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Home My WebLink AboutApplications, WC, and Licenses Prior to 2010 � 1. ' ' 1 �FC.C� �� TOWN OF YARMOUTH BOARD OF HEALTH ,, <—�^-'�. Gt33 � 5 I� ;; M jz �o �,, � APPLICATIONFORLICENSE/PERNl�l'-�9 �, NOV 1 0 2008 '� + �, d. * Please complete form and attach all necessary documents by December S 08 Failure to do so will result in the retum of your applicahon pac et H D E PT. NAME OF ESTABLISHMENT: �SUC�'t � E Cy TEL. # JCD�'7�1�(o�gg LOCATION ADDRESS:J�` �-�I $ �LC MAILING ADDRESS: S M.6 OWNER NAME: C� ( (} TAX ID FEIN or S N : $ CORFORATION NAME (IF APPLICABLE): nI f4 MANAGER'S NAME: 1UG 1 " TEL. # 5' MarLrrrG aDD�ss:�� nJ Erv�wN Ra�l , A.�/1�5-raus ,� i r�s ticft- oa�48 POOL CERTIFICATIONS: /� The pool supervisor must be certified as a Poo1 Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minunum of two employees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies ofexnployee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a Gle at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: �'� All food service estabiislunents 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 aew copies and maintain a file at your establishment. 1. Z, PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Z. HEIMLICH CERTIFICATIONS: /�If�' Atl 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-choking procedures below and attach copies of employee certifications to this form. The FIealth Department will not use past years' records. You must provide new wpies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERA3IT# LICINSE REQi7IltED FEE PERM[I'# LICENSE REQUIRED FEE PERA9T# _B&B S55 _CABIN S55 MOTEL S55 INN ... .. ....35q.. ._.—� --- -- ---��Aiv��---�-- S�i— .._ __. __ .. - ,� FfX�.SBAea:--:,-...-m�n.,.,---� _LODGE S55 _TRAILERPARK 8105 WfIIRI,pOOL $80ea. FOOD 5ERVICE: LICENSE REQUIKED FEE PERMIS#? LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI2# _0-100 SEATS S85 _CONIINEN'IAL S35 NON-PROFIT S30 _>100 SEATS 5160 _COMMON VIC. 360 WHOLESALE S80 RETAIL SER�7CE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT€f LICENSE REQiJIRED FEE PERMI'I# . LICENSE REQiIIRED FEE PERMIT# �<50sq.8. 550 g�DQ� _>25,OOOsq.ft. 5225 _VENDING-FOOD 525 _<25,OOOsq.ft. S80 _FROZENDESSERT 840 IOBACCO 555 �a�iE cxa:vcE: sio AMOiJNT DUE _ $_ 5o .00 ""'"pLEASE TIIR'V OVER A'VD CONII'LETE OTHER SIDE OF FORNI'*•** . . '�... ADMII�TISTRAITON .� ., 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 ATPACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to conrinuous 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 haue 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 pnor to opening. PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. —FOOLZ.ti05IN�: v�ut�oor m grounc�swimming poo�musE�e drain�r covere wi n seven ays o�` closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yannouth 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 Departmem. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooldng,prepazation, or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILdTl'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMEN'T,ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 11�g�� SIGNATURE: � ��-��"-'"'^'" PRINT NAME&'ITTLE: C C-�JI�K io�zi!os � y . . `� ' ;, � The Commonwealth ofMassachusetts DepaK�nent of Industria!Accidents MBHNb�tl� 600 Washington Street, �"Floor Boston,Mass. 02111 R'orkers'Compeasatioe[avonnce Af6davit:Baildiog/PlambieglEkctricat Coetractors Pleaee PRII�P k�bh name: address: siri state� zip� pLone# � work site locati�(Cull addnssk � . . ❑ I am a lameowner performing all work myself. Project Type: ❑New Consttucd�QRemodel ❑ I am a sole�proprie[or and 6ave no one working in any�ppacity. ❑Building Addition . . Ly 1 am an�ployer/p�roviding w�kers'compens/at�ion f�my employees wodcing on Utis job. . . commav osme: /I � �V V�/_ � ln_-�� /� . . . . . . iA�'tl8: ' F�ll�� . IYfV� �V . . .. . . �.- G��s1 u�rrr�a� � 6u-r��- 5a�• ']7r- �4�� u.o,.a�. (�fZ�nl iTr �fR-f� tN� Cd ,�. i.uC•142- 88-�3 Iamasole �n , . -;, � _ � �'� __�- . .... , s� ... . >. �:F,�. _� '�.�. ,_ r>.��h�..�.U.�w,e ❑ � pr� eEoy gmeral coetraetor,or iomeawner(eirde ou)and have lticed the conkacWcs listed below wlro have the following waakecs'coropensation polices: � 9mwav une• �� . . . addrees•. � � . . dt9' � � - oiaae g' � � � . � . . i�naaKeea _�y�K � . �_ . ,. . _., . . .-. „ .. . . . , .. . �; 2, ,q,.+-._ aom�v me• addras• �•� � : . . � . . . . � n�o�e/f. - . . . . inma�eeca . . . � �yg. ___ . . . . Faive`ssve ��`� � �:.� .. <. � ,.� > � , .�_ �...z;#� x;,-,�.,.�: �. 3 ? ca.Q.ge a�reyiea me smw.2Sn�FM'.L tsi eu w!a ue�tlx.ta�r.�pe�.Nin.[��e�p cs s13M-M�aarer �Y�'dp��mf as wd n eM pemltlea In t�e firo Ka STO�WORK ORDBH aM�6oe KS1M.M a dty aphst ee. 1 udenhM 1�at a apy af W6 fhtmeN eny 6e tarward[d 410e Omec atlweMl�Nm af He DIA far taveta6e v�nYee, . . . /b beirby cerpJy' rnler tAe paln mApenehJes nI rJrry pti�N�e injonxdtan proviJe(aborr h bve m�d co�r�ect� . � �8�� I�te �t� O/� 0 . r.