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Home My WebLink AboutApplications, WC and Licenses Prior to 2010r� GLC �; ��: p �t° [`� '.� � ��^� TOWN OF YARMOUTH BOARD OF HEAI��ry�` p NOV 2 5 2008 � APPLICATION FOR LICENSE I4�;II�'"�2 �; � �� * Please complete form and attach all necessar�, cu��b�ece �N T• Failure to do so will result in the return�yow applicahon pac et. NAME OF ESTABLISHMENT: .c n�`�"" /�i �L. #�5�a')��a-9q90 '� LOCATION ADDRESS: I ✓t � MAILING ADDRESS: D`JS ✓i c ZD OWNER NAME: L TAX ID FEIN or S N : � CORFORATION NAME (IF APPLICAB ): y� MANAGER'S NAME: '�n.i Cc��t�� TEL. # MAILING ADDRESS: 0'�j$ y S� 0.9 ti l (�l 3720� POOL CERTIFICATIONS: � � The pool supervisor must be cerrified 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 list a minimum of two employees cun•ently 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 gt use past years' records. You must provide new copies and maiataiu a file at your place of business. �N l. 2. _.._-._ _ 3 _ _. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service estabiishments 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. ��.c�.m_�r �,�i/.rS 2. HI�ZX �e �+our �"?. PERSON IN CHARGE: � Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. �. `R��l�� 3A,us 2 ll�x D� ��„� P HEIMLICH CERTIFICATIONS: 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. �Z;��.�,� 3�.�...� a . 2, �iSA oW�n 3. .� o�.� Ntl,,..e.,., 4. (.ev p .Yrc RESTAURANT SEATING: TOTAL # IID`� OFFICE USE ONLY LODGItiG: LICENSE REQUIRED FbE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQTJIItED FEE PERMIT# _B&B S55 _CABIN S55 _MOI'EL S55 _INN S55 _CAMP S55 _SWIMMINGPOOL SSOea. _LODGE S55 _IRAILERPARK �105 WHII2I.POOL 580ea. FOOD 5ERVICE: L?C�N�F,RFQTnREn Frr-�t�,n¢;r� ._ .._ cic�.rcEn.:,'.�".,�:D :�E iLti.P,T;: . ..__L:i�Eh'SE�Ftc�u"Z`D- Fc.E �YEicivflT# ' _0-100 SEATS SSS _CONT[NEN'TAL $35 r` NON-PROFit S30 1 >100 SEATS SI60 O -(�r�L f COMMON VIC. 560 (J [ �I'l,r') _WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMII'# LICENSE REQT.IQtED FEE PERMIT# LICENSE REQiJIRED FEE PERM[T# � _<SOsq.B. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD 525 QS,OOOsq.ft. 580 _FROZENDESSERT S40 TOBACCO 555 ��ti7E cxnvcE: sio AMOIJNT DUE _ $ 220.00 ""`"`PLEASE TURx OVER At�'D COMPLETE OTHER SIDE OF FORVI••"** .___.f'' ADMINISTRATION ' " Under Chapter 152, Section ZSC, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemut 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: \I YES 1� NO MOTELS AND OTHER LODGING ESTABLISHI��NTS 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 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(S�days pnor to opening.PLEASE NO'I`E:People are NOT allowed to sit m the pool azea wrtil the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a mornhly basis by a State certified lab. Test resuks must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Pemrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTY TO RETCJRN _ THE COMPLETED RENEWAL APPLICATION(S) AND REQLTIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 1 Dg SIGNATURE: � �--� ( PRINT NAME&TITLE: Q✓� i C� S Yi G al1 �`Ctk�� , imzvoa ' ' � The Commonwealth ofMassachusetts Department of Industrial Accisdents O�ce oflnvestigations 600 Washington Street Boston,MA 021II www.massgov/dia Workers' Compensation Insurance Aftidavit: General Businesses Applicant Information Please Print LeSibly Business/Organization NamP•�West, Inc. dba 99 Restaurant 8 Pub Address: 14 Berry Avenue City/State/Zip: Yarmouth, MA 02673 Phone#: (508)862-9990 Are you an employer? Check the appropriate box: usiness Type(required): 63 5. ❑Retail 1.� I am a employer with employees(full and/ or part-time).* 6. �RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnerslup and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc. employees working for me in any capacity. 8. ❑Non-profit [No workers'comp.insurance required] 9. ❑Enter[ainment 3. ❑ We are a corporahon and iu officers have exercised their right of exemption per c. 152§ 1(4),and we have 10. ❑Manufacturing no employeees. [No wokers'comp.insurance requued]** 11. �Health Care 4. ❑ We are a non-profit organization,staffed by volunteers, 12. 0 Other with no employees. [No workers'comp. insurance req.] *AnY aPP:��t that ctrecks boz#1 must also fill out the section below showing their workers'compensation policy informatioa **If the coryorate of5cas have erzceropted theroselves,bu[the co�poration has othea employea,a workers'compensaaon policy is required and such ar� orgaz�i7arion stwuld check box#l. I am an employer that is providing workers'compensation insurance jor my employees Below is the polrcy informaAion. Inswance Company Name: Zurich American Insurance Co., et al. Insurer's Address: Go Lockton Companies, 444 W. 47th St., Suite 900 City/State/Zip: Kansas City, MO 64112 Policy#or Self-ins.Lic.# W C9137280-02 Expuation Date: 4/15/2009 Attach a copy of the workers'compensation policy declaration page(showing the policy number and eapirarion date) Failwe to secwe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violawr. Be advised that a copy of tlris statement may be forwarded to the Office of Inves6ga6ons ofthe DIA forinsurance coverage verification. I do hereby certify�r the pai s and penalties of perjury that the information provided above is true an conect SiQnahue: Date: � � D Phone#: CD fJ�. ��P • S�p Offuial use only. Do not write in this area,to be completed by ciry or town o�ciaL City or Town: Permit/License# Issuing Authority(circle one) 1.Board of Health 2.Building Depariment 3.City/Town Clerk 4.Licensing Board 5.SelecMen's Office 6.Other Contact Person: Phone#: www.mass.eov �a � �� ,Zgp�'1� � Officers of 99 West, Inc. *No officer owns>5%of stock of the publicly-traded corporation O'Charley's,Inc. O�cer/Address Title Gregory Lee Bums President 3 Buckland Abbey Nashville,TN 37215 37215 John Grady �ce President 4 Mockingbird Lane Walpole,MA 02081 02081 Lawrence Eliot Hyatt Secretary-Treasurer 253 Keswick Grove Lane Franklin,TN 37067 37067 Joseph Rives Rymer,Jr. AssisWnt Secretary 312 Mill Run CirGe Nashville,TN 37221 37221 Robert Jeffrey Williams AssisNant Secretary 31 t2 Koltas Court Brentwood,TN 37027 37027 / ACORDn CERTIFICATE OF LIABIUTY INSURANCE ,,15,�� °"�o,�� OD� Lockton Cmnpmies,LLC-1 Kansas City iHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 444 W.4�th Stree;Suite 900 ONLY AND CONFER$NO RIGHTS UPON THE CERTIFICATE Kmsas CiTy MO 64112-1906 HOLDER.TXIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (816)960-9000 INSURERS AFFORDING COVERAGE NAIC# INaurseD Q�CHART Fy�S,INC. �NSURER A: ZURICH A&tERICAN INSURANCE CO. �4� A17N: JANIS REILLY iNSunER e: LEXINGTON INSURANCE CO. 3038 SIDCO DRIVE iNsursER c: LIBER'IY MUTUAL FII2E INSlJRANCE CO. NASHVILLE iN 37204 INSURER D: INSURER E COVERAGES OCHINOI DA i�"xw°Q�s G'�una°Fago�av°OiimE��IWEERpRMO�EC6tlIFIC�EIEMaM�M1�G THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO7WITHSTANDING ANV REQUIREMENT,TERM OR CONDITION OF ANY CON7RACT OR OTHER DOCUMEN7 WITH RES�C7 TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDRION$OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR U POl1CVEFFECTIVE POLICYWIMTON liR TYPE OF INSINNNCE PoLICY NUMBER pp7� ��p pp1E M �� pENERAI WBIIRV EACH OC RRENCE 1 OOO OOO A X CqMMERCIALGENERALLLIBILIiY GL09137282-02 4/15/2008 4/IS@009 DAMAGETERaNTE�n S ��QQO�OOO GLAIMS MADE X❑OCCUR MED EXP ane peison E �XX X LIQUORLIAB.$I.SM PERSONALSADVINJURY S 1,000,000 GENERFLAGGREGATE S 40.000.000 GEMLAGGREGATELIMRAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY JECT LOC AVT��WB�� COMBINFDSINGLELIMR A X ANYAlf�O BAP9137283A2 4/152008 4/152009 (��B^�) S 2,000,000 ALL OWNED AUTOS gpDILY INJURV �.. (PerVarsan) E 7C17{JCOOC SCHEOULFDAUTOS . X HIRFDAlR05 BODILYINJURV S ��.�� (Pof BaYtlM[) X HpµpyyNEDAUTOS X COMP(1,000 DED) PROPERn'onnaGE $ XXl7IXX3C X COLLISION(1,000 DED (Per accitleert) ppp��EVpg�LRy , AUTOONLY-EAACCIDENT f 3(J�Q{�OQ( nNvnu7o NOTAPPLICABLE ornEnrnnN �Acc E X��OC � AUTOONLY: A� S � EXCE8811MBRELUWBILRY EACHOCCURRENCE S 20 0 0 0 0110 B X pCCUR ❑Cwr.fsnaoE 1210I33 4/15200$ 4/IS/2009 AGcaEcnTE 5 20000 - S XX70{ILI�( urenEun DEDUCTIBLE O FORM $ �� RETENTION $ ' s �X� MPoRKEIt3 CONPENSATON ANO ' X WC STA R �ER A EMGLOYERS'LIABILRY WC9137280-02 4/152006 4/15/2009 ANY PROPRIETORIPARINERIEXECUTIVE E.l.EACH FCCIDENT E 1.(IOO,O00 OFFICERIMEMBEREXCLUDEU9 NO E.�.DISEASE-EAEMPLOVE E 1,000,000 ffya&flaeaibe uMer SPECIAL PROVISIONS hebx E.L.DISEASE-POIICV LIMIT 5 1,000,000 C �� YU2-L9Lr527-227-048 4/IS/2IX78 4/t52009 25oMIAssLATC,IOM£LD/QKE, PROPERTY(ALL SUBIECI TO SUBLM'I5 ffi DEDS �5�� IOM ORD/ICC DESGRIPTqN OF OPERATION9 f LOCATqN3I VEXIGLE8IIXCW&ON8 ADDED BY ENDOftBEMENI'I�EGAL VROVISIONS APPUCABLE DEDUC'[BLE&RETENTIONS APPLY. •'THE COVERAGE LISTED ABOVE DOES NOT EXTEND ANY FURTHER THAN WHAT IS REQUIRED BY THE LEASE/CONTRACT.'•RE:99 RESTAURANT-PUB#20050,14 BERRY AVE.WEST,YARMOV173,MA 02673 CERTIFICATE HOLDER CANCELLATION Z�'IBBBO 8XOUlD ANY OF TIE ABOVE DESCRIBED PoLICES BE CANGELLEC BEGORE THE IXVIMlpN TOWN OF YARMOUTH �TE T�1ERE�.THE 199U@!G INSURER WILL ENOFAVOR TO MNL JO WYS WRRTEN 46 R�UCE 2$$OVTH M�TICE TO THE CERIiICAIE IqI�R NANED TO THE LEFT,BUT FNLURE TO 00 808XRLL YARIVIOZJTkI MA 02664 IMPOSE NO OBl1GRT10N OR LNBILItY OF ANY IWA UPON TIE WBUREf4 RS AOENTB OR REVRESENTATNE8. RESENTATIVE ACOR025(2001/08) F«a��^^��^a��w�,�wa��u^^^�^�^^�^�'^^^��"^^�in°+�'^' �"^+'� �ACORDCORPORATION1986 ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-063 FEE: S160.00 In accordance�vith regula[ions promulgated under authori[y of Chapter 94,Szction 30�A and Chap[er I 1 I, Section 5 of the General Laws,a pennit is l�ereb��grantzd to: 99 West Inc. 14 Bem Avenue West Yarmouth, MA Whose place ofbusiness is: 99 Restaurant & Pub Type of business: Food Seivice To operate a food establishment in: Town of Yarmouth Pernut expires: December 31, 2009 BOARD OF HEALTH: .�fePen SPtaf�, JZ.✓v., �aex�nan. Cl�axeee .�. 9Ce�i(i�c `lliee Cllaixfnan . SEAiING: 170(?8 be7'Stoo15+ 14?Seets) ��(J,,,�,,,-,,�g�ns!�� RESTRICTIONS: �� y'�a�"�m's ✓�^N• 1.Annual report subnutted U�'engineer in November—to incli�de �It¢Q(�ft�. .��ll�¢d review of FAS'I sep[ic svstem and mtrogen tzsting. 2.Two(2)monitoring well resnits(eontinttous data graph)_ 3. Connnuous mamtenance contract for FA5i septic sys[zm. 4. Nitrate loading calculations. December 11.2008 Bruce . Mucphy,MPH, HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-045 FEE: 560.00 This is to Certify that 99 West. Inc. d/b/a 99 Restaurant & Pub 14 Berrv Avenue, West Yazmouth, MA IS HEREBY C;RANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensin¢ authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3EeBen SRtah, `JZ.N., C/katixntaa sEa7mc: 170(28 barstools+ 142 seats) ��LQ¢6 ,`�. .