HomeMy WebLinkAboutApplications, WC, Licenses Prior to 2010 ��
� ' �� � � TOWN OF YARMOUTH BOARD OF HEALT$._ �'-s � G , ' ,- ,;
� � APPLICATION FOR LICENSE/PE 0� � ��5 r� ,� � i
� �,�� ���{ � [U08
* Please complete form and attach all necessary docum�s by` ecemb 1 0
Failure to do so will result in the return of your lication pack . - h' a P7.
9 -
NAME OF ESTABLISHMENT: (� `/�/UGELU G/'1lL11Q IiOND(,�/i�/f-f TEL. # S0�- ��
LOCATION ADDRESS: 2 �t i✓ ST ou re-� .{//�+�r/� pz�6
MAILING ADDRESS:-,-� `f! L�kE S'/fo�� D/1• � �4/I pTGh ! /YIi�L S //ZO D 2LYd
OWNER NAME: __ f/�-' /.�� l! 3Fc k F�C TAX ID (FEIN or SSNI: �� ��
CORFORATION NAME (IF APPLIC BLE): L� T3 �' S S fvoo �SE,�v/�� , �'.e c
MANAGER'S NAME: E�N�ic4 � TEL. # ,S/�J�.5�39-�JS"EJ
MAILING ADDRESS: J• G74 �,�es i�� � /?�� OZ6 �Y
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 ttus form.
1. 2.
Pool operators must list a minimum of two employees cun•ently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitarion(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 Gle at your ptace of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a �le at your estabiishment.
1. �Go� /,5t=/l/Y/�i�D 2. �ATit�ti'� /�ZE.d
PERSON IN CHARGE: _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. Sco/f ��-�n�,4>e�0 2. i✓�rrN�'�iA /y/A�f'd.+i
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich
Maneuver on the premises at all times. Please list yow• 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. � o� �f /!/ /1O 2. BIIATif�c�f� �i��`�✓ '
3. .� t��4 - D,,, ni 4. ��vn�n.,. cry�� i
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RESTAURANT SEATING: TOTA ucE�usEs �mv� 3o C?)
FICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED F'EE PERNIIT d LICENSE REQUIRED FEE PERMIT¥
_B&B S55 _CABIN 555 _MOTEL S55
I1QN S55 CAivu S55 SWIIvIMINGPOOL S80ea.
_LODGE S55 _TRAII.ERPARK 5105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIKED FEE PERMIT# LICENSE REQUIItED FEE PPRMIT# LICENSE REQUIRED FEE PERMI'I#
10-IOOSEArS S85 �_QO} _CONTINEN'I'AL S35 NON-PROFIT 530
_>100SEAT5 S160 ICOMMONVIC. S60 �a"" _WHOLESALE 580
RE'IAIL 5ERVICE: —RESID.ffi7CHEN 580
LICENSE REQUIRED FbE PERMIT# LICENSE REQUIRfiD FEE PERMIT# LICENSE REQi7IItED FEE PERMIT#
_vOsq.ft. 550 _>25,OOOsq.ft. 8225 VENDING-FOOD 525
_<25,OOOsq.ft. S80 _FROZENDESSERT S40 _'IOBACCO S55
�r.��zE c��cE: sio AMOIJNT DUE _ $ /�5.00
"*"•"PLEASE'IIIILV OVER AiVD CO1VII'LETE OTHER SIDE OF FORM""*•*
• Y� ,
ADMINIS'I'RATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taz�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: J /
YES v NO
MOTELS AND OTHER LODGING ESTABLISHNIENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transiern 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 s'vc(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as aznended, 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.PLEASE NOTE:People are NOT allowed to srt m the pool azea until the pool has been inspected
and opened.
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
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heakh Deparhnem 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 resuks 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 Boazd of Health.
OUTDOOR COOHING:
Outdoor cooldng,preparation,or display of any food product by a retail or food service establishmern is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENI', ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
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FIUC: CS�}428-7328 G0�4T�N'I�i
THE COMMONWEALTH OF MASSACHUSETTS
TOW1V OF YARMOUTH
PERMIT NUMBER: #09-002 FEE: S60.00
This is to Certify that LBJ 55 Food Service. Inc. d/b/a D'Aneelo Grilled Sandwiches
1297 Route 28 South Yarmouth MA
IS HEREBY GRANiED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2009 unless
sooner suspended or revoked for violation of the laws of the Coixunonwealth respectine the
licensing of common victuallers. This license is issued in conformity with the autho�ity eranted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersiened have hereunto affixed their official signatures.
BOARD OF HEALTH: .�Eeeen SPcaR�, `JZ.JV., C'/Ea"v[man
sE�rmc: 3 � CPuvcBe�s .`�E. JCeeB7Kex 41ice C'Pia'v[tncuz
`J2a6ent s. `J3��caa�ccuz, C�enf£
���J2..N.
NovemUer 14.2008
Bruce G.Murp iy,MP , , CHO
Director of Health
TOWI� OF YARMOUTH
BOARD OF HEALTH
� PERMTT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-002 FEE: S85.00
Ii�accordance with regidations promulsated under authoriry of Cl�apter 94, Section 305A and Chaptzr
I l 1, Section 5 of the General La��-s,a pennit is herebc aranted to:
LBJ 55 Food Service Ina, 1297 Route 28 South Yarmouth MA
Whose place of business is: D'Aneelo Grilled Sandwiches
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yazmouth
Pernut expires: December 31, 2009 BOARD OF HEALTH: ,�Eeeen S�iaRt, `J2..lV., C'Peabuttan
sFarmc. 3g� C'PraxBe� ,�. 9CeeBiP�ex ?lice C'Peuwtrnan
� Jto�ent s.✓`3aauuc, C'�
�! ��� ✓2.✓V.
r
i�'-o��emUer 14 �008
Bruce G. Murphy,n , R.S.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTA
PERMIT NUMBER: #09-002 FEE: S60.00
This is to Certify that LBJ 55 Food Sen�ce, Inc. d/b/a D'Anselo Grilled Sandwiches
_ 1297 Route 28 South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yatmouth and at that place only and expires December thirty-first 2009 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority eranted to
the licensine authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: ,ffeQe�t SRali, J2.N., C'Raowttan
SEArf.�G: 30 (���4 � ��jt �� J���
J�2aBext `3. `,�3aau�rt, Cdexl£
�'(�c�rzBa�J2.N.
Vocember 14.2008
Bruce . Murp iy,M ,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERI�TIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-002 FEE: S85.00
In accordance witU reeulations promul¢a[ed under authority of CUapter 94, Section 30�A and CUaprer
111,Section�ofthe Ueneral Laws,a pennit is hereb��granted to:
LBJ 55 Food Service Inc. 1297 Route 28 South Yarrnouth, MA
Whose place of business is: D'Aneelo Grilled Sandwiches
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31. 2009 BOARD OF HEALTH: .�eeen SPea/E, J2_✓V., �a[xmcuc
se,aTtNG 30 �.�N[Q2.0 .`� .�P.�(�[FX �lC¢ �[Q[/L�iICIIt
fRo�ext s. 53aeauui, C'detiPc
�M(�'�!rba�/�J2..A-'.
i
tiocember 14_2008
Bruce G. Murphy, n , R.S., CHO
Director of Health
: , � D`AN6Ez.o
�` YA�y TOWN OF YARMOUTH BOARD OF HT�1T.'I�� ���,�
s� j ' APPLICATION FOR LICENSE/PE�LT '�•21i�p�\y�"'�
�--
< _ ; )�" �` ��ioy � ; �,��;
* Please complete form and attach all necessary docu�ietits by December 31, 200'7.
Failure to do so will result in the return of j�our application packet:
NAME OF ESTABLISHMENT: �A�✓GC'LO G��C.��/J Sf�,✓n d,/;cNS TEL. # S�J7 3`!5�ZZZ]
LOCATION ADDRESS: /.� 4? /ylff�N ST SouTH �!{,cin oura � �J�6,�Si
MAILINGADDRESS: 3�/ L,�KE Sy�,c._' �OR. , /✓/A/'Siirtf //'!/LCl, /7'l� � 7_,� Y�
OWNERNAME: /�Au� i!, 3EC�6ti TAX ID (FEIN or Nl�
CORPORATION NAME (IF APPLICABLE): L F3 ? 5 S f p�� Sr/'vlcF �� c•
MANAGER'S NAME: SCa r ,va,cv TEL. #_�Q,}�S'39- Uri�
MAILING ADDRESS: r). �n r �-7 9 f-a✓� rt.,aL�_�..�[� n7� sFs�
POOL CERTIFICATIONS:
The pool supervisor must be certiTied as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this forn►. The Health Department will not use past years' records. I'ou must provide neK�
copies and maintain a file at your place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTffICATIONS:
All food service establishments are required to have at least one full-time employee who is cenified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Ptease attach copies of certification to this application. The Health Department wiil not nse past years'records.
You must provide new copies and maintain a file at your establishment.
i. S'c� � G�F�r�,�✓ 2.--�T���i.s /��1i6�✓
PER�(�N IN C�IARGE: .
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i. SQv� l�ce�NA�K� 2. f1�AT7i�`L%� /YJA/��
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 tnnes. 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.
�. S�Cv � �CRNML✓' 2. /�A NEL/�t /�.eG�
3. /1 s�f� �u�a,9n/ 4.�i n ,J� ✓s+� /1?a�cs.� ✓
RESTAURANT SEATING: TOTAL # � O
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEfl PER'of1T a LICENSE REQti IRED FEE PER4iIT= LICENSE REQti QtED FEE PERyf17=
_B&B S50 _CABIN SSO _MOTEL � S50
INN S50 CA.'�fP Si0 _SN`MYIIDIG POOL S75ea.
LODGE S50 7RAILERPARK 5100 ��'HIRLPOOL S75ra.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT� LICENSE REQI:IRED FEE P£R'�41T g LICEtiSE REQL"IRED FEE PER�III'?
I 0.100 SEATS S75 O �O 7 � —CONTTNEN'IAL S30 _NON-PROFII' S25
_>IOOSEATS 5150 LCOtiL'�IONV[C. S50 �O,q—Oa+�i _H7-IOLESALE S�>
RETAIL SERVICE: —RESID.KITCHEN S7i
LICENSE REQUIRED FEE PERMI'I�= LICENSE REQU[RED FEE PER�97= LICENSE REQIIIRED FEE PERbtIT=
_<50 sq.8. S4i >3i.000 sq.8. S?00 _t'ENDING-FOOD S'_0
_<25,OOOsq.H. S75 _FROZENDESSERT S3i _TOBACCO S50
vn.�CHAVGE: sio AMOUNT DUE _ $ /o�.S.00
**"*'PLEASE TL'R\OVER?1_VD CO�IPLE'IE O'IHER SIDE OF FOR\f'"***
ADIVIINISTRATION
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 COM�NSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �/
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCITPANCI': For pwposes of ihe 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 ofre�dence elsewhere.
Transient occupancy shall generally refer to conrinuous occupancy of not more than th'vty (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.
* NOTE: Enotosea Motel Census must be completed and returned witn tnis applioat�on.
POOLS
POOL OPENING: All swimming,wading and wturlpools which have been closed for the season must be ins
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five( days
pnor to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard p1aLe 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:
Myone who caters within the Town of Yarmouth must notify the Yazmouth Health Departmeut by fiting the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit iwtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board of Heahh.
OUTDOOR COOKING:
Outdoor eeoking,prepareEion,er disp}ay of any food product by a retail or food service establishment isprohibited.
