RETAIL CiR FOOD SERVICE BSTABLISHMHNT IS PROHIBITED. DATE: (� � _SIGIVATLTRE: �'�.,�� PRINT NAME &TITLE: �--d� / l/�� a�— C'ff''c.� �'��c-, , . : � The Commonwea!!h of MassachusetLs • � = Deparlment ojlndustrial.�ccidents ; OfAce s//arestl0u/iis 600 Washington Slreet � Boston. ,1luss. 01111 �" "� '` �Lorkers' Compensation Insurance Affidavit Aoolicant informallon: P►easePlliNTTe�'his nnmc� / '�}17/ 1 �,0A � �/� �� AOMa.�h/V �20��0� b�—�-- M loc�ti�n 03 ,Q e n � S fi yhy�� n 1 ' 1 � � (/ � crt� ehone a � I am a homeowner pertortnin�all work myself. u I am a sole proprieeor ;r.,'. ha�z no one �corkin� in am capaein• (�'I am an empiocer pro�iding workers' compensa[ion f/o�r my empiocees uorkine on[his job. comnam� name: l��— � Y]� l.�Yl ' /�L 6LCN�.��AO A'wM� �20e, ��J�-L aJdress: I�3 Y- Q-4.'�X� �� iitr•: 1�''1 �Y1�1'�M .�(� Q�a� ohone q• . insurance co. policv b ['j I am a solz proprietor. ;eneral contractor, or homeowner(circle onel and hace hired the contractors listed below «ho ha�e thz follo�cin_ «orkcr ,ompensation polices: comnanv name• � Q7eC� �`vs�.(/1 �--�-� n`Irlress• �� 1 � l��/11 C/N.L� � l �y• �� I�� 42-33�' phonep: 7S`I 2`'i3 �33/ - insurance co. polite# � �� 1�1 �Q� � W�L Cor'`� 2(] 2 t � � e comnanv name• addre•<- eitv � � � - ehoee K: insuraneem. � oelievM ■ Failure to sceurc coven`e a�requircd uoder Seenoo 25A of MGL I32 u�lad to Ibe i�paitlw o(erisiW pe�dtln of�A�e op to f1�00.00��d/or oae yean'imprisonmeat�s w�ell ae eivil pendda in the form of a STOP WORK ORDEA aed�flee of SI00.00 a d�r q�imt me. 1 a�denta�d t6at a � copy of thy rtatement m�y be fonv�rded to�he 011fee of invaNg�uom of t6e DIA for eoven6e veritiutlw. /da�hrreby certij}• er rhr pai and penalties ojperjury thm the injornmtian provided abovt rx ar�e and camrct Signaturc �� /h'�Z ib2 � CHi c A C'��Date g 12/�i �l Printname ��/u � ��ilZ,f PhoneN � 7��0`�-�� .. oRcial use onl. do not�ria in�his ana to be eompleted by eitv or Mw�n ollltial ciry or town: Y�M�DT$ _ - permiNieeme M nBuilding Department �Lieensiog Bo�rd Q check if immediate response is required 261 QSe�et[men'f OlTlee . QHtilth Departmeal con�act person: phont M:_ �SOH� 398�2231 ext. nOther � J�G, -23' 99 (Ffti) I I : I i 84RHEK INSOft4NCE TEZ�+81 293 21?i � _ ��t..,, c� �'�� OATE(MM2R"M ACORD« ��'��r��+,, �F ��1��,�� 1'� .fii�ca��c�'-i. : o�faa 9s �o�H+ ' THIS CERTI CATE�51SSUE A MA R OF tNFpRMA tON CiNLV AND CONFERS NO RIOHTS UPON 171E CERTiFICATE WM. F. BOYhek SaBtSxaYiCa A�ncp FiOLDER.THIS GERTSFtCATE pOES PWT ANlEt+1D,EX7EtaD OR 311 Plymouch 8tr��t ALTERTWECOVERAGEAFFORDEDBVTHEPdUGEssELOW. Ha11Ei7f 7O1 02�38 GOM1�ANIESAP�OROiN6GOVERAGE william �. aorhak coMvw,v ,yo_ TBS-243-6332 ve=+�.?81-243-2111 � A IIttas Nstiflaal Iaauraae• Qi'Oup Naucm —i — CAMPMIY � Crpe CoG Child Dpveloymeat Pzo �a�+Px++' Arogr� Sne. C B3 Pmarl 8t. � eomvenv liyaaais baA �2601 p COyBRnCiES . � � � Tws+s*o cErcrFr n u�rn�ran�ra or msuiuNce us,Eo e�.ow nave e�sv issuEe ro rne iwuaEo nnrnm�nov�Fprerne ro�cv ncwoa IN�IG7W.NOTWITMSfMDIN6 ANV REOUWMENT,TFRMOR CONORION OF qNV CON7RCCT WI OTH�ll00CUMENT WITNFE9PECT T04MCMTM43 CERT�iIC�ii6 RUY�(66t�Q bR MAYPpiTAM.THt ai5UP�4NCE tfP01mi0 ir'fNE PIX.ICEs 66SCR�660!