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Home My WebLink AboutApplications, WC, and Licenses Prior to 2010 ^t . . � � � TOWN OF YARMOUTH BOARp;4?�+ , TH afp ��05 .�� `�' � APPLICATIONFORLICENSE -„2Q09�� a NOV 1 $ 2008 ,, ��: � * Please complete form and attach all necessary�ocuments by ecemb 1 .y C E P T. Failure to do so will result in the return of your applicabon packet. NAME OF ESTABLISHMENT: ��" �o ��;f TEL. # �O�Jri 4,�`f LOCATION ADDRESS: /QU � �L-T- Z-� (/1A�frb c� � f'tbl• (l2GG 4 MAILING ADDRESS: ' S/Iti � OWNER NAME: `�/�Ai/L 0%�-n.. TAX ID (FEIN or SSNI� CORFORATION NAME (IF APPLICABLE): c��y}�'ap .S'll,t�t p� f'��/. ��,�H Nn MANAGER'S NAME: ��L OQL�,V��Zo TEL.'�# MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiGed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlris form. 1. 2. Pool operators must list a minimum of two employees cun•en ified in basic water safety,standard First Aid and Community Caz•diopulmonary Resuscitat' n(CPR). ' t these employees below and attach copies ofemployee certifications to this form. The Healt6 epar nt w►Il not use past years' records. You must provide new copies and maintain a file at your pla usiness. 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 Cile at your establishment. 1. T f�UL (..�(l�aA��nd 2. �� C -0"Gc{�'C-f� PERSON IN CHARGE: _ _ _ _ _ _ - - -- -- - - -- - - - --- _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �/9'l1 i��/�D �T�9�v �r1�d�_ 2.�'p k/ /�/C2L-.Zi / /�l�d'rti 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 your employees trained in anti-cholang procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �Q/I�h �=ro f)'ke/ZC.- z._ ��/XI l�'lAfow 3. ��'l�N dL-�n-�-n.o 4._ .�i c-�+. uR/z9 RESTAURANT SEATING: TOTAL # � OFFICE USE ONLY LODGING: � � LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# LICENSE REQUIltED FEE PERMtl's _B&B %55 _CABIN �� $55 _MOI'EL S55 _1NN S55 -_CAMP S55 _SWIMMINGYOOL �80ea. _LODGE S55 _T"RAILERPARK ' $105 _WHIRLpOOL S80ea. FOOD SERVICE: � - � . _ . .n . ., ; � .. _�. ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth is now required to hold issuance or renewal of any license or pernrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGIVED, OR CERT. OF INSURANCE ATTACHED �� OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLLS�MENTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. _ __ _ _ _ — __�- . ,._� ____ __ _ _ _. _ �" " POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opemng. Contact the Health De�arhnent to schedule the inspection five(�days pnor to opening.PLEASE NO'I'E:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL R'ATER 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 CATERIN�POLICY: Anyone who caters within the Town of Yaimouth must notify the Yazmouth Health Departmern 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 PeFmit 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,prepazation,or display of any food product by a retail or food service establishment is prohibited. xn�rrcr.�pern,ita n�n annuallv from 7anuarv 1 to December 31. IT IS YOUR RESPONSIBILITP TO RETURN � � NOTICE NOTICE � TO ` TO EMPl.�OYEES � FMPLOYEES �'he ��monwealth of ��ssachusetts DEP��TMENT OF INDUSTI�IA.I. A�CIDENTS 600 Washington Street, Baston, Massachusetts 02111 b17-72?-4506 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 8z 30, this will give you ❑otic�� that I(we) 6ave provided for paym�nt to our injured employees under the above mentioned chapte:r by insuring with: ASSOCIATED iNDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970 ADDRESS OF INSURANCE COMPANY WMZ 8003685012008 OM01/2009 - 04J01l2W9 POLICY itUMBER EFFECTIVE DATES Rogers& Gray Insurance Agency 640 Route 132 Inc Hyannis MA 02601 (50$) 775-0011 NeLME OF INSURANCE AGENT ADDRESS PHONE Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 El►4PLOYER .1DDRESS 02115/2008 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DA1'E MEDICAL TREATMENT T6e above named insurer is required in cases of��rsonal iry'uries arisiog out of and in the course of employment to furnish adey�ate and reasunable hospitel and medical services in accotdance with the provisions of t6e Workers Compensation Act A copy ot the F'irst Report of Injury must be given to the injured employee. The employee may sdect his or her own physiciaa The reasonable cost of the services provided by the treating plRvsician will be paid by the insureq if the treatment is necessary end reasonably connected to the work related in}u:ey. ln cases requiriog hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEARES?AND BEST MEDICAL FACiLITY NAME OF HUSPL'TAL ADDRESS TO BE POSTED BY EMPLOYER ' . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-028 FEE: $55.00 In accordance wi[h regulations promulgated under au[hority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of the Grneral Laws,a permi[is hereby granted[o: Seafood Sam's of South Yarmouth, Inc., 1006 Route 28, South Yarmouth, MA Whose place ofbusiness is: Seafood Sam's Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expves: December 31 2009 BOARD OF HEALTH: ;�feP¢fe S�ah., J�.JY., ��.�aixltta�t ClEaafeP.o 3E. .7C¢f�� P,�,Yl. �J�{Ce �x.►�a.,. xEsr[ucr�oxs: Disposable Service Only. J�a�PJ[t S.�1Wutut, t.leYR SEnra�rG: 85(45 inside;40 outside) QJfIL�jNefft�c�lU,,l�f�l�L��:/Z..IV. �ltC�It�.�• ""�'�y.�"' November 20 2008 Bruce G.Murphy, ,R.S.,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-017 FEE: $60.00 This is to Certify that Seafood Sam's of South Yarmouth,Inc.d/b/a Seafood Sam's 1006 Route 28, South Yarmouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2009 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 authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: .�felert S�, J2.N., C'.�aixrnan sPnnxG: SS(45 inside;40 oauide) �.�Q-0t�¢d .�. �f�P�IC �lC¢ �AIA!/IKift J`2o6e,Yt `.�. `�awa, C'�e,rk Qnrc(sxeerr�cuun, ✓`2..�V. £a'¢Pa�et. `�• 3fayQo November 20.2008 Bruce G.Murphy, , .5.,CHO Director of Health ./' ��►FooD SRns ` '� TOWN OF YARMOUTH BOARD OF HEALTH �� ° ��s^ S=��y-- APPLICAITON FOR LICENSE/PEItMI'�'�2U�p8��j "I C, r ?�' - * Please complete form and attach all necessary docqmedte by�Decemb�r 31, 2(JID'�. 1 °i Zu�r Failure to do so will result in the retum of your application packet. NAME OF ESTABLISHMENT: �� QoQ �j�}"M �J TEL. # �l�'�l �'3�f0¢ � LOCATION ADDRESS: / d 6 6 1Z? z � MAILING ADDRESS: /}r1E OWNER NAME: aLaw��t d T X ID(F IN or SNl�� CORPORATION NAME (IF A�PLICABLE): ,f�� a� S'y,y�s G� �'A /,� �/�,q,v,�� TivC. MANAGER'S NAME: ` {� L (��L ,i,E�� TEL. # �C��,y�P-,?�P.3 MAILING ADDRESS: z-j 0 wl, � / ,� L—`�- �,/J /.,�� A�t,�J. l L,�,�7 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 o€the certification to this form. 1. Pool operators must list a minimum of two e lo urrently cenified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation . Please list these employees below and attach copies of employee certificarions to tlris form. The Healt partme ill not use past years' records. You mast provide new copies and maintain a file at lace of business. 1. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one ful]-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Flease attach copies ofcertification to ikris applieation. 'i'he Health Departmentwitl not use past years'records. You must provide new copies and maintain a file at your establishment. l._ _ /v /�'P"a7A/it/ �ULi//v�7zd 2. Jo/I�ft�I�1-iv �'irn.lti�l PERSON ZN CHARGE: Eac d establishment must have at least one Person In Charge (PIC) on site during how•s of operation. I.��L- �ULli/I/L�'Ld 2. � � � HEIMLICH CERTffICATIONS: 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-chokmg procedures below and attach copies of employee certifications to this form. The Health Depariment will noY use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��6`� C`� U r f0 ��2 r� - 2. � " 7//d� �I�Ts�✓ 3. l/ yL Dn� 4. c77/N�li� /�s�y RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIlVG: LICENSE REQUIRED FEE PER\97* LICENSE REQL'IRED FEE PERbII?= LICENSE REQti IRED FEE PERyfIT= _B&B S50 _CABIN 550 _MOTEL S50 _[NN 550 � _CA.'NP Si0 _S\�7�1\4ING POOL S75ea. _LODGE 550 _TRAILERPARK 5100 �l�'HIRLPOOL S75ea. r��n es�nan�s. , . `�,� ADMINISTRATION � ,� Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth is now required to hold issuance or renewai of any license or permit to operate a business if a person or company does not have a Certificate of Worker's �� Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � � CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO -- - _ _ __ _ _ - — MOTELS AND OTHER LODGING ESTABLISIIMENTS TRANSIENT OCCUPANCl': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any 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: Enolosea Motel Census must be completed and returned.