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Home My WebLink AboutApplications, WC, Licenses Prior to 2010 � - ' TOWN OF YARMOUTH BOARD OF HEALTH �' u ��'n' C° fz ':; � � APPLICATIONFORLICENSE/PERMIT-�(lU9; '� � �y� � � � 20U8 �� * Please complete form and attach all necessary dd"aument�by� mb ��pT Failure to do so will result in the return of your ap�licahon pac . NAME OF ESTABLISHMENT: �LAcI� S'hee`D L�q� �•.c� �� f TEL. #SU 6 S� LOCATION ADDRESS: o +2 �4 � MAILING ADDRESS: P� �ox �t'kCo e��nr� v1�1�4 QZG� ? OWNER NAME: 7�n�PJ /-� L.�'nd�s TAX ID (FEIN or SSN): CORFORATION NAME (IF APPLICABLE): �'Rrv�el /-4� L�.4Ar}" T.,uC , MANAGER'S NAME: U1arI�t �.J��erbe� TEL. # SZ�fr 7?l .flOL MAILING ADDRESS: � � � ' POOL CERTIFICATIONS: The pool supervisor must be cerrified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. 1. 2- Pool operators must list a minimum of two employees currently certified in basic water safery, standard First Aid and Coxnmunity Caz•diopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department �vill not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2• 3, 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CHARGE: _ -_ _- ----- _ _ — _ _ _ - - _ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. l�Gf'I eJ �t 7hes-b r2 EC � U�i N 2. J A,n�eJ LS!�O-TS HElMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your empioyees trained in anti-cholang procedures below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. �l�N.e S� L3'(��5 2. 3. �rJrlrc �Jc'f�cr�iP� 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODG['_V"G: LICENSE REQUIRED FEE PERMIT k LICENSE REQLTIItED FEE PERMII'# LICENSE REQi71RED FEE PERM[T i+ B&B S55 CABIN S55 _MOTEL S55 � S55 _CAMP S55 _SWIMNIINGPOOL 580ea. LODGE S55 _�I-RAILERPARK 5105 WHIIZI.POOL S80ea. FOOD SERVICE: LICENSE REQUIftED FEE PERMIT# LICENSE REQUIltED FEE PERMCI'# LICENSE REQUIItED FEE PERMIT# �0-1005EATS S85 O�l'�°Gd _CONTINENl'AL S35 ,/ NON-PROFIT �30 >I00 SEATS 5160 �COMMON VIC. S60 �0 J _WHOLESALE 580 RETAIL SERVICE: - —RESID.HI'ICHEN 5S0 LICENSE REQUIRED FEE PERMff# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<SOsq.B. 550 _>25,OOOsq.ft. 5225 _VENDING-FOOD S25 <ZS,OOOsq.ft. 580 _FROZENDESSERT S40 _?OBACCO S» vaxEcxnvcE: sio AMOUNTDUE = S /�{5.06 •"**"pLEASE TL7Lr OVER A�\`D COMI'LEI"E OTHER SIDE OF FORVI**•"' ADMIlVISTRATION • , Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a CertiEcate of Worker's CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED `� OR 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 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thitty (30) days, and an aggregate of not more than ninety(90) days witlun 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 OPENIlVG: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 Department to schedule the inspection five(5�days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area witil the pool has been inspected and opened. POOL R'ATER 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 CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departmeirt. 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. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Heahh. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Pernrits run annually from Januazy 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQiJIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, 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 REQUT A SITE PLAN. DATE: `� ( U� SIGNATURE: ' r riurrr Na�&TTTLE: � e.r G-�-�k� �oizvos � w RANITE STATE INSURANCE COMPANY � � � 3io2 7o6i3-0000 we 8z7-o8-55 --------------------------------------------- 0�3-66-0308-00 PENNSYLVANIA AMES A LIADIS INC 0 BOX 986 �� Member Companies of EST YARMOUTH, MA 02673-0000 American International Group . FJCECUTIVE OFFICES: � 70 PINE STREET,�NEW YORK, N.V, 70270 � EE NAME AND ADDRESS SCHEDULE - WC990610 )� WORKERS COMPENSATION AND EMPLOVERS 8$YDALMOUTHLRDVAN INSURANCE AGENCY INC LIABILITY POLICY INFORMATION PAGE HYANNIS, MA 02601-2759 ISUNED IS � PREVIOUS POLICY NUMBER DRPORATION RENEWAL 00224 02 71iER WORKPLACES NOT SFIOWN ABOVE:SEE NAME AND ADDRESS SLHEDUIE - WC 0610 fEM 2 PpLICy PERIOD f Y:Ot AM.sUrMarA time at the Imurod's l � m+Illny+dArou - � FIIOM 03/08/OS ro 0 08 0 � 3/ / 9 EM3� A. Worken CompensMion Insunncs:�PaK One ot the policy applias to tha Worksn Componsation Lsw pf Me ststes Iisted hers: MA - B. Employen L4b�lity Insunnce: Part Two of ths pollcy applies to the work In s�ch state Ilstsd in Item 3A.� � �- The Ilmits of our Ilability under Part Two are: . � _ . Bodily InJury by Accident S_ 50� �ych acefdent � . Bodily Injury 6y Oisaase S. 00.000 poBcy Iimit � . � . 8odily InJury by Diseus S � 500.000 each employee C. OthK States�lnsurence: pert Thres of the policy appiies to the states, i} any, IIMed bere: �� SEE ENDORSEMENT - WC200306A EM� The promlum for this policY will bs determined by our Manuals ot Rulss, Classlfiutlons, Rates snd RMiny pians. � � All lafo.rmnion roquirod below is sub�act to vsr(ficatton and chenys by audit. � � � Estimnstl Tot�l py�e Par Eslim�bE Gl�asilic�lions CotlaNumber Aamynentlon 57000Fflo- Promium � - . . O Annu�l❑3 Yev mune2tlon �Annu�l ❑3 Y�v ... iEE EXTENSION Of INFORMATION PAGE - WC7754 fAXES/ASSESSMENTS/SURCHARGES � $110 ��ENSE CpNg7qN7(IXCEPT WHERE APPI.�pBLE BV STATE) $ �8 MA - . IIMUM VREMIUM S 2 I 9 MA TOTAL Eg7�E�p7ED PREMIUM a �eaei � � i e�u � � fp. � �i� tl $2 415 � 9emi-AnnuatY � . .. �:i r QuuterlY � Mon1hIY DEPpgRP ' v � � ENOpqgEMENTS�FOHMNUMBEIp SEE ATTACHED FORM SCHEDULE - WC99061 � � �� f �, MAR 3 �. 7q�� ,l.0 ,/27/08 ASSIGNED RISK 66 sue Date 87 Wuln9�ilte Authorl�tl pppr�ent Ive WC000001 � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NL7MBER: #09-026 FEE: S60.00 This is to Certify that 7ames A. Liadis Inc. d/b/a Black Sheep Bah and Grill 720 Route 6A, Yannouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testnnony Whereof, the undersiened have hereunto affixed their official signatures. BOARD OF HEALTH: 3Eeeen SR�a$, `J2.N., C'.�Ltman senra:�: 36 outside ' CI .`�. ,`X¢QPi&4�X,) 41,,iC¢ C.PiatxnUut �6 inside ✓Z(!�?XE �. �M�O[WL� (:C?![R � Q�'K,,I,pI',,, f►t� �..�. `�"^'J'" �. December?,2008 Bruce G. Murphy,MP , .,CHO Director of Health TOWIV" OF YARMOUTH BOARD OF HEALTH PERI�IIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-040 FEE: S85.00 In accordance�cith regulations promulgated under authority of Chapter 94,Section 30�A and Cliapter 1 I 1, Section�of the General La�t�s,a pern�it is herebp gruited to: James A. Liadis Ine., 720 Route 6A, Yannouthport, MA Whose place of business is: Black Sheep Bah and Grill Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31, 2009 BOARD OF HEAL'IH: .�Eeeen S�ial$, `J2.✓V., C'.Ruiixman Cl�a�ePee 3E. 9fe�filke+c, `Uice CIEa"v�man sEA7I1�G: 36 outside �PXI `.�. �AW4lttt� �Rl[�t �6 inside Q�'�R�,.,I�L��„[CR.ft.�r�(l,U,�l�i�t��.JY. `"""�"�. ""'y`�' Dzczmber 2. 2008 Bruce G. Murphy, , R.S., CHO Director of Health �t VAk� TOWN OF YARMOUTH BOARDI?F�A��'� °�� APPLICATION FOR LICENSE/PEIt'11�I1''-�� q� '� �z �r! �q'a�i.i`,l L ' L�t!: ' " Please complete form and attach all necessary documents by'].�ecember 31, 2007 Failure to do so will result in the retum of your application packet. NAME OF ESTABLISHMENT: /}[�� Pep�� TEL. # SIJF—�G.�' �U� LOCATIONADDRESS: 7� iZ�' /o/�- MAILING ADDRESS: � esi- �ln{mc,�1� t�_� �3 OWNER NAME: Ti�r � L.�FF�Tr TAX ID(FEIN or SNI� � CORPORATION NAME (IF APPLICABLE): �'q�p�, j_,�,�pT�s 5,�� MANAGER'S NAME: �� (,,�e�� TEL. # MAILING ADDRESS: fU R �� 4,i� 1.��.f F ✓�rv� n � G.�L 7 3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum oftwo employees currently cenified in basic water safety, standard First Aid and Communiry Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certi5cations to this form. The Health Department will not use past vears' records. 4'ou must provide new• copies and maintain a Cile at your place of business. 1. 2: 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificapon to this application. �'he Health Department witl not nse past years'records. You must provide new copies and maintain a file at your establishment. 1. �f (.vc��rr�e� 2.