#AiH„s3 SU87EC�T6 nit.ntF'tG+iMS, 6XCLUypN6AN0 CONpITIpNB OF&1CN P041�IES.L►11799Nowry 1MY XAVE BELRI AE04GEDlV MOCLPIAIS. �� TYiGOFiN9UMNCE PPLILYNUM6ER �M�,.� I �M��Y�� LIAA75 .. QEHBftA4lu8lLltt j GENFML AGCJt66ATE S Z�060��06 A X COMMe�Gu��Eaai.uneam Cpp 1778070 06/l6/94 � 06/1�/00 �ucra-cbea+roe+_�acc�o1,000,040 �ou��Msaao� Q accuR i v�aaowu a„o�,wuny �i s.000,aoo owNER8dCONTw�CTOFC6PROT ,�AqfOC�unnEN� ;S,O4O OQQ flREMMAGE(Myenefrel S SO.O00 . _ ' ' i�0E15PfMY9roD�) S�r00Q nurOMOiIEIUbIIrtY � A �au�ewro SI�C I,938a54 O6l18f49 � 06j1AJ04 -�Meiueoar�c4Eurnrt Ta1=00Q.00Q uloWN60AUT09 I BQDLLYIN.It1Rv X &GtiEDtA.E6A�JT0i I �� 5 I ,t MIRkPFUT09 SpdLYIIyURY I X taON-oWt.E0AUT04 � ��7 S �� . � ' wiOPENTY0�1w.C� �S �aqqqOLLNEIl1TY AUTDON�Y.EAAC�i�YOLNT 5 �ANY�UTO OTMEN T�{�W AU?'0 ON.V: �^' .. «. i ��_dGCIDlNT : —.-•• ntlGieepA7E�S �»excgssivaaar e�eccuwtee� f I UMBRELLAFORM ' A4C/f�'.aTE f OiXERIHAii tiGCRtIR F61W S K011KEP9 f-0MPENSATId1 ANo .WG O �`�0�"��'�614{N e�wcn,�cc�o�rrr a 500000 A 'TNFPRtlPqlfl'OR/ MC� 20Z1110 O5/30J94 p5f3U/Oa &.as�•�anric�R .s 560000 A:ViTNfiR6f7t�."UTNt 7 pFFIC6R6hR@� DYCLI � � ' &�19E�!!•IUGMPLOYEE 5500000 O7HE0. J 1 � � � � � � i nescRa�a oF o�er+awnsnocaaqravveac�s�sveau�ras cEfLTIF�C�R.'r�+r4t�R � ... ._GaNGfiWiT14N �,... . . . .. �� , . YD10[C�1CA sMoulearros7x6peOw+EaE8cRp�va��saECnwCEt�o6EFaNETne EX►veaT14H OATE TnpriaF,'I{g 198UING COMPANV N�LL ENpGVOR 70 MAIL �C �' t!onvsu�xt�+riorc�mTMec�'��+cn��+o�oewr�aa�aTotne�fcr, BLIT iNUJRG i0 NAIL 9UCN IIOTIOE SWLLL IMPO&F NIS oBLXiPT10N OR LV�BIIIiY ��1g � QFANYWN�iPDXTi64",06iPANY.iTSAiiENT$O zR?NES. AUTMORRW N�R N1�TIVE < wlYliam r. $orhek � ,.. ...�.. . . . .. .. . .,;:� � � .. � + TION 79 . . ..,.. . . . .. . .:: : : itCORO'25�6.�tlB51 , :. _ . • Mena o �+ qugusr c o Brealcfast/Snack/Lunclx o 0 i�mii�se,�v�a.�ictr�n M� s � Breakfast 5nack Mondwy Tueeday Wednesday Thuraday Friday Pancakes�mi1k�w! Wheatita, peac hes, Raisin tosst and Rice CrIspesy Sanana bread, applesauce milk peanut�bikter, O bananas, milk cannmi.pears, tk Snack: Snack: 3nack arn: Rice cakes, am:Mimal Snack: am: grariam • 5nack milk crackers�,`�/C am:Yantlla yogurt crackers, am: ceiery and pm:Green applea pm: Gorp, juice and mlxed fruit pm: crackers and peanut butter, and peanut butter, pm: Pretzels, juice raisins, �uice milk juice pm: wfneac thlns/raislnsjuicc Engllsh mafftna Cheerioe