�ith r�is applicat�on. rooLs 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(S�days 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 CATERING POLICY: Anyone who caters within the Town of Yazrnouth must notify the Yazmouth Health Deparmient by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Perntit umil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOKING: flutdoor cooking,-preparation, or display o€any food prodact bya retail or food set�rice establishment is pre�ebited. � �. � `YA � ._�rF'� "� � ' ° r "y TOWN OF YARMOUTH BOARD U�"1�ALTH(:�" ` o�� APPLICATIONFORLICENSE/PERMI`1'- 2007 #1 NOV 2 S 2006 r , a �`l * Please complete form and attach all necessary documents by Decem eHHA�b�DEPT. Failure to do so will result in the retum of your application pac et. NAME OF ESTABLISHMENT: �)��{-�Ga/l �1/9�+'J TEL. # �P'.�`�'¢�Tb ¢ LOCATION ADDRESS: o- G � Z MAII.INGADDRESS: GuT/� VA��a�n1 � /u�1- GZ� ` ¢- OWNER NAME: � Lo�+/t o T r S ?- CORPORATION NAME (IF APPLICABLE): SGft�i�n �1n°r � -f � a�riN Yllic,r,r��rJ� , .Fwc• MANAGER'S NAME: �f]/L �e Lews�n o TEL. #_f -P�8'�4P3 MAII,INGADDRESS: 26� rarc� tZ�1 �=J?�A�D Lv��j l�ra4• dZJ�7 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool p tor,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the ��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 ofemployee certifications to this form. The Healt6 Departroe t will not use past years' records. You must provide new copies and maintain a file at your place of bus' ess. 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 540.000. Please attach copies of certificarion to this appGcation. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment �. ��v� pU�,�� z. �;►��, ��-e y PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. ��I'I /7/✓/'i C,°� 2. ��/LLsI�- /ti%!�lil� 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. �� l4T6h/ 2. ��KG� �L�f'd1✓ 3. �"p11l1¢9�{9rt/1 �crn/l�y 4.� � 19fc,2c�r RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERM[T# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIl2ED FEE PERM[T# _B&B S50 CAB1N S50 _MOTEL S50 INN $50 CAMI' $50 _SWIIvIIvtII1GPOOL$75ea. � LODGE $50 1'RAII.ERPARK 5100 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQIIIRED FEE PERMI'P N LICENSE REQUII2ED FEE PERMIT# LICINSE REQTJIRED FEE PERM['P k �0-100 SEATS $75 �0 —0 _CONTINENTAL $30 NON-PROFiT $25 _>I00 SEATS SI50 LCOMMON VIC. S50 �o7-oa y _WHOLESALE $75 RETAQ.SERVICE: —RESID.KTTCIIEN S75 LICINSE REQUI[tID FEE PERMTC N LICENSE REQiJIRED FEE PERMIT# LICENSE REQiJIRED FEE PF.RMIT# _<50 sq.ft. S45 _>25,000 sq.ft. 5200 _VENDING-FOOD $20 _QS,OOOsq.ft. S75 _FROZENDESSERT S35 _TOBACCO S50 NAME CHANGE: S10 AMOUNT DUE _ $ /2 S•O O '••""pLEASE TURN OVER AND COA4PLETE OTHER SIDE OF FORM'•••' � , L, . "x�"- ADMINISTRATION � ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INStJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pemvts. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotei 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 ofresdence elsewhere. Transient occupancy shall generatly 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 uoit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the co(lection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opecung. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swittuning pool tnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by Sling the required Temporary Food Service Application fonn 72 hours prior to the catered event. These forms can be obtained at the Hesith Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeatth. OUTDOOR COOHING: Outdooa ces�king,}�epasatia$er display ofany fead groduct by a retail Dr food-senricaestahlishment-is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTl'TO RETURN THE COMPLETED APPLICATION(S) AND REQiJIltED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMb1ENCEMENT. RENOVATIONS MAY RE A SITE PL . DATE: I I�L�` �G SIGNATURE: C,[ii,fi� ��fX!N� PRINT NAME&TITLE: ��/�h/L c'QLON�YLu CS(�/�� omioe _� � � The Cominonwealth of Massochusettc Departwreat of IadxsTrial Accidentc NbN� 60o was6u�Ewe sa,eer, f"F�oo, Bostou,Mass. 02111 ___ -._----._- worra�s°c� tio.Lsv..ee w�vit e.n - kcaail c.a.a.Ho.s bi�S/E � ..�... _ .. ,�.�. . .. z: ';c� .. .�:.,: .��.r� � ., z.H.. ��- �: ��1-�=mm �S'�r� 7 f�iiL eL�n-a e�s: �Z7 z� � clri (� dU��/s vV/d/ spx: � �.� ao: (1 u�.¢ ohooe# .1 U e ' bS 7 7 iJ�+' � wodc site tocalim(tnll addressl: ❑ I am a lamoowrcr perfo�iog all wak myself. Project Type: ❑Ncwv Ca�xucda��Rmiadel I mm a sole and have no ame w m m Bwl ' Addition �I am an�ployer providing w�keca'compensation far my c�loyees wo�cing on this job. . . ai�w• \ ' /.Yl.. / .� . eJtv: ' � el�eW. � ❑ I am a sole pro�ictor,geaersl ea�trxtar,or 4omeowrer(rnr/e awe)a�Lave lmcd the comractois listod below wla have the following w�kus'compensation Polices: ou�� y: niwei: � �r�e: ad�m: el�: olrre A: . .. . __ . -- - . . .. / FaYve O ateR owmee s Rq�d dQ SOeYN 2SA dMGL 3ffi qY led b He IspdtlM KaW W pmMn da de�bfl 1MM a�dlw ene yws'h�ptM�at n wd n eM pwltln h t�e f�Ka STOT WORK OBDER W�B�e df1M.N a dry g�nt�e. 1 oimWd Idt a qpy dtlb f�t�y be fin�d b Ne Omae dI�at He DIA fr cNna�e ver�dW�. �do Ae►ssy n,efy rAe yeau.we of yeri,I►y awr dYs iufon.rlon�novidet o3ove v are m�a a/�r+ecc �'�_ — . �Q,t.c.� ��it�i�uir,c.� n.re l � l ��0�-� erim� ��17%L C�D�oi✓�'7Zo eno�n .��J�''�3,f� omcLlmeWy Mrtw�ifeit�bareab6teNplMdb9dl9�ri�ws�cL1 . ekyortewu: p�tlfeAseB _ ' ' D�t �BnN ❑eYak H�sW�Be napese b ieqd'N Q5dxtsea's O�oe ❑tlaMV D�t ceataet Puaoa: Phwe Y, OOWv cn+a�.a sp.aom) NOTICE � NOTICE TO V TO � EMPLOYEES ; EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY � NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON MA 01803-0970 ADDRESS OF INSURANCE COMPANY WMZ 8003685012006 04/01/2006 - 04/01/2007 POLICY NUMBER . EFFECTIVE DATES Rogers &Gray insurance Agency 640 Route 132 Inc Hyannis MA 02601 (508)775-0011 NAME OF INSURANCE AGENT ADDRESS PHONE Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 EMPLOYER ADDRESS 02/09/2006 EMPLOYER'S WORI{ERS COMPENSATION OFFICER(IF AN]� DATE MEDICAL TREATMENT The above named insurer is reqnired in cases of personal injuries arising ou[of and in the course of employment to fumish adequate and reasonable hospital and medical services in accordance wi[h the provisions of[he Workers Compensation Act. A wpy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the trea[ing physician will be paid by the insurer,if the treatmen[is necessary and reasonably connec[ed to the work related injury. In cases requiring hospital attention,employees are hereby notified tha[ the insurer has arranged tor such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF IIOSPITAL ADDRESS TO BE POSTED BY EMPLOYER TOWN OF YARMOUTH BOARD OF HEALTH PERMTI'TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #07-036 FEE: $75.00 In accordance with reeulations promulgated under authoriry of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the�Ueneral Laws,a peimi[is hereby granted to: � Seafood Sam's of South Yazmouth, Inc., ID06 Route 28 South Yazmouth, MA Whose place ofbusiness is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit e�cpires: December 31, 2007 BOARD oF HEAI.TH: B �J�' �. ��., ' sEn�cr 85(45 inside;40 outside) d{ee le.rc��$Ir�i, �., �/i��hntaat i�sTlucl'ioxs: Disposable Service Only. Qo��. B?at�r�, � � Sl�, R.N. ��.�..,�. R.N. Jan„�y za.200� s�G. �by,�¢ s.,cxo Director of Health THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #0'7-024 FEE: $50.00 This is to Certify that Seafood Sam's of South Yarmouth,Inc.d1b/a Seafood Sam's 1006 Route 28,South YannonYh,MA IS HEREBY GRAN1'ED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. Boa� oF��.�: e .�.�2. � M.�., • sEw�t�[n�G: 85(45 inside;40 outside) d�t ��s, ./�., �/!ce e�� Rode�t 4. B�, � /��Aie.6 Ma$e� A� (�'3ee.cGarurc, R./V. January 24,2007 �ruce G. Murp y,MP , .,CHO D'uector of Health ! ''""`. � �� `-'';, 5�9foop �s � F�q.y TOWN OF YARMOUTH BOAR�^�F�E�L� t . .� + ::o o " y APPLICATION FOR LICENSE/PE � '!�� yg� ,�a/ � _. 7�5 r� x * Please complete form and attach all necessary documents by December 3��Od55 Z005 Failure to do so will result in the return of your applicarion packet. NAME OF ESTABLISFIMENT: ��N�'�ue') cl R H'.I� TEL. # J�10 ,3 t�'�3Sa� LOCATION ADDRESS: i b n� �T z � MAII,ING ADDRESS: )'Av� c owivEx rr�: �� C�o[-u�e�i2 o T.v�ID �nv or s�rr� � CORPORATION NAME (IF APPLICABLE): �f�7a�ir/O S�f Uf J'�� /�n.��.�H� MANAGER'S NAME: �/�,•L �'e(�wE--rt o TEL. # �L d'�P—� MAILINGADDRESS: yl� 1��Gc y2(�. � _ fB•t�Dl�✓ZH, itiiK /�Z�'� POOL CERTIFICATIONS: The pool supervisor must be certifed 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 mus lis ' um of two employees cuttently certified in basic water safety, standazd First Aid and Community Cazdi u onary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to t 's orm. The Health Department will not use past years' records. You must provide uew copies and main in a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establistunents, 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 maiatain a file at your establishment. ' � i. ��1-tl L �oLaN�rc j z. dr��- �c�w��Z PERSON IN CI�ARGE: . . . . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEF�;FCH 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 attxeti copies of employee certifications to this 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. �/�R t�/ �"1g.I'dN 2. ��'S ��G/ZL-'LC... 3. 