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Home My WebLink AboutApplications, WC, Licenses Prior to 2010 ISE � � TOWN OF YARMOUTH BOARD OF HEALTH ' , � � �� APPLICATION FOR LICENSE/PERMTl'e�`l,00�� .,, �"''''i � °. " NCV 1 "! 200E * Please complete form and attach all necessary c�oetan ts by er IS 2008. Failure to do so will result in the retum of��}ur "pY�cat�on pac e . - LThi D�PT. NAME OF ESTABLISHMENT: �U�E.25 �A{L��15 �. TEL. #�9��"�1 I"�3S�-{ LOCATION ADDRESS: U� i v� MAILING ADDRESS: o � vv� /�- o OWNER NAME:�A�vv��5 � '��.112.1�1.1 TAX ID (FEIN or SSNI: CORFORATION NAME (IF APPLICABLE): MANAGER'S NAME: � F��'v�o TEL. #c��-]9�v MAILING ADDRESS: �Rvv.� POOL CERTIFICATIONS: The pooi supervisor must be certi6ed as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. 1. 2. Pool operators must list a minunum of two employees cun•ently certified in hasic water safety,standard Fust Aid and Community Cardiopulmouazy Resuscitation(CPR). Please list these employees below and attach copies ofemployee 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 establislunents are requn•ed to have at least one full-time empioyee 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 Chazge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at teast one employee hained in the Hennlich 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 fonn. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # C� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMII'# LICENSE REQUIRED FEE PERMIT� B&B S55 CABIN S55 MOTEL S55 INN S55 CAMP S5� SWIIvIMINGPOOL S80ea. _LODGE S55 _TRAILERPARK 5105 _WHIRLPOOL 580ea. FOOD SERVICE: LICENSE REQURtED FEE PER'�IIS# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-100SEATS S85 �r�9�Z(a _CONTINEIVTAL S35 NON-PROFCI S30 _>100 SEAI'S 5160 _COMMON VIC. S60 _WHOLESALE S80 REIAIL SERVICE: —RESID.KII'CHEN �80 LICENSE REQUIRED FPE PERMII'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. 350 _>25,000 sq.8. 5225 _�'ENDING-FOOD 525 _<25,OOOsq.ft. S80 LFROZENDESSERT 340 �O`"1'C�a' _TOBACCO 555 tiAJ�iE CHA\GE: SIO AMOUNI'DLTE _ $ /ZS. o� "*"'*pLEASE TURV OVER A�VD CO;VIPLETE OTHER SIDE OF FORVI•""** ADMINISTRATTON Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED� Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe 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. 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 siac(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 deSned in M.G.L. c. 64G or 830 CNIR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimrning,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 opemng. PLEASE NOT'E: People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL 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 Yannouth 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 rrozen Dessert Pemut until ihe above terms haue been met. OUTSIDE CAF'ES: Outside cafes(i.e., outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooldng preparation, or display ofany food product by a retail or food service establishmem is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETiJRN TI�IE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLTSHIVfENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TIIE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �t_ 1�j- jj�; SIGNAT� � PRINT NAME&:'ITL . U � io�zvos �\ The Coinmonwealth of Massachusetts Department oftndushial Accidents N�CE N� 600 Washington Street, fh Floor Boston,Mass. 0211I Workers'Compeesatlon iosorance Aifidsvit;Bai�dieg/p�nmbioglEkrhical Contnctors A�t i.firenflSsr• Pleaae P��1T kvlMv °a'°e' ��'1///Y � ��C�L�� addrtss: �_� c_yt _Y��7l�lS �7�� siate� � zio� Gt�/�Y/ohone# c� / /��Y�'U worksitelocation(fiilladdrcssl: �//7 ��iO c� /�� N /it2(�,C��. 1/��/� ❑ I am a homeowcer pecforming aZwark mysel£ Project T e: ❑New Constcucti��Remodel ❑ I am a so(e�proprie[or and t�ave no one working in ar�y capacity. ❑Building Addition � �am a�employer providing workers'compensation for my employees working on this job. com asme• Qi�� /// a�J d�aa: ci : /S �� - � e& U � � �Jx� .� . -�' � i a ZZLC S��o�/� !� -�� c . � .�. � �..�y: � . .Y'^.i(F �� ❑ I azn a sole proprietor,geceral eoatraetor,or Yomeowner(cirde one)and have hired ihe�contractas listed below wlw have the following workecs'compensarion polices: � �jd_� comuwav.rmc. . .. . . � addresse � . . � . � . eltY' oAosc& . . . � ineaxe eo. _ � ��g � . � � . . mmoaav a�me• add►as: c�P:� � . . . � oha�e S• . � . ImvaOee Ca �olitq# A1ti�T�!"7i'�i�Lt�liiM��ee�y . . Faive b xeme covua6e a reqi'ed aadQ SMba 25A ef MGL 132 we Ind b tl�e ... ... . , , . . .. . oAe Ynn'�mPrboAmmt a wr9 as dN peeaNles in t0e far�Na STOr WORK ORDER�aed�i 8ee d��da 8ae R b f1,SN.M aodler': cqryetfhhflahmeWmyhefarwardedbtAeO�e�IoveMlgaWosd/leDlAforcoverage�2rfBntln. y�O�tmalendmWdtWt• /to hertby cerafy r er n1e patna anJ penel�iv ofperjury that the inforw,uNan provlded ebope is nve and mrrert . . S�g°°wre Date �// �•�O . Prim � S t2- � Phone#�� d `3�<'�c�� oBxial ose enty do nM wrife u lhis orea to he mmpkhd 6y.dly or bwv e�eehl . � cily or tawu: � . . ��i��# ��o� BoaN � []e4erk Kmmediat reapome b`xqd.-ed -_. . � . � � �'t O�ee . . . ❑Hnkh DqnrOamt m°hct Perwa: p6oae#; �Othe+ t�.�s�.mm� . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NtJMBER: #09-026 FEE: $85.00 In accordauce wi[h re�ulations promulga[ed under authoriTy of Chap[er 94, Sec[ion 305A and Chapter ll 1, Section 5 of the General Laws,a permit is 6ereby granted to: James F. Hurley, 119 Route 28, West Yarmouth, MA Whose place of business is: Putters Pazadise Type of business: Food Service To operate a food establishment in: Town of Y�tmouth Permit expires: December 31, 2009 BOARD oF HEALTEI: 3feFeir. S�, J2.N., @�atx" matt (.�axfee .�1. ,`Ke.ffi�elG `t1iCe Chaix�ttart Seating:Zero(0) ✓�A.BYJl� `.;. �n0((tft� � Q�`�f�L,,f�L��,,[eY11�r�C{U,,(�/�I�L��.�..N. `^""'d"�• "`""J`" November 20.2008 ruce G. Murphy,MP . .,CHO Director of Health . . _ _ __ _.... THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-002 FEE: $40.00 This is to Certify that James F. Hurlev d/b/a Putters Paradise I 19 Route 28, West Yazmouth, MA IS HEREBY GRANTEll A UCENSE FOR THE MANUFACTURING OF FROZEN DESSERTS AlVD/OR ICE CREAM MIX For the yeaz commencing with March first 2009 This License is subject to the Rules and Re�ations of the Massachusetts Department of Public Health Relarive to [he Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regulations of the Board of Health granting this License, and to the provision of the General Laws Chap ter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with Vie provisions of Section 65J said Chapter. 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Project Type: ❑New Consuvcbon❑Remod¢1 ❑ I mn a sole proprietor and have no one working in mry ca�xicity. ❑Building Addition �I am an employer providing workps'compensation for my emplo7�ees worlcing on this job. . comoav�sme• ��.�.�_I /l�� ` .(�Uw �� . .a�a.: 1 l� �-`� �;n: �_��n �'Ulf1' L�-(o'�� a• 5�1`� 1 � 9 y tssmaececa. ��i.��i . P^�.� (/Lp.S ��02 . . . . _. . . .. . . .. ... .., ,� �+.�'�..�^.. ❑ I am a sole proprietor,Sweral coatracMr,or Yomeowser(clyde ont)�d have hicai tbe con�acfois Iisted yelow who have� t6e following woik�s'compensation polices: somouv ome• � � addras• �'• � � nlaee#- . Snmaacc eo. nolicv# vmouv uwe: Wdras• e_i_lY: �#• irmaeee eo. naLt�v x h11�kWYlWyiirU�itrraWu� . . .. . . .. .. Faive r aeeme wmase n Rqd'M i�dv SatlN?SA a[MC.L 152 ni kW b tYe IspwMM af�Yal peaalQe�[a�e�b f1 SN.N md/K`". ooe ydn'lepr6xsest a�we9�s dH peealtles Ia tYe(orm e[a 3TOr WORK ORDER ud��dS109.N�day aplest oe, I mdmhW tlnt a eepy af Nb Ma4aem�y he fwward[d b the Omce d loweM�tleas stthe DIA fer t�venge ver�atls�. I do�Aereby cerbjy nder Hiepeins aed penahier of perjury th�tbe lefonnatton prowded above is dare m�d rnrrcet Signalum / � Date ��/a'� / Print S —� P6oM#�S� b �� 3�d� o�eial ox owy ae aot.v�sa m ws■rr�to ee.»mpkfea ey ary or m.ru o�ew . .. .. .. rity or Oowa: P�T�p �BuidinE Depar�ent ❑tYeek if imme�ar rta�wme is required � �,��g�� 03ekaOaee's O�ce m�adperaon: ��«�� lM1-,Qa s.v aow� .Pbooe q: � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISIIIVIENT PERMTT NUMBER: #08-076 FEE: $75.00 In accordance with regulaRons promulgated under authority of Chapter 94,Sectiou 305A and Chapter 111,Secrion 5 of the General Laws,a perniit is hereby gianted to: . James F. Hurley, 119 Route 28, West Yarmouth, MA Whose piace of business is: Putters Paradise Mini Golf Type ofbusiness• Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD oF HEALTII: .�feeen SRaPi, JZ.✓V., C'l�aL[mait (.R�axPeo .�.9CePXi�e,,ac,} ?I�ice CR�aixman Searing:Zero(0) . �41Lt S.�KOILUL� I.CPJ[R Qnrt C�xeer�Braunc, ✓2..N. Decemberl3 2007 Bmce .Murphy, , .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-003 FEE: $35.00 Tlris is to Certify that James F. Hurley d/6/a Putters Paradise Mini Golf ll 9 Route 28, West Yarmouth, MA IS HEREBY GRANI'ED A LICENSE FOR THE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with Mazch fust 2008 T'his License is subject to the Rules and Regulations of the Massachusetts Department of Public Health Relarive to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regularions of the Board of Health granting ttus License, and to the provision of the General Laws Cha�pter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with the provisions of Secrion 65J said Chapter. BOARD OF HEALTH: S Q� *Regulauon 105 CMR 561:009 requires . ,�i��P��fl6��/��U[FtilCfL montlily plate count and colifotm tests. ,t. � � . 1 / . � .- r w.