NOTICE:Permits run annually from January 1 to December 31. I'I'IS YOUR RESPONSIBII.ITY TO RETIJRN
THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TfIE BOARD OF HEALTFI PRIOR
TO COMME:VCEMEVT. REVOVATIONS MAY REQUIRE A SITE PLAN.
DATE: f I� 2 � — v �7 SIGNATURE: ��� r/ ����
� //
PRINr NAME&TITLE: � u L (/_ d�c c`fr� ���_s/�c,,,;
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11J�912007 15:07 508-540-9255 DFM INSlJF2ANCE PAGE 01102
.A_CQBp�, CERTIFICATE (�F LIABILITY INSURANGE OATEQdWd�IYWY�
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F��cER (SOS}540-4555 FAX (S08)540-9255 THIS CER7lF�ATE IS ISSUED AS A MATTER OF(MFORh1ATICN
OFM Tnsurance Agency, Snc. ONLYAp16L;pHFERBNORiGHTSUP0477HECERTF�A7E
P.O. 6DX 56S HOL6ER.THIS GERTIFIGATE�S NOT AMENa,EXTEND OR
AL7ER TH�CDVERAC>E AFFORpED BY TIiE PDUCES BELOW.
66$ Main Street
Falmouth, MA 025qI-OS85 IN3uRER5,4FF�tDfNGcpYERpGE NAJCA!
�msuneo L67 SS Footl Service Inc. insw�R�; 7{� �over ZnS. Gr�Oup
ABA: D'Angelo u+suac�a: The Ins. Co. af the State of Pen sylvania
dha D'Mgelo wsu�Rc:
341 Lakeshare Ori�e ixs�rto;
Marstons Mi71s, MA 02648 n�&u�ne
COVERA
THE PQI,ACIES OF INSURANGE LI3TED eELQW HAYE BEEN IS6UEDTQ THE INSVRE�NAkE6fA9OVE FOR TNE POLICY PERI00INpICq7Ep.ryptyytT}Z$TAPI�ING
ANY REqUIREMENT,TERM OR C,pNDIT�N OF AfVY CONTftACT OR 6TFiER DOCLIM�NT W ITH RESPECT TO W�-lfCa{'�'}�IS CERTIF@CAT�AqAV 6E 355Um OR
hAAY PERTAIN.THE INSURpNCE AFFORDEO BY TFIE POLiCIES DESCRIBED NEREIN IS S(1B.IEC'f Tp ALL THE TERA15,EXCLU3ION5 AND CAPDITqN3 OF SUCN
POUGIF$.AG6REGATE LlMtITS SHOVYN MAY HAVE BEEN REQUCEb eY PA�CkA�Ap$,
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ICATE
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1146 Main Streex � reao r� � a,� ,
Ya�pqutk� MA 02664 �urxo R NT�1
/
4CORa25{2pp1RIS) FAX: C508)428-7328 w.pACttlF� ORp71UN1988
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHII�NT
PERMIT NUMBER: #08-027 FEE: $75.00
In accordance with re�ations promulgated under authoriry of Chapter 94,Sec6on 305A and Chapter
1 ll,Seclion 5 of the eneral Laws,a pem'ut is hereby granted to:
LBJ 55 Food Service Inc., 1297 Route 28, South Yarmouth MA
Whose place of business is: D'AnQelo Crrilled Sandwiches
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2008 BOARD OF HEALTH: 3feee�c SRur�. :lZ.JV., C'Pcuixanaez
SEA[mrG: 30 �(,f�auPea ,`�, J�CeP�if�c `U[C¢ C'P�aixrnan
J`2a�e�ct �. J`3�u�z, ��e�cPt
Qiva (�xeesdcrune, 52..N.
November 26 2007
ruce G.Murphy ,R.S.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER; #08-023 FEE: $50.00
This is to Certify that LBJ 55 Food Service, Inc. d/b/a D'AnQelo Grilled Sandwiches
1297 Route 28, South Yarmouth, MA
IS HEREBY GRANIED A
COMAZON VICTUALLER'S LICENSE
In said Town ofYarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: .�Eeeen SP�aRt, 52.JV., '(,Pavr�n' aa
sEnrnvc: 3o C'�av�eo .�..9CePfiP�e�c `llice C'havunan
� .�t.�(3xau,n.,✓`2..N.
,
November 26.2007
Bmce G. hy, H .S.,CHO
Director of Health
� cPc-#t d71! v��,o
3 °`��c TOWN OF YARMOUTH BOARD OF HEALTH ( , , s � ,,,, , �
_ � : ac
° , �_ V
APPLICATION FOR LICENSE/PERMTI'-2007
�`� * Please com lete form and attach a11 neces �D �.
p sary documents by Decemb r 31 0 � 2006
Failure to do so wiil result in the return of your application pac etHEALTH DEPT.
NAME OF ESTABLISFIIvfENT: f�.�/I/ECGO C/�i✓D�✓;Ct/ 1 Hd P TEL. #,5�a' 39y-ZZZ)
LOCATION ADDRESS: /G4'7 /92'+i ' S i .��+r.v �4�.i»o�zri+ o ze6 �
MAILING ADDRES S: -��i Lst�.- Sr��rcG �sri✓% /y •c s r�i,r /1� //� /h-1 D '�69
OWNER NAME: 'v,�� v ��cxr� T[�X ID (�'EIN or SSl�'
CORPORATION NAME IF APPL,I�ABLE): L.B 3 5� ��� S�zu.ce �rtc .
MANAGER'S NAME: �Cv N ,ES��,�i✓�,�✓� 1'EL. # 5 v� s'3 i-n;/�
MAILINGADDRESS: U� �j( .�FINo���;c/+, //24 � Dti63 -Tr
POOL CERTIFICATIONS:
The pooi supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certificat�on to this form.
l. 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 empioyee
certifications to this form. The Heslt6 Department will not use past years' records. You roust provide new
copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protectio� Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertification to this application. The Health Department wiil not use past years' records.
You must provide new copies and maintain a t'de at your establishment.
l. Sce 1f �'vatirJ 2. �A�>�ei9 /�9/t'-G�+'
L�s� c��� bt, fjm,�,�o9 �Ss/�E�
PERSON IN CHARGE:
Each food establishment must have at least o�e Person In Chazge (PIC) on site during hours of operation.
1. �L�t� �`�n%�iR� 2. �✓9'7H�'ci A /�it'�=`r✓
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at ]east one employee trained ia 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.
0
1. SLvl� v�r_:r'«�rtJ 2. ���-�7itr=t.��� ��i',l%r�'
3. �!�s�r,� t/JJ��9ic� 4.
RESTALJRANT SEATING: TOTAL#
OFFICE U5E ONLY
LODGIIVG:
LICENSE REQiTIItED FEE PERMIT# LICINSE REQiJIltF..D FEE PERMIT I! LICENSE REQI7IRED FEE PERMI'I'#
_B&B S50 CABIN $50 MOTEL $50
INN $50 CAMP $50 SWIMIvIING POOL$75ea.
_LODGE $50 1RAII,ERPARK $100 WIIIRI,POOL $75ea.
FOOD SERVICE:
LICENSE REQiJ1RED FEE PERM[T# LICENSE REQUIItF.D FEE PF,RMIT# LICINSE REQiJIltED FEE PERMIT# �
�0-100 SEATS $95 07'0 � _CONTINENTAL $30 NON-PROFTT S25
_>t00 SEATS 5150 1COMMON VIC. $50 � 0�7-02� _WgOLESAI,E S75
RETAQ.SERVICE: —RESID.KTTCI-IEN $75
LICENSE REQiJIRF,D FEE PERMiT# LICENSE REQUIl2ED FEE PFRMIT# LICENSE REQUII2ED FEE PF.RMIT p
_<SOsq.ft. S45 _>25,OOOsq.ft. $200 _VENDING-FOOD $20
_QS,OOOsq.ft. S75 _FROZINDESSERT S35 _TOBACCO S50
NAME CHANGE: S10 AMOUNT DUE _ $ IZ S.00
•`•'•PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM•"`•
ADMINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yazrnouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON 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
APPROPRL4TELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations ofMotel or Hotel use, Transient occ;upancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Traosient occupants must have and be able to demonstrate that they maintain a principai 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 sha11 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 haue been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspecUon five(S�days
pnor 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 wittun seven(7) days of
closing.
FOOD SERVICE
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuits must be sent to the Health
Department. Failure to do so will 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 Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking,p��paration,or dis}�lay of any food prflduct by a retail or food service establishment is prohikited.
NOTICE:Pemvts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTI'Y TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: %l � c 06 _ SIGNATURE: , ���! i/ /���
�
°" � ' �
PRINT NAME&TITLE: ���c, � r�`,z'��/� � �!r ti�.;��
ionvoc
AC�RDM CERTIFICATE OF LIABILITY INSURANCE onTe(rnxioomrr)
11/21/2006
PRODUCER (508)540-4555 FAX (508)540-9255 THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION
DFM Insurance Agency, Inc. ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. BOX 565 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
668 Main Street
Falmouth, MA 02541-0565 INSURERSAFFORDINGCOVERAGE NAIC#
INSURED LBJ 55 Food Service Inc. iNsuaean: The Hanover Ins. Group
DBA: D'Angelo INSURERB: TIIE Ins. Co. of the State of Pen sylvania
dba D'Angelo INSURERC:
341 Lakeshore Drive iNsuaeaa - j�. :
Marstons Mills, MA 02648 INSURERE: _
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFOR�ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 7ERMS,EXCIUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' rypE OF INSIIRqNCE POLIGY NUMBER POLICY EFFECTNE POLILY EXPIRATION LIMITS
GENEftALLIRBILITY� OHN-SBDSE/OH-OO �OS�OZ�ZOOG �5�0].�2�A] EACHOCCURRENCE . $ 1�QpQ p0
X COMMERQAL GENERAL LIABILITY DAMAGE TO RENTE� $ 3QQ�OO
CLAIMS MADE a OCCUR MED EXP(Any one person) 5 $�00�
A PERSONAL&ADV INJURV S ],�OOO�OO
GENERAL AGGREGATE $ 2�QOO�OO
GENIAGGREGATELIMITAPPLIESPER: PRO�UCTS-COMP/OPAGG $ Z�OOO�OOO
POLICV PRO-
JECT LOC
AUTOMOBILE LIABILITY
ANVAUTO (Eaag deD`SINGLELIMR a
ALL OWNED AUTOS
BODILY INJURV $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODI�V INJURY $
NON-0W NE�AUTOS (Per accitlent)
PROPERTYDAMAGE $
(Per amiCenry
GAftAGELIABILITY AUTOONLV-EAACCIDENT 5
ANVAUTO
OTHERTHAN �ACC $ �
AUTOONLV: AGG $
EXCESS/UMBRELLALIABILrtY EACHOCCURRENCE E
OCCUR � CLAIMS MADE AGGREGATE $
8
OEDUCTIBLE
$
RETENTION $ $
WORKERSCOMPENSATIONAND WC H9M1-SE-21 OB�OZ�ZOOE OH�OL�ZOOI WCSTATU- OTH-
� EMPLOYERS LIABtLHt`. . . ..