4. ' RESTAURANT SEATING: TOTAL# OF`FICE USE ONLY LODGING: LICENSE REQITIItED FEE PERMIT# LICINSE REQUIItED FEE PERMI'I'It LICENSE REQUIl2ED FEE PERMIT# BBcB $50 CABIN S50 MOTEL S50 _INN E50 � CAMP $50 SWIlNNIIPIGPOOLS75ea. _LODGE S50 � _TRAII,ERPARK $50 WfIIRI.POOL �75ea. FOOD SERV[CE: LICENSE REQUIItED FEE PF.RMIT N LICENSE REQUIItED FEE PERMIT# LICENSE REQi7IItED FEE PERMIT'# I 0-100 SEATS $75 O�i�OSa CON1'INENTAL $30 NON-PROFIT $25 >100 SEATS 5150 / COMMON VIC. S50 ��.b�� _WHOLESALE S75 RETAIL SERVICE: LICINSE R&QUIItED FEE PFRMI1'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMI1'# _<SOsq.ft. E45 >25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ /2$.OQ "•"""pLEASE TURN OVER AIVD COMPLETE OTHER SmE OF FORM""""" . i \ \ ADl�iIDiI3TRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now reqoired to hold issuance or renewal of any license or pemvt to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A'I"I'ACHED STATE WORKER'S CO PENSATION INSURANCE AFFIDAVTP MUST BE COMPLETED AND SIGNED,OR � CERT. OF INSLTRANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior t enewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTTI'TO RE'�'URN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT TF�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMR�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. • ADDITIONAL REGULATIONS POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts�eust be tested on a monttily basis by a State certified lab. Test results must be sent to the I-Iealth Department. Failure to do so will result in the suspension or revocarion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approva!from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food produ a retail or food service establishmem is prohibited. �/ % ��/6 3'/ 0 � � DAT'E: SIGNATURE: PRINT NAME&TITLE: �� U � 09/28/OS . - , _ �� NOTICE �� ; NOTICE TO ? TO EMPLOYEES � EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 11 NORTH AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WMZ8003685012005 04/01/2005 - 04/01/2006 POLICY NUMBER EFFECTIVE DATES Rogers &Gray Insurance Agency 640 Route 132 Inc Hyannis, MA 02601 (508) 775-0011 NAME OF INSURANCE AGENT � ADDRESS � � - � - ��--- -PHONE- Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 EMPLOYER ADDRESS 02/22/2005 EMPLOYER'S WORKERS COMPENSATION OFFICER pF AN7� DATE MEDICAL TREATMENT The above named insurer is required io cases of personal injuries arising out of and in the course of employment to turnish adequate and reasonable hospital and medical services in acwrdance with[he provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by[he insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospi[al a[ten6on,employees are hereby noti5ed that the insurer has arranged for such atten[ion at[he NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER TOWN OF YARMOUTH BOARD OF HEALTH PERMTl'TO OPERATE A FOOD ESTABLISHMENT —_ __ _ - --- PERMIT NUMBER: #06-052 FEE: $75.00 In accordance with regulations promulgated under authonty of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Paul Colonero/Seafood Sam's of South Yarmouth, Inc., 1006 Route 28, South Yarmouth, MA Whose place ofbusiness is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit eacpires: December 31, 2006 BoaxD oF HEaLTH: L3e.c�rik$. l�iv�oK, i19.$.f � ' SEATING: 85(45 IIlslde;40 outside) � Pa�� t/M� o�S�, �Uice G�ls4i/[�cass RESTRICTIONS: Di5p058b1C SEIv1CC Only. ROOB�[6 f. B�lf�G/K� � � �!�!� R.N. +��i� R./Y. December 9.2005 � Btuce G. Muiphy,Iv; FJ, .S.,CHO D'uector of Heatth THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-041 FEE: $50.00 This is to Certify that Paul ColonerolSeafood Sam's of South Yarmouth,Inc.d/b/a Seafood Sam's 1006 Route 28,South Yazmouth,MA IS HEREBY GRAN'PED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and eacpires 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 is3ssued in confornrity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned haue hereunto affiaced their official signatures. BOARD OF HEALTH: Be�.xi.c �f. (joad,o.r, �19..2�5,.{ ' sEn'r[n�G: 85(45 inside;40 outside) pc�tic�/Ho�vl�nto�, �/lce(:�taiAintr,ss ��,./�� j� R.N. December9.2005 �" Bruce G. Mu�phy, .,CAO Director of Health . , cl�� aa 3��3� � �►�� s�s ,`Yq ° � "� TOWN OF YARMOUTH BOARD OF HEAIL' o -` APPLICATION FOR LICENSE/PERMI�z^� 2 - „ �:; _ _ r �/S - * Please complete form and attach all nece "�ocu�n by D b 31,1�5�40 2 2004 Failure to do so will resuit in the re � �f�i�,p�rfiba�fion packe . " ALTH DEPT. NAME OF ESTABLISHIvIENT: • C 4� h'S TEL. # U �.��'`r LOCATION ADDRESS: I 6 6 6 IZT 7 � MAILING ADDRESS: OWNER/CORPORATIONNAME: � {h/� aL�,v�=ycd GAa=eon S'Aro�f e f f �9/iIC �srr/t�1.�vG. MANAGER'S NAME: /9UL QLrrvc�J TEL. # .Sb F�S'FP'34P3 MAIL.INGADDRESS: '�/ �Tn H�s Iv�4-�. � S/l.Lnt�/�ci�� /yr9- �, ZT�7 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must Gst a mini m o o em ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmo R su itati PR). Please list these employees below and attach copies of empioyee certifications to thi e H th Department will not use past years' records. You must provide new copies and ma tain 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 certiSed 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 Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �Aw� C.o�o�ero 2. �ArrcJ mASaN PERSON IN CIIARGE: _ _ _ _ _ _ — - --- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. I. �(IRrTC,J /Y1PrSonl 2. �Ru,� L'o�oJPlO HEIMLICH CERTIFICATIONS: All food service establishments with 25 seais or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. �hr�C.✓ /+1A�J'e�l 2. 'rRc./ `jt�rCl/ 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERM[T N LICINSE REQUIItED FEE PERMI'I'# LICENSE REQUIltED FEE PERMIT k B&B $50 CABIN $50 _MOTEL $50 INN S50 CAMI' $50 _$WIIvfIv1ING POOL S75ea LODGE $50 1'RAII.ERPARK S50 � _WHIItLPOOL S75ea. FOOD SERV(CE: LTCENSE REQUIItED FEE PERMIT#� LICENSE REQi7Il2ED FEE PF.RMIT N LICINSE REQUIItED FEE PERMIT# I 0-100 SEATS S75 O S�b _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150 I COMMON VICT. $50 �0�3 _WHOLESALE $75 RETA[L SERVICE: LICENSE REQUIItED FEE PERMIT# LICINSE REQUII2ED FEE PERM[T# LICENSE REQi7Il2F..D FEE PERMIT N _<50 sq.ft. S45 >25,000 sq.ft. 5200 _VENDINQ-FOOD E20 _Q5,000 sq.ft. S75 FROZEN DESSERT $35 _TOBACCO .��525 � � NAME CHANGE: $10 AMOUNT DUE =j'$ 2 .00 ` ••"•"pLEASE TURN OVER AIYD COMPLETE OTHER SIDE OF FORM••"••' �_�_.--' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVII'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and Gens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIA'I'ELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITl'TO RETURN THE COMPLETED APPLICATION(S) AND REQIJIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT TFIE HEALTHDEPARTMENTFOR INSPECTION 7-10 DAYS PRIOR TO OPENII�TG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY'I'HE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been ciosed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food 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 requued Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. - ,FRO�EN I3E�RTS• __ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. �UTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � /v /� DATE: '��la� SIGNATURE: I CZ�-Q l�o�o�x�d' PRINT NAME& TITLE: �Awl Co�a.Je�a �i`�ec�c�e,�� 10/22/04 �� 4 NOTICE ; NOTICE TO ? TO EMPLOYEES � EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 021ll 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 11 NORTH AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY . WMZ 8003685012004 001 04/O7/2004 - 04/Ot/2005 POLICY NUMBER EFFECTIVE DATES Rogers& �ay fnsura�ce Agensy _ . 640 Route 132 Inc Hyannis, MA02601 - - - (508�77SQ011 NAME OF INSURANCE AGENT ADDRESS PHONE Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 EMPLOYER ADDRESS 02/20/2004 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases o[personal injuries arising out of and in the course of employment to fumish adequate and reasonable hospital and medical services io accordance with the provisions of the Workers Compensation Act. A copy otthe First Report of Injvry mus[be given[o the iojured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,i[the treatmeot is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the . NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #OS-054 FEE: 75.00 In accordance with reRulations promulga[ed under authority of Chapter 94,Section 305A mmd Chapter I 11,Section 5 of tite�ieneral Laws,a permit is hereby granted to: Paul Colonero/Seafood Sam's of South Yarmouth, Ina 1006 Route 28 South Yarmouth, MA Whose place ofbusiness is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2005 BOARD OF HEALTH: Be�s$, l�'atd�wc,��, • SEATING: 85(45 lOSld¢;40 o,�;a�� p��ar�s� v�ef�.,�.z 1�es'1'1uc1'[oxs: Disposable service Only. /lo/r�3t�. B e�{e� ��iafi,�./�� A�us '�6o�c�w, R.N. January 19.2005 Bruce G.Murphy, S.,CHO Director of Health 'I'HE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-043 FEE: 50.00 This is to Certify that Paul ColonerolSeafood Sam's of South Yazmouth,Inc.d/b/a Seafood Sam's 1006 Route 28,South Yarmouth,MA IS HERF,BY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazrnouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendmerns thereto. In Testimony Whereof, the undersigned have hereunto affu�ed their official signatures. sEw'citvc: 85(45 inside;40 outside) BOARD OF HEALTH: �Q� (�'a3do�r,, /Z1.