-----��itv� u �/ P�R�9N IN C�IAAGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. J/}�Vlrf L_Iit�J.l=( 2. ��P�l�f4JLv7cc�h�� HEIMLICH CERTIFICATIONS: �� Ce All food service establishments with 25 seats oi 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 tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. _ �I�MC�T�z!+1Ji(' 2. � ,ti( ,i`G� 3. �lri1� L� �c.rhe� 4. . /�r.t-t f1/r' , ?e tiJ RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER`vfl"I# LICENSE REQL'IRED FEE PERbIIT� L[CENSE REQL'IItED FEE PER�fIT= _BBcB S50 _CABIN S50 _MOTEL SSO INN S50 CA:'�fP S50 SR'IVI�IING POOL S75ea. _LODGE 550 7-RAILERPARK 5100 _RT-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQL�IRED FEE PER1417= LICENSE REQti IRED FEE PER�f17= I 0.100 SEA7S S75 �'�g-030 _CONTINEN7AL S?0 _NON-PROflT S?i _>100 SEATS 5150 /�CO:bLbiON VIC. S50 6$'O _R7-IOLESALE S75 REiAIL SERVICE: —RESID.KITCHEN 57i LICENSE REQUIRED FEE PER�4fIT= LICENSE REQL7RED FEE PER\�T= LICE?v'SE REQL7RED FEE PER�IIT� _<50 sq.8. S45 _>25.000 sq.R. 5200 _VENDING-FOOD S20 <25,OOOsq.B. S75 _FROZENDESSERT S3i _TOBACCO Si0 VA:�CHA'VGE: S10 AMOUnTDUE _ $ /ZS.00 *"*"•PLEASE 7L'R�O�'ER 21_\'D CO�iPLETE OiHER SIDE OF FOR\i"^**• ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR , / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�/ Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENI'OCCUPANCl': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transiem occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days witlun any si�c(6)month period. Use of a guest uait as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: En�tosed Motel Census must be comnleted and returned wir�this�P�icat�on. POOLS POOL OPENING: All swimming,wading and whidpools which have been closed for the season must be ins by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( days pnor to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count b}za Statecertified 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 ctosing. FOOD SERVICE CATERING POLICY: Anyone who caters wittun the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. 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 Pernrit until the above ternts 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,prepazatioq or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January i to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN THE COMI'LETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�ICEME>TT. RE�IOVATIO�IS MAY REQUI�E A SITE PLAN. DATE: �� o�,� �� SIGNATURE: '�`�� /l�� Gi[��/ PRINT:VAh1E&TITLE: I'P,T� � io?uro PRODUCER THIS CERl1FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE eryden 8 Sullivan Insuianoa Agerwy Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 88 Falrm�th Road ALTER T1iE COVERAGE AFFORDED BY THE POLICIES BELOW Hyamis, MA 02801 . COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Jarres A Liadis Inc Po Bo�c�6 Weat Yam�ath, MA 0287&0000 TMIS IS TO CERTIFY TFIAT THE POLICIES OF INSURANCE LIS�ED BELOW W WE BEEN ISSUED TO TFff INSURED NAMIED ABOVE FOR THE POLICY PEPoOD INDICATED,NOT NRf HSTANDING AN'f REQURBdENT,TERM OR COPDITION�AN'(COPRRACT OR OTHER DOCUMEPR WRH RESPECT TO WFACH THIS CERTIFlCATE MAY 8E ISSUED OR MAY PERTAIN,TF�INSURANCE AFFORDED THE POLICIES DESCWBEA HER9N IS SUBJECT TO ALLTHETEFqAS,EXCLUSIONS AND COI�DfTIONS OF SUCH POLICIES.LMITS SFpWN . MAY HAVE BEEN REDUCED BY PND CWMS. � L7R MEOFNlIMUNGE Pp.ICYMUNBER POIRY�FE�NEGA7E PqJCyE1aM710NDAlE q coMr�rnn ��or�aes•iaecm LIMITS VROPRETORI Aft7NER81E�C1ffIYE FICERS APE: Nc�o�0 2245902 3/08f2007 3/08/2008 �nrraer�MRs R ApqlotoMMOpa�m�Ory. ' RCCDEHf S SOO, BFAREVOLICYLF%f $ 300. BEA4EfACM EMPLOYEE S SOO, RIPTqN OF OPERI►TIOt�1VEHICIfi&SPECYLL ROAS CERi1F�ATE HOLDER ANCELLATtON TOWNOFYARMOUTH BHdRDNryOFTHE�BWEDESCRBEDPOLCE6BEC/WCELLEDBEFORETHE ATTN:LINDA HILL �rt�Ton onh nfneoF,nie�ssuNccoMrunwu�oEnvoR ro wLL� 1146 MAIN ST MY8 WRIfTEN NOTCE T07HE CERTFIGTE HOI.OER NALED TO Tlff LEFT.BUT SOUTH YARAAOUTH, MA 02884 ru urse ro nou suc�rar��u��rosE No oe��ror�at�we�m oF �wrKNo urox n�wwan.rts ufHrs ae a�rrsEserrtar�s AUTHORIZED REPRESENRATNE /�+�- �/4�+t'd`'� i// • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISI3MENT PERMIT NUMBER: #08-030 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Secrion 305A aud Chapter 111,Section 5 of the�ieneral Laws,a permit is 6ereby granted to: James A. Liadis Inc., 720 Route 6A, Yarmouthport, MA Whose place of business is: Black Sheep Bah and Grill Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expues: December 31, 2008 BOARD OF HEALTH: ,`�feeeiz SPiaFi, �J2.rV., C'�aixnran ('.ffaxeea ,�.9feQCiPxn `tiice('�aix�na�t sEA[na�: 36 outside .� �• �'�� 56 inside ��ns ��- November 26,2007 Bmce G. Murphy, .5.,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #08-026 FEE: $50.00 Tlris is to Certify that James A. Liadis Inc. d/b/a Black Sheep Bah and Crrill 720 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMI170N VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signahues. BOARD OF HEALTH: ��e�ya�in�, J��r�`�".M.1�.�m.C'P��nan SEA�IING: 36 011t51dE � - ��Q�� /��/� $61ILSIdf ✓(�W�V��G��G�LQ�. �rn�lU!/t� l:[XJL(L . ✓/�(�l�i��i(.t�(L �L�1C/11Q�� ,�r - . � {AlIIG � ✓M✓Y. . November 26.2007 ruc G.Mwphy, . .,CHO D'uector of Health � ' ,-�, r�'` �: � �B�Y� D °`:""�y TOWN OF YARMOUTH BOARD o ,� APPLICATIONFORLICENSE��' �2 � . � DEC O 1 2006 �`" � DEPT. r��x * Please complete form and attach all necessary-documents by D Failure to do so will result in the return of your application packet. � NAME OF ESTABLISHIv1ENT: C,�k�ee I� r�� TEL. #� -S(XJ� LOCATION ADDRESS: U fZf' !} MAII.ING ADDRESS: l� C> �M a� 7G� A . OWNER NAME: L�"'A b T IN r CORPORATION NAME (IF APPLICABLE): SqMe,�' /-�, �-T�4D.�,�' �>vC, MANAGER'S NAME: ("'�G'��rs G,.! e'f��e r� � � TEL. # MAILINGADDRESS: PC) l��c ��((, POOL CERTIFICATIONS: 1'he 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. l. 2. Pool operators must list a minunum of two employees currently certified in basic water safery, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Ptease list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are reqwred 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 EstabGshments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wili not use past years' records. You must provide new copies and maintain a fde at your establishment 1. 2. PERSON IN CHARGE: _- -----_ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. TflM.ef LT�o21' 2. ��v4S�• (-��t��re HEIMLICH CERTIF'ICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. V AN�ss�4 �� 0 2. C�Ut t We�e . 3. vr �"LAr .r 4.� G�an..� LJGtLd' cP RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiIIRF.D FEE PERM[T# LICENSE REQiJIRF.D FEE PERMIT# LICENSE REQUIItED FEE PERMIT N _B&B E50 _CABIN $50 _MOTEL S50 _INN $50 _CAMP $50 _SWIM[��TGPOOL$75ea. _LODGE $50 _ _TRAII.,ERPARK 5100 WHIl2I.POOL $75ea. FOOD SERVICE: LICENSE REQIIIRED FEE PERMIT# LICINSE REQUII2ED FEE pERMIT# LICINSE REQUIltED FEE PERMI'T k LO-100 SEATS $75 �7��(o _CON1'INENTAL $30 _NON-PROFff $25 _>]OOSEATS $150 �COMMONVIC. S50 07-0 ,�j _WHOLESALE S75 RETAQ.SERVICE: —RESID.KITCI�IE;N $75 LICENSE REQiJIItF,D FEE PF,RMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIItED FEE pERMIT# _<50 sq.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.R $75 _FROZIN DESSERT S35 TOBACCO S50 NAME CHANGE: $10 AMOUNT DUE _ $ l2S.00 "•"•PGEASE T[1RN OVER AND COMPLETE OTHER SIDE OF FORM•^'*• -. � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a 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 ninery(90) days within any six(6)month period. Use of a guest u�it as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the cotlection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be coasidered Transient. POOLS POOL OPENING:All swimming,wadi�g and whirlpools which have been closed for the season must be ins ected by the Heatth Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certiSed lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Departmern by filing the required Temporary Food Service Applicatio�form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuits must be sent to the Health Department. Failure to do so will resu(t in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdeor cooking,preparation, or display of any food product by a retail or food service establishment is pFohibited. NOTICE:Pemvts run annually from January i to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND PROVED BY THE BOARD OF HEALTH PRIOR TO COM1�iENCEMENT. RENOVATIONS MAY RE A SITE PL DATE: I� � UL __ SIGNATURE: 2��%�]- � PRINT NAME& �te / I' - LL�l�11' /Y 5-. �omro� ! ' � � � k GRANITE STATE INSURANCE COMPANY 70613-0000 WC 873-SO-jp � i 3 i oz ----------------------------------------•--- � 013-66-0306-00 � . - . PENNSYLVANIA t • . . . � JAMES A LIADIS INC � PO eoX 986 Member Companies of WEST YAFtMOUTH, MA 02673-0000 �� American International Group EXECUTIVE OFFICES: .