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Home My WebLink AboutApplications, WC, Licenses Prior to 2010 _. ,}; �' < k�.X.Ge,�� TOWN OF YARMOUTH BOARD OF HEALTH � : i� t t' � 1< �� APPLICATION FOR LICENSE/PEI�VIIT-2009 ' \�,�� J ; �� * Please complete form and attach all necessary document`s_by'-�ecem��2BB8: � Failure to do so will result in the return of ycsttt apphcahon packet. NAME OF ESTABLISHMENT: dS ��'vt�t- � I � TEL. # S�d'' ��`! �`�� LOCATION ADDRESS: 6 2_ � � /c S y,4'/�/!rc �+-�/i G[�6 � MAILING ADDRESS: OWNER NAME: �9.J�l�i A>"� ✓�� /I.a1�-� TAX ID (FEIN or SSNI: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: / , ..o ,.c,/�-� TEL. # �d'' 6 - �-S J MAILING ADDRESS: G 'L ��.S.d� �4/�Mu , ✓'�l f�. � �� POOL CERTIFICATIONS: The pool supervisor must be certified as a Poo(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 cwrently certified in basic water safety, standard First Aid and Community Cardiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies ofemployee cei7ifications 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 requn•ed 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. /�l/j ��i �°i!.-t ��nA )✓ 2. � PERSON IN CHARGE: Each f'ood establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �,1 ��iA•`1 /i'!J/��J 2.�i✓iC�QiCel? �:./t��*'/`� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all tnnes. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to tlris foi�n. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. � � l/,a-y ,/�,�r�rv,�-� a. �- �.ti. ✓�Corto+�/ 3. S„ � ,�r �2�.�✓ 4. ��., n �;z.�✓ RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIVG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItbD FEE PERMIT# LICENSE REQU[RED FEE PERMIT k B&B S55 CABIN S55 _MOTEL S55 IIviv S55 CAMF S» _SA�IMNIINGYOOL 580ea. LODGE S55 IRAILERPARK SI05 _WHIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT t? LIGENSE REQUIRED FEE PERMIT H �0-100 SEATS S85 �O�j^l�J _CON7INEN-IAL S35 NON-PROFII S30 >100 SEATS 5160 1 COMMON VIC. S60 '� �bS�I _WHOLESALE S80 RET91L SER�7CE: —RESID.KITCHEN SRO LICENSE REQUIRED FEE PERMIr# LICENSE REQUIKED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# vOsq.ft. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25 <25,OOOsq.ft. S80 _FROZENDESSERT 540 �ACCO SSi v.a�7E cx,��cE: sio AMOLTNT DUE _ $ � � � � FFtt*•pLEASE TL'R\OVERA\'D CO.�IPLEIE OTHER SIDE OF FORVI**`"* r-, � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES ier NO MOTELS APiD OT`HER LODGING ESTABLISIiMENTS TRr1NSIENT OCCUPANCI': For purposes ofthe limitarions ofMotel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vc(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days pnor to opening. PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TEST'ING: 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 Yarmouth must notify the Yazmouth Health Department by filing the requued Temporary Food Service Application form 72 hours prior to the catered event. These forrns 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 have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking, prepazatioq or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRI:D FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHNIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COIvIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: Z �j �' SIGNATURE: � � l�� PRINT NAME&TITLE: ��r�R � ,� F Yc— io�z��os AI:AI:11. CERTIFI��i'E t�F iM$�iRL1N�E; �.