`K¢�l�P��,l�j �,!,C¢ �l�tt ✓�.O�PJ[t �. �AC011ttt, ICPI�R Q/tft �MCCfL�QUIlL� ✓Z..lv. December 11.2008 Bruce G. Murphy, S., CHO Director of Health = � :°" TOWN OF YARMOUTH BOARD OF HEAL�I �� `��b C� C� I� 0 M f� DD � �� APPLICATION FOR LICENSE/PERM3T�,200�5 ,� �a ,a ?j UEC 2 0 2007 "A�iO * Please complete form and attach all necessary documents by'I)e�er 31, 007 Failure to do so will result in the return of your appliction packet. HEALTH DEPT. NAME OF ESTABLISHHI��NT: 99 Restaurant & Pub TEL. # (508)862-9990 LOCATION ADDRESS: 14 Berry Avenue MAILING ADDRESS: 3038 Sidco Drive, Nashviile TN 37204 OWNER NAME: 99 West, Inc. TAX ID (FEIN or SSI� CORPORATION NAME(IF APPLICABLE): 99 West, Inc. MANAGER'S NAME: �M`Kr r-�`f TEL. # MAILING ADDRESS: 3038 Sidco Drive, Nashville TN 37204 ' 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 mnst.list a minimum of two employees currently certified in basic water safety, standard First Ai�'and Commututy Cazdiopulmona�y Resuscitation(CPR). Please list these employees below and attach copies of employee certificarions to this fbYtn. 'T6e Health Department will not use past years' records. You must provide new copies and mainta3n a tite at your place of business. 1: 2. 3. 4. FOOD PROTETION MANAGERS - CERTIFICATIONS: All food service e§tatili'shments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the Stata Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicaUon. The TIealth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Thomas F Sweenev 2,�1_cK .�P,�p�iOU/e PERSON IN CHARGE: Each food establishmenfmust have at least one Person Tn Charge (PIC�on site during hours of operarion. Alex Dephoure . . Jo n S Halunen . �• Kim6erlv A ct Au6in 2, Anthonv loeeeh omhine Jr � � Thomas F Sweeney . � � - �� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employeee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procecures below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new co�ies and maintain a �le at your place of business. �, Thomas F w nev 2, _f�lPx �e�J/�oU/� 3 4. RESTAURANT SEATING: TOTAL # /l00 . ..-�::: OFFICE USE ONLY LODGING: � � � �� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#4 _B&B $50 _CABIN E50 MOTEL $50 _� $50 _�pMp $50 _SN[pqM1NGP00L $75ea _LODGE $50 _TRAILERPARK E100 _WHIRI,POOL $75ea FOOD SERVICE LICENSE REQUIRED FEE__ PERMFT#--- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT"#% 0•f00 SEATS $75 CONTINENTAL $30 NON-PROFTT $25 L>]00 seats $150 �Q�—O�t2 �COMMON VIC. $50 S�O WHOLESALE $75 RETAIL SERVICE: RESID.KITCHEN $75 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING•FOOD S20 _<25,000 sq.ft. � — ��"�`"'- � $75 —FROZEN DESSERT $35 _TOBACCO $50 NAME CHANGE: $10 �, AMOUNT DUE_$ �00• DD *""*"YLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*""• � � �� _ _ _ } . . . . ' . . .�a � ' ADNIINISTRATION Under Ch�pter 152, Secrion 25C; $ubsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a CectiScate of WoTlcer's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSUR�INCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEDT_ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PLEASE GI�C�'K APPROPRIATELY IF PAID: YES�_ NO MOTELS AND OTHER LODGING ESTABLISHMENT3 . TRANSIENT UCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy ,�_ � limited to the temporary and short term occupancy, ordinarily and customarily associat�ti with mote7 and h ;' , Transient occup$nts must have and be able to demonstrate that they maiptain a principal place of residence . " ' � ;: Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and att aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a resideaae Ar dwelGng unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupa�y Excise, as defined in M.G.L. c. 64G or 830 CMR 64G,as amended, shall generallybe considered Transient, •-- * NOTE: Enc�osed Motel Census must be completed and returned with tn�s appucation: ;" POOLS ` � ,; POOL OPENING: All swimming,wading and whirlpools which have been closed for the.season mwst be ins by the FIealth.Department prior to opening. Contact the Health Department to schedule the inspection five(� pnor to opening. _ . ' POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plakg c}� by a State certified lab, prior to opening, and quarterly thereafter. ,�#,� POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered wit6in seven(� d��' closing. i i�_}� FOOD SERVICE i�`- ��' CATERING-POLICY: � ' ` Anyone who cateis within the Town of Yazrnouth must notify the Yarmouth Heal�De�u'Iinent by� ' Temporary Food Service Application form 72 hours prtor to the catered eveiit. hese r►ns'cat►be � Health Department. ,; _.�= � FROZEN DESSERTS: ��}1e � Frozen desserts must be tested on a monthly basis by a'State certified lab. Test.ressilts . _ sent o the , Department. Failure to do so will result in the suspension or r6vosation of yoiYr�ro e�sert � above terms have been met. OUTSIDE CAFES: �� Outside cafes(i.e.,outdoor seating with waiter/waitress service)>must haue prior appr,m!al&om the Board o, . Outdoor coaktng,pteparation,.9r display_of.anx.£Qo�product b a C�tallilr f92d-SetY1s�ESSahliahmPnt�.p[oh' �� OUTDOQR COOKING: Y L 3� %� NOTICE:Permits run annually from January 1 to December 31. TT YS Y�UR RE5'POI+i'S�;:Ti7' TO RET� TI� COMPLETED APPLICATION(S) AND REQiJiRED FEE(S)B�'DECEM$ER 31, 20U7. ' {� ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR PO�L (i.e., P�� ,ING, '" ' ' EQUIPMENT,ETC.)>NNST BE REPORTED TO AND APPROVED BY Tf�BOARD OF �'fH P #�� , TO COMMENCEME�IT. RENOVATI0:�1S 1v1AY REQUIRE A STT�;PIAN. ' :� � � � .._ DATE:�f J$ O SIGNATURE: : , - _ � .�� '��`, ~ PRINT NAME&TITLE: � -� s �� A-�'�L io so o� �'�``. ACORD.M CERTIFICATE OF LIABILITY INSURANCE oansnoos 04/l3/2�0� vnooucen �� THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION LOCKTON COMPANIES,LLGi KANSAS CITY ONLY AND CONFERS NO RIGHTS UPON THE CERTIPICATE 444 W.47th Street,Suife 900 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Kansas Ciry Mo 64112-1906 E G_QY�RAGE AFEQg�€_ B.Y_T.tI�P_4�&lES_�E�.YY (816)960�9000 INSURERS AFFOROING COVERAGE irvsurseo 0'CHARLEY'S�INC. INSURERA: Z RICH MER[CAN INSURANCE C ��6B� ATTN: JANISREILLY IN URERB: -�— 3038 SlDCA ORNE � uaFa.E:_ - NASHVILLE TN 37204 — THIS CERTIFICATE OF INSURANCE DOES NQT CONSTINTE A CONTRA BETWEEN THE ISSUING COYERAGES OCHINOI DA IN E D IFI DER. THE POliCIES OF iNSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE FOR 7HE POLICY PERIOD IND�ATED.NO7WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRAGT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER7IFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICiES DESCRIBED HEREIN IS SUBJECT TO ALL TME TERMS,EXCLUStONS AND CON�ITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CIAIMS. INSR POIICYEFFEGTVE POUCYIXPIM710N TYPEOFINSURANCE I POLICYNlM1BER DATE DA �DDIY1' LIMITS GENERALLIABIUTY ( FACXOCCURRENCE i XXXXXXX _ COMMERCIAIGENERAlLL1B�LITV NOTAPPLICABL6 I HREDAMNGE onefire S XXXXXXX __ CLFIMSMPDE � OCCUR MEDF�(P.(Amonaoan�n� 3 XXXXXXX_ PERSONAL&ADVINJURY XXXXXXX NERPLAGGREGATE $_ XXXXXXX GEN'LAGGREGATEL�MITAPPLIESPER' PRODVCTS�C %OPAGG f XXXXXXX__ POUCY P lOC �AUTOMOBILEIIABILITY COMBINE�SWGLELIMR a XXXXXXX ar�vauTo NOTAPPLICABLL• (eaaawmw) __ A AILOWNEDAUTOS BOOIIYINJURY g XXXXXXX SCMEDULEDAUTOS (��e��) — -------'-- HIREDWTOS BO�iLYINJUPV $ XXXXXXX (ParacdtleM) NON-0WNEDAUTOS -- "' PROPERTYDAMAGE �S XXXXXXX _ _'_ __ IVeraCciCeN) GARAGELIA8ILIN I AUTOONLV�EAACGDENT S XXXXXXX ANVAUTO N09'APPL[CADI.G I OTHERTHAN EAACC XXXXXXX � nuroor+�r: A� $ XXXXXXX E%CESSLIA81lITY EACHOCCURRENCE $ XXXXXXX �ocCUR ❑Cwms rnnnE NO"T APPLICAI3I.F. AccaecaTE S . XXXXXXX XXXXXXX O�M&4E�V' XXXXXXX OEDUCTBLE FORM -$ - RETENTION g � S XXXXXXX WC STA7U- OTH /� WORKERSCOMPENSATIONAND � WC9137280•Oi I O4IIS/ZOO� OA/ISrLOOS X TAitYlltd/I .. E - ENPLOYERS'LIA&LI7Y E l EACMACCIDENT S I,OOO OOO E.L.DISEASE-EPEMPIOVEE $ I.00O,OOO __ e.�.oisEnse�Poucv u�art s I 000 000 OTHER � OESCRIPT70N OF OPERATIONS�LOCATIONSNEHICLE52%CLUSqNS ADDED 8V ENOORSEMENTISPECIAL PROVISIONS AOUITIONAL iNSlIREO' RER L R: 2573839 SHW LD ANY OF THE ABOVE DESCIUBED POliC1E8 8E CANGELIED BEFORE THE EXPIRATIDN TOWN OFYARMOUTH DATE THEHEOF,THE IS8UING INSURERWILL ENOEAWR TO MAIL —3�— D0.V8 WRITTEN ATTN:BUILDING DEPT. NOME TO TNE CERTIFIGATE HOLDER NAMEO TO TME LEFT,BUT PAILURE TO DO SO SHALI i 146 ROUTE 28 SOUTH YARMOUTH MA 02664 IMPOSE Ii0 OBLIGATION OR LIABILITY OF PNY NINQ UPON TNE INSU�R, �TS AGENTS OR REPRESENTATIVEB. . AUTNORIZED REPRESENTATVE ACORD25-$(7197) Forouesnorcrtparaliqlniscen�rsm.conwcunam,mberlimamt�e'ProOuarwaun�bowwtlaprtifproclwmwaa'aCxixmt �A O CORPORATION1986 / � O'CHARLEY'S INC. I I O'Charley's • Stoney River Legendary Steaks • Ninety Nine Restaurant � June 5,2008 r ,� � � 0,5 ,s ,�� rs '_ �� Is Li VIA US MAIL �,' n � � , Town of Yarmouth BoardofHealth Ht,�?LTH D�PI, 1146 Route 28 South Yarmouth,MA ', RE: 99 Restaurant#20051 at 158-160 Dean Street ' Food Establishment License Renewal ' Deaz Sir/Madam: On behalf of the subject-matter restaurant, we submitted the above renewal along with the appropriate fees on November 19, 2007. However, we have not received the newlv issued permit. Please inform of issuance status and fax a copy to 615.742.8136. ' Please submit any correspondence or permits to the corporate oftice at: 3038 Sidco Drive, Attn: License Compliance,Nashville,T'N 37204. If there are addirional requirements, please contact me at your earliest. Sincerely, G� Nicole Hardin-Matthews Pazalegal/Liquor Licensing Mgr. P(615) 782-8821 F (615)742-8136 nicole.hardin@ochazleys.com Enclosures RSC Restaurant Support Center 615-256-8500 • Fax 615-782-5043 • 3038 Sidco Drive • Nashville,TN 37204 FSC Financial Services Center 615-256-5500 • Fax 615-742-8141 • 500 Wllson Pike Cirde Ste 340 • Brentwood,TN 37027 �: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOU'I'H PERMIT NUMBER: #08-063A FEE: $50.00 This is to Certify that 99 West, Inc. cUb/a 99 Restaurant & Pub 14 Berry Avenue, West Yarmouth, MA IS HEREBY GRAN'CED A COMAZON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. Tlris license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3Eelen S�, J2.✓V., C'.�a�xnta�t sFnru�G: 170(28 barstools+142 seats) C�ax�eo `.�f..7E¢�if�eJlG �lC¢ C�aiXnilitt J2a�ext .rt.�io.�un, '(.�iPi Qnea C�'ieendEauim, J2..N. �� M�b i o.2ooa ��-�-�-•/� � Bruce G.Murph ,R.S.,CHO D'uector of Heal TOWN OF YARMOUTH BOARD OF HEALTH PERNII'P TO OPERATE A FOOD ESTABLIS�IlVIENT PERMIT NUMBER: #OS-097A FEE: $150.00 In accordance with re arions promulgated under authoriry of Chapter 94,Secrion 305A and Chapter 11 I,Section 5 of the�eneral Laws,a pemrit is hereby granted to: 99 West, Inc., 14 Berry Avenue, West Yarmouth, MA Whose place of business is: 99 Restaurant&Pub Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BonRn oF HEaLTx: 3feeea Sffa�i, JZ..N., C'�awunaa C�a�tle.a .�..7'Ce�iR�e�n,c,} `U,i,ce CPaiHnta�n sEnruJc: 170(28 barstoals+ 142 seats) J�A�PJ[E 3.�Mltlpft l,C¢/[R � RESIRICTIONS: Qf1It �EBQcun, J2..N. 1.Annual report submitted by engineer in November—to include �(t¢�ft ,`�al�¢D review of FASI'sepric s�ystem and nitrogen testing. 2.Two(2)monitoring well results(continuoas data graph). 3. Conhnuous maintenance contract for FAST sepric system. 