�� N NG L. (.�v Pn��n 508 • ?71 - [�� 8R e�a.�ez udy de mf wNte fm thb m.te be mmpk+ed bs dlr ur w�..�iai �. . � � � eHy or 4wo: . . �yytt�q �� ❑chai Him�eNale te�peme b reqmN � ��g�� ❑SdcaY�'s O�u . �FIaNY Dryu�et coYut pvaea: Pg�p: ❑�' a�.:m sw�.mm) . . o � o � � o A ' ^�� v� .c � v� U G ^� ^ m � W � �' .y T � O � M � ^id � � � �� .� �x � � � x � �� o x � °' � � �� " 0 NxL. � � o �, w w�A u .. „ �, � l� w 4..'d N O � fy '+�A � a � x � W ° � xo � m, 3 0 0 � � ww �v "' v '^ x w � � �� '�~ `"o O � E,W,, 9.� � � � o � � � Qf� ;, E N O v � Q W w'a' M � � f-" 0.�1 a � A p . � � � F � 3 p � O � E" � .9 [r 0 a� ,'^S Q 'O C N O o� O _ v p p �p7 S! p �i�c.7 cE .� ;� in �' . a� �k w s Z y :° � ,r� OW. p� �o � � `° � y v W v�n v, a� y al � o .0 �i � A o � 4r N O � y O � 4� iri �1 �u vi V .� t� � �� m-• c3 7 ��„ p. v H .G� ¢, '9 � K a y-' N O v Y v w � � o �� o a. t-� H a � 'T A 7d�.eif OF C'R�6Co� =-�°' Y"1�.^ TOWN OF YARMOUTH BOARD OF HEALT� „ a .E�j _ APPLICATION FOR LICENSE/P�RM�,T�QO! ��u� � s { � .:-+� �� ±ov i 4 20�7 � " P lease comp l e te form an d a ttac h a ll necessary do�iim�nt§I Y y D e cem r 31, 2007. Failure to do so will result in the return of your appl�cation packet. NAME OF ESTABLISHMENT: �DUr 6F Q� � TEL. # �g•�71 • �4� LOCATION ADDRESS: ,�.�I � µ� 3 MAILING ADDRESS: � E ' OWNER NAME: N I X IN r N � � - CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: ('� I U TEL. #_�J-"ng•�a •�'lOS MAILINGADDRESS: � NEW�h�UAJ �2�� (�A S"fONS ()1i(-�s thq 0�1ny� POOL CERTIFICATIONS: �I ��Y The pool supervisor must be cerdfied as a Pool Operator, as required b��State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form.__ 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these empioyees below and attacl�copies ofemployee certifications to this form. T6e I�ealth Department will not use past years' records. i'ou must provide new� copies and maintain a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: /�1 I� All food service establishments aze required to have at least one full-time employee who is cenified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, l05 CMR 590.000. Please attach copies of cerFification to ihis applieation. The Health Department wftl not use past years'records. You must provide new copies and maintain a Tle at your estabfishment. 1. 2. PERSON IN�HARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: /�1 I/�" All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich 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 noi use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER19T 4 LICENSE REQUIRED FEE PER�9]'¢ LICENSE REQi IRED FEE PER�iIT= _B&B S50 _CABIN S50 _MOTEL S50 _INN S50 _CA.'�fP S50 _S�'1'IYf.�41NG POOL S75ea. _LODGE S50 _TRAILERPARK 5100 R$IRLpOOL S75ea. FOOD SERVICE: LICENSE REQLIIRED FEE PERMIT# LICENSE REQIIIRED FEE PER\41T s LICEtiSE REQti IRED FEE PER�➢T= _0.100 SEATS S75 _CONTINEN7AL S30 NON-PROFIT S?i _>100 SEATS 5150 CO:bL'�SON VIC. S50 R7-IOLESALE S7> RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIKED FEE PERMIT= LICENSE REQL7RED FEE PERbDT= � LICENSE REQL'IILED FEE PER�fIT= L<SOsq.B. 345 �0$–Qpl _>2i,00(Isq.B. 5200 VENDING-FOOD S?0 _Q5,00(1 sq.ft. S75 _FROZEN DESSERT S3> TOBACCO S50 �iA�CHA'YGE: S10 AMOUnT DUE _ $ `�S. 00 *"*"'pLEASE TCR\OVER�\D CO�iPLETE O7'HER SIDE OF FOR�I�*^** ADA�IINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or wmpany 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 ta�ces and liens must be paid prior to renewat or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transiem occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewh�e. Transiert 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. a 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Ea�iosea Motel Census must be comnleted and returned Wicn ct�iis aPP�ioation. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(� pnor to opening. POOL WATER 1'ES'I'ING: The water must be tested for pseudomonas,totai coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirruning pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Departme�rt by fiting the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Permit umil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval&om the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,pr�paraiion,nr_display ofanp food product hya retail or food servic�establishment is prohibited. NOTICE:Permits run annuaily from January i to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMME?10EME�IT. REVOVATIONS MAY REQUIRE A SITE PLAN. DATE: Il'I�J'�Q7 SIGNATURE: (�(J.C,�VL(/C/ —r PRINT:VAME&TITLE:f'J i C� • �(1� L�1 UK, OW�� io;oo� � The Co�ninonwewlth of Massachusetts Department of IndusTrial Accidents N�.'aN�r�s 600 R'ashington SYreet, �"'Flaor Boston,Maxs. 02I11 Workers'Comp�aatio�Ioevaaee A�davk:Baildi�glPl�mbie�JEkclricil Co�tractors Am�t LGrwtla: Pleue PRIIiT ketblv name: address: city state� zio� ohme q work site locffii�(fut]addressl: ❑ I�a homeowcer perfotming all work myself. ProjectType: ❑New Camstrucu��Remodei ❑ I am a sole pro�ie[or a�have no one wocking in any cap�city. � ❑Bwlding Addition [�I azn an employer pnroviding workess'compensati�for my emp/lo�y�ees working on tbis job. . i�". �/7 i��_Ul- [��ltlr/C _(_.17� _ __ ---- - --- --._ _ comoav mr. . .