B OFFlCER/MEM ER EJ(CIUDED ECUTIVE E.L.EACH ACCIDEM ���� $ SOO�OO
If yes,tlescnbe untler
E.L.DISEASE�EA EMPLOVE $ SOO�OO
SPECIAL PROVISIONS belaw E.L.DISEASE-POLICV LIMIT $ SOO�OOO
OTHER
OESCRIPTION OF OPERATIONS I LOCATIONS/VEHIGLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ERTI ATE LDE AN TI N
SHOULD ANV OF THEABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WIIL ENDEAVOR TO MAIL
Town of Yarmouth lO DAVSWRITTENNOTICETOTXECERTIFICATEXOLDERNAMEDTOTNELEFT,
Board of Health BUTFAILURETOMAILSUCHNOTICESHALLIMPOSENOOBLIGATIONORLIAeILITY
1146 Main Street OFANYqNDUPON INSURER,RSAGENTS REPR ENTATNES.
Yarmouth, MA 02664 AUTHORIZEDREPRE TATN �
_ • ,i
ACORD25(2001/08) F�� (508)428-7328 OACORDCORPORATION19S8
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #07-039 FEE: $75.00
In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter
i l l,Section 5 of the General Laws,a peimit is hereby granted to: .
LBJ 55 Food Service Inc., 1297 Route 28, South Yarmouth, MA
Whose place ofbusiness is: D'Angelo Sandwich Shop
Type ofbusiness: Food Service
To operate a food estaUlishment in: Town of Yarmouth
Permit expires: December 31. 2007 BOARD OF HEALTH: B $. , M.$., '
SEAr[rrG: 30 d�se�c4�ia�i, ./Y., ?/ice C��i�xan
O�k M�
R�(j+re�c6�.u�c, R./V.
January 25.2007
Bruce G. Murphy, S.,CHO
Director of Health
'I'HE COMMONWEALI'H OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #07-027 FEE: $50.00
This is to Certify that LBJ 55 Food Service, Inc. d/b/a D'An�elo Sandwich Shop
1297 Route 28, South Yarmouth, MA
IS HEREBY GRAN1'ED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place oniy and expires December thirty-first 2007 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. T}ils license is issued in conformity with the authority granted to
the Gcensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
SEATin,G: 3O BOARD OF HEALTH: !� .�rKuc$. �iO' 3dok, �19.`�., "
d� �k, /1.�., v� e�.�
Rod�t 4. B�, �
n�M��
�.� ��, a.�v.
.r�,�y zs.zoo�
B��G. P y> ,cxo
D'uector of Health
� Yq x^"�'.'1 ��A-`/� ^. _
� .-vcaii
�e-R.� TOWN OF YARMOUTH BOARi�fQF�r�L N
r o
���i APPLICATION FOR LICE�IS�, P�9���006.� ��,�
,,, � ,
�"y * Please complete form and attach all ne�es�ary�d+Dc ments l�December 31,2005.
Failure to do so will result in the retiim of your application packet. -'
NAME OF ESTABLISIIIVIENT: ,�l ,�n/C��-c) Sf}�/oWicH �/l�u� TEL. #�� 3-9�/-ZZZ7
LOCATIONADDRESS: /297 /Ylfj-�n/ S� � So. �-/aAs�nur,-i f'!4/�_ �1266u
MAILINGADDRESS: 3�i LAKE S�v,cE /J�/y9K.troxs /�'1,!(�. /y,t 026Y�
OWNER NAME: �.4 u L ✓ /.4E cK Ede TAX ID (FEIN or SS �Nj�}.,�!
CORPORATION NAME (IF APPLICABLE): L�3 S 5� �veo �F���'« . �
MANAGER'S NAME: Sca �F /�r.�nn.ca TEL. # So;�- S3 9 �vS/ �
MAILINGADDRESS: �'Ci r �3a r .pANo ,.�r�[w , 1�1�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operatoe(�) �d attach a copy of the certification to this form.
1. 2.
Pool operators must list a min;mum 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 ofemployee
certifications to this form. The HeaUh Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this appiication. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
1. �c,r�� �� k��rao 2. �f�rz�-�ceA �/�/���
PERSON IN CHARGE:
Each food establislunent must have at least one Person In Charge(PIC) on site during hours of operation.
1. Se6l-f�F,���;� 2. ,��1'- ��'l�/rf�✓
HEER�;�H 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
attaeki eopies of employee certiScations 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. ��Ge � ���/1�0 2. �?7f/G�,�1� /!��/'�r/
3. �ASN�1 � 4. !N� d�},v !!�¢d
^. `/ ,
RESTAURANT SEATING: TOTAL# � 7
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERNIIT tl LICINSE REQUIItED FEE PERMI'I'It LICINSE REQUIl2ED FEE PERMIT#
BBcB $50 _CABIN S50 _ _MOTEL $50
_INN $50 CAMP $50 _SWIIvIIKIIdG POOL$75ea.
_LODGE $50 _TRAII�ER PARK $50 _WI-IIRI.POOL S75ea.
FOOD SERV[CE:
LICENSE REQiJII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMPP t! -
� 0-100SEATS $95 �S 66� CON1'INENTAL $30 NON-PROFIT $25
>700 SEATS 5150 �COMMON VIC. $50 S'v�'06'�7� _WHOLESALE $75
RETAII.SERVICE:
LICINSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMII'# LICENSE REQUIIiED FEE PERMII'#
_<SOsq.ft. $45 >25,OOOsq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.ft. $95 _FROZEN DESSERT S35 _TOBACCO S25
NAME CHANGE: S10 AMOUNT DUE _ $ /2 S. 0 0
"•"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••""
„
AD11�IIl�iISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Inswance. THE ATTACHED STA7'E WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACFIED °'
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run aonually from January 1 to December 3 L IT IS YOUR RESPONSIBII.I1'Y TO RETIJRN
THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEI�IING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISI�vv1EEIVT, MOT'EL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO
COMl��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested 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 wvered within seven(7) days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts mus�be tested on a monthly basis by a State certified lab. T�st resu#s must be sent to the Hea�th
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernrit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHeahh.
OUTDOOR COOKING:
Outdoor cooking, preparation,or display of any food product by a retail or food service establishme�is prohibited.
DATE: /�- Z2-D � SIGNATURE: fL�L�- !�
PRINT NAME&TITLE: /'A u c 1/ � C/-��w � l���/�'�w�
o9naios
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/55 Food Service, Inc.
341 Iake Shore Drive
HEALT'H DEPT. Marstons Mills, MA 02648
508•428•3560
faz: 508•428•7328
e-mail: 1bj55@aol.com
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South Yazmouth, MA 02664 West Chatham,MA 02669
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AC01iU 2S(Y001N6) �D CORF�R4T10N 78l5
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-098 FEE: $75.00
In accordance with regilations promulgated under authority of Chapter 94,Section 305A and Chapter
11 l,Section 5 of the General Laws,a pernii[is hereby granted to:
LBJ 55 Food Service, Ina 1297 Route 28, South Yarmouth, MA
Whose place of business is: D'An�elo Sandwich Shop
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31_ 2006 BOARD OF HEALTH: B ic$ /1'1.9j, •
SEA�G: 30 �"`s�; �°�.`., v�et�.�
���
A«.��j.�d�.,�, R.N.
January 24.2006
Bruce G. Murphy ,RS., CHO
Director of Heal
THE COMIIZONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #06-071 FEE: $50.00
This is to Ceriify that LB7 55 Food Service Inc d/b/a D'Angelo Sandwich Shon
1297 Route 28 South Yazmout MA
IS HEREBY GRAN1'ED A
COMl�ION VICTITALLER'S LICENSE
In said Town of Yazmouth and at that place only and expires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confomuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affuced their official signatures.
BOARD OF HEALTH: B $. , hf,�y., .
sEw�'trrc: 30 d�ee���, �,, vice�s�i�inta+t
Rod�at 4. B� �
P�M��
�1.� ��, R.N
January 24.2006
Bruce G. Murphy, ,RS., CHO
Director of Health
\
oF •Y.�� �d SJc •
�,� �o Z' O � llT OF YARMOUTH
� : —y
MATTq��
�, 1196 ROUTE 2S SOUTH YARMOUTH MASSACHUSETTS 016644451
�'"��,>�,,,�o��"� Telephone (508) 398-2231, Ext. 241 — FaY (508) 760-3472
B OARD O F HEALTH r ,zr � , �,� .� ip
To: Yarmouth Board ofHealth Permit Holders A PR 2 1 2005
From: DavidD. FlahertyJr_, RS. ;�Dr HEALTHUEpT,
Heakh Inspector ✓ '
Town of Yarmouth
Re: Federal Tas ID Number
Date: March 22, 2005 -
The Massachusetts Deparhnent of Revenue is now requiring t]�at we furnish detailed information
to them regarding all permits and licenses that we issue. One of the details that they require we
send to them is every establisbment's Federal Employer ldeutification Number(FEIIV)otherwyse
Imown as yow"Tax ID Number". This is purely for administrative purposes only.
Some businesses use the owner's Social Security Number (SSI� for this purpose, If this is the
case for your establishment, be assured that we will not allow this information to be public
record.
Please Sll out the fields below and return this letter to
Yarmouth Heakh Department
ll46 Route 28
South Yarmouth, MA 02664
Thank you for your anticipated compliance, If you have any questions regazdiug this �tter,
please do noi hesitaie to call. Ttie office �ours are:�ionday ta Friday, g:3�a.m to 430 p.a�, Tt;e
telephone number is(508) 398-2231, ext. 241.
Establishment: _ � ����l'i=CJ ���t��
s �/%DG✓�/./ FEINorSSN: %)�{ ��
LocaUonAddress: ���� ��J� ,j j ��-,j— y� �� ` �
, �Ct�+:�-u�, ��� � Zl� c.,
� ;��� �
signature: it��t �/ ;%?���,. ,�.
r
Print:_ C".4�.c � I/ J�C-/i r•t, Title: ���i,ata �
� � , tlon
cled
s�aper
7 . .. Oh�F'q b$q �
� °`%R�s TOWN OF YARMOIITH BOARD OF '� '� —� `� �� -' '°�
r = APPLICATION FOR LICENSE/PE � D E C 0 3 2004
O���Y
��'� ,� ..,, ..
* Please complete form and attach all necessary d ecem r��OQ� DEPT.
Failure to do so will result in the retum of ' ap 'cation pac .
NAME OF ESTABLISHMENT i�' �Lp S f}n/D L✓fc.1+ �/fi/ TF;i. # R�I —ZZz�
LOCATIONADDRESS /2�r� /I7lfi,v S� S'd_ /1,citt�ut�l /Y14 v 2�y
MAILINGADDRESS: LA f s/1U�f D,�. /�7,qRs��r /I!�!/ d2L�/e�
OWNER/CORPORATION NAME: BSS� 0�p �,e,/��c� , Z� �,
MANAGER'S NAME 2/+a � E cx�,L TEL # �2� 3 ��a
MAII,ING ADDRESS: �'/kM� ` - -
POOL CERTIFICATIONS:
The pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two emplo ees currently certified in hasic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation �CPR). Ptease Gst these employees below and attach copies of
empioyee certifications to ttus form. The Health Department will not use past years' records. You must
provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
1. sCoff �l'�I/L1Ap 2. /�i�-rt�kU� �fl �`�v
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. Sce N ��R A/h�n 2. A/R rHE ii/t ��4,��✓
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. S�oN NJ�2�I�1Ro 2. �d,vrv�+u /l�els�t,✓
3. d/f}7ritu',a i'Y16l,r<n/ 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQiJII2F.D FEE PERMIT# LICENSE REQIIIItRD FEE PERMIT# LICENSE REQUIl2ED FEE PERMLT#
_B&B $50 _CABIN �50 _MOTEL $50
_INN $50 CAMP S50 SWAfIvIII1GPOOLS75ea.