^ Decembet 13.2007 B e ,yMui'p ,MP , . , Director of Health _ ba°�' � o��a,y TOWN OF YARMOIITH BOARD OF HEALTTT '�\'� '�` s ( � ' �l „� �� APPLICATION FOR LICENSE/PERMIT-2009 D E C 0 5 Z 0 0 6 o � ; � �,�„. * Please complete form and attach all necessary documents by Decemb ��(�O�{ UE�'t. Failure to do so will result in the return of your application pack . NAME OF ESTABLISIIIvIENT:_Pu,{-�-Q� P ,c� lrn I ti, , �� TEL. #.S�S �'71 � 3 y� LOCATION ADDRESS: 1 (Z+E � MAU.INGADDRESS: � iJi �-} � '�14, OWNER NAME: . Aw� TAX IN r CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �(-�-vy�� TEL. # �5's �y o 3 4n rl MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minunum oftwo employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee 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 540.000. Please attach copies of certification to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmenL I. �t�.-r� �ri-��, 2. _ _ - - _ --- _ IN GE: __ -- — -_ --__ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATION5: 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. l. 2. 3. 4. RESTAURAN'T SEATING: TOTAL# OFFICE USE ONLY LODGING: � LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERM[T It LICENSE REQUIl2ED FEE PF.RMCI'# __B&B S50 CABIN $50 MOTEL $50 INN $50 CAMP $50 SWIIvII�qNG POOL$75ea. _LODGE $50 _ _1RAII,ERPARK $]00 WfIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIl2ED FEE PF.RMIT# LICINSE REQUIItED FEE PERMI'C# LICENSE REQUIl2ED FEE PERMI'L# 10-IOOSEATS $95 07–OSI _CONTINENTAL $30 NON-PROFIT $25 _>l00 SEATS $150 _COMMON VIC. S50 WI-IOLESALE 575 RETAIL SERVICE: —RESID.KTTCIIIEN $75 LICENSE REQiJIItF,D FEE PERMI'T# LICENSE REQLJIl2ED FEE PERMI'I'# LICENSE REQiJIl2ED FEE PERMI'1'H _60sq.R. $45 _>25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOO sq.ft. $75 LFROZIN DESSERT S35 0 7�OOa TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE _ $_//p .�� "•••PLEASE TURN OVER APiD COMPLETE OTHER SIDE OF FORM•"""• ADAIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED /� OR 7' WORKER'S CONIP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es 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 limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short tenn 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. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certiSed lab, prior to opening, and quarterly thereaffer. 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 Yannouth must notify the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application fonn?2 hours prior to the catered event. These fonns 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 Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTTCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COM11�1ENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. DATE:��_ SIGNAT � PRINT NAME&TITiI�: S �%� 2 � �omioc � ' " �� :� : r qAti�'��a.�,�`n')m's -.�::� acois�� +��T1FtC�TE t�� I[��F�A��E - - - " �� - � � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION .. pp�gr ONLY AND WNFERS NO RIGHTS UPON THE CERTIFICATE ' . DOWLING & 0 NEIL INS AGC ATERTHECOVERAGE�A ORDEDBYTHE OLIqES�B�ELTOW. OR �. 222 WEST MAIN STREET - PO BOX 1990 COMPANIES AFFORDIN�COVERAOE HVANNIS MA 02601 COMPANv .. . LGR A AMER AN URTC IN URANCE COMPANY � COMPANY UIf11RED B HURLEY, JAMES C D DBA PUTTERS PARADISE , COMPANv c �1 G PO BOX 48 C F ` V .. HYANNISPORT MA 02647 COMPANV � 0 06 t�at�� NDICATEO, NOTWIT STAND NGPANV'RECUIRIEMENTNTERMSORDCONDRION OFBANV CONTRACT O INSURED �E �� +�� CT TO WHICH TIHIS �� CERfIFICATE MAY BE ISSUED�OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES S � CT TO ALL THE TERMS, . IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REUUCED BY PAI LA YOLICY FFFECiIYE POLICY IMTO LIy1T8 CO 7ypE OF WSUIUNGE POIJCY NUYBFA � ��M��m pA�Ny�pp�ly) L OENERALAOOREOATE 6 f1E11EML lJA&t17Y PRODUCTS-COMP/OP A00. S � COMMEFCIAL GENERAL WBILITV CWM9 MADE�OCCUR. PERSONAL&AOV.INJURY 5 EACH OCCUPRENCE 5 �� pNMFA'S 8 CONiMCTOF'S PPOT. FIPE DAMAOE(Any on�flr�) 6 ME�.EXPENSE(Any ons p�roon) ` µT��wT. � COMBINED 81NQLE a ' � LIMR ANVAUtO pLLOWNEDAUT03 BODILVIWURV a � (P�r Pereon) SCHmULED AUf03 HIRED AUf03 BODILV INJURV $ (P�r AccldsnQ NON-OWNED All�OS PROPERfVDAMA6E E � AUfOONLV•EAACCIDEM 6 OMUfiE IJABLLI7Y � � OTHER TNAN AUfO ONLV � ' �"�a EACH ACCIDEM � � AO�flEOATE i .. EACH OCCURRENCE 6 F]ICESE lU1BIlliV S AO�FEOATE UMBRELLA FORM . - p7}1ER THAN UMBRELLA FORM WORI�1'ECOYPENE�710NANG BTAMORYLIMRS .:. .:..:;_:�,A, , - p �,�,e��r (UB-0405882-9-06) 01-07-06 07-01-07 �CHACCIDEM �_�� THE PROPRIEfOW INCL DISEASE-POLICV LIMff i PAHfNERSJE%ECUT��E DISEA9E-EACH EMPLOYEE i � OFFlCFA9ARE: x EXCL . OTiFA pEgpdp7�px pF ppEppllONS/LOCATONS/VEMICLES/NESiHIC710N8/SPECLLL 17EY8. �. . THIS REPLACES ANY PRIOR CFRTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE _.. �.i4��T�.H41A£[# :! 'CAYi't`iEEUI��N : �N. . . .. ��SXOUID ANV�OF iHE IIBOVE DESCNBED��POl1qE8 BE CANCELIEU BEFORE 7ME � EXPIpATON DAIE 7MEPEOF, THE ISSUINO COYPANYWiLL EMDFAV011 T01WL TOWN OF YARMOUTH 10 DAYS ��TTEx N0110ETO7NECFA71FlCA7ENOlDEAMIWEDT07NE PERMITS AND LICENSES LFFT, BU7 FAIWNE 7o NNL SUCH N0710E BHALL IYPOSE NO OBllfMtl�M �N 1 7 46 RT 28 . W181LIT'OF ANV qND UPDX 7HE COYPANY,ITB AfiE11T8 OP NEPNE3EMTAlIVEi S. VARMOUTH MA 02064 py7110PoZED XEPHESENTA7IYE �� :'�.��::-. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-051 FEE: $75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A mmd Chapter 111,Section 5 of the�'ieneral Laws,a pernut is hereby ganted to: . 7ames E Hudey 119 Route 28 West Yarmouth MA Whose place of business is: Putters Paradise Mini Golf Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31. 2007 BOARD OF I�AI.TH: L3 $. , /y�., ' ��s�, �� e�� s�c�g:z�o co� R�t 4. a�, e�.� P�t�k M�S� �9.�.� (j� R.N. January 30.2007 Bruce G. Murphy , S.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-002 FEE: $35.00 This is to Gertify that Iames F. Hudev d/b/a Putters Pazadise Mini Golf 119 Route 28 West Yarmouth, MA IS HEREBY GRANT'ED A LICENSE FOR THE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the yeaz commencing with Mazch first 2007 Tlus License is subject to the Rules and Re�ations of the Massachusetts Depaztment of Public Health Relative to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regularions of the Board of Health granting this License, and to the provision of the General Laws Chap ter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with tiie provisions of Section 65J said Chapter. BOARD OF HEALTH: B G'o3�orc /�j, e�i�itiu,� *Regulation 105 CMR 561.009 requires ay�i �2./�. yice �� monthly plate count and coliform tests. ,�, G� Z��,�y� � ��ee�eJtnt R� January 30.2007 ce G.M h , , H Director of He�alth ' � c�.-'��' � P�r�zsPA-Qa�i�s� 3��^R.yc TOWN OF YARMOUTH BOARD OF HEALT��IO°7' o��= APPLICATION FOR LICENSE/PERMTT.- 2006 �J, * Please complete form and attach all necessary"docu�enls�}��ecember 31, 2005. Failure to do so will result in the retum qf yout�ppi`ication packet. rr� oF ESTaBLis�NT: �i 1�.�rs �CLra�is�, I�lin�i �-�ol�L. s�� l I -'��1y LOCATION ADDRESS: 1 � �I P � � � )Afm��.�l, , Y1'1 R C��(�1� MAILING ADDRE�: n� v-r-F JYl� DaC.� �. OWNER NAME: J��5 � t-�t�.r�sLl TAX ID(FEIN or SS1Vl �� CORPORATION NAME (IF APPLICABLE): !-� A MANAGER'S NAME: Gt.w�L- , TEL. #SbS�-7�yD�'-`G1'� MAILING ADDRESS_ c — \'�POOL CERTIFICATIONS: NThe 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 certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. \\jX FOOD PROTECTION MANAGERS - CERTIFICATIONS: N�'`All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 2. PERSQN IN CIIARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEA+ff,�CH 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 attacfi eopies 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. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEF. PERMIT# LICENSE REQiJII2F.D FEE PERMIT# LICINSE REQUII2ED FEE PF12MIT# B&B $50 CABIN $50 _____ _MOTEL $50 _INN $50 CAMP $50 _SWIIvIIvIINGPOOL$75ea. _LODGE $50 TRAU.,ER PARK $50 ___ __WfiIItLPOOL $75ea. FOOD SERV[CE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT fl LICENSE REQLTIRED FEE PERMIT# ( 0-100 SEATS $75 �OG—O�I3 CONT'INEN1'AL $30 NON-PROFIT $25 >100 SEATS �150 COMMON VIC. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMTT N LICENSE REQUIl2ED FEE PERMIT N LICENSE REQUIl2ED FEE PERMI'I'# _dOsq.R. $45 >25,OOOsq.ft. $200 __,VENDING-FOOD $20 __<25,000 sq.ft. $75 �FROZEN DESSERT $35 �Y TOBACCO $25 __ ___ NAME CHANGE: S10 AMOUNT DUE _ $ �(p .00 `•"•"pLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM""""" �� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'ued to hold issuance or renewal of any license or pernilt to operate a business if a person or company does not have a Certificate of Worker's Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TF� COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISIIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CO1bIMENCEMENT. RENOVATIONS MAY REQL7IRE A SITE PLAN. ADDITIONAL REGULATIONS � �� POOLS —�OOL OPENING: All swimming,wading d whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirruning pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: � Each food establishment which se�s 'r sells ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: 1v Anyone who caters within the To of Yarmouth 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 H FROZEN DESSERTS• bep,� en desse�Ys-must ed en a monthly_basis bya State certified lab. Test resuks znust-be sent to t�Health � a�^� re to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: `�, �Q( Outside cafes(i.e.,outdobi se t9ng with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking, prepazation,�or �lay of any food product by a retail or food service establishme�is prohibited. � (_ �ATE: \1— l�- (�5� siGrraTu�:�!