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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 AcqPv�Ca,s ""': a � TOWN OF YARMOUTH BOARl) Q�' A�,'II� � � I " � � ,� �,� � �o � APPLICATION FOR LICENSE/P��2�(1 ,�.1��p � �'"" � � �` NOV 1 4 2008 * Please complete form and attach all necessary documents by Decemb ZS 2008. Failure to do so will result in the retum ofyour applicataon pac . HEALTH DEF'T. NAME OF ESTABLISHMENT: � [ q r�u� [' o S TEL. #St1k �?l1 - 6S 3 ( LOCATION ADDRESS: �//6 (�TE' fs v.�2c� 0.r'w� „J}� b261 Z MAILING ADDRESS: OWNER NAME: L4 Pla c� q �KC TAX ID (FEIN or SSN)• CORRORATION NAME (IF APPLICABLE): MANAGER'SNAME: Ef�a;.1 /7a�nirP- Z TEL. # 't'!'-/- Z�f4 S/ Sy MAILINGADDRESS: �/S Ancl�wt�e Lti til) �Grw�s✓�'l-� ►Q- t1ZC � ? POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum oftwo employees curre�rtly certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Gle at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments ue required to have at least one fixll-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 Cde at your establishment. i. Zc�e / ��nf u-Z z. �-�r�i h l��,w�.{ re Z PERSON IN CHARGE: _ Each food establistunent must have at least one Person In Charge (PIC) on site during hours of operation. 1. �;��ip�-�e� N1uvc�Id�G 2. 2ce� KAw+��_ HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig 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 f'ile at your place of business. 1. �oe/ �Q,vv�r Lt. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PfiRMIT# LICENSE REQtTIItED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN $55 MOIEL S55 _INN S55 _CAMP S55 _SWA�IIvIINGPOOL S80ea. _LODGE S55 _1RAILERPARK 5105 WHIItLPOOL $80ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED fiEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S85 _CONI"INENTAL S35 NON-PROFIT S30 I >ioosEnrs si6o #aq'�I6 /co�oxvic. s6o #69-Olb wxoLEsEu.E sso RE'IAIL SERVICE: —RESID.KI2CHEN S80 LICENSE REQUIRED FEE PERMIT!? LICENSE REQUIILED FEE PERMII'# LICENSE REQU(RED FEE PERMIT# _<jOsq.ft. S50 _>25,OOOsq.ft. 822� VENDING-FOOD S25 _<z5,000 sq.ft. S80 � _FROZEN DESSERT S40 TOBACCO S55 va�iE cxAvcE: sio AMOUNT DUE _ � 220 .00 `"""pLEASE TDR'�OVER AhD CO.'VIPLETE OTHER SIDE OF FOR�1•"*** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE AT"I'ACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED_� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOT'ELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to 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(�days pnor to opemng.PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuhs must be sent to the Heaith Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdo_or cooldng,prepazation, or display of any food product by a retail or food service establishmern is prohibited. _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETIJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIliED 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: j � ' /3�l� SIGNATURE: �,�"�—�� ' PRINT NAME&TITLE:� �'rA�✓� �K-��J�- Z 2 oC l �,L.t..2. io�z vos � The Commonwealth ofMassachusetts DepaNment of Iaduslrial Accidenu NLieIN�s 600 Washington Street, �"F(oor Boston,Mass. 02111 Workers'Compeosation Iesaranee A�davk:Baiidiag/Plambi�g/Electricai Coetractora .. .__.,_�.,_.�_..v. C��s P1��71'1e�61v name F-� C�j nt�I CGS addass: 1 � �► �`E Z� , C '7^ . ? '�i+ �A )?FT �.�'Wff��^ state' � zio�U� ! � oh�e# JOO � 1 / � ��S J � work site location(fiill addressl' �� ❑ I mm a homeowcer perfocming all wo�1c myself. Project Type: ❑New Const�uch�❑Remodel . ❑ I�a sole�proprietor and have�one wodciog in�y�capacity. ❑Birilding Addition � �] I am an employer providiog wotke�s'compeasation fa my employeex wodcing�1Lis job. comonv ume• '"Y"C 4Q}/ �� ... . .� . - . .��..- y!� 2 T� Z rr �in (w�e� � �-/c,..-.-�-.��t a/1 t�- �n• ?'l( ��S 3 / ,.. �. ,,._4 -. � w e, 0 3 32u � � ,,:, ,,,.� .�f:�� .�r��_:. ❑ I am a sole proprietor,general coetraeMr,or hameawwer(drde owe)and have luced tbe contractas listed belmv who have the following wockers compensa[ion polices: ' . -- --- l2od �.t,.�,,c,t, l �aiwt �e .aara.: I�S Q,ot�e W�a V�^�-� �,._i[�o • 1a --- Il)a<d•L� ... a� ✓�- ��: 'Ek (� 1�(�- - 7ffoa invawce eo. P a.�c... e {,[,�- � odier# � .... . .. . . ._ . .. . < .`� . eay.. adm'tls' dM . . . . . . . ��' � . � --- - . . . - - -..—.___ . : .� ---- - __ _ �. _.. . —.. . --- - — _ im ea � ��i6�eo�3i ;.:v, , a '--'�! ,. ,�...:�z, :�°.�,.�� Failee te areve wenEe n reqd'ad�adv Sedb�2SA d MGL 152 eu led b IYe�W�[ui�lotl Pe�ltln da 5e�a s�,srw,war ene ynn'Inptleaommt a weH n eM pe�altla 1�tre[�rw Ka 370�WORK ORDBH aW�9ee d3100.M a d�y q�at�e. 1 odeshW lhat■ cepyKNieatatrmemmybefwwaNMbNeO�eetl�atlYeDlAfarewengeverlpntla�. � � � !do her�eby��der tLe ptns d,�n pe�u(�iu ofperj�ry tbat N+e Infaraidlon providel a6oae is dve aid correet . �� lT.a�t-- /�. Date ��3 �d � Print�f N �C'c.�v �1'e� Z Phone# �7 �; ZY ( S I �.5 a�d.�me.wy ao oot.nac r tms■.ea to ee cemplettd Ur dlr nr mwa.mad . . . dry,a.b�va: - . . pa�iflieme d �BoYdinE UMu7meat ❑�1cen�Board ❑chedc Hlmucdhh reyame ia�dnd ❑��e � ce¢hct penen: P`°K�7 �a lmidAA LInl7 . . � From:Debnie Kleponis FaxID:781-444-0090 Itodman Date: ll/13/2 :�8 10:49 AM Page: 2 of . y . OPID DIC ��YY�� ACORD_ CER'�'IFICATE OF LIABILITY INSURANCE r.