_LODGE $50 TRAII,ERPARK S50 WI-IIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMII'# LICENSE REQUIItED FEE PERMIT# LICENSE REQi7IIZED FEE PERM[T#
( 0-]00 SEATS E75 �OS�O _CON1'INENTAL $30 NON-PROFIT $25
_>100SEATS $150 �COMMONVICT. S50 5-(3�/� _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQiJIl2ED FEE PERMI'T# LICENSE REQUIl2ED FEE PF.,RMI1'# LICENSE REQiJIRED FEE PERMIT M
_dOsq.ft $45 >25,OOOsq.ft. 5200 _VENDING-FOOD S20
_QS,OOOsq.ft. S75 _FROZENDESSERT $35 TOBACCO $25
NAME CHANGE: $10 AMOITNT DUE _ $_ �02 S•Od
•"•"•pLEASE TURN OVER AND COMPLETE OTHBR SIDE OF FORM"••••
.r•� T
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 l�
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January I to December 31. IT IS YOUR ItESPONSIBIL.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTMINTFORINSPECTION 7-10
DAYS PRIOR TO OPENING FOR Tf� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR
TO COMA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDTITONAL 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 T'ESTING: The water must be tested for pseudomo�as, total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN�ESSERTS:
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 yout Frozen Dessert Pernrit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
DATE: ll 3� �y SIGNATURE:����
PRINT NAME& TITLE: /�S�Of��
10/22/04
9 'i,
——"`��= Tht Comnronweahk of Massachusetts
_ DepardneRt ojlxdwstriu/Accidentc
— N�e�N�1M�t
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Boston,Mass. 02111
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� ...,. . .:. . , . . .. � _ .. . .
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amorv�e_ .� �f1 :r/6 F c�D C L�T �'�' �uo Sf�u![c �rt_- >
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the following workets'compeneation polices:
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11:1E/2Qe4 19: 32 568-640-5255 DFId INSURAN� PAGE 02
� � ���.. CERTIFICATE OF LIABILITY INSURANCE °""`�"'°°"`"",
IPRO9VCER 11 26�2��4
� (508)540-4555 FAX (SQ8)540-9255 7HiSCERTIFiCA7EfSISSUEDASAMATTEROFINFORMATION
�'�,, DFT1 Insurance qgQncy, Inc. oNI,YANDcoNFERSNORiGH75UPONTHECERTIFICATE
'� P.O. BOX 565 HOLDER.THIS CERTIFlCqTE pOES NOT AMENC,EXiEND OR
; 668 Maj n Street 7ER 7HC COVERAGE A��ORpEp Br TN[p 1 5 BELOYJ.
� Falmouth, MA 025a1-OS65 � INSURERSAfFORDINGCov�RppE Natk
�M1�WRED Lbj 55 0o Qrv�ce IaC, . �HSURFRA Gencorp Insurance NeYwork 0020
Aba D'angelo iriwR�ee: Granite State insurance Company
3M11 Lak.ashore Orive wsuar�c;
MarStw�s Mills, MA 02648 ir+suaEno:
�NSJRER E
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ANV REQVIREMEN7,TEr�M OR CON61T)ON OF ANY CqNTpqC7 OR O7HER COCUMEN7 W ITH RESPECT TO WtACH THI9 CERTIF'CATE MAY 6fl ISSUED OR
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ir • acateeuncu c.�.ois¢nse.E+wno s 500.00
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oi�rt I
iEeCICFf10N OC OnFRApON51 L�CniqxB/VENICLt3 J[%CLUSpN3 ADDEp OY e�yOR9EMENT i SOEEp�nppy�gpyg
Location: 1297 Main Street South Yarmputh, Ma. 02664
1 AT M ER
11A710N
� SMOUTA4NYO�TYEADOVEDESCWlEDP041GES6BC4NCELLinaEFORETME
���'RON qpTE THENEOF,TH�I$$IryN01NffiIRER YYILL ENDEAWR TO 4CL
SO DGY>WqITiENNOTiCETOTi1RCFR7IFICATENOIDFRNMQDTQTMEI�C(,
TOM17 Of Yarmouth BUTFqLVREi0MNL8UCXNQTICESM1Uy1MPo3ENDOBLqqTpryORLIGBRIIY
1146 Main Street OCAryyqNDYVONTME�Ni RFR,RSAG[NT$ +pTry�s,
Yarmouth, MA 02664 �� wxe FEPHS$FNT
�CORD 25(?A01Po8J
�ACORD CORPORA710N 7988
TOWN OF YARMOUTH
BOARD OF HEALTg
PERMIT TO OPERr�TE A FOOD ESTABLISHMENT
PERMiT NUMBER: #OS-057 FEE: 75.00
In accordance with reQulations promulgated under aWhority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�ieneaal Laws,a peimit is hereby granted W:
LBJ 55 Food 5ervice Inc. 1297 Route 28 South Yarmouth, MA
Whose place of business is: D'An�elo Sandwich Shop
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yannouth
Pernvt expires: December 31. 2005 BOARD OF HEALTH: Be�wxln `.b. �,iyJ,$, •
3EATING: 30 !J�M �
� v:�
a�� a� e�
d�Sl�, R.N.
R.��j�w� R.N.
Jmm,�y zo.aoos
Bruce G. Miuphy, .,cxo
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #OS-044 FEE: $50.00
This is to Certify that LBJ 55 Food Service, Inc. d/b/a D'Aneelo Sandwich Shon
1297 Route 28 South Yarmout MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yazmouth and at that place only and expires December thirty-firsi 2005 unless
sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornrity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereo� the undersigned have hereunto affu�ed their official signatures.
BOARD OF HEALTH: Be�«u�c `.b. (�'oadar, i19.$. •
SEA�� 3o n�.�� v�ef�
a�t� a� et�
� Sl.�k, R.N.
��i�, R.N.
January 20,2005
ruce G. Miup y,MP , .,CHO
Director of Health
' ; �,b,'l�ko�� ,2�' ��Nc�w
�`;`'R.y � TOWN OF YARMOUTH BOARD O �E` '�H f�� i`� � '� ;j �7 j� �
3 � APPLICATION FOR LICENSE/P L �10�!
r��.�,r ,�,�i NOV 2 4 2003
* Please complete form and attach all necessary do��nen s by Decembe 3���.� � DEPT.
Failure to do so will result in the return of y�ur application packe .
NAMEOFESTABLISHMENT• %)�AN�'i-Go S9.✓oe,,%icH Sfta/� TFT # 39 -2ZZ7
LOCATION ADDRESS� /�7 /Ilffi.v S i ,�oa rH L A,crnau yN, /Y/�} i�Z6��L
Y Gk�.Y� � — R
OWNER/CORPORATIONNAME� fluc Il- .E�'E K�2
MANAGER'S NAME• 5��,,/� �ir�,rr�.n T # ��`��2�
1�AILINGADDRESS• iZ�i7 /�"la � S'i So �+i-� L/A�cr�n,,� �i. /i�il DZd6fC
, ,
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as rcquired by State law. Please list the designated
Pool Operat_o_r(s�and_attac:h a copy_o_f the certification to this form. _ -_ _ _ _ ..
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The 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 - CERTIPICATIONS:
All food service establishments aze tequired 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. Th�Healtb.Department will not use past years' records.
You must provide new copies and maintain a file at your establishil�ept.
1. �G b f� l5f2i1.�Axr, 2. yA7N�A %�,��C.��
"��—
PEPcShc�i iiv i,IiH�v�__ _ - --- - — ___ _ __- < --- — _ —
Each food establishment must have at least one Person In Charge (PIC)on site during hours of�peration.
1. �Q��� lr1�.Cn1.4�,�-�' 2. �]C,��'11�//A �/G�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Fleim(ich � '
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' recor�s.
You must provide new copies and maintain a file at your place of business.
1. �C� �iR�rA-L,D 2. �,��e,�.s.r /�orvn�,/ ,
3.��L:�a ,��v�✓ 4. L 1 Z [ 0'f�'
RESTAURANT SEATING: TOTAL# �uN �Y1� l�fS�' .
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT p LICENSE REQUIRGD FGE PERMIT N LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABM S50 _MOTBL $50
_INN S50 _CAMP 550 _SWIMMING POOL S75ea �
_LODGE E50 _TRAfLER PARK� S50 _WHIRLPOOL S75ea.
F'2QD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� 0-100 SEATS S75 O��F_Q� _CONTMENTAL 530 _NON-PROFIT §25
_>100SEATS $I50 �COMMON VICT. S50 0�'6 � _WHOLESALE S75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT fl LICENSE REQUIRtiD FHB PERMIT N UCENSE REQUIRED FEE PERMIT#
_<50 sq.ft S45 >25,000 sq.ft. E200 _VENDING-FOOD S20
<25,000 sq.fl. $75 _FRO'T.F.N DGSSIiR"P 535 TOBACCO S25
NAMECHANGE: �10 AMOUNTDUE _ $ J2S.Oa
*••�*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*•*
R �
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 �
2$
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHGD
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
N01'ICE: 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, 2003.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DGPARTMENT 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 FG ATION
�-`-
- POOLS
.. . .. . . -r�-'.�- . . . _ ... -. _ _--� '- -- -- _.
POOL OF�t+1IriiG:�itswunming,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.
PQOL CL03ING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of
: closing.
FOOD SERVICE
CONSUMER VI ORY•
Each food establishment wluch serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATE iN PU I Y•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FRt3 ;F.�1� �. gT ___ _
Fmzen d���rts must be tested on a mo�fh�y basis by a State ce�tified iab. Test resui[s musi 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.
OUT ID �S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mi sti have prior appmval from the Boazd of Health.
OUTDOOR COOKIN :
Outdoor cooking,preparation,or display of any food product by a retai!or food service establishment is prohibited.
Dti`I�E: ' l� �3 3IGlVATURE:�p�� �/ /�`��-'� N
Pltt�'IfiAME 8t TCTL:E: /�-t- (/- ��6#'�/L , P/'�t 0�
10/22/03
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YY)
TM io/so/zoos
PROOUCER �508)540-4555 FAX ($OS)540-9255
DFM Insurance Agency, Inc. ONLYANDCONFERSNORIGHTSUPONTHECERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O. BOX 565 ALTER THE COVERAGE AFFORDED BY THE POLICIES BEIOW.
Falmouth, MA 02541-0565 � INSURERS AFFORDING COVERAGE
INSURED LN] 55 Food Service Inc. � INSURERA: Gencorp Insurance Network
Dba D'angelo INSURERe: Granite State Insurance Company
341 LakfShOl'e DPiVe INSURERQ H VeP ns Ce COIn dny
Marstons Mills, MA 02648 INSURERD:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVJITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES�ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS.
LTR T7FE OF INSURANCE � POLICV NUMBER DATE(MM/DDIYY) DATE(MhVDD/YY) � � �LIMITS
GENErtn�unelLl7v HE 5349797-06 OS/O1/2003 OS/O1/2004 EnCHOCCURRENCE $ 1,000,000
X COMMERCIALGENERALLIABILITY FIREDAMAGE(Anyone(re) $ 3Q0,000
CLAIMS MAOE O OCCUR MED EXP(My one pe5on) $ 15�000
A PERSONALBADVINJURV $
GENERALAGGREGATE $ 2�000,000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $
POLICY PR� LOC
JECT
Au70M0&lEuaalLlTr ME 5349813-06 OS/O1/2003 OS/O1/2004 COMeINED5INGLELIMIT E
ANVAUTO �- -� � � . (EaacciCenq 1,000,000
ALLOWNEDAUTOS .. - � � -- �- �
BODILVINJURV E
X SCHEDULEDAUTOS (Perperson)- � . _ . ... . .
