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Home My WebLink AboutApplications, WC, Licenses Prior to 2010 � � � � ^� � ' TOWN OF YARMOUTH BOARD OF HEALTH _ � APPLICATION FOR LICENSE/PERNIIT- 2�9 � .;;� � �,, . . , � Ec i s 2�as , * Please complete form and attach all necessary do�up'i�tYt��}+ '' ` er 5 2008 Failure to do so will result in the return of yqs�ap c pa �.'! t' [-i::(-� NAME OF ESTABLISHMENT: Elder Services of Cape Cod and Islands, Ir�L. # (508) 394-4630 LOCATIONADDRESS: 528 Forest Avenue, Yarmouth MAILING ADDRESS: OWNER NAME: Elriar Carvirac nf CanP f.od and the Islan3's�X ID (FEIN ar SSN)• CORFORATION NAME (IF APPLICABLE): MANAGER'S NAME: Karen Kel ly, Gai l Murray TEL. # - MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies of exnployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your ptace of business. 1. 2, 3. 4. FOOD PROTEGTION 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 Establislunents, 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- Kareo Ke> >�r -�;ta r.nnrd;natnr 2./cathy Hambleton-Nut. Site Supv. PERSON IN CHARGE: Each iood establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.Karen Kellv- SD 2. Gail Murray- MOW 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-chokuig 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. Cathv Hambleton- Nut. Site Supervisor 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMI'I# LICENSE REQUIItED FEE PERNIlT a _B&B S55 _CABIN 555 MOTEL S55 _INN S�5 _Ct4'vIP Si5 _SWIIvA4INGPOOl S80ea. _LODGE S55 _1RARERPARK S1Q5 WIIIItI,POOL 580ea � FOOD SERVICE: � LICENSE REQiTII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIKED FEE PERMII'# _0-1005EATS SSS _CON7INENTAL $35 1NON-PROFfI $30 �(��/��J �>100SEATS 5160 _COMMONVIC. �60 WHOLESALE S80 RE'IAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIItED FEE PERMIT# LICENSE REQLIIRED FEE PERMIT!! _<SOsq.ft. 550 _>25,OOOsq.ft. 5225 VENDING-FOOD 525 . _- _._. . _ --._ .. --- --_.-- --�- --- � <25,OOOsq.ft.� S80 - � - _FROZENDESSERT 840 ?OBACCO SSi va:�tE c�nvcE: sio AMOi7NT DUE _ $ �30,00 "'**'PLEASE TUR\OVER AND C0;1�LETE OTHER SIDE OF FORVI**"• � . F ' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED XXX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISffi1�NTS 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 motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety (90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opemng. Contact the Health De�artment to schedule the inspection five(�days pnor to opening.PLEASE NOTE:People are NOT allowed to sit�n the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL 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 Yazmouth must notify the Yarmouth Health Depamnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Hea.lth Department FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHea}th. OUTDOOR COOHING: Outdoor coo_king,_preparation,or display of any food product by a retail or food service establishmern is prohibked. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLTRN 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 EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��- � 2-C�C�� SIGNATLTRE:�c�� G��-d-� PRINTNAME&TI'TLE: Linda Zevi�as, Nutrition Program Manager io�zi�os . ..... ,.,..._.,.. ��..._ ,... �,..��. .,�,�o� �.�.. ��y�o��...��a��y. �� .�..��N�ar ..��ELDERSERVN,._.... -' _ -- -- . - ' - �Client#:39689 � ACORD�. CERTIFICATE OF LIABILITY INSURANCE ,02;;0$°"",�, rRooucErs iHIS CERTIFICAI'E IS ISSUEDAS A MATTER OF INPORMATION NUB(ntemational New England ONLY AND CONFERS ND RIGHTS UPON THE CERTIPICATE 265 Orleans Road HOLDER.THIS CERTIFICATE OOES NOT AMEN�,EXTEN�OR ALTERTHE COVERAGEAFFORDED BY THE POLICIES BELOW. North Chatham, MA 02650 � � 508 945-0446 . � INSURERS APFORDING COVERAGE NAIC# wsuaeo INSVR:RA National Grange Mutual Ins Co � Elder Services Of Cape Cod 8 INSURER 6: AIG � � Tha Islands Inc � � � iNsuR=_ac GreatAmerican Ins�Co � 68Route'134 iNsua=_ao: SafetylnsuranceCo � S Dennis,MA 02660 � � INSURERE: COVERQGES THE POUQES-OF INSURAN��E LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO�INDICATED.NOTWITHSTAN�ING ANY REqUIREMEM,TERId OR WNDITION OF ANY CDMRAGT OR OTHER DOCUMENT WITH RESPECT TO WHICH 7HIS CERTIPICATE MAY BE ISSUED OR � MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE�HEREIN IS SUBJECTTO ALL THE TERA\5,EACLUSIONS AND CONDRI9NS OF SU�H � POLIGES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID�..lAIh15. LTR NSR TYPEOFINSURANCE POLICYNUMBER POLICYEiPECTIYE POLICYEXP1RAnON ��NRS . - /{ GENEftALLIABIIItY FRB'I7PSS �b1�08 09107/U9 ��URREM�E S Q4MAGE TO REMm 5 COMMEftC1AL GENERl�L LIPBILRV a " CUIMSMUDE �OCWR �vEDEXP!Anyaieperson) $ PERSJWL&ADVIWlA2V S � GENERALAGGREGATE S GEV'LAGGREGATEL@dR4PPJESPER � PROWCTS�GQdWOPAG3 S . � POLIGY ERa LOC D auronwaae�wearrv 1621868 07101f06 07/01109 COlABIkED51NGlELIhiIT 5 � (Ee acGdenl) AtiY pUTO ALLOINNmNUTOS BODILYINIIIRY � S��OOO�OOO � (Perpermn) � SCHEIXREDAUTOS . X niaEoquTos eooaviwuar 51,000,000 . (Pa�accAerR1 X NON-0NTIEDAUTQS � . � PROPERTY�AMAGE SSOO�OQO . . (Pe�accdenll GARAGELIABIIRY AU'i00NLY-EAACCI�ENT S ANYAUTO OTHERTHAN �A� 5 � AUi00NLV: � S EXCESSiUMBRELLFLIABILRY EACHOCCURRENCE S JCCUR �CLAR.ISMADE � . AGGREGATE 6 I DEWCTIBiE � 5 RETEIirION $ 5 B WORKERSCOMPENSATIONAND WCGSIG�H4Z O�/O'I/OS O7IO�/O9 ��A� �TM EMFLOYERS'LIAeILITY E.LFACHACCIDENT S�OOODO ANY GROPRIEfOR/PARTNERIEXECUTflE OFFICERMEMBERE%CLUDED2 ELDISEASE-EAEMPLOYEE S�QO�OOO ''Y�'.�eindef ELDISE0.5E�POLICYLBdR S50Q000 SPECIALPftOVISIONSG�Iaw � C °TM� Non-Profit D EPP5797833 � W/01lOB 07/01109 . � DESCRIPTION OF OPERATION51 LOCATIONS f VEHICLE51 EXCIUSION4 AODE�BY ENDORSEMEM I SPECIAL PRONSI�NS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TNE ABOVE�ESCRIBE�POLIQES BE CANLELLED BEFORE THE E%PIRATION � FORDISPIAYPURPOSESONLY UATETHEREDF,THEISSUINGINSURERWILLENDE4VORTOMFIL _ DAYSWRRiEN NOTICE tOTHE CERTIFICATE HOLDeR NAMED TO THE LEFT,BUf FAIIURE TO DO SO SHAI.L IMPOSE N008LIGATIDN OR LIABILIT/OF ANV NIN�11PON THE INSURER,RS AGENTS OR � � � RECRESEMATNES. . AIITHOWZE�REPRESENiATIVE . ACORD 25{2061108J � of 2 � #204757 � RT001 0 ACORD CORPOR4TION 198A TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #0-129 FEE: $30.00 [n accordance with regttlations promulga[ed under autltoriry of Chep[er 94, Sec[ion 305A and Chap[er 1 I 1,Section 5 of the General Laws,a permit is hereby granted ro: Elder Services of Cape Cod and the Islands, Inc., 528 Forest Road South Yarmouth, MA Whose place of business is: Elder Services Yarmouth Nutrition Site Type of business: Non-Profit Food Service To operate a food establislunent in: Town of Yarmouth Pemvt expires: December 31. 2009 BoaRD oF HEnI.rH: ,�fe[e�e Sf�, J?,.JY., C1�aL�man. C'Raatfee .�. 9felPilEex ?Iice CRaixrna�r. 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�afqns sr 3�i,iausdn�p ��uaisuei� pa�ap�suoa aq �ou psys �mn �u�amp io a�uaptsai 8 se�mn�san8 e 3o asn �pouad�uou�(9)�ns�Cue vrt�;�nn s,CBP �06)�a�veya alow�ou 3o a;�BaiSEs � P� `�BP �0£) ��!4i �91 aiom �oa 30 �uedn�o snonm�uoo oi ia3ai �Sneiaua� peys �uedn�o �uarsaelZ '�tl^s�[��P?�3o a�d ledrouud e u�iuisuc�(aqi iEyi a;�►�saomap ol al4g a9 PuE an¢y�snm s3uEdno�o auaisu8iy •asn 1��°ii PT�[aiaui quM palzraosse,i�uetuo3sno puE�ijuearpio `�uedn��o uual uoqs pue�Cieiodcua3 aqi oi Palw![ aq neys�uedre�o lua►sueiy`asn Ialog�o Iaioy�3o suo�iB3��►aql3o sasodmd l03 �1i�ld�'dII��O.LAI�S1�iVZI,L S.LNI�NIHSI'I$V.LS�91�iI�QO'I ZI3H,L0 QNV S'I�J.OI�1I O1�I S� �QIF'd,�1�'IH.LdRIdO�Iddd }I��g��d 's;►uuad mo�C3o aou8nss�io leMauai o�.►oud pRd aq�snw saail pas sa�csl yinouus�3o un�oy Q�-I�d.L,Ld Ql1d Q�AIiJIS .LIAH�33d ��t0� S.�I�?RIOAA NO �Q�I��d.L.Ld ��NF�If1SISI 30 �.LZT3� xo`a�x�is axv a�.r.