�. 70 PINE STREET, NEW YORK, N.Y. 10270 � SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# � MA I : • • .��• BRYDEN � SULIIVAN INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS $$ FALMOUTH RD LIABILITY POLICY INFORMATION PAGE HYANNIS, MA 02601-2759 ORPORATION R NIEWSAPOLICYNOOH]Z]�VHH I O7HER WORKPwCEs NOT SHOwN asOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 �'�.. ITEM 2 POLtCV PERIOD tY:01 hM.standartl time at fhe insured's ' ma111n9aAdress FROM 03/08/06 To 03/08/07 ',� rt�M 3 p, Workers Compensation Insurence: Part One of the policy applies to the Workero Compensation Law of the states Iisted ' hare: ', MA ; B. Employers Liability Insuronce: Part Two of the policy applies to the work io each state listed in item 3.A. I. The iimits of ow liabitlty under Part Two are: gadily Injury by Accident S 500,000 each accident � . Bodily In�ury by Disease S 500.000 policy limit Bodily Injury by Disease S 500.000 esch employee f '� C. Other Stetes Insurance: PaR Throe of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A ITEM4 The p�emium for this policy will ba dete�mined by our Manuals of Rules, Classifications, Rates and Rating Plans. � All information required balow is subjact to verification and change by audit. Eatimatadiotal patePer Estimatad Classiiications Lotla NumEar {� Aemuneration f100 OF Re P�emium LJ Annual �3 Year munentlon �q��ual �3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $42 IXPENSE CONSTANT(IXCEPT W HEflE APPLICABLE BV STAIE) $264 MA MINIMUM PREMIUM S Z�7 MA 7'OTAL ESTIMATED PREMIUM 5� 2 38 It indieatatl below, in�arim atljusiments of pramium shall ba matle: . � Semi-Annually � �uartatly �� Monthty DEVOSRPpEMIUM ENDORSEMENTS�FONMNUMBER) SEE ATTACHED FORM SCHEDULE - WL990612 MAR 2 7 20� 03/16/06 ASSIGNED RISK 66 - Issue Date - ��uin9��e AulhorizeA Rapresentative �wC 00 00 01 3998] r TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIIMBER: #07-046 FEE: $75.00 In accordance with regulatioas promulgated under authority of Chapter 94,Section 305A and Chapter I 1 l,Section 5 of the General Iaws,a peimit is hereby granted to: . James A. Liadis Inc. 720 Route 6A, Yarmouthport MA Whose place of business is: Black Sheep Bah& Grill Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit e�cpires: December 31_ 2007 BOARD OF HEALTH: B $. ,�$., • a��""sl�, rv�., v�e� SEa17NG: 36 outside /jpdg�6�, 8�� ,(B3i�,s 56 inside �1��(y�J� +�lf�, R.N. January 30.2007 ! Bruce G. Mutphy, , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-033 FEE: 50.00 This is to Certify that James A. Liadis Inc. d/b/a Black Sheep Bah& Griil 720 Route 6A, Yarmouthport MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�ires December thirty-first 2007 unless ' sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: B $. (ia�ac, M.`.b., �t«s�rc sEA1'ArG: 36 ouiside �eg��y� �r,/�1,, ?/� el�.,,y,��y s6�;ae RoL�at�. /3� G'!�k P�M�S� �a� g� R.�. .raz„�y so.200� ruce G. Murphy, H S.,CHO D'uector of Heaith . - ; , � , 8cac�q S�P ��Y"R TOWN OF YARMOUTH BOARD OF HE TH ! ? ' o ��? APPLICATION FOR LICENSE/PERMTT- 6 i ,��5 � i �� * Please complete form and attach all necessary documents�b,��e�efi�er 31;�00�. � ��2 Failure to do so wi(1 resuit in the return of yow application p Tcet:� rr.� oFESTaBLis�rrr:__`��;�cShee�, �'al� � Cr�ll �L. # 50�-3GZ-sooy LOCATIONADDRESS: ?Zo m�rN s+, o ��s- MAII.ING ADDRESS: i�O O WP A/Yhcou I� M R. c��l?3 OWNERNAME: SAm6S a� ��5 TAXID(FEINorSSN)�(�,�/ CORPORATION NAME (IF APPLICABLE): �'�y„cc A. L=.4D�S S�c, MANAGER'S NAME: Chc�-ks'�, 1,J�.-4-her �Jee TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to-this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 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 applicarion. T6e Health Department will not use past years' records. You must provide new copies and maintain a£ile at your establishment. �. e��kS w�-t�.,�be� 2. PERSON IN CHARGE: Each food establishment must haue at least one Person In Chazge(PIC) on site during hows of operation. 1. C.�n.✓�r�s W c V�,e-c��oc e 2. TnM.�,r � . L.8.A+7�S HEER�;ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich Maneuver on the premises at all times. Please list your employees trained in anti-cholung procedures below and attael4 eopies of employee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your place of business. 1.� �iAn�.es /'k , L�AD T f 2. 3. i/an�esso� L.� Sa.v�iRrn 4. , . � RESTAiJRANT SEATING: TOTAL# OFFICE USE ONLY �' LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQilIl2ED FEE PERMI1'H LICENSE REQLJIltED FEE PF.RMIT'# _B&B $50 CABIN $50 MOTEL $50 _INN �50 CAMP $50 _SWIIv4vIIPIG POOL$75ea. _LODGE $50 _TRAII.ER PARK S50 WHQ2I,POOL $75ea. FOOD SERVICE: LICINSE REQiJIRED FEE PERM[T# LICENSE REQlJII2ED FEE PERMIT# LICENSE REQiJIl2ED FEE PEgMII'# ( 0-100 SEATS $75 �(�-�L� CON7'INENTAL $30 _NON-PROFiT $25 _>ioosEnTs aiso I cotVmtoxvic. sso �06��(8 wxoLEsa� a�s RETA[L SERVICE: LICENSE R&QUIItED FEE PERMI'I'# LICINSE REQUIItF,D FEE PERMC[# LICENSE REQUII2ED FEE PFRMIT# _60 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD S20 _QS,OOOsq.ft. E95 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 � AMOUNT DUE _ $ I�..S.O� � "•`""pLEASE TURN OVER AND COMPLETE OTHER 5IDE OF RORM"•••" ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmoath is now required to hold issuance or renewal of any license or pemvt to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prio to renewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO N01'ICE:Pemuts run annually from January 1 to December 31. Tl'IS YOUR RESPONSIBII.ITY TO RETURN 'I'HE COMPLETED APPLICATION(S)AND REQLJIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMR�NCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozendesserts m+�st be teste�on a monthly basis by a State certifiecf lab. '�est resuits mast be sentto the Heahh 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishmecrt is prohibited. DATE: �� U SIGNATURE: /"�� PRINTNAME&TITL . �J A�/' VQ ' G``'��5 �� 09/28105 � � GRANITE STATE INSURANCE COMPANY 70613-0000 WC 872-74-88 13102 ------------------------------------------- ot3-66-0305-00 � . . • . PENNSYLVANIA . .. • . . . JAMES A9LIADIS INC W�ST�YAi2M0UTH, MA 026 �� Member Companies of 73-000o American Internationai Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.V. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# MA I : ' � •� ' BRYDEN � SULLIVAN INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS $8 fALMOUTH RD LIABILITY POLICY INFORMATION PAGE HYANN I S, MA 02601-2759 INSURED IS PREVIOUS POLICV NUMBER CORPORATION NEW OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRE55 SCHEDULE - WC 0610 tTEM 2 POLICV GERIOD 12:01 AM.stanEard Nme a[the insuretl's mailin9adtlrest FHOM 03/08/05 ro 03/08/06 rtEM 3 p. Workers Compensation Insurance: Part One of the poliey applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Pan Two of the policy applies to the work in each state listed in item 3.A. The limits of our iiability under Part Two are: � BodilY Injury by Aecident $ 100,000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury bV Disease $ 100.000 each employee C. Other States Insurance: Part Three of ihe policy applies So the states, if any, listed here: SEE ENDORSEMENT - WC200306A iT�M a The premium for this polic� will be determined by our Manuais of Rules, Classifications. Ratas and Rating Plans. All information required below is subject to verification and change bV audit. Estimated Tohl Rate Per Estimated Classitications Cotle Number Remunantion Et00 OF Re- P�emium � Annual ❑3 Year muneration �q��ual �3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $47 El(PENSE CONSTAM(E%CEPT WHENE APPLICABLE BY STATE) $264 MA MINIMUM PREMIUM S 2�� MA TOTAL E577MATED PHEMIUM S� Z $ If intlicated below, iMerim adluslmems oi premium shail he matle: � Semi-Annvalty � Quarteriy � Monihty DEVOSRVREMIUM ENOORSEMENTS(FORMNUMBEP) SEE ATTACHED fORM SCHEOULE - WC990612 04/04/05 ASSIGNED RISK 66 Issue Date Issuing Ottice - Authorized Nepresentative WC 00 00 O7 3998] �NSURED'S COPY TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNII'T NLJMBER: #06-021 FEE: $75.00 In accordnnce with re ahons proinulgated under authoriry of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a petmit is hereby gsnted to: 7ames A. Liadis Inc., 720 Route 6A, Yarmouthport, MA Whose place of business is: Black Sheep Bah& Grill Type of business: Food Service To operate a food estabGshment in: Town of Yarmouth Pemut expires: December 31 2006 BOARD OF HEALTH: Be�rywxLsa 95. C�'au/oay/y�5. ' �n��.nN�� e� SEATING 36 outside Ka�B3t�y. 8?