HomeMy WebLinkAboutApplications, WC, Licenses Prior to 2010 , ya� �r �, < - ; � - -r��
; , � TOWN OF YARMOUTH BOARD OF HEALTH p � � � � � � D
• APPLICATION FOR LICENSE/PE�i�`=�o�o'" NOV 2 6 lggg
� � � � � . t�
" HE LTH D PT
* Please complete form and attach all necessary documents b��I�ece ��ii�;1999. Fail n
the return of your application packet. ��p2y��5?u
- - - - -------------------------------_�_—�__
--------------------------------------�laamoo�ri«--------- --- ----- -- ---- .
NAMF OF ESTt�RLIS�IMENT� se�,�aecasr�E����t��r�C _ TEL # ���"35y" `��-;�l
LOCATION Ai�DRFSS: 5L8 Foac�r Ro,S4 �p��_�_ .__
r,rerin.rr D F Fn� 4 �'JA •
OWNER/ O O ATION N MF' South D�ryg p�, pZg�p �_T" #
MANAGER'S NAME:
MAiLiNC3 t�nDRESS�
POOL CERTIFICATIONS: ~� '
The pool supervisor must be certified as a Poo1 Operator, as required by new State law. Please list the
designated Pool Operator(s) and at#ach a copy f th�certification to tlus€orm.
I
1. �
Pool operators must fist a minimum of p y s dy certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resus itat� n ( P . ease list these employees below and attach copies of
employee certiScations to this form. The H th Dep nt ' not use past years' records. You must provide
new copies and maintain a file at your place of usiness.
1. 2.
3. 4.
HFIIvII.,ICH 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 Gst your employees trained in anti-cholang 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 maiotaia a fde at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: T4TAI.# _ NON-SM�KINC�-SEATS: TOTpi.�_ — ----
—______________----------------------------------------.---______�_�__�_
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50
INN $50 _CAMP $50
LODGE $50 _TRAII.ER PARK $50
MOTEL $50 _SWIlVIlVIINGPOOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 _CONTINENTAL $30
>100 SEATS $150 I NON-PROFIT $25 Y2k-I1,
COMMON VICT. $50 _WHOLESALE $75
RFTAII..SERVICE•
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 TOBACCO $2�
_<Z5,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.ft. 5200
NAME CHANGE• $10
AMOUNT DUE _ $ Z��
•"•••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""`"'
_ __ . _ . � ,
� ADMINISTRATION � , ,
iJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TF�TOWN OF YARMOUTH IS NOW REQUIRED '
TO HOI,p ISSUA�TCE' OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PE1�S(3I'�-E3R�Ei31t�ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMI'ENSATION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVII'
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. Tl' IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISI-IMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MEYY REQUIRE A SITE PLAN.
ADDITION 1 F TT ATIONS
POOLS
POOL OPENING: ALL SWIMIvIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TkIE WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEIVING, AND QUARTERLY Tf�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIl�IING POOL MUST BE DRAIlVED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
CATE PO I Y•
ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH
DEPARTMENT BY FII,ING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TI-IE CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT Tf� HEALTH
DEPARTMENT.
FRO�N DF 4ERT4�
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII,ITRE TO DO SO WII.L RESULT IN Tf�
SUSPENSION ORREVOCATION OF YOURFROZENDESSERTPERMIT UNTIL 1�ABOVE TERMS HAVE
BE�N MET. -
OUTCIDE F�.0
OiTTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), ��HAVE pRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
OUTDOOR 00 iNC'.
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHIv1ENT IS PROHIBITED.
DATE: // / SIGNATURE: � vr(/�s I'1�
PRINT NAME& TITLE: CJ_/����h'�j �,h, l/f NRL /�I(,l�
I1/12/99
�
�� American Red Cross 286 So��h s<<ee�
Ca e Cod Ch8 te� Hyannis, Massachusetls 02601
P P � Tet.(508) 775-1540
�� FAX(508) 77b2209
STAT�MEN"f OF AGI2EEMENT
This document, once signed, represents an agreement behveen Elder Services and tlte
Cape Cod Chapter, American Red Cross, Hyamiis, MA for Health and Safety lraining.
The Cape Cod Chapter will send an authorized instructor(s) to the location designated
below ro conduct a training course at the agreed upon date(s) and time(s).
COURSE TO BE TAUGHT: Chokesaver
LOCATION OF TRAINING: 68 Rt. 134, S. Dennis
DATE(S): 2/17/99
TIME(S): 930am-1 I am
FEE: $7.00 per person (10 billed min.)
Please make checks payable to: Cape Cod Cl�apter, American Red Cross
All participants must be on time and remain in the classroom for the entire class. Breaks
and mealtimes will be scheduled when appropriate.
