HomeMy WebLinkAboutApplications, WC, and Licenses Prior to 2010 . ,_ _ TOWN OF YARMOUTH BOARD OF HEALTH G3 G��0 �
APPLICATION FOR LICENS�,/PERMIT=2010
' �� " ` � � DEC 1 ) i i�19
*Please complete form and attach all necessary dqc�mnents by Dece tr i .
Failure to do so will result in the return of your appGcataon p
NAME OF ESTABLISHMENT: i�� e-✓c«�,-t�c� EL. # J� ZC�v Ia o�
LOCATION ADDRESS: � � �,
MAILING ADD 76 d p
OWNER NAME: � F or : �
CORPORATION N (I AP LICABL�): �uqc
MANAGER'S NAME: I.Jc� TEL. # 22'Z
MAILING ADDRESS: G o
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 certificarion to tiris form.
- -- - ---- —
--_
1. . 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Comtnunity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - 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 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 t'ile at your estab6shment.
1. 2.
PERSON IN CHARGE:
__- - ------ --- _ _ — - - -
_---
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your emnployees trained in anti-chokuig procedures below and
attach copies of employee certificarions to this form. The Health Department will not use past years' records.
You must provide new copies and maintsin a t'ile at your place of busiuess.
L 2.
3 4
RESTAURA.NT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIREA FEE PERMIT# LICENSE REQITIRED FE$ PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&.B $55 _CABIN $55 _MOTEL $55 �
,�ATI 455 �CAD� S55 ,SWL'�1P+�?�'G POOL S80ex.
_LODGE $55 _TRAILERPARK $105 WHIRI,POOL S80ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQU(RED FEE PERMIT tl LICENSE REQUIRED FEE PERMiT#
,0.100 SEATS $85 _CONTINENTAL S35 NON-PROF[T 530
>1005EATS $160 iCOMMONVIC. $60 WHOLESALE $80
RETA/I,SERVICE: —RESID.KI'ICHEN 580
LiCENSE REQUII2ED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
1<SOsq.B. $50 �iD-o3� _>25,OOOsq.ft. 5225 _VENDING-FOOD $25
_Q5,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S55
xnMEcaatvsE: sts AMOUNTDUE = S 50.00
"•"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••••
AD111�IIINISTRATION '
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
Compensarion Insurance. THE A1"1'ACHED STATE WORKER'S COMPENSATION INSURANCE .
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED ' -
OR , /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Y
Town of Yarmouth ta��es and liens must be paid prio .to renewal or issuance of your pernrits. PLEASE CI�CK
APPROPRIATELY 1F PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHIVI�NTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use, Transieirt 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 ofresidence elsewhere.
Transient occupancy shall generally refer to cominuous 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 Transieirt.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must beu�spected
by the Health Depamnent prior to opening. Contact the Health Depardmern to schedule the ittspection three(3)days
pnor to opening. PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has baen inspected
and opened.
POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmoufh Health Department by Sling the reqwred
Temporary Food Service Applicarion 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 resuk in the suspension or revocation of your Frozen Dessert Permit untit the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor searing with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,prepararioq or displa�of any foodproduct b�a retail or food service establishmeart is prohibitett. _____ _
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBIIITY TO RETURN
TfIE COMPLETED RENEWAL APFLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISI�VIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI'T'E PLAN.
DATE: �a IlU o 1 SIGNATURE: �- �./
PRINT NAME&TITLE: � ' °
09/25/09
.' �\ The Commonwealth of Massachusetts
' Deparhnent ojlnduslrial Accidentc
NlfciN�
600 Washingtoa Sdeet, 7`"'Floor
Boston,Mass. 02111
Worlcers'Compe�satioa�I�sarance AfGdavit:Buildiog/Plambieg/Elec[rical Coatraetors � �
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❑ I am a 6om�wcer perfocming all w�k myself. Project Type: ❑New Con 'on QRemodel
❑ I arn a sole�propcie[or and Lave no one wodcing in any�capacity. ❑Building Addition
�t am an�ployer providin wockecs'co 'on for my employces wodciag on Utis job.
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Technology Insurance Company
A Stock Insurance Company
� � 20 Trafalgar Square,Suite 459 �
Nashua, NH 03063
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 4
INSURANCE POLICY � INFORMATION PAGE
Ncci Code: 39071
1. Insured: Policy Number: TWC3206281
Bass River Mercantile, Ina
Individual Partnership
2 N. Main St X �Corporation or ___
South Yarmouth MA 02664 Federal Tax ID: 043457481
- Otherwnrkplacesnatsl�ownabove:-.. - . .. ... .. . . - � Risktd: - �-- .... . . ". .-... .
See Extension of Information Page Renewal of: New
Producer:
AmTrust North America,Inc.
c/o Paychex Agency,Ine.
150 Sawgrass Drive .
RochesterNY 14620�
2. The policy period is from 6/27/2009 to 6/27/2010 12:01 a.m. at the insured's mailing address.
--__ __-- - ... — — - -
3. A. Workers Compensation Insurance: Part One.of the policy applies m the Workers Compensation Law of
the states listed here: Massachuseris � � � � �
B. �Employers Liabiliry Inswaoce: Part Tw�o of the policy applies to work in each s[ated listed in item 3.A.
The limits of our liability under Part Two are: �
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
. ..__ .._ ._ .__.. _... . _..__.
____-__...
__ _ _
.__.___ . ..__ _ . ._ _
MA $ 100,000 each accident $ 50Q000 policy limit $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here:
All s[ates except ND, OH,WA,WV,WY and State(s) Designated in Item 3A.
D. This policy includes these endorsements and schedules: �
W C OO OO OO A,W C 99 00 01 B,W C 00 01 13A,W C 00 03 08,W C 00 04 14,W C 20 01 01,W C 20 03 01,W C
20 03 02,W C 20 03 03C,W C 20 04 01,W C 20 04 O5,W C 20 06 01A,W C 20 O6 04
4. �:he premium�for this policy will he determined by our Manuals of Rules,Classifications,Rates and Rating
Plans. All informa[ion required below is su7ject to verification and change by audit.
See Extension of lnformation Page
TOTAL ESTIMATED ANNUAL PREMIUM 538
STATE ASSESSMENT 16
TOTAL ESTIMATED COST 554
Minimum Premium 306
Deposit Premium 554
Issue Date: 6/2/2009 Countersigned by: __. __ ,_
. . �. Authorized Representative
Technology Insurance Company WC 99 00 0� B
2of4
WORKERS COMPENSATION AND EMPLOYERS LIABILIN INSURANCE POLICY INFORMATION PAGE
Insured: Bass River Mercantile, Inc. Policy Number: TWC3206281
EXTENSION OF INFORMATION PAGE FOR ITEM #1
ITEM 1: NAMED INSURED and WORKPLACES
WORKPLACES:
2 N. Main St South Yamouth MA 02664
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #10-038 FEE: 50.00
In accordance with regula[ions promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the Generel Laws,a pemtit is hereby granted to:
Stephen E. Wolfe, 2 North Main Street, South Yarmouth, MA
Whose place ofbusiness is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food estabiishment in: Town of Yazmouth
Permit expires: December 31. 2010 BonRD oF IIEALTH: ��Baiarc SBK�e��'�, �
w��-,►� e.s�,�.�, ec�
���t�.
� ,
FebruarK 19.2010
ruce G.Mutphy ,R.S.,CHO
Director of Heal
.� .
a.R. D 5 0 �� Liquorc,S
� TOWN OF YARMOUTH BOARD OF HEALTH �1
��� APPLICATION FOR LICENSE/PERMIT-2009 \�p f ," � �
�—. �� - �,1 ; Z008
* Please complete form and attach all necessary documsnts b ' e`cemb 15 2008. �
Failure to do so will result in the return ofybi}r ap}ilicahon pac .����E � �_ �C�;-�-
�
NAME OF ESTABLISHIv1ENT: �'� � , �:L L� uo2s TEL. #�c�8-�J E,o-Sy��
LOCATIONADDRESS: �f _3/ �o :�-t� �c3 So:.�f/� A^_.Ma..�f-�f
MAILING ADDRESS: �f� �
OWNER NAME: t .�+ �.�-,o::.v �_- Lro �z�^� TAX ID (FEIN or SSN):
CORFORATION NAME (IF APPLICABLE): l�Ass'�,��,/�2 r�.s c.aun/t t--� aua^-�' 7'ru L-
MANAGER'S NAME: S.o,'r� � TEL. #.5vd -�4.0 -�y�q
MAILING ADDRESS: ��
POOL CERTIFICATIONS:
The pool supervisor must be certi6ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonazy Resuscitation(CPR). Piease list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a Gle at your place of business.
l. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents 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 Heaith Department will not use past years' records.
You must provide new copies and maintain a file at your estabfishment.
1. 2.
PERSON IN CHARGE:
- _ _
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at 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 tlris 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.
RESTAL7RANT SEATING: TOTAL #
OFFICE USE ONLY
LODG�iG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMII'# LICENSE REQU[RED FEE PERIvIIT�
B&B S55 CABIN S55 MOIEL 555
INN S55 CiuV1F S» S�4Ti�thiIIv6 POOL S^o0es.