<tr�pt� 56 inside � cQ�suls� R./V. fQn�t�j'?eenLatsrw� R./V. December 2 2005 � Bruce G.Murphy, RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-018 FEE: $50.00 This is to Certify that James A. Liadis Inc, d/b/a Black Sheep Bah& Crrill 720 Route 6A, Yazmouthport, MA IS HEI2EBY GRANTED A COMNION VICTIJALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General I.aws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: /.�e�nu�c `.�. �'auO.osr� M.`.15. G��iai�unwc sEw'rn�rG: 36 outside p�t�:�sk,fM1o�l�/� 'U� G'� 56 iaside R�o/�plss}p�, QZVG/N�tyA,f��Jl1� d/� d�41ly K✓�'. _ _- _ ---. _�9.� R.N. __ December 2.2005 Bmce G. Mmphy RS.,CHO Director of Health r �� . ,`_YA c�#I Z� �I 3?°��c TOWN OF YARMOUTH BO O :. _ � is APPLICATION FOR LI "2� � � � � ' ' �� , '- �� 6 '~�� A 2��5 • Please complete form and attach all neces A'' d ments by Dece er�'QRL(�0$�. Failure to do so will result in the retum of your application pa k�EALTH DE PT. NAME OF ESTABLISHMENT: � c h �- �n//P TEL. # S�P36.1;;�� LOCATIONADDRESS: 7�2t� ?-hlQf} l�R�rnvu�,.ort MAILING ADDRESS: ?�U x `'r i� l,�eSf ��xou� p�6 OWNER(CORPORATION NAME: ,T�+.nt er , L=cfta�'S' TN� . MANAGER°s rraME: CG��lP �tP� �t,. # ?��-77/�SJvL �.nvGann�ss: /� ir�+-� � ��1 %�Ps ��. uoZ67� 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 emplo ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation �CPR). Please Gst these employees below and attach copies of employee certiEcations to this form. The Heatth Department will not use past years' records. You must provide new copies aud maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANACrERS -CERTIFICATIONS: All food service establishments aze required to have at least one full-rime employee who is certified as a Food Pmtection 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 Hea(t6 Department will not use past years' records. You must provide new copies and roaintain a t'de at your est�blishment� 1. ��;/`�er /�p+�,prhPP 2. ✓ii-�n�s N . �D3�' PERSON IN CHARGE: Each food establishment must haue at least one Person In Charge(PIC) on site during hours of operation. 1. l�(�i'��PS �Je�iPrJee 2. .Ti{.�-�e,r- � _ ��h�..T-f HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar 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£de at your place of business. 1. . ��r � ��a�r 2. 3. 4. RESTAURANT SEATING: TOTAL# �7 OFFICE USE ONLY LODGIlVG: LICENSE REQUIItF.D FEE PERM[T# LICENSE REQIRRF,D FEE PERMI7'fk LICENSE REQUIItED FEE PERMIT'# _B&B $50 CABIN $50 MOTEL $50 _INN S50 _ _CAMI' S50 _SWIIvIIv1II1G POOL S75ea. LODGE $50 _TRATL.ER PARK $50 WfIIRI.POOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT p LICINSE REQUIItED FEE PERMiT N LICINSE REQiJIltED FEE PERMII'# �0.100 SEATS S75 .�� _CON1'INENTAL $30 NON-PROFIT $25 >100 SEATS $150 �COMMON VICT. S50 �OS .� _WHOLESALE $75 RETAII.SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQI)IItED FEE PERMIT# LICENSE REQUIl2F..D FEE PERMIT N _<SOsq.ft $45 >25,OOOsq.ft. S200 _VENDTNG-FOOD $20 _QS,OOOsq.ft. S75 _FROZENDESSERT S35 _TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $�� '•""•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•^^•• � � � , . ADMINIS'I'RATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITI'TO RETURN TfIE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISFIMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULAITONS POOLS POOL OPENING:All swirrvning,wading and whiripools which have been ciosed for the season must be inspected by the Health Department prior to opening. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard piate 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 CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POT.ICY: Anyone w o 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 Heatth Department. FROZEN DESSERTS: Frozen esserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited. � // DATE: ��,��-5 SIGNATURF��s��,�i/�/�A PRINT NAME& TITLE:G' A S�S.��li1/�'l�i l�a ,�'/'/�b'�� 10/22/04 � WCRIBMA :: MWCARP Application Status Seazch Page 1 of 1 WCRIBMA ::MWCARPApplication Status Search MWCARP Overview Producer Community Home SeleM either the employer's NAML or the employer's FEIN number to search. {`� Employer's Name � FEIN-Fed.Emp.ID# � NOTICE: By accessing this section of the Bureau's web site,you accept and agree to the terms and conditions for use that are set forth throughout this web site. STATUS key reference - CARffiER NUMBER key reference Tentative Client Covera e Recemed Status Carrier Employer Name/Address Name ID g Date Effective Status Date Number Date JAMES A LIADIS INC DBA . BLACK SHEEP BAH AND GRILLE oi69339 o3/oy/2oo5 03/08/2005 �SIGNED o3/i4/zoo5 13102 PO BOX 986 WESTYARMOUTH,MA � 026�30000 https://www.wcribma.org/mass/Producer/ApplicationStatusSearch/StatusSeazchPage.aspx 3/IS/2005 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-163 FEE: 75.00 . In�accordance with regulations promulga[ed imder authoriTy�of Chapter 94,Section 305A m�d Chapter ]11,Section 5 of the General Laws,a permit is hereby granted to: James A. Liadis Inc., 720 Route 6A, Yarmouthport MA Whose place of business�is: Black Sheep Bah& Grill Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit eacpires: December 31. 2005 BOARD OF FIEALTH: Be�ywxi.s `�. (�atdo.y, M.`�l. ' �� "s .a� v�et� . sEATING: 36 outside /tpppyK�. Bqpypy��*� 56 inside �/B(�y $�y�� /t,/{! �Qitra�, /l./�. March 16.2005 B�vice G. Murphy, ,RS.,CHO Director of Heahh THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-099 FEE: 50.00 This is to Certify that James A. Liadis Inc. d/b/a Black Sheep Bah& Grill 720 Route 6 Yazmouthport MA IS HEREBY GRANTED A CONIMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their o�iciat signatures. BOARD OF HEALTH: Bertyaari�s `.25. �3�ws, M.`.b. G��sai�ea�c sEn'1'ir�c: 36 outside n�� v� e�.�K s6�ns�ae Ro6en.t�. BRorwry � d+/� Sk�l� R.N. � �i� R.M. March 16.2005 ruce G.Murphy, , S.,CHO Director of Health . , �b�aq � �°"i i°�""o TOWN OF YARMOUTH BOARD OF HE41L� w � � ��; '? s ,^c; ��;; APPLICATION FOR LICENSF,./�E`R�%2005 D E C 2 2 2004 � ' Please complete form and attach all necessa�o�ents by Decemb r 31, 2004. Failwe to do so will result in the retum ofyour application pac etHEALTH DEPT. NAME OF ESTABLISHMENT: aGIL. �r i I I� � TEL. #�fc-;�t��ao�f LOCATIONADDRESS: `�a-o �,�,+2 �p �43 �.rn.��,�� Par-F �n�b�5 MAILING ADDRESS: OWNER/CORPORATIONNAME:pa.wi.elc�l'V�a-i-I. ��v.Q�vc,e�o ✓/�Iac.k54.pn-P3o.-h ��-1�i/ li� MANAGER'SNAME: bav2 �uc��,.e TEL. #Safr-��5985"c� MAII.INGADDRESS: �'-}� rn .�xvrR �Q � `i��s+�la,rMocJ`�'1'i , o�r„l'� POOL CERTIFICATIONS: TLe poot supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation �CPR). Please Gst these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a Yde at your establishment. ��m�.� M �y z. ��-� �o ��c�c�c2 PERSON IN CHARGE: - - — -- -- _ _-- - -- --- --- --- E food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1��MGl � 14�( 2. l JP�� l 7� 'JvG—�N �(� HEIl�ILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employe� e trained in the Aeimlich Maneuver on the premises at a11 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. Yo must provide new copies and maiutain a file at your place of business. i��tvtnc�- M�y z. I��vi � ��c-�.,r�2 3. 4. RESTAURANT SEATING: TOTAL#`�1 I OF'F'ICE USE ONLY LODGING: � LICENSE REQUIltED FEE PERMIT# LICENSE REQUII2ED FEE PF.RMIT# LICENSE REQLTIItED FEE PERMI7'# B&B $50 CABIN $50 _MOTEL S50 INN $50 CAMP S50 _SWIMIvIINGPOOLS75ea. LODGE $50 TRAII,ERPARK $50 Wf�RI.POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERM[T# LICENSE REQUIItED FEE PERM['C# LICENSE REQUIItED FEE PERMI'P# �0.100 SEATS S75 �D S.