`.�5. ' � v�ef� �Sl� R.iK� �4.�Cj�dQ.�.,�, R.IV. January 19,2005 ruce G.M hy, . .,CHO Director of Health _ . . �,b��: , 3i°F�Ryc TOWN OF YARMOUTH BOARD,OF H�� C,� I��b �Hr�s� r;; .'.i APPLICATION FOR LICENS F,� IT�2 4 D E L p 2 2003 � * Please complete form and attach all necessary doc �` nts b y December , . �� DCPT. Failure to do so will result in the retum of your application packet. NAME OF ESTABLISHMENT• � D [) f1 Fi ' f 'rFr � R`�u '� � .3�Y LOCATION ADDRESS• / b D� 1Z� • 2 � fJM L OWNER/CORPORATION NAME• ��R✓L (1 ci�.w�r c j S�?I fuuo S'il H �f a-� �1��i��o✓lLf�L�✓�'.. MANAGER'SNAME: �/Iv� �G[-c,vrn�+ T # ° o &=P��-3Y�3 MAILINGADDRESS: `7` l /�;AN�J l�✓/!h. t. S%hv�0l•i/�GN, /�'J�`I• D ZS":�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pooi Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a mini m f two employees currently certified in basic water safety, standard First Aid and Community C dio ulmo' Resuscitation (CPR). Please list these employees below and attach copies of employee certific 'on to s rrn. The Health Department will not use past years' records. You must provide new cop► a d m ntaiu a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �A71-�LN lr'7ASUN 2, ��/h/L (�iLUwLX� PERSONIN CHAKUE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. t. ��tfft-�J �oL-eti�-yu 2. �O,v�rtf��✓ C��R� � I3EIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heim(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' records. You must provide new copies and maintain a file at your place of business. i. �6� p-L-h ��«2� 2, r.�t9�t�� i�f�;,. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE PERMIT k _B&B S50 _CAB[N S50 _MOTEL 550 _INN S50 _CAMP S50 _SWIMMMGPOOL575ea _LODGE $50 TRAILGR PARK 550 WHIRLPOOL S75ea FOOD SERVICE: �� LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRED FEE PBRMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $75 '�0�-� _CONTINENTAL S30 NON-PROFIT . S25 _>100 SEATS EI50 �COMMON VICT. S50 �6�0 _WHOLESALE S75 RETAIL SERVICE: LICENSE R6QUtRED FEE PERMIT# LICENS6 REQUIRBD FEE PGRMIT k LfCENSE REQUIRED FEE PERMIT# _<50 sq.ft. E45 _>25,000 sq.ft. $200 VENDING-FOOD S20 _Q5,000 sq.ft. S75 _F'RO%F,N DBSSIiR"P $35 _TOBACCO ..� S25 �y� \ NAMECHANGE: $10 AMOUNTDUE �$ � ZS-OO � �__-_- - --.___. *""**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*"« ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a 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 SICNED, OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: Permits run annual(y from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMI'LETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPAR11vIENT 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 PffiOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaztment 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. ��az�v ��ss��: _ _ Fmzen desserts must be tested on a monthly basis by a State ceRified lab. Test results must be se�t 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. OUT5IDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),p�have prior appmval from the Board of Health. QjITDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ( �y DATE: III Z3 �� SIGNATURE�, C�z� �� PRINTNAME& 7'ITLE: LQ(-cn„az '�-�}: 10/22/03 _ � . The Co►nmonwealth ojMassachusetls s : Department ojlndustria/.-iccidents ; 011/ce01/erestlosdiis 600 Washington Sl�eet Bnstort.Mass. 02111 ` °� 'V W'orkers' Compensation Insurance Affidavit Annlicant information: PleasePRiNTTesGtdt nam�: St/1�vo� VA.0 c �I- S. yfhi7Mote��1 1.J� location: /O 0� ,/��- d B ut� s• Ys}rw� o u.fh h2�4 O d G�'F ehon M �SO�') 3 9'�- 3 Y O� � I am a homecuner pertorming all work myseif. � I am a sole proprittor_-,', ha�e no one ��orkin_ in any capacin• [�I am an empfo}er pro�idin� workers' compensation for my employees workine on this job. comnanr name: vPA""�o� ��M �S oT S. �q-�-rviar��/r �,>c � . . aJAress: /006 /Qf. �� eitv: v - Y.��o�"�� ehone N• ��0 8l 3 ei�-j .�G� insuranceco. g•-L� �'"1, h�w'�u-g� _''��lA�✓cC �d. �o��p (JM2. So036�S0/J.003 � I am a sole proprietor. qeneral contractor. or homeowner(circle onel and ha�e hired the contractors listed below aho ha�e the follu�cin; ��arker; compensation polices: vn address. cin�: nhone N: insurnncc co. pelie��# eomoanv name: addresr [�y: Qhoee N• � � � .� insuranee ca � � eeliev M - • Failure ro secure covenee u«qwred uoder Secaoe ZSA o(MGL l52 u�Ind W l0e i�pai�of cri�iW pndtle oh O�e op to 51300.00��d/or ooe ynn'Impri�onment u w�ell af tiril peedNo ie the form oh STOP WORK ORDER aed�Ilot of f100.00�d�y qtiott me. 1 a�dmta�d t6at■ copy of tAN ehtement m�y be fonr�rded to tAe ORiee of InvatlaHiom of Me DIA for eoven«veriflntlw. � /dn hrreby cmijy under rhe pains aed prnal�iet ajperjury thm thtlnjornm8on provided ubovt is trnt and eor�r� Signature Due Print name Phone M .. olTicial use onh� do not rrite in�his arn ro be completed by cih ortowe ollleial ciry or town: Y��DT$ _ permiNicceae N nBuildiog Dep�rtmmt �Licemioe Bo�rd �check if immediate respome if required 261 �Selectmen'f Oflite � �HnItE Department conuct person: pAone M:_ �SOB� 398—?231 eat. nOtAer �� NOTICE � " � NOTICE TO � TO EMPLOYEES � EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 11 NORTH AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970 ADDRESS OF INSURANCE COMPANY WMZ 8003685012003 001 04/01/2003 - 04/01/2004 POLICY NUMBER EFFECTIVE DATES Rogers & Gray Insurance Agency 640 lyanough Rd Rte 132 Inc Hyannis, MA 02601 508 775-0011 NAME OF WSURANCE AGENT ADDRESS PHONE Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 EMPLOYER ADDRESS 02/10/2003 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries aristng ou[of and in the course of employment to furnish adequate and reasonable hospi[al and medical services in accordance with the provisions of the Workers Compensa[ion Act. A copy of the First Report of Injury must be given to the Injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by[he treating physician will be paid by the insurer,if[he treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital atten[ion,employees are hereby notified that [he insurer has arranged for such at[ention at the NEAREST AND BEST MEDICAL FACILIN NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER � . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NCTMBER: #04-095 FEE: 75.00 In accordance with rec,nilations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I I,Sectian 5 of the�eneral Laws,a peruut is hereby�ted to: Paul Colonero/Seafood Sam's of South Yarmouth, Inc., 1006 Route 28, South Yarmouth, MA Whose place of business is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pem�it e�cpires: December 31. 2004 BOARD oF HEALTH: B�$. 4o+�don, M.$. ' SEATING: $S(45 In3idC;40 outsi(IE� pa�tia(s iWWaRla�t�E �Uloe��uxa�C xEsriucrioxs: ths�o�vle ser�i�e o�y. Rod�vct 4. B�r«wy L�lia,4 e�f.� S!� R.N. J�u�z�_zooa � Bruce G. Mwphy, H, . ., CHO Direcwr of Heakh THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-070 FEE: 50.00 Ttris is to Certify that Paul Colonero/Seafood Sam's of South Yazmouth,Inc.d/b/a Seafood Sam's 1006 Route 28, South Yarmouth,MA IS I IF.REBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confomuty with the suthority granted to the licensing authorities by Generai Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTA: B�y�a$. C�'o•td.ac, M.$. SEATING: 85(45 IllSidC;40 OI1tSIdC) �Ma� v:�e� Rod�t 4. B�, Gl�r,4 � R.N. J�n,�y 2�.zooa • Bruce G.Mutphy, H, ,CHO Director of Health , ' �,3or7 �i�"`.�woD SaMs r ��r R.y TOWN OF YARMOUTH BOARD OF H 3 � APPLICATION FOR LICENSE/PE�II . ` `" � C� C�i C�s' U M L�S � � 's � -; . �'' ��P,�ob� zoo3 * Please complete form and attach all necessary documents by Dece er Failure to do so will result in the return of yow application p keNt EALTH DEPT. N T I T• ` # � J'-�Y LOCATION ADDRESS: Jb t1 b R-T-C n S �� OWNER/CORPORATION NAME: S�L-�i�I'n�./� . ,9.�'i J G� c , Gl�r�o✓1�� y!✓� MANAGER'S NAME: ��aLewv?�n TEL. #, �'��'eGF-,y"/F� MAILING ADDRESS: Lf/ ,�:A Nss L,.-�i„ . [�- J i9/�o/-✓�z E/, /r'!✓1 D 25��7 . POOL CERTIFICATIONS: The pool superviso must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opeiato•(s) a }ka 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 Cazdiopulmonary Resuscita6on(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' recorda. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. i. Lt/ Prl�2�=A/ L�. /��S'o�V 2. _ PRR. ON IN HAR[' � _ _ . - - — - - - - -- -- Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. �/�1/L l,d�hJ ��c 2. /�/3'j�t,/ �'!/�-c'�NL�-U HE�yILICH 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 anri-choking procedures below and attach copies of employee certifications to this form. The Health Departmeet will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �F}Y� �0�-o�ul-�lt-o 2. /✓!�"'7q'C-�4 ��Lrnii-�zo 3. 