�+eois ii�ia�os pR�� THIB CER7IFICATE 181SSUED AS A MAT7ER OF INFORMA710N ONLY AND CONFERB NO RIGXTS UPON THE CERTIFICA7E Ao�mn InBUTanCe AqenCy, InC. HOLDER.TM�6 CER7IFICATE DUES NOT AMEN0.E%7END OR 195 Rocemasy St. , Hltlg. A AL7ERTXECOVERAGEAFFORDEDBYTHEPOLIdE88ELOW. NeedGaa I9� 02499-3238 Bhone:981-2�7-7800 - fax:761-449-0090 INSURERSAFFORDIN6COVERAGE �# �� - NsuREan�. Public Service Mutual N WPER 8- LdPldya CIb3 �IIp YLCOt NSURER C-. HCSC Yi�Olil .. LbCaLSOA 705 N 7th Av � Suite A-3 r+suerno�. _ Spokaae WA 9..209 H�p�E.. COVEMGES -- � � THEPoLICIESOFINSUFPNCEl51EDB:10W1WVEBEEN1591ED�OMEINSURFDINAE0P80`/EfORTHEPOUCYPERqDR",�1�TED.h fHSiPNDNG PNYREOUIRDAENT,IERMOFCON01Ti0NOFPNYCONTRACTOROTHER00CUMENTNA +^ESPEQ'TOVVHICHTHISCFFtIFlG.fEM4YF. JEOOR MAYPERTPIN.THEINSURPNCEAFFORDEDBYTHEPoLICIESDESCRIBEDHEREIN65U& C'TOALLTHETERMS.EXCLUSIONSANDCANI 150FSUCH PoLICES.AGGREGFTE LMRS SHONM MAP HAVE BEEN REp1Cm BY GAID aNMS. pOLICVMA1892 ' DF��1 DAIE MMrDDIYY WfB LTR IYPEOFN8W11NCF _ �. Eq( )CCURRENCE f GEIERFL II�BLITY �, : , COMMERCIPLGENERPI .ABRIt'I PRE� SES�EOoccuen�a) s � MEGiJ(P�Myanepersm) S CIAMS MPLE C I OCCUR I PERSONPLBPDVINJURY 5 -�- � GENFAPLPGGREGATE i " PROWCTS-COMPIOPAGG S GENi FGGREGATE LIMIT PPHLES PER-. � . PoLICY jEC'�T LOC AIROMOBLELUBLRV COMBINFDSNGLELIMIi f (Ea acoEerR) lWY NUTO PLLONMmPLT05 BODILYINJURY s �Px Dersm) SCHEWLEDAUTOS HIRmPUT05 " BODILYIN.URY s (Px ecclaertl NON-0WNmAUT05 FRO�ERttOPMAGE s - IPer,cieert) - '.. ' Pli�� Y-E/ACCIpENT S GARAOE WBLRY i PNYAUTO � ��. � FAACC S - PL.: RV�. AGG S EN. � rCURRENCE 5 E%tESSNMBREUJ�llA&IITY , OCCUP �CLr.MSMPOE . PG(� :GATE t i S DEWCTIBLE - S REfENTqN 1 - Nqfd(6MCOMPEN9ATpNAlD , TORYLIMRS ER EMPLOYHt3'LU&LRY y�03329808 08/15/OS 08/15/09 E�Encr�nccioer+r s500000 A qNYPROPRETOfliPMTNER�EXEfIIlNE EL.DISFASE-FJ�EMaOYE S SODUUU OFFICER�IAEM�R DtCL�OED'+ Ifyes.OBscnbe�nEer E1.DISEASE-WLICYLMR SSOOOOO SPECW!PROVISIONS telow - 011ER DESLRVfIONOF OP6tAM�N3/LOCAI-�IS IV611LLE5I E%ttU310N8 AOD�BY EIDORSB�EM I SPECIAL PROVISIONS CER7IFlCATEHOLDER _� CANCELLA110N TOWN-�_ SI10UlD AM'OF TE ABOVE OESCPoB�" -'IES BE CANCaLED B60FE 11E E%flR1TON DATETIBIE#.TIEISSUNGINSUPBt\M- �.�I1IEAVORTOMNL SO UAYSNRffTEN NOTYETOl/ECHiTFItATEHOLDERWIi JTOTlEL9T.&1TFPILUFETODOSOSNRLL II�PpSENOOBLIGATONORLIA&lITYOii. YKlIDIAONTEINSIRt6LfBR4ENf30R RE?REeHiTATVES. Tovm of West Yasmouth A �ACORD CORPORA110N 1988 ACORD 25(2001108) TOWI\ OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-016 FEE: S160.00 In accordance�vith regulations promulgated nnder authoriri of Chapter 94,Szction 305A and Chap[er 1 l l. Sec[ion� of the General Laws,a permit is herzby eranted to: La Playa Inc., 416 Route 28, West Yarmouth, MA Whose place ofbusiness is: Acanulcos Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemut expires: December 31, 2009 BowRD oF HEALrx: .�feeen S�iaPt, `JZ.✓V., C'/Eainmaa ClkaxCe.s ,�. 9feP.�iPte�x,�j `U,,ice ('Rucixrncur: SFATIIvG: 117 .�0�'PJ[E 3. .I�. MM4�Wfl� lXRIIR QfltL ��M.eClt�QIIIK� �../Y. � �,:;�,�y:� ...,«yK. , Not�etuber ll.2008 Bruce G. utphy H, R.S.,CHO Director of Healt THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-010 FEE: 560.00 This is to Certify that La Plava Inc. d/b/a Acapulcos 416 Route 28, West Yarmouth, MA IS HEREBY GRATi7ED 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 ►icensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ,�Ee[en S�iaPc, J�2.✓V., C'Aainntan sE�rr.:c: 111 ��ilEex�� 71�ice C'IEai�u►Lan �.renrt a,� ��, �..N � tiovember 17.2008 ruce urp y, . , Director of Health ' �;� f}cstPuccoS ,�"��s_ TOWN OF YARMOUTH BOARD OF A `� � �;T APPLICATION FOR LICENSElREP�1� �� ,, r'�. �� ' � ``% 3 `? �OU7 * Please complete form and attach all necessary�oc�ents December 31, 2007. Failure to do so will result in the return o�your application packet. NAME OF ESTABLISHMENT: F�r� �„1 n� MpYicuh �ZQs�cwYawt' � ('r N�-'.icTEL. # SoSs'T�1-tds-31 LOCATION ADDRESS: 41(o tLlc�vi �+ 127E a8 �1n� ur,,,� 4-t.. i.,t R n a�l MAILING ADDRESS: ,S�A�nn� OWNERNAME: �k ��c.J-tA ivic T XIDfF INor Nl- CORPORATION NAME (ff APPLICA LE): j_�, ��,,�,�� ,,.« ' MANAGER'S NAME: I �,�'e TEL. # -f�U �9 s/}sS MAILING ADDRESS: S n ,. , �,{q.- POOL CERTIFICATIONS: V The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operater(s)_aadauach a copy nf the-certific�tion to thisform. 1. 2 Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certiScations to this form. The Health Department will not use past years' records. You must provide new� copies and maintain a file at your place of business. 1. 2. 3. q, FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who is cenified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR g90.000. Please attach copies of cenification ro ihis application. The Health Department witl not use past years'records. You must provide new copies and maintain a file at your establishment. i. �--�_rA°q�r�m4 re7 z. 7 fr� � �an�� c eZ P�RS9N TN C�3ARGE: _ _ _ _ - — - -- -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �oe � L�C�Yv� it�Z 2.� �� Y�-� �v� y�z�ic�\G. HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificaTions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t"ile at your place of business. i. �.� KtnW1�r�L 2. 3. 4. RESTAURANT SEATING: TOTAL # / /l� OFFICE USE ONLY LOI�ING: LICENSE REQUIRED FEE PER'�fIT 4 LICENSE REQL'IItED FEE PER�III R LICENSE REQIIIRED FEE PERbIIT= _B&B S50 _CABIN S50 MOiEL S50 . _INN S50 _CA.LiP S50 � � S\VItif�1ING�00L S75ea. - _LODGE S50 _7RAILERPARK 5100 ��'HIRLPOOL S75ea. FOOD SERVICE: LICENSE�REQUIRED FEE PERMIT� LICENSE REQIIIRED FEE P£R�-D7 s LICEA"SE REQti1RED FEE PER\-ilT= _0.100 SEA7S S75 _CONTINEN7AL S?0 hON-PROFIi S25 I >100SEATS 5150 ��3 I CO;�iONVIC. S50 �OS"�� _��7-IOLESALE 57> RETA►L SERVICE: —RESID.KITCHEN 57i LICENSE REQUIRED FEE PERMIi= LICENSE REQL'IRED FEE PER�Di- LICE?QSE REQL7RED FEE PERbIIT= _a50sq.ft. S45 _>3i,000sq.d. S?00 dENDING-FOOD S_'0 _QS,OOOsq.B. S75 _FROZENDESSERT S35 TOBACCO Si0 v.