Whenever possible, please submit a list of tl�e participants prior to the start of class.
Please sign both copies of this Statement of Agreement and retum one copy to our
office at: 286 South Street, Hyannis, MA 02601, Attn: Glen Freiband.
�'����� �-e /'�i c� N���r�-i�N �J'����f��
Signed � Title Date
����� /U���,�e C�z�,�� ���'-5'
Signed Title Date
/��/����j United Way
1i/• °ic:,i..c,W.i„c
�
The Commonwea/!h ojMassachusetu
= Deparlmen! ojlndustria/.-I ccidents
_ a Ol11ce o//svesllOsWis
600 Washrngton Slreet
Bosron.Mass. 02111
` �� ,, R'orkers' Compensation Insurance Affidavit
Annlicant information: p� e.�pRnvrr.en.ry
Elder Services of Cape Cod �
mmc� anrl icl �-dS �RQ �
68 Route 134
luca�ion� Sp��}h n n 'g ��� �a��e
�tt� ohon e \�'� ���,�,�-I �•�L :
� I am a homeouner perturmin, all work myself.
J I am a sole propriecor _r.,', ha�z no one ��orkine in any capacin•
f71 I am an emplocer pro�iding workers' compensation for my emplo}ees korkine on this job.
'Y�
�.:om an n �
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aslAress• i ,(LM�.
tih�: �.�` � ehon Y•
insurance co. poliev N
� I am a sole proprietor. _eneral contractor. or homeowner(eircle anel and hace hired the conttactors listed below ��ho ha�e
the follo�cin_ «orkrr; :ompensation polices:
comoanv name•
address•
��n�� ehone p•
insurancc ro. pelier p
�m�anv name•
addr «:
�h" nhoe �•
iniutance eo. �� M
t
F�ilure ro securt coveraQe as required uoder Secnon ZSA of MGL 152 n�Ind to the ieporidoe ot eridul pndtla oh O�e ep ro 51,500.00 a�d/or
one ynn'imprisonmenl u w�ell u civil penddef io the form of a STOP WOitK OADER�ed�Oet of SI00.00�dar qaimt m� 1��denb�d H�1•
topy of�hia etatement m�y be fonv�rded to�Ae ORce of Inve�Ng�tlom of Me DU tor emenfe veriliutlw.
/do here6y tertij}'urtder th[pai and �rta(�irr ojperjury thaf 1he injormation provided o6ovt is tnre and corred �
Signature �J " �f' -�'�I � �� � �� � � ��
Print namc ��- 1�. �J't/� � �/�� Phone N �� G� � '� � y� / ��C�
.- ofTicial use ooh do no�write in�his arn�o br completed by eity or ro�vn oflltial
city or lown: YA�M�DT� _ � permiNieense N nBuiidiae Departmea�
OLiceaaioe Bo�rd
� check if immediale responee ie requircd Z61 �Sdectmenb O(fitt
�He�ItA Dep�nmtot
con�ac� person: phont N:_ CSOS� 398�2231 e �at. nOther
_z. �J:' lyji 1L: �1 ��J..i.�iJ14�.'i i �_..�r.:��. . L�t�.��i ��� r-...� _ .
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��a«icr� � THI9 CCRi1FICAT! 18 �186UED A9 A MATTL',q OF INFORMATOI/
NORCROSS � LEIGHTON INC ONLY AND CONFER6 NO q1OliT6 UPON THE ClRTIFlCATE
MOLDER h118 CER'TIFlCATL' DOEB NOT AMEND lXTEND Oq
HTTP :��WWW.NLINS .COM ALTEq TH[ COVEMO! AFFORDED EY 7HE POLICIEBBE�pW,
437 $TATION AVE coMVANiCa AFFORDINq CpyERAOE
S YARMOUTH MA 026G4 cour�rrv �
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ELDER SF.RVICES OF CAPE COD e ARSEL� PRpTECTION II�S CO
& THE ZSLANDS INC coMr,wr
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TMIS 16 TO CERTiFY TN�77}�E POLICIE$OF IN6UFiANCF LI'JTED BELOW HAVE 9EEN 19SUED TO iNE IN3URE0 NAMED ABOVE FOR THE POUCY PERIOD
IhDIC/.TED, NOTWRM9TANDINp ANY qE�UIREMENT, TERM Oq CONUITION OF ANY CONTMCT OA OTHER DOCUMEM WRH flE9PECT TO WHlCN THiS
GERiiFICAiE MNV BE 165UED OR MAV PEqTAiN,TT7F IN9URANCE AFFOHDED BY THE POLICIE6 OE6CRI9E0 HEfiEIN 19 SVAJECT TO ALL TNE TEfitA9,
EXGLUS�ONS AND CONDITION9 OF 6UCH POIJCIEB. LIMITS SHOWN MAV HAVE 6EEN REOUCED BY GAID CUIM&.