4. Nitrate loading calculations. March 10 2008 Bruce G.Murphy ,R.S.,CHO D'uector of Heal � ._ , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHl1-IENT PERMTT NUMBER: #08-097 FEE: $150.00 In accordance with regulations promulgated under authority of Chap[er 94,Secrion 305A and Chaptet 11 I,Section 5 f the General Laws,a pe�t is hereby granted to: 99 West, Inc., 14 Berry Avenue, West Yarmouth MA Whose place of business is: 99 Restaurant&Pub Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: ber 3 t 2008 BoaRD oF�ALTII: ,q�f�e.��e��e6t�S� /fq�a��,�J�-2�.o.N-&.,-- '(-�O�ux�' qea�n SEATAIG: � i� ��-t S'��S"�'l��Sr�J l./iu�Lf.Ca .7C.J�.�GLifWL VICC l.!lQ�XfilQIL 52aBvrE s. `.,(3�auttt, C'� t�srxtc`iioxs: Q�uc(��xeettl�quu�y, `J2„lv. 1.Annualrepo rt submitted by engineer in November—to include �ue�ft,`�p�ee review of'FAST sepdc s�ystem. 2.Two(2)monitoring well results(continuous data graph). 3. Conhnuous maintenance con4act for FAST septic system. 4. Nitrate loading calculaiions. January 16.2008 Bruce G.Mutphy,MPH,R.S.,CHO Director of Health r � �,�- ,� I _ __ � _ o':"'°1 TOWN OF YARMOUTH BOARD OF HEALT�" , �d' � � � ��-�' " �'r �-�-� ''�''� �._ � APPLICATION FOR LICEN$E/PERMIT-2007 } U E C 0 4 2006 �� * Please com lete form and attach all nece � P ssary documents by December 1�,��r�-H DEPT. Failure to do so will result in the retum of your application packe . NA�MEOFESTABLISF�fENT: Q9 {�,��,�vaw,.�,1- 'rEL. #So8•S�'a•99g ; LOCATION ADDRESS:�_'�y 4.�,.c L �h9r�wdvJ� ; MAILING ADDRESS: (Nes..� �/1�r c�►�t o4 c.�'� I OWNER NAME: _�l 5 W�k�vr T X ID (FEIN or 4Tj�� CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: TEL. # ; MAII.,ING ADDRESS: N^e�tl {C,l. .0 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Pi� 'i ie 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 currentiy certified in basic water safery, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. i. �2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All 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 Establisbments, 105 CMR 540.000. Please attach copies of certification to this application. The Healt6 Department will oot use past years' records. You must provide new copies and maintain a file at your establishment 1. 'f°"'� Swr,;4Ny 2. A�F.Zc D��lovtt-�. PERS9N�I GHARGE: ---- _ - -_ - - - ___ _ -- - -- _ _ _- - - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. J��, ic��.�.� 2. HERdL,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 �r� sw�ruy 2. P..�7� orr�a.;+�-� 3. 1c�rti ST ov��w 4. San..14 �c�i RESTAURANT SEATING: TOTAL# I6Z) OFFICE USE ONLY LODGING: LICENSE REQiJIItED FEE PERMIT'# LICENSE REQL1IItED FEE PERMIT'# LICENSE REQUIltED FEE PERMIT# � _B&B $50 _CABIN S50 MOTEL $50 _INN $50 _CAMP $50 _SWIIvIIvIlNGPOOL$75ea. � _LODGE $50 _TRAII,ERPARK E100 WfIIRI,POOL S75ea. FOOD SERVICE: LTCENSE REQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMI1'# LICENSE REQUIl2ED FEE PIItMIT# _0.100 SEATS $75 _CONTINENTAL S30 NON-PROFIT $25 L»oos�.ars a�so 46o7-o�Ly /co�oxvic. aso #o�-o3s _v�o�snr.E a�s RETAII.SERV[CE: —RESID.KITCI��N $75 LICENSE REQUIItID FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _<SOsq.ft. $45 >25,0(IOsq.ft. $200 VIIVDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $50 NAMECHANGE: S10 AMOUNTDUE _ $_aOO- OO •'•'•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'••,^ �_ . � � �.._ _:.,��z��- � ` �..- r , ADMIlVISTRATION 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 COMPENSAITON INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED; Oli CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pemvts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHhIENTS 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 ofresidence eLcewhere. Transient occupancy shall generaily 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 shaii 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(�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 Fnust 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 Deparkmerrt by filing the requirec! Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heatth Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cookingrprEparation,-or displag ofan3�-food product by aretail o�foodservice establishment isprohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RE'TIJRN 'THE COMPLETED APPLICATION(S) AND REQiJIItED FEE(S)BY DECEMBER 31, 2006. 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. DATE: �1"Z�"� SIGNATURE: PRIN1'NAME&TTTLE: / -�"Z%•^� nrc c i T6�o M+�rd{,'r.t iomros ° -------...---------------- ---------_--- ------- ----------..._...---- OPTE(MIA/OIJ/YY� /�CORfy,. Gk�Fi'r1FIGl�Tr OF' l_I/�I31L11"Y IN�IJf-fiANCE �,nsrzoo� _,_r_._or�zonooc___. --- ---_--_.._---------�---— rnooucen � TF�IS GC-R7IFICATf_IS ISSUED AS A MATTER OP INFORMATION LocklonCanpnnies ONLY ANU CONfCRS NO RIGHT6 UPON T�1E CERTIFICAT[ 4AA W.47tli Sireel,Suile 900 h101_DL"R.TFIIS CERTIFIGATE DOES NOT AMENU, EXTC:ND OR Kansas Cily Mo fiA I 12�190fi _ALTE RZH�..�Q�F�lLGE..FjfFQk?,��T�.p_411F1GS_�F�,.4 W�___ (D16�960-9000 IN6URFRS AFFORDING COVF.RAGE ...__'_"_._._.____.._____'__'._.-_____..___—___'.._.____..-__'_ _'_ "�__-�__..____"_—__�-'��...—_.—"_._... . vuuneo U�CHAItLEY'S,INC.,O'CfIAFlLF.I"S,9�JRf:STAUHANTS �Nsonenq;_'LURICI-IAMF.P.ICANINSU2ANC6C0. ,,.,___ IOGG(M7 �ND310NI:YI7IVEHLEC,FNOMYSTEAI(S wsm�ceo_--,-----._.._.,�___,_-�.._._--_---._- ;10:10 SIDC,O ORIVl wsunra r._._-�--.__._�..—__... _.—_'_'__ IJASHVII.LE.TN 1720A nuuae,no:__ _'.____"_'___'_______,____.. �.__J�.__.___._��..___'_'___'_'-__""'._..�""'"__..` INSURFHk' _' ____'__" __ THIS CERTIFICATIi OP INSUOANCE DOCS NOT CONSTITUTt A CONTRACT LifTW[LN THE ISSUINC covg'RnG[.s.--------DA ..-..--_----.---,------_-_.-__-1N�.Fr�[sl.�niogizeo ii51'nr_sSN?�+SNF_gp�?.41�.�5L�+ _L�. ES ��+SEI&1fIEE�14LRE8. TH[ POUCIESOI=INSUPnNCFLISTf00@I.OW HnVE f3F.EN19SUEDTOTHE WSl1RE0NAME0A�OVF. FORTH[ POIICY PERIOOINDIC�TEO.NOTWITHSTANOWG ANY REQUIFlEMENT, TERM 04C(NIU�T�ONOF ANV (:ON'fRACi OH OTHER UOCUMEN7 WITH RESPEC7' 70 WIVICII THIS CEFlTIFICATE MAY BE ISSU6D OR MAY PERT�IN, THf:INSLIRANCEi AFfOFID[D fiY THL POLIGES OfiSCFlI�ED HGREIN IS SU13.IFCf TO hll.1'HE TERMS,EXClUS10N5 ANO CAN[)ITIONS OF SUCFI POLIQES.AGG�EGnt@I.IMITS StIOWN M4Y H�VE.AEEN p[DUCEqBY PnlOCLnIAiS. _, _,_ '_"__"'_"...."'_-" —_"""____--" _ iNS� 1'OIICVEfFECTIVF POIICYf:XPi(inT10H 4� �YPE.OKIHSUIIANCL__ ______�OUGYNIIMFlEI `___ ��LMNM'v_�__I((irglM�d�Uj7('�YJ_�____...�INITS ___ CENf:11N.i.I�flILITV cACMOCWNHENCE _ i �� /+ X COMM[11CIALGl1�f�1-A1.1II�01L1iY OL•091772R7.-00 04l152006 fkV15l2007 FIOE�AN.A6EIMrvww�o� � 1.0OO�OQ_ �a.niMs�enne L A I a:rem UEO EXP LM�om � i XXXXXXX X 41QUORLt�4o.. I5M ___ rensorie�snwwiunr a .__,�,IX�0,000 - - a��nninacaeonrc � 40.000000 GENt�CGNEGATB LIMR qP1+UES P8R PHOOUCTS�CONP �GG S 2 OW O -- VHO� 1'� - X POIICY IECT 1 IIOC ___ _..- �_- -- — AUTOMOOIlEL1AGll.lTv GOMOWEOSINGLEIIMIT j XXXXXXX nNvnuro NOTAPPI.ICABI.G �e"`d°`"n � � nuawNeonuras noonnwum i XXXXXXX sGNF.outlonuros (rcryasw) _ _�_ wneowros a��y�Flr � e XXXXXXX NON�OWNE04UTOS (PorecdtleM� � ___ rtwrenTronunce � XXXXXXX - '--` - (Po�acdUcM GMAGEIIADIIITY v AVTOONIV�GACCIOENT i XXX7{XXx .wvnuro � NOTAPPLICAqI,E on+Ennuu � XXXXXXX � AUTOONLY: ppG f XXXXXXX E%CES54AB�I.ITY � E�CHOCCUfl1iENCE 1 XXXXXXX �occuA ��CUtM3 YADE NOT APPLICAIILB nowEcnre � XXXXXXX - , (-luunnaue t XXXXXXX . . oeoucnu�c � �1 ronu XXXXXXX flETENTION t � i xX7�X7�X A WOflKEfl9COMPENS�TOH�NU W�13�28�-(� (J��/�$/�QQ6 QQ/�$/�0] J( wCSTAN� �iN• FMPLOYEqS'11�BtUTY EA.� qACCIDENT i 1�� E.LD 'EA9E•�A AV Y I OOUOOU C.L MSEASE�PpACY LII.flT i 1 �1 OTHEII OESCflIPTION OF OPEHATIOH3fl.00ATIOHSNEHiCLEBICXCLUSIONB�DOEO BY ENDORSENEM/SPECIAL PROVISIONS pPPIICABLBDHDUCT78LBS&�RBTHNTTONS APPLY � C C OLOE Ao ION/�LINSUflEPNISUAE �e en� CA O Q6QQ74Q 6HWLOANYOFTNEABOVEDESC111B�POLIC�SBECqNCBLLkLBEF0118THEEY%HATpN ' TO WHOM IT MAY CONCERN nATE TNENEOi,TN!ISSUNU INBUPEp WILL ENOEAVOq TO MAII 30 OAYS Mp1TrEH NOTICE TO TNE CEHTIflCATE N04DE11 NAMED70 iHE LEFf�BUf FARUPE T00090 SF4LL INI'USE NO 08UGATION OA UABILRY OF ANY KkA WON TNE UiSUROfl,IT8 AGWI'8 OR � flEPflESENfATIVEs. AUTHOP2E0 REPFlESEMATIVE , . ACOHD25-S(7/97) Fww��^s�a�«�e+�aw++��uwwAe��u�erw�rAau��weam�w�mroeeWmaapereode�onua��, oACORDCORPOflATI0N7988 � _ __ __ __ ___ _ _ _ , , . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-035 FEE: $50.00 This is to Certify that 99 West Inc. d/b/a 99 Restaurant 14 Berry Avenue, West Yazmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 200?unless sooner suspended or revoked for violaUon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomvty with the authority ganted to the licensing authoriUes by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their offrcial signatures. BOARD OF HEALTH: B is.`?1. �M. `�., ' sEn'mvG: 160 ��us�i, ./r., �/�(��i '�nran Qo�elit Q B3orwc, �e�i.�C P�Ma��..�t� A..��j� R.N. Januazy 30_2007 Bruce G. iup H,RS.,CHO Director of H th TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #07-049 FEE: $150.00 In accordance with reeulations promulgated under a�rthority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Zieneral Lacvs,a peimit is hereby granted to: 99 West Inc. 14 Berry Avenue, West Yazmouth, MA Whose place of business is: 99 Restaurant Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernrit expires: December 31_ 2007 BonRD oFHFnLTiI: BeK' `.b. Cio+t�ok,/��., G�� a�lr4lr, /l.N., �Uics G� SEATTAIG; 1fiO � - . !��O 67IIl�Mo � RESIRICTIONS � I.Annual repor[submitted by engineer in November—to include Aiut�'3e�tdattac, R.I�. review of FAST septicsystem. 2.Two(2)monitoring well results(continuous data,graph). 3. Contmuous maintenance contract for FAST sephc system. 4. Nitrate loading calculations. Jam�ar r�30.2007 ruce G. Murp , H,RS.,CHO Dir . , Cr��73i37d � ?�Fv q� TOWN OF YARMOi7TH BOARD OF HEAL,,TH f ad�' ��s APPLICATION FOR LICENSE/,P,ERA�II't'-20b5 '` /ys�Q * Please complete form and attach all neces�;do ' t�oj becembe l, � �� Failure to do so will result in the retu�n pf y " plication pac y Z g � Fq �'Op . NAME OF ESTABLISffib1ENT: TEL. # - LOCATION ADDRESS: \ � MAILING ADDRESS: S OWNER/CORPORATION NAME: � h MANAGER'S NAME: S� �, # MAILINGADDRESS� M POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1• 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation �CPR). Please list these employees below and attach copies of employee certifications to tivs form. The Health Department will 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 All food service estabiishments are required to have at least one full-time employee who is certified as a Food � Protection Manager, as defined in the State Saciitary Code for Food Service Establishments, 105 CMR 590.000. Piease attach copies of certificarion to this application. The Health Department will uot use past years' records. You must provide new copies and maintain a fde at your establishment 1. H�C'� l)P tClh(�i �� 2. \ ►�oVN,IAS �u�@.o�n`o') PERSON IN CHARGE Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. � 1. Y��'M �\ pc��Yl�C� 2. ^ 'M � \ � ! HEIMLICH CERTIFICATIONS � All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich I 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 wilt not use past years' records. You must provide new copies and maintain a fde at your place of business. i 1. 2. 3� 4. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY LICENSE REQUII2F,D FEE PERMII'# LICINSE REQIJIRED FEE pgItt�q1�q yICENSE REQUIltED FEE PERMIT# —�B $50 _CABIN $50 MOTEL $50 _INN $50 _CAMP S50 _SWIIvIIvIIIQGPOOLS�Sea. _LODGE S50 _TRAII,ERPARK $50 _WI-IIItI,pppL $75ea. FOOD SERVICE: . LICINSE REQUIItED FEE PERMIT# LICINSE REQIIIItED FEE PERMI1'# LICENSE REQUII2ED FEE PF..RMIT'N _0-]00 SEATS a75 _CON1'INEN1'qI, $30 NON-PROFIT $25 ( >100 SEATS 5750 �(pb-0%8 /COMMON VICT. S50 �_'OE.I�- _WI-IOLESALE $75 RETAIL SERVICE: LICINSE REQiJIItED FEE pggTqT g I.[CENSE REQiJIItED FEE PERMII'# LICENSE REQiJIRF.D FEE pERMIT# _<SOsq.R $45 _>25,OOOsq.ft. $200 _VENDp•IG-FOOD S20 _<25,000 sq,ft. $75 _FROZEN DESSERT S35 _TOBACCO $25 NAME CHANGE: S10 AMOUNT DUE _ $ 20O . Oa ""•'PLEASE TURN OVER AND COMPLETE O'1'HER 5IDE OF FORM••••• ADMINIS'IRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazrnouth is now required to hold issuance or renewal of any license orpemiit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAViT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pennits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN TfIE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPARTMIIVTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOT'EL OR POOL (i.e., PAINTiNG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO CONIlvIENCEMENT. RENOVATIONS MAY REQIJIRE 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 1`ESTING: 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 estab ishment wtuch serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POT.ICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must e tested on a monthly basis by a State certified lab. Test resuks must be sent to the Health Department. Failure to do so will resuk in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor searing with waiter/waitress service),must have prior approval from the Boud ofHealth. I OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food prod by a retail or food service establishment is prohibited. % nA�: Z 2� L� s�GrrA�: - . • r�urrr rr�& Trri,E: r .N� �n io�a2�oa � ACORD,. CERTIFICATE OF LIABILITY INSURANCE p4/�5/2006 oa�z�iioo vaooucen THIS CERTIAICATE IS ISSUED AS A MATTER OF INFORMATION Lockron Companies ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE i 444 W.47th Street,Suite 900 I HOLDEFi.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Karisas City Mo 64112-190fi F�OVERAGE AFFORDED BY THE POUGIES RF I (a�s�� INSURERS AFFOROING COVERAOE I ��qE� 0'CHARLEYS,INC.DBA �N3UflER A: FEDERAL INSURANCE CO. CHITBB � �� 99 RESTAURANTS �NSURER 8: LEXIPIGTON INSURANCE CO. . 160 OLYMPIA AVENUE _ u�surr�c:SAFETY NATTONAL ST.LOUIS WOBURN MA 01801 �r�sunsn o:ALLIANZ CRC-CHICAGO INSUREfl E: COVERAGES CC THE POLICIES QF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATEO.NO7Wfh1STANDING ANY REIXI�REMEN7, 7ERM OR CONORION OF�ANY CONTRACT OR OTHER DOCUMENT WI7H RESPECT TO WHICH TiIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV TME POLICIES DESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POlIC1E5.AGGREGATE LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CI.AIMS. � T/P F I NU R POLICY BFFECTIVE Pol1CY El�IM770N GBlERNLlU1BILRY OCGURPENCE i IOOOOOO A X co��cu�csErv�wu.uneiuTv 35346831 04/152005 04115/2006 FlRE araac s 1000000 �� A MED IXP ane rem s )Q'�QQQ( PERSONAL8AOV1 Y f I OOOOOO GENEAFLAGGREOAiE 3 JOOOOOO GEN'LAGGREGA7E LINfT APPIJES PEFC P .COMPrOP AG[i 9 Z OOO OOO X C/ P�� AU�pIOBILE W&LITY CO�.SINED 91NGlE IIMIT : A X �wv avro 73256576 04/15/2005 04/15/2006 ��m^0 i 1'000'000 ,��. nuoNv�onuros � ��, eoonriwuRr ' �� SCNEDUIIDnuras (Pxa�) JC FIIRED AUTOS X NONOWNE�AIROS �IY�RY i '� X COMP(I.000 D�) ��o��E ' � X COLL IOOODED I��q GAMUG IlABM11TY . AUTOONLV-EA ACCIDENT 9 uav n�rro NOT APPLICABLE on+en nun � avroaav: ,�a e 7�L'CCX7LY � excEss uneartv . � eacr�accurss�ence e 5,000,000 7C occuR ❑cuvasMaoe nc,�nEcnrs f 5000000 B ❑�� 03303b7 04/15l2005 09/15YL006 � 7�QC4GQC o�uucne� w� net�rnwe+ a � : X7000CC{ C woq�nacarver�snironum LDC0500t24 04I15l2005 09J15/2006 X ��"n' �' vwwrexs we�urr EL EACFI ACGDENf 9 1 OOO OOO ELOISEA9E- f EL.DI9EASE-POUCV LIAAf 9 (�� D oniEn CLP3005922 04/15R005 04/152006 75M[ASSLMT.tOMF7.DlQt�. PROPFRTY(ALL RISKlRCI SUHIECI7'O SUBLM7S&DEDS B L[ [IORL[ABR.ITY 4I79526 04/15/2005 pylSR,� IOMORD/[CC - 1.SM PFR OCCSM AGG oesewvnoN or oa�anonsn.oennar�ac�aexewswhs aoaeo er oioons�ExrBrecu�vxov�swrrs - 99 Rataurewa.LLC/99 West,Lrc./94 Restauronta of Bouon,LLC/99 Resteuraots of Vermon[,LLC RTIfl O R n i CE N �8� sHou�o uir oF n�e�eove oescwem va�aEs ee cAncat.en e�oxe n��n�� For Verilicaiion Purposes Onry . DA1E TXEREOF.TNE 189WN0 INSURER WILL ENOEAVOfl TOMAIL 30 DAV9 W11rtTFN NOfICETOIXECERI1RtATE HDLUFA NAME�TOIHEIEFf�BVTFAILURETO00 3091NLL .. IMPOSE NO 08L1011TN)NOR WBILITYOF ANYImlOUPONTXE 818URFA� 17S AGENiS OR NEPRlBENfAliVES. AV1710qIZEp pEPpCgp�{ATNE _i'l i .l�=o. �:r'=..;_ ACORD25-S(7/9� r>w+.w.�.�ww.�.nmer,�wu«..u,.�,.,,e.,n.remu,.�r,00-,..r„wm,e,,,,w,p,myy�ww�ne.oewwy.. pACOf3OCORPORA770N7988 j . . . � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT I PERMIT NUMBER: #06-078 FEE: $150.00 In accordazice with re�u1ations promulgateci under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�',eneral I.aws,a pemut is hereby granted to: 99 Restaurant Inc., 14 Berrv Avenue West Yarmouth, MA Whose place of business is: 99 Restaurant&Pub Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemvt e�cpires: December 31 2006 BOARD oF HEaLTH: B $, i1J,$,, �k�i�,c S��G: �� a��s`� �°�``., v�e� RE311t[c�'[oxs: See reverse side. RoGe?t�B�a+[nk, G�lrJt� Pr.#�ab�llo`�olt �J.,.� R.N. Januarv i l,2006 Bruce G.Miuphy, ,RS.,CHO Director of Heaith THE C011�IMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-062 FEE: 50.00 1'his is to Certify that 99 Restaurant Inc. d/b/a 99 Restaurant&Pub 14 Berry Avenue, West Yarmouth, MA IS IIERF,BY GRANTED A COMMON VICT[7ALLER'S LICENSE In said Town of Yazmouth and at that place only and e�cpires December thiriy-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General I,aws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B `�. �o�o�,, M.�., . 3EATING �� /�� s�, .�, v:�et� � K/�v�a�e�[�i/��./BAl�O(4-VL� � � /'GiR[C�/7/C�[J�f/XO� �v.�g ka�, a.a. .r�,�y i i.Zoo6 • Bruce G.Murphy ,RS.,CHO Director of Heaith � O��Y`�R �� '�o TOWN OF YARMOUTH �, ;_, `'3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 MqTTACHEfS �^�,,,,,,,,�„�� Telephone (508) 39&2231,Ext. 241 — Fax (508) 760-3472 i B OARD O F HEALTH �� (- �? c; � � i � �`,�JG 0 5 2005 i To: A112005 Yazmouth Board of Health License/Permit Holders HEALTH DEPT. II From: Yarmouth Health Department i Re: Taac Identification Numbers i � Date: July 27, 2005 I j __ � _. _ - ___ _ _ _ ; IThe Massachusetts Department of Revenue is now requiring that the Heaith Department fumish � to them detailed information regarding all permits and licenses that we issue. One of the required details is to pmvide a t� identification number, whether it be an establishment's Federal ; Employer ldentification Number (FEIl� or, in the case of an individua7's license, a Social � Security Number (SSI�. This information will be used by the Aealth Department purely for administrative purposes only. Wouid you please fill out the fields below and retu�n this letter to: Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you haue any questions regarding this matter, please do not hesitate to ca11. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is(508) 398-2231, ext. 241. L,�a�.�,�.n�.a: yq ,�s��-�,� -f �r�� ssrz: Location Addtess: /� ��rr✓ �-��. Signature: �ii��. �� Print: ��/f� /� Title: p/.E' C/� /-�i'J/Y/A�. S!/CS . � Prin[ed on L � Recycled Paper ./ � . ��,��.a � oF_,,qR � _ ��rsa3a-taeNwcfi,_N�NE _ � �.o TOWN OF YARMOUTH BOARD H ' o_ ,S , APPLICATION FOR LICEN -2004 Q � C� �; � ��I C� DD ��? `y " ' . ' ' Please complete form and attach all necessary � A ents by Decem er.5�1�i0tl3� 2Q03 Failure to do so will result in the return of ur application pac e . �-iEALTH DEP7. I N MF OF T�RLISI-LMENT• 9 �J-i4v�nvi'r TF # 5ard �G2 95�a LOCATION ADDRE • /e1 ,.e 14u� MAILING ADD F 4• �c,/ ,�r�e.�, �v� � � I�2r�� ,� Yr�t oLv>� OWNER/CORPORATION NAMF• tp g ��_�.w., �,,,,� � 11�ANAGER'S NAME• 3�vi. 1c�/ „ TFT # �8� 93 845� MAILING ADDRE4. ; ' 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 cepy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currentiy 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 i provide new copies and maintain a file at your place of business. i 1• 2. 3. 4. FOOD PROTECTION ANAG R - RTIFI ATIONS• All food service establishrrtents 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, l05 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. "/Or'� �r�'"�� 2. k� r+ Cao.,� w _ �"�It$Gi�i R3 Cf-tr'i�i�L': _ — _ —_ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.—_.� � W� �XAN 1 vL 2 C�R<�I �A)?m)»4e�. FIMi ICH C RT FICATION : All food service establishments with 25 seats or more must have at least one emp(oyee 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 aew copies and maintain a file at your place of business. 1. TO.r+�' �wc�e.�•cy 2. �i. �.e-- 3. 4. BESTAURANT SEATING: TOTAL# I GO OFFICE USE ONLY LODGINC: LICENSE REQUIRED FEE PERMIT N LICENSE R6QUfRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# _B&.B $50 _C 1BIN $50 _MOTEL a50 _INN $50 _CAMP $50 _SWIMMING POOL E75ea. _LODGE S50 _TRAILER PARK S50 WHIRLPOOL E75ea. FOOD SFRVICE: LICENSEREQUIRED FEE PERMIT# LICFNSFREOUIRFD-6F�'-- �r� "' � � - --- � ��. _ _ . �.. , �.tt4.� q UCENSE RI:QUIRED FEE PERMIT# _U-100 SEATS� $75 _CONTINENTAL S30 _NON-PROFIT a25 �� 1>100SEATS SI50 D �O�(S 1 COMMONVICT. S50 �0�"0� _W►{OLESALE $75 RRTAI� S RVI & , LICENSE REQUIRED FEE PERMIT k LICENSG REQUfRED PEE PERMIT N LICBNSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sy.lt. $200 _VENDING-POOD S20 _<25,000 sq.ft. $75 _FRO"1.EN DI:SSIiR'f $35 _T06ACC0 S25 NAMF qN • $Ip AMOUNT DUE _ $ 200•00 � ""•*•PLEASE TURIV OVER ANU COMPLF.TE OTHER SIDE OF FORM«..«. ; - � ADMINISTRATION . Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal ; of any license or pernut to operate a business if a person or wmpany does not have a CeRificate of Worker's ' Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED / Q$ / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '( Town of Yarmouth taxes and liens must be paid prior to renewa( or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PATD: YES NO NOTTCE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITl'TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CON1'ACT THE HEALTH DEPAR'IMENT 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 I POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health DeparUnent prior to opening. POOL WA'TER 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 selis ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yarrnouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Deparknent. FdtE,'ZEAID'ESSE�tTSc - - --- 'i Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health DepaRment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside caies(i.e.,outda,r seatirig�vith�vaitPr/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of ar.y food prod t by a retail or f d rvice establishment is proltibited. DATE: I � SIGNATURE: PRINT NAME&TITLE: 10/22/03 • • e om�\ The Commonwealth ojMassachusetls : Department ojlndustrial.