_LODGE S55 _TRAII.ER PARK 5105 _WHQtLPOOL 580ee.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICINSE REQUIItED FEE PERMI'I# LICENSE REQUIRED FEE PERMIT#
0.100 SEATS SSi _CONfINENTAL S35 NON-PROFII' S30
>100 SEATS 5160 COMMON VIC. S60 WHOLESALE 580
RE7AII.5ERVICE: —RESID.ffi"ICHEN 580
LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII# LICENSE REQUIRED FEE PERMIT#
� <jOsq.ft. 5i0 �Oq-�� _>25,OOOsq.ft. S225 _VENDING-FOOD $25
Q5,000 sq.ft. 580 _FROZEN DESSERT 540 I TOBACCO $55 �g
�amtEc�,vcE: sio AMOiJNTDUE _ $ l05.bo
""**"PLEASE TIIRV OVER AND COI�IPLETE OTHER SIDE OF FORi�S'•***
� • .
ADMINI5TRATION
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 WORI{ER'S COMPENSATTON INSURANCE
AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth tvices and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHNIENTS
TRANSIENT OCCUPANCI': For puiposes 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 residence elsewhere.
Transient occupancy shall generally refer to wntinuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days witivn any six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as de6ned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimrning,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days
pnor to opemng. PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CI.OSING: 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 Yaimouth must notify the Yazmouth Health Departmem by filing the required
Temporary Food Service Application form 72 hours prior to the catered evern. 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 Pennit 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 ofHeahh.
OUTDOOR COOHING:
Outdoor cooking,preparatioq or display of any food product by a retail or food service estabiishmem is prohibited.
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.TTY TO RETIJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
,
DATE: /L - 4 � �V SIGNATURE� —' 1 ^��,-�-��7 ��
PRINTNAME&TTTL�: �/d.rm�:,v� C . Li,� uzvn.' f�'^,�S >
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torz��oa
11/ L2/ LVVV 11 �LV� JJ I'9l'1 11JJ4 V0.1Y1110.1 LLV• VV-111VV���J11(>10.A tG4(jli L �
CERTIFICATE OF LIABILITY INSURANCE °���i�B :
Protlucer THIS CERTIFICATE 16 IS6UeD AS A MATTER OF . �'�`�
INFORMATION ONLV AND CONFERS NO RIGHTS UPON THE .:.%•s�;.
Frst Cerd�nal Cap. -� CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT �'�:-"'
f0 British Amedoen Blvd. qMEND,EXTEND OR ALTER THE COVERAGE AFFORDEO BY - '
Latham,NY 52110-0141 �
THE POLICIES BELOW.
_ INSURERS AFFORDIN6 COVERAGE NA1C#
Insurea �� INSURER A: MA Retsfl MerchaMs WC 6ro Inc.
. Bass River�iscouM Llquors,inc. INSURER B:
B37 Rte.SB
8oUtA VermauN,.MA 02864 INSURER C: ,
� INSURER D: -
� - - INSURERE: ���
COVERAGES ' '"
7ME PCICIES OF INS A E S7ED BEL HAVE BEEN ISSUED TD 7HE INSUI�D NAMED ABOVE PDR TM!POUCY PERIOD ItO1CATlD�NOTMTFqTANOINO � '-;'.i;
ANY REOIHREWENT 1L'RA4 OR CONDITION OF ANV CONTRACT q3 Q7HER DOCUMENt N1TH RESPECTTO NMlqi 1HI9 CERTIRCATE MAV BE ISSUED d2 MAV - .
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AtiOREOATE UPWT88f1PMJ MPY WiVE BEEN REDtJCED BY PAIDCWMS.
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CERTIFICATE HOLDER nounow�iwurm:iwuaaa�errers: CANCELLATION �
�� SFIWR�ANYOFTFIEABOVE�ESCRIEEDPOLIGESBEGANCELI�OBEFORE '
TOwn o(YarmWth THE EXPIRA710NDATE TNERE�,IHE ISSlANO1NSURERN7LL EN�FAVOR TO
ATTN:HealtliDepl. hWil�5_DAYSNTtITfE1JN0'11CL'TOIHECERTiFlC/REh10L�ERNNMED
� 1146RWIB28 T07HELEFT,BUTFAILURETODOS06HALLIN�OSENOOBLIOAI)ONOR �
6ouN Vef1ltDUfh,MA 02864 L�ABILITYOF ANV KIND UPON filE IN9URER,IT9 A(lEN7S OF2 .
. � REPRESENTA7NE5.
AUTHORREDREP S NTA
�ii,'
. ' ' .i.�'i-.
. � :%{!''��7
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLISAMENT
PERMIT NUMBER: #09-026 FEE: 550.00
In aceordance�ci[h reeulations promulgated iwder authorirv of Chapter 94, Section 30�A and Cl�apter
ll 1, Section�of the�eneral Laws,a permit is herebp grai�ted to:
Bass River Discount Liquors Inc., 931 Route 28, South Yarmouth, MA
Whose place of business is: Bass River Discount Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31 2009 BowRD oF HEAL"IH: ,�feeeet SlfaPt, `J2✓Y, C'I�aixnuut
P.Ilctxfeo !E. .9Cellilie�x,,} `V,i,ce C'&a�uruin
REsl7ucirohs: Przpackaged candy,gnm, soda,chips. �Mx `.;. ✓�KOWft� I:CYJ[li
. Q�`�t�2,,f�t���„X4R/lBt/Q�,l,l�f�/�t��✓Z..IV.
"""`y"�' ""`� "'
December 17.2008 Bruce G.Mutphy, H, .5., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #09-018 FEE: S55.00
This is to Czmfi cha� Bass River Discount Lipuors Inc. d/b/a Bass River Discount Liquors
931 Route 28 SoLth Y�r_m__outjl, 1�LA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
Thig�e�it is v,Uranted' nfor�tin��vith Article V�o�the Satt�ta�r Code ofThe Cotnmon�cealth ofMassachusetts,and
zxpi s ecem er 31.��� un es"s sooner suspen e or revo e '
December U 2008 BOARD OF HEALTH: .`�R.�¢tt S�� ./2..1v.� ��./�ALIBUift
�.�QX�¢d .`�. `.XR�I�AC� �iCe �RlXltUiK
.fZO�FIlf `.�. ✓�A101UIt� CePI[�
Q�'�t�1,f,pL���j,,KCCt1.�r]C�U,,1�1�f�t���../v.
"""'`.Y'� �• ""'y_o"
ce . Murp y,M , . ,
Director of Health
, - 1�� n u^��yM1� �,� '� �
°`�R�. TOWN OF YARMOUTH BOARD OF HE,�M�, 1 � p� U E C 1 S 2006
�C�i APPLICATION FOR LICENSE/PERM�T�2��� �
� ' � .
* Please complete form and attach all necessary docume�Cs by December TH DEPT.
Failure to do so will result in the return of your application packet.
Nt1MEOFESTABLISffiVIENT: /�' ,oSS�/ ;U�/�, �iscou.v�- �.,'�q�,c.o2s �,. # So�-��,o-Sy9�
LOCATIONADDRESS: 93 J �ow-�� 28 �'ou..�N y.oz..+o��-h�
MAILING ADDRESS: SA �
OWNERNAME: _ A�mo�� [_ • �A�-�-z-oN T XID(FEINorSSN1
CORPORATIONNAME (IF' APPLICABLE)�13As3 !�- i!/E2 �iCl.�7a.N�' �-��dud'�--r a'we,
MANAGER'S NAME: �S'qm� TEL. #
MAILING ADDRESS: «
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
_ . _Pool O�erator(s)and attach a copy of the certification_t_o this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You roust provide new
capies and maintain a file at your place of business.
1. Z.
3. 4.
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
Ail food service establishments are required to have at least one fWl-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. The Health Department wiil not use past years' records.
You must provide new copies and maintain a file at your establishmen�
1. Z,
PERSON IFI CHARCrE:
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 ceRifications 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.
RESTAURANT SEATING: TOTAL#
Lo�wc:
OFF'ICE USE ONLY
LICENSE REQiJIRED FEE PERMI1'# LICENSE REQUIItED FEE PF.RMIT# LICENSE REQUII2F,D FEE PERMIT#
B.4cB S50 CABIN S50 MOTEL S50
_INN $50 _ _CAMP $50 SWAAfING POOL$75ea. �
_LODGE $50 _TRAII,ERPARK $100 WI�IIRI,POOL $75ea.
FOOD SERVICE:
LICENSE REQiIIItED FEE PF.,RMIT# LICENSE REQUIItED FEE PERM[T# LICENSE REQiJIRED FEE PERMIT#
_0.100 SEATS $75 _CONI7NEN'TAL $30 NON-PROFIT $25
_>100 SEATS 5150 _COMMON VIC. S50 WHOLESALE $75
RETAQ,SERVICE: —RESID.KITCHEN $'75
LICENSE REQiJIltED FEE PERMIT# LICENSE REQLJIl2ED FEE PERMI1'# LICENSE REQIJIItED FEE PF,RMI'P N
� <SOsq.ft. S45 �n�-o?h >25,OOOsq.R. $200 _VENDING-FOOD $20
_QS,OOOsq.ft. S75 _FROZENDESSERT 535 I TOBACCO S50 �[J��a-(p
NAMECHANGE: E70 ' AMOUNTDUE _ $ QS-dO
•"""PLEASE TURN OVER AND 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 pemut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVII'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 to renewal or issuance of your pernuts. PLEASE CFiECK
APPROPRIATELY IF PAID:
YES.�_ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
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 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 Yarmouth must notify the Yazmouth Health Department by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
_ -_ Qutdo�conking,preparation, or disglay of anyfood product by a retail or food service establishment is prohibit�ed.
NOTICE:Permits run annually from January 1 to December 3 I. TT IS YOUR RESPONSIBILITY TO RETURN
TI�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
AI.L RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COD�IENCEMENT. RENOVATIONS MAY A SITE PLAN.
DATE: l z - 1 5E— 0� SIGNA .