� � PRINT NAME&TITLE: �T �/ 09/28/OS ��— The Commomvealth of Massachusetts � - DepaR�ent ojI»dyshaal Accidents �� I N� 6lal Woshington SYreey f"Flaor � �, � Boston,Mass. 011ll wo��co��ao■�.s�.�n�a,ort:B.ua��rmmn�tKa��co■mc� ..+^s�s. � �"�,� �: �A-ri.�5 , .r�. N, u—Lr� a�5: P (� f3v�� citv Tll,ia✓1✓1 I f—l�f �� te� 1 Y 17"1 zio' L��nL��o--Iwwu . YJ �cJ'�-/Sl� woi4 site lacati�ffiill addressl: ❑ I am a homeowner performing all wadc myself. Pro�ect Type: ❑New Conatructiao DR�odel � I am a sole pn�etor and have ao oce wo ' in any ca� Buil ' Addition �'i . '�€ �'3'P��-x`��',`� .....: . _."�.�?'�'�...,� . � . . ... . . s��P�Y�M��S wmkets'compensati�faa my�ployees wodcing��ub. � ��.m�. P��-��-� ,R�� '1�� -� �: � � � �_a-� �: t.,�� U ar-v�� a�--�� sa� -� � � -� s y � ` - . o c�� E3 �a �� I am a sole proprietor,geaeral eo■tracMr,or Mmeowaer(cue%owef�d have hired the contrac[ois Iislad below who have the following workes'compemgation polices: ssoouv�• addrm�: db' oYre 6• �. �( � Y�^,- r.;..�•'sr.4.S , z�._.r . itH'�- � .:x.t.._ .. ... . .� . _ �Yv Y�e- �' Cih: oYre�- ea . _ - * . _ . _._ _ . . . �% ,�`s,au�,�;.'�'+a. ��:',�:• i . ._ . FaLare is xtee wvea6e n�eqdad odv SedM 2SA KMGL LS2 n�Wd b tYe�Kah�id pe��Mn d�6e R b 31,SM,N aM/`r we Y�+R'i�ptbsaweet as wd n dvY pmitln la t�e fsra af a 3TOr WORK ORDEA ud a B�e dS160.N a day apint.a I aWmh�d WN a npy rf t06 Maieemt my he t�rwaN[d b tAe Omee�IsreWptle�e KHe DIA tarpve'a`e veri�ntln. !Ao hereby ce ' der tAe palea adpyw/Iiu o perjrry at tAe iefonn�lon providal ebove 6 we iwl corrert �. � / Date � (-- ��—a 5 Prim � PhoneN _ XJ� � � � �Y(�� e�eid ase owy a..w w.re r rhis area m ne�ed bs dlr er bwn.mcid dty ar fewa: permW6teese# flBoidiee Deqr�mt ❑tleek N�nedVie reapeme 6�a'vM ��6 Beatd QStls�n's Omte ��Lqu��esf anfael petaen' l�6xe 8; �OIYa ln+�d s��awl .�►CAI:11. CERTIFICQTE �� 1N�URAN�E ' °"�""`°°'"" ' rnooucen � � THIS CERTIPICATE IS ISSUED AS�A MA7TER OF INFORMATION ONLY AND CONPERS NO RIOHTS UPON TME CERTIFICATE DOw�ING & o NEIL INS AGC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 222 WEST MAIN STREET ALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW. PO BOX 1990 COMPANIESAFFORDINGCOVERAGE HYANNIS MA 02601 COMPANV 22LGR A AMERICAN 2URICH INSURANCE COMPANY IN8UNED COMPANV HURLEV, JAMES B OBA PUTTERS PARADISE COMPnNv PO BOX 48 HVANNISPORT MA 02647 C COMPANY � CUYERAOES ��. � THIS IS TO CERTIFY THAT THE POLIGES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MSURED NAMED ABOVE FOR THE POLICV PERIOD �� INDICATED, NOTWITHSTANDING ANY RE�UIREMENT, 7ERM OR CONDITION OF ANV CONTRACT OR O7HER DOCUMEN7 WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCFIBED HEHEIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS. CO �ypEOFiNSUIUNCE POLICYNUMBFA P�UCYEFFECiNE POLICYD�IMTON UMIiS �rn on�n�nomm on�nrnoo�m (iENEM�WB�Ur GENERALAGGFEGATE S COMMEPCIAL GENEPAL LIABILIT' PRODUCTS-COMP/OP AGG. g CWMS MA�E�OCCUR. PERSONAL&ADV.INJURV 5 � OWNER'S 8 COMPqGTOWS PROT. EACM OCCURRENCE 5 FIRE DAMAGE(Aoy one flre) 6 MED.EXPENSE(Any on�prtson) g AUTOYOBRE WBIl17Y . COMBINED SING�E S ANY AUTO UMIT ALL OWNED AUTOS BODILV IWURV SCHE�ULE�AUTOS (Pet Penan� g HIRE�AUTOS BODILV INJURV $ NON-ON/NED AUTOS (Per Accideni) PROPERn'DAMAGE 8 a��WB�Ur AUTO ONLV-EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE g DICESS U�BILI7Y EACH OCCURPENCE 5 UMBPELL4FORM AGGREGA7E g OTHER T11AN UMBREW FORM A WdiKEX'II COYPENSI1710N AND STATUTOPY L1Mff5 EYPLOYEIMSl1ABiLITV (UB-0405682-9-OS) 01-01-OS 01-Oi-06 THE PROPRIETOR/ EACH ACCIDENT 3 ��00 OOC PARTNERS/EXECUTIVE INCL DI3EASE-POLICY LIMR 5 5pp�pp� OFFICERS ARE: X EXCL DI3EA3E-EACH EMPLOYEE 5 10O.00C omEn cesanrnox oF or�unoxsnounows�x�aEsmesrnicnoxs�areeuu irers THIS REPLACES ANV PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CENTIFICATE iidEffER -�ANCELEATION .. ... . :. � � SNOULD ANY OF 7XE ABOVE�DEBGNBEO POLIdEB BE CANCELLED BEFOAE 711E�. � E]�IMiiON DAIE 7NEpEOF, 7HE ISSUINO COMPANYWILL ENOEIIVOR TOIWL TOWN OF VARMOUTH 10 DAVS MIfll7'7EM MOIICETO7HECFA71FlCAlEMdDENIWYEOTO7NE LICENSE AND STICKER DEPT IEFi, BUT FULUNE TO YUL sUcx xoneE a�Wi IYPosE xo Oeuopnox oH 1 146 ROUTE 28 Upg�U7Y OF ANY WNO UPON T7E COYPANY,IT5 AffEN78 di NEPPESENTATVEA SOUTH VARMOUTH MA 02664 AU7Xd11gD PEPItESEtlTATVE ACORII 26-5(3/S91 . . . .. . �` - ��. � . AICOEtG CQ 77gN 19g: TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-093 FEE: 75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter I 11,Section 5 of the General Laws,a perntit is hereby ganted to: James F. Hurley, 119 Route 28, West Yarmouth MA Whose place of business is: Putters Paradise Mini Golf Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2006 BOARD oF HEALTH: ,l� .`b. , M..95., ' eVeeN��us"s`trc�i, .�K, vtr:e e/r�s.xcs� s�cu,g:zero(o) RoLPnt 4. B�, 'C/�.k A�Ma.� ,a�.t �„�a�.,�, R✓v. January 24.2006 ruce G.Murphy H,RS.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-004 FEE: $35.00 This is to Certify that 7ames F. Hurlev d/b/a Putters Paradise Mim Golf 119 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE FOR THE MANUrACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the yeaz commencing with Mazch first 2006 This License is subject to the Rules and Re�ations of the Massachusetts Department of Public Health Relative to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regulations of the Boazd of Health granting Nus License, and to the provision of the General Laws C]�ter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with tfie provisions of Section 65J said Chapter. y P BOARD OF HEALTH:�a��`�. , �M .��uHi��s *Regulation 105 CMR 561.009 requires , monthl late count and colifoan tesls. � �ro�wa � , R.N. January 24,2006 Bruce . Mutphy,MP , , Director of Health . � �d-bb3�'1��lo �, �5-vr�ts Pa'rr��is � r `.'�-"'4 o TOWN OF YARMOUTH BgARD O�HEr�L ��s OPPLICATION FOR � . � ��1$T�- 200 D E C 1 4 Z004 �� * Please complete form and attach all na� cuments by Dece L. _ EPT. Failure to do so will result in the r of your application packet. NAME OF ESTABLISfIMENT ��tT� 1�s A�R�A-t�. �� TEL #�2�`rZ'73�y LOCATIONADDRESS: 1��t Q�- � c�=�-- �LirrG anDxEss �� k ��. . �..��S �1a-� o-�. t�'�- OWNER/CORPORATION NAME: � s l-� � MANAGER'S NAME: t + TFi". #b�`� D 3 MAILING ADDRESS: �c ,� �I- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated --�oe!-0perator{s}en�-aftaeh a�opy of the certif eation to Yhis form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 Tile at your place of business. l. 2. 3. 4. FOOD PROT'ECTION MANAGERS - CERTIk'ICATIONS 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. TLe Healt6 Department will not use past years' records. You must provide new copies and maintai� 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. 2. HEIMLICH CERTIFICATIONS All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Tle at your place of business. 1. Z, 3. 4. RESTAURANT SEATING: TOTAL# O OFFICE USE ONLY LODGING: LICF.NSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT fl LICENSE REQUIl2ED FEE PERMI'L# ._B.@B $50 _CABIN $50 MOTEL S50 _INN $50 _ CAM[' $50 _SWIIviT�IINGPOOLS75ea. __LODGE $50 _ TRAII,ERPARK $50 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQi)IItED FEE PERM[T# LICENSE REQUIltED FEE PERMI1'# �0-100SEATS E75 $f0�O7�c _CON'1'INENTAL $30 NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RETAII.SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQIIIItED FEE PERMIT k LICENSE REQ[JIl2FD FEE PERMIT# _<SOsq.ft. $45 >25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.R. $75 ( FROZENDESSERT $35 ��S'� TOBACCO $25 NAME CHANGE: $]0 AMOUNT DUE _ $ //O�OO •"""*PLEASE TURN OVER APID 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 Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVI'I'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED / OR 1�WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid pno to renewal or issuance of your pemrits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITI'TO RETLJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIlvIENT, MOTEL OR POOL (i.e., PAIN'I'ING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COl�IIvIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and 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 establistunent which serves or sells ready-to-eat,raw orundercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth 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 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 Pemut 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 establishtnent is pro6ibited. DATE: / � � SIGNATURE: � PRINT NAME & TITLE � : � 10/22/04 `� The Comneonwealth of Mwssochusetls � �� Departnrentoflndustria/Accidents Nlk'IN� �' = a 600 R'askingwn Streey f"'Floor ` ,3 Bostoa,Mass. 02111 '"wurlcer.°c�paaatiuw I.se,■«nffia.vn:Bda��g/Plemn�■g/Eketr�cal co■o-,ero.s , . :.. ., , .� _ . . ... ... ... �..�: � , - .,, :;�. . ..:�r , ,, ,;;, ..<<_��...._ a ?n:.•�� a '�-' , r%3 name: ��[`iLr�� . � ... �i�CQ� S`c-�1 .. add�ess: I� d � O '� �,� , n ry citv �� /\ �S PrrT'�" smte: \ 7`��'1— zio: ac�6`P/ohme# �� 3 � wark site locatia�ffnll addressl: ❑ I am a homeowcer perFoiming all woh myself. Prqect Type: ❑New Cm�ructim�Remadel I a sole ��r,,aod have no one workin��m,any cayecft�. B�ril ' Addition . . . . -'�' ' . a� ��.�tk . �. `"P!?$� >��.�.�..,•.��. . , .. ,.:... . :.: ... .. .. ��I am an employer providiog workecs'compensati�f�my�ployees wo�cing oa tbis job. �...,�: p��'�`.P�r3 1 F�'�v-c �1,�-=�--� �.