-iccidenrs ; O///ceo//srestlOsWis 600 Washington Slreet Bnsron. Mass. 02111 '� ,` Wbrkers' Compensation Insurance Affidavit nam�� a.�� '�rl e� i �SLC1L14f1;_ '� � ✓1+ S FP U J�+N�— � G I I�?I�/�� /�—(/p ' � ✓/w A � p — U� -5 5 � f am homecµner pzn�rming all work myself. � I am a solz proprie[or_r.,'. ha�z no one ��orkin_ in am capacin• �m an employer pro�iding workers' compensation for my emplo}ees workine on this job. tomnan�� name: �(�fC55' citv: phone p• insurance co. nolicy M � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�e hired the contractors listed below ��ho ha�e the follo��in_ ��orkzr; ,ompensation polices: companv name: address• tin�: phone p• � insurancc co. Delier# comnanv namr . addrcs�• �y: Fhoee N• insaron�e ce. eeliev M � • Failure to seeure covenLe��required uuder Seenos ZSA o(MGL 152 u�ind b tYt i�pooOw of eri�iW peultles of�O�e ap ro f1,500.00 i�d/or oae yun•Imprisoameat u w�d1 o tiril peealHa ia Ae lorm of�STOi WORK ORDER�ad i Ilee ofS100.00�d�r�pie�f s� 1��denta�d t!tl• topy of thia statemrnt y be fo �rded to the OIT e of Invotlptlom of Me DIA for emq�e verillaW�. � /do hereby certi • ndtr r pai a d na �es ojprrjury�hm the injormaNnn prorided above is true a�d co�►ea Signaturc ( U Printname � ( � � P eneN �`�i0(�—��J�°1 kD .. oRcial use only do not�rite in this area to be eompleted by tily or Iorve ollltial eiry or mwn: Y�M�IITQ _ penaiNieeeu N nBuilding Departmeut . pLieeosioe Bo�rd �check if immrdi�tc response is required 261 �S�Itetmen'e Otlfee (508) 398-2231 pat. �Hea1tE Departmem . contact person: pAone M•_ __ _ nOlher � �; I ACf.�Rdi. 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A1E:POLICfESOFINSUR/ifJCELISiED•BELOW��HAVE BEEN�ISSWED70THE INSURE6NAMEDABOVE FORTHE POl.l6Y PERlOD�INUICAFED:NfF1WfFH5F/ENDING � ANY:.REQUIREMENT,.TERM�ARCONDITION'OE�AN1'CQNTRACT OR p'CHER.D(1CHMEfF€OLffH RESPECT TO WHICH THIS CER7IEIBP.iE WfA.Y�'$E ISSUED��OR � �'21AY PERTAIN;.THE INSURACNCE�RFFORDED eY'7HE P�LIGES DESCRIBEO�HEREIP!IS:�.SUBJECT TO�AGL THE TERMS;EXCCl1SIONS��ANET60N�{TIONS OFSUCH` POGGIES.AGGREGATELIMRS SHOWN MkY HAVEBEEN REOUCEDBY PAIDCWMS. . MSR. � �. .. ....� .: POCIEY EEEEC.TIVE P061GY:EI�IRRT(OM �. ' �:, . SYPEOF�UISIIRANCE � POtICYN17N8ER LINRS . �OENEWtLlIF8141['L � .. . . �. :EACHOCCURR NCE 5 �. LQ�O QIY... � A ��' COIdMERCIALGENERrtClIABILITY 35346SJI � . � OG/ISI�I003 ��15��f� FIREORMAGE � me11re S ��X�9� CWMSM4�E.� OCCUR. � � . . . � '.' �".kAEDE%P M ane� n '3 ' }`�`�. � X� LIOUORI36�.13�Y . �. � .. . �.' , .. �. PERSONAL&FW�.I�R�IRY "S ��' �`OfOO�fIOGI''.. .. X�� LIIvffl'INCEUf?ESSIl2 :: .� ,. . ` ' . ..... GENe[rALd�GREGATE .8 �-,:- 1'VOlP00f1�� .. :..GENLkOPaREGqTELIMFFAPPLIESPER� . . . . �.PRODUCFS-COMPlOPAGG 9..�.. IOO��OQQ:.. . ��' PoHCY -ECT X -�lOC - . A!lT0190BILE LL161lIfY � .� . . � � CAp�INED51NaLE EIMIT � A X:.ar�v�wro . � � 732565�96 � 04/15/2003 � 04/F52004' 1��^4 �8 ,. 1,006,000 '. �' u�owweo auros � � ' ° � . . BO�ICk'INJURY 5 � �. ;, SCHEDl�1FE6AtlT05 �� ' �� 4BaPa�} . ., . ��. HIREO-AIf�05�. . � .. BOEHkY'IN.NRY� . , X�.' RON-qNfNEDACiS05. «'��d�� .J€:.EOMP6I.O�ODEI� PRORR[�c'fw'.uRtA4GE °p,- ��z; . :Xi COLI.TQQ�`DEi1�'. � '` . , � 1�*acad�e�.. , . , _. ' ' � ......:OA LWBIIff,Y� . . . . AUGO'ONL'Y.-EAACCIUENT�•5. ,X�OO� . . X� - nn.r.nuro � � itfOTAPPLFCABLE� .. .' ::en,uuc. �s X3C�X7�S�L�. orH�rznuw �. .. ��_ . - nuraoe�er < n�c:tx �:7�Y �ess�wswm� � '�e�acemas� -s . � �fl0_: ; .. �M 7£� oecuR cunrx�nube -%zccRE�x� ,s�� ,�S��OQ�. z&, _ U, � :.. Q�96880425 . .. 04E15/20.6� tr4�5i2Q4Y4 '�. ' �. .`� . , : � waer��u , '. nEor�ctie�e.�roMe . . ��:�..,+ , � , ,.�. : -, .;� , �, _ � _ ,.. , . REfEMION .' S � i :. . g ��..�. . c wow��ooM�r;�f�or,�wo �,cosoaizs aatrsizaas oaiisnoo-a` i� w��ra�,- °T�-s.= ; EMPLOYERS LWBICR•Y . ' E:L.EACFACCIOENT � S� �� F O�OOO�.: ` C� � LDC0500124 . Q4/15/2003 OM1�I�SIZOOM1� ElC:DISFASE�-EA�EMPLO 8 � LO�D�Q�'�. � E!.DISEA9E-�BOCIGY CiMft S ��: I OOO OOQ�- D oiHErt � � � CLP30Q3236 04/15/20U3 04/15/2004 g50MI:oSS�I.am,SInMP[.oOD/QUnt�, �PROPHRTY(Atii:RFSK/RL� � SIIHIECLI'O�SqBi]MIRS&.DEDiIC3IDL=ES �.DE9CPPfIDNOiOPEMilON9lkOCA710NSN6fIClE&IXGI:U810NSAODEDBYENWRSEMENTISPECLLLPROVISqNS � � �� . - � CERsT,FF..tElt kiQbdER �ao � - ek:.:.. CEilLC@CLqSI�M .: .��:: � .,r . .�.". � . ��8�9&�' � SHOULOANY�OFTNEABQN�UE9CRIBEPPOLIGIESBECANEELEEO;BEFCRETHEEXPIRY\`GIOlk , For tkarffication Pucposes Onty a,�ix�a�sxE'asuw��r�sun�rnu� erio�,iisiig`xc»wnc, 3Q u.trs ivn6rres � - � NOliCESPSHECER�IFifATE.XOIDER�NRNEQTCLIfE.CEF4,BURFALLIIRET4IUIXSOSHqLL � .. MPdSE RC O9EI�Iq[l OIF COC�ItlfY�OF, pffl�qNCt7¢ORTN�INBURER;.F@3'�/I0ENi5 OH" � .. - ��ru'�a- �,:, =� ' x�r " r-�}'•; �'�, IrCOR62S3�(7F47f�.. ' ' _ �.y� . , r.�. -., .. 3, , , � . . � . . �.� �� - �x;='. f :' I - • TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-045 FEE: $150.00 In accordance with re ations promulgated under authariry of Chapter 94,Section 305A and Chapter 111,Section 5 of the Laws,a permit is hereby ganted to: Ninety-Nme Restauran/Pub, 14 Bercy Avenue, West Yarmouth, MA Whose place of business is: N'mety-Nine Restaurant/Pub Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut etcpires: December 31. 2004 BOARD OF HEALTH: B $. l�auGon, M.$., �ia�t�wc SEATA]G: 160 �/��:�� ,N�� v� /:�� RESTRICTIONS: SCC ICVCBe 31(le. J(�p/0�/7�� BdpG/M�L�/�(i{F�lI�, , Offfi(QK S�Q� K✓I. December 3.2003 � ruce G. Murp , , S.,CHO Director of Health. 'RESTRICTIONS: 1. Annual report submitted by engineer in November- to include review of chromaglass batching septic system 2. Two (2)monitoring well results(continuous data graph). 3. Nitrate loading calculations. 4. Continuous maintenance contract for F.A.S.T. septic system r . ,.. THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NiJMBER: #04-034 FEE: $50.00 This is to Certify that_ Ninetv-Nine Restaurant/Pub 14 Berrv Avenue West Yarmout MA IS HF,REBY GRANT'ED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violauon of the laws of the Commomvealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereo� the undersigned have hereunto affixed their official signatures. Boa.xn oF HEAI,TH: B/�e�r�y�a,�x�c:a��h!. f�ido,�.,e M� ..�. • . SEATING: 1(>O Yrw'l[�Ct1e MCfJ VICi .�.�ffil�/Il(fi�IG R,P/O�,P/f��. 83BVIK��y/�� K /C�. _ December 3_2003 Bruce G. Murphy ,RS.,CHO Director af Health i � I ' - - cl�#P1Y�S�f� �bD� _N,��,,,_u,u� ��`,"R.y� TOWN OF YARMOUTH BOARD OF HEALTH ��, ��., � t� �•- I � 1 o �., APPLICATION FOR LICENSE/PERMIT-2003 \\ ��`J 2 Z 2QO2 r �w? ��' � ' * Please complete form and attach a11 necessary documents by tTece�Se" 31 2002. � Failure to do so will result in the retum of your applicatiq� ke . f��'��'-`��E PT. �� _ T i.:< ,.,.A. # - e - 99a � L T• J � D ' /s'� IC� 1$ 0 J h T (� MANAGER'S N�MF• M W � P � TEL # �SdS- 9S90 �• MAILING ADDRESS: � a � , POO . RTIFI ATION : The pool supervisor mast be certified as a Pooi Operator,as required by State law. Please list the designated Pool Opaiator(s)and attach a copy of the certification to this form. 1. 2. _ Pool operators must list a min;mum of two employees currenUy certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2, 3. 4. FOOD PROTECTION MASIA(iER4 - CERTIFICATICIPJ • ' All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 'fi0vr� SW�G�� 2. �f.iNn CND►t�l PFRSON IN HAR('r • _ ; - - -- --- - - __ _ _— Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 6�•IIM. CILD�'11�+1 2. I�JI�L�r1YSN lspdc �YK HE MLI H RTIFI ATION • All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking pmcedures 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. '1D�'�'1, sc�C °U+'�( 2. I'j'!��-liC�6� Girsrl.ra N�f 3. wH. 7n `k* 4. ' RF�TAtTR ANT SEATIlV : TOTAL# __ _ _ --- --- - _ _ Id�PS,ING: OFFI . E O .Y �� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT k _B&B S50 _CABIN S50 _JvfOTEL � S50 ' _1NT1 S50 _CAMP $SO _SWA4MING POOL$SOea . i _LODGE $50 _TRAILER PARK a50 _WHIRLPOOL §25ea � FOOD SERVIC a i LICENSE REQ(TIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# , _0-100 SEATS S75 _CON'I'INENTAL �30 NON-PROFIT $25 1 >ioo sEnrs Siso �43-028 � COMMON VICT. $50 D�J'DI _WHOLESALE E�s RFTAIi.cFgyl� ; LICENSE REQUIRED FEE PERMIT# LICENSE REQ[JIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _<25,000 sq.R $75 _TOBACCO S20 _<50 sq.ft. S45 _ >25,000 sq.ft. 5200 _FROZEN DESSERT$33 NAMECHANGE: $10 AMOiJNT DUE _ $ 2pO.0o . � '****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"••* � ADMINISTRATION . r Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSIJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� OR 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:Pernuts 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 TI-�HEALTH DEPAR'CMENT 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 Depazhnent prior to opemng. 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 NSU � AD I O Y: ' h food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post onsumer Advisoriea l4'ATERIN(' 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 obtamed at the Health Department. FRn7EN-DESSER'��--- --- --- - -- - ' 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 yow Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),Illlist haue 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: 1 SIGNATURE: �l-�� .f.� PRINT NAME &TITLE: �� a 0/]8/02 � f I SAGIFAX 101]102 213PM SHEPPqq�ql{�9ppl1GHLIN y}JRCOI PAGE I ! AGQ�Dn CERTIFICATE OF LIABILITY INSURANCE ;o�17J02°"" rAoouceA TNIS CFATIFICATE IS ISSUED AS A MA7TER OF INFORMATICIN � SheppardRfleyCoughlin ONLY AND CONFFAS NO RtGH7S UPON iHE CHiTIFICATE sa High svee� Na.o�. n+is CERTIFICATE �Es rwr w�n�o, ocr�o oR sosmn,Mn oziio-z�o a�r� rHe cov�ace ,a�or:nen ar nie aouaEs e�.ow. 617398-1800 INSURFRSAFFORDING COVERAGE INeURED INSIIREA A:�3Uf8(ICC COTpBfl�lO}E18 S�B�E O}PA ��5��'�� INSURER B: 180 Olymp�Avenue iNsua EA c: Wo6um,MA 01601 INSORER D: INSl1RER E C01/FRAGES THE POL1dESOF W9URqNCE LJSTEp gELpyy HAVE BEEN �SUm TO iHE N3UFiED NANED ABOVE FqiTHEPqJCVPFILOD INDICATED. NOTN�i}i3TANDING ANV RE�l11HENu��T, 'ISiM OR CONDff10N OF ANY CONiRACT OR p7HER DOCUMQJT NRIFi f�6PECT TO WHICH iHIS CE47fIFICATE MAV @E 16SUm OR MAY PE3ifMN, THE INSURANCE AFFORDm BY THE PpJqES DE3CPoB� HFRON 13 3U&IECT TO ALL THE TESiYIS,IXCLUSIONSAND CONDfiIONS OF SUCH PqJqES. A(�,REGATEL1NffSSNONMMAVNAVEBEIIJREDt1CmBYPAIDCWMS. �N POU EFFECiIVE POLIGYEXPIR�tTIDN LTA 7YPEOFIN9UflANCE PoLIGYNUNBER DATE MM D� DATE MM UD LIMI79 GENERALLIABILIIY EACHOCCURFENCE $ COMMERGALGENESiALLIABILITY FIREDAMAGE�AnymefireJ T CLAIMSMADE�OCCt1R ME�IXP(Anymapemon) S PERSONAL&ADVINJl1RY $ GENERALAGGREGATE S GEN'LAGGRH'aATELIMITAPPLIESPER: PPODLICTS-GOMP/OPAGG S POLICY PRO- JECT LOC AIITOMOBILE LIABILI7Y COMBINEDSINGLE LIMIT ANYAUTO (Eaeccldent� � ALLOWNEDAl1TOS BODILYINJUPY $ SCH EDU LED AUTOS (Per perem) HIR ED�l1TOS BODILYtNJLIRV $ NON-DWNEDAt1T05 (ParaccldeM) � PROPERIVDAMAGE s (Pereccitlent) GARAGELIABILI7Y AIJTODNLY-ERACCIDENT $ ANYAl1T0 OTHER7HAN �ACC $ �UTODNLY: AGG S IXCE99LIABILIIY EACHOCCURRENCE $ OCCIIR �CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE a RETENTION $ $ A WORKERSCOMPENSATIONAND WC4$.