PRINT NAME&TTIZE: o u D u.z N /1-t S
ioii�ioc
12/13/2006 30 : 11 : 19 AM Cherri L. Tunison-Kelly First Cardinal Corp. Page 2
CERTIFICATE OF LIABILITY INSURANCE °°'izii o6
Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF
Firet Cardinal Corp. � INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
10 British Ameriwn elvd. � CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT
Latham,NY 12110-0141 � � ��" � ��' �'' I� n AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY
THE POLICIES BELOW.
DEC 1 5 ZOO6 �NSURERS AFFORDING COVERAGE NAIC #
Insured INSURER A: MA Retail Merchanis WC Group Inc.
Bass River Diswunt Liquors,Inc. HEALYf"� ��PT. INSURER B:
931 Rte.28
South Yarmaith„ MA 02664 INSURER C:
WSURER D
INSURER E:
COVERAGES
7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIICV PERIOD INDICATED,NOIYNTHSTANDING
ANY REQIIIREMENT 7ERM OR CONDITION OF ANV CON7f2ACT OR OTHER DOCUMENT UMTH RESPECT TO WHICM IHIS CERTiFlCA7E MAY BE iSSUED OR MAY
PERTAIN TNE INSURAf�E AFFORDED BV hIE POLICIES DESCRIBEDHEREIN IS SUBJECT TO ALL THE 7ERMS,EXCLUSIONS AND CONDIitONS OF SUCH POLICIES.
AGGREGAiE LIMITS SHOVYN MqV HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY
nOUL EFFEGTIVE DATE POLICY IXPIftPTION
wsn�la iHSRD TYPEOFINSURMlCE FpLICYNUMBEFi (MMIODNV DATE MM/0D IJMITS
OEN6�ALLW&LITY FACHOCCURRENCE $
COMMERC]ALGENH7ALLIABILITY FIREOAMAGE(MyanePoe) $
CLAIMSMH�E O OCCUR MEDEJ�(Myoreparwn) $
PERSONPL 6AOV INJURV a
6ENERAL AGORE6ATE $
GEN'LAGGREGATELIMITAPPLIESPER: PRODUGTS-COMP/OPAGG $
PRO�
POLICY JECT LOG �
AUTOMOBILE LIRBILITY CpM&Nm 9NGLE LIMIT
ANVFUTO fEeewtlerrt7 $ .
ALL OWNm AIIfOS BOdLV INJURY
SCHEDULmAUT05 ����'� $
HIRED AUTOS gp01LV INJURY
NON-ONMm AlJr05 (Px axitleM) $
PfEOPHiTV DAMAGE $
(Pa emide�
GARAGELIABILITV AUTOONLV-EAACCIDINf $
ANV AVTO pTHER THAN �� $
AUTOONLV AGG E
IXCE55 LIABILITY EACH OCCURRENCE a
OCGVR ❑ CLNMSMPDE AGGREGATE a
$
OEOUGTIBLE f
�TENTION � 5 � S
WOfiKERSCOMPENSGTIONRNO WC$TATU- 0T44
EMPLOYERSLWBILRV X TORv�IMRS ER
AM'PROPRIEfFRIPARfNER/D�CVfIVE EL EqCH ACGCQJf
A OFFIG6i/MEMBERIXCLWED7 a 100,000
Ifyes.tlesmibeun0er N� �14�00$0�0]7107 1/0�/�] 7/��/0$ ELpSEASE-EAFMPLOYEE
SPECIPL PROVISONS bebw S 100,000
EL.pSFASE-PO�ICYLIMIT $ r�000
OTXER
OESCRIPTION OF OPQtATIONS�LOCATIONS!VFSIICLES IXCU1.50NS ADOED BY ENOORSEMEM/�EGPL PROVISIONS
Faz k 508-398-2365
CERTIFICATE HOLDER noanorva�irvwrsm�.wsuaea�Errax�. CANCELLATION
Town of Yarmouth SHOULD ANV OF THE ABW E OESCRIBED POLICIES BE CANCELLED BEFORE
7HE EXPIRAiIONDA7ETHEREOF,THEISSUINGINSURERYNLLENDEAVORTO
ATTN:Health Dept. MAIL 35 DAYS WRI77EN NOTICE TO THE CER7IFICATE HOLDER NAMED
1146 Route 28 Tb h1E LEFf,BUT FAILURE TO DO SO SHALL IMPOSE NOOBIIGATION OR
South Yafmalth,MA 02664 LIABILITV OF ANY KIND UPON TiE INSURER,ITS AGEN75 OR
� REPRESENTAIiVES.
AUh10RIZE D REPRESENTATIVE
� r� �
t
TOWN OF YARMOUTH
BOARD OF HEALTg
PERMiT TO OPERATE A FOOD ESTABLLS�NT
PERMIT NUMBER: #07-035 FEE: $45.00
In accordance with re¢ulations promulgated under authority of Chapter 94,Section 305A and Chapter
. I 1],Section 5 of the C�,eneral Laws,a peimi[is hereby granted to:
Bass River Discount Liquors Inc. 931 Route 28 South Yazmout MA
Whose place of business is: Bass River Discount Liquors
Type of business: Retail Food Service less than 50 squaze feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31 2007 BOARD OF HF,ALTH: L� �y, �M�y,� •
��"�S`t�, �:�et�.�
RFCTTucTtoxs: Prepackaged candy,gum,soda,chips. n���
�9«.t(f�, R.N.
March 2�-200� ruce G.Miuphy, .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-026 FEE: $50.00
This is to Cer6fy ti�at Bass River Discount Liquors Inc. d/b/a Bass River Discount Liquors
9 I Ro t S o rth Y r+*�o h MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBiTi'ION OF TOBACCO PRODUCTS
AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
�s����an�in ccmfor�u�t ��Articy��iVl�o�'�ere�anitacy Cale of The Commonwealth of Massachusetts,and
2007 ked"
_ M��b z�.zoo� sonxD oF�fu.�: B�.�. �jm�.�, iL1.�.,
a� s�, a.�., v�e�
a�t� a�, et�
p����
a.�.�g�, R.n�.
�u . um �n' ,
Director of Heakli
��' �.R. l.iquoPS
" 3i���^'+.yc TOWN OF YARMOUTH BOARD OF HEA�:TH � � � � � �Vj [� �o
���s APPLICATION FOR LICENSE/PERdt�ITf�2'00(
��� �� • � uEC 0 7 2009
* Please complete form and attach a1l necessary documents by Decem er 31, 2005.
Failure to do so will result in the retum of your appGcation pa e�EALTH DEPT.
NAME OF ESTABLISfIIv1ENT:�/a SS �l � vE2 -���cocw f' ��tQuak>' �L. #soe- 960 -Sy99
LOCATIONADDRESS: 93 / /�ou��c- 28 So�ct/� �i�/irnv�tlf
MAII,ING ADDRESS: S r+�c=
OWNERNAME: A i»o.va �. !'Jt,cZ.ON T ID or S :
CORPORATION NAME IF PLICABLE): "�� Ss'�i :✓E.L ��s eou.n� �-- C.��v�s� S,�c .
MANAGER'SNAME: �A Mo/vD E- �,v�czoiv TEL. #Soe- 76o-s�99
MAIL,ING ADDRESS: A M �
POOL CERTIFICATIONS:
The pool supervisor must be certi6ed as a Pool Operator,as required by State law. Please list the designated
--�oat 1�p�r�ter(s�an�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 Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - 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 Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Heelth Department will not use past years' records.
You must provide new copies and maiutain a t'de at your establishment.
1. 2.
- - PERSON_IN('HAR('.F ----- -- -
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. Z.
HEIlF�FeH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attaeti copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a£de at your place of business.
1. 2.
3. 4.
RESTAIJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQITII2ED FEE PERMIT# LICENSE REQiTII2ED FEE PERMIT N LICENSE REQUII2ED FEE PERMII'N
_BBcB $50 _CABIN $50 _MOTEL $50
_INN $50 _CAMP S50 _SWIMIvllNG POOL$75ea. �
_LODGE $50 TRAII.ER PARK $50 _WfIIRI,POOL $75ee.
FOOD SERVICE:
LICINSE REQIJII2ED FEE PERM[T# LICENSE REQilII2ED FEE PERMIT tl LICENSE REQUIliED FEE PIItMIT#
0-100 SEATS $75 CONT"INEN1'AL $30 NON-PROFiT S25
_>100 SEATS 5150 _COMMON VIC. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE R&Qi)IItED FEE PERMI1'# LICINSE REQUII2ED FEE PERMI1'# LICENSE REQUII2ED FEE PERMIT N
� <SOsq.ft. $45 ��-oH _>25,OOOsq.ft. 5200 _VENDING-FOOD $20
_QS,OOOsq.ft. $75 _FROZENDESSERT $35 ( TOBACCO E25 �Il//
NAME CHANGE: S10 AMOUNT DUE _ $ ']p.��
"""""PLEASE TURN OVER AND COMPL6TE OTHER SIDE OF FORM•"•""
ADNIINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any7icense or pemvt to operate a business if a person or company does not have a Certificate of Worker's
Compensaxion Insurance. THE ATTACHED STA1'E WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSLJRANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES__� NO
NOTICE:Permits run annualiy from January 1 to December 31. I'I'IS YOUR RESPONSIBIL.ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPEC'ITON 7-
10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COIVIMENCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming;wading and whiilpools 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 who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing 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:
�'rozen desserts must betested on a monthly basis by a State certified lab. Test�esul�s mustbe sent to the Health--
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board ofHeahh.
OUTDOOR COOHING:
Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmern is prohibited.