C
X HIRE�AUTOS
BODILV INJURV $
X NON-0WNEDAUTOS (Peracdtlenl)
PROPERTV DAMAGE 5
(Perettident) I���uded
GARAGEWIBILI7Y AUTOONLV-EAACCIDENT E
ANV AUTO OTHER THAN �ACC E
AUTOONLY: qGG $
E%CESSLIABILITY EACMOCCURRENCE $
OCCUR ❑CLAIMSMA�E AGGREGATE $
a
DEDUCTIBLE §
RETENTION 5 $
WORKERSCOMPENSATIONAND C 7$2-SS-97 08/O1/2003 OS/O1/2004 TORVLIMITS ER
EMPLOVERS'LIABILITY
E.L.EACH ACCIDENT $ 500�000
B
E.L.DISEASE-EAEMPLOVE $ 500�000
E.L.DISEASE-POLICYLIMIT $ SOO�QOO
OTHER
OESCRIPTION OF OPERATONSILOCATIONSNEXICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PRONSIONS
D'Angelo Franchising Corp named as " Additional Insured " .. �
_,
CERTIFICATEHOLDER J( ADDIiIONALINSURED;INSURERLEffER CANCELLATION . � �
� SHOULDANYOFTIEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE7HE -���U`�' �'��.
EXPIRATONUATETHEREOF,iHEISSUINGCOMPANYWILLENDEAVORTOMAIL '
D'Angelo FI'ellChising Co�p � �SI—DAYSWRITTENNOTIGETOTHECERTIFICATEHOIDERNAMEDTOTHELEFf, �
Attention: Ka�en E. Foley &17FAILURETOMAILSUCHNOTICESHALLIMPOSENOOBLIGA770NORLIABILITV
600 PI'OVldenCe Hl9hWay OFANVKINDUPONTHECOMPANV, EPRESENTATIVES.
Dedhiln� MA 02026 EDREPRESE A
FA%: (781)461-1896
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-059 FEE: 75.00
In accordance with re ations promulgated under authority of Chapter 94,Sectian 305A and Chapter
11 I,Section 5 of the�eral Laws,a petmit is hereby granted to:
Paul V. Becker, 1297 Route 28, South Yarmouth, MA
Whose place ofbusiness is: D'An�elo Sandwich Shov
Type of business: Food Service
To operate a food establishmem in: Town of Yarmouth
Pemvt expires: December 31. 2004 BOARD OF HEALTH: BekJa�In$. �M.$.
SEATAIG: 30 �M� v:� e�
. R�o�+�t��r�,�Gl�4
�.`�.�
December 17_2003
Bruce G.Murphy, H, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #04-044 FEE: 50.00
This is to Certify that_ Paul V. Becker dlbJa D'An¢elo Sandwich Shou
1297 Route 28 South Yarmout MA
IS HEREBY GRANTED A
COMI�ION VICTUALLER'S LICEI�ISE
In said Town of Yarmouth and at that place only and �p ires December thirty-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
—_-fieensing-of eammoa-victualler'r This-lieense is issn�-ia co�ormitq vvith the-authoritygranted
to the licensing authorities by General Laws, Chapter 140, and amendmems thereto.
In Testimony Whereof, the undersigned have hereurno aflviced their official signatures.
BOARD OF HEALTH: Basfawri� 2. �j'o�do.r, M.$. '
s���: 3o p�c.a�� v:�ef.��
Ro%it 4. B�a�rc, els�4
�f� 8 , R.N.
Decemberl7 2003
� . M ny, � ,cxo
Director of Health
_ �
�vAR.L TOWN OF YARMOUTH BOARD OF � /// �� RNc�D
� '��
3 � APPLICATION FOR LICENSE/PE T `�,�' � � � � � '�`' � �'.7 i ; i:;-
rc��s � . �
* Please complete form and attach all necessary do �s ecemb�i 31 2�� � L 2 ���Jf i
Failure to do so will result in the return of y "', pp cation packet. � C .�,
�t A ���` ��
NAME OF ESTABLISHMENT: � L �/O ic�l r TEL. #57/�-395/-ZZ2�
I s • 2�i t s^ � .c o�rr A- a
DRE • 3 Y r L,a,e� ,C /. ,q
c • LB 5 5' u ° � �� �, re.
AG ' : SG�7y` o T . # -7�u - `I
MAILING ADDRESS: >Z97 /1//a-iN ST ,S'ouTN c�,9,C/�1a=t�69 F /�A OZ66 y
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desigiated
Ponl Operator(s) and attac_h a_co�y o_f 1he certificaUon to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTLFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
1. SCo� �f�/�.tl�D 2.�f}'r1iAU.� ///�;��.Y�,
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2.
HE�jy1LICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. �'� !'>f RNA- D 2. �,�➢�C1� ����v✓
3. /ih+FS � �� 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWIbIlv1ING POOL$SOea
_LODGE $50 _TRAILER PARK E50 _WfiIRLPOOL S25ea
FOOD SERVICE:
LICENSE REQtJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-IOOSEATS $75 O �0 S _CONTINENTAL $30 _NON-PROFIT E25
_>100 SEATS $I50 ( COMMON VICT. $50 �03�OZ2 WHOLESALE S75
RETAILSERVICE:
LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 _TOBACW S20
<50 sq.ft. $45 _>25,000 sq.ft $200 FROZEN DESSERT$35
NAMECHANGE: $10 AMOUNTDUE _ $ 12S.Ob
. ""*'*PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM**•**
ADMINISTRATION
Under Chapter 152, SecUon 25C, SubsecUon 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 Yarmouth taaces and liens must be paid pnor to newal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE: Permits run annually from January I to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002.
SEASONAL ESTABLISHIvIENTS 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.
ADDITIONAL REGULATIONS
POOLS
POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of 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 DESSERT5:
Frozen dessarts must be tested on a mon�hly basis by a State certified lab. Test resuits must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),znust have prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DAT'E: 0 7� SIGNATURE:� �, 7 4�3-
r�rT rraME & TiTLE: �/,�w�.. 1�. Fc�'�,� , {�d�-S�
ioiisio2
.� � �
The Commonwealth of Massachusetts
s" : Departmenr ojlndustria/.-lccidenls
; Ol/IC001/01'CSUO�!!I/f
- 600 Washington Srreet
' Bosron. Mass. 01111
" W'orAers' Compensatian Insurance Affidavit
AR���cant informallon: P(e+��ePRINTTi�eGi�jy
onmc� f/����,C�iv .S���LUIGf/ S���
��-�7 //!�" C'/'
location� . )/1� J /
�� JD..IiI� �.9��C)��'� � �!1 /J2��� ehon p ��-.3�7 —Z��
� I am a home�penbrming all µork myself.
0 I �m a solz proprieror �r.� hs�e no one norking in am capatin�
� am an emplocer pro�idine µorkers� compensation for mc employees warkine on thisjob.
� � � � i i
comnan� name: �177� _ � J/l� ��N�CL�
eddfCsS: �2`l / /1/17iN � �
titv: -�Y�l-t�fi �P�JN/T� i//�'r • �heneu. �Ll�.. ��I`` �ZZZJ
� � �/ n
insuranceco. (^�/ANi f$ S//�%L� -FA.� C�U�� polievM WC- !�l)$�lC-�SOJb'D:�
� � am a sole proprietor. �eneral contractor. or homeowner(circfe onel and hace hired the contracrors lisred below ��ho ha�e
thz follu�cin2 �corkrrs compensation polices:
�.panv name:
address•
cin�: nhone N•
ins�ra�cc co. oelie��#
comoanv name:
.. _.__-�---- - - _ __. _. . -- - -_. ._ _
address•
titv. ehoee M•
insuranee co�_ ppRev M
t
F�iiure to sccure covenee u reqwred under Setaoo ZSA of MGL 153 n�lad W t�e i�pai4o�of eri�i�l pedtle of���e ap lo 51,500.00��d/or
ooe ye�n'imprisonment at w�ell n eivii peatitla io�hr form of�STOP WORK ORDER�ed�Ilee of SI00.00 i d�r tpimt a� I a�denu�d�hu a
eopy ot thh eta�emrnt m�y be for.varded ro�6e ORiee of InvaNeuioef of t6e DG for eoven�e reribatix .
� /do�hrreby ce ' under rhe parns d pt iet ojperjury thallht injornmlian provid�d abovt is tntt and en
Signature ��-� // " � [� �y Q�/
Print na� ��LC �- .�/ .. /�L C����'' Phone M �(� " �20" .��� J
.. aRci�l use onh do no�rrite in this ara ro be completrd by cih ortown ollki�l
eity or town: YARMODT$ permiNieeox N nBuildioe Departmec�
� � �Lieensiog Bo�rd
�eheck if immedia�e response ie required Z61 �Selectmen'�ORee
(508) 398-7231 �t, �Holth Dep�nmmt
connc�person: phone M:_ � _ nOt�er
10/16/2002 15:07 508-540-9255 DFM INSURANCE pAGE 02
ACORD C ATE OF ABiLITY INSURANCE °^�°"^�'°°�"
� io�isizooz
v °R C508)540-a555 F C508)540-9tSi
DFM Znsu�ance 4gency, Inc. ONLYANOCONFER3NOfi16HTSUPONTMECERTIFIC/Q6
HOLDHR THIS CERTIFICATi DOES NO7 AMlND,RXTEMD OR
F•lnouth Mall unic 97 ALTERTHEGOVERAGEArFORDEDBYTHEPOUCIlSIIE40W.
P. 0. eoz 565
Felmouth, MA oY5s1-a56s , INSURERS AFFOROING COVERAGE
insurtW Lbj SS FoOtl S�r�1ce Snc. INSUAERA: Ha�ovar Insu�ance Conpany
Dba U'anqele iNsunEnB: G��nie• State Ynsu�ance Company
3{1 Lakeshore Drivs 1NSURCRC:
MarSLons pills, MA 02646 IN3URER0:
iNSUftERE; �
COVE ES
OLICIES OF NSUft4NCE LIbT� ELOW HAVE BEEN ISSUED TO M INSURE�IVAMED MOVB FOR TM POLIGY P .NOM'I ,
ANY RE�UIREMFNT,'�'ER�1 OR UJNOITION OF ANY CONTRACT OR OTHER DOCUM17ENT�RH RESPECT TO WHICH THIS CER7iFICATE MAY BE ISSUS)OR
N,AY PERTAIN,THE W9URANCE AFfORDED BY THE P�UGIES D6SCRISEO HEREIN IS SUBJECT 70 ALL iME 7ERN15,EXCLUSIQNS M1D CAN�ITIONS OF5VOH
POl.!qES.ACaGREGATE I.In91755M0'NN M4v MAVE 9@EIJ REDUCED BV PPJO GL41MS. �
LT0. n'rE0FiM5UNWCE POLICVMlNiER 01TEIM�YDDlf'/) �A�fi�MWDW'!YI V�s
��+�nn��ue�uT+' Mn 5;49813 os os/a1/2ooi as/oi/zoo3 Enaacuucr+ce s i;000,aoo
CONMe.RQAI GENEWLL L1INNIRV FIRE DNMAGE(�Y�o fri) 5 .3 00,0 DC
CW�u$MiOE f {OCCUR MEOEXG�Myql�pl^.qnJ S �. J,S�p00
U
p PFR80fULd�DYIWURY f 1;000�000
GENEWunGora,a�7E 3 2;000.000
GEMLAOOnEOATELMITAPPLIE6ofiR ►ROWCT9•coMProPAG6 S Y;QOO.000
vo��cv ��a �oc �
suran�oeae ur�surv � wa�eiaen siwa�E UMR �
nNvwTO (E�aK3detq $ .