�Q�'.� OB�.�O�OZ OB�.�O�03. X ORYLIM� Tq EMPLOYEAg'LIABILI7Y EL.EACHACCIDENT y,rj��QQ EL.DISEASE-EAEMPIDYEE SSOO�UOO OTXEP EL.DISEASE-POLICYLIMIT S�O�OOO DESCHIPfION OF OPEBATIONB/LOCATIONS�IIEHICLEB/IXCLUSIONS ADDED BY ENDOBS EMENTJSPECIAL PROVISiDN9 **Supplememal Name** First Supplem�tal Name applies b all pdicies-eS Boston,Inc,etal Pdicy#WC4653p13-:99 West,Inc. Pdicy;{f WC4559p13-:99 Nor1h,Inc. (See Atmdi�Desaiplrons) CERTIFICATEXd.DER ADDfiIONALIN5l1RED;INSUflEALERER CANCELLATION 9HOOl�ANYOFTHE ABOVEDESCPIBED POLICI6 BECANCELLED BEFOqETM E E]fPIMTKIN �$BOS�OfI�FIC. DATETHEPEOF,TXEI8301Nfi INSUPER WILL ENDEAVOX i0 MAIL_DAYS WqITTEN 16001ympieAvenue NOTICETOTHECEfiTIFICATE HOLDEqNAME�TOTHEIEFT,BUTFAIWPE7D00303HALl WQbUT�MA 018oi IMP09ENDOBLIGATIONOflLIABIUlYOFANVKINDUPoNiNE�NSONER,IT3AGEN750N NEPNESENTATIY6. Al1THOP12EDqEPfl6ENTATI E ��o lv. �.�sr3�+�- ACORD 25'S(7I�1 1 of 3 #t53�7 RpY O AWRD CORPORATION 1988 r � 1 O y b i N y � I � o �,� � � ' o � � o.�.� y ' A , � � �� ¢'ao � � � W v� '�' cu � � � � �; 1 H w �C �''�.c � N ��A � ,¢,�'� Y tW/1 c� '" 3� � � ��QA 9 w � U � � Z � � �� o , .. � F � o �"a A aVi� � b �� Q � � � z � Aa .�� , w � � zw ��oo o � � O � � � �"'a � � �v � W � F �" z �' Y�� ',�.� a `" 'x � °' w ow d � � � �U � � � Wz � � � o �� H � � �° �o.�a � ° ; � 3 °' � �'S�� '� `� �..I � � � � i" y N � � -/. oo � 7 O .d t�y� � 'C , � � U c�y�C7 � ' W o �o ..�p � ; x � o �� N F, � 5a� w N � C�' y � O Q�� N ,,. ,..LTa� '� 'J"'O o � ^ i � .� p'O � � � U � 0.5 0 � � � p � � �y � •p I T 'b �y � �� a i vi N C i'."� d � � i W ,.� �' � � N �" Q �Z � P.. E� .� �i;a� � � � —Y ' � i , k�NE'7y-N�N6 , �3�� TH BOARD OF HEALTH '�'�'' ' � ��ICENSE/PERMIT -2002 � G3 L� CU ��_. u �,:,� ��:� ; * Please complete form and attach all necessary documents by December 31, 2001. Failure d�i�l�es�}n the return of your application packet. f�'0/O �l007 �:lGG • 4�0 OF ST LIS NT: — IJ �" TE . LOCATION ADD FSS• !�f ,,��I�c,� �'L/�� , MAILING ADD FSS: lfon �,�4,ri(�iYi A-t� WO[3�P�) M�) piC�D/ 9WNER/CORPORATION NAME: q� WCS T .9l'�C I1�6 �td,�i mai N F� �T t f) �!3 �-t`� MANAGER'S NAMF• � # MAILING ADDRESS: POOL CER FI ATION • � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated + Pool Operator(s) and attach a copy nf the certif cation 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' rewrds. You must provide new copies and maintain a fde at your place of business. ; 1 2. i 3• 4. ,� � I �OD PROTECTION MANAGERS - CERTIFI ATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificaUon to this application. The Health Department will not use past years' records. Yoa must provide new copies and maintain a£ile at your establishment. 1.G2�i�S�"� 2. -PERSON IN��tA��E: _ _ - _ _ _ Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFI ATION�• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at ali times. Please list your employees trained in anfi-choking procedures below and attach wpies of employee certifications to tlus 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. a�fC.� la�rS'a, k1�..'� 2. 3. 4. RESTAiJRANT 4EATIN : TOTAL#� OFFI . U . ON .V LODGING: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _BBcB $50 � _CABIN $50 _MOTEL $50 _1NN S50 _CAMP $50 _SWIMMING POOL SSOea _LODGE $50 _TRAII,ER PARK $50 _WfiIRLPOOL $25ea FOOD SFRVICE LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 �>100 SEATS $150 o0`-Oo�^0'(8 �COMMON VICT. $50 Ud^6ti _W(-IOLESALE $75 RFTA►i SFRVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO S20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHeNGE: S10 AMOUNT DUE _ $""2�5qtOp' **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**' � / _.. . . .. . ----_. ___ . --, .__ . � . _,. � - Y f'{ C ` ,,�I �. ` � ��.I l i . � � � . ` Y..a. , ADMINISTRATT6N'� >- ,w�� , � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISI-Il�4ENTS ARE TO CONTACT"IT�HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL 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 wunt by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered witkrin seven(7)days of closing. FOOD SERVICE CONS IMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERNG POLICY: Anyone who caters within the Town of Yazmouth must notify the Yannouth 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 Deparhnent. _ — — --- — — -- — --___ _ _ _ FROZEN DESSFRTS• Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),mu have prior appmval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ��/ ��/0 � SIGNATURE: PRINT NAME& TITLE: s'V-9.�O�e�lL. (J�VYy-�� o9i1 tiot (S�+'��' � SAGIFRX 1030101 9:OBPM SHEPPABRA11S4LLC P IPD 772CL'�Al PAGE 1 � �D� CERTIFICATE OF LIABILITY INSURANCE io�sii�o � rnoouG d . THIS CFATIPICATE IS ISSUFD AS A NATTFA OF INPORMA�r�ppl She�pard Riley Coughlin orns �wo coNFr�s No RIGHTS UPdJ trie CFATIFICqTE 99 F3igh Street ,"uT��itie�crnr��,a�E�FOROFo er�niE�ao�i.ici�B��r Bos�on, MA 02110-2320 617 348-190D INSURERSAFFORDMGCOYERAGE iNSIIflE� INSl1RERA:A1REr1CaR Home Assurance Company 99 Boston, Inc. etel IHSJac'n 9: 160 Ofympia Avenue 4 WOI7uCR� MIi O1SO7 i iNSUP'cR C: 'I INSUREF G: INSUReR E COVFRJY9ES THE P�IIdESOFINSUWWCE IJSTED BELOW HAVE BEBJ IS9Jm TO iHE W�1f�D NM�D PBOVE FORTHEPOUCYPEPo�INDICATED. N07WRHSTANDING ANV R�OUIFFMENT, TEA1A OR CONDff1ON OF ANV CONiH0.CT OR OTHER DOWMEN7 WRH F�SPEC7 TO WHICFi THIS CER'fIFICATE MAV BE IS9Um OR MNY PBTNN, THE IN5IRPNCE PFFORDm BY iHE POLIqES DESCPoBED H6iEIN IS Sl&IECT TO ALL THE TQA7S,IXCLU310NSAND CONDffi0N30F SUCFi PdJqE=S Af�iEGA7ELIMRSSHOWNMAYHAVEBEIIJREDUCmBYPAIDq1JMS. NSX POL�CYEfFEGTIYE P�LICYIXPINATIDN �Tp IYPEOFIN90HANCE � POLICYNUN9EB DA7E MM DD �ATE MM 0� ��b�Tg �E1lEflALL1A81U7Y EAGHOCCURRENCE E 49MMERCU.lG6VE3!i�ALLIABILITY FIREDAMAGEIAnyrn<firc) S CLAIMSMADE�IOCCUR ; MEDIXP(Anyonap8raonJ $ PERSONALBhDVINJUFY 5 GENERALA6GREGATE S G�VIAGGRg'iATELIMITAPPLI6PER: PRO�lJGTS-COMP/DPAC.Ca 6 POLICY PR� LOC 'JECT AU�fOMOBI�E LIABILI7Y COMBINEDSINGLELIMIT S ANYAUTO (Eneccltleni) ALLOWNEDAl1T05 6DD�LYINJURY S 6CN EDU L ED Al1TDS (Por penm) HIREDAUTOS 9DDILYINJURY $ NON-DW NED AUTOS _ (Per eccidml) PROPEPIY�AMAGE S (Pereccltleni) GABAGELIABILIIY AUTOONLY-EAACCIDENT $ ANYAUTO EAACC S OTHERTHAN I 0.0TODNLC AGG S IXCE39UABILIIY . EACHOCCl1RRENCE t OCGUR �CLAIMS MADE AGGREGATE 0 $ DEDUCTIBLE § REfENTION S s A WORKEIiSCOMPENBATIONAND WC4SSZ44O � OF)�30�0�. 06/30/02 7Wpqy�j�j7g �Ep EN PLOYEXS'LIABIIITV � ELEACHACCIDENT SSOO OOO ELDISEAS'e-FJiEMPIDYeE $SOO OOO � EL.DISEASE-POLICYLIMIT YSOO OOO OTHQi I I DESCPIPTION OF OPERATIONSJ�OCATIONSJYEHICLESf IXCL11310N5 ADDED BY EN�OPS EM ENT/SPEqA L PPOVI910N9 Evid ence of Insurance Volu rtary Compensation ; Other States Coverage Wcel MA Lmt-500,000 Lmt-5D0�000 Lmt-500,000 Waiver of Subrogation as Requireti by Contract Eorm# WC000313 Edt (See Attached Descriptions) CERTIFICATEHOLDER A�DITOWLINSUPEU,INSlIPFALEffER CANCELLATION - . 9H011 LOANYOFTH EABOVE D6CNIBED PJLICI6 BECANCELLEO BEFOREiH E E�IflATON DATETMEflEOF,THE IS9UING INSUHEP W�LL DIDEAYON TO MAIL_�AYS WpITfEN NOTICETCITHECERfIPICATE HOLDEflNAMED70TNELFFT,BUTPAILUPE70 W 30SHALL IMPOSENOOBLIGATION OR LIABILIIYOF ANYKIND UPON THE�N9UPEfl,iTSAGEN73ON NEPR6ENTATIVE3. � AOTHOpREDREPPESENT�TIVE �� - A�+� �•s(�l�)1 o f 3 #3 4 9 4 6 gp,y o acoRo coaaaRo.nori isee I SAGIFAX 10 101 <:OBPM SHEPPARDRILEYCOUGHLIN � PAGe 3 E�E'�RI:P'�fQN� {�or��int�d �rn Pa�e 1� ;; _ Date: O1/O1/00 Voluntary Compensation Endorsement Form# WC000311 Stop Gap - Monopolistic States Form# WCD00303 Notice of Cancellation - � of Days : 90 except 10 Non-Payment Form# WC990610 ** Supplemental Name ** � `3'3 l�Boi,� iRC. � I aMsz�a(o�)s» 3 of 3 #34946 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-048 FEE: $150.00 In accordance with regulationspromulga[ed under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General I.aws,a permit is hereby ganted to: 99 Wect ip�„ 14 Re venue„Wect Yarmouth MA Whose place of business is: Ninety-Nine Restati*��*t Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: Derember 31 2002 BOARD OF HEALTH: s�. �o(Pi�foi. sea�r¢�c: 16o t�n D. ��'.— .�` 1ee [� ttE'.s'r�uCnoNs: See reverse side.� � �7• �• [:�� a�rtek 7JY�Aeukotl 'ri�de.c Slrak. �?Z. Februarv 22 ,2002 Bruce G.Murphy, H, .5.,CHO Director of Health *RESTRICTIONS: 1. Annual report submitted by engineer in November-to include review of chromaglass batching septic system. 2. Two (2)monitoring well results(continuous data graph). 3. Nitrate loading calculations: 4. Continuous maintenance contract for F.A.S.T. septic system. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #02-031 FEE: $50.00 This is to Certify that 99 West Inc d/b/a Ninet�Nine Restaurant 14 Rerrv AvenLe Weet Yarmouth_MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violaUon of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confornuty with the authonty granted to the licensing authorities by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto�xed their of�icial signatures. BOARD OF HEALTH: (/,kaalea:�. Z�ke�. (�/Fal�r.Han SEATING: 1G0 rc� �7�K, �e'L D.. �1GC (iwuc �s�iick'yXeDauxatG � 'Ska�4. . J:-� Februarv 22 ,2002 �� _ ruce G.Murphy,MP , HO Director of Aealth • NI/12� —�I, � ' ' L�,C'L�IdZ TOWN OF YARMOUTH BQARD�F HEALTH � � '� �'�� D � ` APPLICATION FOR LIC'LNS�/PERNtTi'- 2000 DEC 0 3 1999 # ' , ��ooti�s��e°� . EAIT�i�DEPT. Please compiete form and attach all necessary documents by December 31, 1999. o o so will result in the return of your application packet. ----------------------------------------------- -----------_--- ------------- - F T I � - ' � u _ - ------------------� LO�'ATION AnnRFc IN � � Q (,Lo�� .�. ��G YLfiF� # oa��3� D > ' MA LI �LGADDRES4� /N Rerru /� � ' O �e��e c�F �,/�.� )Ll AE ot�_��_ / D POOL C�TIFICATION��-----------MV____�_�__�__�________�_�_�,------_,_____ The pool supervisor must be certitied as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certiScation to t}us fonn. 1. 2 Pool operators must list a minimum of two employees cunently 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 Deparhnent wiii not use past years' records. You must provide new copies and maintain a file at your place of busioess. 1. 2 3. 4. HEIl��Ld H RTIFI ATION All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. l7n�,_( Qo�`�Y" 2. -� � ,P' CI 3. �'1� r:a-/�.n n l C— ,e�r r,. tic 4. -� nG w.� (e��-S �r !1; ' RESTAURANTSEATINCs: TQTA�#� _.I�ID1�I-S1u18I�TG-S�r�'S: T(1'�t1�.# -_��- -----------------------�----------- ------------�_�___.____�� LODGING• OFFI .F. i14F. nNi V LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 _CABIN $50 —� $50 _CAMI' $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. FOOD .RVI F• —W�LP�I- $25ea. ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 ( >100 SEATS $150 Y2K_Kl NON-PROFIT $25 ( �COMMON VICT. $50 y�_2(o _WHOLESALE $75 AETA . cFuvrrE• LICENSE REQUIRED FEE PERMIT # LICENSE REQi.TIltgD FEE PERMIT# _<50 sq.ft. $45 TOBACCO — $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.R. $200 NAMF' rA— A�v�F� $10 AMOUNT DUE _ $ ZD�.