-: ' �^h�M��,m ' • � . .. , . ,. „ :: � �: .: �5-2, �8 vnooucEn THIS CERTIFICATE IS ISSUED AS�A MATTER OF INFORMATION �� LOVEQUIST-MURRAV INS � HOLDER �THS CERTIFCATEIDO 5 NOT AME D,CDRENDAOR a0 eoX a8 . ALTER TH�COVERAGE AFFORDED BY TNE POLICIES BELOW. WE57 DENNIS MA 02670 COMPANIESAFFORDINCaCOVERAGE � - � � � COMPANV 755CH - A TRAVE�'ERS PROPERTV CASUALTV COMPANY OF AMERICA INSUREO ' - � - � , COMPANV � . MORAN. WILLIAM D6A . - � ' 8 . BASS RIVER GRILL ' 62 HIGHBANK RD - . COMPANY . 5. VARMOU7H MA 02664 � C ' . � � COMPANV D COIFERAOE6 THIS IS 70 CERTIFV THAT THE POIICIES�OF INSUqANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED, NOTNITHSTANDING ANY RE�UIREMENT, TERM OR CON�ITION OF ANV COMRACT OR OTHER DOCUMEN7 WITH RESPECT TO WHICM THIS � CERTIPICATE MAV BE ISSUED OR MAV PERTAIN, 7HE INSURANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO AL� THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � �� iYPE OF INSUqANCE POUCy NUMBEp POl1CV EFFECTVE. POUCY E1��ppT10N wrE�wr�no�m onh�eu�cam uri,s oexEnu uaeiur � - GENERALAGGREGATE g COMMERCIAL GENERAL�IABILITV PRODUCT$-COMP/OPqGG. g CLAIMS MApE�OCCUR. PERSONAL 8 ADV.INJURV g OWNER'S 8 CONTAACTOR'S PROT. EACH OCCURqENCE $ FIPE DAMAGE(Any one fire) g a MED.EXPENSE(Any ane person) a AUTONOBILE 11qgR17y ANY AUTO COMBINED SING�E $ IIMR ALL OWNED AUT03 SCHEOl1LE0 AUTOS BODILV INJURV �PerPereon� � HIREo aUTOS NON-OVJfJED AUTOS BODII.Y INJURY $ (PerA<cidenq . PROPEHfYDAMAGE g cna�c,f unewtr AUTOONLV�EAqCCIDENT $ ANY AUTO OTHER TMAN AUIO ONLV: EACH qCCIDENT g AGGREGATE § IXCESS WBIll7Y . EACM OCCURRENCE $ UMBRELLA PORM A6GREGATE $ OTMER TMqN UM9RELLA FOFM � � A WOHKEp•S COYPEN511TON qMp ENPLOven'SlueiU7Y (7PJU6-OO90M45-O-08) 04-08-OS O4-OB-O9 gTATUTOf�vUMRS j[ THE PROPFIETOW EACH ACCIDENT g PARiNERS/EXECIITIVE INCL 013EASE-POLICV LIMR g OFFICERS ARE: X IXCl p�ryEp OISEASE-EqCH EMPLOVEE ¢ � DESCItlP710N�OPEppTONS/LOCA77pM5�VEHIQEg/pESliXC710N5/SPECW.�YS � THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CEtC[tFICA7E HOLDER . ��`�� ... BXWLD qNY pF 7HE ABOVE pE$qaBED POl1dES BE CANCEl1E0 BEFONE 7XE �� F7IPIMTON 'UA7E 7NENEOF, 7NE ISSUING COYPANY WILL ENOEpVOq TOI�W� TOWN OF VARMOUTH 1O DAVS `�T� NOnCET0711ECERiffICq7EXOlDENpqA1EDT07HE 1146 ROUTE 28 IEFT. BUT FAIWpE TO YpR gUq� NOTCE SHALL IYPOSE MO OBl1GpTON 011 $Ol1TH YARMOUTH MA 02664 . ��uTr��'�NDUVONiXECOYPANN,ITSpGEIiTgpppEppEgFJ�TAt1VE5. AU7NqpgD flEPXESENTA7IV/E� � ACxliiD 25+5 C+�fs3} � i/ '�'� :_�A'i.`OEiD�OI�lrOt{A71Ch 99SS��. • FROM :LOVERUISTMURRY FRX N0. �506 76a 2211 Dec. 19 20a6 09�44RM P1 RightFax N1-1 12I19/2008 6:06:2z AM PAGE 31003 Fax Server ACORD_ CERTIFICATE OF INSURANCE narE�bw�ornvr� +z_ie-0e PROWCER TH13 CERTIFICATE IS 139UED pS A MAT7ER OF INFORYIATION ONLT AlID CONFERS NO RKiHTG UPON TNE CERTIFICpTE IAVfi(�UfST-MURRAY!NS HOLDER. 