�za�o��g sscua.r.rnv�v ��ItiVV�IRSi�ii 1�IOI.LVSI�t�dL1i0� S�2I�iHOAA �.LV.I.S Q�H�V.LLV �H.L 'aoue�nsui uoqesuadmo� s,ia�o�3o a�gq�a� s an8q �oa saop 6ved�ua� io aosiad s,� ssauisnq B a�Eiado o� �na�ad io asaa�g ,CuE 30 ismauai io a�uenss►p�oq ol palmbal mou si yinouus�3o w�+oZ aqi`9 uorlaasqnS `�SZ uo?;�S `ZS I �id8q�iapun xo�.v�.su�u�av . . rmm:n�auraoem cnnson At HUB Intemational NE LLC FaxIQ HUB Intemational Ne To:Peborah Tranfaglia Date:S/292007 0323 P6q Page:1 of 2 ACORD_ CERTIFICATE OF LIABILITY INSURANCE OPID °"��^��°^�� ELDER-2 08/29/07 aaooucez THIS CERTIFICATE IS ISSUE�AS A MATTER OF INFOflMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HUB IateinatiOnal NeW EnglaAd HOL�ER.THIS CERTIFlCATE DOES NOT AMEND,EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. So.Yazmouth MA 02564 � Phone:508�-394-0946 Fax:508-760-1407 INSURERSAFFORDMGCOVERAGE NAIC� � � RlSURED 11.5URE2X ereac�nexiun meuxance [a � n�uRE3 e: A.I.6 Eldex Sexvices Of Cape Cotl �^��E4��- 68 Route 134 in�uae3o�. S Dennis MA 02660 I�URE�E. COVERAGES iHEFOLICIESGFItJSF/JJCELS�DBELOItiFW.I'EEEENISSUE�TOh131N5Uf�DNMqZUBO'JEFOFT-ExliCl'FERIGDIVGKA�D.NOPNfiFSTAN'ING � AIJ"P.E0.1FE�1EI�R,iEP.IA OR C�NO TIxJ�P.NIY EONI3ACT OR OliEF DGCUNENr W ITH RE�FECT TO WHICH T115 CEn^!IF CATE MCY EE ISSLED OR M1WY PE:1RN,TiE IIJAtP,iW�E oFFORCED BY THE POl CIES DESCP.IEEDHER`_IN I£3£JECTTOFIL 7FE IEP.MS,ERC_.�IqJS Ml�C�'ADRIIX.S=F A�CH POLICIES.A��GP.EGCIE lllAl-S SHOWT M51'HA�/E BEJJ 3EDU�D B"PAID ClA1hiS � LTR NSR TYPEOFb15URFlI��E POLICYNUMBER DATE�;MM/pDM') D4'fE�FTdiDDiYY� IJMrtS GENERALLIPBAITY EhC10CCURFENC= $SDOOOOO A X c�n,nn�ecr,�eer��u_ineiun GI,p5093797 09/23/O6 12/01/07 Faewiis=€;eacec�a,_a� 5100000 CLHIn15�4i:E �OCWR � htEDExFipnycreperscr) E5000 FER��w�anDvlw„a- $1000000 X PROFESSIONAL � cew�<.cc�cnre g3000000 GENLT3GREGHTELIVITFPP IESPER: FP.OJUCiS-�X'iMP!OPAGC $$OOOOOO P�icv �a �oc Emp Ben. 1000000 AVPJNOBILE LIA841TV � NJVMO COVEhEDSIl.GLELINiT $ (Ee acci]ai-) PLL OWREJ?,Jr05 fODIL"INLP.° $ S6EDLLED<UTO� (Per pa.seni HIP,EDASIrCS H�T-'WNEDAUT�1 EODII"iNLP" $ (Per�ci0en[) F'RO'EP,T"Di*Nl.GE $ � (Pe'emtlen[) GARPGE LWB0.ITY AlTO�Y-J�4CCI�EM $ NJV MO OiHER-HN. =�.^CC $ - AITOON_Y-. �`G S EXCESSNMBRELLA�Lq86T' EAC-10'CURFE�JC= $ O�LUR �CLAIMiM4DE � AG�#GaT= $ $ �EOUCPBLE $ RETMI�N $ $ WORHERS COMPEH54TION 4ND X T'P"�LINITa' VEP, EA9LOVERS'LV.BILITY - $ ONYP4GPR�OP/PK.qNER'E<=Qllb'E 6$S6ZS� O7�OZ�O� O7�OS�OB E_.FACHnCCL'EP!- $IOOOOO OF=1C�/�AEM�R EXCUAED] If yzs aescribe under E_CI'sEISE-E4ENPLOrEE $1��00 SP_CWLPRG�'ISIONS[elow E._CI325E-PJLICI'LMT $rj�000Q OTHER �ESCRIPTON JF OPERPTPJNS I LOCFTiCNS I VEHICLES/E%CLUSIONS ADCED BY ENGORSEMENT/SPECINL PRCVISIONS CERTIFICATE HOLDER CANCELLATION SHGULD ANY OFTME PBOVE GESCRIBED POLICIES BE CANCEI.LK�BEFORE THE E%PIRATION DATETHEREOF,TF�RSUIHGPlSURERiYILLENDEAYCRTOMAIL ZO DAYSWFIiTEN NOIICE i0 THE CERPiICATE HOLDER N4MED TO THE LEFT,BU!FNLUPE TOOO50 SH4LL IMPOSE NOOBLIG4TION GR LIABILITYOF ANV KIND UVJN TIE INSURER,A'S pGENT$JR . � ftEPRESEMATNES. RUTMO R RES NTATVEI(/_�)��(�a�- ��- ! ACORD 25(2001lO8) O ACORD CORPORATIDN 1989 � � �Illli!1?Il�lillll!!Illllilllllllllll�IIIIllllllllilllillllll � � � � MASSACHUSETTS �EPT.OFREVENU'c � � PO Box7010 . . � � . � Chelsea.,�MA OZ150-7D10 . _ � :9'i!W� � . - i ��.�1'�� 1�'� I�� - . ALAN LeBOVIDGE, COMMISSIONER LAURIE MCGRATH, ACTING DEPUTY COMMISSIONER ELDER SERVICES OF CAPE COD & THE 870 Notice 30048 ISLANDS Exemption 68 ROUTE 134 ' Number 042 523 904 50 DENNIS, MA 02660 n .y �[ � . . � . ' UQI�. 12��/fU� Bureau TSD MGT SERV Phonz (617) 887-6367 Dear Taxpayer, A eeview of our records indicates that the Massachusetts sales/use tax exerription for ELDER SERVICES OP CAPE COD & THE ISLANDS, a tax-exempt 501(c) (3) organization, wiii expire on D1/02105. The Department of Revenue is issuing this notice in lieu of a new Form St-2, "Certificate of Exemption". The notice verifies that the Massachusetts Department ot Revenue has renewed the sales/use tax exemption for ELDER SERVICES OF CAPE COD 8� THE ISLANDS.subject to the conditions stated in Massachusetts General Laws, Chapter 64H, sections 6(d) or(e), as applicable. The'organization remains responsible for maintaining its exempt status and for reporting any loss or change of its status to the Department of Revenue. Absenf fhe Department of Revenue's receipt of information from fhe taxpayer.by fhe.expiration date of the current cerfifrcate that the enfity no longer holds exempt status under the a6ove provisiQns, the faxpayer's cerfifrcate is renewed. This renewal will expire on 01/02H3. The taxpayer's exisiing Form ST-2, in combination with this renewal notice may be presented as evidence of the entity's continuing exempt.status. Provided that this requirement is met, aii purchases of tangibie personal property by the t�cpayer are exempt from sales%use taxatiQn under Chapter 64H or I respectively, to the extent that such.property is used in the conducl of the purchaser's business. Any abuse or misuse of this notice by any tax-exempt arganization or any unauthorized use by any individuai constitutes a serious violation and will lead to revocation. Willful misuse of this notice is subject to criminal sanctions of up to one year in prison and $10,000 in fines ($50,000 for corporations),' This notice may be teproduced. Sincerely, Alan LeBovidge Commissioner of Revenue / � � TOWN OF YARMOUTFI BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMIT NLJMBER: #08-111 FEE: $25.00 In accordance with resulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 ofthe�eneral Laws,a pemtit is hereby granted to: Elder Services of Cape Cod and the Islands Inc. 528 Forest Road South Yarmouth MA Whose place of business is: Elder Services Yarmouth Nutririon Site Type ofbusiness: Non-Profit Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2008 BOARD oF�ALTII: ,�EeQerc Sl�, J2.N., e(�avanan (.�ax[ee .�. 9Cel�iRe�x,,� `vnice('.Pai�ta►earr. ssnrtrrG: 120-Congregate D'"�Room ��Il� S, J�KpI(ut l.l¢YR ��uin,'`./�V .r�„�y i�.zoos Bruce G.Murphy, .5., CHO Director of Health . : e /776N�S�riE o°`��c TOWN OF YARMOUTH BOARD OF HEALTH� .��EC ]. 5 "''�6 � APPLICATION FOR LICENSE/PERMIT-20ppp � '�' r .�s � :. � � � �" * Please complete form and attach all necessary documents by Dece � __. __ J Failure to do so will result in the retum of your application packet. NAMEOFESTABLISFIlvIENT: Elder Services of Cape Cod and the Island�IIl�N. 508-398-5060 LOCATIONADDRESS: __ F�u F��a�r a�ad, South Yarm�uth, Ma 0266a MAILINGADDRESS: GS 2-rE f3�/ S DENNts d'Z� OWNERNAME: Elder Services of Cape Cod and the Islar�' $DeGFEINorS41�)� CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: Caroline Kosowicz TEL. # 398-5060 MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Ptease list these employees below and attach copies ofemployee certifications to this form. T6e Health Departmeat will not use past years' records. You must provide new copies aad 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 wilI not use past years' records. You must provide new copies and maintain �fde at your establishment I.Caroline Kosowicz 2. PERSON IA�EFFA1t6E; __ — ___- _--- - ---------- —_ __ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1 Caroline Kosowicz 2 Janet Donahue HEIMLICH CERTIF'ICATIONS: 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 Caroline Kosowicz 2 Janet Donahue 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIIVG: LICENSE REQLJIItED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT tt _B&B S50 _CABIN S50 MOTEL $50 _INN $50 _CAMP $50 _ _SWIIvIIvIINGPOOL$75es. _LODGE $50 � _TRAII,ERPt1RK $100 WHII2I.POOL $75ea. FOOD SERV[CE: LICENSE REQiIIRED FEE PERMIT# LICENSE REQiTIItED FEE PERMIT# LICINSE REQi7IRED FEE PERMI'C# _0-100SEATS $95 _CON1'INENLAL $30 1NON-PROFIT S25 �'07—OZ� _>]00SEATS 5150 _COMMONVIC. S50 WHOLESAI.E 575 RETAII,SERVICE: —RESID.KTTCIIEN $75 LICINSE REQiIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQiJIRF.D FEE PERMIT# _<5p sy.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.R $75 _FROZENDESSERT S35 TOBACCO S50 NAME CHANGE: S10 AMOUNT DUE _ $ Z.S.OO ••"••PLEASE TURN OVERAttD COMPLETE OTHER SIDE OF FORM'•"'• ADMINISTRAITON ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURA.NCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED xx OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tar�es and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISH11�1IENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be ]imited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Traosie�occupants must have and be able to demonsuate that they maintain a principa(place ofresidence eisewhere. Transient occupancy shall generaily refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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 consider�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 Heaith Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomoaas,total coliform and standard plate count by a State certiSed lab, prior to opemng, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered evem. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board ofHeahh. OU1'DOOR COOKING: Outdoor cooking,preparation,or display of anXfood product-by a retail ox food service-establishmernis pro6ibited. N01TCE:Pecmits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.ITY TO RE'TURN Tf� COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATION5 TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 12/12/2006 SIGNATURE: �� Ve� C,.1�lOr1- '�l�l/� Te4-S � PRINTNAME&TITLE: I�IYd.I rlD� ��(z�/1-uj {'�1��-G�tK.r�L io�i�ia • oRv CERTIFICATE OF LIABILITY INSURANCE oP,o DATE(MNJDD/YYYY) ELDER-2 10 12 06 � . Pnonucea . THIS CERTIFICATE IS ISSUED AS A MA7TER OF INFORMATION � � � � ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE � HUB International New Enqland HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 437 Station Ave � ALTER THE COVERAGE AFFORDED BY THE POLICIES BEIOW. So.Yarmouth MA 02664 � . Phone: 508-394-0946 � Fax:506-760-1407 � INSURERSAFFORDINGCOVERAGE NAIC# � INSURED - . INSURERA � Great Am�riwn In¢ezanw Co . . . .. .. . MSURERB: A.I.G - Elder Services Of Cape COCS �NSURERQ � � 68 Route 134 � INSURERD: S Dennis MA 02660 � � � � � INSURER E: - COVERAGES � � � . � THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FORTHE POLICV PERIOD INDICATED.NOTWRHSTANDING ANV REQUIREMENT,iERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAYPERTAIN,THE INSURANCE AFFOROED BYTHE POLICIES OESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CANDITIONS OF SUCH POUCIES.AGGREGA7E LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAIDCLAIMS � � . . LTR NSR 7YPE OF INSURANCE - POLICV NUMBER OATE MMIDDM' PDATE MMIDDm LIMITS GENERALLIABILITV � EACHOCCURRENCE SSOOOOOO A X X COMMERCIALGENERALLIA81L17V GLP5093797 - 09/23/06 09/23J07 p{�MISES(Eaoccurence 5100��0 CLAIMSMADE aOCCUR � MEDD(P(Mydieperson) $SOOO � PERSONALBAOVINJURY S�.00OOOO X PROE'ESSIONAL � � � � � GENEwuAGGrzecnTE � S 3000000 GEMLAGGREGATELIMRAPPLIESPER � � . PRODUCTS•COMP/OPAGG S,3O00000 . POLICY PRP � LOC � . . JECT AUTOMOBILE LIA8ILRY . qpryq�7p . � (EaaBtiUeD`SINGLELIMR :$ ALL OWNE�AUTOS . � � � BODILYINJURY E. � SCHEDULEDAUTOS . � (P�Pa�saN � . - HIREDAUTOS � � � � � BODILViNJURV - 5 NON-0WNEDAUTOS ' . (PereCotlanl) � . PROPER7V�AMACaE $ (Per acdtlent) . . GARAGE LIABILRY � AUTO ONLV-EA ACCIDENT S AMYAUTO � 1 . EAACC S OTHER7HAN � AUTOONLV: � pGG E EXGESS/UMBRELLALIABILITY � FACHOCCURRENCE 5 OCCUR ' � CLAIMS MADE AGGREGATE E E DEDUCTIBLE y RETENTION E y WORKERSCOMPENSATONAND - . X TORVLIMRS� FR � S EMPLOVNtS'LIABNJ7V 6948264 07/OS/06 . 07/01/07�. e.�.encHnccio�ur s100000 ANV PROPRIEfOR/PARTNElLEXECUT7VE . OFFICERIMEMBEREXCWDED? � - E.LDISEASE-EAEMPLOVE SSOOOOO Hyes tlesaibe under � SPECIALPROVISIONSbelow � E.LOISEASE-POLICVLIMR SSOOOOO OTXER �DESCRIPTION OF OPERAIiONS I LOCA770N51 VENICLE5/EXCLUSIONS ADDEO BV ENUORSEMENT/SPECIAL PROVISIONS , Social Service Agency � � CERTIFICATE HOLDER CANCELLATION � . � . . . � . SHOUTAANYOPTHEABOVEUESCRIBEDPOLICIESBECANCELLEDBEFORETHEE%PIRATON DATETHEREOF�THEISSUINGiNSURERWILLENDEAVORTOMPJL SO DAYSWRITTEN . NOTiCE TO THE CERIIFlCATEHOLUER NAMED TO THE LEFf,BUT FAILURE 70 DO SO SMALL . . IMPOSE NO OBLIGATION OR LIABILITV OF ANY IOND UPON TME INSURER�18 AGENTS OR � REPRESENTATNES. . . AU7H PRE$EN�IVEI^� (%� /!! ( b� ACORD 25(2001/OB) . �ACORD CORPORATION 1988 .� � � �iiii��ii�iiiii�iu��i�i�iu�!ii�ii�iiiiiiiiiiiiiiiiiii�iii � � � MAS5;4CHUSETTS DEPT.OF REVENUE ' . POBox7010 . . _ � . � Chelsea,MA 02150-7010 � - IIII{IIi� �Illillllll �" � ALAN LeBOVIDGE, COMMISSIONER LAURIE MCGRATH, ACTING DEPUTY COMMISSIONER ELDER SERVICES OF CAPE COQ & THE 87D Notice 30048 ISLANDS Exemption 68 ROUTE 134 ' Number 042 523 904 SO DENNIS, MA 02660 Date 42i07f84 Bureau TSD MGT SERV Phone (617) 887-6367 Dear Taxpayer, A review of our records indicates lhat the Massachusetts sales/use tax exerription for ELDER SERVICES OF CAPE COD & THE ISLANDS, a tax-exempt 501(c) (3) organization, will expire on 01/02l05. The Department of Revenue is issuing thi's notice in lieu of a new Form St-2, "Certificate of Exemption". The notice verifies that the Massachusetts Department of Revenue has renewed the sales/use tax ezemption for ELDER SERVICES OF CAPE COD & THE ISLANDS subject to the conditions stated in Massachusetts Generai Laws, Chapter 64H, sections 6(d) or{e), as applicabie. The'organization remains responsible•for maintaining its exempt status and for reporting any/oss or change of its stafus to the Departrr�ent of Revenue. Absent the Depar(ment of Revenue's receiRt.of infortnation from the f,axpayer .by the.expiration date of the cument certificate that the entity no longer holds exempf status under the above provisions, the taxpayer's-certificate is renewed. This renewa/will expire on 01/02H5. The taxpayer's existing Form ST-2, in combination with this renewal notice may be presented as evidence of the entity's continuing exempt.sta4us. Provided that this requirement is met, all purchases of tangibie personal property by the t�cpayer are exempt from sales1use taxatipn under Chapter 64H or I respectively,to the extent that s�ch,property is used in the conduct of the purchaser's business. Any.abuse or misuse of this notice by any tax-exempt arganization or any unauthorized use by any individual constitutes a serious violation and will lead to revocation. �Ilful misuse of this notice is subject to criminal sanctions of up to one year in prison and $10,000 in fines ($50,000 for corporations). This notice may be teproduced. Sincerely, Alan LeBovidge Commissioner of Revenue � ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMIT NUMBER: #07-076 FEE: $25.00 In accordance with regu(ations promulgated under authonty of Chapter 94,Sec[ion 305A and Chapter 111,Secti�5 of the Ceneral Laws,a permit is hereby granted to: Elder Services of Cape Cod and the Islands Inc. 528 Forest Road South Yarmouth MA Whose piace of business is: Yarmouth Nutrition Site Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Pernvt e�cpires: December 31_ 2007 Bon12D oF HEnLTH: 6 l.c$. �l.$., ' .��"s� �'., v� e�n sEn�ru�G: 120-Congregate Dining Room Rt��. B4ouwc, � P��fa`�dr.,�o�` A...� �j�, R.N. _Feb�vary 22.2007 � Bruce G. Mwphy,MP , .,CHO �irector of Health ` � ��h�{S�3`� � �cEs �f YAR TOWN OF YARMOUTH BOARD OF HE��YH�5 •�'��3 T� o ! '�= APPLICATION FOR LICENSE/,�,E��2006 � D E C 1 2 2005 * Please complete form and attach all necessary do�Cuh�ts by Decem �,41��pEP7'. Failure to do so will result in the return pf}�our applicat�on packet. NAMEOFESTABLISHIVIENT: Elder Services of Cape Cod and the IslandsTEL. #398-5060 LOCATION ADDRESS: 523 Forest Road MAII,ING ADDRESS: Sout Yarmout OWNERNAME: Fldar Sarvirac nf Cana Cnri R Tclands TAXID (FEINOrSSN1: CORPORATION NAME(IF APPLICABLE): same MANAGER'SNAME: Caroline Kosowicz 1'EL. # ' MAILINGADDRESS: 68 Route 134. South Dennis, MA 02660 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and atYach a copy of the certification to this form. N/A 1. 2. Pool operators must list a miaimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a 51e 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 ofcertification to this application. The Health Department will not use past years' records. You must provide �ew copies and maintain a file at your establishment. 1. 2. PERSOI��N�I�ARCaE: _ _ _-- - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1 Anne Rowe Z. Caroline Kosowicz HEIIb�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-chokuig procedures below and attae}i eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintaiu a t"de at your place of business. 1 Anne Rowe 2 Caroline Kosowicz 3. 