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ACORD��I.'f�G-� ����"e�, � e�...;�." s a.. �a:".:i "s' . � i��.,�:}..� e�' � � � � i.:. . .. . ., .
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMITNUMBER: Y2K-16 FEE: $25.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
I 11,Section 5 of the General Laws,a permit is hereby granted to:
Rlder Services of('�e ('nd Xc Tcland5, Tne_ 52R Forest Roari Snnth Yarmn,�h A�TA
Whose place of business is: Yarmouth Senior Center
Type of business: Non-Profit Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTfi:���/.+.}naltg�/, C'�/�w„q��/nq � n
�y�oan Gc.7JnuClivan�nK.//.� Vica l.�inma
sen'rMG: 120-Congregate Dining Room Ko6e.E J. [Srown, l.lar�
a6.�fG��G,&y���
;��f O' ou l��
December 1 , 19 9�
Bruce G. Murphy,MPH,R.S.,
Director of Health
r - - - � �C'+4fIlG6LtY1 `��4bICl'��I'4f-�
` TOVVN OF YARMOUTH BOARD OF HEALTH W � � � � d � �
;, APPLICATION FOR LICENSE/PERMIT- 1999 p�� 0 3 1998
* Please complete form and attach all necessary documents by December 31, 1998. Failu e NFt�AI,�H✓@�1.3�1t i
the return of your application packet. Elder Services of Cape Cod
----------------------------------------------
anctisFantts,-hr�:----------------------------------------------------------
NAMR OF ESTABLI4HMENT' 68 Ro�te 1�a TEL. #
i.nC'ATION ADDRESS South Denni� MA 02860 ,
MAILING ADDRESS
C O T N NAME•
MANt1GER'S NAMF� 6NA� A� EL # �f�� d
IN D
----------------------------------- ------ -
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to ttvs form.
1. 2.
Pool operators must Gst a miivmum of two employees cutrendy certified in basic water safety, standard First Aid and
Commumty Cazdio�ulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certificahons to tlus 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.
�/ 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 ase past years' records.
You must provide new copies and maintain a file at your place of business.
1. �le�b Vor� de�' dSfeN z. Annn �'YIa��P �'{�e�✓r'� .
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
--------------- _—_---____------------------------------------------------------------------------
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 TRAII.ER PARK $50
MOTEL $50 _SWIlvA�IINGPOOL $SOea.
_WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERNIIT #
0-100 SEATS $75 CONTINENTAL $30
_>100 SEATS $150 I NON-PROFIT $25 �"
_COMMON VICT. $50 _WHOLESALE $75
�TAIL SERVICE:
LICENSE REQLTIItED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
<50 sq.ft. $45 TOBACCO $20
_<Z5,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200
NAME CHANGE• $10
� � AMOUNT DUE _ $ � " l�l�Fl I V�
•""""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"`""
�� } ADMINISTRATION °
LrNDER CHAPTER 152; SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQUIRED
T�0 HOLD ISSUANCE;OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A '
P R$�]1+�:,�R .CtQ:1Y�ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
�S'CTILANCE.� 1"$E ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR.
CERT. OF INS[JRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTI-I TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES NO
NOTICE: PERMITS RUN ANNL)ALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR
RESPONSIBILII'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIKED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTHPRIOR
TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MLJST BE INSPECTED BY TI-IE HEALTH DEPARTMENT, AND TI-IE WATER TESTED FOR
PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMNIING POOL MUST�E DRAINED OR COVERED
WITHIN SEVEN (7) DAYS OF CLOSING.
�/ FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH
HEALTH DEP?cRT1�N'f BY FILING THE REQ[tIREII TE1v1�ORARY�QOI3 SERVICE APPLICATIQIV
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-�
HEALTH DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MIIST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN
Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS
HAVE BEEN MET.
OUTSIDE CAFES:
OLITSIDE CAFES (i.e., OU'I'DOOR SEATING WITH WAITER/WAITRESS SERVICE), MiJST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHA�NT IS PROHIBITED.
DATE: �°' I SIGNATURE: �
PRINT NAME& TITLE: C'�. )R(jA�r't t I'�SC'Al M�.