4. BF�TAURANT SEATING: TOTAL# LoncnvG: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLT[RED FEE PERMIT# _B&.B $50 _CABIN S50 _MOTEL $50 _INN S50 _CAMP $50 _SWIMMING POOL$SOea _LODGE S50 _TRAILER PARK S50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-]00 SEATS S75 �63- _CONTiNENTAL S30 _NON-PROFIT $25 >10(1 SEATS 5150 I COMMON VICT. $50 O B _WHOLESAI,E $75 RFTA I RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO S20 <25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. S45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ I 2S•OO ••'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•** � _ _ __ _ _ � ' '- ADMINISTRATION iUnder Chapter'152, Section 25C;Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ;of�ny iie�nsa oY''�i�ilnit 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 _O� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to�enewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES �� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISI IlvfENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPiING: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 commt by a State certified lab,prior to opening, and quarterly thereafrer. 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 Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. k�OZEN 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), us 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. DATE: ( Z[ �� G� SIGNATURE:___-�_l�iC �� PRINT NAME & TITLE: ��iL_ �U�N�''�d — ��j'. 10/18/02 '--. THIS ENDORSEMENT CHANGES THE POL�CY. PLEASE READ IT CAREFULLY. AMENDMENT OF INFORMATION PAGE APPLYING PUBLISHED MOD .86/1.00 �Gja,6Lh'�"'s � �"_/' � This enUps¢m¢n�is attac�etl lo t�e pWity inEica�ed p¢i�.aM is eHective on tha aate sWtetl�erein,a112:01 A.M.,slantlartl time at t�e aadress of ihe insumE as tleScnEeC in Ihe intwmatim Oage. Po�icy No. Safety Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WMZ 8003685012002 0500 �ssuedto 04/Ol/2003 08/01/2002 002 Seafood Sam's of S. Yarmou[h, Inc. dba Seafood Sam's Addieonal Premium Return Premium ISSUED BY: ASSOCIATED INDUSTRIES OF MqSSACHUSETTS MUTUAL INSURANCE COMPANY �33.00 PLACING OFFICE 804 KIND OF AUDIT: - cwm��y�ea honieE Represenlative .:OMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NO. WMZ 8003685012002 002 EXTENSION OF INFORMATION PAGE �UOTE PAGE NO. 2 Esfimated Total Rates Per CODE $100 of Estlmated Annual Premiums CLASSIFICATION OF OPERATIONS Annual Sub ect to NO. Remuneratlon ��Remun- 1 AIIONer eration Modifiwtion ,-20 Intrastate I.D. 111111 ]8/O1/2002 TO 04/O1/2003 'otal Scheduled Premium For Period 3,646 ?ate Deviation 9037 0.1000 -365 'otal Manual Premium with Deviation 3 �281 ?mployers Liability 9807 1.00°s 33 500/500/500-Class 9807 ,dditional YPemium For Increased Limits 9848 17 500/500/500-Class 9807 ubject to Experience Modifier/Merit Rating 3,331 :xperience Modification Factor 9898 0.8600 -466 INTER published remium Adjusted By Experience Modifier/Merit Rating 9999 2,865 ubject to ARAP Surcharge 2,865 RAP SUrcharge < 111111 > 0277 1.0000 �remium Adjusted By ARAp 2,865 otal Estimated Standard Premium 9999 2,865 . ��bject to Premium Discount 2,865 %oense Constant 0900 zy4 �bject to Mass Assessment 3,179 olicy Total 3,109 'ass Assessment 143 AP 4921.01(9-89) . . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NiJMBER: #03-143 FEE: $75.00 In accordance with reQulations promutgated under authority of Chap[er 94,Section 305A and Chapter 111,Section 5 of the Zieoeral Laws,a permit is hereby granted to: Seafood Sam's of South Yarmouth, Inc., 1006 Route 28, South Yarmouth, MA Whose pJace of business is: Seafood Saxn's Type of business: Food Service To operate a food establishment in: Town of Yarniouth Pernut e�ires: December 31. 2003 BOARD oF�.a�.'�: �e�. �dlt�4e�, �iFar,uxaK - __ - -- - -- -- --- sea'rurc. 85(45 inside;40 outside) �a�?J. �, 'fll.ZI., �/iee RFR'rtuc'r�oNs: Disposable Service Only. � � �. �waMc, elau� .. �a.Orit�6�Xe?�aurux� �d,ea Skak. ,��t. Januarv27.2003 Bruce G.Murphy, H, .,CHO Director of Heaith THE COMMONR'EALTH OF MASSikCHiJSETTS , . , � :, TOW1V OF YARMOUTH ;�,. < . .. ; , ; PERMIT NUMBER: #03-088 FEE: $50.00 This is to Certify that Seafood Sam's of South Yarmouth. Inc. d/b/a Seafood Sam's� - _ 1006 Route 28r South Yarmouth, MA IS HERF.BY GRANTED A , , COMMON VICTUALLER'S LICENSE ' '° .r ,'" � In said Town of Yarmouth and at that place anly and expires December thirty-first 2003 unless sooner suspen or revo ' ' w�af the ' : licensing of common victualler's. This license is issued in conformity with the authority gra�ted to �':the licensing suthorities by General Laws, Chapter 140;and amendments thereto. _ In Testimony Whereo�the undersigned have hereunto affixed their official signatures. B0.4RD OF YEALTH: �iFa�lia;� xelltkaa. �a�«�a�C sEn'1'tr7c: 85(45 inside;40 outside) �. �Jozdow. ��., `�/iee a��. �ataawc. L�[ark �a�k 7XdDauxatt �efus S�fak, R.72. January 27.2003 ce . urp y, Director of Health c�� , . r' � TOWN OF YARMOUTH BOARD OF HEA��+4; �ti� Q `� � `S � �'� � D APPLICATIONFORLICENSE/PE ,lQ1� 23 ZOvP * Please complete form and attach all necessary documents by° ,�� l, Ol. Failur t¢{�i/�p�ql�jgga�t_in! the retum of your application packet. -- NAME OF ESTABLISHMENT: . � i�n n' T_F.T__ # _ _ _ r ,3S'dy LOCATION ADDRESS: l(!(S !. TL'tt_ Z�.S . !/I/h'l.h�� r'1L MAILING AD RESS: SftK� OWNER/CORPORATION NAME: �"�—�v0 ,PfFti+'S �' . vl. ZN� . MANAGER'SNAME: � .9✓� QLun��7ve TET # �/��'�� MAII.ING ADDRESS: SA"H� POOL CERTIFICATIONS: T6e 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 mini um f t mployees currently certified in basic water safeTy, standazd First Aid and Community Cardiopulmo es ci tion (CPR). Please list these employees below and attach copies of employee certifications to th' . T e Health Department will not use past years' records. You must provide new copies and ma' tain 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 Protection Manager, as defined in the State Sazutary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Gi/f�fl ��v Mo4-J'af✓ z. _��}J'r`��/L,4 �u�t/1 y PERSON IN CHARG�: __ . ___ _ __ _ Each food establishxnent must have at least one Person In Chazge (PIC)on site during hours of operation. i. ��hIL �rtLrn�c=rw 2. � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your place of business. �. �- � y 2�-� 2. �� 3.��fLon�-✓L u 4. ' �' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN S50 _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-]00 SEATS S75 d"�6� _CONTINENTAL S30 NON-PROFIT $25 _>100 SEATS $150 I COMMON VICT. $50 6a _WHOLESALE $75 $ETAIL SERVICE: LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. $75 TOBACCO S20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN RT$33"��-� NAMECAANGE: $]0 AMOUNTDU = $ /ZS.00 *"**•PLEASE TIJRN OVER AND COMPLETE OTHER SIDE OF FORM*** � .� , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPART1vIMEN'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. ADDITIONAL REGULATIONS POOLS POOL OPErTING: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. ('ATERNG POi.ICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hows prior to the catered event. Thses forms can be obtained at the Health Department. FROZFN DESSERTS: _ _ _ _ _ _ _ _ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. __ -- _ _ - _ _ ___ - DATE: � Z SIGNATURE:�/ L�%f.�/l �G'�/'�-� PRINT NAME& T'ITLE: /C' , 09/11/Ol � - �- - Eczd�ern Cadua��l-y 325 Oonald J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY � INFORMATION PAGE � Policy Number: WC96 192152 Bureau File# 213458 �_ � FederallD#: 1. Named Insured/Mailing Address: Seafood Sam's Of South Yarmouth, Inc. Legal Entity: Corporetion DBA Seafood Sam's P.O. Box 1307 Mashpee, MA 02649 Insured Location Addresses: 1. 1006 Route 28 Yarmouth, MA 02675 2. Policy Period: The policy period is from 08/01/2001 to 08101/2002 12:01 A.M. Standard Time, at the insured's mailing address. 3. Coverages � i � A Workers' Compensation Insurance: Part One of the policy applies to the Workers' � � Compensation Law of the states listed here: Massachusetts � B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except those listed above in item 3A and ND, OH, WA, WV, &WY. D. This policy includes these endorsements and schedules: Refer to Attached Schedule Total Estimated Annual Premium: $4,715.00 1fi�-� L�`'s ��y �" � � ��'rr�3Z� �z �fzt��j ��1� �'�4. � BY Date: 07/19/2001 orized representative) MK ' . - � - Eczd�ei n Cadua,�y W� „' , (Ed.4-84) 325 Donald J. Lynch Boulevard, Marlborough, Massachusetts 01752-4729 (NCCI Carrier 16942) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY EXTENSION OF INFORMATION PAGE Policy Number: WC96 792152 (Seafood Sam's) 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classification, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Classification Class Total Estimated $100 of Annual Description Code Annual Remuneration Premiums Remuneration Massachusetts Rating Restaurant-Noc 9079 $ 246,562 $ 2.08 $ 5,128 Coverage B-500/500l500 9807 $ $ 51 Experience Modification (@8/1l2001) .83(=17%Credit) $ �$$�� Standard Premium $ 4,299 Expense ConstaM � $ 214 Division of Industrial Accidents Assessment $ 202 Total Estimated Annual Premium $ 4,715 The minimum premium applicable to this policy is �200.00 ,f' ; � �� ji Si� � �t G TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-165 FEE: $75.00 In accordance wiYh re�ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 3 of the Gen�al Laws,a pecmit is hereby ganted to: S afond Cam'c of South Yarmnuth_ inc 1006 Rnute 2R So rthi Yannoirth_ MA Whose place of business is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31_2002 BOARD OF HEALTH: eiLaalea ik. Z�. �� sEn�t'¢aG: 85(45 inside;ao o��> �D. C�. 