��ciia.�vcE: sio AMOUnTDUE _ $ 200 . 00 "••"'PLEASE TL'RV OVER A\D COJIPLE'IE OTHER SIDE OF FOR\i"*'•* , AD1�fIl�iISTRATION 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 busiciess if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMFENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiJPANCY: For purposes of the limitations of Motel or Hotel use,Transiem axupancy shall be limited to the temporary and short term occupancy, ordinarily and customazily associated with motel and hotel use: Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewheae. 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 dwelfing unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: En�tosea Motel Census must be completed and returned.�tn ttvs aPptioac�on. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opemng. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count - by a State certified lab, prior to opening, and quarteriy 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 fiting the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heaith Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sern to the Heakh Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemtit urnil 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: Outdaor cooking,preparation,oc display of any food�roduct by a_retail or food service establishment is prohibited. NO'ITCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN Tf�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME?ICEME�IT. REVOVATIO:VS MAY REQUIRE A SITE PLAN. DATE: // - f�` 6 � SIG�IATURE: (/�S �-"-�^`' �Q ��— � PRI:VT:VAME&TITLE: �'�yd/y/ Yad 1n/bQ Z ia:�o� . � TAe Cominonweahh of Massachusetts Depar[ment of ledustrial Accidents N�aNiw�M� 600 R'ashington Streey �"'Floor Boston,Mass. 02111 workers'compe�sado■Ioseantt.4�davk:Baildiog/Plambiag/Elec[rical coehactors Fleue P'ItIl�1T kd�ls name: address: SiN sfate� zio� ohane R wotk site location(full addressl: ❑ I�a homeowmer petfornting all work myself. Project Type: ❑New Constcucu�ORemodel ❑ I am a sole pm�uietor and have no one working in any capecity. ❑Building Addition ❑ I am an employer providing waicecs'compeasation f�my�ployees working am tbis job. . _ . ._ _. . ____ . _. ____. . . . . . cemoaav mr. � ad�ees• citv: oYoee M: j�_.��. S'�� 7T�-�'f'�� r ❑ I am a sole proprietor,geeeral co,tractor,or homeowwer(prdt oweJ aed have hiiad We contwc[as lislad below who have� the following wmkecs'compensation polices: wnmev name• . ad�s• eltY: p�e#• IY�aK!t0. OBIIL'Y M w�nuv uoe• sddren• dh• � oMee#- - ___ __ . _ __. _.._ __.. __ _— W to. �ft ____- LlreitiiililiwtY�rrry- . � .� . . .. . . Faive Y a[tue awwade a reqlud odv�2SA NMGL 152 n�Mad p He I�p�itlM�f aW W pe�Nfe da 6e y bf1,3M.M�N/�r� e.e ynn'hepHxs-mt n we!u dN pmltln ie the hro�ta ST(N WORK OBDEH ud�ese KSIBO.M a dq galnt ve. 1 odenhrd IM a apy of tY6 sh6enmt my 6e t�nn�ded ro t0e Omce o[lave#�tlen ef He DtA for ovaage verMe�tlse. /do hereby cerfffy axAer tLe p/ns awd penrhks ofperjary thrt NYe l�farardlan provldad e6oae is bre rwd�rrect �,s�� ' �t -�q-o'}- erim� 2c e � a m i �Z rno,K a "n'{ a`}9 s � k s a�ew sx oely ao noe.rrke Y[Ws..r�w ae ce�qNed br tilr er e...n omcw . .. eily or fewa: �px q ��yd�g p�o� ❑ehedc Himme�ale rcapsme h�oitM �y p�� tl�Deprdeet ta°hd pvae°' Phe�e M; ❑016c ln+�a�mml ' from_S.Hale for Deborah Kleponis Att Rodman In5U2nce FaxID:781-44407!30 Noastan To�ZoN Date: 1 V142007 11�07 AM Page:2 oF 2 ACOR_D__ CERTIFICATE OF LIABIL.ITY INSURANCE �SR DK °°","""°°"""°, _ _ ACAPUI9 ii in/o� YRODIICER IIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORM:6210N „P1LY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE Rodman Insuranca Agency, Inc. '�.IULDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR la5 Rosemary st. , Bldg. A :'+LTER THE COVERAGEAFFORDED BY THE POIJCIES BELOW. Needham MA 02494-3238 � � Phone: 781-267-7800 Fax: 781-6d4-0090 IAV;i1RERSAFFORDINGCOVERAGE NAIC# in:uxeo _._.. ._ _- . !��:�RA R�blic Sezvice Mutual - _. . _. __... ,v.� e LaPlaya dba Acapnlcos -� -- --- - -�� ___-_. West YaLmouth Location �vs��= � c 705 W 7th Ave Suite A-3 � n.wzeo: Spokane WA 99204 . _ . . ___ RE COVERAGES "`-�- THE POLICIES OF MSURNNCE LISTED BELOW HAIIE BEEN ISSUED TO THE MSUR�'-1�N iR9E1�1�,F 1VE FOR TFff PIX.ICY pERIpD MICATED.N6TWITHSTANDNG lW Y REOUIREMEIJT,TERM OR CONDRION OF PNY CONTRACT OR OTHEft DOCU.9FM'`Nil i�F;ISPECT TO WHICH THIS CERTIflCATE MAY BE ISSUED OR RMY PERTAIN,THE WSURqNCE AFFORpED BV THE POLICIES OESCRIBm HEREIH 5;uyJ[�.1'i O FLL THE TEftMS,E%CLUSIONS AND CONDITIONS OF SUCH POIJCIES.AGG(�G�TE I.MITS SHOWN MAV HI1VE BEEN REOI10Ep BV PAID CLAIMS. o'�._. -_---_- ___ _ _ _____- .__-____ - �OI'rFi.i'ECTIVE -POLIEYE%PIW11qN ..- .-..-.. ----'-------� LTR RD TYPFOi1N5UppNtE OQYCYNUMB91 JIT'..�IfaOD�VV� M1F�MMOpYV) LMflS GFNERPI YqBILITY -- FACHOCCURRENCE { COAB.ERCWLC£XERALLWEIIIfV �� ....-...--.. . '��- ,PREMSES(Feu[wrel6e) S . .__ _ _. _..__.—.. . .. cuinswoE �occua t.lEOEm�prryanePersml I .. -- PER�lALeFOVYlJURY 4 .—. .� ---_ ._ � GhllERPLA6GRfGFi[ g �� GM'LAIiGFEGALEIIMIiAPRESPFA: � VRfAUCTS-CIXAP/OPqGG � $ POIICY PRO- JECT LOC MITOIAOBILE UFBYIiY — .—.—.. COM(11Nm SMGIE LMIT /WYl�UiO i (Eaatltlpry) � ALLOWXFOPIIi05 ' - SCHHJULF�PlITOS I dOUILVWURV $ �Per�.ersm) MaEnaitns ...—--' .... ' uuwowNeo�wros I ewn�vweuav S (cerar��eeop PftOF[RTY�NAi(it $ ' (w��uenp G]RAGELMBILITY — . __ ...