4. RESTAURANT SEATING: TOTAL# 120 OFFICE USE ONLY LODGING: LICENSE REQiJII2ED FEE PERMI'1'# LICENSE REQUII2ED FEE PERMI'1'tt LICENSE REQiJIItED FEE PERMI'f'# B&B $50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIIvIIvIINGPOOLS75ea. LODGE S50 _TRAII,ER PARK S50 _WI-IIR.LPOOL $75ee. FOOD SERVICE: LICENSE REQiJIItED FEE PERMIT N LICENSE REQiJIItED FEE PERMIT# LICENSE REQiJIl2ED FEE PERMI1'# 0-100 SEATS $75 CON'PINENTAL $30 I NON-PROFIT $25 �' p6-(0! >t00 SEATS E150 _COMMON ViC. S50 _WHOLESALE $75 RETAIL SERVICE: LICENSE RfiQIIII2FD FEE PERMIT# LICENSE REQUIItED FEE PERMI1'# LICENSE REQi7IItED FEE PERMTL# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 <25,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ 2-5.o0 •""""PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••+"" AD1I�IINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSITRANCE ATTACHED X OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frazen desserts inust be fested on a monihTybasis by a State certifie�Tab.- Test iesuIfs must be sent to tfieHeaTtTi 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 ofHeahh. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmem is prohibited. DATE: November 28, 2005 SIGNATURE:�,��,�✓ PRINTNAME&TITLE: Ellen McDonough_ Nutrition Program Manayar 09/28/OS ='`� The Coinmonwealth ofMassachwselts �= —__� _'� Department af Indy��trirtl Accidentc - — NMtaN�rlM�r - = 6oa w�hM�,�sa� f'F�. - - so�,M�. oaril ,.. wo�•c��■i..�wma.�s.ua��ce■axco., ..... . ,. - r t x=;7 rgwu W ::x � :� ..... x's'su.':.r.:�s5.��i'�.:-i+"r.k�cd49 . $^ '�" �aruv�s'� 2'�..b....td �: Elder Services of Cape Cod and the Islands, Inc. ,�g: 528 Forest Road �, South Yarmouth ��: MA rin. 02664 �* 398-5060 ��;ni�;m��,�• Yarmouth Senior Center o t�a��m,�: Projed Type: ❑New Caosavcuan o�,� I am a sole 'etor avd have no�e woduog m�y cayecrt�. Bwl ' Additan �. . �... � ` ��'�:�.�;��- .. �.: . . .. . � I mm��ployer providiog wadceis'compensatian for my employces wo�cing oa this job. �o....�: Elder Services of Cepe Cod & Islands, Inc. ,�,s.; 68 Route 134 �,. South Dennis, Ma. 02660 �* (508) 394-4630 - fi708355 ❑ I am a sole proprie[or,ge�erd e�trxWr,or iomeew�er(cirde oweJ�d have ltim)the�listed below wla have the following worke�s'compensalion polices: ea��• ad�s: dlv: oYwelk ao. M �^tv:..�i� , . .. x..0� ... `.0 � . . .. �. ,s+.... . :aa.... xr_ #x..�:w.. ..., . . . . ... . . . .. 9�'tl�' CHY' YM�!IJ: - -.. . � - — -� ----� ----- ----- -- --- -- ----- -- - ----- ---- -- ----- --- 8 . .�3a �+ *yr.:;..+�'.a��*.u� :� ;�s;� �.�:... Faiare b aeeme eevuate u reqetrM etiv Satle�2SA KMC.L 132 eu kW b IYe h�tW datdul pe�al8d d�6e�b S1,3KN ad��r e.eynn�ImptWa�eetawdndHpeoltlnlethtfer�ofa3T07WORKOADERud�BeedflM.M�dryapMtve. i�awm�. e�py KHh MaeeweM my 4e forwaNM b Ne Omce a[lsv�tled etme DIA tr avenge verl�ntl�e. !da hereby cer6fy rnler Me pdes and pene/oes ojperjiny fiet the infonwoNon provldel abone u arre m�d cerroct ��R �/��^ �� November 28, 2005 rrim�x Fllen McDonough. Nutrition Proqram Manager phone# (508)394-4630 a�chl eae onry au oee..rks h t�..�m ee o..qetea ey dly nr Nwu.�riN dty or lown: perdfAkeue# �BeidinE Depar�eet D�leenfmg B�N ❑eYMc if immedVh re�pemc h reqoi�ed 03dxU�e�'s Omoe ❑FI�qY DeM�deet ceutact pe+sou: phwe#; ❑Olhc ��a sp.zam� TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-109 FEE: $25.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Cliapter 111,Section 5 of the General Laws,a permit is hereby granted to: Elder Services of Cape Cod and the Islands 528 Forest Road South Yannouth, MA Whose place of business is: Elder Services Yarmouth Nutrition Site Type ofbusiness: Non-Profit Food Service To operate a food establishment in: Town of Yannouth Pernut e�[pires: December 31. 2006 aoARD OF HEALTH: B �. /H�•. �i��s�, �'., v� e�� SEATING: 120-Congregate Dining Room RoGe'1��• B3oruk� � n�M�� .,,�, a.�v. Ianuary30.2006 Bruce G.Iviurphy; ,R.S.,CHO Director of Heal ,OF�Y`jR �� ,'�o TOWN OF YARMOUTH ; �- ' 0 `'3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 r ` ' �'-J5 H MI1TiACHEES � � i »�o,,,�"�o,br Telephone (508) 39£i2231, Ex4 241 — Fa�c (508) 760-3472 ' ' � � �f�,:-�_____"�.J B O A R D O F H E A L T H To: A112005 Yarmouth Boazd of Health License/Permit Holders From: Yarmouth Heaith Department Re: Tax Identification Numbers Date: July 27, 2005 The Massachusetts Department of Revenue is now requiring that the Health Department fumish to them detailed information regazding all permits and licenses that we issue. One of the required details is to provide a taac identification number, whether it be an establishment's Federal Employer ldentificatio� Number (FEll� or, in the case of an individual's license, a Social Security Number (SSl�. This information will be used by the Health Department purely for administrative purposes only. Would you please fill out the fields below and return this letter to: Yazmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated Compliance. If you haue any questions regarding this matter, please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is (508) 398-2231, etrt. 241. Establishment _��u�D�__��[�, � _ FEIN or SSN: ��._�� $ /�rFsT � Location Address: sOv ♦w�ov V Z4G � / Signature: � . Print: 1 Title: � �Jl�_ ��....., ��.Printed on �.�Recycled \ . Z.�� Paper �-t��11�3� �2� v� ` 2��v R1� TOWN OF YARMOUTH BOARD OF HEAL��`-� ��o.�� ? APPLICATION FOR LICENSE/PERMIT- 0 D E C 2 8 2004 �y * Please complete form and attach all nece�ary documents by D ��pT. Failure to do so will result in the ret�rn of your application pac NAMEOFESTABLISHMENT-ri,� c < v mouth Nutrition Site TEL # 34F3 5060 LOCATIONADDRESS' 528 ForPct Road MAILING ADDRESS: South Yarmouth OWNER/CORPORATIONNAME� Fider �pN� ;ces �f Cape r�� an� th�� an�ci Tnc MANAGER'S NAME: Carol i ne Kosowi cz TF,L # MAILINGADDRESS: 68 Route 134, South Dennis, MA 02660 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. N�A 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certiScations to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of cercification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. Caroline Kosowicz Z PERSON IN CHA1tGE: ----- - -- -- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Caroline Kosowicz 2. HEIMI,ICH 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# 120 OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PF.RMIT# LICINSE REQUIItED FEE pERM[T q LICENSE REQUIltED FEE PERMI"t'# _BBcB $50 _CABIN $50 _MOTEL $50 . _ —� $50 _ . CAMP _---- S50 __. _SWIIviMQ?GPOOLE75ea. _LODGE $50 _TRAII,ER PARK $50 WI-IIRI.POOL S75ea. ... �..� FOOD 5ERVICE: � LICENSE REQiIIItED FEE PERMIT q LICENSE REQiJIItED FEE PERM11'# LICENSE REQUIlZED FEE PERMI1'k _0.100SEATS a75 _CONT'INENI'AL $30 �NON-PROFIT $25 �'o�.� _>t00 SEATS 5150 � _COMMON VICT. S50 WHOLESALE $75 RETAQ.SERVICE: LICENSE REQUIItED FEE PERMIT# LICINSE REQiJIItF,D FEE PERMIT tl LICENSE REQIJIItED FEE pgRt�q1•p _<SOsq.R $45 _>25,OOOsq.ft. 5200 _VENDING-FOOD S20 _Q5,000 sq.ft. $75 _FROZEN DESSERT S35 _TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 2S. 00 '`"""pLEASE TURN OVER AND COMPLETE OTHER S7DE 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 INSiJRANCE ATTACHED X OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOT'ICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMSER 31, 2004: SEASONALESTABLIS�Il�SENTS ARE TO CONTACT THE HEALTHDEPAR'TMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO CONINiENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULAITONS POOLS POOL OPENIIVG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the HeaTth Department pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVLSORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY• Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hows prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSER�'3: - - 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 seatingwithwaiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: December 21, 2004 SIGNATCTRE: , PRINTNAME& TI'TLE: Marv Rola i Nutrition Program Manager Cape Cod and the Islands, Inc. 10/22/04 OEt-UB-20fl4 11:40am From-NORCROSS LEIGHTON 5087601407 T-964 P.002/D02 F-780 +"`"""`= `'_'"+ � �rRt+t+► 1 t VF LtABILITY '"o"'�� INSURANC� oaia a DA7E�+��n Norrrosg C Lcightaes Cap� y4C. TFI�� E3.bF+R-2 10 06 04 C.J.MCCa,��yy Ius.Agen FICATE IS 16StlEC AS A AAATT�R OF INFO1iMAl10N 437 $tatipn Ave ��=nc, ONLY AND CONF�g Nq RIGF{f$ppp��7}��C��iFtCATE SO.Yarittauth �i ALTER'�1'11C{OS'uCERTIFICATE QpES NdT AMENU,EXTEND QR 02564 . ve�cn�e nFFOKuto aY THE POLICtES BELdW. Phcne= 508-394-09d4 Fa.x;50$-'76Q-1407 iNSUReo � lNSURER.4AFFORCENGCOVERqGE ��ya: Grea� NAIC# Atnasiean 2Aeuya�yCe Co Elder ServS.ces Of Ca e x+sur�Ra SaEet Tnsurance C 6B Rnu�e 134 P Cod iNsurt�Rc: A.i.G � S neanig Mq V2660 RV&urv�tq COVERAGES �pxq�g, hIE rroUC1ES oF iN5UWwcE uSTEo Bs40W twv�BEErI t�SUED ia 7HE msURE�tran�Fp paovEFWx'fHE POLICrPER160 t�oICATpo.NOTWrttisTANUiNG � M�nYP�ERTUIaREMFJvf.hRMORCANDIt1aNOFMrvCON7FACT�R[�TtIFR a POLiCIE5.A6G�f�n7ELl�rt's�O�WNlm�eYiHEPouqESOESCRIBEDH4iEINISBy��3PFC1'TomnGMTmst:khTIFlCA'lEMAYeEISSUEnOR �Tw ��B�!R�UCFA BY PAIP CLRIAIS, 7'F�ETERM3�E%CLU3IONSANO CAN�ITbNS OF SUIXi GEt1ERAL4n9�L(iv u�� PoGICYxUAReER �FFEC7IVE �PMY �N7E i�Alp V� A X coeaMFr�r;,w�kp��y�m, Gyp5093797 US 23 04 �"�'�4��° a 10p00D0 c�"i"'SM+aE a occua / / 09/23/O5 aa�p��,� s 7000Qo x Pk�r7r'y"SSzp�• GLP5093797 MEor�mWaa�o Og/�3/04 09/23/05 p� �"°"� a 5000 "'"4dA01'+��Rv a ip00000 � fiEN7.AGGREGA'reLIMRMa41ESPEfc � � aw�nu�oorsEr3�7e ' pp��y. � � a 5000000 LO° �DQ�T3'�� s30000p0 AUTOMOBILE 4ABILffY $nfa. $ �yp�p 10000UU 162�,B6B � 07/Ol/04 07/OI/OS �M�9��R s . ALLOWNEpA{1TpS SCHmt11.FAAUYos X H��T� �� .