�d�i�"t _CONI'INEN1'AL $30 NON-PROFiT $25 _>100 SEATS 5150 �COMMON VICT. S50 OS-66� _WHOLESALE $75 RETAII.SERV[CE: LICENSE REQUIRED FEE PERMI'C N LICENSE REQUII2E;D FEE PERMIT# LICENSE REQiTI2F.D FEE PERMIT ri _d0 sq.ft. $45 _>25,000 sq.ft. 5200 _VENDING-FOOD S20 _Q5,000 sq.ft. S75 FROZEN DESSERT $35 _TOBACCO S25 NAME CHANGE: $10 AMOUNT DUE _ $ /aS�6d '•"'*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•" ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STAT`E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED L'�� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES l- NO N01TCE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISf�fENT5 ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10 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 COMA�NCEMENT. RENOVATIONS MAY REQIJIItE 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 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 ADVLSORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred 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 Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mnst have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. DATE: � � " (5 SIGNATURE: � " PRINT NAME& TITLE: G l4 eS i 10/22/04 =='-�— TheComneonwealthofMassachusetts _ - _ Depa�tment of Iadesfrial Accidentc _ — NLpN� =' 600 Washing�oa Sbcet, �'Floor '-' ,, � Bostmy Mass. 02111 � Worlcen'Campeasahoe I�sva�ee Affid�ri�B�il bi�JEkdrital Co�trxtors .... - ' _.,. ..e:; "�r r„ �."vi .::," . ..„ � - .� �„ �,a��`�=i` ,. . ._. name: .f ��c.C'�S�l.� .. .. � �i 1 I � . �: �� si4L7Gl31NN-(SV-Tn O✓-`' s�e: '�"(!� uo_ Q�67� ohmek ��'��a--�b�y work sifi locati�(full addiesst � . ❑ I�a 6omaowna perfoxmiog alt wa¢k mysclf. Projed Type: ❑New Caostcuetion�R�adel I am a sok 'etor and have�oce w in� Bwl ' Addition � am an emPbYer�O�idin8 w�k�s'comPensation f«mY�PbY�W'�o8 an iLis job. �v roe• aidte�s• dd: . eY�e Y: mm a sole propiidor,gwaal eo�tractor,or Yomeow�er(drele ewe)ffid have hiiad the comaactas listod below who have the following wotkas'wmpensation polices: �...�_��(�'�trrc� �� `�Su rc,�-�-,c_e � � 4 y c� � M�d��I-� SP++-1��--� � � �: (�.w N-�rA _ Nv i ay�3 ��: �r �. �i 9�`` ��: .aa�.• s�.: �r: F.r.n w+a.e�e..y.�a oaQsww ssntMrr.�a mt,a n�r�.ww.rerrd�..we.t.de.p asi,sM.«aw.r �y�...•m�era..a�...�a,.aw��n.br.w srorwos�coenee.ea,eo�.rsie�.w a a.y.�.�. �weyaw n�. tapy eftW+fa6eae�t my 6e hrwaMM M t0e Omta d Imatlptl�r d Ne DIA hrawf`e serNntlw !do hosby ' rnler peiea m�d fPerjwy M�Me iwfonwrlon prodAAed abeve 6 bve ewd esnect �B�rc —�o� LFS�b � Ptintname /�r- PhoneM Sb$36.�--SZ76`�L r�e6lmeo�ly MaNwAteilYbareabheaa�PkfedbYdl9�riPwn�1 dly or tawo: p�ltl�e/ Dc�r�mt ❑eheck i(i�1e re�sese h rtqeM ��6 BeW �Sdxl�a'a O�tt ❑F�1k�� eeahet pvaea: PM�e q; �014v c+�s,p..moof TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-099 FEE: $75.00 In accotdance with regulations promulgated imder authoriry of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a pettnit is hereby granted to: Pamela May&Dave Dugener, 720 Route 6A, Yarmouthport MA Whose place of business is: Biack Sheep Bah& Grill, Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31. 2005 BOARD OF HEALTH: Se�rain `.D. C�'oadoK, M._`15. ' p��f��t v� e� sen'rnvG: 36 outside Rod�,t 4. B�,.., � 56 inside d�fe% $�t�t, /1,/�, ��j� R.N. Febniary 2,2005 Bruce G. Murphy,MPH,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NCTMBER: #OS-067 FEE: $50.00 1'his is to Certify that Pamela May&Dave Dugener d/b/a Black Sheep Bah& Grill Inc _ 720 Route 6t� Yarmouthport MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwea(th respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ,/l3�e��S_ a. �' c `.�. (�aadt�ss, /yl.`.b. L��sain,ncais SEATING: 36 011YS1dC /'G(/(f�/��} v�qg e�GK 56 inside Rp�6�. g�y�!(� �!� �!�l�, R.M. � �j�. R.N. Febmary 2.2005 Bruce G. Murphy,MPH,RS.,CHO Director of Health . � �.,�3�3�1�✓ � � 3°fs"+.0 TOWN OF YARMOUTH BOARD OF H�ALTH �-d; �- � ��.. ", ' '��' APPLICATION FOR LICENSE/PE IT-2004 `��_ ` Ur� 0 1 2003 * Please complete form and attach all necessary doc �"�ts byDecember 1, 2003.. Failure to do so will result in the return of your lication packet. HEALTH DEPT. N MF. OF T LI MF.NT: G�k os�� ;�; I� �L�,� T .. #SDSt-��7,n4 LOCATION ADDRES S �r3-C� ��aLv � 1'� ,`Ia �u�� +-d. ii>� t �^�1� o z '7'T- ' c ER/ T N M 1 ER' ME: - '`' r MAILING ADDRESS: 7,� 0 c �l-P (n A y�,u-�n.to� `1--(-� �n✓ti M✓� oze'�S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. �. . _ _. L . .._ . __ . Pool operators must list a minimum of two employees curcendy 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 are required to have at least one full-time employee who is certified as a Food ProYection Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS 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 establishmeat. � j ��v._.i � 2. �� ,,.,,�1�� o. Nlc�-�-, , PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. � l� � )� ��51_n�s2.r/ 2�C o_k a �0.�-1 _ HEIMLICH CERTIFICATIONS: All food service estabiishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i._,�GlU� � k ): ,GP�Yt a.✓ 2. ��✓Y�2�1 C� E"��/ 3. 4. RESTAURANT SEATING: TOTAL#� wncuvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRBD fGE PERMIT# LICENSE REQUIRED FEE PERMIT N _B&B $50 _CABIN S50 _MOTEL S50 _INN $50 _CAMP S50 _SWIMMING POOL E75ea . _LODGE b50 - - _'fR�tFbB�-pA[LK. _,�.SQ. _._. �.__. _ WHIRLPOOL S75ea . _..__,.---- - -- FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRBD FBE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0.100 SEA7'S S75 �Q�? _CONTMENTAL S30 _NON-PROFIT 525 >I00 SEATS 5150 1COMMON VICT. S50 O� N�O�{p _WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PGRMIT# LICENSG REQUIRBD FEE PERMIT it LICGNSE RGQUIRED FEE PERMIT i! _<50 sq.ft. S45 _>25,000 sq.ft. $20(1 VHNDING-FOOD S20 <25,000 sq.ft. S75 _�ROZEN DESSIiR'I' S35 _TOBACCO S25 NAMECHANGE: $10 AMOUNTDUE _ $ /a,S, Ot) *""•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*"" ADMINISTRATION Under Chapter 152, Sec6on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernvt to operate a business if a person or company does not have a CeRificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � � Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces 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 ] to December 31. IT IS YOUR RESPONSIBILITl'TO RET'[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. AADITIONAL REGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openmg. 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 closmg. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or uridercooked 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 resuits 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 CAF�S• �utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. �iTDOOR COOKING: Outdoor cooking,pteparation,or display of any food product by a retail or food service establislunent is prohibited. ._ > i � DATE: 1 i I �l Ci SIGNATURE�— � � ��y� PRINT NAME& TITLE:��yy��F�r.� � , I�'�Czv� —�(t�%�'i r� -fr 10/22/03 � The Commonwea/th ojMassachusetls = Department ojlndustria/.-Iccidents ; Omeeollarest/Dsalsis 600 Washington Street Bosrox. Mass. 01111 ` W'orkers' Compensa[ion Insurance Affidavit ARnlicant informafion: p► n.