raisins, Fru1t mlx- melon, Special- K Weffles, milk, and peanut butter, mi'lk kiwi apples, eannedpe aches, apple syrup mllk, dJ vanllra yo�u rt, mllk Snaek: whoie whea�toast Snack Snack: am: Carrots Snack: am: Cheese•its, am: Graham w/peanut butter Snack; a►n:gia er milk crackers, mitk dip' milk am: Pratzels, milk sna�pe, m�tk pm: Teddy pm: Pesnut butker pm: Triscuits, prm: pm: Kice Cakee Graham,Ju�ce and crackers, juice juxce p�. �-��:7 /r►i� baun�d�P'e�� 1 lNa€flee�nd 'Nheaties, fiagels and cream Cheerios, freah Applt cinnamon peaches, milk pineapple, milk cheese, O ), miik biueberries, m3tk Isread, fresh pears Snack Snack Snack Snack Snack• am: rice cakee, am: cheese-its, am: Pretzele mi#k am: 'Fed1y am: graham milk milk pm: Wheat t'hins, grahams� milk rtrackers milk pPm: Apples and pma GOTtP, �uice satsins pm: Chee j and pm: ce�ery, eanuebutter crackers, ulce raielns, anu[ butter�uice French toast w/ Garn flakes Sliced eggs,whole KiYr 1T3@IOtt Blaeberry appTe syrup, mitk raisins, mit�C wheat taast, pears, slices, miik muffins, canned milk Snack peaches, milk S»aek Snaek Snack am: rice catces, Snack am: pretzels, miMk am:wheat thins, am:peanut butker millc am: Teddy prn: graham milk and crackers, milk, pm: cheese 6c grahams, crackere, eanut pm: cheese•its pm: banana crackers, juice pm: Green apples, butter,�uice juice smunchSes and peanut butter, iu�ce Raisin toast,w/ Rice Kriepiea, _ p�eanut butter pears, milk Snack Snack am: apple�uice, am: Graham milk crackers milk pm:Trtacuite, pm: Pretzels, juicc milk Lunch Monday Tuesday Wednesday Thursday Friday Chicken Ep�aalad��ets, Turkey on Toasted cheese .American chop casserale, egg w-!"cucumber and Portuguese sandwlches, pasta suey green beans, noodles, mixed red peppers bread,celery salad w/beans frult salad vegetahles, strips, (rench v�tieks,w/dip and mixed p�neappie d�ess�ng, canned grapes vegetables, p¢ars ovange slices Fresh vegetabte Tana pockets, Ham and checse Meat laaf, Ghicken drum chowder, cheese broccol� w/french on whole wheat mashed potatoes, sticks, mashed chunks, soa�r dressing d3p, bread, carrot peas and corn potatoes, mixed crackere, frwt canned pears sticks, dip, mix banana vegetables, fruik salad appleslices c�unks mix Spaghett!w/meat Chicken salad 3n Peanut buttee and English tnuffln Taco w/ round sauce, spin�h bun, tamato and fruit preserves, pizza with tomato beef, Ie�tuce, salad, mixed fruit cucumbers with ellced cucumber, sauce, cheese, tomato, cheese, cheese salad, with dip garden salad, teco sauce, appMe saace watermefon cw�ned peaches epplesauce Taros w/ground Turkey roll�ups w/ Cald cut platter Ja w/rice, beans, Macaronl 6L turkey, tomato, cranberry sauce w1 aatmeal bread, �inguica, on ch+eese, raw lettuce, cheese, carrots sZlcks w/ celery sticks, portuguese