7J�D., ?�ice xEs'rwcnoxs �ann: Disposable Service Only. ,�Be�t�. �C. �lerk �a�riek�awrelC skefe.s SrEak. ,�'� June 12 ,2002 ruce G. Murphy;MPH, .,C Director of Heakh THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-099 FEE:_ $50.00 This is to Certify that Seafood Sazn's of South YarmouttL Inc. d/b/a Seafood Sam's 1006 Rnute 2R Snuth Yarmnuth_ MA IS HEREBY GRANTED A COMNION VICTUALLER'S LICENSE In said Town of Yazmouth 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 wrth 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: �£anlea'�. Zdlikac, �rai+uxa.i sen'rwG: 85(45 iaside;40 outside) '�fa�xGs�. C�fmtalaa, �D.. �/ite �� . � �attia(e�Dauxetr � S� � ��Z. June t3 ,2002 ruce G.M hy,MP , ,CHO D'vector of Health � . , „ � G�3 [� � L� UdC�� L� TOWN OF YARMOUTH BOARD OF ��0� JAN 0 3 2000 APPLICATION FOR LICENSE 2�( ${ HEALTN DEPT. ' Please complete form and attach all necessary documents by Dece 31, 2000. Failure to do so will result in the return of your application packet. ------------------------------------------ -------- 7r - ----- ---------------------------------------------------------------- NAME OF F T R I4HM N �-Frro-n ,S�y h �S T # 7`'y �� LOCATION AnnuF�� 0 6 fi�� z � vl�J-2 y o�rtr � L� � - � � � 4 � /'�Gl/7""� T•(iC ' • L Go,vE-�.,, � 3 �I,ING ADDRESS• Y l �r�4N U t...�vi L fl�v0 l,.fc Ll� l'�� a z J'�� -------------------------------------------------- ---------------------------------___—__------ POO . . .RTIFI .ATION • T6e pool supervisor must be certified as a Pool Operator, as reyuired by new State law. Please list the designated Pool Ope to s)and attach a copy of the certification to tlus form. i. 2 Pool operators must list a minimum of two employees currenUy 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. Yoa must provide new copies and maintain a ftle at your plsce of business. 1. 2 3. 4. HF i I H RTIFI ATION�• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your empioyees trained in anti-choking procedures below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. �i�uL �� 2. CLrrn�,.�c= �/�rr� 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# - --------------------------___—_------------------------ --------------------------------------- L�D�,INC, OFFICE USE ONi Y LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# =B&B / � $50 _CABIN $50 INN lU $50 _CAMP $50 _LODGE J $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. FOOD SERVIC'F• —��P�L $25ea. NOTE: Per the new 105 CMR 590.0011 State Sanitary Code for Food Estabiishments,the effective date for food protection manager certitication is October 1,2001. LICENSE REQUIRED FEE PERMI� LICENSE REQUIRED FEE PERMIT# _0-100 SEAT3 $'75 � S �01-I�J6 _CONTINENTAI, $30 _>100 SEATS $150 _NON-PROFIT $2g _COMMON VICT. $50 V �OI-O8� _�OLESALE $�g $ET�IL SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO — $20 _45,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAMF r atvr.F• $10 _ _ _- AMOUNTDUE _ $ �tS�� . "•`•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••*� %� ' ADMINISTRATION . Under�h�pler 152;S¢ction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemiit to operate a business if a person or company does not ha�e a Certificate of Worker's Campensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ) / CERT. OF INSURANCE ATTACHED �� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taices and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES f NO NOTICE:Pernuts run annua(ly from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLIS�NTS ARE TO CONTACT TF�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO QPENRVG FOR THE SEA50N. 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. ennTl�inNAi.RF.C,iTi.ATIONS POOLS POOL OPENING:All swimming,wading and whirlpoois which have been closed for the season must be inspected by the Health Department,az►d the water tested for pseudomonas,total coliform and standard plate count by a State certified lab, pnor to openuig,and quarcerly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE n��y �TATE SANITARY CODE FOR FOOD ESTAI3LISILMENTS: The effecHve date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection manager. Tius provision is effective ane yearfrom the date vfpromulgation of 105 C�v1R 590.00(l. , - - The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories. CA'TERi�IC POLICY• Anyone who caters wrthin the Town of Yarmouth must notify the Yarmouth Health Department by filing the requu'ed Temporary Food Service ApplicaUon form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �OZFN DESSER7'S• Fmzen 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. OUTSIDF�'AFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHIN� Outdoor cooking,prePaiarion,or display of any food product by a retail or food service establishment is prohibited. DATE: / y�2 1 � � SIGNATURE: ��A-� �� PRINT NAME &TITLE: �l�h/L �(Lvn.t�-r�.s / i�tiC� 11/16/00 ' ' � NOTICE NOTICE TO � TO EMPLOYEES ` EMPLOYEES 4 v The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Secfions 21,22 _30,this will give you notice that I (we) have provided For payment to our injured employees under the above mentioned chapter by insuring with: Eastern Casualty Insurance Company (Name of Insurance Company) 325 Donald J. Lynch Blvd., Marlborough, MA 01752 (Address of Insurance Company) WC96192152 08-01-2000 TO 08-01-2001 (Policy Number) (Effective Dates) Hart Insurance Agency,Inc. 240 Main Street,Buzzards Bay,MA 02532 (508) 759-7326 (Name of Insurance Agent,Address,Phone) Seafood Sam's Of South Yarmouth, Inc. DBA Seafood Sam's 1006 Route 28,Yarmouth,MA 02675 (Employer,Address) Employer's Worker's Compensation Officer(If Any) , MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employmeut to furnish adequate and reasonable hospital aad medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Inquiry must be given to the injured employee. The employee must select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by insurer, if t�e treatment is 6ecessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the (Name of Hospital) (Address) TO BE POSTED BY EMPLOYER WC 7506e(Ed. 1-89) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O1-082 FEE: $50.00 This is to Certify that Se�food Sam'c of South Ya`rmouth_ Inc d/b/a Seafood Sam's 1006 RontP 2R 4o rth Y rmo � h MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirry-first 2001 unless sooner suspended or revoked for viola6on of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned haue hereunto �xed their official signatures. BOARD OF HEALTH: �d�?l. �etlea, elraGuxawc sEn'rt�G: 85(45 inside;40 outside) ��Cd�f• xCf�'tCc. �/iCe �CQf/tatasC �o�eit�, b'ao[v.�, �/ fi'�ieoc 'arxi.r D. Cjoado�c. 9 .D. March 8 ,2001 ruce G. Murp ry,MP , .,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #01-130 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 ll,Section 5 of the General Laws,a permit is hereby granted to: Ceafood Sam'c nf Sn � h Yarmonth inc 100h Rnute 2R 4onth Yarmnnth, A�A Whose place of business is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: $d�l. �etrea, elraia.xa.c Sen'r�rrc: 85(45 inside;40 outside) �(,�y�, z�, �/� �J�'� �s'r2icTTONs �e.at�nt: Disposable Service Only. �o�MJtt�, �ourK, � S'eoa�xi.� D. Cmrdo.r, nl.D. March R ,2001 ruce G. Murphy, H, .S., CHO Director of Heaith ��r_�[� ��Il7lC w .�; i � TOWN OF YARMOUTH BOARp OF HEALTH r ! '. � x , ,,,� � APPLICATION FOR LICENS�/P�RMY3'=200 ,��i p�� M Q '� ' � � L�i� , H=A!_�;-+ DE�'7. * Please complete form and attach all necessary documents by I7ecember 31, 1999. Failur -to-�a'�a� u m the re_tum of your application packet. -------------------------------------- ----- • ------- ------------------------------------------------------------� N T C'�' u I�H ' . # O� `/ L TI vG6 � z LIN /tu �1. � ZG - M .✓o R' 9'17r�- oLa,v�-xo . # 3 � MAILINGADDRESS: �-f l �iA-h:J l.�rtt �______----------L='T9J�A/J w��/�---�?yf __-d�`��-------_�___��_��. 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 ttus form. 1. 2, Pool operators ust list a minimum of two employees currently certified in basic water safety, standazd First Aid and Co u ' y Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee cations to this form. 'I'he Hea1t6 Depardnent will not use past years' records. You must provide new copies d maintaia a file at your place of business. 1. 2. 3. 