�Y004000 X xouawNEppvro$ m��rv�..q s 10000Q0 ��E�' ��ai�� s SOOOpO ANYAITl,f . �TO�.�/•EA� s �SYCNMsn�r�•UAOIYrr AU�TO N7rypry FAACC s CCCIIK �G a ❑cl,FeABMnGH GACHOccypqgy�p� S � A66�GrY�E s ��xn� w4,�r,,.,�n � s �+ortKExs coMrprl9nnoN aHp s . .RMP�l9R1p`ERs'11AdIUryF� � � S V ��WMEM p�,�� X tli . wM 769193� u�/oi�oa n�/oalos s.�,�„��,,,. s ioa000 s�cd�°,�""'�"""�� oTM� , F� ni°°pg�'E^B^" E 100D00 e�ou�.P�yyyq� s5000q0 . .� . P . . . . f YEN � . . . . . . . . . . AODR.6 �ND . @MQJ7'1 L Pppy1S10Ne ;RnFicnre r+o�eR C 1.4A p ..++�.«..� Nx+YwwrM�lf� ��u��➢JR11 � � - . � , ,.:.��:.. ETanw�� ..#�'�MOpiT , ;._..: . . .�.: , ..- � . . .. . � .::� . , , . ., . >;.:.; - �� -- s�–F-�-�a�'a —��T0,�4R.aYLLLI.. . - . . ��*'''+lNN�?�iL.RS1EYN.t�M1YJi�9�Nl'hElf�B�,,,��r . �1�7}17�{�` �'. - V�.IY�AS+kT743tlf} 4 : ' -[ - ' �.;. . . ;::. .. ' '. S 'M.4 -•.?� �ylAkap,. �. . ...::, : , ;.:. �.-:: ..-..; - . . :. . 3 .._. .,'. :: . . . , - . . �-:: .,� . .7.'l ... 1Y8 ..: TOWN OF YARMOUTH BOARD OF HEALTH PERMTI'TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #OS-109 FEE: $25.00 In e°�°rdance cxnth re�(ations promulgated under authority of Chapter 94,Section 3USA�d Chapter 111,Section 5 of the�'ieneral Laws,a permit is hereby granted to: Elder Services of Cape Cod and the Islands Inc 528 Forest Road South Yazmouth, MA Whose place of business is: Elder Services Yarmouth Nutrition Site Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yazmouth Pemrit expires: December 31 2005 BonRD oF I�'ALTH: Be.�us$, (�o+�dorq M.$, • sEn�ruJc: 1 zo-con Pab�ic�s Ma.`be�irxol�, vios e� E gregate Dining Room �Qp�6�B a�e�s�t ��[�i,�J�� A.�� R.N. Febrnary2_2005 , mce G.M�uphy, RS.,CHO ' Director of Health ' �.,. ��3 vSZ� � 2,s� o�e R.y TOWN OF YARMOUTH BOARD O Ai.T o � APPLICATION FOR LICENSF� � Tt-20b4 � � � � � �, � � r��? ,.�'." z,� �, * Please complete form and attach all neces '" c�mi�ts by Dece ber��82�0�. 2004 Failure to do so will result in the retucl�:`�f yoeCr applicatron pa ket. .x NAMF OF FSTAi3LISHMENT• E1der Services of Caoe Cod & Isl , TEL. #394-4630 LOCATIONADDRESS� 68 Route 134, South Dennis, MA 02660 MATiiNGADDRESS• Yarmouth Senior Dining Yarmouth Senior Ctr 528 Forest Rd OWNER/CORPORATIONN�ME• Elder Services IvLANAGER'S NAME• Ci ndy Prete TEL. # 398-5060 MATT ING ADDRESS• 528 Forest Rd. Yarmouth _ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. N/A 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. Cindv Prete, Manaqer 2. PERSON IN CHARGE: Each food establishxnent must have at least one Person In Chazge (PIC) on site during hours of operation. 1. indy Prete — 2• HFIMLICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must pmvide new copies and maintain a file at your place of business. ',I 1. Cindy Prete 2• 3, 4. RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL S50 INN $50 _CAMP $50 _SWIMMING POOL$75ea. LODGE S50 _TRA[LER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS S75 _CONTINENTAL $30 X NON-PROFIT $25 � Q�t� >I00 SEATS $I50 _COMMON VICT. S50 _WHOLESALE $75 RFTAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.fl. $200 _VENDING-FOOD $20 � <25,000 sq.ft. S75 _FROZEN DESSERT $35 _TOBACCO S25 NAMECHANGE: $l0 AMOUNTDUE _ $ *'"•*'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* L ` ADMINISTRATION Under Chapter 152, Section 25C, Subsecfion 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MiJST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED X � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED X Town of Yazmouth taz�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOTICE:Permits run annualty from January 1 to I�cember 31. IT IS YOUR RESPONSIBILITY TO RETCTRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISFIME'sNTS ARE TO CONTACT'THE HEALTH DEPAR'I'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR TI� 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 T POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products 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. 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 Pertnit until the above terms have been met. OUT�i FF' ; Outside cafes(i.e.,outdoor seating with waiter/waitcess service),must have prior approval from the Board of Health. QUTDOOR COO iN • Outdoor cooking,prepara6on,or display of any food product by a retail or food service establistunent is prohibited. DATE: 02/10/04 SIGNATURE: ��%'�'Lf/.L�i � A� PRINT NAME& TITLE: _Marv Rolanti . Nutrition Proqram Director Elder Services of Cape Cod and the Islands, Inc. 10l22/03 . . � The Commonwealth ojMassachusetts : : Departmen! of Industrial,-fccidenls ; Omceallaresdostliis 600 Washington Slreet Bosron, Mass 01111 ` W'orkers' Compensation Insurance Aftidavit ARnlicant informallon: PfessePRiNT7edGi�h n,mr Yarmouth Senior Dining loc�i�nn' �9R Fnract Rnatl� C Varmnuth� MD nZ660 . �� ehoneM 508-398-5060 � 1 am a homeoµner pzrturming all work mysdf. 0 I am a sole proprietor ar.d ha�e no one��orkine in any capacin� Q,] I am an employer pro�iding workers' compensation for my employees workina on this job. ane Fldar Carvirae nf fana fnd and tha I5lands Inc ldress• 68 ROUte 134 ��.. South Dennis, MA 02660 etieneM• 394-4630 insur�nceco NOY'Cr055 and Leighton poi;��a 7819838 � I am a sole proprietor. general contractor. or homeowner(circle onq and hace hired the contractors listed below' uho ha�e the follu��ing «arkzrs :ompensation polices: tompanv n+mr — -a d ress• cih- phone M• insur�ncc ro oeliev# comQanv namr - addrc • - .:..•• pheee M• insuranee eo K tt"'* t F�ilure to seeurc covera�e as required usder Seenoe SSA of MGL ISS a�lad to�be i�po�itiw o(erisi�l pndtln of a Ou op to SI¢00.00��d/or ooe yean'imprisonment u w�ell n eivil ptedHa io the torm of a STOf WORK ORDER��d a li�t of 5100.00�dry'K�issf mt 1��denh�d tLt a eopy of tAH statemrnt m�y be fonr�rded to tpe Otlice of Iavotlt�Uom of�e DU ta eoven�e verillntla�. . I do�hrreby certijp under the ains and pmal�its ajpnjury�hm the injornmtion provided abort is an[and eon[et Signaturt�� \ ; ��-��A Date _ 02/70/04 _ � Prim name Marv Rolanti . Nutrition Proaram Director rhoneM 508-394-4630 X 131 oRcial use onl� do no�rrile in�his ana to bt compltted by ti7 or fow'e oflleial eitv or row.n. Y��DTQ permilAieeeee p nBuildio`Dep�nmcai ' -- � �Lieeosioe Bo�rd �eheek if immediate response i�required Z61 ❑Seleetmen'�ORiet �Hed1A Departmeat � aonuct person: phone M:_ �SOS� 398-2231 eat. nOtAer - - I Information and Instructions � �1as�achusett; General L�«s chapter I�� section '_5 requires ail employers to pro�ide workers' compensation for their empl��}ees. .as yuoted from the "la�.'�, an eneplo�•ee is defined as e�ery person in the service of another under any cuntract of hire, express or implied, oral or written. ?,n enrpLn•er is defined as an indi� idual. partnership, association. corporation or other legal entit}•, or any nso or more of die fore�_oinc en2aged in a join[ enterprise. and including the leeal representatives of a deceased employer, or the recei�er or trustee of an indi�idual . partnership. association or other legal entity, employing emplocees. Ho�cever the u��ner of a d«elling house ha�in_ not more than three apartments and who resides therein, or the occupant of the d��ellina house �f another uho emplo}s persons to do maintenance , construction or rcpair work on such dwelline house .