bresd braccoli w/dlp, canned pears dip, orange elices yogurt i1ip,grapes applecauce partuguese bread, mtxed frpit Ham&cheese on Fish sticks, e portuguese hreud, naodles, mix� cucumber Si vegetables, celery sticks, p�neapple chonks french d�essing dlpr, apple slices THIRST QITENCHERS �As parents, we would never dream of giving our kids any type of addicting drug. But that's jusk what we are doing when we allow aur chitdren ta drink colas that are not labelec� "caffeine-frea." �Caffeine is an addicting drug that can cause shaking, nervousness, grouchiness, diarrhea and frequent urination. 1Colas, whether they are stare brand, Pepsi ar Coca Cala tw s cantain caffeine uniess they are ! speci�cally marked "caffeine-free." ♦On the ather hand, you'il find prodacts such as 7UP which say caffeine free. Well, yes, 7UP is oaffeine free, but 7UP never had caffeine. The manufactures are trying to make you believe this is a better product. Aiso, manufacturers of Minute Maid Lemon and Lime, and Orange Crush are making their products with i0% real fruit juice, making them sound as if thay ara a good source of nutritian. However, that means if you are drinking an 8 oance glass of ane of these sodas, only about Iflz tablespoons is reai fruit juice. 'The other 90% of the soda is water and su�ar - a vety expensive saurce far a very smail amaunt of nutrients. . ♦Sa, when the long hat days of surnmer are upon us and the kids are looking for something cold to drink after playing at tha beaclr or aut in the yard, what da you do? What's the alternative? "'P!'ATER!! Good, old-fashioned, piain, cotd water. Keep a pitcher in the refrigerator and you've gat the best (and mosk ecanomical ) khirst quencher available. No, water is no suhstituxe f�s the anclk a,.d juic� �hat �ur kicis neaci daiiy with their meals, but it's a great replacement far atl thase essential body fluids kids lase when they sweat when they are hard at play. *****�**********��********�***�*******************��*****�************************ ' SUMMER NUTRITION IDan't forget the �i t/.� FOOD GROUPS needed daily when planning summer meals. Kids ages 1-10 nead the foliawing amounts daily as the MINIMUM RECOMMENDED NUMBER QF SERYINGSt ti+MILK: 3 servings daily; includes yogurt, cheese, cvttage cheese, ice milk - 8 ounces each, 4►MEATc 2 servings daiiy; 2-3 ounces per serving; include cooked tean meats, fish, poulkty, dried beans and peas, peanut bukter, nuks, seeds, eggs. �►FRUITS & VEGETABLES: 4 servings daily; i/2 cup equals ane serving, 1 medium frait equals ane serving. �►GRAINt 4 servings daily; includes breads, English tnuffins, cereals, pastas, rice, muffins. 