4. HFIl�IL.I H RTIFI ATION � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at atl 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. AJL- C'�LQsvc_'7t�1 2. �L"/2 �� C "f�KP�r7�Z-� 3. �LA-�t ��e c� �l9-;2 4. RESTAURt�NTSEt�TING: TOTA�,# N(1N-SMOKING�EATS: TOTAFJ# — - -----___--------------------------------------------------•___---------------------------------------- OFFICE USE ONLY LODGING: LICEN3E REQUIItED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlVIl�IING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # �0-100 SEATS $75 �I�Fq _CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 Y2k--B� _WHOLESALE $75 RFT ii. . ERVI E: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 aMotnvT nuE = $ I Z�— "'"`PLEASE TITRN OVER AND COMPLETE OTHER SIDE OF FORM'•Re 1// — w, ADMINISTRATION � UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIItED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMI'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � QB 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. TT IS YOUR RESPONSIBILTI'Y TO RETURN TI-� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT TEIE HEALTH DEPARTMENT FOR INSPEC'ITON 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIM1vIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TFIE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENIlVG, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlvIlV1IIQG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WiTHIN Tf-IE TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIltED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI-IESE 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 RESITLTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TEIE SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL.Tf�ABOVE TERMS HAVE BEEN MET.—--- _ -- —_ OUTSIDE CAk'ES: OIITSIDE CAFES(i.e., OiITDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISP ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITE . DATE:�2 �4 SIGNATURE. PRINT NAME& TITLE: �Q ,v Z�� 11/12/99 , � The Commonwea/th ojMassachusetts = : Department oj/ndustrial.-Iccidents ; Omee ol/eresayst/iis 600 Washington Streer _ ' Bnston. Mass. 02111 " �Lbrkers' Compensation Insurance Affidavit Annlicant informallon: p► As��p n�mr Loc�tion: ��` nhone a � I am a homeowner pzn�rtning alI work myself. � I am a solz proprirtor r..,'. ha�z no one norkin� in am capacin� �� I am an emplocer pro�iding uorkers' compensation fucmy emplosees uork+n¢oRthis je�--- - - - - comnan�� name: `-'��D� �R'� S � J . y,�/YHdGtrTs1. �.✓` asldress: /OD(o /Q-�. �d'' titv: J , y-9�^�t O r.G��/ `{9� D o2.G G � phone p• CSD�S .3 � �- ',i' SO� insuranceco. F�S�P�'� ��Slt-Al7�y Z.rl$, oolicyk r9"7� s� � 1 am a sole proprietoc general contractor. or homeowner Icircle onel and hace hired the contractors listed below ��ho ha�e thz follu�cin_ «orkzrs compensation polices: tomp v natne: � ad d ress• citv�: phone p• insur�nsc co. po�i��•p eomoanv name: � _ ___ . __.__ . ._ _. iddresr cih': phoee�• insaronee co. �gn M • F�iiure to�eeure covenae as requved under Secnoe 25A of MGL 152 u�Ind to th i�po�iooe of erid�fl pe�dtla of�O�e ap�o S1�00.00��d/or one yean'imprisonment��w�ell a eivil peedHa io�he form o(�SfOP WORK ORDER nd a Ilee off100.0p a d�r q�iat me. [udmu�d Hat a eopy of thia staumem miy be fonvvded to�he 011iee of InvaNpuom of the DIA for eoven�e rerifluW�. !do hrreby ctn' under rhr pain nd pena!(ies ojperjury thm tht injormation provided above it bve md cor►ect Signature � %�AO Print name L CJ � . d one M J ' �l�O �✓ < �J .. olTicial use onl� do not wri�e in this�rea to bt eomplHed by eity or Imve ollltial ciry or town: Y�MODT$ _ � permitAiteeu M nBuilding Dep�rtmm� - ❑Lieemio6 Board � chrck if immrdiate response is required 261 �Sdettmen'�Ofliee (508) 398--?231 eEt. �HealtADep�rtment conuct person: pAone M:_ __ _ nOtAer TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT � PERMIT NUMBER: Y2K-149 FEE: $75.00 ' In accordance with regulations promulgated under authority of Chapter 94, Sec[ion 305A and Chapter 11 l, Sec[ion 5 of[he General Laws,a permi[is hereby granted[o: Seafood Sam's of South Yarmonth TnS, 1006 Route 2R Snnth Yarmn rth MA Whose place of business is: Seafood Sam's Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�'��/. .�pet�pQy, C'�ao-„quq.nq � n senTTnrG: 85(45 inside;40 ouuide) �[�oan� _JulCivan, l�r/., Vice l.�airma 2�si'alc7'toNs �F rxv: Disposable Service Only. Ko6orE g�g �ro/agn/, C�e,r/� a�r/i¢Claa�ak/o�leky-�✓dooPes ich.aaC dau��Cin Januarv 28 ,2000 ruce G.Murphy, MPH, R. ., C Director of Health THE COMMONWEALTH OF MASSACAUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-84 FEE: $50.00 This is to Certify that Seafood Sam's of South Yannouth Inc d/b/a Seafood Sam's 100h RontP 2R,,,South Y�rmnuth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violatron of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto �xed their official signatures. BOARD OF HEALTH: �(Ji��IP. .��tt�, C�at.mqa�a n ' /� sEwTIPrG: 85(45 inside;40 outside) `��joa/n G�.7�/u��ivan,/l��e �//., Vice l,�iair.naa Kab¢rt Jg •n6�rowpn� l.Ls/rk a6�eelle Ja�o/a�y-✓�looPeS • �l0' �l�n Ianuary 28 ,2000 ruce G. Murphy, MP , ,CHO Director of Health --�,a-'"� F.�.� r^q r•T�ry, �� ea�t �m� . . �� ;=;'i ��U , ^ z � ' � Cc � � U' C� DD TOWN OF YARMOUT�1�op �� p�qN 2 5 1999 Gt� � 1 1998 APPLICATION FOR LICEPI��IT A 1999 �� * Plea HEA _T r DEPT. tach all necessary documents by December 31, 1998. Failure HEALTH, Ep . the return of your application packet. --------------------------------------- ----------------------------------------------------- - -- --- - NAME OF ESTABLI HI�fENT: �'�---sHaa J' TEL. # Sa�39Y.33 d tI LOCATION ADDRESS ! a Q 6 I�-� �-� . G A�,�wvr�{i ,k . a 2GG y MAILING ADDRESS: �'//7'+ � E- `J r/"�' Uf� /�YL,�u/"✓Tb� LA�G A AGER'S NAME: RuL 6G.n,r>,+. TEL. # MAiiINGADDRFSS• �-/l ,�� J !z� �� AJ�O/v�G � h - O2� ------�--------�---�---�-�-�------�-�-�-��----�--��---�-�-------------------------- - --- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to t}us form. 1. . . — _ Z - -_ Pool oper rs st ' ' �m of two employees currernly certified in basic water safery, standazd First Aid and Commum 'o� Resuscitation(CPR). Please list these employees below and attach copies of employee certificatio t t}us fo . he Health Department will not use past years' records. You must provide new copies and � tai a file at your place of business. 1. 2. 3. 4. HEIMLICH CER'I'IFICATIONS: All food service establishments with 25 seaxs 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-chokmg 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. ��11lL (�d�1��o 2. �L/YIZ Lue� %�✓,�- 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ------____------------ ---------------------- -- ---------------- ----- ------------- . .. . _ .. . ------- — ----- ..�crns t7e� nari v ---- ------ --� . � � vrrac.��-�v...�r � _ . . . _. . . ___ . LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAII,ER PARK $50 MOT'EL $50 _SWIMIvIIIVG POOL $SOea. _WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT # ( 0-100 SEATS $75 �I7��SL CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 95�92 WHOLESALE $'75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $'75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 .______ NAME CHANGE: $10 /� AMOUNT DUE $ IZ�— "*"•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•' • + , • . ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TI-�TOWN OF YARMOLJTH IS NOW REQUIRED TO HOLD FSSUANCE 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 TOY!►�N OF.3t'ARMOUTti.�A�A.LI�NS MUST BE PAID PRIOR TO RENEWAL�`i�SUANCE OF YOL�.yPERMITS. PLEAS"'��IC"�iPPROPRIATELY IF PAID: YES NO N01TCE: PERMITS RUN ANN[JALLY FROM JANUARY 1 TO IIECEMBER 31. TT IS YOUR RESPONSIBILIT'Y TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. 3EASONAL ESTABLISHIv1ENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIvIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMNIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT,AND Tf�WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNl'BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY Tf�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING POOL MU3T BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TF�SE FORMS CAN BE OBTAINED AT TI-IE 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 Tf-IE SUSPENSION OR REVOCATION OF YOUR FROZEN DBSSERT PERMIT LTNTII..Tf�ABOVE TERMS HA�BEE3d1\��-----__ _-_ _ - _ _ _ ____ .— ___ _ __ _ _ _ __ __ _ OUTSIDE CAFES: OIJTSIDE CAFES (i.e., OiJ'I'DOOR SEATING WITH WAITER/WAITRESS SERVICE),M[JST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISf�vv1EEIVT IS PROHIBTTED. . ,/:=: c�-��t � S�uiGNAT[JR$: �`✓ C�ifi(i�- (��/� I�x!�'�.-,�4� rs:, _ _ � �� ,,: T=��8��rrrr,E:� L �a(.�r N��'c--a ��5. � • ♦ � The Commonwea/th ojMassachusetts � Deparlment ojlndustria/,-Iccidenls _ e Olflieot/sresaysaliis 600 Washington Slreet Boston, Mass. 01111 �� 'y Workers' Compensation Insurance Affidavit Anolicant information: PfeAsePRIRT'Tes.'ida �:,m� ��Fdt�p ✓11 h`� _ _ L�catian: �G�� M1-�rZ z � �it� cl ' !//�/iiv V/ iT � / l�1' G Z� � % phone M ��-�3 ��y � I am a homeowner p ortning all work myselE � I am a sole proprieror �cd hacz no one��orking in am capaciry �am an employer pro�idine workers' compensacion for my employees workine on this job. comnan�� name: V �� +'�7GG`� ��J V i� y. .:.