DATE: /1 -,3D ' �-� SIGNAT -
PRINT NAME&TITLE:�/�'� �rL� � , � tt zo N �t c s ,
09/28/OS
' - NQV. 3Q. 2P05 1 :67PM FIRST CARDINAL 5182131961 NQ. QSQ P. 1
CERTIFICATE OF LIABlLlTY INSURANCE �11/30/05
��� n� �zt� arei issu nsa
INFORMATIpN OMIY IWD CONFERS NO RKaF1T8 UPON THE
=;rst i�iMitn!Corp. CERTiFICATE HOLDER. T1�ItS CEK'1lRICASE DOES NQT
10 Btitish Amerran Blwl. AMEND.EXfEND OR ALTER ThIE GGYERAGE AFFORDcD 8Y
�atham,M't2t t0�t47 }}{E FQL�C�S 6ElOW.
INSUl4ERS AFFORDtfdG COVERAGE NAIC#�
isured INSUlZER fl• Ir1A R�xi Msrchants VYC tm.
Bass Rivar Di000urd L'pws,itr. INSllR6R B'
931 Rte.28 �0�� tPi3UftER C:
So�hYartmuth.,
INSURER D:
1NSURER E'
�OV r�
a oF s��.oww�va s m
arrr aeexa�rtr s�ra+oR caonrori oR�wr�T ue o�R oocxr�Hr vu�m ResFecrro vaaa+r+�s�rcnf�+'�wr sE u�o arc xnv
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qE6p b44YHA BEEN 8 P
� �7MEDFZE P'O��RArON
N4F�l0. MMMD OF � FA�OCCYfl�'�
GO�ML�B6lI7 q(y��(�pyq�elk $
t!.GH�.LU.HIIA7Y lI�O�(�'F�'/oue
CV3M6MI� � � P9t$ON/1-BMfM.RA3Y $
6Br61hL ALi3f6GATE
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REFERENCE:
/ K
wakxa•ednpen�tloe aovert,�b wnvideu hy oomucsn ay om+l�a 9.n riberotrewn[t.iquors,Ne.
CWSTiged�notepPN��M a�Ro►^a appmved a1M ue�qnadTN eaR RYtee o6mwdL19uois.Nm-
eAroatl+em.ottS00a
CER FICA H R w� � ��Fl�°
PqL BE
Town Of YarmOtdh n��RanonDn�'mertEaF,rnr�ssuwe�wsu�xvau_ee�,avoR�ro
ATTN:H9thh Oept. MAK�DAYS WWTTEN NC110E TO hE�TEh10L0EF2 NANER
�rasFmumze To ovrRawRer000�swu�»avosEnoosuaanoN«z
SoutA YamwtAh►M�2664 un&uT�ra°arrcloM u�ON1f1E rc�NER.frs fu�Nis OR
RfcPRE5HN7A'IA/ES.
l�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
-- - - _ - - _ _
_-
PERMIT NUMBER: #06-011 FEE: $45.00
In accordance with re ations promtilgated under authority of Chapter 94,Section 305A and Chapter
111,Seclion 5 of the�eral Laws,a pennit is hereby granted to:
Bass River Discount Liquors Inc. 931 Route 28 South Yarmout MA
Whose place of business is: Bass River Discount Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut eapires:_ December 31. 2006 BOARD OF FIF,AI.TH: Beryaru�r.$. �'o+xjony/y�j, •
�S��TTONs: �a�k8g���a�,�,�,�� S. P�tif�� v�ef�
r a�+d�rt 4. 8�, �
d/�K �4l�l� R.N.
A.� �j� R.N.
December 8 2005 ruce G.M
Director of H�eal�th' �RS.,CHO
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #06-01 l FEE: $25.00
TLis is to Ce,tify that Bass River Discount Liquors Inc d/b/a Bass River Discount Liquors
931 Ro�t 28 SoLth YarmoLth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBiTTION OF TOBACCO PRODUCT
AS PER Tf� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
�����I��*�f�����u��n�cle V�of the Sa�tazv Code of The Commonwealth of Massachusetts,and
s�Lspeided or revo ed'
_ December 8.2005 BOt1RD OF I�AI,TH: B $. (�p�y �$., .
P i��a��u, v�e��
R�� B� Lt�,.�
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:
o��"a TOWN OF YARMOUTH BOARD OF HEA
���s APPLICATION FOR CENSE/PERMI`f- 005 �v '` � �� °°' s DD
��..
* Please complete form and attach all nece ` documents by Dec er��,�'L�. Z004
Failure to do so will result in the return of your application p k�EAL-i H DE PT.
NAME OF ESTABLISHMENT: ss %✓Ea :t4�co/Z� TEL #3o�-�I60 S�/�j�
LOCATIONADDRESS: 93! �o�..-�C 28 ac��-,d Yicme�l'N
MAILING ADDRESS: _
OWNER/CORPORATION N s = 7��"sC�un. /�.� ..eo2S �n,c
MANAGER'SNAME: �mon,D L • .C�vtzo.✓ TEI,. #_S06'-760 -sy4q
MAII,ING ADDRESS: Ssvn�
POOL CERTIFICATIONS:
The pooi supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated
Pool Operator(s) and attach a copy of the certiScation to this form.
1. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of
employee certifications to this form. 'I'he Health Department will uot 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 - CERTIF'ICATIONS:
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 Estab►ishments, 105 CMR 590.000.
Please attach copies of certification to this appGcaxion. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a t'ile at your establishment.
1. 2.
PERSON IN CI��tfiE:--__ . _ __ _ __- - _- -- - - -_ _ _ ___
Each food establishment must have at least one Person In Charge(PIC) on site during.Rours of operation.
l. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Aeimlich
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 Tile at your place of business.
1. 2.
3. 4.
RESTAiJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIl2ED FEE PERMIT'# LICINSE REQiJIIiRD FEE PERMIT'H LICINSE REQ[JI2ED FEE PERMII'#
B&B S50 _CABIN $50 MOTEL $50
_INN $50 CAMP S50 _SWIIvIIvIINGPOOLS75ea.
LODGE $50 _TRAILERPARK $50 _WIIIRI.POOL $75ea.
FOOD SERV[CE: �
LICENSE REQUIRED FEE PERMI1'k LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS E75 CON1'INEN1'AL $30 NON-PROF[T $25
>]00 SEATS $150 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIItED FEE� PERMfC# � LICINSE REQiJIItED FEE PERMII't! LICENSE REQiJI2ED FEE PF..RMIT#
1<SOsq.ft. S45 �� �O�jS _>25,OOOsq.ft. $200 _VIIVDIN(3-FOOD $20
_Q5,000 sq.ft. S75 _FROZEN DESSERT $35 1TOBACCO S25 b �
NAME CHANGE: $10 AMOUNT DUE _ $ 70 �00
�'•"••PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM^^•••
J '� �
, �
ADMINISI`RATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not 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 Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_� NO
NOTICE:Permits cun annually from January 1 to December 3 L IT IS YOUR RESPONSIBIL,ITY TO RETORN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONALESTABLISfIMENTS ARE TO CONTACT TF�HEALTHDEPARTMENTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISIIl�IENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO CONINIENCEMENT. RENOVATIONS MAY REQUII2E A SITE PLAN.
ADDTITONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Hea(th 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 CI,OSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food estab 'slunent wtuch serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Departrnent by filing the
reqwred Temporary Food Service AppGcation form 72 hours pnor to the catered event. Thses forms can be
obtained at the Health Department.
FRO���BESSERTS: - -
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparatioq or display ofany food product by a retail or food service establishment is prohibited.
/� �
DATE: 1 � ' Zo �-o� SIGNATURE. C- n--
PRINTNAME& TITLE: /5Ay/nu�c.v E. �AuZo � Y'/�-t-S ,
10/22/04
. i 'K .o '- - - - - �
DEC 0 6 2004 ��
HEALTf-I LitN7
PROOF OF WORKERS' COMPENSATION COVERAGE
Certificate Holder: Date:
Town af Va�mouth 11/30/U4
ATTN: Health nenc. Policy Number:
1146 Route 28 0140005�1a77105
South Va�mouth, MA 02664
Effective Date:
1/O1/05
Expiration Date:
PlanParticipant: — _ _ iiolioc
Bass River Dis<ounf Lipuors, in�. Statutory Limits:
sai ete. za EachAccident: too,000
sautn varmouch„ nq oz554 Disease-PolicyLimk 5oo,aoa
Disease-Each Employee 10 0,o a a
This is to certify that the Plan Participant named above is insured with the
Massachusetts Retail Me�chants WC 6!'ollp Inc.
under the policy number and for the period indicated above. This policy covers the entire
obligation of this policyholder for Workers' Compensation under the Commonwealth of
Massachusetts Woricers' Compensation Act with respect to all operations in the
Commonwealth of Massachusetts, and with respect to operations outside Massachusetts, to
the policyholder's regular Massachusetts employees only.
If said policy is cancelled, or changed prior to the expiration date indicated above, in such a
manner as to affect this certificate, written notice of such cancellation will be given to the
certificate holder above. Notice by regular mail so addressed shall be sufficiant compliance
with this provision. No liability is assumed in the event of failure to give such notice.