�r �m �he _r��unds or buildin�� appurtenant thereto shall nuc because uf such emplocment be deemed to be an emplo}zr. �1GL �hnp�er f�= ;ection _� alse states that e�en state or local licensing agenec shall �cithhold the issuance or rene��al of a license or permit to operate a business or to construct buildings in t6e commonw'ealth foran}� :ipplicant �cho has not produced acceptable e�idence of compliance with the insurance coverrge required. Additionall�, neither the commom�ealth nor am of i�s political subdicisions shall enter inro am contract for the performance of public ��ork uncil acceptable evidence of compliance with the insurance requirements of this chapter ha�e been presented to the cunvactin_ authurin. Appli�.:nts Please till in the �vorkers' compensation affida�it completeh-. by checking the box that applies to}�our situation and suppl�im� compan} names. �ddres� and phone numbers as all affidavits ma� be submitted to the Department of Industrial Accidents for contirmation uf insurance covera¢e. Also be sure to sign and date t6e atf►da�•it The aftida�it should be remrned to thz cin or town that the application for the permit or license is being requested. noe the Department of lndustrial .-�ccidents. Should �ou ha�e any questions regardine the "law"or ifyou aze rcquired to obtain a ��orkers� compensation polic}. please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Deparunent has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you rcgarding tt�e applicant. Please be sure to fill in the permidlicense number which will be used as a refercnce number. The aff daviu may be returned to the Department by mail or FAX unless other arrangemenu have been made. The Office of lnvesti¢ations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. Tlie Department's address, teleQhone and faac number: The Commonwealth Of Massachusetts Departmeat of Industrial Accidents Iff1C!d Imstl�ttl�K 600 Washingtou Street Boston,Ma 02111 fax #: (61'n 727-7749 phone #: (bl� 727-4900 e:t 406, 409 or 395 ACORD_ CERTIFICATE OF LIABILITY INSURANCE OpID DATE(MM/D�Mryy) ELDEA-2 09 29 03 PROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO Norcross 6 Leighton Cape Loc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE C.J.McCaxthy Ins.Agency,inc. HOLDER.THIS CERTIFICATE DOES NOTAMEND, EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDE� BY THE POLICIES BELOW So.Yarmouth �MA 02664 Phone: 508�-394-0946 Fax:508-760-1407 INSURERS AFFORDING COVERAGE NAIC# INSURED -• ' � INSURERA Safet Insurance Co an - ' -' - � INSURER e: A.I.G � Elder Services O£ Cape Cod iNsuaEac: Hartford Insurance 22357 68 Route 134 - - . iNsuaEao: Great American insurance Co S Dennis MA 02660 � INSURER E � COVERAGES - THE POLICIES OF�NSUR4NCE LISTED BELOW HAVE BEEN ISSUE�TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHtCH THIS CERTIFICATE MAY BE ISSUEO OR MP,Y PERTAIN,THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PAID CWMS. LTR NSR TVPEOFINSURANCE POLICYNUMBER DATE MMIDDIV DATE MMIDOIW UMRS OENERALLIABILITY EACNOCCURRENCE S SOOOOOO D X COMMERCIALGENERALLIABILffY gZppgg � 09/23/03 09/23/04 PREMISES aoceuronce) S 1�� CLAIMSMADE ❑OCCUR MEDIXP(Anyoneperson) SSOOO X Pro£essional SINDER 09/23/03 09/23/04 PERSONALBADVINJURV s 1000000 GENERALAGGREGATE S $OOOOOO - GEMLAGGREGATELIMRAPPLIESPER: PRODUCfS-COMP/OPAGG S 3000000 POLICY JE� LOC AUTOMOBILE 11A81LITY COM8INED SINGLE LIMff A ANYAUfO 1621868 07/O1/03 07/01�04 �aaecidanq S ALL OWNED AUTOS � ' BODILVINJURV $ SOOOOOO SCHEDULED Alff05 (Pu person) X HIREDAIl�0.S � BODIIYINJURY E SOOOOOO X NONAWNEDAUTQS . (Pxamident) . PROPERTVDAMAGE g SOOOOO ' (Peramitlenq GARAOELIABILITY � . AUTOONLY-EAACCIDEM $ ANV AUTO 07HER THAN �A�� 5' � AUTOONLV: -AGG $ IXGESSIUMBRELLALiABILITV EACNOCCURRENCE S OCCUR � CLAIMSMADE AGGREfSATE g S DmUGTIBLE f REfENT10N S E WORKERSGOMPENSATIONAND - X TORYLIMRS ER EMPLOYERS'LIABILITV B ANVPROPRIEfOR/PARTNEWEXECUTIVE 7819838 O��OZ�O3 O7�OZ�OA ELEACHACGDEM SZOOOOO OFFICEWMEMBERIXCLUDED? � ELDISEASE-EAEMP�O $ ZOOOOO Hyes tleceriba under � SPEGALPROVISIONSbdow E.LOISEASE-POLICYUMR S .r]��Q�� OTMER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADOED BY ENDORSEMQIT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ______1 SMOULDANYOFTNEABOVEDESCRIBEDPOUCIESBECANGELLEDBEFORETHEE%PIRATION DATE THEREOF,THE ISSUING INSURER WILL ENOEAVOR TO MAIL SO DAYS WRITTEN 'NOTICE TO TME CERTIFlCATE HOIDER NAMED TO THE LEFT,BUT FPJLURE TO DO 50 SHALL IMPOSE NO OBLIOATION OR LIABILITY OF ANV KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATNES. . AUTXORIZED RESENTATNE � ACORD 25 (2001/08) ' c CORD ORPORATION 1 ACORD_ CERTIFICATE OF LIABILITY INSURANCE �P�� °"'�`M""°°""'"' I ELDER-2 09 29 03 PROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO� Norcxoss & Leighton Cape Loc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE C.J.Mecarthy Ins.Agency,Inc. HOLDER.THISCERTIFICATEDOESNOTAMEND, EXTENDOR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. So.Yazmouth MA 02664 � Phone: 508-394-0946 Fax:508-760-1407 INSURERS AFFORDING COVERAGE NAIC# INSUREO •• � � � MSURQtK Safet Insurance Co an . . _ � � - nuuaEae: A.I.G - Elder Services O£ Cape Cod i�suR�r+c: Hartford Znaurance 22357 68 Aoute 134 � � iNsueQto: Great American Insurance Co 3 Dennis MA 02660 INSURER E COVERAGES - THE POLIqES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED W1MED ABOVE FOR THE POLICY PERIOD INDICATED.NO7WITHSTANDING ' ANY REOUIREMENT,TERM OR CANDITION OF ANY CONTRACT OR OTHER DOCUf�NT WITH RESPECT TO WHICH THIS CERTIfICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLJCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PPJD CLApAS, LTR NSR TYPE OF INSURANGE PGLICV NUMBER pp DATE M UMRS °�0L4L��T�" EApiOCCURRENCE s 3000000 D X �MMERCIALGENERALWI&LRV giNDEA 09/23/03 04/23/04 az�isEs F.,a,,,,� s 100000 . CI.AIMSMADE ❑OCGUR � MEDEXP(MYanapeisan) s5000 ! X Professional HZNDER 09/23/03 09/23/OQ vmsoria�anoviwurtr s 1000000 � - GENERALAGGREGAlE s 3000000 � ' GEN'LAGGREGATELIMRAPPLIESPER: -PROOUCf3-COMP/OPA06 S 3000000 i POLIGY jE� LOC I AUTOMOBILE LIABILITY COMBINED9NOLEUMR s A ANVAUfO 162186B 07/Ol/03 07/Ol/04 �'°"'d°"b ALL OWNW AUTOS � BODILVINJURV S 1�� SCHmULED AUTOS W�V��) X HIRm AUf05 ' BODIIV NJURY I X NON-0WN�AUTOS �«ap,ydpiU S SOOOODO - I raOaQmDu.u6E S 500000 I ' �er.aiaenq OARAOHLIABILITY � . � AUfOONLY-EAACCID@!f S ANYAUTO EAACC S� 07FiER 7FIAN . AUfOON�M _�d s EXCESSNMBRELLA LU�BILITY FApi OCCl1RRQJCE S � OCCUR �CLAIMS MADE AGGREGATE S S OEWCfIBLE s RETENTION S s WORKERB COMPENSATION AND - % 7p�,UMR3 ER B EMPLOVERS'LNBILITY 7819838 07/OS/03 07/Ol/04 EIEA(�iACCIDINT s 100000 ANY PROPRIEfORIPARTNQLIXECUTNE OFFICERIMQABERIXp.UDED? ' ELOISEASE•EAEMPL S SO0000 �yes tl��u�� ELDiSEASE-PoUCYUMIi s500000 WECUL PROVI90NS 6elav OTHER OESCRIPTIONOFOPERATIONSILACATION3/VEHICLE57EXC1U510N3AD0E0BVENWRSEMENT/SPECIALPROVL410N3 n 2 � ' ry�r '� W iq .� � 1!:% r� `�'J FEB 0 9 Z004 HEALTH DEpr CERTIFICATE HOLDER CANCELLATION �__��1 3XOULD ANY OF THE ABOV!DESCRIBEG POLIqES BE CppGp,�m BEFORE TXE IXPIRATION DATE THEREOF,TNE ISSUMG INSURER NALL ENOEAVOR TO MAIL SO DAYS WRITTEN 'NOi10E TD THH CERTIFlCATE NOLDER NAMW TO THE LEFT,BUT RAILURE TO 00 SO SNALL � IMPOSE NO OBLIOATION OR UABILRY OF ANV KIND UPON THE INSURER,RS AfiENTS OR REPRESENTATNES. . AUTHORI�D RESENTATIVE . � ACORD 25 (2001/08) I CORD ORPORATION 1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-156 FEE: 25.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter I I 1,Section 5 of the eral Laws,a pemut is hereby granted to: Elder Services of Cape Cod and Isfands, 528 Forest Road, Souffi Yazmouth, MA Whose place of business is: Elder Services Yarmouth Senior Dining Type ofbusiness: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit easpires: December 3 l. 2004 BOARD oF HF.ni.TH: Be�w�irs �!. (foedox,M.$. ' �M� v:�ef�. sewllNc: 120-Congregate Dining Room /�o�'et� /43ocwty �a4.