� .�: 11� (�.�,��p �v a�: W - � c�.r—rn,�zs,._�-. NI� ��3�� ZJ� 7 �/-7 � j � � ZZk(3 - NDS �-9�5� �� I am a sole proprietor,ge�erai eo�trxtor,or homeov►�er(cirtk oue)�d have hirod tbe contcactas listed below who have tLe followiag wakers'com�wnsa[ion polices: soe�v uoe• d�eu: dtv �e�: ca M �,z'�. . �,r �:�.,4 . � +�,�_ >. .. ,_ ... . . .. ._. . . . . � �� adtraa• eHc: oMre#_ ca # ,. .. . .. ' . .� "...:- ` ._.. ^ FaYve Y xcve wRa�e a rtq�fuad ude See1N�2SA KMGL LS2 en led b IYe 1�da1�YY peaNb da ese R b Sl.KM a�4�r . �yn..•n�ere..o�...a..a.��d m�dr..t.srorwowcoeoEe..a.e�.rsie�.oe aa,y.�en.�. �ma,a.a mc. apy ef We pa4neY my 6e[erwaNrd!e Ne Omee 11nvMIpWm W Me DIA[or nvenge verllkatlN. /do bereby ce ler�e pd�syw��ihka at Me tnfonwdioe proroiled ebore 6 we o9 conect / Si � ' Date /2 �C�'' �`� P � � Phone S �� 77� -S !��U e�d�l ex oely da eat wrHe Y tW un b 6e onpieted by dly er 4wn a�Ll dlyortawn: perdNieene/ ^'�-" Depaiemmt ❑eheck KimmdWOe rt�eme h'MMdred �SdMd'�Omce ❑tleaM!D�f c�abd Pmoe. Phxe N; �pQ pwuN S�yt 3oN1 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHII�IENT PERMIT NUMBER: #05-0'76 FEE: 75.00 In accordance wiTh re�1 ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the(Ueneral Laws,a peimit is hereby granted to: _ James F. Hurlev 119 Route 28 West Yazmouth, MA Whose place of business"is: Putter's Paradise Mini Golf Type ofbusiness: Food ervic To operate a food establishment in: Town of Yazmouth Perntit eacpires: December 31. 2005 BOARD oF HEALTH: Buc�ixt.s$ (�o3dwg M._`Yi, • v�M�� v:�e�� s�a�g:z�co> a�t�. e�, e� � �l�k, R.N. �4�, R.N. a�„�zi_zoos ruce G. Mucphy, P S.,CHO Duector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-006 FEE: $35.00 Tlris is to Certify that James F. Hurlev d/b/a Putters Pazadise 119 Route 28, West Yarmouth, MA IS HEI2EBY GRAN1'ED A LICENSE FOR TYE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with March first 2005 This License is subject to the Rules and Re ations of the Massachusetts Department of Public Health Relative to the Manufactunng of FROZEN DESS�TS and ICE CREAM Iv1II�, to the Rules and Regulations of the Board of Health ganting this License, and to the provision of the Genera! Laws C ter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with�e provisions of Sedion 65J said Chapter. BOARD OF HEALTH: $ �J,$ G�� *Regulation]OSCMR561.009requires ��j�• e�y�y monthiy plate count and colifotm tests. e��, 6 R � fl.t.� ,�R . January 21.2005 ruce G. M Director of Heal�th� � � '- �#� bb (S► �-I4a � °`�'9 a TOWN OF YARMOUTH BOA D`'Qfi H.,� EALTH � �� r��= APPLICATION FOR LICEN S�t�.1111T -2004 NOV 1 O Z003 ��"'� J ��4� � * Please complete form and attach all nece� tl, dd�?ments by Decem r��/QIQUf&1 DEPT. Failure to do so will result in the ret " f your application packe . NA FOF ST iSHMENT� P/� TT PA-(C_��iSC rYliu , Csc�L� TFi � �s77i735y LOCATION ADDRESS: I I 9 2�i- �g , , y f}-rmo i�-, m ,q �z�,-7 MAILING ADD F44• p D P,c��c y� ��/ A-►� a� �S r�' � M A- D��-12 OWNER/CORPORATIONN E• �1 H-n'�� F �i-��IL�i� MANAGER'S NAME: � (�-�-.�� TFT # S��qp ��Qp Marr IN r ADDRE�S• s�,-,r,t �OL 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 aopy of the certificatioa to this fnrcn. 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 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 MANA �R - RTIPI ATIONS• 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 roaintain a file at your establishment. 1. Z. PERSGN I'iv CHaRGE• Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation. 1. 2, H�IMLICH 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 tile at your place of business. 1. 2. 3. 4, RESTA A T EATIN : TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED rEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN S50 _MOTEL $50 _INM $50 _CAMP $50 _SWIMMING POOL$75ea. _LODGE S50 _TRAILER PARK .550 _WHIRLPOOL S75ea FOOD SERVICF• L[CENSE REQUIRED FEE PERMIT# UCGNSE REQUIRBD FEE PERMIT# LICENSE REQUIRED FEE PERM[T# I 0-100SEATS S75 D�{'dd'� _CONTINENTAL S30 _NON-PROF[T $25 >100 SEATS $I50 _COMMON VICT. S50 _WHOLESALE $75 RETAIL SERVICE• L[CENSE REQUIRED FEE PERMIT# LICENSG REQUIRED FE8 F'ERMIT# UCENSE REQUIRED FEE PGRMIT# _�50 sq.ft. $45 _>25,000 sq.ft. $200 _VHNDING FOOD $20 _Q5,000 sq.ft. S75 �PRp"I.EN DBSSGR'1' S35 d`'�—dO _TODACCO S25 nnMecknrvce: aw AMOUNTDUE = S_ I IO . C�(� *""*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•":.« ADMINISTRATIOPI 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 ATTACHEU STATE WORKER'S CUMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE AT'I'ACHED � 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� NO NOTICE:Permits nut artnually from January 1 to December 31. IT IS YOUR RESPONS[BILITY TO RETi.JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISIIMENTS ARE TO CONT'ACT TH�I-I�ALTH DEPARTMENT FOR INSPECT'ION 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 TE5TING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, ar�d quar[erly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE ('ONSU FR ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERNG 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 Departrnent. FdiQ�El�T I3�SS�ATS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. n � DATE: � l—rJ �(�_ SIGNATURG: • � PRINT NAME & TITLE: �''3'r{��S 10/22/03 � The Commonwealth ojMassachusetu : Department ojlndrestria/.-iccidencs ; Ofllee sllar�st/O�t/iis 600 Washington Street ' Boston. Mass. 01111 " °� ' W'orkers' Compensation lnsurance Affidavit fY� I.FU � nom��. � � 5 L/= � � ��, �� I �'(`�'1 � � m�' (n�,�_rno��a �`� ch �7q� �i �l"DD � I am a hom cµner penurming all work myseif. � I am a solz proprizmr �-� ha�z no one working in am capacit}� `�,Y I am an employer pro�iding workers' compensation for my employees uorkine on this job. Y'�' n � L /�.�� ` , (�(� � comnam namr. 1' �.1/TI��7 �f I� A"�`YG S �: 1 � 1 I A.� 1 �� 1 � ,��«.5: o � � y �'^ tih': � � L 5 [� �( ��!J �� ohone p: � U � / � �� L � ' u ��ch - me�i� ��— �--� (� �i� D ��5��,��o �o��a � I am a sole proprietor. �enerai contractor, or homeowner(circle one! and hace hired the contractors listed beloµ ��ho ha�z thr follo��in_ �corkzr- compensation polices: m nv n address• {�rv- ohone M• insur�nce co �oficv# eomoanv namr � addrc••. tiri• _ phoee M: ��.��.�..�.�� eoRev N . ■ F�iiun to seeurt covenee u required uader Setnoe SSA a(MGL IS2 u�ind to lYe inpriOw o(erisi�fl pe�dtln oh�u ep w 51�00.00 ud/or one ynn' imprisonment u w�ell u eiril penddn io the form o(�STOP WORK ORDER�ed�Oee of SI00.00�d�r q�imt ma I udmmd Hat a topy of thh statemrnt mry be fonr�rdrd to tde ORce of►nveetig�uom af tAe DG for cmen�e reri0utlo�. /da hrreby cenijy un r rhr pains art�a(�itr ojpery'ury thm 1he injonnation provided above is but and cnrrcct Signature ` aie .U' �'� �— Print name � �' '^, � one M �� J C�� ., olTci�l use onl�� do not wri�e in this arn ro be rompleted by cih or Io�vn ollleial tity or town• y�MODT� _ permiNianu M nBuildiog Departmm� pLiceesio6 Bo�rd � theek if immedia�e response if required 261 ❑Seieetmen'e ORce �HedtE Dep�rtmtm - coa�act person: � phoneN;_ �SO8� 398—?231 est. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-020 FEE: 75.00 In accordance with re ations promulgated under authority of Chapter 94,Seclion 305A aod Chapter 111,Section 5 of tLe�eral Laws,a peimit is haeby grffited to: 7ames F. Hurley, 119 Route 28, West Yarmouth, MA Whose place ofbusiness is: Putter's Pazadise Mini Goff Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Pernut e�ires: December 31. 2004 BOARn oF HEnLTH: B�a�in$. Qo�icpi+�c,M.`.b� n�.aa�,�rt, v� Seating:Zero(0) Ro�eAt�. B3orwa, �e/i�s � R.N. November20.2003 iuce G. Murp ,MP ,CH Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-003 FEE: 35.00 This is to Certify that James F. Hurlev d/b/a Putters Pazadise 119 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE FOR THE MAN[JFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with Mazch Srst 2004 T'his License is subject to the Rules and Re�ations of the Massachusetts Departrnent of Public Health Relative ___ __to the Manufactu�n�of FROZEN DESSERTS and ICE CREAM��{� to the Rules and Re��'ons of the Board of Heaith granting tTris License, an�to tfie provision of ihe Gener"-1 a Chapfa�-94 as mnende�Gy Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with tFie provisions of Section 65J said Chapter. BOARD OF HEALTH:�QtLi�i c��Uf rai�vxa�c *Regulation 105 CMR 561.009 requires montlily plate co�mt and colifoim tests. Q� . B R . November 20.2003 ruce .Mtup y,MPH, . Director of Health � �°`a R o TOWN OF YARMOUTH BOARD OF HEALTH;--��%- �� '-;s APPLICATION FOR LICENSE/PF,�I�NiIT= 2003 �j ' u v' �:;; lDI �,;. �y,-: ti „}�� ;y,t t � � n J * Please complete form and attach all necessaryFlocu�ients by�I�ece ,er 31, 200 ��"" Failure to do so will result in the re�tg't�,o t'your application pa k��EA' T'- ��{=uT i � � NAME OF EST�RLIS FNT• P �TT �� aR ani�7= ��N� �.,.�� TFi #5 oR�"�I '7'�q��/ LOCATION A DRFS : 119 RT a8 � .�f�Rmp u�I-1 � m A L�aL�7_ MAILINGADDRESS• P(> (bD '-�$ N-l)F�-f1ntS PneT mR �2-l0�!'7 OWNER/COIZPORATION N MF• �T�-ryi�5 F' }.�t i 2L�/ MANAGFR'S NAME• SA1Yt T i #S'p$'7qi��JcY� MAILINGADDRESS• SA-rn POOL CERTIFICATION • The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) andattach a copy nf The-certificatio�to tkus forni.- _ 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health 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 MA A ER - C RT FI ATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2 PERSOI�T IN AR[',F• Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2 H�IMLICH CERTIFICATION�• 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. l. 2 3. 