�� s. ���
Administrator,
FIRST CARDINAL COkPORATION
30 BRITISH AMERICAN HLVD
LATHAM. NV 12110
NOV. 30, 2004 11 ; OSAM N0. 870 P. 2
�
PROOF OF WORKERS� COMPENSq770N COVERAGE
Certificate Holder. I
7oNn o{ Ya�Mpy=h , ���
4nN: Heaith nept. ; 11l30/a4
1146 Route 2a
Soutn Yar�outn, Mq 02664 P0�1 �1fU��;
' � �OOa503a77 05
Ef�— �`
vo vug
Plah Pa�ticipant� Ex iraton Date;
3/01/p6
Basa RSVer D4seovnc L1a4urs, Ine,
931 Rte. 28 • $�� u��:
South YerTouxh,� MA U2664 '
Each AccfdsrR: 10 0,o a o
I Diaease-poli li � so 0,o 0 0
�v mit
dieeas¢{�ch Etnployee i o a,a o 0
This is to certify that the Plan Parficipant named above is insured with the
Massaepusettr Retail MerphSnLs wC 6royp =pp,
under the policy number and for the period indicated above, This policy coyers the entire
obligation of this policyholder for Workers�Corripensation under the Commonweaith of
Massachusetts Workers�Compensation Act with respect to all operations in the
Commonwealth of Massachusetts; and�� �SPe�� ope�tiohs outside Massachwsetts,to '�
the policyholder's regular MassacF�usetts emp�oyees ony.
Ifsaid policy is cancelled, or changed priorto the e�iration date indicated above, in such a
manner as to affect this cer{�ficate,.wriBen notice of such cancellafion will be given to the
cerfifrcate holder above, Notice b�r reeular mail so addressed shall be sUfficiant compliance
with this provisian. No liability is assumad in the event of faifure to give such notice.
��td$', j�� �
Administra(er,
FIRST CqRDlNpL CORPORA7IDN
30 HRITTSH qNEqj��N B��
� LATNAM, NY i2110
i
I
NOV. 30. 2004 11 : OBAM N0. 870 P. 1
� � �
, . Iz �r . _ . �
F��CARD/NAL CORPORATlON N 0 V 3 0 2004 ;
; 10 British AmericQn Blvd
� Latham NY 1211 p HEALTH �EP�i�.�
FAX TRANSMISSION
' FAX: 518/213-1902
TELEPNONE:518/213-1900 or 800/9,48,4850
To: I
Town of Yarmauth
Attn: Heqlth Dep�.
Fax: (508) 398-0�36
From: Susan Hicks;
Customer Service, ext. 1537
Date: i i/30/20p4 �
Re; Certificate af Insurqnce �
� ,
Insured: gass • �
River Discount Liquors, Inc.
I
As requested, proof of Worke�� coverage.
�
First CardinaC is the adminislrator for fhe cbove noted hust
We handle only the workers' coMp�nsation coveroge.
P�eose confdc}the insureq with pny questions regprding a�y
other required cerrif�Q}e$
�f You have any questions, you mqy reach me at
800/948-4850
Number of pages including co���. 2
oc� '
i i
�
I
�
�
� I
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHII�NT
PERMIT NUMBER: #OS-035 FEE: $45.00
In accordance with re�(ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�ieneral Laws,a permit is hereby granted to:
Bass River Discount Liquors Inc. 931 Route 28 South Yarmout MA
Whose place of business is: Bass River Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31 2005 BOARD oF HFALTH: Be.c�rtrc$. C�'o�do�M.$. '
��M� v� ef�
�s�rxicnoxs: Prepackaged candy,gum,soda,chips Rod�.Rt 4. Beorwc, �
� S!u!� R.N.
A.�¢�, R.N.
January 31.2005 Bn�ce G. hy, RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #OS-028 FEE: $25.00
This is to Certify that Bass River Discount Liquors Inc. d/b/a Bass River Liquors
— 9 1 Ro� 28 o ih Y rm�nr��A
LS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBiJTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION
� S 't is�an�in confor�ity��cle V[of the Sa�ta�y Code of The Commonwealth of Massachuseus,and
2005 e55 suspenaea or revo
January 31.2005 BOARD OF HEALTH: B �. 4o+r�.o�g/��., .
���,y� v� e�
a��. a�, e�,�
� Sl,�l� R.N.
���, R.A!
Director ofMH al�th� ����—
` , �#�86?..,
oP�Y!�R t L�] � � � � y �" �pi
_ � o TOWN OF YARMOUTH BOARD OF E�TH C I� `i s
�, ,= APPLICATION FOR LICENSE ���'� NOV 2 $ 2003
* Please complete form and attach all necessary do en � y December 31, �ALTH DEPT.
Failure to do so will result in the return of y application packet.
� C i uorLs So6-76o-S 9�}
LocaT�orranDxEss• a3 � �o�..�� z.B so Aa,>-,o�:+N riA�;
,o m E '�
OWNER/CORPORATIONNAME• �/�ss Zi %✓E2 � 'sco4.� -/� ��r,.co2s S,vc
ER' N �iA m ND L- �Ac.�zo��/ g-362-92 �9
MAILINGADDRESS: lsr r?o�f� 6A [vE�f A!!NS�AE �G /VJ,oy .
POOL CERTIFICATION :
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 eopy of the certification to Yhis form.
1. 2,
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' rewrds. You must
provide new copies and maintain a file at your place of busiuess.
1. 2.
3. 4.
�OD PROTECTION MANAGERS - CERTIFICATIONS•
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certificaUon to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
_ _ _ _ . _ — -
5 II�CHA . - _ _ - - -- -
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies aad maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
4FFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT N LICENSE REQUtRED FEE PERMIT#
_B&B S50 _CABtN a50 _MOTEL S50
_INN S50 _CAMP E50 _SWIMMING POOL S75ea
_LODGE $50 _TRAILER PARK S50 WHIRLPOOL S75ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k
_0-]00 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25
>I00 SEATS $I50 _COMMON VICT. S50 _WHOLESALE S75
RETA[L SERVICE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQI)IRED FEE PERMIT#
I <SOsq.ft. $45 � �0( _>25.00(Isq.ft. 5200 _VENDMG-FOOD S20
<25,000 sq.ft. $75 _FROZEN DGSSLR'I' S35 1 TOBACCO $25 i��7 �1/3
LYAME CHANGE: SIO AMOUNT DUE _ $ 70 •00
"*`••pLEASE TURN OV ER AND COMPLETE OTHER SIDE OF FORM««...
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now requued to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES �C NO
N01TCE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
�QUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH��(}�- -
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPEIVING:A}I swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health DeparUnent prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified tab, 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 pmducts are required to post
Consumer Advisories.
CATERING POLICY:
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 Department.
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 DesseR Permit until the
above terms have been met.
9UTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitness service),mi sti have pxior approval from the Board of Heaith.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service estabiishment is prohibited.
DATE: l l - 2 B - G 3 SIGNATURE: e�
PRINT NAME& TITLE:_�Ay r�a�� E . �/,I u zoN pjz Es
10/22/03
DEC. 1. 2003"12 ; 08P '"`°"`FIRST CARDINAL CORP - N0. 004—P. 3/3
- �•••••••. �.���IFI(,h � � vr �rv��iRANCE °°�"°''°°'m
12/01/03
Pp°DY� THIS CERTIFICqTE IS ISSUED AS A MATTER OF IWFOpW1TION
FifSt Cardinal Corp. � ONLY IWD CANFERS NO RK9H7S UPON h1E CER77FICATE
Hrn.DER. nUS CEp►1flCATE oOES NOT AMEND, EXTEND OR
10 Bfftish At11EfIC2n Blvd. ALIER THE COVERpGE AFFORbED 9Y 7HE POLItlFS BELOW.
Latham, NY 12170 � � � � � �� � D coyppr�Eg pFFpqp�r�G�pyEpp�
D E C 0 1 �'� Massachusetts Retall Merchants Workers Compensation
�
20�3 A Grvup, Ina
Bass River Discount Liquors, Inc. HEALI-H LlEPT. B'"�
931 Rte.28 �,W,r
South Yarmouth, MA 02664 �
oanAr+v i
D �
CDVERK��
THIS IS TO CERI7FY 1}IpT YHE POUGES OF INSURANCE USTED 9ELOIN HAVE BEEN�33Um TO TFIE MBUqED NAMEA AHOVE FQR 7HE POLICY PEplpp ''
MDICATEu,NOTNffHS7'qNDINO ANY REqU1REMEnT,7ERM OR t�tdDiTION OF ANV COMTipcf OR OTiFR OOCUMEM'WITH RESPECT 70 WHICH THIS i
CERTIFICA'fE MAY H8�SSUED OR MAV PEHIAIN,T}IE INSURANCE qFFdppEp BY iTIE POLICIE6 OFSCF�BED HERFIN IS SUBIECT TO N.L TFIE iFJ{1Ag,
EXCL�spNS AN�CaN�IT10NS OF SUCN GOLIGIE3.UMITS BFpWN MAY HpVE BEEN pEDUCEp BY PAID GAIMS.