�r ��IQ . Mazch 5.2004 Bruce G. Mu�phy, H . .,CHO Director of Health � . ��3�y3q �zs� ` f�R.y TOWN OF YARMOUTH BO O E'-��S�a.v�ces 3= � APPLICATION FOR LIG�Pi�� ='2 �, [� (�; � � M � � �C�i a. ;';, ', . * Please complete form and attach all necessary documents by Decem er$��Om2'j ��(�3 Failure to do so will result in the return of your application pa et. NAMFnFF4TARiT4HMFNT• Elder Services Yarmouth Nutrition Site TEL # 398-5060 LOCATIONADDRF_SS• 528 Forest Road MA�LING Ai�D�SS• South Yarmouth — OWNER/CORpORATIONNAMF• Elder Services of Cape Cod and the Islands. Inc. MANAGER'SNAME• Anne te Kowalski TEL. # 394-u�3n MAiLINGADDRFSS• 68 Route 134, South Dennis, MA 02660 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool O�erato s and attach a copy of the certificat�on to_this form. 1. N/A 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 pmvide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MAI�TAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Health Department will not use past years' records. You must provide new copies aud maintain a fde at your establishment. 1. Annette Kowalski 2. _ PFR. N TN('HAR(}F.'- _ _ — - __ _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Annette Kowalski 2. uFLMLICH 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 a11 times. Please list your employees trained in anti-choktng procedures below and attach copies of empioyee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Anne+ta K�wals�i 2• 3. 4. RESTAURANT SEATIlVG: TOTAL# 120 OFFICE USE ONLY LQnGING LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWavIMING POOL$SOea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS $75 _CON'IINENTAL $30 I NON-PROFIT S25 - O �6J >100 SEATS $I50 COMMON VICT. $50 WHOLESALE 575 RETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft $75 _TOBACCO S20 _<50 sq.ft. S45 _>25,000 sq.R. E200 _FROZEN DESSERT$35 NAMECHANGE: $t0 AMOUNTDUE _ $ 25.00 **•"•PLEASE TURN OVER AND COMPLETE OTF�R SIDE OF FORM*•**• _ ADMINISTRATION I Under Chapter 152, Se,c6on 25C, Subsecfion 6,the Town of Yarmouth is now required to hold issuance or renewal of apy licerase or p�rr}�it 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 X � 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 RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISF�vfENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPIING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparhnent 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 pmducts 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. FROZEN DESSERTS: Frozen�sserts musitie fested on a monthly basi§by a �tate certified laT.Test results must be sent to tiie 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 pmduct by a retail or food service establishment is pmhibited. DATE: December 31 2002 SIGNATURE• �� 6 0 /a�/� PRINTNAME & TITLE: Marv Rolanti , Nutrition Proaram Director Cape Cod and the Islands, Inc. 10/18/02 . 07/19/2002 09:14 5087601407 NORCROSS E LEIGHTON PAGE �2 �--�p GERTIFICATE OF LIABILITY INSURANC�LDER�2 °"o�"9°"a2 PRDOVCEP THIS CERTIFICn7e IS Isaueo�as A MA77ER oF INFORMA710N Noraroaa i Leiqhton Cap� Loc. ONLY AND CONFERS NO itlGHTS UPON THE CERTIFICATE C.J.MOC�rYhy Iaa.Tyeasay,Zno. HOLDlR.TMIb CCRTI�K,A70 DOl6 fYOT AMEND�EXTEND OR 637 8 tation ]►w ALTER THE COYERqt3E AFFORDED BY 7NE POLICIE8 BELOW. 9o.Ydrnwuth ffiA 02664 Phone: 508-394-0946 Fax:508-760-1�07 IN6URERSAFfOFtOINO�COVERAOE IN41lRED . INBUREflA T=Q xasuranae Cr OA INBURFR& 6raaite 9taLe Ins. Ce. . � 68 Acute 134 �i or c;ape coa ��+�+�+G $ �naie M71 02660 ��RERR inauqEw e COVERA�3ES TNE f`OLIGIEC OF ItJOURANO[�l3TCD OELCW HAVE 9EEN ILaVED TO THG IN3LIRCD WIMCDIbOV�rOR TFIC GOLICY PERIOU INUIVATEU.�NV 1 WI I Mu IqNUINO ANY REQUIREMENT,TERM OR CpryDfTlpP�pF p,Ny OpNTppCT OR OTMER OOCUMENT WITFI RESPECT 70 WHICH THIS CERTIFICATE MAY 9E I&SUED OR MAY PERTAIN,TF�E MSURANCE qFFORDED BY THE Pf1UCIE5 OESCRI9ED MEREIN IS SUBJECT TO ALL THE TERMS,EXCLIAStONS AND CONOITIOf33 pF SUCFI '�UCIE6.qCGRECATE LY.yTG 31�OWN MAY I IAyE 9EEN RE WCED BY P/11D CU1M3. LTR Y TVPEOFINBURANCE POLICYNUM9ER OATE MMNOf/ d�T! MMfD LIMITd ��E"�"�� na�accunaENCE S lOOOOOO A X �MMERCW.GEIIENAI,�IA&I,fiY �jjS4O�IZOB 07/Ol/02 07/O1/03 FIREOAMAO�(AnypMfln) s 100000 cuiMs�uoE �occuR . uEo oca(Any w,.p.rsant f 15000 X. P=Of�stipnpZ � �PERSpNALlAOYIWURY z 5000000 � GENvau�opREaA'rE ; S 3000000 � GEN'LAOGREf7A7ElIMI7M%,�9vER: PROOUCTS.COMPppA00 s 3000000 �C JECT I LOC '-- AuronweaE wewn �� ANVAUiO . � I�rtuwum Ciurl.E LIMR S ' i � (��ccmmtJ ALL OWNEp A�JTQS _.— � sC�+ECULED AUf0.5 ' acoi�v w:�av 5 _ � !Per pe�a) i � Y:Ifl�AUTCS i �, ' �_ NGN-0WN , I. � :SCOlLY INJUOv I . Y.-_— �A��"` I (hrawidar..) f IPROP,FilIY OAM/.OG f I� waGmQ 041tA0E LU0ILRY , �. '. � urt/1 tuu v.c��fpOF_NT S ��.ANYAUTO � I ETACC �'S _` OTHER TN1 V ' . AUTOONIY: �p0 '. i . ExCE68uwe�LT' I EnG+OCGURrtENCE S r�f�� ,�'LAIM9MApE I I —� I ACOFECATE p I I S �� OGDI:CTiOIE �� - � � NEfENfION S I �� ..__._ � �wonKeneeeM��W/�TIONAHC S i ., EMPLOYEAY LIA�ILITY � i roRv�urarts ' Eri i � I Z905961 07/O1/02 � 07/O1l03 ' =� �ncr�ncaoexr � s 1�0000 =..GYSEASE�EnEMPL E lUUA00 I ciwc� ��i =LC19EV9E-POLICYLIMR 5 SOOOOO i � i i r[ESCRIPTION OF OPERATIpNyiLpC�npNyypXICIEEIE%C W SIOHb ADDED BY ENOORSEMENTI9PECIAL PNOV1910N3 � ! CERTlFICATE MOLDER �N �aruww asu�co-iHeuRert�rr� CANCELlf1TION � __' _S EXOULO�NYOITH�ApOVCDE9CRIBEDV�LICIE9BECANCELLm6EWflCTMEl1(PIM � MTE TMPIlOf,TME MOUINO INSURFR WILL ENOlAV011 TO MAI� 1�pAr9 WRITfE71 �NOTIC!TO TN�Cl1177flCATE HOLOEA NAMEp TO THE LEFT,BUT RAILIl11[TO�80 SHA�L I IMM07EN00lLqATIpNORWtDIl1lYCsµy OU EIN911MER,ITSAQlNTSOR R�NE9ENfATNF4. A117M011LElG RlME-0ENTIITIVE ACORD 26S(7Ig7) Bob Lin iat �� C��C� TIQN 1YBB �� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #03-163 FEE: $25.00 In accordance with regulations promulgated under authoriry ofChapter 94,Section 305A and Chapter 1 I 1,Section 5 of the Generat Laws,a permit is hereby granted to: Elder Services of Cape Cod and the Islands, Inc., 528 Forest Road, South Yarmouth, MA Whose place of business is: Elder Services Yarmouth Nutrition Site Type of business: Non-Profrt Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2003 BOAxD OF HEALTH: (�kazlea�. ��, e��xa.c �D. c�. �e a., v� sEnrnaG: 120-Congegate Dining Room �o6art�. �aaa.w, � �abtLt�� s�. �n. Febn�ary 14.2003 ruce G.Murphy, ,R. HO Director of Health . ', '�`�yr E1,DeRSvcs. 1{aa . N�razi�naro TOWN OF YARMOUTH BOARD OF A �'3 s �rt APPLICATION FOR LICENSE/P�;��h�tf�+ �`3 Gi� C� � �' � M L� UD � � � �� : � * Please complete form and attach all necessary documents by December�f, 2001. Failu trn��oQulll��lt i the return of your application packet. HEALTli DEF T, NAME OF ESTABLISHMENT: Elder Services Yarmouth Nutrition Site TEL. # 398-5060 LOCATION ADDRESS: 528 Forest Road I�vAILING ADDRESS: South Yarmouth OWNER/CORPORATIONNAME: Elder Services of Cape Cod and the Islands. Inc. MANAGER'SNAME: Annette Kowalski TEL. # 304-4630 MAILINGADDRESS: 68 Route 134, South Dennis, MA 02660 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated . Pool Operatnr(s)and attach a copy of the certification to this form. 1. N/A 2. Pool operators must list a minunum 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 Aealth 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 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 file at your establishment. l. Annette Kowalski 2. FERS�NIN CHAKC'iE` -- — _ _ ___ _ - -- — _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Annette Kowalski 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 certificaUons 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# 120 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN S50 _MOTEL $50 _INN $50 _CAMP . $50 _SWIMMING POOL$SOea. _LODGE $50 TRAILER PARK $50 WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100SEATS $75 _CONTINENTAL $30 �NON-PROFIT $25 �02—i31 >IOO SEATS $I50 _COMMON VICT. �50 WHOLESALE $75 �ETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERM[T# _TOBACCO $20 _Q5,000 sq.ft. $75 TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 NnMEct�nNCE: g�o AMOUNTDUE _ $ 25.00 *`*'•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 a�y 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 Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOTICE:Pemuts run