�.. - Nlia oNLv-EqACCIpENI 4 PM'AVTO -'- OINERiHWd EHALC $ � . . . .. 4ROONLY: AG(: S .._ E%CESS;UMBREWLIABIL�TY FACHOCI'URf�NCF $ OCCUR �CIAIXSIMDE " ��—- M,GREGATE S y Ct0UC1�btF ---- S REiENMM 4 .._ _._.—_—.__ --_ —.___._ f . _ .�__� WOflI(ERBCOMPFN5qTI0NA1p � �. A EMtIAYER3'LIi841lY I �lM2YLWlf$ ER _ ��uvNrxu�uieroaivuerrvecmrr.carme �0332d807 , ;t:1.5/07 08/15/08 e.�.ee.cxaccroera s 500000 OFFICEWAIEMgER IXCLUDECT ' uyes,ues>�oewaer � E�.o�sEv,e-eneMr�ovee s 500000 saEcuaaaavisiorsoemw � --- o*Hea —.._—— ei.ascasE-caicvurmr s 500000 �F9CRIVTpH Of OYERGlbN9�LOCqTONS-VEXICLEB:ENCLU4pN91OpFy BY ENppp3FMEp�:gpE[IN F'�VISIO��i CERTIFICATE HOL�ER CANCE�LATION B�K_,_ .N(��•�pqyyOFT1ERBOVE0E6CRIBEO�OIICI�BECINCELLEDBSORETIEEXVIR0.T10H 1�a1F111EPEUF.THE188NNGIXSUpERWILLENOFpVOFTOMqL �.O DpYSWqITlFp };F{�,}y}�5.��{��k�,A„k,�,;,k�, I�O'.iE TOTIF CERTFICpTE I�p�pFR NRMEO TOT1E LFFT.BVlFRILME TO OO SO SNALI, ###}#+ti�.FiF#*f#4if*#**kF**tt**k IIR.�SENOOBLIGiT10NORWBRITYOippY1<WpUPDXTryFryBUPER.ITSRGRITSOR **}k##tt�k*1f*%#1*it**t4**i1t** I:E�`4E6FlIfq1NEC ,rsswxrxxxx+fxs+��.rf>;t>t+f*x++�� auiy� / v ACOR�25(2001/08) —.. .'.. �ACORD CORPORATION 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #08-013 FEE: $150.00 In accordance with regttlations promulgated under authoriTy of Chapter 94,Sectiou 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby-granted to: La Pla a Inc. 416 Route 28 West Yarmouth MA Whose place of business is: Acanulws Meacican Restaurant&Cantina Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2008 BonRD oF�ALTH: ,�feP�c Sf$a�, `JZ.JV., CP�awunaec ('Rrav��eo 3E..7CeePiPe�c `llice 'CRatixannn SEAT[NG: 117 � � ��t� �� QfLfL s ✓t..lV. _ November 20.2007 Bruce G.Murphy,MP , .,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-010 FEE: $50.00 This is to Certify that La Plava Inc. d/b/a Acanulcos Me�can Restaurant& Cantina 416 Route 28, West Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violauon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws,Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3feeert SRtaPt, `J2..N., CPp�atwwnaa SEASING: 117 � � � �� '� �n V `�a6Qnl 3. � IXRXIt , `./t..N November 20 2007 ce . u y, , Director of Health - F=g �D�D�g�� `T7' fJCRPULCO$ 3°� .�c TOWN OF YARMOUTH BOA�D � TH� � r� � � � � � D APPLICATION FOR LI�7S� E � => 07 r�`� / * Please com lete form and attach aJl hec �� N 0 V 1 7 �2 Q p 6 p e�ssa�"y documents by Dec mber 31, 200 . Failure to do so will result in the return ofyour application a�ep,LTH DEPT. NAME OF ESTABLISHIv1ENT: � \Go N� �e5�v ea�C`I'EL. # SOk '�i1� tcS 3 ( LOCATION ADDRESS: +•111., t,t�c,�;,n `u e��4� �?T��..fi W-ya.t,,,..E ��-+�. 1J�0. oac.,�3 MAII,INGADDRE3S: Sc.�,.ne c.0 0.ha�� OWNER NAME: T X ID (FEIN or SSTTI� CORPORATION NAME (IF APPLICABLE): L G ��,,.,,c� �,nc: MANAGER'S NAME: Z ae i �G M,r e 2_ T —s TEL. # 7��I 244 S 1 k$ MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated __ __ Pool O�erator(s) and attach��o�zy_Qf1be_certificationYnlhis fQrm- __ ___._ __ _ 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 ofemployee 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. /'�– Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ali food service establishments aze required to have at least one fuil-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this appGcation. T6e Heaith Department will not use past years' records. You must provide new copies and maintain a t"de at your establishment 1. �oe � 1�c�m� �e Z 2. gExsor��r e�c,�: ___ �._ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. �c�e / f��vr� fe2 2. �\� 4 ��n �Grv�� (eZ HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. I. .LUt t l�t.� w,�!2-L 2. �.-�w��n �C�w: ,,( �e.� 3. 4. RESTALJRANT SEATING: TOTAL# I t'1 OFFICE USE ONLY LODGING: LICENSE REQiTII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT I! LICENSE REQUIl2ED FEE PERMI1'# _BBcB S50 CABIN $50 MOTEL S50 _INN $50 CAMP $50 SWIIvIIvIINGPOOLS75ea. _LODGE $50 _ TRAILERPARK $100 WIIIRI,POOL $75ea. FOOD SERV[CE: - � LICENSE REQIJIl2ED FEE PF.RMI1'# LICENSE REQUIRF,D FEE PERMTC# LICINSE REQIIIRED FEE PERMIT N _0-100 SEATS $75 _CONT'INENTAL $30 NON-PROFTT E25 �>100SEATS $150 �J"07-01 /COMMONVIC. $50 0 �1/ _WHOLESALE S75 � RETAQ.SERVICE: —RESID.KTTCIIEN S75 LICINSE REQIJIRED FEE PF.RMIT# LICENSE REQUIRED FEE PERMI'C# LICENSE REQI7IRED FEE PERMI1'# _<SOsq.ft. S45 _>25,OOOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO S50 NAME CHANGE: S10 AMOUNT DUE _ $ 200 .o0 ••••"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM`"'•• ADMIlVISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STAT'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and Gens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: \� YES 7�- NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be abie to demonstrate that they maintain a prinapal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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, shali generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools wlrich 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 swimmiag pool Fnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yvmouth must notify the Yarmouth Health Departme�rt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heahh. OUTDOOR COOKING: Outdoor co_oking,preparation,or display of any faod product by a retail nifood service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETCJ, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � ; /� -r 3 -� � �SIf�NAT[JiZB: s 2vuc,..� ati.,.