_ _ � �
• � The Commonweallh ojMassachusetu
: Department ojlndust�ialAccidents
� Of/Jce o//arest7pstfiis
600 Wnshington Street
Bnston, Mass. 01171
` W'orkers' Compensation Insurance Affidavit
Arznlicant intormatio=��e�Scrv-ices-of-Eap� �eas�YRINTSed��Fa
namr
and Islands, Inc.
�-13�
i���ad��:
South D.nniA, MA 02680
cit�� ohone e 1 0�'35 y- Y6.3 0
� I am a hamzouner pzrt�rmin� all uork myself.
� I am a solz propriztor �c� ha�z no one ��orkin_ in am' capacih
� I am an emplo}er pro� in� workers' compensation fot my employees workine on [his job.
�d�r Services of Cape Cod
compan�� aame: a�d �S�a�C�S. �fiC.
68 Route 134
,����ss. South Dennis MA o2660
citr phone p:
��3 S y� - Y6�? 6
insur�nce co ���t'����' H"Y�L • � oolicy# D�d��� � /5Q
� I am a solz proprieror. oeneral contractor, or homeowner Icircle onel and hace hired the con[ractors listed below «ho ha�e
thr follu«in_ �wrkr; compensation polices:
m m n m :
address•
�� ohone N•
insuranccco. li 'N
iom�v name•
addres<•
ti : nhoee M•
insurance co ,�oflev M
a
Failurt to ucurc rovenge as required ueder Secdoo 25A of MGL IS3 us lud to[Ee iopaidoo of erimlul peodtle�of�Ou ap ro 51�00.00 ud/or
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eopy of tAb�t�tement may be forw�rded to the ORee of Investig�tiom of the DIA tor eoven�e verifita6w.
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" THE ARBELLA INDEMNITY INSURANCE COMPANY
: WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY
INFORMATION PAGE
Policy Number: Renewal of:
0007060795 0007060797
Agent Code
1. Named Insured and Address: Agent Name & Address81
ELDER SERV. OF CAPE COD AND NORCROSS & LEIGHTON INC.
THE ISLANDS INC.
68 ROUTE 134 170 APPLETON STREET
S . DENNIS, MA 02660 LOWELL, MA 01852
Named insured is:
Corporation
Other workplaces not shown above:
See attached general endorsement note .
2. Policy period: From: To:
07/O1/98 07/Ol/99
12:01 A.M. standard at address of named insured
3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers'
Compensation Law of the states listed here:
MA
�
B. Employers Liability Insurance: Part two of the policy applies to work in each state
listed in Item 3.A. The limits of our liability under Part Two are:
I
Bodily Injury By Accident Each Accident
Bodily Injury By Disease $100 , 000 Each Employee
Bodily Injury By Disease $100, 00o policy Limit
$500, 000
C. This policy includes these endorsements and schedules:
WC 200306A WC00-04-06 WC00-04-14 WC20-03-01 WC20-03-02
WC20-03-03 WC20-06-01
4. The premium for this policy wi11 be determined by our Manuals of Rules, Classifications,
Rates and Rating Plans. All information required on the attached extension of Information
Page is subject to verification and change by audit.
Minimum Deposit Total Estimated
Premium emium Annual Premium 19 183 . 7
The premium adjustment period is annual.
RGIICfti�SS i c.E 5��e�t�./�fill�� i� �.
►v ����-�if`+�,fi��,
Countersigned by i � �� �" Date 7��'�� 98
E
WC000001 A i �
+�..�,�.C� l?.t�r. --,
r
..T,/>..�./,./�/�/� .., (■ �.■■. , yy�.{ . . : . ...,,
LS.�G�Cn!-�n.:; ■���k/����E' LR����� ': DATE(MMiDD/YY) �:
.., 07/02/98
_ ,..:, _.,,.> .:,: ,
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON.THE REVERSE SIDE OF THIS FORM.�
PflOWCEH p„CNNee,nS08-394-0946 COMPANY BINDEHf
NORCROSS & LEIGHTON INC THE HARTFORD
HTTP: ��WWW.NLINS .COM op� EFFELi1VE nrne DAIE P��nON nMe
437 STATION AVE X a�n X izoi er.�
S YARMOLPPH MA 02664 07/Ol 98 12 : 01 PM 07/Ol/99 NOON
THIS BINDEP IS ISSUED TO EXTEND COVEMGE IN T1E ABOVE NAMED COMCANV
CODE: O B O B 14 SU&CODE: �' PER E%PIRING POLICV t: O BLNBUS G O.3
"eu°srowen m: CELDS 5 0-1 DESCNIPTON OF OPEHATONSNENICLES/PHOPERTY(Izlutlhg Lwtlon)
wsuneo NON-PROFIT SOCIAL SERVICE AGENCY
ELDER SERVICES OF CAPE COD LIABILITY COVERAGES ARE INSURED WITH
& THE ISLANDS INC FRONTIER INSURANCE COMPANY
68 ROUTE 134 THE AUTOMOBILE AND THE WORKERS COMPEN-
S DENNIS MA 02660 SATION ARE INSURED WITH ARBELLA
C4#�f�iS#�.4 R�rll'CS
: ;; ;:
_:_..:. :.