Pll OWN�AUTOS �
BOOILYIWUM S
"oCMEp,lFOAU?OS (P�b��l
rtlNEo�wT09 i BODIIYIWU�' ,
NOIv-0WNEDMUT03 (PBfdCC00M) S .
YRORRT'O�IxaGE s
' (M1r saddanp
CARAGEW&UTY AU700NLV•G4aCC�Giluf 5 '
ANYAUTO OTMBiTMPN f�ACC S
AUTOONLw ,v,G f ..
F7cCFssuneniiv WCMOCCUPAENCE i
OCCUR CI CUIMS MAC1E AQ61lEGAlE E _—
9
oenuene�e a
RET�NTION 3 3
NroRKlnSCOMVFNsnTloxrfo � 00536500600 08/O1/2002 Di/O1/2003 YLpdrtS X
EMPLOYERS'YMWN
B E.L.E4CMaCGIo[NT 5 500 000
iE�,p1`�EA`„E'q�eMv�m s SOO,OOO
EL.D�sew9E�P0UCYUNIT 3 SO0,000
NE0.
OESC iqNOf O M E%CL OORSFM ISVCCMLI 1
Location: 1287 Aain Street South YAI'meuth, Ma. 02664�
t
CER TE R �ppTION/�LIMSUR�;IN$URERLETfER I N �
SMOV4A/�+�c�THe�e6vEDC3pYCECrotteieamCqNCEILFD&bFORE�HE ��
. E)PII+AY�ONGGTFTXlJtEOF,TMEi35UIN6COMPANYWILLENOEAWF',TOMNL �
,�n pAYS WI�IRFN NOiIC[TO TME CLRTIFlGATE MOLOER NAMEII TO T!E LfR� ..
Town Of Yarmeut6 BUTFNLURETOYaCSUCNHoncelwLLLIMM9ENO08LM,ATroN�nW/J14YY
1146 Nain Streei � OFANYqNGUOONTneGoa�ANY,IT5A0lNT& �l1VEi5.
Yarmauth� MA D2669 Dqriaaub T
���
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERA'I'E A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-035 FEE:_ $75.00
In accordance with re�u1ations promuigated under authority of Chapter 94,Section 305A and Chapter
I11,Section 5 offhe�ieneral Laws,a permit is hereby grar��ted to:
LBJ/55 Food Service, Inc., 1297 Route 28, South Yazmouth, MA
Whose place of business is: D'Angelo Sandwich Shop
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pennit e�tpires: December 31. 2003 BOARD OF HEALTH: �iFa,dia`rf�. xe+Ut�Fax, ���L�a.0
sEwr�c: so D. � 711.D.. 2iue
�. �. �
�aartik�or.xott
'rj' Skak. ,��l. ,
December 5 ,2002
ruce .M H,R.S.,CHO
Director of H th
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLJMBER: #03-022 FEE: $50.00
Tlvs is to Certify that- LBJ/55 Food Service Inc d/b/a D'Angelo Sandwich Shon
1297 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yazmouth.and at tUat place only and expires December thirty-first 2003 unless
_ _ s�anersaspend�or revoked forvialatian af the taws of the Comnonwealth�spectmgth� _
licensing of common victualler's. This license is issued in conformity with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: �a;� SCdU�c, �abuxa�c
SEATING: 30 �CK�QMt/.�G D. �, �K D., �1CC
R�t'�. ��tOAWti, �
�abrtab'�D�
� S . �?Z.
December 5 ,2002
Director of H�ealY �
� ' - D'Rn��rbZo
� � `�`�� ''�`T�'N O YARMOUTH BOARD OF HEALTH
`' �� � � r �?�ION FOR LICENSE/PERNIIT -2002 � ��"
� "��F.i. i;�� �s :� �' �'% I fc ID
���.r�a 6 �a��
'� Please complete form�tid attach all necessary documents by December 31, 2001. Failur to ¢�c��i(�r��in
thefreturn of your application packet.
HEA
AME OF ESTABLISHMENT: A/G<L� ,�/o iclf d TEL. # ZZZ7
LOCATION ADDRESS: /29� '� 2d /�/4��/ S% ,�tu� y,q�-/�cufi�
MAILIN ADDRESS: � 0�� �! raR rLLl tJZ6
C O E: �L Q 5fi.o '^ a o S �,rce �',t� ,yu� [iE4C�.� /CS
ER'S N o �r2n TEL. # 0 — -S�%y
G ADD eSo?T
POO RTIFI ATION :
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 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 busiaess.
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 certificaUon to this application. The Health Department will not use past years' records.
You m�p�ide new copies and maintain a file at your establishment.
[�7
1.�r/ ��.r.N.�o z. �,41 rk�cl,� /�.�9sCfi.�/
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �F .x°2`� /J�it�/�-Rf� 2. /16A1f1-�U/� /�/j�d.l�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1.� �N/�-R/ 2. /1�H�fc '�t 6r�
3. JftinEs ��� e! 4..,�infl� .9xf1-�
RESTAURANT SEATING: TOTAL#`.�
OFFICE USE ONLY
�ODGING:
L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWIMMING POOL$SOea
_LODGE $50 _TRAILER PARK $50 WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� 0.100 SEATS $'75 �Oo1 _CONTINENTAL $30 _NON-PROFIT $25
>I00 SEATS $150 � COMMON VICT. $50 �Od�� _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT#�:,•��' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _Q5,000 sq.ft. $75 _TOBACCO $20
_<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35
NpMECHANGE: $10 AMOUNTDUE _ $ 125.00
***:*pLEASE T(JRN OVER AND COMPLETE OTHER SIDE OF FORM•****
Mc k
ADMINISTRATION F
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED V
Q8 /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES ✓ NO
NOTICE:Pemuts run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETLJRN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISfIlvIENTS ARE TO CONTACT TI�HEALTH DEPARTIvIEN'I'FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITION� RFGULATIONS
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 swimining pool must be drained or covered within seven (7) days of
closing.
FOOD SERVICE
('ONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal pmducts are required to post
Consumer Advisories.
('ATF,RNG POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZ N 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 COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: Z � u l SIGNATURE: i�� �/�o���/�'�—
PRINT NAME & TITLE: I f�u� � �F�K��'t'
09/11/O1
�\
The Commonwea/th ojMassachusetts
: Deparlmenl ojlndustrial.-Iccidents
� ; Omceallsresl/osWis
" � 600 Washington Street
' Bosron, Mass. 02111
� v� '` w'orkers' Compensation Insurance Affidavit
Agnlicant information: PI s:eYR11V'T7..dc��
oams C_, �J�SS �Ur10 cS�R+/IGC ���-� ✓J6� �/7N`�E(_.()
tstcatierL_ �2�7 f�/kr�/ S'j � 22' Sou rtl �f�,t�Xou fTi
ut� �'^� .L//l0�l�I�A 11Z��5G ehonep ��d�'j/`�LZZJ
� I am a homeo ner pznortning all work myself.
� I am a sole propriemr ar.,'. ha�e no one ��orkin_ in am capacin�
�m an employer pro�idinoµorkers' compensation for my employees working on this job.
tomnant' name: 1/�.vG�L� Jf���(.✓��N S/fe1
aJdress: �2�/'T ,Gf �-O ///�N ��
titr: �µ'!-E '�//F��s�/"� phene�•
insur�nce co //�'S%l�iC^� <��.SU,'f�r�-/ �i[y (,N oolicy# W � Q � 7 �/T Z
� I am a sole proprieror. _eneral contractor. or homeowner(circle onel and hace hired[he contractors listed below ��ho ha�e
thz follo�cin_ «orker ,ompensation policas:
snm2anv name:
address:
cih': phone M•
insurance co. oelie�•#
eomoanv name:
addresr � � �
titv: ehoee X• �
insuranee co. eeRev M
t
F�ilure ro secure covenge�s required under Secnoo SSA o(MGL 152 u�lud to tAe inpritlw W erisi�l pe�dtla of a O�e op ro SI�00.00��d/or
one ynn'imprisonment u w�dl u eivil penalHe�io tAc torm of�STOP WORK ORDER�ed�Oee of SI00.00�d�r Ktio�t m� 1 udmb�d thu a
eopy ot�Ay statement may be fonnrded to the 0111et ot Inveftit�tlom of IEe DU for eoven�e veri0utlo�.
I do-hrreby ce/�J r}•under thr pai and natries ojperjury�hat the injormation providtd abovt is bve md co ett
Signaturc /l�v ��y� Date / Z �s d
Printname //fu � !/� �C/CfJL PhoneX SU � `�P`F)���a L
.. oRcial use onh do no�w ri�e in this arca ro be tompleted by tity or tmva ollfeial
city or�own: YA���T$ _ permiNieeme a n8uildiog Departmeu�
OLiteesin`Bo�rd
❑cAeck if immediarc response ie required 261 pSdectmen'�Otfice
�HoItE Dep�rtmeot -
con�act person: phan�M:_ �508� 398—?231 eat. nOtAer
" ACORD CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDIVY)
11�3��2��1
PROOUCER �508)540-45$$ FAX ($08)540-92$$
DFM_Insurance Agency, Inc. ONLYANDCONFERSNORIGHTSUPONTHECERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Faliaouth Mall Unit 33 ALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW.
P. 0. Box 565 INSURERSAFFORDINGCOVERAGE
Falmouih, MA 02541-0565
INSURED �bj SS Food $e1'ViCe IIIC. INSURERA: Het10Ve1' Insu�anCe Company
Dba D'angelo INSURERB: Eastern CaSYalty InsurenCe Compeny
341 Lakeshot'e D1'l V2 INSURERC:
MaI'Stons Mi115� MA 02648 INSURERD:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS.
LTR 7'YFEOFINSURANCE PoLICYNUMBER DATE�MhUDD/YY) DATE�MM/DDIYY) LIMITS
GENERnLLIABILI7r MN 5349513 O4 OS/O1/2OOI OS/O1/2002 �CHOCCURRENCE $ 1,000,000
COMMERCIALGENERALLIABILITV FIREDAMAGE(Anyonefre) $ ;pp�000
CLAIMS MADE ❑OCCUR ME�EXP(My one person) S 15,000
A PERSONAL 8 ADV INJURV $ 3�000�000
GENERALAGGREGATE $ Z�000.000
GEN'LAGGREGATELIMRAPPLIESPER: PRODUCTS-COMP/OPAGG E j�OOO�OOO
POLICV PR� LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANV AUTO (Ea accitlent) a
ALL OWNED AUTOS
BODILV INJURV $
$CHEDULE�AUTO$ (P�Pe50�)
HIRED AUTOS
BODILV INJURV S
NON-OWNED AUTOS (Per accitlent)
PROPERTVDAMAGE f
(Peraccitlenq
GARAGELIABILITY AUTOONLY-EAACCIDENT 5
ANVAUTO OTHERTHAN �ACC E
AUTOONLV: qGG 5
E%GESSLIABILITY EACHOCWRRENCE 5
OCCUR O CLAIMSMADE AGGREGATE 5
a
oeoucrie�E g
RETEkT:ON $ . g
WORKERSCOMPENsw7tONnND C 95 39942 O8/O1/2001 O8/O1/2002 TORVLIMITS ER
EMPLOYER$'LIABILITY
E.L.EACHACCIDENT $ 500�000
B
E.L.DISEASE-EAEMPLOVE $ SOO�000
E.L.DISEASE-POLICYLIMIT $ $00.000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BV ENDORSEMENT/SPECIAI PROVISIONS
ocation: 1297 Main Street South Yarmouth, Ma.