—z PRINTNAMEBcTTPLE: �G i�r�o,e� iomioc , 11/16/2006 15:14 7814440090 ROIN•1AN IN9JRMIC,E AG PAGE 02/B2 Public Service Mutual Insurance Company Ona Paik A�enlre NBwYa�k.NY 10Rt6-SB07 Bf Typ.e: Direet Bill BIII Plsn: Plan 610 Pay 10 Doxn Mthly WORKERS CORAPENSATION AND EMPL.OYERS tJA9RlTY�N5URANCE POI�Ci1 INFORMN710N PAOE N CI Cainparry No.i 8152 ' Pnor Par�y r�md�: Wc�e^°2 5 ENDQRuEMENT ��Num� �C�� ?roducerCode:d206467615 . Producer and Maill�Addrsss: AAaiGng Address: � qatlman Insurance Agency, inc. 1.aP�aYa dba+4cap�lcos c/o David Rengqlf 145 Rosemary Street 705 W 7th Ave Ste A.3 Bldg.A gp�ne,WA 992042838 Needham�MA 024943298 7he Insured:Corporation Otner worl�iaces not shown above: Named Insurad:laPlaya 2.The poliey perlod is from S115120�6 to SI1512007 1201 A.M.Standard Time at Your maling address shown above. 3. A. Workers Compensation insurance:Part One of 1he P°IieY aPpl'�es to t�e Workers'Compe nsatian Law of ihe stateS I�ted here: Massachusetts 6. Employers Liadlity insurance:Part 7wo of the policy applies to wark in�ch state listed in Item 3.A. The Ilmi[s of our liabiliry under Part Two are: BadilY Injury by Accider�t $ �4.5ffiQ �ch 9ccident Bodiy Mjury by D�ease $ 5�Q,�L Do�wY limit Badily Injury by D'isease $ 500�00o each empwyee C. Other States Insuranoe:Part l'hree of the poficy app�ies to the states,if any,listed here: D. 7tiis poliey fncludes the followin9 endorsements and schedules: S¢e Extension of IrAonrretion Page 4, The premium for thls policy wIN be deterrnined by our Manuals of Rul�s,Class'rfications, Rates and Rating Plans. All informatron required be�ow Is s+ibject to veifi�tio^a^d��'ge by audit. Premium Basis Rate Per Estimated �, Cafe Total Estimated $100 of Annual Classifica' ns S�, P�o. No. AnnualRemuierallan Ne+nu2� re iu See Ex�slon of IMormstlan Page $5,716 Loss ConstaM:SO E�ryense Cor�stant Char9e: 5284 Minimum Premium $2�8 Deposit Premlum S6,W0 Tota�EsUmated Annusi Premium: $B,WD Additional Premium: $3�375 Premium Adjustment Period: AnnuaNy Servicing omce: New Er�gland eranch � �� • Counrersigned 9l`26f2006 at New York N.Y. by THIS INFOHMAl7pN PA[iE WflH'ME WOi�ICERS COYP�NSATION At1P ENPLOYERS lIA9KITY INSURAlICE POIIGY/W� ENDMi3EMEMS.IF ANY�ISSUED 70 FOHM A pART THEFiEOF.COMPLElE6?F�ABOtlE IWI1ABEflEO P0�1CY. �AMan 1d97 pg�1 of 8 �p�IBh4 1987 Nalbnal Coundl an COmPenaeVai InasMCe pRODUt�R COPY P►acess Date:9P26PZ006 11:36:36 AM .� 5762 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NiJMBER: #07-011 FEE: $50.00 This is to Certify that La Plava Inc. d/b/a Acaaulcos 416 Route 28 West Yarmouth, MA IS HEREBY GRANT`ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 uriless sooner suspended or revoked for violation of the laws of the Commonwea(th respecting the licensing of common victuallers. This license is issued in confomrity with the authority granted to the licensing authorities by General Laws, Chapter 14q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B �r�c `15. M,`�5., . sEniu,rG: i t7 a�fs�`el rs st'rr�ry .N., v:ce ekr�n�cwc Ro6�+�t�. Beo�we, e1e3.6 P�(a Mc.`ae�oll i9.,.i(jaee .d�s�rc, R.N' December]].2006 ruce . wP Y, , . ., H Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHNIENT ) PERNIIT NUMBER: #07-0018 FEE: $150.00 In accordance wit6 reg�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Cieneral Laws,a permit is hereby granted to: La Playa Inc., 416 Route 28, West Yarmouth, MA Whose place of business is: Acanulcos Type of business: Food Service ' To operate a food establishment in: Town of Yarmouth Pemtit eacpires: December 31. 2006 BOARD oF HEALTH: B `.b. , M. `.?5., " ��"`�, .�v., v� e� SEATttaG: 1 I7 /j�6�, B�� r.�![ia�/Hv�Se�iwtok A.��j� R.N. December 11.2006 Bruce G. Murpt , H,RS.,CHO Director of Heal . 'a " 1� ✓AcAPut.c.o,s _ TOWN OF YARMOUTH BOARD 'I��'�� sAq1 ? Q 3 -',e APPLICATION FOR LICENSE/P -`�06 0 �y �'� nV Q r * Please complete form and attach all necessary do�ments by DecembeN31, �OQS?005 Failwe to do so will result in the return afyour application packet. rraME oF ESTasLis�rrr: L A ��la�ic� r a�� 3 R �C�1 �'u l C c�s �L. # so�- ��f-�s 3� LOCATION ADDRESS: �/ I[� �i� s � 12�e ��' �/V �/�cn�o c.+'th M � MAII,ING ADDRESS: S ya u�' � OWNER NAME� l.:- r YZ 1Z 1 n% � (�.l l�Y2,(= '� TAX ID(FEIN or S SI� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: E �12 A i��% �L �a n,��2 C 2 TEL. # 508 � � �l-�S.3i MAILING ADDRESS: S�/G M�a r n. ST 12 E � a fr u 1, �/ih�� u�I� M la POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2_ Pool operators must list a minimum of two employees currently certi&ed in basic water safety, standard First Aid and Community Cardioputmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �. L �'�L�� i rv l� w n.��i�LZ a. Z o �L 12�=l ti.� i 2 =z 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sazutary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wiR not use past years' records. You must provide new copies and maintain a file at your establishment. L E �'2/a ��J CL la M( f2L�- 2. Z n �L Y�- /�r M 12 CZ PERSON IN CHARGE: . Each food establishment must haue at least one Person In Charge(PIC) on site during hours of operation. 1. 2_ HEIlb��CH 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 attae�i copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiTII2fiD FEE PERMI1'# LICINSE REQi7IItED FEE PERMII'It LICENSE REQUII2ED FEE PERMII'# _BBcB $50 _CABIN $50 MOTEL $50 _1NN E50 _CAMP S50 _SWBvft��IGPOOL$75ea. _LODGE $50 TRAII.ER PARK $50 WHIItI,pOOL $75ea. FOOD SERVICE: LICENSE REQUIl2ED FEE PERMIT N LICINSE REQtJIl2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _0-100 SEATS $75 CON1'INEN1'AL $30 NON-PROFTT �25 �>100 SEATS 5150 .