7N18 CEHTIFICATE OOES NOT AYENO,EXTEND OR PU IlOX 38 pLTER TH�COYERAOE AFFORDED BY Tlf POLM',IEg BELOW. COMPAN�ES AFFOftDINO COVERqGE WF:57'DEIVVIS.MA 112fi71/ COI�ANY 7�SCH A 7RpVELER3INtfhY'T ASti[CNMENr NSURED �ppNy B MORAN WILSdAM D.BA rP3 � - ,�, l3ASS AIVER GNLL C0IAPANY '- -� Fz�cxsnNK xp c �l�-� 1 g ZD08 S. YARMOLiTH,MA fl?l��q CO�aPlWv D covEenae HEALTN� DcPT. � iM66 TO CERnF1111ar rxE oOLrJEs OF M WR�NCE LIB�FD�I.M111�vE F�q1 NMIED TO 7HE IN6uREo 1YYED pBOYE FOR TNE VOUCv PEROU WpCOTED, NpiVAfV6TylqHp CNY R60VIRElIGNf�TFqY Op WNpITIpN pF ANr CONTR�Cf OR OTHFJ�ppCU�plF�y'M REBVECi i0 wW p�TM9 CERMCA�E NAr BE IBBYEU OR MAY VERT4K l�ff N9UR WCE AFFORDEU Bf THE VOUCIEE DEHGRIBEp NERENi Ib BUBJECT TO 4LL i11E TE111W�EI(CLU810q9 ONDCONpIfqNB OF BUCN OOLMJEe. Ll�IIT96HONN IMY H4YE 9FEx 4EDIICEO BY VAID CL�INB. co noucv� ao�cveuv LTR 7YPEOFINSIIR�NCE PouCYNUNBER DATE(MMIDUIY�) oA7E upuT9 OlNEqRL 41ABILITY OENERALAC7CiRE0ATE $ CDMMERCIALOENERAL pRODIK;T$�GOMp/Opq(30. $ CIAIM3MADE OCCUR. PEF,50NALRRIIDV.INJURY $ OWNER'S8$CONTRACTOF5P80T. EACHOCUIftRENGE $ FlRE DAMAOE(Any one Frn) $ MED.EXPEN3E(My aie�eon) $ AUTOYDBILE LIABILITY ANVAU70 COMBINEDSINOLELIMfr $ ALLOWNEDAUT03 BOOILVIWURv��pq�) � SCHEDULEAUTQS BODILVIWURY�PwfAoeklnq $ HIREDAUTOS PROPEAIyD/1MA6E $� NON�OW NED AU703 OARAAE IIABILI7Y ANYqUi06 AUTODNLY•EAqCCIDENT E OTHER THI�N AUib ONLV: ENCHACCIDENT � �C�RE6ATE � E1LCG65 LIpNLIT' UMBRELLAFORM EACN OCCURRENCE $ OTHERTHANUMBRELLAFOftM q0(3RE(3ATE $ WORKERS COMPQNSATION AND A EMPOLY�11'9�IABILITY UB-0080M450�OB 04•�-� O4p&OB $TATUTORV LIMITS X THEVROPR�ETOW EACHACCIqfiNT 3 100�000 PpRTNEftS�EXECUTNE INCL DI5EIl5E-POLICVUMIT S SOQ000 OFFICERSARE: X 6XC4 DISERSE-EACHEMPLOVEE $ �pp,DOD OTNER DESCKIVTION O!'OPlRATION7�LOCqTON9(VEHICLE9IRESTRICTION4�9VFCILL REN9 �l Ils k�:r�,�['n5 nrrv p��pF CCFTIFICATP[95UPD TO THE CPAlII7CA7E HCtlDCR At7Rtt'CINO wORKPRS COA�COV4R/LL3¢ 771¢woRK�!RSCUMPCNSA770NF0[1CY00E4N07PROV1DUC9v6kA(Y�FURnx'IxnN W11.,I;I�M. CERTIflCA7E HOLOER CANCELLATION aXOVID qNY OF11iEABOVE OE3CRI8E0 POLICIEu^BE C�NCELLE[I BEFOqE THE TOR'N ON YARMOU17i E%PIRATIUN D�iE THEREOF,TME I:Sl�INO COLIPAN�WILL ENOEAVpq TO GAIL+O PAVB WqITTEN NUIICE TOTHE CERTIFICATE HOI.DER NnMED TD THE LEFT,BVr 114�Rh�� FRILURE TO MAIL BUCH NQTICE 6NALL IMP096 NOoeua�nOH op LIAB�uTY oc flNVNIND UPhN THE IX7MPANY,ITH Af�ENT9pR REPRESENTF11VE3. SOUTH YARMOUTH,MA 02664 �Unro�a�D R@PR63EMAT�VE AcoR�zss(�rns) Charles J Clark' � FROM :LOVEQUISTMURAY FRX N�. :SaB 760 2211 Dec. 18 2666 12�61PM P1 ACORD CERTIFICATE OF �IABILITY INSURANCE °"�'""'°°'''^�", - i2 ie zooe �o�� (508)398-2282 FAX: (508)760-2211 THI3 CER71FICpTE 19 139UED AS A MATTER OF INFORMATION Oceanaida Ineuraace Gx'ou ONLY AND CONFERS NO RIOHTS UPON THE CERTIFlCATE P HOLDER. THIS CERTIFICATE DOE5 NOT AMEN�, EXTEND OR Lovequist-Murray Ineusanae ALTER THE COVERAGE AFFORDED 8Y 7HE POLICIES BELOW. PO Hox 38 Waet Dennia MA 02670 INSURERSqFPORDING,cOVER„AGE NAiC9 iusuwEo —'-.. ..... .... ._ . INSURLRAUBLI . ........ _... .__. ._.__.__—.. /?tt Vernon William Moran S Kevin Moran DHA: Baaa Ri.ver INSURERf�� 62 Highbank Road iNsurteR c: iNFUREp D; .... . _.._'_'___ South Yarmouth MP. 02664 INSUf2ERE: THE POUCIES DF IN6UFANCE LISTED BELOW HAVE BEEN I65UED TO THE INSUREp NAMED ABOVE FOR THE POLICV PERI00IN�ICATED. NOTYNTHSTANDING ANY REOUIREMENT,T�RM DR CON�ITION OP ANY CONTRACT DR OTHER DOCUMENT NA7N RF_SPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR AAAY PERTAIN. THE INSURANCE AFFOR�ED 8V ThIE P6LICIES pESCRIBED HERE�N IS SU9JFCT Tp ALL THE TEFMS, FXCWSIONS hND CONDITIONS OF SUCH POLICIES. q LIIUITS SHOWN MqY.;HB V,pq1R. INSRROG'L ryvEOF�N3UR/fNCE POLICYNUM6ER D4�TEYMMUDIVYE DATEMUD��N IIMITS cenEnn��wei4iTr 1,000,000 X COMMERCwLCENEWILUAHII.IN �N.M(iEi'OREM'EU rr;�hUSE5leeperermlcaL.