TYPE OF WSURANCE COVEMGEIFOHMS I AMOUM DEDUCiIBLE �� COINS% .
PpOP�TY CAUSESOFLOSS Contents 2]_2 � ��� �j0�
e�sic �enono�SPEC EXtYa Expense I 50, 000
EDP Floater 72 , 488 250
Em lo ee Dishonest 25, 000 500
GENEPALIIABILITY Professional Liability PO�.1Cy: GENERALAGGREGATE i3� ���� ���
�{ COMMEfiCIALGENEHALLIABILITY Limits : $1� ���� ��0 per occurrence PRODUCTS-COMP/OPAGG S
CIAIMSMAUE oOCCUfl $.3 � ���� ��� general aggregate PERSONAL&AOVIWURV $1� ��0� ���
�� � OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1� O O O � O O O
FIflE DAMAGE(My ona fire) S .rJ�� ���
RETRO DATE FOR CLAIMS MA�E: MED E%P(My one person) $ S� O O O
AUTOMOBfiE LIABILRY COMBINEO SINGLE lIM1T $
ANY AUTO BODILV INJl1RY(Per person) S 1� O O O� O O O
ALL OWNED AUTOS BODILV INJURY(Per accitlenU $1� O O O� O O O
SCHEUULED AUTO$ PFOPERTY DAMAGE S S O O� O O O
X M�FED AUTOS MEOICAL PAVMENTS $
}{ NON�OWNED AUTOS PERSONAL INJURV PROT $
_ UNINSURED MOTORIST $
E
AUTO PHYSICAL DAMAGE pEDUCTIBLE ALL VEHICLES SCHEUULED VEHICLES ACTUAL CASH VALUE
COLLISION: STATED AMOUNT S
OiHEF THAN COL: 07HER
GARAGE 1JA81LffY AUTO ONLY�EA ACCIDQJT $
ANY AUTO OTHEfl iHAN AUTO ONLY:
EACH ACCIDENT f �
� AGGREGATE $
EXCES$LUIBLITY EACH OCCURRENCE f
UMBFELLA f-0RM AGGREGATE S
O1HER THAN 11MBRELLA FORM REfHO DATE FOR CLAIMS MADE: SELF-INSURED REfENTION $
X STATUTORV LIMITS
W011KEH'S COMPENSATION EACH ACCIDENT S 1�Q� ���
AND
EMPLOYEN'$LIABRRY DISEASE-POLICV LIMR $ S O O� O O O
DISEASE-EACH EMPLOVEE S ]_O O � O O O .
$PECI�L DIRECTORS & OFFICERS LIABILITY INCLUDING EMPLOYMENT PRACTICE LIABILITY
o,;,�iON& FOR ALL EMPLOYEES for $1, 000, 000 WITH FRONTIER INSURANCE COMPANY;
COVEHAGES MONEY MATTERS BOND FOR $5, 000 WITH THE HARTFORD
NAME:&'ADDRESS
.. . ... .. . :. . ...: ::. ::. ..::. .:.:, ..
... .. ..._.......
MOqTGAGEE ADDITIONAL INSURED
LO55 PAYEE
LOAN t
HEPRESENTAiNE �
� aurabeth Chilson MC (C)
ACtfR{t:74S 12143 N:fSTE IMAESftFRTtT S7'!'�LTE INF6RMATH]N ilN::AEVEflSE SI6E ::i�AC6RD;:CtSBPitRATIQN i993��.
� TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTI'TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 99-26 FEE: Waived
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and
Chaptet 111,Section 5 of the General Laws,a permit is hereby granted to:
Town nf Yarmouth 528 Fnrrst Road South Yarmnnth_ MA
Whose place of business is: Yarmouth Senior Center
Type of business: Non-Profit Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 1999 BOARD OF HEALTH:�d��/.+�et�a�, C'�/�irmry/a�nn / /J/
oan G. �nul�ivam� K.//.� Vice C,hairman
ssn'ruvc: 120-Congregate Dining Room o�ert� e,rown, ��er�
Cy(�a�6.��� sa�/o��G�-�l�P �
' ///lG�BL olOKl��tHL
_December 16 , 19 98 ��
Bruce G. Mutphy,MPH, S., O
Director of Health