�06"00� �COMMON VIC. a50 06��6� _WHOLESALE S75 RETAIL SERVICE: LICENSE REQI7IItF,D FEE PERMIT# LICENSE REQIIIItED FEE PERMIT N LICENSE REQi7IItF.D FEE PERMIT# _<SOsq.ft. $45 _>25,OOOsq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT $35 TOSACCO $25 NAME CHANGE: E10 AMOUNT DUE _ $ 200 .oa "•"•"pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM"•••• ADNIIl�TISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernilt 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'ITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernuts run annually from January 1 to December 31. I'I'IS YOUR RESPONSIBII.ITY TO RETURN 'THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISFIIvIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CO1�IIvIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products are requ'ved to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departanent. FROZEN-IIESSERTS: 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 Pemvt 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 cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: ( �— I �/ �S SIGNATIJRE: PRIN'T NAME&TITLE: 12 �lV I L� �'rS� �� N� 09/28/OS � �� The Cominonweatth of Mwssachuset�s DePar[ment of Industrial Accidertu � - N�eIN� � - 600 R'ashington Stree� 7'"Flow� �� Boston,Maas. 02I11 � Wo�era'Compeesabo�t�eseee A�vk:Bn'Idi�/PI�mM�/Eleetrical Coetrxtaas � ,..:. � .., e� ys`:'. r F...�:wt .:a-. ,. in.ar t& vu�Y, a �'�.. .•. ,W'�isra�'�a§`:*YA�"-, a _ , .. . , . a�� ,�sa:'� .., �,.. � �� : � � P 1��v� � n�c- � �3 �a(� ,� c,��n�� l c 0� add�ess: �"� � � �1�-'l I IV S 1 ' I�T� �- � ��. W , �� a�2 I�tc�u'T[+ ��: /11�� r'� aP� �. �'�� "�� / -�s3/ work site locati�ffoll add�essk ❑ I am a homoowner performiog all wak myself. Projact Type: ❑New Cams�uctim QRmiodel I�a sole �dor and have m�e w in an ❑B�ril ' Addition I�an�ployer providiug w«kas'compeesation for my�ployees wodcing m tbis job. . . . �..�.�: �-- Y� 1�1 I�U /� 2 NG D 13� .�I c�1 Pc,1(Cl?S' �: �l � � M v� � N s T ��r� �� R t�w�1�i-� �a- DS- � 3 i- G s 3i U r�i re s�2�<«� a�uruA� co ��yo �os ❑ I am a sole proprietoy ge�sl eoitrxtor,or Yomoowaer(cire%owe)a�have ltiied tbe conteactots lisled below who have the following wcekets'compeosa[ion polices: •ddn� db• oY�e A: 8 • (Z� p Mr�N � NSu2.q ,vL�= aates.:___ � t'� S' K..�S�'P-i�.Q i..� S�' � �c:�.C� ' A _ Ju i s� l�t �-b3��4� �� 8l - a��- �oa �.: �t c�h�v�n ,�, _ �. � ' - IzV�CC' �lLl°C(,t�L . " � �- � �2 C _ � FaiveYaeevearvyesrtq�trNoAerSatlu25A�MGL1ffimisdblYe�iWrdarlN�tlpnaltlnKa4m�bQ3M,MaWx oae yean'ImprYoemot a�we8 n cM pmltln ia f!e br�Na 5fOr WORC ORIIER arl�B�e tf1N.N a dry ap�t�e I odenhW Idt■ npy�Nb Na�nt dy be hrwarad b Ne Omee at1mMl�Waro ef Ik DIA tar�er�veef�nWa i��,arsy�s�ie.a�e a��of ery rAat Me tefennmMu proddal abnae 6 ave nd mmet �;� �.-- l' ' �u.«,� � J/--�o/b� p�� v�� 21� n-t �� L 1� Pna�a Sb d''- `��/ -f�s 3% arecw.seo.ry a.■otmrihrm.arnbeea�fdArdlr.rw...mdd dy or tewa: pvdtlic�e i flBsidYa De.p�ttent ❑tYedc H1mm�Be�apene h�eqQed �� QSdM�a'a O�m �dnM�Depr�af rostaRpeiaea: pYaaeN; 1�1(f� c.ioa sK 1am) ACORD CERTIFICATE OF LIABILITY INSURANCE CSR DR DATE(MM/DWYYYI� ACAPUI9 11 02 OS PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE itodman Iasurance Agency, inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 145 Rosemary St., Hldg. A � ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Needham MA 02494-3236 � Phone: 781-247-7800 Fax:781-444-0090 INSURERSAFFORDINGCOVERAGE NAIC# INSURED MSURERA: F1rEID3II�S Fl1I1fI 'Zj$73 INSURERB: p�S1C Service Mutual LaPlaya dba Acapulcos INSURERC: David Renggli 705 W 7th Ave Suite A-3 INSUftERD' Spokane WA 99204 INSURER E' COVERAGES � THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDING ANY RE�UIREMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT W RH RESPECT TO W HICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS,EXCLUSIONS AND CONDRIONS OF SUCH POLICIES.AGGREGATE LIMRS SHOWN M1NY HAVE BEEN REDUCED BY PAID CLAIMS. c ucr�cairuno LTR N9R TVPEOFINSURPNCE POLJCVNUMBER DATE MM/D� DATE MW��/YY LIMITS GENERALLIABILIN EACHOCCURRENCE S ZOOOOO A b' COMMERCIALGENERALLIABILITV S30MXX60844223 �$�16�0$ OB/16/06 PREMISES aoccurence 31�0000 CLAIMSMADE � OCCUR MEDEXP(Arryor�eperson) S SOOO . PERSONALBADVINJURV 4 ],OOOOOO GENER4LAG6REGATE $ ZOOOOOO GEN'LAGGREGATELIMITAPPLIESPER: PRODI/CTS-COMP/OPAGG $ ZOOOOOO � POLICV jE� �OC AIITOMOBILE LIABILJTY . COMBINED SINGLE LIMIT ANYAU70 (EaaccideM) $ ALLOYJNEDAUTOS � BODILVINJURY S SCHEDULEDAUT0.S � (Perpersan) __. __ HIRED AUTOS . .__. __ .__.. ..- BODILV INJURV $ NON-0WNEDAUTOS � � � / . � (PerawlEem) ��. � (ut%�'� i �(/ PROPERTV�AMNGE �/ ) (Peraccideni) $ GARAGE LIABILITY . .. �L �/J�� (i� E AUTOONLY- AACCIDENT $ ANVAUTO "' r •• . OTHER THAN �+�+CC $ . . AUTOONLV: AGG $ EXGESSNMBRELLALJABILITY . � EACHOCCURRENCE S OCCUR � CLAIMSMHDE �� AGGREGATE $ $ DEDUCTIBLE S RE7ENTION $ � $ WORKER3 COMPEN9ATION AND - EMPLOYERS'LIABILITY TORV LIMITS ER B ANVPROPftIETOR/PARTNER/EXECUTfVE wCOZS'�OZOS OB�SS�OS 08/15/06 E.L.EACHACCIDENT SSOOOOO OFFICER/MEMBER EXCLUDED? � Ifyes tlascrlbe urMer E.L.DISE4SE-EAEMPLOYE $ SOOOOO SPECIALPROVISIONSbelow E.L.DISEASE-POLICVLIMIT SSQQQQQ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXC�USIONS AOUED BY ENOOR3EMENT/SPECl/LL PROVISIONS Re: 416 Route 26, ➢P Yarmouth, Mass, CERTIFICATE HOLDER CANCELLATION SAMPL-- $H�ULOANYOFTHEABOVEDE3CRIBE�POIJCIESBECANCELLEDBEFORETHEEXPIRATION OATETHEREOF,THEISSUINGINSURERWILLENDEAVORTOMPJL ZO DAV3WRITTEN NOTIGE TO THE CERTIFICATE XOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALI. IMPOSE NO OBLIWTION OR LIABILITY OF ANY KINO UPON THE INSURER ITS AGENTS OR SAMPLS__"'__"'_"'_""'____ . .REPkE4ENTATNE3... � R E ACORD 25(2007/08) �ACORD CORPORATION 1 TOWN OF YARMOUTH BOARD OF HEALTH PERMTf TO OPERATE A FOOD ESTABLISHNIENT PERMIT IVIJMBER: #06-007 FF.E: $150.00 In accordsnce with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I I,Seclion 5 of the�'ieneral Laws,a pemut is hereby>granted to: La Playa Inc., 416 Route 28, West Yazmouth, MA Whose place of business is: Acaoulcos Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 2005 BOARD oF HEai,'rH: 8e�c$. � M.