CERTIFICATEHOLDER AOIXTIONALINSURED;INSURERLETfER CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TME
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILLENOEAVOR TO MNL
]Q_DAVS WRITTEN NOTICE TO THE CERTFICATE HOLDER NAMED TO THE LEFf,
ToW11 Of YaI'mouth BUTFAI�URETOMAILSUCXNOTICESHALLIMPOSENOOBLIGATIONORLIABILITV
1146 Mein Stl'eet OFANV NDUPONTHECOMPANV,ITS GENTSORR E NTATIVES.
YarmoYth, MA 02664 AUTHO EDR RESENTA
c
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-016 FEE: $'15.00
In accordance with regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111,Section 5 of the General Laws,a permit is hereby ganted to:
i.R.T-55 Foocl Service inc_ 1297 Rnute 2R S� � h Yarmo, h MA
Whose place of business is: D'Angelo Sandwich Shop
Type of business: Food Service
To operate a food establishment in: Town of Yannouth
Permit expires: December 31. 2002 BOARD OF HEALTH: ���. ZePfGFr�, ��inaxa.c
SEATQJG: 30 , � ��6?�RH�t�1i7L D. �QK, D., �/[CC
Fuvow 7• �IOQWt.
�
J'd�11azV z$ �2.�2 ..
Bruce G.Murphy, .5.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLIMBER: #02-012 FEE: $50.00
This is to Certify that LBJ-55 Food Service. Inc. d/b/a D'Angelo Sandwich Sho�
1 97 Ro� R Couth Yarmonth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity wtth the authority granted
to the licensing authorides by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: eka�dea?�, xd�. �fai��maK
SEATQJG: 30 `�' D. �/Je��� D.. ��
� %� �t0[6�K. (iw�e
Paariek 9 wx
January 25 ,2002
ruce G.Murphy, ,R ., CHO
Director of Health
1�'f�i �f� ��<<c�;
^ � TOWN OF YARMOUTH BOARD OF HEALTH 2� �E� 2 2 �999
, �. APPLICATION FOR LICENSE/PERMIT- 2000 HEALTH DEPT.
* Please complete form and attach alt necessary documents by December 31, 1999. Failure to do so will result in
the return of your application packet —
--------------------------------------- �1�=T,lfj.s_����u�=!�._���-----------------------------------------�
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-----------_W�_�__��_:�`-4 VEI�---�-�---P�l9J���-----------------------__—_.
POOL CERTIFICATIONS�
The pool supervisor must be certified as_a Pool Operator, as re�uired by new State taw. Please list the
designated Pool Operator(s) and attach a copy of the certificaUon to ttus form.
1. 2.
Pool operators must list a minimum o£two employees cunently certified in basic water safety, standazd Fust Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Depa�tment 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,I H . RTIFI ATION
All food service estabfishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. SLvifi gl��tl�� 2. _ L�IAT�/�//iA �u1-�E�
3. B 4.
RESTAURANT SEATII�iG: TOTAL# � NpN=Si�FOIfHdG SEAT3: TOTAb# - -- -
_____--_____---------------------------------------�._------------------------______.�_____—_
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERNIIT # LICENSE REQUIItED FEE PERMIT#
_B&B $50 CABIN $50
_INN $50 CAMP $50
_LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMNIING POOL $SOea.
WHIRI.POOL $25ea.
FOOD .RVI .
LICENSE REQUIItED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $75 Y2JC-�18 _CONTINENTAL $30
_>100 SEATS $150 �NON-PROFIT $25
�COMMON VICT. $50 2K-5 WHOLESALE $75
FT ii ERVI E•
LICENSE REQLIIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT #
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE = S I ZS -
„"`pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•••
�
�
ADMINISTRATION
UNDER GHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQLII1tED .
T(7 HOLD ISSiJANCE 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 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'Y TO RETURN Tf� COMI'LETED APPLICATION(S) AND REQUIltED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TEIE HEALTH DEPAR'TMENT FOR INSPEC'I'ION'7-10
DAYS PRIOR TO OPENIlVG FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, M07'EL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COMIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWININIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENT, AND TI-IE WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEIVING; AND QUARTERLY TI�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIlvIIl�TG 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 REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM '72
HOURS PRIOR TO TE� CATERED EVENT. TI-IESE FORMS CAN BE OBTAINED AT TI� HEALTH
DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN TI-IE
SUSPINSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,Tf-IE ABOVE TERMS HAVE
BEEN MET. _
_
OUTSIDE CAFES
OUTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �[j�HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
Oi 1't'I�OOR COOKING•
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHI�fENT IS PROHIBITED.
DATE: / / �� SIGNATURE:�"�- T/��'�/"`�--
PRINT NAME& TITLE:��}u (, V i�7L�/f�`� ���S,
1 ll12/99 �
, ; �
The Commonwea/th ojMassachusens
� ° Department ojlndustrial.accidents
; O/Aee ellares!/o:Wis
600 Washington Slreet
' Boston. Mass. 02111
` Wbrkers' Compensation Insurance Affidavit
ARnlicant information: PI n� pR1NTTreai.sp
n�mr- U��i✓GG (.ti ��n/OG/iU�l .f�,�
location: ���7 /�l�T'✓ -S% ���'�io
cit. ���c�r-� `�fj/L//7eu./Ir �il 4
ehone a 3 Y_2ZZ 7
� I am a homeowner erturming all work myself.
� I am a solz propriator _r..'. ha�z no one ��orking in am capacin�
� I am an employer pro�iding workers'-compensation for my employees workine on this jab.
comnanv name:
�-�� �-�y ����c� LP�s� t��o S-r'���ti
nddress: �2`l 7 �k�N S� ��Qs•r Q�N6�L� �
�7 �
citv: JOCc r7� C�f/�L/ltOLl�P� phenep• 7-�f'� �22.Z �
�suranceco. LA�s�tin/ �lts�(��jr�'/ nolicvp wCgJ 3C1�y2
� I am a solz proprietor. general contractar, or homeowner(circle onel and ha�e hired[he contractors listed beloµ ��ho ha�e
the follu�cing �+arkcr_ compensation polices:
cnmoanv name: -
address•
cin�: phone M•
insurancc co. � polit�•#
[omoany name: . . _.
address:
[ih': phoee N•
insursnee co. eeflev N
t
F�ilun to fecure coveraQt as requved ueder Secnoo SSA of MGL 1S2 n�lad to tAt i�poriOw of erisiW peultla of�O�e op ro 51300.00 a�d/or
ooe yun'imprisonment aa w�dl a tivil peodHa io Mt lorm ot�STOP WORK ORDER asd i Ost of SIOOAO a d�r qaio�t m� I udennW Hat a
topy of tAy statement m�y be fonnrdtd to the 011iet ot InvnNg�Uom of Mt DG for eoveng verilluUw.
/do-hrreby ce/n/t'�}•under rbe paru d pen (titt ojperjury that the injonnation provid�d above is nrre and cnrrca
Signamrc /U�— v i�/�� Date L�2//�l�
, � �
Print name ���C C- l� ��C/(LiL- Phone N J U,I �Z.f� 3� `v
.• olTicial use onl. do not..rite in this arn ro be completed by cih or town ollleial
ein or towe: Y�MODT$ _ � permiNiteex N n8uildioq Departmem
�Lietaeios Board
� check if immrdia�t responte i�required 261 ❑Seleetmen'f ORce
�He�trE Departmmt
contact person: phone M;_ �508� 398�2231 eat. nOther
11ia0/88 19:22 FRX 5085409255 DF3[ INSIIRhNCE (�J002
�N , : [q•��.�� '� ]��
� �//"11►��0 "����w+s+"��.��,�iil��^ 'S3 .: r� ,...'s� t� f,n '3t� ,. DATEIMMNCA'M
.s'�� �. �.t • .. .. ....
. ': .. ... ..:..:.....m ..,�u....o-. x . , ,:.- . . . . ..F., ..... .... _,.... , ,: . . ,,.«.,^r'^. . :�s,..!.:�....,fi�s' . '�. il/30/99 w
PROD� o� �usuRANCE acEu[v, 1NC TNIS CERTIFICATE IS ISSUEO AS A MA7TER OF INFORNATION
FALNOUTN µ4lL UNST 33 ONLV AND CONFERS NO RIGHIS YOON THE CEffi1FIWTE
HOLDER 'Ri13 CEFiTiRlCATE DOES NOT 1WEN0, FXTEND ON
V.O. BO7l 565 ALTER TNE CpVEqpqE AFFORDED BY TME �OUCIES BELOW.
Fu.XouTM nn 025a1 COMPANIESAFFORDINQCOVEnAGE
IcaMP�NY EASTERN Cn5Ua4TY INSURAMCE COM7ANY
A
ws�p� LBJ/55 wW SERYICE, INC. I
CONPANY
OBA D'ANGEL�S I 6
3G1 �pKESNORE CRIYE �� �pAN�
M1IRSTOHS M[LlS MA 02648 �C
COMPMN
a
..�: ., .,�a�:ah���'�'"'..�'.-.�u �'' e+?�.; '" �..cy:.t.:�A.. .�."�.': .. ....v`«.'�.:<°,�,5'r �' M�...:.:,:.�'a� sv`'.,'^..F:�:..:..'^". ��� uw'.,.�ke,_ , �.::�!e�'�,°C�'�,_.*�.,;".,;..'.
7Mi9 IS TO CERT�N TNqT hiE Pp��CIEb OF INSUqqNCE UST�DELOW HAVE BEEN 196UED TO TME�NSUFlED NAMED 4BOYE FOR THE PO�IC'/PERIOD
INDIGATED,NOTYYI1775TANDIN6 ANY FEOUIREMENT,TERM Oii COND1710N OF ANY CONTAACT OP OTMFA DOCUMENT WfTM RESPECT TO WMICFI?HIS
CERTfFlCA?E MAY BE isSU�D OR MAv pERTAIN.7HE iNSUFl4NCE AFFoqDED BY iHE vo�ICIES DESGAIBED HEREYN Is 6UBIECT TO ALL 7HE TERMS,
IXCLJSIONS AND CONDiTiONS OF SUCH POUCIE$,I,IMITS bHOWN M4Y HAVE B'cEN REIXICE�BY ppJD CLAaAS.
L�� iYvfOi1NSUMMCF �OUC7MUY�61 1 pU �yMlOYT17 W7FN pRY1N .. __ .-_. _..YMITL
�
I pENFq►llwNry i i GENEqRLACiGII[ca�E i
�MEACJPLGENEiNILU�fi�UTV '� '�Ucls-COMP/OPAGG e _^
CUM4NALF �p�Ud �I IPE0.1�Vµ0.A0V!NJUAT S
owYEA98 CON1iV1(7iDF5 PlibT �� I EACH OCCURfENGE 9
i
� I FlqE OAMAGE(My one fin) E
MED EXi(My e�.rsnm� S
♦UTOMOOLF WB¢liV �
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-1 �I N.�OwNED Wt05
eoa�ri��r
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PROPERTYOMMG¢ S
MMUE llAB1UN � �
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-
iVlTAUlO OhIENTMANAUTaONLV: :i'�.� '... . .� . .. ..