� '"`•"pLEASE TURN OVER AND COMPI,ETE pTH�R SIDE OF FORM••••• lJ�' r__. _.__ . . . . ... ._ _i ' ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOt7TH IS NOW REQUIR�D TO HOLD iSSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINES3IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK APP�OPRIATELY IF PAID: YES ✓ NO NOTICE: PERMITS RUN ANN[JAI-LY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. i SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE ItEPORTID TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMA�NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. Ai�DITIONAL REGiTLATI2NS POOLS POOL OPENING: ALL SWIMbIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY Tf�HEAL'I'H DEPARTMENT, AND'ff�WATER TESTED FOR PSEUDOMONAS,TQTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�IG, AND QUAR`fEItI-Y THEREAFTER ; POOL CLOSING:EVERY OUTDOOR IN GROUND SWIMIv1ING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WTfHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Ti�1'ARMOiJTH HEALTH DEPARTMENT BY FII,ING Tf�REQUIRfiD TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DESSERT� FROZEN DESSERTS MUST BE TESTED ON A MONTHI.Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEA1-TH DEPARTNIENT_ FAII-'URE TO DO SO WII,L RESLTLT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNI'II-THE AB�VE TERMS HAVE - -HEE#Iv��----- — - _—__ _ OUTSIDE CAFE�� T HAVE PRIOR OiTi'SIDE CAFES(i.e.,OUTDOOR SEATING WITH WAI'TER/WAITRESS SERVICE),1�IIL� APPROVAL FROM Tf�BOARD OF HEALTH. OiTTDOOR COOKiNG� OUTDOOR COOKING,PREPARA'TION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIv1ENT IS PROHIBITED• DATE: SIGNATURE: PRINT NAME& TITLE: ll/12/99 ^ I �07/18 10:18 1828 FROM: �� 772 9009 T0: 6179330821 PAGE: 2 07/19/9B 3WN OB:Y5 FAZ 772 8009 Shepnard R11ey Consh9la �OOY ent : 8 mteP�ow'M �� CERTIFICATE OF LIABILITY INSURAIdCE 07/19/99 � � 7HLS CL°RfIF7CATE 1S ISRUED AS A GN7T6Fi OF INPOi1dWT10N wwoU00� ONLY AND �NFERS NQ fi16HT8 UPON n+e CERfIF1CA7fi 9heppard Riley Cough].ia xQ��, � c�ftmcn� oo� Nor Ara�ao, �No aR 99 High 3trcet AL7ER 7f2 covENA�E �R� Bv 1H[ PouqES eFr.ow. $08tOn, MA 02110-232� 1NStJABiSAFFORDiNGCOVERA�GE 617 348-1900 . . —• -- ,�,,,�,,,, N�'o�Uinion .Fire Insurance ��C iuuneo � � " � 99 Restauraat Pubs. Iac n�a: , . 16� Olympia Avenue n+�+�G .._ —. — - Woburn, MA 01801 a�eunEam , ... . . . auun�v e GOVERAG� TNE POIJp60FINSURANCE LtST@C BEL.ON'MAVE 9ffN I� TO THE INSUF� NAN�ABOV@ FOATIiEPOUC�'PEAIOGINOICATE0. ND7WRM ANY R6QNRBJ@!T. TERM OR COP101T10N OF Mh'CAMRACT OR 07NER �OC%11MEM WITFi WE9PK7 TO WNIOH 'IMIB CERI�FlGTE 6dAV BE 188UED OR MAY PERTNN. TliE INBURANCE AFFOAOEO 6Y iHE POLIdEB D� ilEHEIN 19 SUBIH.T 70 ALL 1HE TERMS.EXCLUSlONB AND CONpT10N9 OF SVGi POUqFS AGGR96A7E LlM1T5�Ni4Y HAVE 9ffN fi�UC�BY PAID C�A@AS. ,� `� . .. � 7YP6Q6V610111PIGQ NDNC�'xtm10lII �� E �� RKORIIM6G(Nf'��1 , , CQIMERCU1LGQiGPN.LIFBLRV �ep�plpyalw S, ��„� .n_� �.�„��. . . . — QE(�Epp�aG6flE�76 6 . . pAOWOYS•COMPArA96 S . . p�TE�aMFL@dPEA: � I.00 I ��Y ��auVa�Euurt I • -- I aNr,wm �— vm4vw,war $ auarmE0rtri05 l�row+on) °f'�Di1�'TOS eoou.r c+mm �onu�os vH�er�v e �� • Rwem�r�fl� , � AIl700NLY-GAFOOmBtT i MN�l7AolulY GM1AOC 3 ANYAlf10 �OONLY: N06 6 p�H p�q@1CG 5 C�e u�LITM p4tmeo�lE ,� . �p f�J�� e . x nmuenetE . ' '� �� ° 06/30/99 06/34/00 x �" O1"� A W��nrm WC9550652 ��,��r i500, 000 w�a�orewu+�r e�a�-e�a�v� t500i,D00 E�rneen�.Pauwuwr a500, 000 arxm I s p�710N 0/d�iWImM1.O0A710NSN��P00lD8Y�IOO�BEMG�� . ** workers Comp Information w• Wcel MA Lmt-500,00� Lmt-500,000 Lmt-Sa0, 000 ��7 YE NOLD6i omanu.r�:��¢n� CANCELLATI N sxauta xri0F7xene0YFo�lO POLJC�setGxea6eu BaPaC7nC�� To whom it may conaern . . . . w��ere�eoR++e�oms�+ mu sroewvOx roewr._ oavaw�6T+'B+ xonoaro�ne ammwcme xaamiwweovosxeivr�eurwwem moo�ei+a.� �MPWano OOLIC��now dlLw�ufYOFlwvwNO UPONn+!IN3UPex.rt!AQEN78� A71VG4. �� RA'Y �ACORD COflPOiiATION 1�8 acoan�.spt�1 of 2 #13475 TOWN OF YARMOUTH ' BOARD OF HEALTH 1 PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: Y2K-41 FEE: $I50.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1(1, Section 5 of the General Laws,a pertnit is hereby gra�rted[o: Niner,y-Nine Restanrant/PnhS, 14 Rem Avenue Weat Yarmnnth_ MA Whose place of business is: Ninetv-Nine Restaurant/Pubs Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�'d n�/.+�et�g@a, C'��.,q,�//,.�/ /� SEATMG: 160 �v�oan C�. �ulliwart� �//.� Vics l,�irma 2�s77uc77oNs: See reverse side. Ko%B,t `.�. /3,o,,,n, C'�,l � a6.;�1��a��y-.�1� s� ��f �o,��n December 15 , 19 99 ruce G.Murphy,MP , R. HO Director of Health . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-26 FEE: $50.00 This is to Certify that Ninetv-Nine RestauranUWbc 14 R m+ Avem� West Yarmonth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto at�ixed their official signahues. BOARD OF HEALTH: �l�'I�.+�slt�g�, C�.;.�q�K q � /� SEA'['¢�]G: 160 oan Gc.7�/u�llivaR.,n�a //.� Vice l.�airman o�srt/y/ .�/�Jrowea� l.la/r,� a6rielle Ja�O[��y�/dooPet , �IOeC'�y�� December IS , 19 9� ' ruce G. Murphy, MPH, O Director of Health , � �.., � �C(12C5}Cc U,rc�vY /�� zfii''�� TOWN OF YARMOUTH B�?�I,iD 9F H�A�:3'�' ' � <-.,, APPLICATION FOR LICE�iSE1�ERMIT- 1999 5 �j�'�'-� ' u ;3yg � .+ ^�� '�,_J ��..:�' HE ''i.Ti-, ' Please complete form and attach all necessary documents by December 31, 1998. Fail the return of your application packet. --------------------------------------------------------------------------------------------------------------------- ---- NAME OF ESTABLISHIvIENT: qa ReQ�o,..�a..�f- �,.6s TEL. #�so$� F362 9940 LOCATIONADDRFSS ly t�e..��.��.,��e�. �esf �l .-�� p o�6� 1bLAiI ING ADDRESS' T N T MANA(TFR' NA�iF' PAu L r'x f30BER TEL # ' 08) 4��7�- 8a8$ MAiT.iNGADDRFSS' RR Seulti•�F l�eNn Re� W�.NSGpEC (r(o4 oah�r� -------------------------------------------------------------------------------------------------- -- POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to t}us form. I. 2: Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Commumty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificat�ons to t}us 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. HEIMLICH CERTIFICATIONS: —, All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholang procedures below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �nul 13o6Pr 2. CrAi4 I�o�PR 3. s-Fe�re o'Ne1L/ 4. �Iu� l..�ALs4/ RESTAURANT SEATING: TOTAL# 1�� NON-SMOKING SEATS: TOTAL# l3D �_�__-------------------- ----------------------------- ----------------------------------- _ _ - -- — -- . — _ _-9I�I��-USE �NF,Y _ --� LODGING: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $30 INN $50 CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIlvIIvIING POOL $SOea. WHIltLPOOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 �>I00 SEATS $150 99"$0 NON-PROFIT $25 I COMMON VICT. $50 �L�/ WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ Z�Y9 �' "•"•"pLEASE TURN OVER APiD COMPLETE OTHER SIDE OF FORM'"•"• . . . . _ ... �,. o ADIVIINISTRATION iINDER CHAPTER 152; SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOUTH IS NOW REQUIliED 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�SURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED 1$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS ST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APP RIATELY IF PAID: YES NO NOTICE: PERMITS RU�T-ANNIiALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILTI'Y TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND THE WATER TESTED FOR � —PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENIIVG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlvIlVIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH M[JST NOTIF'Y THE YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� 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 YOUR FROZEN DESSERT PERMIT UNTII.Tf�ABOVE TERMS ------- _ _ _ - -- --- _ _ _-- - -- — — Ht1VE BEEN MET. OUTSIDE CAFES: OiTI'SIDE CAFES(i.e.,OiJTDOOR SEATING W1TH WAITER/WAITRESS SERVICE),MLJST 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 ESTABLISFIMENT IS PROHIBITED. DATE: $ S SIGNATURE: �� PRINT NAME & TITLE: �a�.� l G, (jofaETL �wu�/ �ast¢yiH� ��ZN P/� 'z"-6 � 10/08 18:07 1822 FROY: 772 8008 TO: 67/U�3UtlY7 PAGE: 2 ' � 30/OE/Y8 TUS 18:50 FAI 772 i00Y SIIepDard Rile7 CouBhlin Ia002 ��" � 07 10/98 » '"" _.__....... - �ori� .. . 7M6 C�tT1FICA7E 18 B!!!m AS A YATiot os affORY�nON 9hepyard Riley Coughlln �Y �►� �� Rwwrs una+ TME �ar��TE 150 Fedesal Street, Suite 1100 ��' TM� �� ' �� °R ALlHt 7HE COVERAOE AFFOROED BY TF@ POLIC� BELOW. H08tOII, Ma oaiio ��pAp�gA�pp�pCpyBq�QE . . .. ... . ."--" W�vMn �NewHa ahire Ineurance Co wu� .. _._.. _.. 99 Reetaurants Iac �e�tional iJnioa Fire Insurance 160 Olympia Avenue �,� ' "' ' — Woburn, MA 01801 c , caa�u+r _ . _. . D ..,.,.,�...„;,.:.„_,._„ «....T_.._........,..... .... ................... ..,................... ............................ �..,. ........TMIS IS TO C6i7¢Y TW1T 7H!POLICIES OF WBURANCE IlBT� BEIOW WWE BEOI IB&Im 70'MR INSIAt� NMAmA9WEFOftT}RPOIJCYPlWOD 9mIC/17FD. N07YNTMSTANDIMG ANY PEONRlMQR�lIIW OR CONIXTION OF ANY CONiRAL'T Wi 0T11FR OOCULffM YNYl1 RESF'�. TO WMCiI T}O6 CER7ffICATE MAY BE 166Um OR MAY VERTNN. Tlff W6URAlIC[ARORDEA 8Y 71� POIIC�O�CMMD HERBN IS SUBIH)T TO ALL i}IE T6RMa EXCIA190N5Alm CONd1I0N5OF S11G1 POIlC�B.LrYi'85HOUM.MAY W WE Bff]I RFDUf.'�sY PA�CMYS . ..._ W MYORMpIR�' �OIJLYMN� �OUGY/!�.`MV� 1011f.YC@RAIIGN Wfii ,.,,, o��eaiwwm a�a�m B aomau-u�un GL6121814 06/30/98 06/30/99 a�nuu�c�re s3 000,,000 ��y v�oucn�owruornoa 0 0 D 0 �� R rensaw.�wuN.Nnv d QOD�000 av�a8ico�n�c�oxBPavr �oxumm+ee sl,. 000 x i�uor Liabili �� . �.+� +500 000 �ne�v a. QO 000 •u�arnsnw�mm � caeeimano�eu1at � INY AufO — ALLqNpmAVIO! lOOLYOYUIY � BG�ULm�IR03 �� _.. ._ !0�lOAlflOi /Op4,� f IIONON7ml1U�'00 �� ... �- — PFqPGKiY WMO! 1 ��y AUI'0 ppLYaAACCmRtI 3 �xr�uro anmenury�uroaar. -^�---�==:�° lAtlf ACCDO1f i _ . ... A(iGp6G►7P � -. .- �p N�r H�C110CClA�aC� iumi��rqp� AOON�O�a[ i . OIXQliNW��os��pp� f )► wowmsoorrms�roM�re WC3470849 06 30/98 06/30 99 X euiu�acrurrte �ROYW'�TM rxaacaoa�r a500000 nern�ue+ow g � pgc�vacruvr t50000Q �� o�-ucHaerw�-c 500000 on� onewvnox ar a�er�no�snauno�e�sro�ew�mu Bvidenen of Iasurance w,,..... _n..,,�.,.,,,,, �--=---�""=M^�',......,. .. ... . . .......... _...r.,�,«,....�.�....�..�. . .. ..............w�«.....a.a.._...__.�.A..«...�.. f IIOIRD YI►Of 71��Yd[CSQ�1'OLItlN�i�'�III'�lQp!7XE 0@91A71GN GY{1i71�4MMlIINOOOQAl1YYtL��VO117011NL �p_GHYIIIII7!!I N071G�W 71i C6[IMGI!MOLCrR M�m7D71f lDf, wr rwu�e ro r�n.aiu�wonv sxu�uvott ta aatmnax ai u�rv v �w+r nm o�iun a� I ... ............ .. . �7.Iix?�s...�A�L......... .......... ................� TOWN OF YARMOUTH BOARD OF HEALTH �I PERMTI'TO OPERATE A FOOD ESTABLIS�NT � PERMIT NUMBER: 99-50 FEE: $150.00 i ; � In accordance with regulations promulgated uuder authority of Chapter 94,S�tion 305A and � Chapter 111,Section 5 of the General Laws,a pecmit is hereby granted to: I — 99 W ct Tn 14 Berrv Avem�e �xlect Varmnnth A�A Whose place of business is: Ninetv-Nine Recra r n -R b Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 1999 BOARD OF HEALTH:�'�{��'/.