4. FSTA RANT EATiNC': TOTAL#�_ LODGING: OFFICE U E ON •Y LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 � _CAMP $SO _SWIMMINGPOOL$SOea. _LODGE $50 _TRAILER PARK $50 _WH[RLPOOL $25ea. FOOD SERVI(' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100SEATS $75 63'6�6 _CONTINENTAL $30 _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. a50 _WHOLESALE $75 RFTAP�FRVICE LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 I FROZEN DESSERT$35 �Q�3 NAMECHANGF.� $]0 AMOUNTDUE _ $ I�O .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT 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 prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISF�vvfENTS ARE TO CONTACT THE HEALTH DEPAR'I'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. A1>DITIONAL 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 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 wluch serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health 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 dessefts tnust�ie tes e�on a mouthly�iasis by a State 6ertified Iali. Test results must be senf to the I�ealth Department. Failure to do so will result in the suspension or revocation of yow Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. niJTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: �1-U$-D� SIGNATURE; �� ' ` PRINT NAME & TITL�: 10/18/02 � � The Commonwealth ojMassachusetts � Deparfinent ojlndustria/.-lccidents ; 0//IC001/ereSdOsWIf 600 Washington Slreet ' Bostort. Mass. 02111 ` �� • W'orkers' Compensation Insurance Affidavit A�olicant information: PleaseYRI1VTTedGi�t�r n�mi� �A"YYIFS � �lA_Q. `U �v��«nn P� (�ox y� •� �(1\S �6R f fY��}" � n a-(s�`-f� ehon tIS�� 790 400 � I am a homecwner pzrt�rming all work m}selE � 1 am a solz propriztor �c,', ha�z no one ��orking in am capacin• (�, I am an emploiu pro�idins workers' compensation for my employees working on this job. comnanr name• �lATrrl�S P�A'�1`J�t-, YYl l N l ( F-G� aildress: �� q ��_ 01-� sjt : �u.-c ,�p� D.�-1o7� �nooea• �R '7"11 -739� insur�nce co 2//�c /CLf�-�/YIGQIC/-h'I C../�� policv p jo Z.Z,[AQ -�O/�.��"71-Q-� � I am a sole proprietor. qeneral contractor, or homeowner(circle anel and ha�e hired the contractors listed belou �.ho ha�e thr follu�ein_ ��orkzr> ,ompensation polices: comoanv name: Tddresr. citc: ohone H: insurancc to. pelicr# tomnTnv name• addrees• � � [�y: �hoee M• inivrance co. �oliev p e Failure ro secure coveraQe a requtred ueder Secnoe 25A of MGL IS2 u�Ind to t!e i�pori0oe of trisiul peultlea oh O�e ap ro SI�00.00��d/or ooe ynn'imprisonment��w�dl aa eiril pemlNn io the lorm of�STOP WORK ORDER aed�Ilee of f100.00�d�r q�imt me. [a�dmh�d�l�t a copy of thH shtement m�y be fonvvdrd ro the 0lffee o(InvnNg�uom of tEe DIA(o►coren�e veriffatlx � I da�hrreby cenij}�+�nder rhe pains and oertal�ies ojperjury that tht injornmlinn provided abovt is tntt and corrcct � (/ / Signaturc��/.,,,. �� Xi�.i'�-�'� Date Il-�R-Oa.. Printnam� oneM .�� 7�(C� 3yvU .� aRci�l use onh� do not�rite in this aro�ro be completed by eiry ar rown o01eia1 city or town: YARMO�TQ permiUliceme p nBuildinL Dep�rtmeot ❑Lieen�iog Boud � check i(immediau response ie required 261 �Sdettmrnb ORae (508) 398-?231 Cat. �HedtE Depanmmt contac�person: phone M;_ __ _ nOlher TOWN OF YARMOUTH BOARD OF$EALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-016 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter ll 1,Section 5 of the General Laws,a pernut is hereby ganted to: James F. Hurley, 119 Route 28, West Yazmouth, MA Whose place of business is: Putter's Pazadise Mini Golf Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pernut espires: December 31. 2003 soARD oF HEnI,T'H: �4w�lea�, ze!likox, �abu,�aec � D. Cje�da�c �ll.D.. 9/ree seating:zaro(o) , ,�a�. '�'eae�c, �E �a�tlek7K�IJar�att �� s�. ��. November 20 ,2002 ruce G.Murphy, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT N[JMBER: #03-003 FEE: $35.00 This is to Certify that James F. Hurley d/b/a Putters Pazadise 119 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE FOR TIiE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with March first 2003 — - This Lie�se is subjceEto-the�tules a�R ions ofthe Massachusetfis Denart�rtent o€-I��lic H�1th Relative to the Manufactunng of FROZEN DESS�S and ICE CREAM MII{, to the Rules and Regulations of the Boazd of Aealth ganting this License, and to the provision of the General Laws Chap ter 94 as amended by Chapter 373 ofthe Acts of 1934,and may be revoked or suspended in accordance with tFie provisiom of Section 65J said Chapter. BOARD OF HEALTH: �a r?�, '�elli/t�t. (� "Regulation 105 CMR 561.009 requ'ves o�� D ej/� �� monthly plate count and coliform tests. �� '� Sk , �yl. November 20.2002 ruce G.Murphy, p Director of Health ' . Pu„�`s Pa rua��s E ''�� " TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2002 �dd' 70 f�'//D. GTV R,.. * Please comp?ete form and attach all necessary documents by December 31, 2001. Failure to�o�a�h��°-iesult in the return of your application paeket. ' NAME OF ESTABLISHMENT: �'�/�.�5 �l-IrF'/��/Sr TEL. # Sz-9, �7/�3iy LOCATION ADDRESS: //% �tc-':a�� tJ yd�%I'�t%Gl77t /!7/� f��21c�3 MAILING ADDRESS: �'� ,�'D,e S/d h�s/.��JJiS ,�'c�✓�u �/� �� /7 OWNER/CORPORATION NAME: .Ti?ty�FS F /�i�.5'L cZ! MANAGER'S NAME: �%�nF' T TEL. #SZ��' �9�35/E�t� MAILING ADDRESS: � ��5? /�/_ /�,�12'T.�� z� Y% 6��' �7iT�-3s,� 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 currently certified in basic water safeTy, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your plsce of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CI�ARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. Z• 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQU[RED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN $50 _MOTEL $50 � INN $50 CAMP $50 _SWIMMING POOL$SOea LODGE $50 TRAILER PA2K $50 _WHTRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T k LICENSE REQUIRED FEE PERMIT# I 0-100SEATS $75 Oa�/ _CONTINENTAL $30 _NON-PROFIT $25 NOO SEATS $150 COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEl' PERMIT tt LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 �FROZEN DESSERT$35 '�$r}—!� NAME CHANGE: $10 AMOUNT DUE _ $ I/O. OO •**•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �1�Z �S I ADMINISTRATION r 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 � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISI�vIEN"I'S 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 tesYed 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 swimining pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departrnent 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),mus have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. /I /— DATE: I(-�'-�I SIGNATURE:/'j� i�v,� � � t.�v�-1� , PRINT NAME& TITL�:-'"�� :i}�,�v�a =� � .4}�1 _i�.. ��q� � 09/1 I/O1 . . � The Commonwealth ojMassachusetts : Department ojlndustria/.-lccidents a 011lte 01/areStlys/Ji/f 600 Washington Street � Bostort, Mass. OZlll �" '"� '` W'orkers' Compensation Insurance Affidavit Aoolicant information: PleanYRIlVTTesGida n�m��. "—L.Prrv� �� -(.�-2� . loc�tion�. p(` �iL- x �t� cm l{4H�t-%1-% �5 �L,YT �/1/-� ri�/.. N7 ehonex�Z��E `7�C� 3�� I am a homeoµner pzn�rtning all µork myself. [� I am a solz proprieror �r.,', ha�z no one ��orkin2 in am capacity � 1 am an emplo}er pro�idins workers' compensa[ion for my emplo}ees workine on this job. comnam� namr �l-l-T��US i`�F�T('�(.S� (Y�� l-� � �`��-� addrecs� I 1 �j Zfi� �-`G �ty� 1 ti% (a-1�Lt,M �''Z� L�� (�=�-(_. 7 3 ohone q• `�`Z�� 7 7 1 -7_'� t �-�_ � q insur�nteco �✓/t%:,4//d7� � ��IJ�/U'if ��% C%l�. poficyb ti�'� �� '�/��/'-��-� �� I am a solz propriecor. _eneral contractor. or homeowner(circle one! and hace hired the contractors lisred belou �.ho ha�e the folluu in_ ��arkzr ;ompensation polices: com{Lv n me• - �dress• �� ohone N• insur�ncc co policr M comoanv name• addre • ciri ehoee 16 � insarance co °O��K — e Failure to�ecure covenge�s reqmred uuder Secnoe SSA o(MGL IS2 u�Ind ro Ibe iapaidoe o(enaiW pesdtln oh��e op to 51,500.00 ud�or oae yein' imprisonment u well u civil pendtln io the form of�SfOP WORK ORDER aed a flee of SI00.00�d�r Ktiost ma t a�denn�d t6u■ eopy of tAb sutemen�m�y be(or.v�rded ro the Oltfet of Invatlg�Gom of tAe DU tor emera�t verillnUo�. /da hrreby certijy nder thr pains and prrtal�ies ojperjury rhm tha injonnalion provided above is tiue and tanect Signamrc � � � �� i / � -- Printn �- c '" /-9 � PhoneN G7,�� c� -3�/dCi .• oRd�l use onlv do na�.rite in tAis arn ro be oompleted by eity or low�n alfltial citv or town: Y�M�L/'fQ _ . permiUlitenee M nBui�dioe Department - �-- �Liceosiog Bovd p check if immediate response ie required 261 ❑Sdatmm9 ORee �Huilh Dep�rtmmt canlactperson� DhontN•_ �SOB� 398+2.Z31 eEt. nOther TOWN OF YARMOUTH BOARD OF HEALT'H PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #02-031 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby ganted to: J mec F Hurley,119 Route 2R West Yarmouth_ MA Whose place of business is: Putter's Paradise Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2002 BOARD OF HEALTH: L/lw3fea�. ZelluFr�, ekaisara.a ��ri.c D. C�o�rdoa, '�K D.. 2/1ee Seating:Zero(0) ��• �� .« �a0uek'�7Pc?