��..: �� -rE a8 �: i,��sT y� r,�du�h m,� a��: ��F- 7�i - ��-$� ,��. ca�ANiT� ST�r� �n►s co � �. wc,��Q-�a - oq .. � .. . . . .... . . . . . . . , .�..�... . . r ,.�y Ytfi�xl a.�. v: ❑ I am a sole proprietor,ge��ai cwMelor,or 4omeowaer(drele oxrJ and have hired tbe conh�acWis�listed below who have tLe following workas'compensation polices: commv noe' � . ■d_dr�ss: citv' oYe�e 8: . ieooaiee ea oatlev# coemv�se• �- ctiv: Na�e Y: . __ ... . . _. __. _- - --. _ __ _.._ .___..---- -- - -�--..._----... --.—__.- ------ . . . __-- - in�a�ee m. �M ♦YW}iWiWYa�i�tiPrM�rf�: �.. .. . . .. . _ . .. . . Fdlae Y xtve ewvf¢n ieq�M odv SaMM 2SA dMGL 1�en Wd b He h�pltlN dvi�Yal pe�Wio da Bas�b f1.5KM uNM� �oe yefn'ImprYwmnt a wd n dH pnaMin 1�f6e[wf Ka STOr R'ORK ORDER ud a Sae KS1M.N a day aplat�e. 1 odenhad tWt■ npydWtMahwlryhe[orwaM[dbtleOmcea[I�veMIplNmo[IheDlAt�cwua=eve�Nnrtln. � I do har y ce rnder eAie palns l penaMea or rerj�ury M�t Ms tnfonneRon providel above k ave w�d romet �� ,cQ(n�.�� /� '��D� 'rQQ Print name ri � • � I�CJ V� Phone# J��1' �Y U V emew ose o.ry ae aa.Mfe b w.,re.w ae rnoq�+cd Ar dlr.r rwe.mad eily or fewa: pv�iHBueu g QgpWlag peput�mes� ❑chcck K�Mh&re�eese e re9ai�ed ❑Sdrelsn's O�e ONeaMh Ilega�l�n1 coefaR Pe+aoa. P��y; ❑p� 1.�.�a�mw� TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISI�IVVIENT PERMIT NUMBER: #08-001 FEE: $45.00 In accordance with re�fions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of[he�ieneral Laws,a pemrit is hereby granted to: Nancv Wilbw, 327 Route 28 West Yarmouth MA Whose place of business is: A Touch of Cane Cod Type of business: _ Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2008 Bon1zD oF HEnLTT-I: ,�Ee[ery S�aIE, �LN., CHuixntan (.R�ax�ee ,�.9CePeiR�e�c ?Jice Cifaiwnan `2aBeXt 3. `.�aw�curc, C'� Qrira�iee�c�acun., J2..N. November 16.2007 ruce .Mutphy,MP ,$. ., D'uector of Health : #�q� �� - c� � ��. � - 2°Fs'e10 TOWN OF YARMOUTH BOARD OF HEALTH � �' � o�°� APPLICATION FOR LICENSE/PERMIT-2007 NO V 2 S 2006 r ' s , � �'�✓ * Please com lete form and attach all neces u� y� P sary doc enfs b December H H D� _��j Failure to do so will result in the return of your application packet. NAME OF ESTABLISHIvIENT: TEL. #��'I I'�� LOCATION ADDRESS: (� �'"�� MAILING ADDRESS: ' OWNER NAME: U T ID IN r CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /�G ► p TEL. # 77GLj MAILING ADDRESS: � ST S !l.(-S G POOL CERTIFICATIONS: NI�I' The pool supervisor must be cert�fied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach wpies ofempioyee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a t"de at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: !�I A' Ail 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 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 maintain a fde at your establishmen� 1. 2, PEI�SON I�V CHARGE; _ _ ___ _-- ___ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: /�1 I� All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich Maneuver on the premises at all times. Please list your employees trained in anti-chokrng 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 fde at your place of business. 1. 2, 3. 4. RESTAiJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQi7Il2F,D FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# _BBcB S50 _CABIN S50 MOTEL $50 _INN $50 _CAMP $50 _SWA�II.4INGPOOL$75ea. _LODGE $50 _TRAQ,ERPARK 5100 WIIIRLPOOL $75ea FOOD SERViCE: ISCENSE REQUIRED FEE PF.RMI1'# LICENSE REQUIItED FEE pERMI7'g [,ICINSE REQITIItED FEE PERMIT# _0-]00SEATS E75 _CON1'INENTqL $30 NON-PROFfT $25 _>100 SEATS SI50 _COMMON VIC. S50 WHOLESALE $75 RETAII,SERVICE: —RESID.KITCIIEN $75 LICINSE REQIRRED FEE PERM[T# LICENSE REQUII2F,D FEE PERMI7'# LICENSE REQi)IltED FEE PERMIT# / <50 sq.ft. S45 7'� � >25,000 sq.ft. 5200 _VENDING-FOOD S20 _QS,OOOsq.ft. S75 _FROZENDESSERT S35 TOBACCO S50 NAME CHANGE: E10 AMOUNT DUE _ $ �S.00 •••""PLEASE TURN OVER MiD COMPLETE OTHER 5IDE OF FORM'••^^ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiTRANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of resdence elsewhere. Transient occupancy shall generatiy 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 genera(ly be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 Yazmouth must notify the Yarmouth Health Department by Sling the requ'ved 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 resuits must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOKING: 4vtdQor coQking,prepazation,ordisplay of any food product by a retail or food service establishment is prohibited. NOTICE:Pernrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMbIENCEMENT. RENOVATIONS MAY REQUIRE A SI PLAN. DATE: I I'ZO'0�o SIGNATURE: `-'D PRINT NAME&TITLE: N � 1 I� ]0/17/06 r _ �\ Tlie CosimomveaJth ofMassachusem Depa�tmeet oflndaslria[Accidenls NMarN� 60o woah;,�groe streer, 1"P/oo. Boston,Masc. 02111 �- R'orlce�sy Compnsatio�Lsmaece Affid�vk:Bo7 ' 6ug/Eketrical Co�trxtors . ,. ..._.