�. ' SEATING: 117 ��s�e��f°�""` �Sl�. arv. A.��j�, R.N rro��t��s zoos mc;e G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSET"I'S TOWN OF YARMOUTH , PERMIT NUMBER: #06-007 FEE: $50.00 This is to Certify that La Plava Inc. d/b/a Acapulcos 416 Route 28, West Yarmouth, MA IS HEREBY GRANCED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or reyoked for violation of the laws of the Commonwealth respecting the licensing of common victuailers. This license is issued in confornrity 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 signariues. BOARD OF HEALTH: Be�ry�«.i�s :�1. Cjo�do�c, �l9.:7�. ' SEATAIG: 11� A��, v�ef� Ro6�t�. B.a�, U� �f� sl� R.N. .��j� �6��, R . November 15 2005 � Bruce . Murphy , . ., H Duector of Heal 3 °`;""�sc TOWN OF YARMOUTH�fh�l�,� �_ LTH -- - a - ,� ��',= APPLICATION FOR LICENS�/� ` 005 �� +�a � � * Please complete form and attach all nec8rsary documents by Decem'er 31E20640 1005 Failure to do so will resuit in the retum of your applicalion pac e�E,,,, ,, _,, U E PT. , NAME OF ESTABLISfIMENT: xI P u I C,0.4 TEL. # O�'-�,�/-G.i 3I LOCATION ADDRESS' �//� /� �I e '� �. W Ycz rn'IG�-t ��, J�( tJ MAILING ADDRESS: � .�7 M C' OWNER/CORPORATIONNAPvIE: C c ' UYr� rPz TAX �D N o2SS# ; /�`� MANAGER'S NAME: �= C.� ►1 �tw��r Pz TEL. # S- f- C�S 3/ MAILING ADDRESS: �// � � E . \ p r Y��c1 h �( POOL CERTIFICATIONS: ,,.- The pool supervisor must be certifie a Pool Operator,as r �red by State law. Please list the designated Pool Operator(s) and attach a cop the certification to thi rm. �_ . 1. — i � � 2. Pool operators mu st a minimum of two lo ees currently certified in basi ater safery, standard First Aid and Communi ardiopulmonary Resu ' tion �CPR). Please list these oyees below and attach copies of employee c cations to this form. e Health Department will use past years' records. You must provide w copies and maintai £de at your place of busin i. � dd � �, , � ,- � a. Z � e / R�� -z, 3! 4. FOOD PRO'I'ECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food 3ervice Establishments, 105 CMR 590.000. Please attach copies of certification to this appGcation. The Health Departmeut will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. ��s'd «, �d �ni� � 2 2. � e / Qo16,� is-� Z PERSON IN CHAliGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. I. ��rd�ti � � �y,i/ P L._ 2. 7,v � � /�Cel �„ ��e �. �- 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-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. i. �-�r a, � �R �.", ,� � Z 2. 3. 4. RESTAURANT SEATING: TOTAL# I�� _ ioncuvc: --- ___ _ _____ _ OFFICEUSEONLY LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT H LICENSE REQUII2ED FEE PERMIT'# _B&B $50 _CABIN $50 _MOTEL S50 _INN E50 _CAMI' S50 _SWIIvf[�fING POOL S75ea. _LODGE $50 T'RAII,F.R PARK S50 WfIIRI,POOL $75ea. FOOD SERVICE: " LICENSE REQUIRED FEE PERMI1'# LICINSH REQUIItED FEE PF.RMIT# LICENSE REQUIItED FEE P �# � _0-100 SEATS S75 _CON1'INENTAL $30 _NON-PROFiT $25�- � L>]00 SEATS $150 � �COMMON VICT. $50 �1`-a S-IlB _WHOLESALE ��/5� � RETA[L SERVICE: _ LICENSE REQilIl2ED FEE PERMIT# LICINSE REQUIItED FEE PERMTl'# LICENSE REQ[JIItED FEE PF..RM[T# �<SOsq.ft. $45 >25,IXlOsq.ft. $200 _VENDING-FOOD S20 Q5,000 sq.ft. S75 _FROZENhDESSERT $35 _TOBACCO $25 NE H$c[inxcs: $�o r AMOIJNT DUE = S ?1�0.00 ••"""pL%ASE TURN OVER AND COMPLETE OTHER SIDE!OF FORM••••• �� c-� �c-,,, � � I ��!`•�� ` 1 � ��L.. i � i.�:.; i 9 � l�e<<r/�` � d,a8� �c,,�-L� �..; � t r ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to o�erate a business if a person or wmpany does not have a Certificate of Worker's Compeasation Insurance. '�aAT�`�G'H�D SThT� �VOIiI�R'S COMPEAISATIQIY Il�IS�[TRA11iCF AFFIDAViT MLPST BE�TIIPLETED AND SIGNEH,OR CTRT. OF INSt9RANCE ATTACf�D � WORKERi'�GOMP. AFFIDAVIT SIGNED AND ATTACHED� �/ Toam ci�`"Yarmout6 taxes and li�s must be paid prior to renewal or issuance of your permits. PLEASE CHECIG° �4PPROPRIATELY IF P�t1D: / YES // NO NOTICE:Permits run annually from Januazy 1 to December 31. TT IS YOUR RESPONSIBII.TI'1'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMIIVT FORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COD�NCEMENT. RENOVATIONS MAY REQLJIRE A SITE PLAN. ADDTITONAL REGULATIONS POOLS __ _ _ _- - - POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER T'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or underwoked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. 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 seati�g with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is pro6ibited. DATE: l'�—�/— D � `�GN.ATURE: �i/"��G�---�. t �'I'NEiME&TTPLE: /v!al��y,��. r � 10/22/04 �-- �c_ � �a`� -- 3cc � e��c� �� o � D�e(�h�� -��_�� - _ - - � --- -- - - --- -- -� N{.IQ'Ul'l -VD V D"J - wawwn TNIS CERTIFILA7E IS ISSUED AS A IAATTER OF MIFORMATION ONIY AND CONFERS NO RIGH7S UPON THE CEHTIF{CATE Rad�ean Insurance Agencp, Inc. HOLDER. THIS CERTtFICATE DOES NDT AMEMD, EXTEND OR 145 Rosemary St. , Bldq. A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Heedham 1!A 02494-3238 i Pdone: 781-24T-7800 Faz: 781-444-0090 {INSURERSAFFOROINGCOVERAGE �NAfCX ---_____...