�r�uxn2Y '�dea Slak. ,��Z. Februa�y 7 ,2002 ruce G.Murphy,MPH, ., Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMITNLJMBER: #02-002 FEE: $35.00 This is to Certify that James F. Hurlev d/b/a Putters Paradise 119 Route 28, West Yazmouth, MA IS HEREBY GRANTED A LICENSE FOR THE MANUFACT[JRING OF FROZEN DESSERTS AND/OR ICE CREAM 1VIII� For the year commencing with March first 2002 This License is subject to the Rules and Re�u lations of the Massachusetts Department of Public Health Relative to the Manufacturing of FROZEN DESSERTS and ICE CREAM MDC to the Rules and Regulations of the Boazd of Health�r anting this Liceose, and to the provision of the �'ieneral Laws Chapfer 94 as amended by Chapter 373 of the Acts of 1934, and may be revoked or suspended in accordance with the provisions of Seciion 65J said Chapter. BOARD OF HEALTH: �rcufea r'�f. 'Cefli�ea, �aGraxasc *Regulation ]OS CMR 561.009 requires 8e.r� D. C�azda.�, ylL.D.. ?/�ee �tvrsxax monthly plate count and coliform tests. �a6att� �'zou.a, (,le� �aauek'�'JfdDar�ratt �efe�c Skak, R.'�Z. February 7_2002 ruce . urp y, . ., Director of Healtt� ;. �, _ t_�, ✓77E2S OqQRDtSE MiNi Gat.F TOWN OF YARMOUTH � ��,H'�A�.� Q C� C�' Izs � M C� � APPLICATION FOR LICE /P�I'�"'200� D E C 1 4 2000 ' Please complete form and attach all necessary documents by December 3�,�2 0 F lui'�Q��d'ppi�igsu in the return of your application packet. --------------------------------------------------------------------------------------- --------------------------------------------- � � T P r-r s P ��s� ��n i � � �o�F � �--- � z rn o ' � � i o OWNER/CORPORaTTnN N ivrE• � s s C � .� �2��-,� , MATTIN . D F 9• p(j Q,dy y� �0 � �S � � � —�-�1�_Q/r(L1 /1�E4- l�,�(o �rl ---------------------------"'-------------------------'-'--------"_------------'------_"-------'----------------------'--------"----- POO . . RTIFI ATION • The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. I. 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 Heaith Department will uot use past years' records. Yoa must provide new copies and maintain a file at your place of business. l. Z. 3. 4. HE M .ICH C RTIFI ATION • All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking pmcedures 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 file at your place of business. 1. Z. 3• 4. RESTAURANT SEATING: TOTAL# D NON-SMOKING SEATS: TOTAL# U ----------------------------------------------------------------------------------------------------------------------- OFFICE USE ON Y i 01�GING: LICENSE REQUIRED FEE PERMIT# LICENSE REQ[JIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOT'EL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVI F• — NOTE: Per t6e new 105 CMR 590.000 State Sanitary Code for Food Estsbtishments,the effective date for food protection manager certification is October i,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# / 0-100 SEATS $75 ��_O(a3_ _CONTINENTAI, $30 _>100 SEATS $150 _NON-PROFIT $25 _COMMON VICT. $50 _WHOLESALE $75 �T RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $2p _<25,000 sq.R. $75 / FROZEN DESSERT $35 �S'6I -p0 _>25,000 sq.ft. $200 N �. AN �• $10 AMOUNT DUE _ � //0.bo **•`*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ..w.+ _._ . _ � ADMINISTRATION Under Chapter 152, Secrion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any,license�or peniiit tp 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 2 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Pernuts 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, 2000. SEASONAL ESTABLISHMhNTS ARE TO CONTACT THE HEALTH DEPAR'I'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG 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 RFGULATIONS POOLS POOL OPENING: All swinuniug,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 standazd plate count by a State certified lab, prior to opemng, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swiimning pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODF FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certiticarion is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection manager. This 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 Conswner advisory,Food Code 3-60311,will be implemented January l,2001. Only establishments which sell or serve ready-to-eat, raw or undercooked animal products are required to have consumer advisories. CATERiNG POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depariment by filing the requu�ed Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FR(17FN DF$SERTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failute to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. niJTSIDF�S_ Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. oIT'�'DOOR COOKiNG: Outdoor cooking,preparatton,or display of any food pmduct by a retail or food service establishment is prohibited. DATE: � �� g-�SIGNATURE:�� / PRINT NAME &TITLE: �e�a�/� ��/�1� l'� �r'�'��'� 11/16/00 � . � The Commonwealth ojMassachusetts : Depar�ment ojfndust�ral�ccidents a 011lceo/%vestl�stliis 600 Washington Slreet Bnston, Mass. 02111 '"�y,y W'orkers' Compensation Insurance Atfidavit ARplicant information: PleasePRIlaTTedi'hi�¢ namc� �f)YYI�i �. -E-�tA(LL� ��/ C�UTI"�'�S PA'(�'�IS f Y�'1 f� � �r0,� �— I t�on� 1l� �-P �� l✓�qi �° !� �b�i4� �iAvlaiS� �IN�'� Y�'ll4 ��'647� cjt• L �-��'1i1 r`� (A -� ,1 � D,�% �� phone p ��'/(� 3 HOO � I am a hom oµner pertorming all work myself. � —� � I am a solz proprietor �cd hacz no one��orkin_ in am capaciry � I am an employer pro�idine aorkers' compensation for my employees workine on this job. com,Panr name• �l�yj !C�( �Q�%lGKl�t// �iLiS /��Cza�t L'O 3Jdress• �/l �� ,• �"'"'�,-� nn � i � � �� yhonep: insur�nce co ,� -�� ^ �-� ` �policy N �� 5�.��' �� ' �7t�`U � I am a sole proprietor. oeneral contractor, or homeowner(cirde onel and hace hired the contractors listed belou ��ho ha�e thz follu�cin= �corker compensation polices: companv name• �dress• _;...� yhone k• insur�ncc co Dolity# m an •adr �y phoee q• .�.. eoli v N F�ilure to secure covengt as required uoder Seerioo 25A of MGL 152 ue Idd lo t6e iopai800 of erioiul peadtla of��e up to fl¢00.00 a�d/or one ynn'imprisonment��well aa eivil penilHe�io thc form at�SfOP WORK ORDER�ed a 6oe of fI00.00 a d�y apiost me. [a�denta�d tLt■ topy of�hia snlement may be forwarded to the ORce ot Inve�tig�6om otthe DIA tor eovengt veriRtadu. /do hrreby certijy�nder rhe pains and p nalties ojperjury fhat�he injormalion provided abovt is true and coned SignaNre '-�/ � � 1� -a S—d<� Print name.� Fis Fa'lA Phone# S�� `�`�� 3 y�� ., otlicial use anl�� do not wri�e in this arn ro be completed by eiry or rown oflieial city or town: Y�M�DTQ _ permiNicense p nBuildiog Departmem � OLietosiog Bovd p check if immediah response is required � 261 pSdectmen'�ORee pHcalt6 Dep�nmeet contact person: phone p;_ �508} 398�2231 ext. nOther IrmuM i,v5 PIAI � a1:OI:De CERTIFI�ATE t?F 1NStJRANGE ' °�R`""�°°�"� � 11-OB-00 PPODUCEX THIS CERTIFICATE IS ISSUED AS�A MATTER OF INFORMATION �� ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE oow�inl� & o NEIL iNs acc HO�DER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 222 wEST MAIN 57REEr ALTERTHECOVERAGEAFFORDEDBVTHEPOLICIESBELOW. v o sox �sso HYANNIS MA 02601 COMPANIESAFFORDINGCOVERAGE COMPANV 22LGR A 2URICH AMERICAN INSURANCE COMPANY INSUHED COMPANV HURLEV, JAMES g OBA PUTTERS PARADISE COMPANv PO BOX 48 HYANNISPORT MA 02647 C COMPANV D C61lERAtiES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR��THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY RE4UIREMENT, TERM OR CONDRION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIRC.4TE MAY BE ISSUED OR M4Y PFR?AIN, THE INSURANCE AFFORDEC BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO HLL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. �� TVPE OF INSURANCE POLICY NUMBER P�UCY EFFECiNE POLICV QPIfiqTION �JMITS DAiE�MNWD\VY) DATE�IAM\UD\Y'� CaENEXALLWBIl1TV GENEPALAGGREGATE $ COMMERCIAL GENERAL LIA9ILITV PRODUCTS-COMP/OP AGG. $ CLqIMS MA�E�OCCUR. PERSONAL&ADV.INJURY g OWNER'S&CONTRACTOR'S PROT. EACH OCCURPENCE g FIRE DAMAGE(Any ane firo) g MED.EXPENSE(Any one person) § AIITOMOBILE LIABIl17V COMBINED SINGLE $ ANV AUTO LIMR ALL OWNE�AUTOS 60�ILV INJURV SCHEDULE�AUTOS (PerPerson) $ HIRE�AUTOS � BODILV INJURV NON-OWNEDAUTOS (PerAccitlent) § PROPEHIY DAMAGE $ GANAGE 1JA81117V AUTO ONLV-EA ACCIDENT $ �ANV AUTO OTHER THAN AUTO ONLV: � EACH ACCIDENT $ AGGREGATE g IXCE55 LIABIIIiY EACH OCCURRENCE $ UMBREiLAFOFM AGGREGATE S OTHEFTHAN UMBRELLA FOPM A WONKEq'SCOMPENSA710NAND EGPLOYEN'SIIABWiY (UB-575X521-3-00) 01-01-00 01-01-01 STATUTOFVLIMITS THE PROPRIEfOR/ EACH ACCIOENT $ 1 OO,000�� PARTNEFS/E%ECUTNE INCL OISEASE-POUCV LIMIT $ 500,OOO OFFICERS ARE: X EXCL DISEASE-EACH EMPLOVEE $ 100,O00 on�ea OESCNIPTION OF OPEMilONS/LOCATIONS/VENIClES/11E57ii1CT10N5/SPECULL IiEMS THIS REPLACES ANV PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CPHTI£I�ATE H€IEDER GkNCELL71'k[UN SNOUID ANV OF 7NE ABOVE DESCNIBED POl1QE5 fiE CANCELLED BEFONE TiE �� E1IPIqA710N DAiE iHEflEOF, iXE ISSUIXG COMPANY WILL ENDEpVOq TO MNL TOWN OF VARMOUTH 10 DAVS Wfi1TlEN NOTICETOTHECEq71FICAiEXOLDEpNqyEDTO7XE ATTN: LICENSES 1146 ROl1TE 28 ��. BUT FAIWflE TO MqIL SUCH NOTCE SHqLL IMPOSE NO OB4Op710N ON SOUTH VARMOUTH MA 02664 �B�47VOFANYNINDUPONTiECOMPoIXY,IT5A0ENT50qpEPHESENTA71VE5. AUiHOXRED fiEPPESENTA�� ACbR625.S(3195) ��b�6C0 :.�, l9S3:��. / y�IeaH3o lo��anQ O � `'S `HdY�I `�ydmy� •rJ aonig [OOZ` 6 qa '¢' �� '"�y�Ol?, 0 3�'�?'1tG �7 �'c�i fi �� 0)aaZ:�a�leas • a'•'� ''�l'�'�.' "�: �l''»'l� 7°bfJ47�'�( '�� 1�� H.L'IH�H 30 Q2IdOg TO Z I£ QuTa Q :sazrdxa�tuuad �nocu.