1 slice bread eqaals one serving; �/x cup cooked pasta or rice equals ane serving. Avaid the tow nutritionai vaIue foads such as hat dogs and balogna, and replace them wit6 tuna fish or peanut batter - cold pasta salads with some added chicken or tuna make a great tunch. Keep lots of fresh fruits handy for snacks. Take advantage of fresh vegetables sold at road side garden stands. **********************�***************************************�*******�*�******�**** HOMEMADE SHAKE AND BAKE CHICKEN - serves 4 •�/e cup flour •�/z teaspoan dried thyme •t1a teaspoan pepper •2 teaspoon paprika •4 chicken drumsticks or thighs •ilx teaspoon salt •'/z cup milk +�/2 teaspoon garlic powder ♦Preheat aven ta 375 degrees. Gambine everything but tha chicken legs and rniik in a plastic bag, ar any container wikh a cover that is large enough to shake the chicksn in. Dip ihe chicken in milk and shake off the excess. Add the chicken to the bag or container and shake to coat evenly. Place chicken on a baking sheet and bake far about an haur untit chicken is tender and coating is crisp. ♦SHOPPING HINT: Watch prices on chio�Cen thighs and drumski�ks. sometitnes prices go as low as .64 cents a �und making them ona of the best buys you can get for a high quality soarce of protein. Also, don't pay the high prices af the supermarkets for the spices and herbs you need. Look for stores that sell khem laose, by the ounce, and you can by the quantity you need for just a few pennies. • W . " . . . � . . � G r r m o M 01 O N > � � � - � . � � Q a u O �-1 N � y � � � . � . \ � �-� �L W � � a�°i N . � . O O O f/� U _! � � � o �O . . � � - O o E ►�. �- �.., a E � � V � � r � � �1 t�i a.� - . d .l� Q S � � , �O �O � 10 � t 0 Z Z o L � A ' m y C "' � W a C y � o C� v N � Cl -p - . � � � ¢ C1 n :� -' y � � _ � ._ � y �- m . � i. . . . . t n W � d r ~ L V V o Q � � � °o � W o� n tn � :'. o L t o �o a ., � � � iO � a � � Q f0 N 3 7 V w '6 ~ '� � � � � a� M � y J c. a �6 N d m J 2 Q d �+ � a, c� LV « m f' N y N °' LL .p � O N t � Z W � o �y m � m ~ � U J � � o � a LL. � � ,-� W c � 'J O c a W � � 9 U m >, H cLi o A a � t � �„ V � W _ •� N .�+ . .�.t�^� �� r-I J'°. � iL m � � � ~ a N W .��:�. U . . N � O . ~ . .. � � . . � N �C. c �l ` m 0 N N � � � � � . _ . ri y�' L �� V a .. � � . . , U . e t w � W n m � _ � r O e. m � �O N q 'O � . . - � N � � tl U cn 3 � � , � a o � c � c — w �e ,�; Gf 9 � �, a y � �1 � � •� � � a � V f.l ' 'p - f.l. . . � N V ' � � C � la Z '�� LL �Q _ J . . . � (`09 a . . � Q C N J N CAPE CHILDCODEVEL� PACaE 02 ' .�c� .„_ �G"+ �. ��' HF�,1'B GAtlfi! ['At�r�r��!�t'�tii'ltMRN'1• , �� Gn� �"� /�7�Yk.M�f��f/No , o� bv � . ADD�BSS OF 3"?AY CARE�� Th�s O!liae #or Childzaa grW�► dAy Gars sagulatiaas. 202 CNR 7.00, re�quirm t.bac Gber Licearaa have a l�saleh care consu.ttaac. Tbe gnaiilicatfc�s and reapaasibiiici�s ot Chis p�rson ax's dsrrczibaci bElov. 