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Health Dept. °�A70N °A'^� T"E"�� TME � �•m � exoe.vox ro w�a i
15 oAvs wemEx nct�ee ru me teA'rn�rr�Xo�orn rW�tv ro n��r,
1146 ROUt6 2B !y�fARURE TO NpIL Supl NO�ICE SH�I.L WPGSE NO 06LIG�7pN Oq WBIIJ1t li
S. Yarmouth, MA 02664 oF axr ,axo uroN n� axw�m,, �,s � �, �A�, i
�.UIIIORQEb X@R�ENpT�7IVE�j �
ACOFiD?S$(3/99) ^' '—"`�`^"'v�ACORD OORpbRA71pN 1998. I�
�
I
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLT.SHII�IENT
PERNIIT NUMBER: #04-016 FEE: 45.00
In accordance with resulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�ieneral Laws,a permit is hereby granted to:
Bass River Discount Liquors Inc., 931 Route 28, South Yarmouth, MA
Whose place of business is: Bass River Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yannouth
Pernut e�cpires: December 31. 2004 BOARD oF IIEAI.'['x: Be�ya.vrLsi `.b. �, /l�`�. '
�.a��u, v:� e�
1tESTxic�'toxs: Prepackaged candy>g�,n,soda,oh�ps. Rodest�. B�aewr� G�/q+tdr
a�e�s�c �'�iali. /1./y.
r� � /
y �, n�/
December 3.2003 n�ce G. M hy, Ij S.,CHO
D'uector of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-013 FEE: $25.00
This is to c�tify thst Bass River Discowrt Liquors Inc. d/b/a Bass River Liquors
931 Route 28 South YarmoutlL MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBLTTION OF TOBACCO PRODUCTS
AS PER'I'E�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
��is an�i��ox�itsy with Artic$���V�o the Sa�t�y Code of The Commonwealth ofMassachusetts,and
e s sooner or revo
December 3.2003 BOARD OF HEALTH: B �. go+�o�r., /��., '
���.a�.� v� et�
Ro6wtt�. B�a, Cl�6
� �R.N.
> � �, ��
��_ -� - � �
�ruce . MurP Y, H, �, �'
Director of Health ' �'
,:••• ` .i; [3.2. DiScouNr Cipvor25 _
�f�R.y TOWN OF YARMOUTH BOARD O A�.1'H' ,� �
� o \
o ., APPLiCATION FOR LICEN � h T ' 0�3'+'� do/
"�i ��'�, � a
* Please complete form and attach all necessary�'�y'm s by Dec"em���], 2002.
Failure to do so will result in the retum of your application packet.
NAMF nF FSTARI ISHMFNT' ss :✓E2 sC�ua i r�,co21' TEL #5oB-96l1-SY(i�J
In('ATinNAn RE �/3% i�oufE 2B SO yN2mu :� l-M, /�A ���.
rvrnrr nvc; nDDRESs� SAr"lE
OWNFR/('(IRPnRAT1nN NAME� �Hss �h %vc'2 �J+sco�.�.�` �� eQuo�s �.vc.
MANAGER'SNAME• �l .av.>,o ,.� �. LnuzoN TEL #.�a8- �bo-5y99
1�tAiLIN ADDRESS• SAMr
POOL CERTIFICATIONS:
The pool supervisor must be ceMified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and aEtach a copy cf the certificatiorr to this form. -
1. 2•
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2•
3. 4.
FOOD PROTECTION MANAGERS - 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 file at your establishment.
1. 2•
PERSON IN CIiAR�'i�:---- _ _ _ -
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2•
HEIMLICH CERTIFICATIONS•
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-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. 2•
3. 4.
RFSTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODCING:
� LICENSE REQUIRED FEE PERMIT# LICF.NSE RGQUIRED FEF, PERMIT# UCENSE REQUIRF,D PEE PERMIT k
BBc6 $50 _CABiN SSC _MCTEL g50
INN E50 CAMP $50 _SWIMMING POOL$75ea
LODGE S50 TRAILER PARK $50 _WH(RLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 _CONTMENTAL S30 _NON-PROFIT $25
_>IOOSEATS $I50 _COMMONVICT. S50 _WHOLESALE 575
RETA[L SERVICE: �
LICENSE REQUTRED FEE PERMIT# LICENSE REQU(RED FEE PERMI"C# LICENSE REQUIRED FEE PERMIT#
�<50 sq.ft. $45 �J��� _>25,000 sq.ft. 5200 _VENDING-FOOD S20
_Q5,000 sq.fl. S75 _FRO'/.HN DESSERT S35 �T0I3ACC0 $25 �o3-c��
NAME CHANGE: EIO AMOUNT DUE _ $ 7 p ,a p
**"'*PLEASE TURN OVER AND 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'"S`Tt1TE`VVORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGIYED,'QR` '
-CERT.-0F INSURANCE ATTACHED - _.
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE 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. RENQVATIONS MAY REQUIRE A SITE PLAN:
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closetl for tAe S�a�e'mastbe 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.
CATERNG POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses Forms can be
obtained at the Health Department.
ERQZElY_DESSEBTS: - ----.---
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 of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food produc by a retail or food service establishment is prohibited.
DATE: I 2 - � - d L SIGNATURE: � L
PRINT NAME & TITLE: �Aym ,V d E. I.iv u Z ON �/-'t S.
]0/18/02
pFC, 2. 2002 1�)�OOAM fIRST CARD]NAL 5182?31901 NQ '82 P. ?
Massachusetts Retail Merchants
Workers' Compensation Group, Inc.
190 �orDes Road, Suite 237
Braintree, MA 02184-2613
Certificate Holder. ! pete; ��
; Town of Yarmouth 72/D2/02 I
j Health Depa�ment I Policv Number.
' 1146 Route 28 1676-07 �
S.Yarmouth, MA 42664 �ff�ctiv4 Date: !
� I D1l01/03
i Exoiration Dffie� -I
� Plan Participant: � 01/01/04 �
I Bass River Discuunt Liquors, Inc.
I 931 Rte. 28 ,I Statutorv Limits; _
i South Yarmoutih, MA 0266a eecr,o.cciaenc 3mo 000
�is�saPoliry Llmh S50C.W0
IDisease-fiech Emplayae $10Q,000 'I
�a
This is to c:ertify that the Plan Participant named above is insured with the
Massaehusetts R�tail Merchants Workers'Compensation Oroup, Inc.
under the policy number and for the period indicated above. ThiS policy covers the entiri=,
obligatlon of this poltcyholder for Worlcers' CompensaGon under the Commonwealth of
Massachusetts Workers'Compensation Act with respe�Yo all operations in the
Commonweafth of Massachusetts, and with respect to operations outside Massachuset�s, to
the policyholder's regular Massachusetts employees only,
IF said policy is cancelled, or changed prior to the expiration date Indicated above, in such a
manner as to effect this certificate, written notiCe of such cancellation will be given to the
certificate holder above. Notice by regular mail so addressed shall be su�ciant compliai�ce
wit#lhis-prouiSiOn.—NaaiabAity isassumed in 1he event ofiallt�re t2giYg�4ch_notic�. _
Massachusetts RMail
Merchants Workers'
CompensatYon Group,lnc.
i�fC�tQ7,� .S'. ��
Administrator,
First Cardinal Corporation
10 BriEsh American Bivd.
Lathem NY 1217D•1415
i_L _ . --�
Massachusetts Retail Merchants � � �
Workers' Compensation Group, Inc. � ;
,�_..__.__. .
190 Forbes Road, Suite 237
Braintree, MA 02184-2613
�---
Certificate Holder: � Date: __
j Town of Yarmouth 12/02/02
�i Health Department Policy Number:_
1146 Route 28 1676-07
S. Yarmouth, MA 02664
I Effective Date__
I 01/01/03
�- l Expiration Date:
I Plan Participant: - 4 -- -01la1%04
�i Bass River Discount Liquors, Inc. I
Statutorv Limits:
I 931 Rte. 28 I ;
' South Yarmouth, MA 02664 � Each nccident $io0,000 '
�. ' Disease-Policy Limif $500,000 �
, j Disease-Each Employee $100,000
�-____ ._— --._I —
This is to certify that the Plan Participant named above is insured with the
Massachusetts Retail Merchants Workers' Compensation Group, Inc.
under the policy number and for the period indicated above. This policy covers the entire
obligation of this policyholder for Workers' Compensation under the Commonwealth of
Massachusetts Workers' Compensation Act with respect to all operations in the
Commonwealth of Massachusetts, and with respect to operations outside Massachusetts, to
the policyholder's regular Massachusetts employees only.
If said policy is cancelled, or changed prior to the expiration date indicated above, in such a
manner as to affect this certificate, written notice of such cancellation will be given to the
certificate holder above. Notice by regular mail so addressed shall be sufficiant compliance
with this provision. ivo Iiabiiity is assumed in the event of iailure to give such notice.
Massachusetts Retail
Merchants Workers'
Compensation Group, Inc.
i�[GCtG/tt� .S. ���
Administrator,
First Cardinal Corporation
10 British American Blvd.
Latham NY 12110-1415
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-032 FEE: $45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
I 11,Section 5 of tlte General Laws,a permit is hereby granted to:
Bass River Discouirt Liquors Inc., 931 Route 28, South Yarmouth,MA
Whose place of business is: Bass River Discaunt Lic�uors
Type of busmess: Retail Food Service less than 50 square feet
To operate a food establishment ia Town of Yazmouth
. Pernrit expires: December_31. 2003__BOARD oF�AL'rH: L�iFazlee�. xeUtkos. �
. _ • D. �jmra'n�i. 'ixD..�`I/iee_ _ . __
�STTuc'noNs: Prepackaged candy>Sum,soda,chips. �a�. b'uaw. �
�a�uek�orMretl
.'f�olel�,c Sl�'a�E. ��l.
January 9 .2003 Sruce G.Murphy,MP ,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS —
. � � TOW1�I'OF YARMOUTH �� � � . . �.`, . ,
BOARD OF HEALTH
PERMIT NUMBER: #03-022 � : FEE: $25.00
'['h�s;s w Certify t�at Bass River Discount Lic�uors Inc. d/b/a:Bass River Discount Liquors
931 Route 28, South Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUC'I'S :, _
AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
T6is, it is i witl�Article V I of the S���y Code of The Commoflwealth of Massachusetts,and
exp�es�eceu�er�.�����s sooner suspended or revoked.