( EAGFIAIX.90ENT f
� �EW7E 8
OfLE56WIBIU7v � ' Fi�G10CC+JMENCE 5
uNBPELIAFORM I I A^vGREWTE I
omEn iww u.nneu,�Fonre —�--
A 'NOMIW COYPEMRlTO�WO i � % STaMOiIY�MI15 :. ......�....,
.:�:�.:::".':,:..: ::'.::.(,
I '��� ��� HC95 39942 8l01/94 � 6/07/DO 'EACnusipENT E 500�000
M�PR�PPoENw X INC:
P'NTMCT�F��77'✓E I . � � 7SEASE�0.tK.'YLIMIT�� b 500 OOD
OFRC�6u1E: pccL pSFJs�.�MEMpIpyEE y SOO,OOO
on+R+
i I I �
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o[aem�nox or MErunoM.V1ACJlnolqrv[XlctFelaaECUI�iEYs I
8!
ouwceios F000 snops
LOCATIUNS: 1. 697 MA1y STREEP CNqTNMI, N1� 02633
_...
2. 12971W[N STREET SqRH 7ARlqUiX NA. 0266L
'� . .�w .., .�'��ir,«: �:ar� �r:o�+ .;� ": ,.�.`»w �,�Ht '�"°'».'F. t
, ._ ...�,..� .. .. . . , ,,,. :.ux;:u �'"�a..!�� :��..'.:�.'' .,.:.:.�a�t..��
sxouW un eF Tne AaOVE bmu�Eo rouCIE6 Ye rJWCEUID eEFCNE na
mnAanou o�7E rMUFor. m[ �asuMu COM►nxv w�LL ExofAWll ro rn<
7pHN OF YkRM0U7N �p��yyp�77FN N01KF TO TryE CEAT1FIbiE MOlD9��M�t0 T1E IEFT,
11i(� MpIN S`REET BUT fAIW{IE TO IMIL 6UCN MOl1C[9fMt1 IMPOSE NO OWWTON OM WBWry
�RRMOUTx MA 0266a o� aNv �au0 upox nre eeq►�rrv� on neneE6Exram[s
oa p T
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u:
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TOWN OF YARMOUTH
` ' BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-98 FEE: $75.00
In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter
11 l, Section 5 of the General Laws,a permit is hereby ganted to:
i.R.T/55 Fond Service Tnc. 1297 Route 2R Snuth Yarmouth MA
Whose place of business is: D'Angelo Sandwich Shon
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�'d�P/. .�nat�e, C'�.t.,q,u//,n /�
SEATING: 30 �oan C�c.7Jyu��an� �g//.� �ica (��irma
�o�erf/J� . /�ro/a/n� �la/r/�
��rie[le�akola�y-✓doo�
��f aC'auy�l�
Januarv 13 ,2000
Bruce G.Murphy,lvlPH .S.,fZ O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-54 FEE: $50.00
This is to Certify that LBJ/55 Food Service Inc. d/b/a D'Angelo Sandwich Shop
1297 Route 2R Sonth Yarmnuth_ MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2000 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in conformity w�th the authonty granted
to the licensing suthorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
BoaRn oF HE,AI.TH: L'd�'l�.+.�elle/e, C�ia;.,n�a//,. q � /�
SEA'['RdG: 30 oan.G. �ul�an, �/(.� Vice l��a.irman
o6a.r p�� n03row/�, C�.�
a6rie[la/Ja�OG��y-�� ooPse
•�[ ou�Lia
January 13 ,2000
ruce G. Murphy,MPH, .S., O
Director of Health
4 . �;�,;�,; '
, ,;:: ��_ ,�� ��; ,n, �9 L C�; ��Z2�4I
` TOWN OF YARMOUT� B(�C�O�'��1L H
APPLICATION FOR LICENSE/PERMIT- 1 9
' �;�,�+Ll�H DEPT.
* Please complete form and attach a11 necessary documents by December 31, 1998. Failure to do so will result in
the retum of your application packet.
----------------------------------------------------------------------------------------------------------------------------------
NAME OF ESTABLISI�IENT: ;�'A�6�L0 S;�N� {„I��/l S/�? TEL. # �1r�/-Z1�7
A I N D 2�i ��✓ �T /�f zd' � . ace i
MAILINGADDRESS /Z�r7 �-ir✓ S� , i�f ?P , 5��. c,��rcira��rv
T N G S--, �—�i t e �� '
MANAGER'S NAME� u � li'. /��ic�- # Z -3S��
MATT.IN D F � 3�/ /C/ ��/ts/L� ,O/"- �}'f�'}/C.S%Od� /YIiCLJ {/y/�
----------------------------------------------------------------------Y-------------------------------------------- -- -
POOL CERTIFICATIONS:
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 tlus form.
1. 2.
Pool operators must list a minimum of two employees cutreatly certified in basic water safety, standazd First Aid and
Community CazdiopuUnonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to ttus form. The Health Department will pot use past years' records. You must provide new
copies and maintain a file at your ptace of business.
1. 2.
3. 4.
�IEIMLICH 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 rimes. 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 aud maintain a f�le at your place of business.
i. �y u � �F�i���- � a. �%��,� /lr`:��l��.J„�
3. �f�fi 1T.or% u.c 4.
RESTAURANT SEATING: TOTAL# 3U NON-SMOKING SEATS: TOTAL# �J V
-----------------------_________--------_--------------------------------------------------------------
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT #
B&B $50 CABIN $50
INN $50 CAMP $50
LODGE $50 TRAII,ER PARK $50
MOTEL $50 SWIMMING POOL $SOea.
WHIItLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMIT # LICENSE REQUIltED FEE PERMIT #
�0-100 SEATS $75 9�9-/32 _CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
I COMMON VICT. $50 99-7Q WHOLESALE $75
RF.TAII, ERVICE•
LICENSE REQUIltED FEE PERMIT # LICENSE REQUIItED FEE PERMIT #
_<50 sq.ft. $45 _TOBACCO $20
<25,000 sq.ft. $75 FROZEN DESSERT $25
>25,000 sq.ft. $200
N�M� CHANGE• $10
AMOUNT DUE _ $ 17 S �—
•*^""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'""""
ADMINISTRATION
LTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-�TOWN OF YARMOUTH IS NOW REQUIItED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PERSON OR COMPANY bOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION
INSURANCE. 'THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES� NO
NOTICE: PERNIITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILTI'Y TO RETURN Tf� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISF�IENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISF�vv1ENT, 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 WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf� SEASON MUST BE INSPECTED BY Tf-IE HEALTH DEPARTMENT,AND THE WATER TESTED FOR
- PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMA�IING 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 THE YARMOUTH
HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT Tf�
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 TF�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN
Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TF�ABOVE TERMS
_ . _ __ __— -
HAVE BEEN MET.
OUTSIDE CAFES:
OiTI'SIDE CAFES (i.e., OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MIJST HAVE PRIOR
APPROVAL FROM TE�BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISfIMENT IS PROHIBITED.
DATE: l Z ��' �� SIGNATURE: j�� L�/tiJG c�
PRINT NAME& TITLE: �,/���L �� cSGL/i Gic ��z5 i,�JC=/��
/
- �
' � The Commonweallh ojMassachusetls
: Deparlmen�ojlndustrra/.-1 ccidenls
; �///Ce01//YCSU/fll//i
600 Washington S�reer
Boston, Mass. 02111
W'orkers' Compensation Insurance Affidavit
ARpiicant information: P► AsePRINTTes,'hFp
,� __ -- - -- s
namc: l/ ��/UG ��iO .f/�l✓��c�(�/'/ S/'f/��
locati�n' /297 ///��/� .S% �/�%L�' � .
��,. Sr,r�-r!-r ��!��rn�u>r� pno��a Sa,�' 3s S'ZZZ7
� 1 am a homeowner pertorming all work myselE
� I am a solz proprietor�r.d ha�z no one �corkine in am capacih�
�am an employer pro�idine workers' compensacion for my employees workine on this job.
comPanv name• L- !S � ' �S� �D00 ✓�.C/CU%�C -�/LC . . ._.. .
address: J �� �/�'/T+� :�/�'Oit� ��
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��urancsca G�.0 %2/I`� �SEG��YZY -�/1�, (:-U . ooli yp wL4s 399yz
� I am a sole proprietor. general contractor, or homeowner(circle onel and have hirad the contracrors lisred belou ��ho ha�e
thz follu�rin_ ��arkzr compensation polices:
companv namr. �
address:
cjjy: ohone p:
insur7ncc co. politr p
� comoanv name:
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addresr. . . . . . _ .. _..__ _. ._ ._ _- - - . . . _. . . _
e�y: phoee M•
insurance co. po�N
F�ilure to secure covengt as required under Setnoo 25A of MGL IS3 n�lead lo t6e iapaidoe o(erimiW peWtln ot�B�e op to 51.500.00��d/or
one yean'imprisoamrnt a�w�ell a civil pendHn io Me form of i STOP WORK ORDER��d�Ox otSt00.00�dry qdo�t me. 1��denn�d H�t�
eopy of thy stitemmt may be for.varded ro the 01lice of Invatig�uom of the DIA fw eoven�e verille�tlo�.
/do�hrreby cenijp nder the pains and ptgal�ies perjury lhal�he injormalian provided abovt It bwt and eoneR
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., olTicial use onh� do not w rite in Ihis�n�to be eompleted by eih or Imvn otlieid
city or town: y��DTEI _ permilAiceeu M nBuilding Department
OLitensioL Bo�rd
p chrck if immedia�e response ie required Z61 �Seleetmeo'�011fee
(508} 398-2.231 eat. OHcalthDep�nmeet
contact person: pAone p:_ __ _ nOther
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rowciss se[.ow.
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MA4LFaOROUGH, MA 01752 CdA1YANIES pFFpRpINC CAVF.RAC.�:
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. E%CLUSfONS nMl)�ppD(TIONS OF SUCH POIFC:fS, �JMI'fy SHOWN MAY RAVE IiEl�ti W�t)UCE�BY PAID CLFiMS.
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: 99-132 FEE: $75.00
Iu acc;ordanc;e wil6 regulations promulgated under authority of Chapter 94,Section 305A and
Chapter I 11.Sutiun�of the General Laws,a permi[is hereby granted to:
I RT_55 Food 4ervice Tns,�]297 Route 28,�Soi�th Yarmouth MA
Whose place of business is: D'Angelo Sandwich Shoo
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31 1999 BOARD OF HEALTH: �d�l. �ettaB�e, C�(,�t.�//�2 /J
SEATING: 30 �(�oa/n � �nallivam�/K7B.1/.� �ica C,��rmarz
Kober(p�� �6,7ro/wen� l,ler�
. lY�/,//7�aj�riellea JahnoG���//JooPed
///ic�el oCou�hlin
Febmary 9 , 19 99 ti�
Bruce G. Murphy,MPH, .,Q O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERNIIT NUMBER: 99-79 FEE:_ $50.00
This is to Certify that LBJ-55 Food Service Inc. d/b/a D'Angelo Sandwich Shop
7297 Ronte 2A, Sonth Yarmonth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
Gcensing of common victuailer's. This license is issued in confornuty with the authonty granted
to the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereo� the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: L���n/. .�[sJttpeee, Clu(,��r,/�J/a�n/� / /J
SEATING: 30 . �[�ow/n G.cJ7unllivan��KJ�.7//l.� Uice (..�irman
Kober� J. 63rowrt� l.lerk
a6,��e SaG/ol���-�all�Pe�
� � el Cou��lin
Febmary 9 , 19 99 �
G.Murphy,MP ,R .,CHO
Director of Health