�g— 100,000 A �cuiMsr.wuE C''�, occurt CP1127127 2/26/2008 2/26/2009 p�EDFXG wre �eon i 5,000 _ 5 1,000,000 .. , __.._..- � .�._.. ,GENERALAp6REUATE ,6 P�OOO,OOO GEM�AGGREGhTE LIMITAPPLIF.B PFR: r a 2,000,000 X FOUCV �r�� LOC ►pTOMOBILE LV191i.,IlY COMBMED SINGLE IINR ANVAurO (EaeccMent) S ' AILOWNFPA�17os BObfIYIN,IUftY � SCMEOULEDAUI'OB �PO��) ' .................... _. . . ....._"'"'____ _ hI��.RE0FUt0$ Bp�ILyINAURV ..- NON.OWNEDAUI'UB , (PCefApnl) E , —. __._..............___.'"_.'_' _ ._ ._ . .. _._ �; PROPFRTY fWMAf,E s ', �Pmccndnd) OARAOELIABIIIIV ...�'... qUT00NLY-GAC�IDC-NT s pNYAUTO nT�IF-ATNAN 't' AUi00NLY�. �GG F E%CESNUNl1RELW LIN&LIT' � ___.._. OCCUR fV�MISMA�E A_(n„G,REW7'E . . . .. ..__ $__. x oeuucne�e . _..._...__._.a a�reNnor+ s wortKER9COMPEN5Al1�NaND b'IAfU- ' OJH- EMCLOYFiiS'U�9141tt . L._...kf?._._ _... . ANVPROPRIFTONICNRTNEWEXECUI'IYt �'��. ELFACMqCCNENI' S OFFICEft/MEMtlEftE%CLIII1G09 � ' � � � � � � �� -'EL OISFFSE-EN EMYLOYFE 8 If�BB.deectlGo�mtic __. . _. ._'_.___"_ �"' E.L.DI3Ep3E-f'OUC LI S OTMER DElCRIP710N OF OVEH�TION9ll A:4TION$NOYIICLESIEIICLV910N8 Ap0E0 B�'EMDOR9EMENT9PECIA4 VROVISIONS �UO0.K.ER�S CoMP(��Nl:�JS�V � C�-R`ll�'tC'ATF UJ��-�- C'o�l� -71�R.�CTL.y �oM (��2_1 L�2 , CERTIFICATE HOLDER CANCELLATION SHDUL� ANY OF TNE AlOVE oesceiaEo PDLIGIE9 BE CnuCE44EU 9QFORE TNE TO➢7f1 OF YnRMOUTH expwanoru OPTE iHEREOF, T11! 18SUINC INBURER WILL EN�EAVOq Tp MA4 1146 RTE 2O 10 pqyg Wp�TTlN NOTICE TO TME CERTIFICATE NOIDER NANED TO T1E LEFT�BUi $�UTH YARMOUTH, MA 02666 FqIW RE TO DO 6O 6NALL IMVQ9E NO 08LIOATION OR LI?BILITY OF qNY qNP U►ON TIE INSURFRITS T6 RRePRESENTA 9. AVTMOWZEP !P E qVpE - X'! `�" A- _ _ ._ .._ ___ ACORD 25(200�108) OACOR ORPORATION 1BB0 INS0�5�oioe�.oee raoe i a� �5 lG' !S� .�' �' -'"�y TOWN OF YARMOUTH BOARD OF HEA =� ° APPLICATIONFORI.ICENS � '' �` APR '2 4 2008 f , � s �. : * Please complete form and attach all necessary' oc�nts tiy r� � J EPT. Failure to do so will re�lt in the retum your applicaUon packet. NAME OF ESTABLISHMENT: YL r TEL. # .SDd'— 'r/62'35�� LOCATION ADDRESS: L ,n„ C ' MAILING ADDRESS: �� OWNER NAME: o..�N CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ./ � t✓ TEL. # 0 — — ,sjj 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 certiScarion to this form. 1. Z, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Piease list these employees below and attach copies ofemployee certificarions to this form. The Hexlth Depsrtreent will not use past years' records. You must provide ne� copies and maintAin a fde 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 deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Piease attach copies of certificarion to this application. 'i'he Health Deparhnent wiU not use past years'records. You must provide aew copies and maintain a file at your estabGshment. I. !/Si�/ !//�+✓ Z P�RSQI*i iN CIiARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service estab6shments with 25 seats or more must have at least one employee trained in the HeimGch Maneuver on the premises at all times. Please Gst your employees trained in anti-choking procedwes below and attach copies of employee certifications to dus form. The Health Department will not use past years' records. You must provide new copies and maiatain a Cile at your place of business. 