7.OS(i! (b! ��a�c*� t�r± ' p�{�. . Tlte Lf,cea��e erh�i; desiguate a Masw�cbuieCea licaa�ad gltysic�Caa,. —ssgietare�d aurse. nurre practtt3onrr or phyrician's �rai;caat�rltta. p�di.atrir or tasiiy bealch eraiaiwg•aad/or axprriaac�. as t2tsprogram'i 1�aa1Ch CdTQ aOn�ulCdlSC. .1174 GOasvltaunt fb3�.1 saallL 3a C2se d�swlcpe�st ot th�s yrogsam's 2t�altL eare poiicy iaelvdiag a �lais !ar ooaitarl�ag o� ehe psogram�� _iafactia�t c�ezol prcandur�ta: shsll epp� and reaisv t� policy iaitially and at 3,sast yesrly, tha12 spprova aay c�saagas iA e2re policy; sl�all sgprove �irst sid traiais�g aanzaa !oz sr�,a�i; aad s?aail be availslale !or aaassulk:iian a,s a+e�d. �.Ostil (a) ��eh c�rs s�niiev. T!u li,renati, s�s1,j ys�re,a �rrittea heralch Cars golicy �r2tiab �all sddzass a12 II��alth a�cter o! t3� pragz�m, iacluding rcatt sesnansibt2ft#ss tor �msxgeaey �nd yr�Cive lr�alth wes�uras. . . _ .3'he yoz3cy s�all intclvd�: tiJ R2is �oNrgancy telephon� �rs speaitied ia 7.26. ti5? ; Sa) Shs prec�srsa to bie lollovad ia carss o! Sl]sssas or m+ssgamcy, m�sthod o! ksaaspozLatien, aotitiCatiaau o! pereata, aad pzocadures v2sast p�r�e� catmot be�. zur.hasi laciud3ag gzoceds�res to be to2lcwed �hea aa lield eripa; . (3) � pYOCtduxres !or usia� amS �alataia3ag•ffrst aid suppliea; ta) T6e proc�duz�es ta bs lallorad eo evac�ase th�e c�ta�z in th�e �veat vE tir� or oUaar emerqsacy, incivding che �pec3lic pracedares to be follc�nnd tar eva►cnatiag l,afanCs and tadd.taszs lram ebe ceaL�r: {s? 1► qlsn foz thes case o# atildly ill childr+a� at the ceacer 7.25(3! tsy a plaa !oz ai.panssa�g mcascatian �_osts� : t7) A plaas !or ms�tiag iadividusl chf.idsea's speci�ic l�e+r].ch care aeeds; W, iaclvidiag cbw precedurs !or id�akifyiag chlldtin'+r allezgi+�s sad' psokrctiaq chiidsea lsroo� expwsnsr� ta lfiods, chemica2e. +�d at2ur material� to nhieh t�ey ae+� allerqic: iel ?1� proaadnrei tor ideat3t'Yla9 amd z�epostiacJ suspactad ch1ld abuse or a�glact ta the t�e�artmeat ot socia2 Sazviceat and tlse � pzocadwses !oz �deatitytag a�md r�ryort�ing abuae sad a�egl�ct to 'the OtfiC+e !4r Clitldr+ett ptr 7.RSt3) . ts) 1► plaa far lajnrY Praveatioa 9.a5t�) i3Qi 1► yliA ro= tn� m.�t os sar.ce�.ous a�.aa.es:T.oste� : tz�! A p2aa !ar th�e, im�iementaeiaa and maaicoriag o! eompii�aace �rich thc ialmcei�concra2 psotadurss �.�5 (6l m�lt t6e ssqaf.s�enti 03' Clx� hsellth G�te Caosultmat aa d+esCribtd iA zp2 {�& 45{i} {b) . i bava seviwad th�ase retes��eaced xeg�tlatipns anQ. uadezstaad t�ee :apansibiliti�s o! C2ie eltioa aad a+g�ces to ss�ist this cenGerr reg�zdiag tth+a sams. gu ��_ . � . �.bf.fd ,�,,,,,,,r �r� �.e e g ,�`?L 9 � � s. L cease atrat oa �,�a,.�os„Y rz _ �� - - sa Z � e�.. _ . "� .�•":'TM' , ,��`..�. r.. .,+{:-•;:i.' :iG SSf�D.e � , ,� . p , � ';,,�:� �.�� _ _ ' . . ._�x.. . ;,;,,y�."'� ..