�� ,�d��s: 1 o v c R7� z � �>• ,S ylh� a�o�r�-F hal _phone p• V `� a '�J 7 "�V '� 7 issurance co.Eas�.J 4`�S cts�l�y �+15� (u pqlicv tt /�JC 9 6 /`)'�/s� � I am a sole proprietor. oeneral contractor. or homeowner(circfe onel and have hired the contractors lisred below' uho ha�e thr follu«in� ��arker. compensation polices: company name: address: cih�: phone tl• in�uranceco. � polie��p comp�ny name: - _ � - ----- -- — -- ---- address: . . . _---- ---�--- -- . . [itv' ehoee 16 � insurnnce co. po��M F�ilurc to seeure covenge as required under Seedoe 25A of MGL 1S2 n�lud to IYe iapaidoe o(erioiW pe�dtles of�B�e ap to 51.500.00��d/w ooe ynn'imprisonment a�w�AI af civil pendNa io the form of a SI'OP WORK ORDER nd�6oe of f100.00�d�y a�dmt sa 1�Wenh�d Hat t eopy of thy statement may bc lonv�rded to the 011ice ot InvnNgadom of the DIA for eovera{e verilluliw. /do hrreby ce } der the pains en enalliet ojperjury�hm 1he injormation providtd above is nut and ronett Signamrc Print name '�L ( " O�7(/��L(f php��g �'� �—$O a ��O� .. oRci�l use onh do not write in this area to be complelyd by eiN or tow�n olllehl eiry or town: YA�M��TQ _ permilAieeme N nBuildioe Departmen� ❑Llteesins Board �cheek if immediate response ia required 261 �Seleetmen'�011iee (508) 398�2231 pat. OHe�it6 Dep�rtm�at conmct person: phone M;_ _ _ nOther Pe��nM iAy PIAI TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT Ni1MBER: 99-156 F'EE: $75.00 In accordance with regulations promulga[ed under authority of Chap[er 94, Section 305A and Chapter 1 ll, Section�of the Geueral Laws,a permit is hereb}'�an[ed to: S .afood Sam'� of 4o rth Yarmn �th T�, 1006 Ronte 28, 4nnth Yarmonth 1��A Whose place ofbusiness is: Seafood Sam's Type ofbusiness: Food Service To operate a food establishment in: Town of Yannouth Pemut expires: December 31 1999 BOARD OF HEALTH:�p��/. ,�atE�eAe, C'�a[�irmq/a�n /� SEATING: 85 (45 inside;40 outslde) �an � �nullivaro�/K�p.//,� �ice (..�eairman xF,s11uc1zoNs tt'�: Disposable Service Only. o�/¢rt p�� np,rowart� (�lar� . a6rielle Ja�aG��paoPee ic� s � ou�iclin Febn�arv 17 . 19 99 � ruce G. Murphy, ,R. .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-92 FEE: $50.00 This is to Certify that Seafood Sam' of o th Yarmo �rh Inc d/I/a Seafood Sa�m's 1006 Ro � S 4nnth Yarmonth R�A IS I�REBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 1999 uniess 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 with the authority ganted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. , BOI�D �F' �`.dll.�: G��(/•� Ja�pp� l,ha//i�rr�n/a�n� / SEAI7NG: 85(45 II151ae;40 outSlde) �[�oan G.��7 �uJllivan�/K7p.//.� Vice ��irman Ko�rt�,p}.�/,7ro/wert� (,lar� - a�riellee JakoG��pooPed - � �al ou��lin February 17 , 19 99 ruce G. Mutphy,MP RS. HO Director of Health , , �� 'Et,(;�;d ��m TOWN OF YARMOUTH BOARD OF HEALTH � � � � � �, � D APPLICATION FOR LICENSE / PERMI�„�T �,9�� . QE� 1 5 1997 �Y �j ��.� ;iGA.tT� �JEPT. * Plettse Complete form and attach all necessary documents De 1; �9�?. Failure to do so will result in the return of yout application packet. -------------------------------------------- - ---- -------- - ---------------------------------------------- N�ME OF T I NT. �---f� �i, cl ��f}rr� S TEL # i��% i Z `y� AIaDRESS• ! �C7 f T- � z� S-' �r�zg� ,�r��_tH-9 d �;��` G e OWNER/ CORPORATIO�V��' i� � i ' :v - �i1 7,� ' MANAGER' NA1vtF• `� fh� -�� TE �, ��`,�,�r�'i � (G..� � MAILINGADDRE44• �-1 r �E;;3w�J «��hi � � ��iw/J�„�zr1,/a�� d'1F=.�/�3c �t�) ------------------------------------------------------------------------------------------------------------------ POOL CERTIFICATIONS: Pool Operators must list a minimum of two employees currently certified in basic water safety, standard fust aid and�ommunity Cazdiopul�nonary Resuscitatioa(�FIt).Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years records. You must provide new copies and maintain a file at your place of business. 1.�� l� 2. 3. 4. HELMi ICH CE�tTIFICATIONS: 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 aud maintain a file at your place of business. 1. �Ru L ��eLc,;v�� `� i 2. � LiYti�lvc-C: .-�� 3. �'�},c P,/t�n.s3- '� fhLL��r_; 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL# -------------------------------------------------------------------------------------------------------------�---- _ ____ ___ ___ _ OFFICE,3LSE ONL.Y ___ _ _ _ _ _ LODGING: LIC. REQLTIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _B&B $SO _CABIN $50 _INN $50 �CAMI' $SO _LODGE $50 _TRAILER PARK $50 _M01'EL $50 _ SWIM POOL $50ea. _WHIRLPOOL $25ea. FOOD SERVICE: LIC. REQUIRED FEE PERNIIT# LIC. REQLJIRED FEE PERNIIT# i 0-100 SEATS � 9�Go _CON'TINENTAL $30 _>100 SEATS $150 �NON-PROFIT $25 �COM. VICT. $�30� q8•�f1 _WHOLESALE $75 BET�Ii� SEBYI�E: LIC. REQUIRED FEE PERMIT# LIC. REQiTIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq. ft. $75 _FROZ. DESSERT $35 ._>25,000 sq. ft. $200 . AMOUNT DUE = I �✓� ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT , TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INStJRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSUI2ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS PLEASE CHECK APPROPRIATELY IF PAID: YE5 k NO NOTICE: PERMITS RLTN ANNiJALLY FROM JANCTARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 1997 SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING 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 TI�BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. A DITIONAi RFGUi-ATIONS POOLS POOL OPENIIdG: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH I3AVE BEEN CLOSED FOR'1'HE SEASON MUST BE INSPECTEb BY TF� HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO OPEIVING. POOL CLOSING: EVETtY OUTDOOR IN GROUND SWIMNIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(?) DAYS OF CLOSING. FOOD 5ERVICE ('A iNG POL.ICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FRO F�RTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RE5ULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WILL RESLTLT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. O�,ITSiD CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDODR CQOKII+7L'i: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOA PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIv1ENT IS PROAIBITED. �� DATE: I � � �� I %� SIGNATURE:� ��'� ��— ritnv�r Nr� �TiTLE: �� ' ti ��,`' - 10/97 , page 2 of 2 = . • � The Commonwealth ojMassachusetts : Department ojlndustrial.-lccidenrs ; 0//%s ol/sresU�sdiis 600 Washington Street Boston, Mass. 021[1 " W'orkers' Compensation Insurance Affidavit Aoolicant information: PfeasePEt11P1'Ttw� namc: •J �/T�(J C d� ,:-�� . 7� _ location: � L� �� C � � � cit�� _�� 1 !t- .�t 0 U �� l��- � ` � �-` �I phone M 5 �� I am a hameowner pzrtorming allµor myself. 0 I am a sole proprietor�r.d hace no one��orking in am capacih� [7 I am an employer pro�iding workers' compensation for my employees workine on this job. s� com�any oame: �� '�"�� 4' .`j � aJdress: �I1 U �ci �� Zx citv: �� v� �/=�%��L� '✓"9Y=f� phene p: �� •J�.J �``� insuranceco. ��}� I"1fA.' ��9,2' ;dCi�� 1-�vj t%E- policva �C' ��E' �� ' /.�'� � I am a sole proprieror. general contractor. or homeowner(circ(e onel and hace hired the contractors listed belou ��ho hace thr follu�cin� ��arkzr, .ompensation polices: vn ad d resr. c��: yhone N: insurancc co. Doliev p tomp� name: address• ei : psoee p: insunnee co. � pysy M - Failure to seeurt coverige a required under Secnoo 25A o(MGL 152 u�lad to�Ye i�paitlw of erisiW peultln of�O�e�p to 51,500.00 a�d/or one ytan'imprisonment n wAI a tivii pendNa io t6e form oh STOP WORK ORDER�od�6et of 5100.06�d�r qdort me. I ndenh�d Hat a eopy o(thie etatement m�y b�lorwarded to the ORc�of Invt�tlg�6om of the DIA for eovenLe verillatlw. 1 do hrreby cer�ifi.xader rhe pains and penal�ier ojperjury�ha�1he injormation provided above is nue and comect r l Signaturo (�� L�" Date ��l�'�� 7 Print name �-�� - L^��11J�T�( PhoneN ,5�% `l��j � � ., olTicial use only do not+.rite in thii ara to be eompleted by eih or lown olfleial ciry or town: Y�DT$ _ permitAieenu k nBuildiog Department � ❑Lieensiog Bo�rd p cheek if immediate response is required Z61 pStleetmen'�011ite pHealtA Departmeet con�ac�person: pAone a;_ �508} 398-2231 eat. nOther Um n:d iAS PIAI TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-60 FEE: $75.00 In accordauce with regulations promulgated under authority of Chapter 94,Section 395A and Chapter 111,Section 5 of the Cieneral Laws,a petmit is hereby granted to: Ceafood Sam'c of Couth Yarmnnth,,,j�c 1006 Rnute 28�$nuth Yarmonth MA Whose place of busiaess is: Seafood Sam's Type of business: Food Service — To operate a food establishment in: Town of Yarmouth Permit expires: December 31 1998 BOARD OF HEALTH:�� P/. ��eiltae��, Ctiu/�t�,Q.,/��nq � /7/ SEATING: 85 (45 inside:40 outside) �(�oa2 G. Jpulliv�sn�/KJ//.//l.� Vu:e l.hairmaa RESTRICTIONS IF ANY: DlSposable SOtVtCe On�V. Ko�er� � G�rowro� l,Lerh u6,;�� SaGo��s-JJooPe� p , � ic � ou��i[in Januar�, 1998 � L� Bruce G. Murphy,MPH,R .,C O Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-41 FEE: $50.00 This is to Certify that Seafood Sam's of South Yazmouth Inc d/b/a Seafood Sam's 1006 Rnnte 2R So �th Y rmnnth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1998 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 confornuty with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �� etlpeps� C'�w//i�rm�qunq � /� sEw7'iNc: 85(45 inside_40 ou[side) �/�oaa �c�7ul4�an;/KJ/.J/l., Vite l.�aMn,a.� Ko�er�Q�}. �rotu/n�� l.ler� u�riel� �a�oG��-�oope� '��.e�0�u��P,, " Jauuary 5 . 19 98 ' ' �� ' �'`••�• �t ' ruce G. Murphy,MPH, , C Director of Health