1. /��/ i�/��N 2. c(-sd� arLr-'u 3. //t, a nA F-� 4. %v�n a GW�� RESTAURANT SEATING: TOTAL # �,� ��' � �`' �� OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PER:�fIT* LICENSE REQL'IRED FEE PER4fl7 = LICENSE REQli1RED FEE PER�9T= _8&B S50 _CAB1N S50 _MOTEL S50 _INN S50 CA.1SP S50 SW'IYL�IING POOL 575ea � _LODGE S50 _TRAILERPARK 5100 ��'HIRLPOOL S75ra. FOOD SER�7CE: LICENSE REQUIRED. FEE PERIMIT ir LICENSE REQL'IRED FEE PER14ilT� LICENSE REQti1RED FEE PER.VIlT= �0.100 SEATS 575%� 08^�Zcj _CONTINENTAL 530 . �_NON-PROFIT� . S25� _>IOOSEATS SI50 YCOVLbiONVIC. S50 �D –$ (O�o _WI�OLESALE S75 RFTAIL SERVICE: —RESID.KITCHEN S7i LICENSE REQL7RED FEE PER'bffI= LICENSE REQL4RED FEE PER�II?= LICENSE REQUIRED FEE PER�DT= _<SOsq.ft. S45 _>2i,000sq.R. 5200 VENDI'.�G-FOOD 5?0 _<25,OOOsq.B. S75 _FROZENDESSERT S3i �✓ TOBACCO Si0�037 va:�c�vGE: sio AMOU:�T DUE = S � 75 """"�pLEaSE T1:RY OYER�\D CO�iPLE'IE OTHER S1DE 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 does not have a Certificate of Worke.r's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION IN$URANCE R AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be pa�d prior to renewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the liroitat�ons of Motel or Hotel use,Transient occupanc.y st�all be limited to the temporary and short term occupancy, ordina�lY and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate t6at they maintain a PcinciPal Place ofresidence elsewh�e• Transie.nt occupancy shall generally refer to continuous occupancy of not more than thirtY (3�) daYg. and an aggegate of not more than ninety(90) days within any si�c(6)month period. Use of a gu�t unit as a residence or dw,elling �nit shall not be considered transient. Occupancy that is sublect to the collection of Room Ocaiipanc,y F�ccise, as deSned in MG.L. c. 64G or 830 CMR 64G, as amended, sLall B�allY b��°�d��Traz�aaent. * NOTE: Enctosed Motel Census must be completed and returned w�w tt�apphca�on• rooLs POOL OPENING: All swimming,wed'u►S and whirlpools which have beet►c(osed for t6e season mus�fi � �� by the Aealth Department prior to opening. Contact the Heaht►Department to schedule tt�iaspect► prior to opening. POOL W ATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couoc by a State certified Iab, prior to opening, and qnarte►1Y thereatter. POOL CLOSING: Every outdoor in ground swimming Pool must be drained or covered witFtin seven(7)daYs of closing. FQOD SERVICE CATERING POLICY• Anyone who caters witttin the Town of Yazmouth must notifY the Yarm°uW Heakh Depa�t�at b3'filin8�� Tem rary Food Service Application form 72 hours prior to the catered evem. These forms can be°b�a�� Heal h Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified�ab. Test results m°st be se°t to the H Department. Failure to do so wi11 result in the suspens�on or revocation of your Frozen Dessert Permit uadl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating w►th waiter/waitress service)>must have prior approval from the Board ofHeaith OUTDOOR COOKING: Outdoor cooking,Preparation,or display of any food product by a retail or food service es�tab��shme�►t is Pr°hi6ited• NOTICE:Pernrits run annuallY from January 1 to December 31. Tf IS YOUR RESPONSIBII.PIY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlvIENT, MOTEL OR POOL (i.e-, PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTIi PRIOR TO COMME:�tCEMEVT. RE�IOVATIO�IS MAY REQUIRE A SITE PLAN. DATE: � 2 J SIGNANRE: � � A�� n �� PRINT NAME&TITLE: ,,: ,�,r�� The Coraraonwealth ofMassachusetts Department oftrtdustrialAccidents M�eaN� 600 Washington Street, f�Flaor Boston,Mass. 02111 Workers'Compeesatlon Ioserance Atfidavit:Building/Plombi■g/Ekctrical Coetractors �' Phease varntl' M. �: C�tJ '// a � addass:_��L.