Januar�9 ,2003 BOARD OF HEALTH: �Fa�li.c r�. i�iU�a�, �aL�«raa
�c D. Cjazde.a. 7JIG.D.. Yiree
,�o6ars�. �xeawa. �evk
�a0rie�6'jX.c/Deuxott
:�e�[e.s Sksk. R.�Z.
ruce G.Murphy, H, . O
Director of Healih
T B.R . p�sco�nr� LtQ��
�` � � �
TOWN OF YARMOUTH BOARD OF HEALTH
� . APPLICATION FOR LICENSE/PERMIT -2002 �_
� �,E�� 1 7 ��u1
' Ple�omplete form and attach all necessary documents by December 31, 2001. Failure to do so will result in
the return of your application packet.
VLAME OF ESTABLISHMENT: .O.Ss :✓�¢- D:s c c..�a. ,q �-.ares TEL. #�oB-960 -3'S/5q
LOCATIONADDRESS: 93� �outc �8 So. y.�an�+o.,�f/,l, Mn�S.
MAILING ADDRESS: SAM�
OWNER/CORPORATIONNAME:�hAss�i �✓v2 D•1'ce..<.uf' �'$�oKs .l�vc -
MANAGER'S NAME: /SQ�m•ND �• !,a uzaN TEL. #sv8-9b0 sy9�
MAILING ADDRESS: SA M C
POOL CERTLFICATIONS:
The pool supe�visor must be certified as a Pooi Operator,as required by State law. Please list the designated_
Poot flperator(s)atrd atta�h a cogy-afttre c�rtif[�atiorit�this forin: _ _ --__—_ _
1. 2.
Pool operators must list a minimum of two employees cunently 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 Deparhnent will not use past years' records. You must
provide new copies and maintain a Tile 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 certification to this applica6on. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your estabiishment.
1. 2.
PER30N IN CHARGE: - - _ __ _
Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50 _MOTEL $50
iNN $50 CAMP $50 _SWIMMING POOL$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 $75 _CONTINENTAL $30 _NON-PROFIT $25
>100 SEATS $ISO COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 I TOBACCO S20 ��
� <50 sq.ft. $45 ��OQro _>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $10 � AMOUNT DUE _ $ 6S.00
•****PLEASE TiJRN OVER AND 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 Certifica:e of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
� �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RE'I'[.JRN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2001.
SEASONAL ESTABLISHIv1ENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
. . _ POOLS _ _
POOL 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 standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
— - --
FROZEN D�S�RT$c
Fmzen desser[s must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),mus haue prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food pr y a retail or food service establishment is prohibited.
DATE: /Z— /S -0/ SIGNATURE'. �
PRINT NAME&TITLE:J5{�v,y��,yD � • �luZ- n/ /n e��.��N�'
09/11/Ol
Massachusetts Retail Merchants
Workers' Compensation Group, Inc.
190 Forbes Road, Suite 237
BtainUee, MA 02184-2613
__ - , �- —--- --------__,,
Certificate Holder: ' Date:
______--- ____
' 11/30/01 �I
Town of Yarmputh I
I Permits Dept-Attn: Judy Klimm I Polic�Number ,
1146 Route 28 I � 1676-06 I
, S. Yarmouth, MA 02664 � Effective Date:
' _--------
__ I i 1/t/02 i
- __._ _____-- __ __ _ � P
Ex gation Dale: I
'� Plan Participant: � 1%1/03 '
', Bass River piscount Liquors, Inc. �i Statutory Limits;_ _
531 Rte. 28 I _ - - - ',
South Yarmouth, MA 02664 I I Eacn Acadent: Stoo,o00 �
�I ' � Diaease•Pdicy Limit 5500,000 �
', � DiBeaso-Each Employee 5100.OQ0 .
7his is to certify that the Plan Pariisipant named above is insured with the
Massachusetts Retail Merchants Workers' Compensation Group, Inc.
under the policy number and for lhe period indicated above. This policy covers the entire
obligation of this policyholder for Workers' Compensation under the Commonweaith of
Massachusetts Workers' Compensation Act with respect to all operations in the
Commonwealth of Massachusetts, and with respect to operations outside Massachusetts, to
the policyhoider's regular Massachuseris employees only.
if said policy is cancelled, or changed prior to the expiraiion date indicated above, in such a
manner as to affect this certificate, written notice of such canceliation will be given to the
certificate holder above. Notice by regular mail so addressed shall be su�ciant compliance
with this provision. No tiability is assumed in the event of failure to give such notice.
Massachusetts ReWil Merehants
Workers'Compensation Group,
Ine.
i`iClfQ/Lt� .S. �eQ�j
Administrator,
First Cardinai Corporation
10 British American Bivd.
Latham NY 12110-tA15
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-006 FEE: $45.00
In accordance with reQulations promulgated�mder authority of Chapter 94,Section 305A and
Chapter 111,Section 3 of the General Laws,a pennit is hereby ganted to:
Racs River Discount i.inuors inc., 931 Route 2R�South Yarmouth, MA
Whose place of business is: Bass River IJiscount Liquors
Type of business: Retail Food Service less than 50 sauare feet
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31. 2002 BOARD OF HEALTH: �liartlea i�. iCdlikoz, �(/faia.uaw
�D. Cjmrda.c. �'!L.D.. `U�ee
RESTRICTIONS IF ANY: PI'CpdCltagCd Cazl(Iy,gmn,soda,chips. �oSert� b"uavc, �
�abriek�e:exotY
� ' S . ,�?Z.
Mazch 1 _2002 : Bruce G.M h ,R.S.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NiJMBER: #02-004 FEE: $20.00
Th;s is to Cemfy that Bass River Discount Liquors Inc. d/b/a Bass River Discount Liquors
931 Route 28_ South Yarmouth MA
IS HEREBY GRANTED A LICENSE
Far SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This permit is ganted in confoimity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cpires December 3l.2002 �mless sooner suspended or revoked.
March 1 ,2002 BOARD OF HEALTH: �'r�. i�dlikac. �alnsxaec
'��D. CJmcdeK. '�,'.D.. �firee
,�aBed`�. Szacaa. L�fark
�a3rlek'IX�Deuxetl
x $�r
�
Director uf Health �
�Li� �; v�r DisC'G�ti���+
; . 1�C��Gr�.
� TOWN OF YARMOUTH BOARD OF HEALTH � [� r�; .r•=� ; • . r�
° APPLICATION FOR LICENS�fPERM1T-2C0�0�0��§,6� p E C 1 3 1999
" Plaase complete form and attach all necessary documents by December 31, 1999. Fail e���rpepit i
the return of your applicaxion packet.
-----------------------------------------------------_---------------------------------------------------------------------
NAME OF ESTABLISHMENT� �qss'ZI �vc�t'�,'scow�r} �iGi�o2s TEL # 'I�O-549,�
LOCATIONADDRESS: 93l 'l�ou.fc 26 S'a�.+-f/1 �/�ortir�ou.-l-N
D �S'�4Mc
OWNERlCORPORATIONNAME• Ass'!?;vc2 �%�coc� �lm�ozs �.e -
MAN ' FL�o m ow E. �ouzo # b Z- 2
MAILINGADDRESS: t5'i �?fE 6A West B.oZuc�q,blE , A�S-
—__—_-----------------------------------------------------------�----`--------------------------�
POOL CERTIFICATIONS:
The poot 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 ofthe c�tification to tivs form.
1. 2.
Pool operators must Gst a minimum of two employees cunently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please Gst these employees below and attach copies of
employee certifications to this form. The Health Deparlment will not use past years' records. You must provide
new copies and maintain a fde at your piace of business.
l. Z.
3. 4.
HEIl�fC,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 procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTA�NT-SEATII�T�:_ TQTAL-# NOAt_SMDKI�+tCs S�4TS:-TDT.4I.#-- - ---- - _
----------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY
LODGING:
LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT #
_B&B $50 _CABIN $50
_INN $50 _CAMP $50
LODGE $50 TRAII.ER PARK $50
MOTEL $50 _SWIlvllvIlIVG POOL $SOea.
WHIItLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT #
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
13ETAIL SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
�<50 sq.ft. $45 y�-� �TOBACCO $20 2K-ZO
_<Z5,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.R. $200
NAME CHANGE: $10
AMOUNT DUE = S (c���f
•*•"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•"••
� �
ti.
� ADMINISTRATION ~
LTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TF�TOWN OF YARMOUTH IS NOW REQUIRED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PERSON OR COMPiANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSA'FION
INSURANCE. 'T$E ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTI'
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED C
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TA}�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES � NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILIT'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TF�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPEIVING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAIIVTING, NEW
EQUIPMENT,ETC.),MUST BE ItEPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COMIvvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWINiNIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf� SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND T'f�WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPETTING, AND QUARTERLY Tf�REAFTER.
POOL CLOSING:EVERY OtJTDOOR IN GROUND SWIlvIlvIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
�TERING POLICY:
ANYONE WHO CATERS WiTHIN TI�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH
DEPARTMENT BY FII,ING THE REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT Tf� HEALTH
DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI.,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN Tf�
SUSPENSION OR REVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE
BEEN MET: _
OUTSIDE CAFES:
OUTSIDE CAFES(i.e., OiJTDOOR SEA1'ING WITH WAITER/WAITRESS SERVICE), MIJST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OtITDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPL OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHMENT IS PROHIB .
DATE: 1 2 —/0 - 99 SIGNA
PRINTNAME& TITLE�,Oymntia E, �Qu,zoN 1/"2tS,
—��—
11/12/99
Massachusetts Retail Merchants
� Workers' Compensation Group, Inc.