+�ot��pe, C'�a/��q//aq � /� SEATING: 160 � � '�'�jpjow a G, �/u�Uivan�/K�e.//.� Vica l,�irman RESTR[C110NS IF ANY: $Ce revCtSC side. . Ko�r[� p>rown� l,ler� a6.a�sa,6o��y��l�Pa� ��e �'� December 21 , 19�8 ruce G. Murphy,MPH,R:S.,C Director of Heaith 'ItESTRICTIONS: 1. Annual report submitted by engineer in November-to include review of chromaglass batching septic system. 2. Two (2)monitoring well results (continuous data graph). 3. Nitrate loading calculations. 4. Continuous maintenance contract for chromaglass batching septic system. � y THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLTMBER: 99-26 FEE: $50.00 This is to Certify that 99 West Inc M/a Nine�}�-Nine Restaurant -Pub 14 R m, Av��m�P R�ect Yarmn��th A�A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE I In said Town of Yarmouth and at that place only and expires December thirty-first 1999 unless i sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. ; In Testimony Whereof, the undersigned have hereunto affixed their official signatures. �� Bo�n oF�ar,�: �'d��/.+ �eue�e�, C�[�M././�/�rtn / /7 SEATING: IC)� �/�oart C„ �u/�Uivan�/KJ/.J//.� Vice (..�erma.n . Ko�rt� /�rowrt� C..lar� a6,��sa�o��/d�Pe� �a BlOol' ��;. December 21 , 19 98 ruce G. Murphy,MPH,RS., H Director of Health _. _ ,,.�-�� , , 3,�,��a3 , � .,,�..,, �, �-� � . � p �.—.�_ � � TOWN OF YARMOUTH BbARI�OF ��Ix� APPLICATION FOR LICENSE /PERMi'�" - '1998 N O V 2 6 1997 " Please Complete form attd attach all necessary documents by December 31, 1997. EPT�. so witl resuit in the return of your application packet. ------------------------------------------------------------------------------------------------------------------ NAME OF ESTABLISI�iENT: A//it/E� -N��(/E �rr�T TEL. #��4'�81�-�i 4 ADDRESS: /d /3to.t'y /1/� MAILING ADDRESS O O /.r/ S MANAGER'S NAME: off.t/ ��i.vnC�t' TEL.# MAILING ADDRESS: ------------------------------------------------------------------------------------------------------------------ POOL CERTIFiCATIONS: Pool Operators must list a minirnum of two employees currently certified in basic water safety, stand�'d first aid and Coinmunity Cardiopulmonary Resuscitation(CPR).Please list these employees below and attach copies of ernployee certifications to this form. The Hea(t6 Department will oot use past years recorda You muat provide new copies and maintain a fiIe at your place of business. 1. 2 -- 3.�� " � 4._"- . HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich 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 yoar place of business. 1. 1S�lm l�/� .� 2• 3. �%p.,f,.� .C�i/n�irl, 4. cS�(z'�'�i� RESAiJRANT SEATING: TOTAL# NON SMOKING SEATS: TOTAL#_ -------------------------------------------------------------------------------------------------------------�---- OFFICE USE ONLY - - --- - LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT # _B&B $50 _CABIN $50 _INN S50 �CAMP $50 �LODGE $SO _TRAII,ER PARK $50 _MOTEL $50 _ SWIM POOL $�Oea. ^WFIIRLPOOL $25ea. E,QOD SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT # _0-100 SEATS $75 _CONTINENTAL $30 �>100 SEATS 50 9&36 _NON-PROFIT $25 �.COM. VICT. $50 �a�' _WHOLESALB $75 BF�TAIL �EBYi�E� LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq. ft. $75 _FROZ. DESSERT $35 _>25,000 sq. ft. $200 AMOUNT DUE _ � a . � ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUSSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUTRED 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 INSIIRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TA7�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMTTS. P�.EASE CHECK APPROPRIATELY IF PAID: YES_�/ NO NOTICE: PERMITS RUN ANNLJALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED AFPLICATIOI3(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1997 SEASONAL ESTABLISfIMENTS ARE TO CONTACT T'F� HEALTH DBPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (ie. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TQ AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMM�NCEMENT. RENOVATIONS MAY REQLTIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENRJG: ALL 5WIMMING, WADING AND WHIRLPOOL5 WHICH HAVE BEEN CLOSED FOR 1'HE SEASON MUST BE INSPECTEb BY TI�HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE DRAII�I�D ORCOUER�B�VITF�N-�VEN-(?}�A�XSIIF-CI..ASIAiG._ __ _ __ _ FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING 'THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI-� CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT 'I'I�HEALTH DEPARTMENT. ��N D�� FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEl'AR'T14�NT. FAILURE TO DO SO WILL RESLTLT IN TI� SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. O TT ID . FF : OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TFIE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. DATE: / 2� g _ SIGNATURE: PRINT NAME 8c TITLE: �/ /7 �� 10/97 page 2 of 2 _ ,_ � - --- — — - -- _��- � 11128:87 14:41 �617 8330821 � 09 ![AIN OFFICE -�--�—r�ooziouz � � �Qy�CERTlEICATE QF LII�BlLIT;Y (NSURAN�E ,,� �: �. s: ; ?o�`z4 9�' PROOYC[II :.; ^ ._. , a. <� �,Nca.. F..r"a.,i , .>r . .. ... , .,r.... � . I C R IS IS UE A MA O IN ATION Sheppard Riley Coughlit: ONLY AND CONFERS NO RIGNTS UPON THE CERi1FlCATE 150 Federal $treet, Suite 1100 XOLDER. THIS CERTIFICATE OOES NOT AMlND, EXTEND OH ALTER THE COVERAGE AFFOADEO BY TME POLICIE& BELOW Boaton. MA 02110-1720 COMPONIESAFFORDINGCOVERAGE �ANY AIU Ineurance Company A INeypEp Ninety Nine Restaurant-Pubs et el �BM'� Attn: Mr. John Cus�en 160 Olympia Avenue °O��"Y ; Woburn, MA 01801 �� —_� D � uv^"F� . .4, ... . ... � ui ��z ,F . �. a � ` h :V"..':w'b��: �, . . . .'.. � � �ifnti:'. �. . -x � ,`o. c�`. ��TMIS IS TO CFAT�Y TNAT TFIE POLICILS OF INSURANCE LISTED BEIOW MAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV pERIOD � If�iCATED.NOTWITNSTANOING ANY HEQUIREMENT,TERM OR CONDITON OF ANY CONTAACT OR O7HER DOCI'MENT WITH RESPECT TO WNICii THIS CEATIFICATE MAV BE 166UE0 OH MA'I pERTAIN.TFiE INSURANCE AFFOfiOED BY TME POLICIES DESCR�BED HEREItJ IS SUBJECT TO ALL THE TERMS, EXClU310N$AND CONOITIONS OF SUCN POLICIES.IJMRS SFiONM MAV NAVE BEEN R6DUCED BV PAID CUIMS, CO I nK pp INlURANCC POLICY NU4YLR ��T[fFEC7Nf Pq.lOY E11P1lUtqN �� LTR� �AfE1MMIDWYY) � d1TEpiM�OEYYY� ,��Ws�� GFNEPRL WGREGATE !f COMMEfiCMLIiElERALLI481LITY . PROOUGTb•COMP/pPAGG L CUIMSMROE Lj OCCUF I YEPSONALBADV IWURY ;f �: OWNEPB d CONfMC'OR'S PROT� �EACH OCCUPRENCE f FAi£DlIdAGE(MyoMM�� I S � MED E7�(My ane pam�on) ; { AUTOYOBILE WOHRY . � i ��ANY 1U�0 � I ,COM&NED SINAI.E LIMIT � S ! I i ' � AupWfiEDAUfOR � ��"'I I ' BOOILVIWUPY ! � 4CHEDUIEDP,UT08 i i i I�Pa�n) ' f I —� NWEO�l1T05 I ' � �— . �' i 90CILV 1�11UPv � �_� NOH-0VMEOI�UT05 � I ; '�IPM�ccpvip t I ;� I i I i �� VROPERT/p�NSGi i ' WNAO6LWILRY . i . i AUTODNIY.EIA�I�EM ��. f ; : i �YA� ��'' I '�,.. �OTHERT/IANAl1TO0NLY: I . '-1 I ;--I � I �. � £ACaALdDEN' S.. -. � AGGREG�TE � S i , iuECi 4�BIUTY 1 �. . EACX OLCURf1ENCE _5 -� UMBRELL.I�OiM � - , - , - iAGGREGNTE S � OTIER THAY UMBBELtq FOAM � � - 's I WOpKER8C0YPEM8ATWNl1ND .' � . . . : � . WiLOYERi'WyLRy � � . � R''.TOXV LIMITS� � EP { . ' wC1163594 �, 06/30/97 06/30/98 E�E"c""cc'°E"T s 500000 TMEP�oPRi�roRi — '"101 e�orse�-varoruMrc s 500000 � � A PMTHEP&E%ECUTtYE " � OFFKERSARE: ' Ex��i ' 07MEN . EL O�SEASE�E�EMPLO�EE�6O i � 1 OF.Yq1VfIpN pR ppEq�}�ONO'�OC�TiONWEHIClE9BYlCuI RfNS � EVIDENCE OF INSURANCE ��Rr�.Mii�a.:.ss:w .,.. ,... �¢�9. , t�'eixxsirl.i�i o. z�i:;a t3"'�us �::��n� 3 �'� . '' :.. .�",t? 'i;.� :' i ';�.� £'� .A,.L..."^r S RkD...9`.� ...3. , '. a.[u u ��a�" '�§b..�`v.:: 7 �,i.,v::�...3 .....3 . .,. . 'a,... � SIqULD ANY Of 7�IE ABOVE OESC140ED POLICIES !8 LANCEILED lEFOpE TNE � ; Ninety Nine Restauzants-Pubs E%iIRATp1 DAT[ TMlRHOP, THE ggWNfi cmnv��v 'MLL ENOEAVOR TO NAIL x , 160 Olyc�pia Avenue ��p�Y$MfItlT7EN Np710E TO TNE CEIITIRCATE NO�DEp NAYEO TO TXE LER. Woburn, MA O18OI RIlf FAIIURE TO MML$UCX NOTI�E SMALL IWOSE NO 09LIOIITIDN OR WIBIUTY �. Of MIY KIN9 UPWJ TXC Qp�p�NY. ITS AtiENTS OR XEPRESENT►TIYEs. AUTIbR1iED REMIEBENTATIYH ' Thomas W, Sheppard ACORb 25=3'{t156} , , _ _ � , . . , ' '_._"_' �.. . ..: , '-•:r-�,��('flv/1�nnGnnber�n.,�n.• TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-36 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111, Section 5 of the General Laws, a permit is hereby granted to: Whose place of business is: Niney-Nine Restaurant Type of business: Food Service To operate a food establishment in: Town of Vn---*h Permit expires AI h el I f �, l� irmarc SEATING: 160 �j n„ „ `io n (�� u 0i., K.:/., Vice C�hairmarc RESTRICTIONS IF. JI V� "Owa 5encl a lei December 18 I o'd C Plans 1' 'y j�` IL°u�h6ivc Bruce G. Murphy, MPH, R.S., CHO Director of Health RESTRICTIONS: 1. Annual report submitted by engineer in November - to include review of chromaglass batching septic system. 2. Two (2) monitoring well results (continuous data graph). 3. Nitrate loading calculations. 4. Continuous maintenance contract for chromaglass batching septic system. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-22 FEE: $50.00 This is to Certify that 99 West Inc. d/b/a Ninety -Nine Restaurant IS HEREBY GRANTED A COMMON VICTUALLER' S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1998 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3ettp.", ( hairmure SEATING: 160 /��oara �cc7�/u��CCivarc, R. V, Vice C� irmarc RESTRICTIONS IFANY: None Ko�ert }. O�rowrc �abr//iellepp JahoG��e�-,htooPe� ichael0dou 44. December 18 , 1997 Bruce G. Murphy, MPH, R.S., July 29, 1998 TOWN OF YARM 1146 ROUTE 28 SOUTH YARMOUTH MASS. Telephone (508) 398-2231, Ext. 241 — Fax (� John Buntich Ninety Nine Restaurant 14 Berry Avenue West Yarmouth, MA 02673 Dear Mr. Buntich, BOARD OF HEAL The Health Department has not received your engineers annual rel November 1997. Your Food Service Permit has the following rest Z 257 779 813 US Postal Servjr.. Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail (See re ��^.a'17G�iCtS'1L��'11! Postage I $ I Certified Fee Special Delivery Fee Restricted Delivery Fee rn Return Receipt Showing to Whom & Date Delivered n Return Receipt Slowing to Whom, Q Date, & Addressee's Address 0 TOTAL Postage & Fees M Postmark or Date E o 0- I 1. Annual Report submitted by engineer in November - to include review of chromoglass batching septic system. 2. Two (2) monitoring well results (continuous data graph) 3. Nitrate loading calculations 4. Continuous maintenance contract for chromoglass batching septic system Please submit the annual report within five (5) days of receipt of this letter. Failure to reply will result in an Administrative Hearing with the Director of Health, Bruce G. Murphy, to discuss the status of your Food Service Permit. If you should have any questions or comments relative to this matter, please contact me at the Health Office. I can be reached by calling (508)398-2231, ext. 240, Monday through Friday, from 8:30 a.m. to 4:30 p.m. Sincerely, of� z P Colleen E. 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