� �J ✓��,wi[�.__.� c��` /}�V�_(� state ��!" z� O�-° 6 / nhme N �/� /"/ / /d��JJ l� �� 1 work Site location(full addresSl' ❑ I am a homeowner perfoxm�ng all work myself. Project Type: �New Construcr.tion QRemodel �,I am a sole proprietor and have no one working in anY�P�i�y ❑Building Addition �,l am an employer paoviding workas'compensation f�my employees wo�king on 1Lis job. �� /j �? / comoaav�ame: ��P .�.5 /( t�G Ve. �1 �� (L ad�dr. l Z !�/ � /✓I �lA w../� /• �-..G ��: � /�o � v.,�L �,� �# �ux �� z 35�3 insma.�e rn. Ch/+^��4 �sT �� geeeral coatrxtor,or homeoweer(cirde o�.� --.__T,�— ❑ I am a sole proprietoy nej and have hired tLe conhactas listed below who have�. the following workers'compensa[ion polices: eQnwav■ame: �d�ns: cih'• �we# ineaece eo. � nolicv M conwev ame• ad�m: ekv. None# i�vaeu�. � ooLt.q# .�II�f�Fi�I�W1f1e10� . . . . . Faihre to xeme eosera6e n rcq�cd neder SMIe�2SA�MGL 15t wa kfd b 1�e isp�IW Kvi��l�al pnaMia�f a me b f1JM.M a�d/�r��. �Ye�*'�prNonoeat a weB ae dN penaltld in the{or�Ma STO�WORK ORDEA aed�Bne K5180.M a Aay apimt�e. I mdenyad tWt a cpy HtYh flatemeal m�y be forwardM m the O�.e af IaveWl��tlem o[16e DIA tar eavenge verl&tlMa /�o hereby cerb rnder the pn ns an/penahfee oIP�7+RYµet D+e inforuatJon prowdel abore ie prue and cerrect / Sigoature ��`"`•�� jz- �,1 V� �/j� Date Printname �✓�-i / `�/J/(/��"- Phone# � ��- 7` �-L � '�., �� oEkiai uae oWy do nW wrile im[hie a�ra to he amplefed 6y dly or Ywu e�rLl . . . . .. eily or tewu: ��# OBe1d�g Dcpu�ertt ❑eheck H�medi�le reepeeee la reqmred ❑Sdee�m O�ee a m�ct pe'wn: �HraMh Depfrden[ tn+�a s yr aou» P�O°°�' ❑OILer ` FRDM� �OCEANSIDE —INSURRNCE FAX N0. =15087662211 Rpr. 24 2088 01�25PM P1 296 Niein Su'eat,P.O.6ox 38 • • - � . West Dannls,MA 02870 PHt7(50B)398-2282 � ' FX#(508)76b2211 - ' • ' pceanaNielnsumnce.�n n � � :��_ _�� I � ID W � ' APR � 4 2008 y � UEPT. F�a�c To: gruce MurphyfT of Ya�mouth F�O'ri'��9t�-r:Ny L.Moran,CIC. CISR � Fau: 506-7803472 Pageat: 2 P��: Date: U4;-:3/OS Re: Wiliam Moran D A 8ass River Grill cc: 0 Urgent ❑For R iew ❑P��ase Commen4 [)Plitass Ropy O Clsasc Recycle • Commen4s: Hi Bruce—Please be ad ised that the above captloned clic��d t��+�workers canpensetion coverage in force effective 4/8/OS co ering hls restaurant located at E>2 l iigrdiank Rd., South Yarmouth, MA. We have requested a cert'rfl te of insurance for the Town af Y��rmnuth. This cerl�C2tB has to be iesued direcUy by Travelers In urance anq will be fonxarded to ¢�u upon its receipt. In the meantime, following is a copy of his otice of Assignment from the w�ark;is r„rmipensation bureau. Please call with any que tions you may have. Thank you. S:ia�p' ' FRDM �OCERNSIi� -INSURRNCE FAX N0. �15887662211 Rpr. 24 2668 01�25PM P2 ,----'�-.... NOT 'EOFASSIG�ME=1NT ( �-r�{;. _. _. _. _._ .. .._., ._. .-. . _.. ._ _ ` � ' EMPLOVER: C;C)MBO I.D. STqTU3 OF EMPLOYER J " WILLIAM MORAN DSA S SS RIVER GRILL D�U3b4304 :Inr.ii.vidual � 62 HZGHBANR RD 5 YARMOUTR, MA 0266 r.