190 Forbes Road, Suile 237
BrainVee, MA 02184-2613
I. _ _ _ . __ ._.._ ---- --- r— ---.. _--
� � i Date: _ I
Certificate Holder. __ ___
Town of Yarmouth ������
I Permits Dept-Attn: Pat Crowell Policy Number
1146 Route 28 1676-04
� S. Yarmouth, MA 02664
Effectiye Date;__ ;
I -- _. .. _ -- ---- .
1/1100 _ �
_.__ _--- - -- ---- _--._ _ — �iration Da[e:
Plan Participant: �/�/�� �
Bass River Discount L'puors, Inc. i I
' 931 Rte. 28 Statutory_Limits=_ _
South Yarmouth, MA 02664 I �G+A«ieem: S�oo,00a
� - Disease•POlicy Limit E500,000
; � Disease-EadtEmproyee $t00,W0 �.
( . _ .. .._--. . . .---_... -- --.._.__ �—._ _--'-- __'
This is to ceRify that the Plan Participant named above is insured with the
Massachusetts Rehit Merchants Workers' Compensation Group, lnc.
under the policy number and for the period indicated above. This policy covers the entire
obligation of this policyholder for Workers' CompensaGvn under the Commonwealth of
Massachusetts Workers' Compensation Ad with resped to atl operations in the
Commornnreatth of Massachusetts, and with resped to operations outside Massachuseris, to
the policyholders regular Massachusetts employees only.
-
Tfsaid poTicyis cancelled, or changedpnor�o the expiration daTe indicaTed above;irrsuci��
manner as to affed this certificate, written notice of such cancellation will be given to the
certificate holder abave. Notice by regular mail so addressed shall be sufficiant compliance
with this provision. IJo liabi{ity is assumed in the event of failure to give such notice.
Massachusetts Retait MerchaMs
Worksrs'Compeesation Group,
InC.
. /�iC�A�ta� .S• ��f
Administrator,
First Cardinal Corporation
210 Washington Avenue Ext.
Albany NY 12203
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-27 FEE: $45.00
In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter
11 I, Section 5 of the General Laws,a pertnit is hereby granted to:
Racc River ni¢cnnnt T.iauors inc_ 931 Route 2R Snuth Yarmnuth MA
Whose place of business is: Bass River Discount Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�� �P/. �n.t�gg�, C'�yt�.�q�nq � n
�oan G. JuClivan�nK.//.� Vice l..�irma
REST�ucr[oNs �F nt�v: Prepackaged candy,gum,soda,chips. l�o6erf/.c�. �rowgn, (�ler�
a6rieC��a�o[s�y-.�ooPea
u�f �o,���n
Q
December 2l , 19� Btuce G. Murphy, MPH .S. O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-20 FEE: $20.00
This is to Certify thaz Bass River Discount Liquors Inc d/b/a Bass River Diccount Liquors
931 Route 28. South Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUC'T4
AS PER THE YARMOUTH BO R OF HE i TH TOBA O F TT ATION
This pertnit is granted in conformity with Article VI of the Sanitary Code of The Commonwea$h of Massachusetts,and
expires December 31.2000 unless sooner suspended or revoked.
December 21 , 19 99 BOARD OF HEALTH: Gd///. Jeltae, ��xairman
�oan G. �nu[livan� K�/.//.� Vice l��irman
Ko�r[J/ . i�rown� C.[a�
�a6rial[e�a�O[a�y-✓�ooPes
�ae[ �r � '
ruce . urP Y, , •
Director of Health
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1�iOLL V N.LSII�IIL1iQ V
s ' _ �
CERTIFICATE OF LIABILITY INSURANCE °"ii`�""i`°ae�
Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF
First Cardinal Corp. INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
10 British Artrer'ican Blvd. CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT
Latham,NY i21i0-0147 �j � � _ ��s i; �o� AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY
� �- -- THE POLICIES BEIOW.
,.;,, � �, _ .,. , INSlIRERS AFFORDING COVERAGE NAIC#
Insured -` �' INSURER A: MA RetaN MerohaMs WC Group Inc.
Bass River D'scount Liquors,Inc. qL�H DEPT. INSURER B:
931 Rte.28 .. ..
South Yarmouth„MA 02664 INSURER C:
INSURER D: -
INSURER�Er �
COVERAGES
7HE POLIOIE�OF IN�VRANCE UElED BELOW HAVE BEEN I6EVED TO THE IN6URED NAME�ABWE FOR THE AOLJCY PERIO�INDICATEO,NOTVNTH6TANDING
ANY REQUIREMENT 7ERM OR CONDITION oF ANY CONTRACT IX2 OTHER DOCUMENT WITH RE6PECT TO lMiiCH THIS CER7IFICA'fE MAY BE ISSUED OR N1AV
PERTAIN 7HE INSURANCE AFFDRDED BY THE POLICIES DESCRIBED HEREIN IS SI�JECTTO ALL hiE TERMS,EXCLUSIONS AND CON W TONS OF SUCH POLIGES.
AOOREOATE LINHTS SHOYIM MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Poucr
ppp� 6FECTIVEUATE POLN.'YDfPIRhTION
NSRLTR WmD iYPEOFINSIRiNJGE POUCYNUMBER DATE M Uh%TS
OBIERAL W&LITY EACAI OIX'.1&iRENfE $
�OA9MFRGALGENBtALUABILfiY FlREDAMRGE(MywwHre) f
GUIM9 MAOE � OCCVR MIED IXP(My ona pereon)
PER�NPL&PDV INJlR2Y $
OENERAI.ApOREOATE f
GINLAGGREGATEIINATMP�lESPER: PROOVCfS-GDMP/OPAOG f
PRO-
POLICY JECT LOG
Al1TOMOBIlEL1A81LITY �M&NWSIIJGLELIMR �
ANV AVTO IEa amtle�
�LLOWN[OAUTOO BDOILYINJI#EY $
SCH�IR�AUi05 (���0^)
HIRED FUT0.4 BppLY IflJURY s
NONAWIJED AUTOS (�a�b�)
�PROPBtTY DqMM3E $
(Peraaukn(
GqRA6EL1A8NTY AUTOOI�Y-EAACGIDENT j
ANY AU70 ' OTI�R THAN �� $
AUTOOFkY A64 S
IXCRS IJABIUTV EAdi OCGURRELCE $
OCCUR � 0.PIMSMR�E A66REOATE $
$
UEOUGTIBLE $
f�TENTION� E - s
WOfIXERSCO TIONAND x WCSfATU- OTH.
EMPLOYERSLIABII.IfY � TORYLIMITS 62
ANYPROPPoEfER/PARTNER/EXEWTIVE ' . . EL.FACHACGOENT �
A oFcice�rtaeMeEaocc�uo�r S ,00,000
Hy,s,a��e.r NO 014000501077708 t/01Po6 iNiN9 EL.OISEASE-FAB.IPLOY�
saEaa.aaows�o�t�w � S 100,000
E�p�-FroucruMrt $ 500,000
OT R
OESCRIPTION OF OPERATIONS�IOCATIONS�VEHICLE^-J E%CLUSIONS FDOED BV ENOORSEMQJT/6PEqAL VROVISIONS
Fax Y 506396-2365
CERTIFICATEHOLDER noanoNa.iNsvrtm:mautet�ErrEa: CANCELLATION
SHOULD ANYOF 7HE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE
ToW�oi Yarmouth THE EXPIRATONDA7E 7HEREOF,THE ISSUINGINSURER WILL ENDEAVOR70
ATTN:HeafthDept. MAIL 3� DAYSNA2ITTENNOTlCETO7HECER7IFICATEH4.DERNAMED
1146 Route 28 TO hIE LEFT,BUT FAILURE TO DO 50 SHALL IMPOSE NO oBLIGATioN OR
South Yamrouth,MA 02664 LIA&LIIY OF ANY KIND UPON 7HE INSURER,ITs AGEN75 OR
REPRESENTATIVES.
AUTHORIZEDREPRESENTAl1VE �
�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #08-031 FEE: 45.00
In accordance with resularions promulgated under authoriry of Chapter 94,Section 305A and Chapter
111;Section 5 of tLe�ieneral Laws,a permit is hereby gtanted to:
Bass River Discount Liquors Inc., 931 Route 28, South Yazmouth, MA
Whose place of business is: Bass River Discount Liquors
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernrit expires: December 31, 2008 BOARD OF HEALTH: .�feeen S�, J2.JV., �taauna�c
CR�c�e,o :#. .��x�iP�C `vice CRia�ntan
REsitttcnoxs: Prepackaged candy,gum,sode,chips. � 3.✓�. KBlWt� �
QfLft �X¢¢ft�'lY[1Rtt� ✓�..IV. .
December 20.2007 B ce G. u[phy, ,RS.,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOU'I'H
BOARD OF HEALTH
PERMIT NUMBER: #08-023 FEE: $50.00
11us is co Cemfy d�st Bass River Discount Liquors Inc. d/b/a Bass River Discount Liquors
_ 931 Route 28, South Yarmouth, MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBiTTION OF TOBACCO PRODUCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
T6is�e�it ie�an�eid j�ognfor�ity with Aiticle Vl��the Sa�ta�y Code of The Commonwealth of Massachusetts,and
exp s ec ess sooner suspen or revo e .
December 20 2007 BOARD OF HEALTH: .`�¢e¢IL S�Q�� ✓Z..lv.� �O[I►t(UL
. �Q�[eC0 .�.��P�4�X� v[CE�Q[�[Ntp�f.
fl2adext 3. `.,��autet, C�exl�
Q�uc(�'xeen8aurn, J2.✓lr.
Bruce .M y, , . ,
Director of Health