�pRf1V'1'T�sc��y n�ms� �l�il( K� JYl� � p 1 �G-C�V 1 � �V�i� �� J/1/l� n ��n�—��c� Y �� lo✓-I cit� I�R�YNIl�r�� O�fi ehen p ��-��-��,� � I am a homecwner pzrtortning all work myself. � I am a solz proprieior _r.,�. ha�z no one «orkine in am capaciry� � I am an employer pro�idingµorkers' compensacion for my employees workine on this job. m an � .ti✓T �d i I (� Si:.V-[< ✓1 LR CSYYId�/�-� adAress: 1 �(1T i�6� �'P �Ptf I�-� � ""f � �i<v: I�Piz) f-1�t,�'-I- �tJYC�. pno��a• �7� l.l�? Y� K I-i�i�1`�`' . i�1;u�ance co. nolity q [ J� LA� �� I�� I am a sole proprietoc general cantraetor, or homeowner(circle anq and hace hired the contractors listed below uho ha�e the follu��in_ ��orker; :ompensation polices: comoanv name: - - -� � address: ��n'� ehon �• insurancc ro. peliev# s9meany name: tddresr titv: � Qhoes�• insurante co. mlin M 1 F�ilure to seeure covenge�s requlred uoder Seenoo 25A of MGL lS2 u�Ind to Me i�paidw of cri�i�fl peultle of��e up to f1�00.00��d/or ooe yan'imprisoameat n w�Nl u eivil pendNa io the[orm of�STOP WORK ORDER�ed i Ilee otS100.00 a A�r�pinrt s� 1��denn�d ti�t■ eopy of tAif sutemrnt m�y be(onvvdtd to the 011ice of Inve�tlg�uom o(IEe DIA for emn�t veriOpW�, � � � 1 do�hrreby cert' • der rhe 'ns and pertallier ojpery'ury�hat the injormation provided abavt is dut and rnnteL l'Signamre �� I—�� 'U � , 1� C�p Printname � Jl � �'V ' U �r pMg ,��`�7) '`U�� .. aRcial use onl�� do not.rite in this area to be completed by ei�y or torva ollleial eity or town: Y�M�DTQ _ .permiMiteme M nBuildioe Dep�rtmeet � �Lieemioe Board � che[k if immediatc responst i�requirtd 261 �Seiettmen'f Ofllet (508} 398�?231 pat. �HeiltE Dep�rtmeat , conuct person: � pAont M:_ __ _ nOther NOTICE . NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts � DEPARTMENT OF INDUSTRIAL ACCIDENTS � � 600 Washington Street, Boston, Massachusetts 02111 �, 617-727-4800— httpJ/www.state.ma.us/dia � As required by Massachu�tts General Law, Chapter 152, Sections 21,22, &30,this witl give you � noti�that�(we) have provided for�yment to our injured�np�oyees under me above � mentioned chapter by insuring wMh: m O HARTFnRI] FTRR TNSiiRAN("h' (`AMPA N N NAME OF fl�ISURANCE COIiPANY � 0 4401 ILiDDLS SSITL�P gD, � l�IP BARTPORD �,v 1�dt'i — ADDREffi OF INSURANCE COIi1PANY a OR WEC icci99da �POLICY NUMBER OS/01/03 � EFFECTIVE DATES O 'L�S �NAME OF INSURANCE AQENT ADDRESS PHONE � �BLACR SFIEEP BAH & GRILL, INC THE =720-7�� ROirr�? 6A vnRi,rnjrru nnum pra n��5 =EAIPLOYER ADDRESS � _EAIPLOYER'S WORI�RS COMPENSATION OFFlCER(�ANY) DATE � MEDICAL TREATMENT _7hs abo�re namea iro�.ar is requirad ��p of personai inj�wiea ar�g o� of�a 's�8w earae of emptoyn,eM to �Canp�enssVwn Act. A�� m�d modical servl� n axoMan� wflh fM provbbns � the Worlars - Re�wrt � In'ryry m� be ghren to tl�e injured empiopee. Tha emP� �Y =sehct fds or her orim physicimf. it�e►eesonabb�of tl�e a�vkes providsd 6y U�e 6'etlin9 PhYskian will be paid bY a the �sY►ey � 1lts tr�t is nec�sar�r and reasonaby conneeted to ihe wak ►elated aryis�t. h c�es re�iHng �hosPf��at�On,omPbYees are FMreby no�ifad tliat tlfe&�surer has artangsd for such ai[entlon at tlfe � � �NAII�OF HOSPITAL ADDRESS s , TO BE POSTED BY EMPLOYER �,,,W��, � �,�m�.s.a. TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHIVI�NT PERMIT N[JMBER: #04-047 FEE: 75.00 In accordance with re tions promulgeted under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the al Laws,a permit is hereby g anted to: Pam May/Dave Dugener, 720 Route 6A, Yazmouthport, MA Whose place of business is: Black Sheep Bah& Grill, Inc. Type of business: Food Service To operate a food establishmem in: Town of Yarmouth Pemrit e�rpires: December 31, 2004 BOARD OF HEALTH: B�$. (�'o�loirY M.$. ' /��a�b�ii�c"�k� Mo ?/iw L�fiattirwic 3EATIIdG: 36 OU1sIdC R06�W[i �. B-ZOLU� 56 inside m�e�i� e��i�iy �Q./y. December 3.2003 < <- � � /y Bruce G. Murplry, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-036 FEE: 50.00 This is to Certify that Pam May/Dave Du�ener d/b/a Black Sheep Bah& Grill, Inc. 720 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-6rst 2004 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the Gcensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Bo�n oF�ar,�: ,6� �. (fo�, M.�. el,o�,.,�.� 3EATING: 36 OUtSlde A�af�� v� e� 56 inside Qo�s3t�!. Q9�ruy4rs� � � R.M. ,� � Decemba 3_2003 � u �`' ruce G. M hy,MP y .,CHO Director of Health - ``�'��`�� e�ac�SH� � 3=o r qy TOWN OF YARMOUTH BOARD �F�?i�,TH f �� _ � "C�� APPLICATION FOR LICENS -2003 ,j�p�� !� � " `-' u � �� 3�� '� `�2 ZC�� * Please complete form and attach all neces s�+c t�t p t e ts by Dec r , 0 . Failwe to do so will result in the returri b�you�application pacl�etF��p;�;�-:-� �;c r��-, T• g i/ — - �-Y L A I o MATi iNG A DRE S• n� o T �' i � ' � T . # 'a - "1-S I MAii.TNG ADDRFSS: y.1 �a� cQ �}A ) .�(c��'MO�+'�1, M,i� O Z(o'�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated —P�1)gerater(s)aed ettaeh acopy ofihe certificaUon to this for�n. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitadon (CPR). Please list these employees below and attach copies of employee certificarions to this form. The Health Department wiR 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 MA1vAGERS - CERTLFICATIONS: 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 Aealth Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. �[JGLil i!� � ) . !J UG Q,bt Q � 2`.-�!� ' �P.l G2 1'f , f V\al.�-1 i PERSONiI�1-�HA,RGE: _ - _ _ Each food establishment must have at least one Person In Chazge PIC)on site during hours of operation. i.�ou�.i <A (A� .�u cp.u_Q�( z. . ` e�— 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 a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifica6ons 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. l. 2. 3. 4. BESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&.B $50 _CABIN S50 _MOTEL $50 _INN $50 _CAMP $50 _SW[MMINGPOOL$SOea _LODGE $50 _'I'RAILER PARK S50 _WHIRLPOOL $25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQ[JIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 Q�O�3 _CONTINENTAL $30 _NON-PROFIT S25 >10(1 SEATS 5150 I COMMON VICT. $50 �6,?!'Q`'�S WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _TOBACCO $20 _CL5,000 sq.ft. $75 _TOBACCO S20 <50 sq.ft. $45 _>25,000 sq.ft. 5200 _FROZEN DESSERT$33 �vnMEcxnivcE: sio AMOiJNTDUE _ $ 125.00 •***•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*** � . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a bnsiness if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHEB V _O$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taa�es and liens must be paid prior o 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�vfEEN1'S ARE TO CONTACT Tf�HEALTH DEPAR'I'MEN'I'FOR INSPECTION 7-10 DAYS PRIOR TO OPENINGFOR 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 OPEPTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , ,. __ .� DATE: C>c�- SIGNATURE: �� ' PRINT NAME&TITLE: I�q„n t-�.� � 1�' �� -. ��S, nc;�� 10/18/02 • - , �\ The Commonweallh ojMassachusetls : = Department oj/ndustrial.-Iccidents ' ; OlAesol/aresUysWis 600 Washington Streel ' Bnston. Mass. 01111 ` '��'` �1'orkers' Compensation lnsurance Aflidavit mm� _f.��Q � `L S lT��r`-' 13�f� gC-12 i l_� locmion �� ehone M � I am a homecwner pen�rtning all work myselE � I am a solz proprietor �r.� ha�e no one ��orkin� in am capacin• ��-fa�� __ I �m an empioy�c�n�iding uorkers' compensation for my empl�kees warkine on[his job. � comnan�� name: address: cih�: ehon p• insurance co. eolicv k � I am a solz proprietor. general contractor. or homeowner(circle onU and have hired the contractors listed below ��ho ha�e thz follu�cin_ �corkrr tompensation policas: somoanv name: address• citv: ohone M• insurance co. policv M tomoanv name: � �---- ---� — . _ _ . _. . .. ._ _ _ . .___ _ __ - ___ _ . . .. . . _ iddrcer tiri: phoee Me insurance eo. oofln N e F�ilure�o smure cover�ge as requ�red ueder Seenoa 25A o(MGL 152 n�lad W IAe iepailio�Meri�iol padtln of a O�e op w 51300A0 ud/or one yan' imprisonment u w�ell n eivii penNtln io tAe form of�STOP WORK ORDER asd a Ifse of SIOB.OS�d�y qdatt mn 1 ndeoh�d thu� topy of thy statement may be fonnrded to�he 011icr o(lovati`�tiom of Me DIA for eoverf�e verilfutlo�. I do-hrreby ceni • er t r ins and prnalti�r ajperyury�ha rht injormation provided abovt Is true and coned /�$ignaturc 1 �2/�y / � n c� Print name �.