^.G�/ERAGEGROIIP I:�:i64304 1A�WU Fi�� 'l' 2 1�� "overag¢ Under this fls�ignment The waiver of Our R'ghf Co eipplies to Massachuaektc xecoveY £Yom OtY�eFe Endos9ement �, opez'ations only. For, r,oveYage r is available on Poo policlee. " ' � outsicle of Maesachu�eCC�, contact Contact your agenc or deCails. che appro�riate Poo1 or Plan for that stace. _.. ,-_ .. ..—_ ..._._.. -- .,..--- •-- ..... .-- IFISURANCE COMPlWY; AGENT LOV£QUIST MURRAY S A�Y q'gpVELERS PAOkERTY CASLIALTY CO ON OR � P O BOX 38 296 MAZ ST GRODUCER: w DENNiS, MA 02690 ftMERICA � ��5 TINA SMTTIi � �- 0 80X 3556 ��itLANDO, FL 32802-3556 �GENCVFEiN:04344195D l � . .._. .... � ..--�--._. . .._ . _.._ - CLAS5IFZCATZON OF OPERATION CLA.=�S E.�'CIMATED RA'Ck 6S'fTMFiTED COA13 'I'f,:�PAL ANNVAL FRGMIUM P LhtVA'£RATION R6STAURANT NOC SO/!? S70,000 1.14 $738 EMPLOY�RS LIA9ILITY 100/100 SDO °84�� $�9B STANDARD PAEMZUM EXPFNSE CON5TANT 09011 5318 TERROftSSM CHAHGE 974U $2� T07'7+L POLICY MINIMUM PREMI $219 TOTAi ESTIMATED PREMIlJT1 $1,'_�37 D'CA ASSESS. 5.58 544 TOTAL F.STr :PREMZSJM PLUS ASS SSMENT . ,� - � $1,161 IN$TALLMENTBAS�S: Anr_udl DEPOSITPREIdIUM: $1,181 � ' ' � � � '� � � � � � � THIS�9 N0T A B1LL COMMENTS ' . Coverage e£fective 12:01 AM on 041081D8 � DATE OF NOTICE: 09/7.8/08 I f;El'r1itE�aY: Joanne Shea EX9' S30 � • VOLUNTl1RY DZRH:CT JLt G74'�NMSNT ' • . . LETTERID:� 240Z695� "' .-. � �. : . t:{)PY. AGENCX . .. . . . _ . . . cw . . .. G I ' S / ,' � .L{\;7/ n` •�.,. i ; .� �� The Workers'C mpensation Rating and Inspec tion eureau of Maasachuseris �� {` ,_ 101 Arch Street- Bostan, I dA G2�70 �y,.; (61 )439-9030• FAX(817)439-Bp:F3 �vvurt,v.wcribma.org / ,. Apr 24 08 12:OSp p.1 G3 � C� � � M � D From: Bass River Grille Zo0$ APR � 4 To: eruce rv�urphy HEALTH DEPT. Re: Menu (Temporary) Date: 4J24/Z008 Until such time that the power in the restaurant area is up-graded, Bass River Grille proposes the following limited menu items; • TurkeySalad �pre-made) . Ch9cken Salad (pre-made) • Ham Salad �pre-made) . Pota[o Salad (pre-made) • Cole Slaw (pre-made) • Ham (pre-sliced) . Roast Beef(pre-sliced) . Turkey(pre-sliced) • Bread/Rolls • Steamed Hot Dogs . Coffee/Tea • Muffins(not made on premises) • Pastries (not made on premises) • Packaged Snacks Please contact me if you need further information.Thank you foryour professional courtesies! Sincerely, r, �.� I / ` �� ' �y--' L� Willia oran RPR 24 2086 14 :44 FR RFFIN—RLNT MRRKET 4972543852 TO 915067603472 P . 81i01 us�cuwi� 04/24/08 TNI`3 C8A71FICA'�13ISSUBD AS n�T�R OF WFORMATfON ONLY pND COhIFBRS NO RiGH7'611PON'fNS CERI7FICATE HUIDER 7'N�: YRODVCrR CERTIF�CAIE DOF.S NOT Ah1FND.Y.7�T6NP OR ALi7ER TFI£CO�'EiG1GF, qFFORDSD BY TH6 AOLIC�SS BE1.OM'. � LOVEQUIST MUR[tAY iNS AGCX COMPANIES AFFORDIPIG CO'VERAGE �'O*""^'"'� A TRA�ELERS PAOPERTY CASUAL7Y COMPANY OF PO BOX 38 �« pj�qg�CA W DENNIS,MA 02670 ��Y B tarrFfc iNSURED C�� C L6T�¢R MOAAN, �'ILLIAM DBA HASS RIVER GRILL �� D 62 HIGHBANK RD �e'�'�R S YARMOVTH,1v(A 02664 �o�q„r � {prr4R 'CHISIeTOCHR71fY'CFiA'TTESEFf7LICIE50FiN5URAWCEUSIEDBII.D'a'NnV1iBEEN�SSUF.D7'�7'F�1NF�7R��NwMGDABPI HFO�RSPTHE1�roOWHICHTHIS lNDIC/."