azmually 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 ESTABLIS�IMENTS ARE TO CONTACT Tf�HEALTH DEPART'MENT 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. ADDITION 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 quar[erly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE ('ONS MER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF.RING 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. T'hses forms can be obtained at the Health Department. __ _ _ _. _ _____-- - _ . _ FR07FN DFSSERTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE:October 1, 2001 SIGNAT[JRE: PRINT NAME&TITLE:Marv Rolan ' Nutrition Proqram Director Cape Cod and the Islands, Inc. 09/11/O1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #02-131 FEE: $25.00 In accordance with regulations promulgated imder authority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of the General Laws,a permit is hereby granted to: F.1 Pr S .rvi c nf(�}e('od nd h Talanriq, in R For ct Ro rl Rn� h Yarmo �th ��_ Whose place of business is: Elder Services Y�rniouth Nutrition ite Type of business: Non-Profit Food Service To operate a food establishment in:_ Town of Yannouth Pernut expires: December 31_2002 BOARD OF HEALTH: ekwaleo;� z�lfk�, �at�aK �D. �. �D.. ?/�ee sen'ruaG: 120-Congegate Dining Room ��t� �, �k �aatic%�atMrofB 's�efe� .5'�(wk. �� a 8 ,2002 . Bruce G. Murphy,MP .S., CHO Director of Health r_ „ � YAzmorrr� S�v�o,e��2. TOWN OF YARMOUTH BOARD O s Q � � � � N/ � i� � APPLICATION FOR LICENS , , ,x,, , �i DEC 2 Z 2000 �-.. • Please complete form and attach all necessary documents by Dec�b er 31, 2000. Fail dd.�di,w&XER�uIt the return of your application packet.r ------------------------------------------�ld�r__s.��lt.�.------------------------------------------------------------- N M OF T R IS MFNT• i�^fmd✓yh Nu�/�bU S i�2� TEL. #��9�-S�� T (1C`ATi()N AiliIRFCC• m1�.-s7141�at�'(i/ ��3.�' ��.✓es/2�l �- 'i�,�.yl�.�ts. o ��t �,rerr n.Tr. ennuFec• , g ov/,e � ��/Z� .,n.�il N/lt0�l� � nw�.TFR/CORPORATION NtLMF• a,reuer.Fu�ci.re�aF• �ll 17r�� TEL. # ��yl'r .-��Ed �en n.Tn ennuFcc• /}60�� on/lOC-d t/eni ---------------------------------------------- - - POOL CERITFICATIONS: The pool supervisor must be certified as a Pool Operator, as reyuired by new State law. Please list the designated Pool Operator(s) and attach a copy_ofthe cerhfication to t(us form. 1. N�l� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tivs form. The Health Deparlment wiR not use past years' records. Yoa must provide new copies and maintain a file at your place of buainesa. 1. /V�� 2. 3. 4. HRIl�Li.ICH 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 atl times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Hea1tL Department will not use past years' records. You must provide new copies and maintain a file at your place of business. ,. N/� 2. 3, 4. RESTAURANT SEATING: TOTAL# oN NON-SMOKING SEATS: TOTAL# --------------- ----- ----- -------- --•--_-------�-r---------_�_�_..�_�.�a.x..�-_�_...�- --- _ ._ _ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 INN $50 _CAMP $50 LODGE $50 _TRAILER PARK $50 MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: ! NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishment�,the effecHve date for food protection manager certitication is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAL, $30 >100SEATS $I50 / NON-PROFIT $25 �t7L-0�Z COMMON VICT. $50 _WHOLESALE $75 RFT ii.SERVICE: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 Pi MF. (' ANCF $10 AMOUNT DUE _ $ 25,00 *•"••PLEASE TURN OVER AND COMPLETE OTHER 9IDE OF FORM•«'"• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yatmouth is now required to hold issuance or renewal of an$� lidense or pemnit�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 INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED/� OR �T WORKER'S COMP. AFFIDAVTf SIGNED AND ATTACHED Town of Yarmouth ta��es and liens must e paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run anntially ftom January 1 ta December3l. IT IS YOi7R�E8PON3IBiLFi'Y TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2000. SEASONAL ESTABLISF�IIvfENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVA'fIONS 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. Al?DITIONAL 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 opemng, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirruning pool must be drained or covered within seven('n days of closing. FOOD SERVICE NEW STATE SAI�IITARY CODE FOR FOOD TABLI HM NT • The effective date for food protecHon manager certification 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. Tlus provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer 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 implemented January l,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporary Food Service Appiication form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _ FRO�N DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heatth Deparnnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above temts have been met. OUT ID F'F:S• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKINC• Outdoor cooking,preparation,or display of any food p uct by a re ' or food rvice establishment is proLibited. DATE. SIGNATURE: PRINT NAME & TITLE: eF �„/ � '�t� � 11/16/00 �� a�� I(� l � }/�,yyryyr y�rr +i +` r /� onre(rnwonr�� ACORDn #/�L��k ��ir �� L��1�� t1�� , . �7��7�� vnooueen �� THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION NORCROSS & LEIGHTON INC � ONLY AND CONF'ERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR HTTP: //WWW.NLINS. COM ALTER THE COVEflAGE AFFORDED BY THE POLICIESBELOW. 437 STATION AVE COMPANIES AFFORDINQ COVERAGE S YARMOUTH MA 02664 COMPANV A TIG INDEMNITY INSUHEO COMPANV ELDER SERVICES OF CAPE COD B ARBELLA PROTECTION INS CO & THE ISLANDS INC CAMPMlY 68 ROUTE 134 � ARBELLA INDENII�IITY IAiS CO S DENNIS MA 02660 ('qMPANV D Cl2YERAGEB ':.. .�: �:. �u � . ::: .. 'i:.. . ::: :::' . `:' .. ;: . �THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED�BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD �� INDICATED, NOTWffHSTANDING ANY REOUIREMENT,TERM OR CONDIiION OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT�TO WHIGH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED eV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLIpES. LIMITS SHOWN�MAV HAVE BEEN REDUCED 8Y PAID CLAIMS. �� TYPE OP NSURANCE POLICY NUMBEN POLICY EFFECi1VE POLICY E%PIMTON , uM�q �� DAiE(MMIODlYY) DATE(MMNU/VY) GENENALLIAB�IRY MH31407208 07�0�.�00 O�I�OS�OZ GENERALAGGREGATE $3 � OOO� OOC }{ COMMERCULGENERALLIABILITY PPODUCTS-COMPNPAGG a Included CLAIMS MADE �OCCUR PERSONAL 6 ADV INJURV E].� O O O � O O O ��OWNER'S 6 CANfMCTOH'S PROT EACH OCCURFENCE SZ� O O O � O O C X Professional FlREDAMAGE�Myoneflre) 5 1 �� Mm E%P(r�y a»na�) $ 1 S, O O O AUT0IAOBRELUBII.RY 04155400000 07/O1/00 07/Ol/Ol COMBINEO SINGLE LIMR E ANV AlffO ALL OWNED AUTOS BODILV INJURV scHEDU�o nur05 �Pa��fSO"� $1, O O O , O O G X HIRm AUTOS BOUILV INJURY X NON-0WNED AUTOS (Pa��^�� E Z i O O O� O O O PqOPERTYDAMAGE $ SOO� OOO GAFIAGE tlAB67fY AUTO ONLV-EA ACCIOENT S _ ANY AUTO OTMEH THAN AUTO ONLV: . EACH ACCIDENT $ AGGREGATE S E%CESS LUBLRY ' EACH OCCURPENCE E UMBRELIA f-0RM AGGREGATE S 07HER 7HAN UMBFELLA FOHM $ . WONKEXSCOMPENSATiONANG WC0007060799 7�01�� 7��1��1 X 7pp�'�MRS ER r . .. EMVLQYERS'LIAE0.RY _- _.-.-... . - .- — ... __ _ .–_.. . . .–_-_.. __ ECEAGMACCIDENT S Z�QO� OOO . THE PROPflIEfOR/ �N� EL DISEASE-POLICV LIMR E S O O� O O O PARTNERS/EXECUTNE � ELOISEASE-EAEMPIOVEE $ ZOO� OOO OFFICERS ARE: E%CL on+Er+ DESCRIPiiON Of OPEIU7IONSILOCAilON3NENICIES/SPECULL ffEM3 CF�TIFICA7'� =HQL�R : CANC�tiA'CIqN ; ;; SNOUID ANY OF TNE ABOVE UESCNIBED VOl1C1E$ BE CANCELLED BEFOPE iHE E%PIRATON DR7E TfEHEOF, iHE ISSUING COMPANY WILL ENDEAVOR TO MAII �, � DAYS WRf77EN NOTiCE TO 7NE CER71FlCAlE HOIDEH NAMEU TO THE LEFf, BUT FAILUAE TO MNL SUCH N07ICE SHALL IMPOSE NO OBLIGATON OR LIABILRY � OF ANY KIND UPON E PANY, A SENCATIVE3. � RUiXOR�U NEPRESENTA L ,��11/� Maurabeth Chilson CIC MC C __ I g,ACppp"�,tRp�YH71T10N 198: ACOHD �5-3:(11951 _ .� � A o � 0 \ � � V N � y ¢ `� ' . 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