�.�. -� v�- - -- '�a ..� r«. ;.s... _.. . . ,. . name: address: city smte� zio• ohme$ work site locati�(foll add�as): ❑ I am a Lomeowner petfotming a11 wmk myself. Ptojed Type: ❑New Caosr�uctiao�Rmtadel I mm a sole 'etor and bave no ace w in an ❑B ' ' Addition I am an emPbY�Providin8 wakas'compeasation far my�yces wodcing on this job. . � �: I�' � (µbU�M,4 ��19�3 ....��: _�J/�S• 7�1 -�4�� .�2,�� rr�. �ra� !Ns co . . � a89 �8o-�fa ❑ I mm a sole ptopiietor,ge�a�al wotraelor,or komeowur(�dt owe)�d have haod ihe con4ac Wis listed bclow who have the folbwing wakas'compeffiation polices: eonars r�e: � d�relx � �.f: ai�eM: � �rv mc addier e�: oreee t. _ . - -- — --..__. .__ . .. ----- �---_—... _-- -. __ . .. g F�Yaxi�aeeeevwfdea'reqdrNodv9eeW�2SAdMGLLS2oelndYtl�eh�MllrtudYd�mMnd�4eRbf1,SMMaMI�r . ..�yen��ww«nn wa..a.��..�,e ue�..r.srorwoa�eoensa..a.m�.rsiee.w,e.y.p�.�. �oenww nn. apy�tltle MaMae�t my be fiewaMM t�Ne Omee dLre�plYae etMe DIA t�revenge wMnBN. /do Aarby ce jy+rnder His pt m�dpene/tiv ojperj�oy dYat tlYe iwfanwdlos Ssovidel above la anre m.dy/ �� $1�081u1e �� IC I�I�1 ' Print name�� . �.1�� l.Cl v PhoM# .'/llll ' !�� T O� e�d�l ue oaly ds�et wdfe i f W arn b 6t eHplaW b9 dl9 arl�wa a�id dlyartewa: peyiNieeseM " De�t ❑Neek Hiva4le�dpseae 6'eqaired O,�� ❑Sdeedn'f O�ee ❑HeMY Rpr�nt mMtct Pasoe: P�we 9; �OWc c.um Syt mml TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLTMBER: #07-011 F'EE: $45.00 In accordance with reeulations promulgated under authoriry of Chapter 94,Section 305A and Chapter ' 1 I 1,Secrion 5 of the`Ueneral Laws,a pe�mrt is hereby granted to: Nancv Wilbw 327 Route 28 West Yazmouth, MA Whose place of business is: A Touch of Cape Cod Type ofbusiness: Retail Food Service less than 50 squaze feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2007 BOARD oF HEALTH: l3 $• �tdoa, /y1.$•. � d��"`'tSl�. R�v., v�.e� a�r�. a�, e� p�4 M�2�+tt ,�,s�j�, R.N. , L Januarv 24.2007 � .M�P Y> � > Director of Aealth � ��F .YA�'�o TOWN OF YARMOUTH 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 N MTTTqCHEES � �^ko„a,,,�„�P� Tetephone (508) 398-2`231, Ext 241 — Faac (508) 760.3472 B OARD OF HEALTH tl� ,:' �5 � � s i To: Yarmouth Boazd ofHealth Permit Holders �"'� 'i � �;'";5 � HEALTri JEPT.^J From: David D. Flaherty h., RS. ;�D r Heahh Inspector � Town of Yarmouth Re: Federal T�ID Number Date: Mazch 22, 2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all pemuts and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Numbet(FEIN)otherwise Irnown as yow"Tax ID Numbei". This is purely for administrative purposes only. So� businesses use tUe owner's Social Security Number (SSI� for this purpose. If this is the case for your es[ablishment, be assured that we will not allow this information to be public record Please fill out the fields below and retum this letter to Yarmouth Health Department 1146 Rou[e 28 South Yannouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this �tter, piease do not hesitaie to catl. The office hours are Nionday to Friday, 830 a.m to 4:36 p.m i he telepho�number is(508) 398-2231, ext. 241. Establishment:� �rS/,Y'�7 D�( .Q/� ( G1�L FEIN or SSN: /�'�- LocationAddress: J�o� '/ 6U� o7� LU�-ST �-�Y�tOTJT�1, ��( L��73 Sig�ture: n�t: ��l�i�y � . ��i��r Title: �C[J�Cl6R Z�� Printed on ( Recycled '�^� S Paper . � �a�,�, R TdJClt �FCN{NcEOA ' �?�`e Ryc TOWN OF YARMOUTH BOARD OF HEALTH �N� ; APPLICATIONFORLICENSE/PERMIT-200� -, NOV 1 4 2005 ��s * Please complete form and attach all necessary dpcument§�y December 31, 2005. Failure to do so will result in the return of your application packet: NAMEOFESTABLISfIMENT: A TOUCh OF c_,(pE �n� TEL. # 50$•Z7[-lo�l$$ LOCATION ADDRESS: 3a� nv-rE ..2R /�lEs �l/1R titUUYI, , /Yt.d Oa��3 MAILING ADDRESS: Ai OWNERNAME: AIAAJC`/ LeJlLSIJ TAX ID (FEIN or SSN�� CORPORATION NAME (IF APPLICABLE): n( A MANAGER'S NAME: �J G lUlG.6U TEL. # 50& �ag- ��as Nraa,irrG�,nn�ss: le� ,U�rvw� RaAa�RsTous �yt� m,4 0��8 POOL CERTIFICATIONS: n�/A The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: /JJA 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 ofcertification to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i 1. 2. HEIlbg;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 attaefi eopies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. 1. 2. 3. 4. RESTALJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEF, PERMIT tl LICINSE REQUIItED FEE PERMI'I'li LICINSE REQUIItED FEE PERMIT# BBcB $50 CABIN $50 MOTEL $50 _INN S50 _CAMP $50 _SWI[vIIvIINGPOOL$75ea. _LODGE $50 TRAII,ERPARK $50 WfIIRI,POOL $75ea. FOOD 5ERVICE: LICINSE REQiJIItED FEE PERMIT t! LICENSE REQUIRED FEE PERMIT N LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $75 CON1'INENTAL $30 NON-PROFTT $25 _>100 SEATS E150 _COMMON VIC. $50 WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQiJII2ED FEE PF.RMl1'# LICENSE REQUQ2ED FEE PERMIT# ` <50 sq.ft. $45 �O��D��' >25,000 sq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 TOBACCO E25 NAMECHANGE: S10 AMOUNTDUE _ $ �{5-00 "•"""pLEASE TURN OVER A1VD COMPLETE OTHER SmE OF FORM"••"• ADNIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernvt to operate a business if a person or company does not have a 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 J Town of Yarmouth tarces and liens must be paid prior to renewal or issuance of yow pemuts. PI,EASE CHECK APPROPRIATELY IF PAID: / YES J NO NOTICE:Pemtits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISIIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENIlVG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISffi�IEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO C011�NCEMENT. RENOVATIONS MAY REQIJIRE A SITE PLAN. ADDTTIONAL REGULATIONS POOLS POOL OPENING:All swimmin�,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departrnent 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 mustbe 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 waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmem is prohibited. DATE: I 1�10 �D� SIGNATURE: PRINT NAME&TITLE: n(��, / . Il l/ .�iU� DL)Al��s 09/28/OS =�-� The Commonwewhh of Massachwsem !-��:I _ = DeportmeatofledrsdialAccideirts �+ _= NIIe�M� = 600 Washington Stree; 7`"F[oor — Bosto�,Mats. 021I1 ,v, Worlcen Com�easatioe I�swce A�davlt Bv7 b��g/Electr¢a1 CoNraclors ...-_.� � , 1> ,'; '� �.. .' � ,,�,.- . _ :��..�� 5��ye:� r �. ;� ..,�.. �' "�"' a naa�c: a�ess: ciri s�ate� an• N wark site locartion ffoll addressY. ❑ I mm a homoownm�perfoimiog all wak myself. Project Type: ❑New Cmst�ucbao�Remodel I am a sole and have��e w in� B�ril ' Addition I�an emP�Ya P�'��8 wadcas'compensatim f�my employ�s woiking�tLia jvy. . . .. . . �y..�: A -�rr�fr�M o� C�t�E C,�-J �: .�i�� (m�T� �4� �(��sT yAR�avrti , mA a��3 �� 508• 771- ��R� ��. GKA�u�� sr�t� INs Co � w� a - o-�la ❑ I am a sole propridor,geaaal c�trxtor,or 6amaw�er(crrele owe)�d have hirod the conuactas lisled below wlw have the followiog workas'compmsataon polices: �e�: +�m: iltv oi�e/� N umut�e_ �F' �'� �� Faive 1e saec evaf�e n�eqdrcd odQ See1W 24A dMGL L4t m letl b Ik i�pWIW daidW peYtln da de�p bf1.1M.M aW�r oae 7pn'�Priwat a�wd n cM pwltln h t�e br�Na 37'Ot WOBK ORDER nd a me dS1M.N a tlay apint�e. 1 adnshW t�N■ apy aftYb�dy 6e tennrded b Ne Omee otlmWptlHe NUe DIA Por�e ve�lqntlw. �10 eeney ee.Njy rnre.Me pdu s1 pee.utea nf u,d aie afaaudMn p.maiet aeorr 6 mrc wa a.rmt �� ii/io�D.S Primname �� Phoce# .�O• 771 -l0� �� r�cw.se o.y ee.ot.Mfe r mt„rea n 6e�plef�hr�*r.r r.m.m�id dy or fawc Pq�p r�- "' �t ❑eheck V imse�le�ape�ee b rcqofuN ❑��Befrd �iO�m �� P�R; rlO�ie ��dea� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHNIENT PERMIT NUMBER: #06-012 FEE: $45.00 In accordance with regulations promutgated under authoriry of Chapter 94,Section 305A and Chapter 11],Section 5 of the General Laws,a pettnit is hereby granted to: Nanc Wilbur, 327 Route 28 West Yarmouth, MA Whose place of business is: A Touch of Cape Cod Type of business: _ Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yarmouth Permit eacpires: December 31_ 2006 BOARD OF I-IF,AI.TH: ,Be�wKfis$. �'oadorc, ��. ' v�,s�� v�ef� ��a� R.�.��j� R.N. � ;°� . December 9 2005 Bruce . Murp A,R .,—�.H6— Director of H th - 1 185� / A Toow e6 C'nIMCoQ A � � ,�,. �� n , 3°,�c TOWN OF YARMOUTH BOARD OF EALTH Cn3 �� r;; � � ,,> , , APPLICATION FOR LICENSE/PERMTt- 2005 ` '' r; ,s" � �Y' �� NOV 1 6 2004 * Please complete form and attach all nec�§saty ocumeats by Dec er 31, 2004. Failure to do so will resutt in the return o�your application p ALTH UEpT NAME OF ESTABLISHMENT: Tn lC`LI F�� C`_ P� C'rS� TEL #_�A8•']71 •l�4� LOCATION ADDRESS: '�'1 UTE � L�ST �A(h.t[�U7� � �11A l�lv2� MATT.ING ADDRESS: Sdm� OWNER(CORPORATION NAME: LUl Lf3U MANAGER'SNAME: �ANCN IaJll�bU TEL #h�R•�aR•77D5 Nrna.nvG Ann�ss: $�� ur,ow u n A��,� �To�u s �i, � , rv�Q a��l�._ POOL CERTIFICATIONS: !�//a 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 c�y of the certification to this form. _ .�._ _ ____ --- ----�----�_�_ 1. 2. Pool operators must list a minimum of two empio ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach wpies 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. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: !�I/� All food service establistunents aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2. PERSON II`d CHARGE: - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t"de at your place of busiuess. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # Loncm�c: OFFICE USE ONLY LICENSE REQUIItED FEE PERMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 . . . . . . CABIN -- $50 ' � — — . - .. � ._MOTEL �—_-.