—.___..__.._ . ___.___..._ . _.._._..____f--. __ _._.__.. _ _ __._._ _—____—_._ ___ _.____. _. wsw¢o wsuxa.:_ PUblic Satvice [9�tw31 _ ___ 'ezw�rr e I.aPlaya dba Acapulcos Aavid Etengg li `"�'""�R` ---_— _.-- 400 S JefPerson Swite 100 I�,-,,,,�„v Syokane HA 9420! F' -- N9!PEP.E- COVERAGES 7ME PDLICIES OF MSURANCE USTEO BELOVY 144VE BEEN 1SSUEA T0 7NE INSURED ro1WE0 ABW E FOR TME POLICY PEft10D 1NDIf,ATE�.N07WITMSTAfOING MIY REUUIREYENT,TERM OR CIXJDI710N Of PNYCONTfL4CT OR O'NER OOCUMENT WITN RESPEC�TONRIICH THIS CEftT7FfCNTE 4MY BE�SSUEU OR bl4Y PE2TAIN,THE WSURANCE AFFORDED BV THE POLiL1E50ESCRIBED HEREIN IS SUBJECT 70 ALL THE�ER6i5.EXCLUSYONS AND CpVDITIONS OF AICH POlIC1ES.MGGREGATE LWATS SlIOWk MNV HqVE BEEN REDIICED eY PAIO GlA1M5. _ ._'__�.'___—__ T _'..__'-. INSR --- —____._. 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A1C.ts�EU'J.TOS [f:ILIYN1.Wti I I lf�nP�' �I I S ; .fHEUbtEOfL'!'CJS �, � . �'I i : ._. __._._ __ _,_ iI HFYCw'fOS � � � �B(X`L 1 P �-.. y • � I NCµOrtNEDw1f105 � I � �6�er �g � —I � 'i : � _�_ _.___ _ -__— - _.. � I IGRCPe'R^/lNLL?F � i � I I�Lif1P1Y GNUf#LWBI[11V I :YJinpr,�'.:.FAT^�.�N� 4 i �"Y• �u�i nuTG � i '�`it R 14x C ^C ;S i '_- � i ' _ .}- —_ ._..._._ � � � _�_ I a::�GOv_r. u"' �.l-=__ � �fICfGG11M1LAG.11�L1iY61fY [ti}�O�:�LfdiEl�CF 4 F �—• �I ��xcw �: cixn.^.�woe. i i � �ncmEc.�.-c s i .___ " _'_ _.__... ...___.. � f 4 � "__ — .__ _ __. _-___. '�:k�tlCfldLE � ' � S i jlfriEMqu y ' � 1 'WOflMER6CaWFJVS4110NMtl0 '_ '�S - � O-M1 tOR IJfdTS F�__ ��yM°LOY�°�t6�B�°� __e,.n.rcvsr< �s 500000 A i : TO BE ISSUED OB/15/05 , OB/15/06 �.aNVMip'vIE1-wNNEthFNIEeECUtmE � -_ . -_-_ "'_"' ___...._..__ :OGF.G�N C'MEC:PE Ll.VT1G.(l+ � I e�,-osea.,[ cr.cua�_a+ce �s 300000 ��c+vaw".rs�c s oa.n :e��_oa�Fnsc acu�V us�00000 or�q � � i i � DESCNlTpN Oi OPEMTbNSlLOLATqN51 VEMLLEB/E�ClU6fOM�OOmBY[Mpp,6EM6MJAFCML pRONLOt�i Ae: !16 Rte 2B, Hest Yarmouth, Nass. � � CERTIFICATE HOLDER CANCEILAriON � S�L-� 4NOUL04�YO�1NEIBOVEOFi[PNEOPOLiH45BFt14CEllFDBKOM6IHEE%P11NtbW OH1EiXFFFOG.TMEl4&MNGMSUMAMM1tElYOG11tlOR1UN411 1� WYSN:i1tt6N }�pf10E t01f@.^,g[TIfICGTE NOLOER NiKO TO TNE LFT.&1T N4UIIE TO OOSO BNMI �fbO5EX0 OBUGG110N OflLYBILITV Oi�NY I(INp MON TX!MSYI�R IT9 W9�I0 p!1 Town of West Yaxfaouth ^s"^E��"T'�� au ACORD 25(21101108) @ RCORD CORPORATION 1888 _. __ � � �� The Con��nonwealth ofMassachusehs _ Departn�ext ojlndw�Yrial Accideatc � _ _ N�ali�reM�t - 600 Waskingbn Sfreet, 7e8 Floor �x. ' Boston,Mass. 02I11 � Woricas'Com�ewtfoe I�s�a�ee ASd�vk:B�d�og/PI�mMq�Eledncnl Co�hxlers - -��._.., ._:�— - ..x b� �K 8.�:zM`, ..�k`.�,.. +�A'rX,�' name: � C'Ctnf.l�� 'tiICI r�/ aaaRss: � � � -�,� 12�P �-� si�Y�C 1'�'1�U,�� state• � /�' zo• ohme M work sih locaRon(fall add¢ssl: ❑ I am a homeowna yerfoxming all wmk myself. Projed Type: ❑New Caoahuctiao QRenodet I mm a sole �dor and Lave no aoe w in� Addition . ...�.: . . .� � . . .. ..:�. � . . .. .. , .. ❑� I am an employer}xoviding waake�s'compeffiation far my�ployees working a�n ihis job. � K2�r�2�—.�t �S P� (f � G e /LI� r r � .,� � �• 1� � �n .P �-iav�. S 1` � I��/� Clh: �i r �{'/a Lv� �/� C�.,� yg �/ oYwelk L-(�7J {l�� G � . I am a sole ptopiietor,ge�enl co�trxMr,or�omeaw�er(cuele aw�)�d have hired the co�s listed below who have the followiog wakets'compencation polices: �...e: � �a�ol1 c SP r�� tc� 4� �� e..�< �!; � �l� ��IS� Y✓l6�YU � - "a� �r/1 � � � �• J�p e ��c� �� d�lW o�w �,y ��- �-k � a '� �.��-Z� r G �...�• �- �• �s- r FaYve i�rsme eavaqc n reqdred uiQ SatlN BA�AlGL 1ffi m lead H tl�e��[aiNY pn�Mn Ka de�b f1,3KM ndhr �7��+'�PM�at a wM ae dN pmitln te tYe 4r�Na 37'Ot WORIC OFD&R ud�eas dS1M.N a day aplot�e. I udenhW Wt a eepy Htlb Wie�mt my he txwarUrd b He Omce afla�ipWr dlYe DIA hr uv�na�e val6ntlw. I do 6errby c rnder e peiwa�u(pene ' ofpajwry Ma Me h�fenwmton provided above 6�e md cer+�oct � �U�v�—� - � f— /S`lG �— emm�� U l G tz . � �c. rbo�n q��'~ S'�� ` t/3�i� a�id me owy ao na.rtke Y w.un a ae ea�Waed br dtr.r en.n.meW dtyortrwn• � P�# "' -" Deqr�nt ❑ehark Kimme�4�peeee b rtqoM �BeiN �'a O�cc �s,a.�mm�� P�el; fkwe �t TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #OS-199 F'EE: 150.00 In accordance with regulations promulgated under authority of Chaptet 94,Section 305A and Chapter ' 111,Section 5 of the Generai Laws,a permrt is hereby granted to: Efrain Ramirez 416 Route 28 West Yarmout MA Whose place of business is:_ Acaoulcos Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires:_December 31. 2005 BOARD oF HEALTH: l/�►a�a�nriu'ss$. !�'oadoa/,1'M.�, • SEATINC.: 117 r�� t�fm16��/�� v�� RaYBR(.'Y. B�iONIIL� {i(dL� �S!� R.N. A.,.�l�'� R.N. s�t�,t�zo_2ws Bruce G. Murphy,MPH,RS.,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NLJMBER: #OS-118 FEE: 50.00 This is to Certify that Efrain Ramirez d/b/a Acanulcos 416 Route 28 West Yazmouth, MA IS II�I2EBY GRAN1'ED A COMMON VIC1'[JALLER'S LICENSE In said Town of Yarmouth and at that place oniy and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendmems thereto. In Testimony Whereof, the undersigned have hereunto affviced their official signatures. BOARD OF HEALTH: Berclawti,s 2. �+ido,g M..`)!. ' SEATING: 117 /f��, n,� nf �f� V (ilfG Rode+rt 4. BA«ws, C�l�sdi �Sl�, R.N. A..� �j�, RrY. seo��t�zo.zoos NCR Duector of H�eakY}i ' ., H