�yL.vt i'C . M �'� Iq�p�e M ��—36 Z— $Z-�C� —I .. aRcial use onl�� do not write in this trea to be eomple�ed by eih or to�vn ollltial eiry or town: Y�H�DT$ _ permiNieeaee a n8uilding Departmeat � �Licemio6 Board p chrck if immediate response i�required 261 �SeleetmmS ORce (508} 398-2231 eat. �Hultb Dep�rtmmt , ron�act person: pAont N;_ nOther NOTICE INOTICE TO TO EMPL4YEES ENIPLC)YEES The Commonwealth of Massach usetts � DEPARTMENT OF INDUSTRIAL ACCIDENTS �, �, � soo wast,,,,�or,s�reer, �cor,, �us�oz,,, sn-rn-a�oo � As requirod bY IAassach�Generai Law,Chspter 15$Sectbns 21,22, d�30,ihis w�l give you � notioe thst 1(we)have providad for payment to our Injured�loyee s w�der tl�e above � menUa�ad dwpfsr b1l��9�� NHARTFORD FIRE INSURANCE COI�ANY �., NAl1E OF�SURANCE COMPAli11 0 0 � 4401 MIDDLE SETTLEN�NT RD• • �N6W IiARmFORn ADDRESS OFlIlISURANCE COYPANII � �OB NEC RH9944 OS/Ol/02 �pp�y�p EFFECiNE DAT6S � � � n��7 �N�IIIE OF��RANCE AGE� � — PFIONE � � �BLACR SHEEP BAH & GRILL, INC THE �720-722 ROUTE 6A YARMOUTA PORT ZA 02675 �EIAPLOYER ADDRESS � ! � � �EMPI.O1fBi'S WORKERS COMPENSAt10N OFFICER(�ANY) DATE � � WIEDICAL TREATMENT �n»,bov.n�»a In.u.r ts rp�rna in eaa.a v«.ad Y*ri�a arMig oue a.ea In t�.ow.a. a«nploynwnt�o �panhh a�NqWb and t�notibU hap�l and m�dfal serrii.w In aeoo�d�no� rNh 16s provbbm d tlis Wa1aMs �C.a�wtlon Aat. A wpr d 1M FFat R�port of fnJuy muN b� 9iwn fn Ihs �e'ed e�aplo�yw• T!M�ployN mry �Mlad fAs or har oMm physidan. The nMombN ooa o/1M aarvices Pr'ovfd�d by tl�s trw tlng pl�yaicdn vrlM b�p�id by �1M iau�. if Uw traa6Mnt ia r�ry and rw�on�by oo�r»cE�d b fIM work rN�Md injiry. In oara nqulring �ha�piW atle�ion,�pbyNs ors IMnl�y notlfNd�t M�s Murr has anarg�d far a�N�a11 M�Ifon wt 1M � � � —NAI��HOSPITAL ADDRE88 � TC? BE POSTED BY EMPLOI�'ER Farm WC 8B 20 Ot B Prin�d in U.SJ� THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-048 FEE: $50.00 This is to Certify that B1ack Sheep Bah&Grill. Inc. 720 Route 6A, Yarmouthport, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only andexpires December thirty-Srst 2003 unless _ -�ooners�spended or revakeci�'or vialatiarrof the-laws of Ehe Comuionw�lth respec�iBg-th� ---- licensIDg of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140,and amendmeirts thereto. In Testimong Whereo�the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �lia�rlea i�, xdlGF�. (,�iEa6ureaK saw'raaG: 36 outside �. Cdtde�c. �ll.`I�.. `l/lee �airuks.� 56 inside r�1��fo�. �¢att�, �Ot� � nr�Q�tfCk[��C4M�tas� .. . ff J�. ,rp. . Decamber l8 ,2002 . . . . � .. . . .. . I'Uc lll'f1 , ., .. . . Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-073 FEE: $75.00 In accordance withr��ons promulgatad under suthority of Chapter 94,Sedion 305A and CLapter 111,Sectioa 5 ofthe�ieneral Iaws,a permit is hereby granted to: Black Sl�ep Bah&Grill, Inc, 720 Route 6A, Yarmouthport MA VJhose place of business is: Black Sheep Bah&Crrill Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2003 BOARD OF HEALTH: e4anlea�. ze�Oc, �:Fa�irwca.� �u�a«�t�c D. �o:das 7ilt.D.. ?/te� sEn1'INc: 36 outside ,��q�'�', �, (/,�q,� 56 inside �J��p� :f� Ska .7Z. Decemberl8 ,2002 G.M 1 , ,CHO Director of Health - ' • 6�acacS�P `3aN : � ,- :�,r WN OF YARMOUTH BOARD OF HEALTA � PLICATION FOR LICENSE/PERMIT -2002 � a� � �`'q?u'"i3"I ��3. � ' • Please comp ete form and attach a11 necessary documents by December 31, 2001. Failure to do so will result in the return of your application packet. NAME OF ESTABLISIi1�1ENT• �L 1'1-ee� 0..h ��ri 1 I TEL #SD$3G,a-S'a0y LOCATION ADDRFSS• ��C7 2�c ,t-e ln1A ��l[,urwtc��`W+ �o r i- i htl'� MA DRESS: � ��e.. OWNER/CORPORATION NtLMF• 1� Cl� r. Sh��P� Ba.h 4 C.� r�I.(� Zv,� MANAGER'SNfLTvrF:�n.� ��.1 UJ. 17�,a� l TEL. # Sa��3ba�ao�{ MAILING ADDRESS'�.ZO eo.�t2 i L4 �li�rvuo�,�M 'P� r 1—� M WF 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 cunently certified in basic water safeTy, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1.�14V I n � . �vG-P�n�t' 2 "f CA�m�� I� � V� 0.�-i PERSON IN CHARGE: ___ _ -- - - _ ___--- --- ----_. Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1�1�1 V 11� l� . �V G�.�,�� y 2�G�,►'y��.G� 14. V✓� c��-1 HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1.�v�V�t� � , ��S-e.v�-e�✓ 2.��.�-e r �o m c�n O 3. `L ct.-,-,.v l� i�1 . ✓�'1 c.-�� 4. RESTAURANT SEATING: TOTAL#� `" OFFICE USE ONLY LODGING:�'t�, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $9d�... CAB[N $50 _MOTEL $50 INN $50� � �� - CAMP $50 _SWIMMINGPOOL$SOea � LODGE $50 � TRAILER PARK $50 WfiIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100SEATS S75 OZ�Op _CONTINENTAL S30 _NON-PROFIT $25 >100 SEATS $150 1COMMON VICT. S50 �-QO�� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQU[RED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO E20 � <50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAmEc[taxcE: sio AMOiJNTDUE _ $ /2S- (70 *'"•**PLEASE TIIRN OVER AND COMPLETE OTHER SIDE OF FORM**'*' .' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: / YES ✓ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLIS�IMENTS 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 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 Far 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 aze 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. FR07.F.N DFSS .RTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepaza4ion,or display of any food product by a retail or food service establishment is pro6ibited. DATE: �Z I� d 1 SIGNATUREL/-/' � l�' PR1NT NAME&TITLE�A-rv�v�i.�V IF} , �I f�'��d�m"� � 09/11/Ol .. � \ ' The Commonwea/th ojMassachusetts = Deparlment ojlndustrial.-lccidents ; O/11Ce01/OYCSllyfl/Iff 600 Washington Slreet ' Boslon. Mass. 01111 ` '�� '` Rbrkers' Compensation Insurance Affidavit Aoolicant informallon: Pfea�ePRI1V7"4r.7d� nlmc location ��t� phone p � 1 am a homeoµner pertormin�all work myseif. 0 I am a solz propriecor ar.� ha�e no one ��orkin_ in any capacin� �j I am an emplocer pro�idinsµorkers' compensation for my emplocees workine on this job. comnan?� name: �lC�l-�.� �� -�T , � ('1 ( j. I , � address: !:�i Y I��% I '�- `{i 1 l tih�: � Ar �� n y/i"V 1 1 �% �-I .- f"I I"1 ehone p: � l.�C�'��,r� '�.�� I � �/I• `� G'1 '7�� insurance co.�C,i� i�n �`��-ci ,� ��:dt,v��i�� .i1 oolicy p �� l.� L� l � �. �_}, .C.� 1 � 1 am a solz proprietor. ;enerai contracmr, or homeowner Icircle onel and hace hired the contractors lisred belou ��ho ha�e tht follu�cin2 ��arkar> ,ompensation polices: comoanv name• addresr " � � citv: ohone M: � � insur�nce co �olicr# m n nam • .aa��3s• eiri: � ohoee B: � inenrenrw rn pp�hr M _"_ _ ' Failurc to secure covenee as:requlred uoder Secnoa 25A of MGL 152 n�lud[o Mt inporiOw oterid�l peultld ot��e ap m 51300.00��d/or � oae ye�n'imprisonmrnt a�w�ell a�eirii pendtla io the torm of a STOP WORK ORDER�ed�Oee of 5100.00 i d�7 q�iert ma I ndmn�d tL�t■ copy ot thu sntement may be fonv�rded to the Ofiiee of love�ti`�tiom of the DIA tor emera�e veritiatlo�. � I do�hrreby c '}•un er thr pains and lies ojperjury 7hat the injonnarinn providtd abovt is dut and corrret / Signatut� '�� L � Printname �1� I`��1� � � oneM �7) t��—:�(�:�:-1—��'G �{ .. ofTicial use only do not wri�r in this vn ro be rompleted by eih or lowa o111tiN ciry or town: yA��DTQ _ permiNiceeu N nBuildioe Dep�rtmcot � �Litmsio;Boud Q check if immediate response if required 261 �Stlettmen'f ORee �Hnith Dep�nmeet � ron�act penon: phone K:_ �SOE� 395�?231 eat. nOther : . � NOTICE NOTICE �O TO EMPLO�EES ` EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIA►L ACCIDENTS 600 Washington Street,Boston Massachusetts OZlll 617-727-4900 As required by Massachasetfs General Law,Chapter 152,Seckions 21,22 30,this will give you notice that I(we)have previded for payment to oar injared employees nnder the above meetioned chapter by insuring with: Eastern Casualty Insurance Company (Name of Insurance ComP�Y) 325 Donatd J. Lynch Blvd.,Marlboroagh, MA 01752 (Addcess of Inswance Company) WC99 493002 08-01-2001 TQ 08-01-2002 (Policy Number) (Effective Dates) Bryden & Salliv:n Insurance Agency,Inc. 88 Falmouth Road,Hyannis,MA 02601 (508)775-6060 (N�e of Ins�uance Agent,Addrcss,Phone) _ Black Sheep$ah& Grille,Inc.DBA TLe Ssad Wedge 720.722 Roate 6A,Yarmouth Port,MA 02675 (Employer,Address) Employets Worlcet's Compensetion Officer(If Any) (Date) MEDICAL TREATMENT The above eamed insarer is required in cases of personal inja�ies arisiog aut of aad in the conrse of employment to fnrnish adequate and reasonable hospital and medical aervices in accordance with t6e provisiona of the Worker's Compensation Act.A copy of the First R�porE of Inqairy must be given to the injured employee.The employee must select his or her own physician.The reasonable coat of the services provided by the treatiag p6ysician wili be paid 6y-insurer,if the treatment is necessary and reasonably connected to the work related injury.In cases reqairing hospital attention,employees are hereby notified thatthe insarerhss arrnnged for snch attention at the (Name of Hospital) (Addnessl TO BE POSTE� BY EMPLOYER WC 7506e(Ed. 1-89) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiTMBER: #02-008 FEE: $75.00 7n 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 ganted to: � Black Sheen Rah &('rrill inc„ 720 Rnute 6A Yarmouthnnrt MA Whose place of business is: Black Sheep Bah& Grilt Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2002 BOARD OF HEALTH: �. ZePli�, . D. C�mide.