^,._•3� .. . _INN $50 _ _CAMP S50 _SWIIvIIofING POOL S75ea. _LODGE $50 TRAII,ER PARK $50 WII[RI,POOL $75ea. FOOD SERV[CE: LICINSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIl2ED FEE PERM[T# _0-100 SEATS E75 _CON1'IIVF,NTAL $30 NON-PROFIT $25 _>100 SEATS $1S0 COMMON VICT. S50 WHOLESALE E75 RETAII.SERVICE: LICINSE REQiT1RED FEE PERMIT'# � LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# �<SOsq.& $45 ��3 >25,OOOsq.ft. $200 _VENDING-FOOD S20 _Q5,000 sq.ft. S75 FROZEN DESSERT $35 _TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ �{5,00 "*••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••••' t _ r ' � . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yazrnouth taxes and liens must be paid prior to renewai or issuance of your pemiits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TI�COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDiTIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment wluch serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY• Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service AppGcation form 72 hours prior to the catered event. Thses forms can be obtauied at the Health Department. FROZEN DESSERTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: 11'15�0� SIGNATURE: PRINT NAME& TITLE: � I� I G�A1� 10/22/04 ' �• —�`�--.-_�---_= Tke Comnwnwealth of Massochusetls �= _=_ = = Departwrent oflndwstrial Accidexic - — NMCIIi� -= 60o wosh;ngme smet, f"Ftoo. - , Boston,Mass. 02111 � Workers ComRasatio�I�sea�ee A�d�vik Bdl .. M�g/ElectricW Co�daetors ` � �' c �:.",s '�, �;_�'' .,. �v'. . .-. x,.... ?'k. . �;,,y�� .,.-`. �� . r , . / � _. L ' . — � 1 ' f' � �� I -��.- Y{YIGJ$: N —I c � �� _ �y _ L L ••• 3�1C' , II0. _ _ — ObOOE M \ �. WO[Y 512C IOCffil00(fl1II eAdICSSL' �. .. . . ❑ I mm a homoowna perfo�iug all war myaelf. Ptoject Type: ❑New Consuvcdan ORanadel I mm a sole sod have no aae in an B�ril ' Addition I am an�pbyer providiog wakes'compeavatim fa my employees wodcing a�this job. ♦ �.....�: ;� �o�cl�l_, �'�lyE �.C5T3 . �,: 3�'�L �vu�, a$ � (,��S-i-�A��,r�u-l�d, M A a��73 .�.: 504�� i-��l 8R ��.6R.dN �rE �ra-rE i,�s co �.. wc sa8 • v�-�a ❑ I am a sole proprietor,Se�enl catraeter,or iomeewoer(arcle owt)a�Lave hirod ihe contwctas lis[ed betow wlw have the following wodceis'compensation polices: saoor�r�e• . t�a; dtv: nia�e t # �r�se• addrm• �'- ��: � -- FaY6e Y a![R c�ende Y rtqind odQ SaeW�25A dMC.L 15S m Ind b IYe inpolly dc�IW peYl6u d�ie 1p b A+SMiN aW�r e�e ynn't�ptbw�eet n wri as dN pwltln 6 t�e 6r�Ki 37'Ol WORiC 08D&R aW a�dS1M.N a d�y�aMt�a !udashW tYtl■ o�pyKUbYaie�eatmybefarwaMdlsHeOmmofl�NUeDlAhrewe�evvNntlw � !Ao herrby certijy rndsr tAe d pendBea o perJ/oy r6rt NYe iwforwrlon proriJel abow h nve awJ eomct Si Oste ((I lJ/d�/ Prim name _ � . . � P6one# JOS� yI / I-�O 7 O p .�Ni.seey ao.«.rrNerul„rnr.eeee�WefdDrdly.rr,.n.mew dtyorfewn: pQu�tltltteeeM r'- "' Dqnr�eet ❑eYcek if i�t Rapseae b''MWed �Sdx4�n's Omm ❑NeMY lkN��t �l Petsa� �e M; ❑p1� lM1v�d Sy�.mm) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMIT NLJMBER: #OS-003 FEE: 45.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A mmd Chapter 1 I 1,Section 5 of the al Laws,a pennit is hereby granted to: Nancv Wilbur, 327 Route 28 West Yannouth, MA Whose place of business is: A Touch of Cape Cod Type of business: Retail Food Service less than 50 square feet To operate a food establishmexrt in: Town of Yarmouth Permit expires: December 31_ 2004 BOARD OF HEALTH: Be�r�nsi�$. �fo3c�on,�$. ' p��r�� v�ef� Rod�rt�. B� �4 �Sl�k, R.N. Aruc Cf+�ndwc«i, R./V. December 1.2004 ruce . Mw^p Y,Iylp > , Director of Health . �.� ti�a �- �� ;� '� °�""�s TOWN OF YARMOUTH BOARD OF HEALTH r`` 3 � APPLICATION FOR LICENSE/PERMIT-2004 r:.,, ,w'z NOV 1 2 2003 * Please complete form and attach all necessary documents by Decem r��OQ${ DEt'T• Failure to do so will result in the retum of your application pac . • 3a g rsu � � - �88 M� N G ER' N G U p • . 7� IN AD C� 0 Gl=2�� POOL CERTIFICATIONS• The pool supervisor must be certified as a Pool Operator,as required by State law: Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimurn of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list Yhese employees below and attach copies of employee certifications to this form. T6e I-Iealth Department will not use past years' records. You must provide new copies and maintain a file at your place of busiaess. 1. 2, 3. 4. POOD PROTECTION MANA R - RTIFI ATION • All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at yonr establishment. 