�U.NOTWITNSTANDR7G ANY RFQUTAS67ENT,7'E1iM OA WNDR�ON 0!ANY CON7RACT OR�TH��C��T EXCL�ONS nND CONU TUIPODNS U�C�POL^iC�S.1,R�5 H4 04WN MAY NAVE 8�REUUC'PD�Y P-N�ABCLN�s IN IS SUBJC'CI TO+t1-4 Tt�iERMS. �W�. UM1T5 �,�p TVPE Of iNSUR�NCE �W�wM�F'H EFFF:C7'I�C DATP. k:XY�pA7'�ON DA7V. L7R p/r M�-1�DJNYY 06NCML AC��nT6 S CENERAL L�A8ILITY PMOOV(,'l5-COMY/ov Ac(:. S UGOMMEAf�nLGENPNnLLIl�BII.iT' PPASONwkA��JUAY S [� �[1�yNyMnDE G �CCIR. �ACHMCVRILEt�'CE T ,�,I O�vfiEa'S&CUtnRAGTOR'S PR�. PG61��MA4�'lA^]Orc i:c) S ❑ ._.._,— hR.D.G%PCNSS(A"YmcDe!xvn 3 -- COI�R+Ef1frt:CA.eWnT S AU�'OM061LE LiAWLI'tY 0 arvt'nu'ro aouav muiimr f (6ervnwn) O nL,UwN6UAUf05 I� SCNtDULSpAUTOS 60��LYtNIUnY S IPv AeadenQ �] �g��1T0> � NDH-O�A�OS YAOP6R'�'YDnM�GE 5 � GMACBLIAHILfi'Y g}tCE5541ABILCfY epatoCCVFNSNC¢ E O VbffiNELLACOAM �OG62G/�iE F �] OxNpµ}HpNllFtORf�.LAFO�M STAi'N9M1y�.�11T5 DM➢8708 01/08l09 bACH ACCn7EN7 $100 OOQ w N'UkKER'5 COMPENSA'P�ON 7'O BF,f7ET8P.M�U qic�,�gFyoLIC�IIMIT ;506,000 AND DISY-nSE-EACl1EMv1AV6i $)�,�� P.MPIA'�Efi'S LIABILITY OI'iIER pF,4C7tIPfION Ov OPEM1tOR9r1RUTlOM�'EN1[LES/F��•T�MS THE WOItKERS' COMPENSATON POLICY DOF.S NOT PROViDE COVF.RAGE FOR MORAN,Wli-LIAM. rn�pgry,��'ILS ANV Pp1pR CERIINGTE�SSUED TO THb C�TIMIGYu NOI.ONR AF'F�n'LNG q'OAlKEQ3 COMI I:O�MCE TO�VN OF YARMV�� VUrA�HY OP iNC ABp�'C DL'��Fo POLICIRS BE CANCSLLED i��TRe 4XPIIGTTON pniE'CpFFEOR.iAE ISg1ft[if,CONPANY�vM.SN�GVOR'!O AUIL 1��Rl�ZB �B DAYS w WTIEd NOTI[.'R TO THF�%1'�PICATC➢Ol.o¢R HAMED 70'fH6 4CPt� SOUTH YAICMOUTH.MA 0266a svt r�auxrt'ro r+nn-suc�t+once sawu.weuse xo osu�.non ox �,�wIIpA7Y OP A�Y![INP OfON TRE COaffAM'.tI3�CEf(]Y OR PP,�RFSENTA7M5 AW�OAV.IB WMAf[NiAT�� TJi/!.'� �<�V/L ** TOTRL PRGE . 01 ** ,o TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERM[T NUMBER: #08-175 FEE: 75.00 [n accordance with regulations promulgated under authority of C6apter 94,Section 305A and Chapter I(1, Section 5 of the General Laws,a permit is hereby gianted to: Bill Moran, 62 HiRhbank Road South Yarmouth MA Whose place of business is: Bass River Grille Type of business: Food Service To operate a food estabGshment in: Town of Yarmouth Permit expires:_ December 31. 2008 aonitD oF HEnLTH: ,�$�/E �„�r,� � SEATING: 73 � � ,�;,� v� �� REsi2ICTroHS: Disposable Service(fily. f� 3.�� Qu�✓l..N Apri129.2008 � nice G. utphy, , R.S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOW�I OF YARMOUTH PERMIT NUMBER: #08-t06 FEE: $50.00 This is to Certify that Bill Moran d/b/a Bass River Grille at Bass River Golf Course 62 HiAhbank Road South Yazmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE [n 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 confornuty 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: 3Eefe�e Sllal�., 52.N., C'/laixntun sEnrr.vc: �� C.haxlee 3E. .7Cellillex 41ice C'Ilaa�v►tan .r�e 3. .��, el� CGuc (�een6aum, J2.N. £ueP,�e �. 3fsryaa Aori129.2008 Bruce G. Mwphy,M .,CHO Director of Health P . d THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-037 FEE: $50.00 � Tt�is is co cen;ey u,ac Bill Moran d/b/a Bass River Grille 62 Hiq,hh n�ac� 4oL h Y rmo rth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This�er�s�aut�iq2�fortnit�with Article VI f e Sani�Code of The Commonwealth of Massac6usetts,and exp s r er un sooner suspen�or revo e . Apri130.2008 BOARD OF HEALTH: ,`�¢(¢ft $�� .� �qiNfllqlt �¢O .�. :�l�16� �ICC �p4YI1lafL �PXf �. BKUlGIL� UAJIlIF Q��f�l�K/��,,IfC¢f1�(!lI/K� �.,/V. """"!►"�• .`�EQ�(.PA Bmce .Murp y, . , � Director of Health