� .�iee sEn'nrtc: 36 outside �o%rt`3. S'aotaic, elatk 56 inside � �7J��0�rxo �) January 24 ,2002 t� ` B ce G.Murp y,MPI-{ .,CHO Director of Health / THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTA PERMIT NUMBER: #02-005 FEE: $50.00 Tlvs is to Certify that Black Sheep Bah& Grill Inc. d/b/a Black Sheep Bah& Crrill 720 Route 6A, Yarmouthnort_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornvty with the aut6ority granted to the licensing authori6es by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �ia3lee '�f. Zdli�iei, �raia..raa ssnrwc: 36 outside �ewc' D. Cjoadaw 7Il.D.. `�/r,'ee �ravr.xa.c 56 inside �a� S^'7oawt. � �a8ue� e January 24 ,2002 ' � ruce G. urphy ,R.S.,CHO Director of Heal � �� Skn1D(�r1c—D�i..c- , TOWN OF YARMOUTH BOA . �'�EALT�v' `� � �' I'' � i_; APPLICATION FOR LICENSE/P�I�MI'f�-3001 DEC 0 1 2000 , �W_ • Please complete form and attach all necessary documents by December 31, 2000. Fail HE LTH D PT, in the return of your application packet. --------------------------------------- -------------------------- -------------------------------------------------------------- NAME OF ESTABLISHMENT: �a�. (�2a��-,.r i I I TEL. # 3(c�-5bo�-( LOCATION ADDRES4• '1?� �te_ (o A M�ii.ING Ai�D1�F.44• OWNER/CORPORATION NAME: gI c.r.IG �.b.zeD ga.h �L-�ri�n�. MANA('iF.R'S NAMF.� �A�fi 7 , �Duc,.in-Lr TEL. # -1�75-�1 fC MAiiINGAi�DRFS5: �-lZ Br�nd�nrc2 12c� ,�A�,Ya-rn.�ou4-�. MA c52b73 ------------------------------------------------------------- ._____ __--- -- POOL CERTIFICATIONS: 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 of the cert�fication to ttus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deperlment will not use past years' records. Yon must provide new copies and maintain a file at your place of buainesa. 1. 2. 3. 4. HELMi.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 iist your employees trained in anti-choking procedures below and attach wpies of employee certificadons to this form. The Healt6 Department will not use past years' records. You must pmvide new copies and maintain a file at your place of business. 1.. �t�-(2-FF '"�OVI.If-1�-1 2��c�V l� �v'��x.,�.R� 3. a,w`p l�n„—'Vv��.�-�i 4. RESTAURANT SEATING: TOTAL# NON-SM�KING SEATS: TOTAL# ------------------------------------ ---___--- - ---- _--------------- ---------------------------------- OFFICE USE ONLY LODGING• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protecHon manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# / 0-100 SEATS $75 �'�1-Ob _CONTINENTAI, $30 >100 SEATS $150 NON-PROFIT $25 / COMMON VICT. $50 —003 _WHOLESALE $75 BETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<L5,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 �IAME CHANGE: $10 AMOiJNT DUE = S �zS.Oo ••'*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•«*•* � ; - J ADMINISTRATION Under Chapter 152, Sec6on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � / WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE:Permits run annually from Januazy 1 to December 31. IT IS YOUR RESPONSIBILiTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLISHI��ENTS ARE TO CONTACT THE HEALTH DEPAR'TMENT 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 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,pnor to openuig,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NFW cTATE S?L1vITtLRY CODE FOR FOOD ESTABLISHMENTS• The effective date for food protection manager certificarion is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establislunents must haue at least one person-in-charge who is a certified food protection manager. �s 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 3-603.11,will be immplemented January 1,2001. Only establishments which sell or serve ready-to-eat, raw or undercooked azumal products aze required to have consumer advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Depariment. FROZN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�st have prior approvai from the Board of Health. OUTDOOR COOHING• Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. DATE: I 1 � 0 0 0 SIGNATURE: PRINT NAME& TITLE��rr��yr ,� K� . M �'-f — P�2G-5� i�G�-+T 11/16/00 ' ' , ` � The Commonwealth ojMassachusetts : Department ojlndustria/,�ccidents 0 9!llceol/er�sl/Dsdiis � 600 Washington S�reet Bosfon,Mass. 02111 " W'orkers' Compensation Insurance Atfidavit ARplicant information: PieasePRllaTk�'hit n�m�•' �� L.� ��v�ir/Y/ kJ� Ll/! 1 `S �/�,r l � � Inr�ti�n' � F..-�1 Ww � 1'� �� T (q'2._M O U`�-'yl 1 b �� ehone N J�t��.3�002-�b� Y � i am a homeowner pzrtorming all work myself. � ( am a sole proprittor �cd ha�e no one «orking in am capaciry (y'+�I am an employer pro�idin�workers' compensation for my employees workine on this job. �m an �n m • ir U � � � GW� wh �R �ddress� � I /YlOU�''� 00._�- - Ljl, �• F-�'v1 Gli{71'1 I� � phonep: �U �� 'l9d �o l� insur�nce co �CI.S'�-P ✓I'1 l CI.SIJ� � Cpolicy k � L � l -1 l ��U � � I am a sole proprietor. �eneral contractor. or homeowner(circle one) and have hired the contractors listed beloK �rho hace tht follo�cin_ �corkzr :ompensation polices: companv n me• - ^adres • ��p�• ,Dhone k• . in s u r�nte co po��'� comoanv name• - - � - - -__ . _ _ ._ _ . . .. . . -- . _ . _ . __ . ._ . - -- -.__ ._ . __-- -- - addres • �• otioee p• insurance co po�M Failure to secure coverage as required under Seetloa 25A otMGL I52 ue Ind to t6e inpaitlw of erisivl peultla of�B�e ap lo f1.500.00��d/or oae yean'imprisonment�e w�ell aa eivil peodHn io the[orm of a STOP WORK ORDER�od�Ilee of SI00.00�day qaiost me I aWenb�d Hat• topy of thia ehtemrn�may be for.v�rdM to the ORce of IovnHg�Bom of t6e DIA for eovengt veriRutlw. � 1 do�hrreby ij}•under the ains and penal�ies ojperjury that�ht injormotlon providtd above Fs tnu and toned Signaturc � ��I�00� Printname � I'T . M� oneN��S' �l�a-'S�U`I . oRcial use anl�� do not wri�e in�his�rta to be completed by eity or town ollleial ciry or town: Y�M�DTR _ permiNieenx N nBuildiog Departmee� pLieensiog Bo�rd p check if immediate response is required � 261 OSelectmen'�ORce �H�alth Departmeol con�act person: Pha��p;_ �508} 398—?231 eat. nOther Un�iscd i;95 PIAI Black Sheep Bah & Grill 720 Route 6A Yarmouth Port, MA 02675 Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664-4492 Attention: Health Department Subject: State Sanitary Code On November 13, 2000, David Dugener and myself attended an approved course for certified food handling in which we took an exam after completing. We are waiting for the actual certificates at this time. Th ou, Pamela A. May THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O1-003 FEE: $50.00 This is to Certify that Black Sheen Bah& Grill. Inc. d/b/a Black Sheep Bah&C.rill 7 0 Ro � 6A Yarmrnrth nr MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December tlurty-first 2001 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. Ttus license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signahues. BOARD OF HEALTH: $d'lll. �etles, ekaur.xa.a sEnTwG: 36 outside 's�. 'Xdfl/sas, �/iee (�qec 56 inside a�att�, fa'zorwc, e(er� �1Zielrad O�ou��ll�c 5' it.xGc oR . � Decemberl2 ,2000 ruce G.Mwphy,MP HO Director of Health TOWN OF YARMOUTH BQARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-003 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I I 1,Section 5 of the General Laws,a permit is hereby granted to: Rla k 4h n Rah & ('rill Tnc 720 Ronte fiA Yarmonthnart h�A Whose place of business is: Black Sheen Bah& Grill Type of business:_ Food Service To operate a food establishment in:_ Town of Yannouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d 711. �ellea, Lkadr.�ra,c e��. z�, v� �� SEATING: 36 outside ��t� ��, LJ� 56 inside 'jj�Q;�� D. C�o�d,�, 9 D. December 12 ,2000 V `��-'u-C-�'_�� Bruce G. Murphy,MPH, .5., O Director of Health n � d J Q � � � o �, � � � � m �� a � � _ � � �' o � m m � °° � a = � o yo � U7 �n � o d fl. � � � } � � m d � D ��q, pq�� Q � � � � �! 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