1. z. PERSON IN IiAR Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2, HFiMi ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedwes below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. F TA t ANT ATIN : TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S50 _CABIN S50 _MOTEL S50 _�NA1 $50 _CAMP $50 _SWIMMMG POOL S75ea _LODGE S50 _TRAfLER PARK S50 _WHIRLPOOL S75ea FOODSERVI F• LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S75 _CONTINENTAL S30 _NON-PROFIT S25 _�100 SEATS 5150 _COMMON VICT, S50 _WHOLESALE S75 FTA1 .RVI LICENSE REQUIRED FEE PERMIT H LICENSE REQU[RGD FEE PERMIT k LICENSE REQUIRED FEE PERMIT# I <SOsq.ft. S43 ��^6�7 _>25.00Osq.ft. 5200 _VENDING-FOOD S20 _<25,000 sq.ft. S75 _FROZEN DESSERT $35 _TOBACCO S25 NAm �c � $�° AMOUNT DUE _ $ �-° "'•*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"*"• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yattnouth 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 COMPENSA'TION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernvts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HE.ALTH 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 IZF.GULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depadment 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 thereaRer. 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. �ATERi_NG POL•ICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporaty Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Departrnent. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a 3tate certified lab. Test resutts 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. OiJT ID FI+c; Outside cafes(i.e.,outdoor seating with waiter/waitness service),�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 establishment is prohibited. DATE: t! SIGNATU . PRINT NAME&TITLE: G 1 D�vN� 10/22/03 . � The Commanwea!!h ojMassachusetts = Departmenl oflndustria/,-iccidents ; Ol//Ce01/aresUofWis 600 Washington Sfreet Boston.Mass. 02111 ` '��'V W'orkers' Compensation Insurance Affidavit n m•� /Vli W� (JIC � � � 3�� ou a8 ut� ��"�.// y�l /u.� U� ✓l { /`�LN ��f� /�/ ehonep .5"08-�� -��g8" � I am a homecwner pzrtorming all work myself. [�a/I am a solz propriemr r..,', ha�z no one ��orkin� in am capacih• � I am an emplocer pro�i,iing workers' compensation for my employees workine on this job. comnam� namc asldress: tih�: phene u. �surnntt co. oolicv p � I �m a sole proprietor. general contractor. or homeowner(circle onel and have hired the contractors listed below «ho ha�e tht follo��in_ ��arker> compensation polices: comoanv name: � � address: ��n'� nhene q• insurancc co peliev# comoanv name: iddreer. �" phoee�• iniutanee co. m�,* � F�ilure to secure covenge as requved under Secnoe 25A of MGL!S2 n�ind to Nt inpaiOw oteriW�l peWtln of�Ou ap ro 51�00.00 aW/or ooe ynn'impri�onmrnt a wrll n eivil peedHa ie tpe form of�STOP WORK ORDER aed a 6et of 5100.OS t dy q�imt me 1 qdenta�d that t copy of tAia shument m�r be fonv�rded to the 011ice of Invatlqliom of Mt DIA for eoven�e verilkatlo�. �. /da-Arreby cenijy under the painr d pena!(ies ajpery'ury that�ht injormation providtd abave is trne o d rnrrect Signazurc �/ /02. �3 � Printname /U �' W� L/ oneM ��g� ��/ -��gg .� olTicial use onl�� do no�.rite in�his trn to be eompleted by eih ortowe ollltial eity or rown. YARMODTQ - _ per�eiNitenx M nBuildioe Departmm� � ❑Lieeosioe Bo�rd � cheak if immediate response i�required Z61 �SNeetmen'f Ofliet P phone M;_ �508) 398�7231�t. �nOthere Dep�rtmmt , contact erson: _ TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-017 FEE: 5.00 In accordence�+'ith reQularions promulgated under authority of Chapter 94,Secrion 305A and Chapter 11 I,Section 5 of the�ieneral Laws,a permd is hereby granted to: Nancy Wilbur, 327 Route 28 West Yazmouth, MA Whose place of business is: A Touch of Cape Cod Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yarmouth Pemut expires: December 31, 2004 BoaRD oF HEALTH: Be�awMia �. (�oedois, A�1!, • n�.a� v�ef�� a�s�. a�, ee� _ _ _. � �, a.n�. _ December 3.2003 M Directar of H�ealfli _ . _ _ c��613`�a _. �s�R.y TOWN OF YARMOUTH BOARD OF �i�:�C�T�I 'L � �c � " �' ;_ � 2 0 ��s APPLICATION FOR LICENSE/P.LIiIV�IT- 2003 NOV 1 2 2003 �`� , '�`; ` `' * Please complete form and attach all necessa dpcumer�is b��Decembe 3 p Failure to do so wi1L result in.the return�p€you�pplication packe . ��C�H DtpT. � p • • ��8' I.t7F?ATinN A D F � 3�� oU /72.�?3 S�4AnE ` M � A1G f:cJ G ° � C�' (,v # oZ ' 'j0� DRE (o �C1 /l..L d � � -------- � PdOL CERTIFICATIONS: The pool supervisormust be ce�'tified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. L 2. Pool operators must fist a minimum of two employees currently cerfified in basic water'safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and msintain a file at your place of business: 1, 2. 3,. 4• FOOD PROTECTION MANAGERS -CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Pratection Manager„as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Pleaseattach copies of certification to this application The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. L 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. L 2: HE.IMt.ICH CERTIFICA't'IONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver,on the premises at a�l times. Please list your etnployecs trained in anti-chokmg procedures below and attach copies of employee certificaUons to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file af your place of business. 