��3o uxoZ :ui �uaun;stiq�sa poo3�a�eiado oZ a��,uas poo3 :ssauisn43o acLiZ 3to iuiy�astp d s�i nd st ssautsnq;o aoz�d aso� :ol pal��qa�aq s��cuc�ad e`sme7�eaava�ay�}o s uo�i�as `�� aa�dey� PT�VSO£u�!3�aS `b61a�dey�30,C�uoqarie�apun pa3E��nmoid suo�lE��ai y��,H a�uepio��e uI 00'SL ��3 £9��?I3HY�If1N.LIY�RI�d .LNI�L�IHSI'IHt'.LS� Q00,3 � �.LV2I�d0 O.L .LII�I2I�d H.L'I��H 30 Q2IVOg H,Lf10NRI�A 30 NIMO,L THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMITNUMBER: #01-003 FEE: $35.00 This is to Certify that James F Hurletd/b/a Putters Paradise Mi ' olf 119 Route 28, West Yarmouth, MA IS HEREBY GRANTED A LICENSE FOR THE MAN[7FACTURING OF FROZEN DESSERTS AND/OR ICE CREAM D�III� For the year commencing with Mazch first 2001 This License is subject to the Rules and Regulations of the Massachusetts Department of Public Health Relative to the Manufacturing of FROZEN DESSERTS and ICE CREAM MIX,to the Rules and Regulations of the Boazd of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934, and may be revoked or suspended in accordance with the provisions of Section 65J said Chapter. BOARD OF HEALTH: �d�1L �eh'ea, (�� Regulation 105 CMR 561.009 requires ��l, z� v� �� monthly plate count and coliform tests. ��, �q�y GJ(�k �ael d :C' � D. . �K. F ru 9 2 1 Dir ctor of Ha Itl�i � ' . jti�� le'�'�=> t��cAc�,��_ ' -_ TOWN OF YARMOUTH BOARD OF HEALTH G31� !� � � M '' D APPLICATION FOR LICENSE/PERMIT, 2000 �'I� D E C 0 3 1999 ��5 � `�° * Please complete form and attach all necessary documents by Decemtier 31, 1999. Failure t EAL7 DEPT. the retum of your application packet. -------------------------------------------------------------------------------------------------------------#----------------------- F I NT: � � ) T LO ATI - LIN D D v �� OWNER/CORPO aTr N N �� f�m F� r= .�a i2�i�-{ IvIANAGER'S NAME S I�-vY�� T #T�0 ��l aD MAILING ADDRESS: �r'F-w�F � --------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONC The pool supervisor must be certified as a Pool �perator, as re�uired by new State law. Please list the designated Pool Operator(s) and attaeh a copy of the certification to tivs form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd F'ust 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. HEIMI,ICH CERTIFI ATION All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your empioyees 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. 2. 3. 4. REST�iTRANT SEATING: -TOTAL# NON-SM�KINC'i SEATS: TOTA,L# _ _ - - - -------------------------------------------------------------------------------------------------___. OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _B&B $50 CABIN $50 _INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 _MOTEL $50 SWIl�IMINGPOOL $SOea. WHIltLPOOL $25ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 Y2K-4� CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 WHOLESALE $75 AETAIL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT # _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 I FROZEN DESSERT $35 y�-2 _>25,000 sq.ft. $200 NAME CHAN E: $10 AMOUNT DUE = $ I I C' — , '•""•pLEASE TURPi OVER AND COMPLETE OTHER SIDE OF FORM•'••" ; ', � ADMINISTRATION �- � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOLTI'H IS NOW REQUIIZED i TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A � PERSON� OR EOMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVII' MUST BE COMPLETED AND SIGNED, OR I (` CERT. OF INSURANCE ATTACHED� b�,��t1 Yl"1G�-P,(� �?�YYI � '1 !�.,. WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �1 � �� 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 JANLJARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBII,TI'I' TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF3MENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISFIIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMl�fENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWID�vIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMN�VG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIItED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TF� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHL,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII.Tf�ABOVE TERMS HAVE BEEN MET. _ O 1T IDE CAFES OITTSIDE CAFES (i.e, OUIDOOR SEATING WITH WAIT'ER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OiJTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHIvIENT IS PROHIBITED. ,.� nA�: /� -/� �� srGrrATux�:�—��i�� ; `t � � PRINT NAME& TITLE,;�"_��_� �'l�,�Z-�� P�I J!-�F i 11/12/99 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-40 FEE: $75.00 In accordance wi[h regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 i, Section 5 of the General Laws,a permi[is hereby granted[o: James F. HurleX, 119 Rnute 2R West Yarmouth, MA Whose place of business is: Putters Pazadise Mini Golf Type of business: Food Service To operate a food establishment in: Town of Yarxnouth Permit expires: December 31, 2000 BOARD OF HEALTH:�'�{�/. �et�age, C'�at.,q,,/��nq � n/ �I�Jaan�c 7�Yu�llivan�/��9 //l.� Vice l�hairma Seating:Zero(0) I'Ca�erf aJe .�9,7ro/mpn, l,le,r/n a6rialle JakoG��y-✓�tooPed �� n December ]5 , 19 99 Bruce G. Murphy,MPH, R. ., C O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-2 FEE:_$35.00 This is to Certify that James F. Hurlev d/b/a Putters Pazadise Mini Golf 119 Route 28, West Yarmouth,MA IS HEREBY GRANTED A LICENSE FOR THE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with Mazch first 2000 This License is subject to to the Rules and Regulations of the Massachusetts Department of Public Health Relative to the Manufactuing of FROZEN DESSERTS and ICE CREAM MI}C,to the Rules and Regulations of the Board of Health granting this Licease,and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acu of 1934,and may be revoked or suspended in accordance with the provisions of Section 65J said Chapter. BOARD OF HEALTH: �i� �Y��+. .�petgfega, C�iaa�qnq,aa� � /� •Regulation 105 CMR 561.009 reyulres oan G. JuCCivan� �//.� Vice l,�irmart monthly plate count and coliform tests. o6art.� �rown, C�er� a6.��p Sa�/o1��y/-.g�llaoPe� l O d hLin December 15. 1999 ruce . urp y, , . ., Director of Health . �,�#�c�� Narc�C-iis� . ' * TOWN OF YARMOUTH BOARI?,OF �EALTH C�"�� Q � � C� O N/ C�S DD APPLICATION FOR LICENSE/PERMIT- 1999 pE� O � t9gS * Please complete form and attach all necessary documents by December 31, 1998: Fail ektEdtiTd-►�1�i(�Tat � the retum of your application packet. ---------------------------------------------------------------------------------------------------------------------------------------- NAME OF ESTABLISHMENT: �L11Z`c-25 �A-R-f}�cs: TEL. #�zc �•1 � Z34�f LocATrorr AnD�ss: �� g �+� �v=; w y r�,�,�. nn � c�a� �� MAILING ADDRESS' P o i3c� x �l Ss- l+y a�n��s �'c �2-� v�� o,��y 7 OWNER/CORPORATION NAME _��F�n�sS � r+�u2��y � MANAGER'S NAME s�� TEL. # 5�� 7 ti e �y vv MAII.INGADDRESS� �o (��k `i� �v�it �ir!'T tMt�- �,�� (�� -------------------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tivs form. 1. 2. Pool operators must list a minimum of two employees currernly certified in basic water safety, standazd First Aid and Community Cazdio�ulmonary Resuscitaxion(CPR). Please list these employees below and attach copies of employee certificahons to ttus form. The Health Department will not use past years' records. You must provide new copies and maintain a 51e at your place of business. 1. 2. 3. 4. 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-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. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# -------------------------------------------------------------------------------------------------------------------------- t3FFIGE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERNIIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 _SWIlVINffNG POOL $SOea. _WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # �0-100 SEATS $75 — � _CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 CONIMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,OOOsq.ft. $75 �FROZENDESSERT $25 q9-I _>25,000 sq.ft. $200 PiAME CHANGE: $10 AMOUNT DUE _ $ 1� — "•"""PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM*"""" � j � � ADMINISTRATION LJNDER CFIAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOiJTH 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 COMI'ENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ` � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA7�S AND L�ENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK A�'ROPRIATELY IF PAID: YES � NO NOTICE: PERMITS RUN ANNLJALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETiJRN TF� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIlbIMING, WADING AND WHIItI.POOLS WHICH HAVE BEEN CLOSED FOR Tf IE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMEN'I',AND Tf�WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENRVG, AND QUARTERLY TI-IEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIl�IING POOL MIJST BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TENIPORARY 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 MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTII,TI-�ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAF'ES(i.e., OUTDOOR SEAT'ING WITH WAITER/WAITRESS SERVICE),MIJST HAVE PRIOR APPROVAL FROM Tf� BOARD OF HEALTH. OUTDOOR COOKING: OLJTDOOR COOKING, PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHR�NT IS PROHIBTTED. DATE: �� SIGNATURE: � � �� ; rxrivT NaME � Trr�.E:� / 'S l�'��5 �r H�.�-2�C_t�t c.`��2- , ; , w � The Commonwea!!h ojMassachusetls � Deparlmen!ojlndustria/.-Iccidents ; 9Mce o//sresUisWis 600 Washington S1ree1 Boslan, Mass. 02111 W'orkers' Compensation Insunnce Affidavit Agplicant informaHon: Pf +� PRI1aTTi�.F: nam�: �Wlry' G� � ,�� . � . . .-- - - � lucation: � ( GI . 