1. 2• 3. _ 4. RFSTALiRANT �EATING: TOTAL # OFFI�E USE-0NLY i,i)DGING: � LICENSEREQUIRED FEE PERMIT#� � �� I,�CENSEREQU(RGD F@G � PF.RMfT# �� UCENSE�REQUIRED� PEE PERMIT# BBcB � � S50 �CABIN � S50 � _M07'EL � S50 tNN S50 � � � � � CAMP� � �� S50 ' � � _SWIMMING POOL$75ea. _LODGE $50 . _TRAILER��PARK �550 _WHIRLPOOL $75ea FOOD�SERVICE: �� . � � � � LICENSE REQUIRED FEE PERMIT#�� LICENSG REQU(RED PEE {'ERMIT fl LICBNSG REQUIRED FEE PERM[T# �0-]00 SEATS � S75 . - � CONTINENTAL ..S30 _NON-PROFIT S25 >100SEATS 5150 COMMONVICT. $50 WHOLESALE S75 RETAILSERVICE: � �� . � . LICENSERGQUIRED�FEE �PERMIT# � ' LICENSERBQUIRED-FB8 PERMITN � � � LfC6NSBRCQUIRGD FEE PERMITH 1<i0.sq.R. �� S45 � d�✓�67I _>25,OOOsq.R. E200 � _VENDING-FOOD $20 _<25,000 sq.ft. $75 �� _PRO'LBN bCSSERT S35 � � �� _T013ACC0 525 nnntE cxnnce: sio AMOUNT DUE _ $ � **"**PLEASE TURIV OVER AIVD COMPLETE OTHER SIDE OF FORM•*«"" ADMINISTRATION Under Ghapter 132,Section 25C, SUbsection 6,the Town of Yarmouth is now required to hold issuance or renewal of`any licerise or permit to operate a busihess if a person or company does not have a Certificate of Worker's Compensation Insurance, THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAViT 1ViUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATT?.CHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRtATELY IF PAID: / YES d NO NOTICE:Permits run annually from January 1 to December 3 L IT TS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT TEIE HEALTH DEPARTMENT FOR INSPECI'ION 7-]0 DAYS PRIOR TO OPENING FQR THE SEASON. ALL RENOVATIONS TO,AN�' FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.j;':MUST$E REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENQVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPIING:Al1 swimming,wading and whidpools which have been closed for the season must be inspected by the Health Department prior to opening. FOOL WATER TESTING: The water must be'tested fo�pse�domonas, total coliform and standard plate count bya 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 ' ON FR VISORY: Each food establishment which serves or sells ready-to-eat,nw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify'the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. 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. Faiture to do so will result in thesuspension or revocation of your Frozen Dessert Permit until the above terms have been met OUTSIDE CAFESs" QuTside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior approval from the Board of Health. O�JTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: l l SIGNATURE: PRINT NAME&TITLE: c- U � °� ' �� 10/I8IO2 _ ,�,y.. .��,.r . . � The Commonwea!!h ajMassachusetts = : Departmentojlndustrial,-tccidents " O/J/COO//CYCSUy11//IS 600 Washington Sfreef Bnston,Mass. 02111 " N'orkers' Compensation Insurance Affidavit � / �.�� l��ic.6cJF{ d6a. .d ou h ,5-�' ��e,o� �o � 3�� g i + / �/j / i��au�� ' cit� ��r'J� Y . �Il't0U-�' h l�A �0� (07� ehon p �QD ' / I/ " !o`f � � � 1 am a homecKner penortnin,all work m}s f. � [�f am a solz proprie[or �r.d ha�e no one «orking in an} capacih� , � I am an employer pro�i�ins workers' compensacion for my employees uorking on[hisjob. cmm�am�name• �lAress• titv phene+�• insur�ctto. poliev# � I am a solz proprietor._eneral contractor. or homeowner(circle one/and hace hired the contractors listed below «ho ha�e thr follo�cin; ��orkar compensuion polices: cnmpanv name• � � add ress• tin�: nhene e• �ur�ntr co. nelie��M comR3RY�tmr. � . fdd[e3s: ��h" phoee w � iesurxncsso. peRer M t F�ilun to secure covenee as reqwred under Seenos 25A of MCL ISl u�ind W 1Ye i�paiuw o(eri�iW pt�dtln oh O�t op lo S130Y.00��d/or one ynrs'imprisonmeet u w�ell u eivii penaiNn io the fo�m of�STO�WORK ORDER��d�fl�e�S100A!�dq�iait�a 1��dmta�d Wt■ eopy ot thy�n�emeet m�r be lonnrded to tbe Ortiee of lavntie�tlom of Nt DIA tor eoren�e verilfudw. � � 1 da hrreby cenijp under the pains d pena(ries ojperyury rhat the injormation provided abore is nve and corrcet Signaturc l�L,,L�(it-t�/�(JV !�/�02/�3 Printname h. • � �+ !! oneM so8� �� -��FS� ., aRcial use onl� do not write in�his are�to 6e tompleted by eih or towe ollltial ciry or rown: YA�O�T$ _ � penaiNiceeee p n8uildiog Dep�nmee� �Lieemioe Bo�rd 0 eheck if immediite response i�required Z61 �Seleetmen•�011fet (508) 398—T331 p�t, �HeNtE Department . contactperson: pponeM:_ � _ nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHMENT PERMIT NUMBER: #03-071 FEE: 5.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Nancv Wilbw, 327 Route 28, West Yarmouth, MA Whose place of business is: A Touch of Cape Cod Type of business: Retail Food Service less than 50 square feet To operate a food establishment in: Town of Yarmouth Per►nit expires: December 31. 2003 BoaRD oF HEnI.TI I: B�$ �s+edo�r, M.$� n�M��, v�. Rode�t 4. B� G/�s+r�b d/� Sl�k, R.N. December 3.2003 Bruce G. Mwp ry,MP . , Director of Healih