9lJT�Q r��6 I� ��. U) l.l fl�YY��t,t,`l�-I� 1�'1� �_''�l 73 i� pnone p � I am a homeowner p rtortning all work myselE � I am a sole proprieror �cd hacz no one «orking in an} capaciry �m an employer pro�idin� workers' compensation for my employees uorking on this job. comnan�� name: � ��AL7� �� fy'<IJ6�� address: �V �JV �C. � c�c.: ��M f� I. S 1�� 1�� w' (��Lo N� ono�e a• 5�� 7 �l D � 7��b iqsurance to � �� oolicy k l I ' l l Y1 � �� 1 �/ y �f��/) � I am a sole proprietor. general contractor, or homeowner(circle onel and have hired the contractors listed below �.ho hace thz follo�cing �corker_ ;ompensation polices: company name: address: s��: ,yhone q: � insurancc co. poliey# eomp2nY name: address: __ _ __ _ _ ___ _ —_ - -- — _ -- — — - t�: p6oee M• insuraneeco. neRev p F�ilure ro secure covenQe as required under Secdoa 25A o(MGL IS3 a�Idd to tYe i�paidoa of erisiul pe�dtla of�O�e�p ro SI�00.00��d/w � one ye�n'imprisonment a�w�ell a�civil pendHa io the form of a STOP WORK ORDER�nd�6oe of f1B0.00�dty qHo�t�e. I udenh�d ILt a eopy o!thy statement may be fonvarded to the Ofliee ot Inve�tiQidoro of the DIA for emen�e verilladw. . /do�hrreby cenijj•�nder the pa� d e al�i�s y/perjury that�he injormatine providtd above is nue and correct Signazur � / � ��jl� i � Printneme �_5 one# .�� G� J� l�l� .. ofiicial use onh do nat.ri�e in�his arn to be tompleted by eih or lown otlltial city or town: Y��DTfl permiNiceex N nBuildiog Department pLicensiog Bo�rd �check if immediate response is required Z61 OSelectmen'�Offfee (508} 398�2231 eat. OHe�it6 Dep�rtment con�au person: pAone M;_ __ _ nOlher Ua n¢E iA}PIAI 12-0�-9& 2'HG i7£y:1U FAS 508 ?7S 121@__ DOWLISG �,_4'Az.IL. ___,_ �00.^, ' � LITY INSURANCE I �A��MM/UUrt!} 1�QBt�:. ` CERTIFICATE O� LiABI iz�,.z;sa PRCOUCER � �'� THIS CERiIFiCATE iS ISSUEO AS A MdTYER OF tNFORMATION DOWllri� oe O' ?�Tg].1 Insura.nCe j ONCY AN� CONFEpS NO RIGHTS UPON THE CERTIFICRTE AC@Y1C1�, IX]C. : NOL�EH, THIS CERTIFiCA7E OOES N07 4AfIEND, EXTEN� OR 2?2 �vESC h731ri a^t . PO Box 7.99Q �.� �TER THE COVEFAGE AFfOR�p BY THE P4L{CIES BELOW. �jJdTl?115, MFL Ci7_601 '�. INSURERSAFFOpbINGCOVERAGE ..___. . . . _.... .. ____—._—'_..... . . �� INfUREO - . . . . .. ._. __...._ . . _......_.__ . �dRtes �IuY':l�y' D�S�A I irvsunean U.S .r . & G. � _ __ _ Putters �aradise Golf Coursc ��"�"E"e Ir— _._— IP.O. BOx 4B I rrvsunenc . ,. _ . �FIyannis Pcrt, MA 025i7 ��s�RERa _. —. �IN5unER Et COVERA(�S '�'HE POLiCIE30FINSUHqNGE LISTED 3ElOW HAVE BEEN i990-p 76 7FE INBUREQ rvP.hlEtl p(lpyg F�dR7FE'OLlCYPF.GIOp;NllICRTEL. N:i"iWRHSTAk�J!N� !WY H'Z�4IPEIJENT, TF.f7M Op CpNp(fk]N OF ANY COIJTSLiCT O� GlpEfl QOCUMENT WfTH fiESpF„C; Yo W1;IGFI 7HI5 CERTiFICnt�; fAA't �'� �i.��UEO OR �MY PFH(qIN, 7HE LNSUPRIdCE AFFpfiUElJ dY 31�IC POL�.:ES �ESCFiBE� H-pFiN �' eU&IE•:T TG AS_THE 'fF�u.nS,EiClU56NSAN000N�f11uNc_ppSUCI�� POLIGIES. AQGqt3p7�LIMRS SHO�NN UAl'HhYE BEFN HFOJGLU�+Y PAp C�lA.7E. � . i . . .._._.._. .._._.. ..........._. . "'_.-...._. . � � .POLICYEFL�CTIV[�pO�1,CYFXPISiqTIQ!C � i TYPEOFINSURrtNCE POLICYNUM6Efl I pBT�,+�O/Y1'�� OAiEfMMfDD/YYf: LIM!T6 Ayaenenu:.uar.:7r !�1MF301h52$�&400 '�, Q7/U'o1�93 ' 07/UE/9J '.EnNoccoanenc ;s1, OD0�.y00 � ,. �q�OOMMERCIlLLGCeENn�.��lA91Lff1' � I I �F18FUNMAQEW1Y�df4c�9SO��U�� ;_�ataiMs nno� _X xcua, ... ! I l v M�rsen� �.s5� D'J 0 I - .. . '�,. II�a�oaAAanaiirv�um �s1, COQ. 000 ...I .. ... .. -�--- . �,; '. �.9ENPN�AOORECITE ,�SZ� GOO� OOO . --.__.____._�i � �ra�,�aYc<rE�i�roanrr�iesLec�� I � I.� . .� �s2, 600�_�0,0 ''G-W FlO�JCiS-LOMA/fW f�QU I i '�,'�UTOMODILPLIA�fLITY I '�� ' jrP�dBINE�£LtiGtELiM�.I ��. .__.7I nurnuro ' . � I(Eaaro��tl�nij .'e . I1ILLOW'dcCAllToS '�, . ��' • .. .. . _"i�__ ' - I BOD;i1'INJUFY �f 'NI^C'�W\tUAVTO^ I � � .lp f�i0�) I SCMEQU.EJAU'OS ' � 60�I.YINJUPY �,...� .. I C� ,. � , ,(Yttaacltlen!J • ...... .. .... _.. ..__'_..._.... i I _. � _........ .. ..._ . ' I . , i. , IfFOPER";*OAMhGE �,,t � .. I(I'ei Lacltlen:) �QARA�]@Ii�BILIi'/ ! i '�. 'oU1004LY-EAACC@ENi'IY � �!AVYAtJTp I j ', .� � IGTHERTYAN EAAGL �� 5 E%G$SSLIAEW^/ I IFUTOQN=Y! �G'p ,4 ' OCCI�a ..�,,CLAIMS M�DC. ' � I�EACH�CCURRENCE $ . , .. . ` I-J '. I', '' �','.., ,M1OOREOhT` . I � . . . _ JEouCT19LE .. .� �.3 �I ' ______ __—_....__. ' � i " �_� 1 4 �qC7CNTI0N f � ,. .. �.' - _I"'._ .... IS I,wORKEFCCOMGfiNSATONAHo � � . ih'CSTA'1'u- ' �o1H �EMPL6YERS'LU181LITY �. I �� '�, . TVRYLIAAII'Bi EH ...._._".__'__—_'__. ��, ��i I i ''�.E.LGAC1iFccloEvi_....._s.F_.._. _. . ._ ':, . ._ . . . _._ . . .. _I._- - - . __ . - _. ._ ___._ n_ . _ _..____-. I [:DSfASf:-GEMVLOVEE��. ..... i I .. _ " ` - __ ._ __- y— . . __ .__ __" ' I E1.015E4.E�PL�LICYL�MIijf pTttEFl I i � ; i CESCFlIf+TION 9FOPEA4TICN3/LOCATIONSIVEMiCtES/ptCLU51OM6 AqpEO 8'I ENOCRSEMENT/6PEOIAL PqOV1610Ne operations �erformed 'ny tlze na�ned insured ae pzro�rided k�y the terms a+zd COYiditions of thc policy. CERTIF� T R � noomonnL i RLE ft _ CANCELLATION � i SHD'Jii]MdYCFTF�EAAOVE!]ES.:PoPEf/M11C!E58EC4N.^.EI IEp9EFd�T'.�[Wqq7�OH �rC�i"/T1 4A Y[1r7i�0Urr1 ��'�OAiETNEflEOf,iHEISSJINQ:NSl1HG�WItLENUEAVORTOMl11L�,() OAYSWRIiIEN Fi.�tY:: �CdX'.,'� Ot H8d,1[�7 �f@TI'.'ETOTlffC'cYfIF'GAIEHO.CEqNAMEDT07HEl�7,BlJrFNLLB�TO�oFSSHALL �'1'�F �O'"�e 2� i1MPOSEY009LH3qi10NGRLI0.BiWTfOFpfirKlND'JP NThIEIry6URERiTSA[$NTSOfl Scut:� la=rtnuth, 6L'1 02G64 aevacsEnraTives. �AUTH0E1CG0lIlFFe {ryE " ACORG29•S(�/97Y1 0� z #y4zo5 kCA �ACORO CORPQpA410N 7988 Client : 7905 2PUTTERSPA ACORD�, CERTIFICATE OF LIABILITY INSURANCE i2�`o2j a rnooucen THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling & O� Neil Insurance ONLY AND CONPENS NO RIGHTS UPON THE CERTIFICATE Agency, II1C. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OH ALTER THE COVERAGE AFFOHDED BY THE POLICIES BELOW. 222 West Main St . PO Box 1990 Hyannis, MA 02601 INSURERSAFFORDINGCOVERAGE INSURED INSURERA:U.S.F. Ft G. James Hurley D/B/A ,NsuReRe: Putters Paradise Golf Course INSUqERC: � P.O. BOX 4 B INSURER 0: Hyannis Port, MA 02647 INSURERE: COVERAGES THE PoLICIES OF MSURANCE IJS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORhIE POLICY PERIO ANY REQU6iEMENT, TERM OR COND(TpN OF ANV COMAACT OR OTHER DOCUMEM WfTH RESPECT TO WHICH THIS CEFifIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 7HE POLIC�S DESCR�ED HEREIN IS SUBJECT TO ALL THE TERMS,IXCWSpNSANDCONDRpNSOF3UCH POLICES. AGGREGATE LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �N� T'PEOFINSURANCE POLICYNUMBER �UCYEFFECTIVEPOLICYEXPIMTIO ��u�� .� OENERALLIABILITY 1MP30145284400 C7/06/98 07/06/99 EACHOCCURFENCE EZ �00 00� X �MMERCIkl.OENERALLIABIUTV FIREDAMAOE(AnyonaftreJESO OOO CLAIMSMAOE� OCCUR MEDEXP(Anyone0e�eon) SS OOO PERSONALBADVINJURY SZ OOO OOO OENERALAOOREOATE SZ O�OO OOO GENLA(i�REOA7ELIMRAPPLIESPER: PqODUCTS-COMP/OPA�O $2 QOO OOO POLICY PR� �OC AUTOMOBILE LIABILITY COMBINED SIN�LE LIMIT ANYAUTO � (Eaaccltlen�) S ALLOWNEDAUTOS � �� BODILYINJURY . s SCHEDULEDAUTOS � � � � (Pefpefaan) . . -� - HIREDAUTOS -'.�. � . BODILYINJURY . �� NON-OWNEDAUTOS . � (Paraeditlenq . s � . � . ' . �� . PROPERTY OqMAGE S � � � (PerucbeM) dARAOELiABILITV pUTOONLY-EAACCIDENT $ 3U � ANYAUTO EAACC 9 " OTHERTHAN AUTOONLY: pG0 S EXCESSLIABILI7Y EACHOCCURRENCE $ OCCUR � CLAIMSMAD pdpqEpp7E g �� 3 DEDUCTIBLE E RETENTION $ s � WORKERSCOMPENSATIONIIND WCSTATU- OTH- EMPLOYERS'LIABW7Y . E.L.EACHACCIDENT 3 ' E.L.DISEASE-EAEMPLAYE 3 - E.I.DISEASE-POLICYLIMIT S OTHEN DESCRIPfIONOFOPERAilONS/LOCATIONSNEHICLES/IXCLUSIONSAODEO BYENDORSEMENTlSPECIALPROVISIONS Operations performed by the named insured as provided by the terms and conditions of the policy. CERTIFICATE HOLDER aoomorwuNsur�awsurra��r�ve CANCELLpTION ��-- &7W LDANYOFTFEABOVE OEBCPoBEDPoLICESBE GNCELIED BEFdETf E7Q9N1ION � TOWIl Of Yarmouth UAiETHEREOF,THEISSUINOINBURERWILLENDEAVORTOMAIL]Q_DAYSWq177EN Attn: Board of Aealth N07ICETOTffCEHrIF�qp7EFpLpERNMEDTOhfLEFf,BUfFAIUkETODOSOSFMLL 1146 Route 2$ IMPoSENOOBLI�ATIONIXiLIABiL17YOFANYKINDU NTHEINSURERRSACiENTSOR South Yarmouth, MA 02664 REPRESENTATIVE& � AUTHORIZEDREPRE TIVE � ACORD25-S�7/9n1 pf 2 #14265 j(j� OACORDCORPORATION1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-30 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby ganted to: _ iam c F Hurl y 1 19 Ronte 28 ��lect Yarm�t„j� 1��A Whose place of business is: Putters Paradise Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Pernrit expires: December 31 1999 BOARD OF HEALTH:�d��/.+�[o�t�pp,, C'�/,�M,�„/a/an , /�/ oan G�. 7J/u�llivan�/KJ0,//.� Vice l,hairman Seating:Zero(0) �o�ert a.D1.[/��romQn� (,(er� - a6rial(e Ja�roG��x�ooPee K�f �C'o �� December 16 , 19 98 Bruce G. Mwphy,MPH,RS. H Director of Health _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-1 FEE: $35.00 This is to Certify that James F Hurlev d/b/a Putters Paradise 119 Route 28, West Yarmouth, MA IS HEREBY GRAN'1'ED A LICENSE FOR THE MANUFACTURING OF FROZEN DESSERTS AND/OR ICE CREAM MIIZ For the year commencing with March fitst 19 9� This License is subject to to the Rules and Re ations of the Massachusetts Deparhnent of Public Health Relative to the Manufactuing of FROZEN DES�RTS and ICE CREAM IviA,to the Rules and Regulations , of the Boazd of Health granting dris License,and to the pmvision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934, and may be revoked or suspended in accordance with the pmvisions of Section 657 said Chapter. BOARD OF HEALTH: ��n `�elt�epe� C�Iuslrmanq � /� *Reguletion 105 CMR 561.009 requires oan Gc.-�� nal(ivan�� Vice l.,�aa•man monthly plate count and colifoim tests. �o�ert_t. O�rowaa, ��a� . . . � a6rie��a�ole��-�ooPee a�� i ' u ' I2ecember 16. 1998 �� Director of He�altl � . .> �