HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 . � , � � ��
�°� � TOWN OF YARMOUTH BOARD OF HEALTI� ,-- '� :,
� APPLICATION FOR LICENSE/PERMI'��f�2009 ��' �
, � � �� �� ,'�v, � d� zU08
* Please complete form and attach all necessary documents by D�cemb 1 S 2008.
Failure to do so will result in the return of�ow Sppficabon pack .,`-' ! �F i-'I-.
� -
NAME OF ESTABLISHMENT: ANN t ��n �S K/f h n TEL. #.�,f-77S- 7]7/
LOCATION ADDRESS: �7i aT, ,�S'/
MAILING ADDRESS: � U
OWNER NAME: 172br'Q� 1d r-�-2. TAX ID (FEIN or S Nl•
CORFORATION NAME (IF APPLICABLE): ��K , LL C
MANAGER'S NAME: TEL. #��';-3� - 7Ss6/
MaiL�rrG aDD�ss: 3 8 .S'T'n ner u;n �r• ,�" crn�n uT�,�yA ��i �u
POOL CERTIFICATIONS:
The pool supervisor must be certi6ed as a Pool Operator,as required hy State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. Z.
Pool operators must list a mniimum 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 ofexnployee
certifications to this form. The Heaith Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Piease 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.
l. I�ru.. .7uar�-e- 2. 1 U ler �u�i��e_-
PERSON IN CHARCr�:
. _ - -
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i. l�r�. �UDt-t�� z. U/er �UC ��
—�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
t. I�hra �uar� 2.
3. 4.
RESTAURANT SEATING: TOTAL # .36
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERM[T#? LICENSE REQIIIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT=
_B&B S55 _CABIN S55 _MOTEL S55
—�N ��5 —Ca'� �» _SWIMMINGYOOL SSOea.
_LODGE S55 _'I'RpII.ER PARK 5105 _WHIRLpOOL S80ea.
FOOD SERVICE:
LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII"# LICENSE REQUIItED FEE PERMIT#k
I 0.100 SEATS SSS �9��� _CONI'INENTAL S35 _NON-PROFIT S30
_>100 SEATS SI60 I COMMON VIC. 360 ?�6�—�33 _WgOLESALE 580
RETAIL SER�7CE: —RESID.KII'CHEN 580
LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQL7RED FEE PERMII'#
—<�Osq.n. `��0 _>25,OOOsq.f}. 5225 _VENDING-FOOD 525
_<25,000 sq.ft. S80 _FROZEN DESSERT %40 _I'OBACCO 555
�a�7E cx.a.�cE: sio AMOUNT DUE _ $ /y�, ��
"'"*'PLEASE TURti OVER AND CO.'1-IpLETE OTFIER SIDE OF FORVI**^*•
ADMINISTRA'ITON
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not haue a CertiScate of Worker's
Compensation Insurance. THE AT'I'ACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTI'MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth tu�es and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitarions 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 s'vc(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as 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 openu�g. Contact the Health Department to schedule the inspection five(S�days
prior to opening. PLEASE NOTE:People are NOT allowed to stt m the pool area until the pool has been inspected
and opened.
POOL WATER 1'ESTING: 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 CI.OSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by Sling the required
Temporary Food Service Application form'72 hours prior to the catered event. These forms can be obtained at the
Health Deparhnent.
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 Boazd ofHeaith.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited.
NOTTCE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RET[JRN
THE COMI'LETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TIIE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: I� Zb SIGNATURE: ,�i�/�Jil ���
PRiNTNAME&TITLE: �CI�/'(.l_ �- • ��/�'�- " �Wn�
iarzvas
' �\ The Com�nonweahh ofMassachusdts
Department of Industrial Accidents
�f N�
600 Washington Street, 7`"Floor
Boston,Mass. 011ll
Workers'Compe■sation ios�ance Af6davit:Baildiag/Plombieg/Eleclrical Cootnct�s
�t�aWa^ p�ue Pun�r��u.
�: .hra ��,►'�
address: �X � )��11'�.� F�'{� !' �� � ' .
ci�/�f��� state� 1"I� zio Q��O�l�ohone# -�QK ���O' GJ���O
work site location ffiill arldassl �
❑ I am a homeowner performing all wo�lc myself. Project Type: ❑New Construcd�❑Re,model
❑ I�n a sole�proprietor aod have no one working in anY�����Y� ❑Buildiug A�ition �
❑ I am an lo er vi woikas'com (�� ���UG�h)
�P Y y�P�ro �8 pensati�for my�ployees working�t6is job. .
comoanv me: /fiN/�AI �I' � l l'I r Pl l /�'/�
�a�: `�'71 Pl T. oLg
�ty: W � �/��rma rrh , MR ��w- .�D�'— 77� y7�1
,��. Guarn :�r�t . 4raua .,,� �7� �� 9a�qs�
. .� � _ _ :�x, . �� � ,�,�� _ .
❑ I am a sole propriefor,ge�eral costncMr,oc homeewner(drele oeeJ and Lave hired the conhactois lis[ed below who have�
� the following wo�fce�'compensation polices:
mnmvoame. �. ' . . . . . .
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upgdtlNtlaie�eateuy6et+rwardWatEeOmecatlaw�bpetHeD4lfirpven6everlBntlw. ���e� luMfaheAtYata
/Ao heeby cer6fy xxder tAe petns andP�ns/6es.' A�Miat f6s iefornraton prevlJel above 6 bwe rwd aorrret� . .
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Print name 1/�P�YYA , . L J �6 �� � Phone# ��' �,���7�,� � �
o�efd ex anty do aM wrils d this un ta 4 mmPkfed 6Y dtS ar bwn a�dal .
eily or towo: � . ��M
I—I�e.an�p�.«ent
❑eheek Nimme�6e re�me b rcqe'vM . .. ��°�6 Board
QSdaime�'a O�ee .
ceehe[ptteen• OHnM�IMpa�at
tn+is�d s�mo�l ��' �e+
� GUARD Workers' Comcensation and Emnlover's Liabilftv Poliev
NorGUARD InsuraMe Company -A Stodc Company
I NSURA NCE Policy Number TTWC908992
G R OU P Reeewal of NEW
NCCI No.[25844]
Policy Informatioo Page �
_--------_._----_ __ ..___ ......_.�--------_..----- -------- -----._---)
{1] Named Insured and MailiAg Address Agency
TfDK LLC HUB INTERNATIONAL NEW I
38 S[oney Hill Dr ENGLAND �
South Yarmouth, MA 02664 299 Ballardvale Street
Wilmington, MA 01887-1013
llgency Code: MAMLGASO
Federal Employer's ID Inwred is Limited Liability Corp (LLC)
,
{
Additional Names of Iesured �
(N2) ANN &FRAN'S KLTCHEN �
Locations on Policy {
I
�
(Ll) 471 Main St , West Yarmouth, MA 02673 �
to�/ozJ2oo8 - o�ro2/2oo9) }
��._._ __ __ ___ —_-- ------�--------�
[2] Policy Period �
�rom)uly 02, 2008 to July 02, 2009, 12:01 AM, standard Lime at the iosured's mailing address.
. .'_". ._. ..... . __ _. i
\ .._..._��._,.._ ......_.... .�_._� _... . . .........
__._. __.._._.__ ...._.......'__ �
[3] Coverage �
A. Workers' Compensation Insurance - Part One of this poficy applies to[he Workers' Compensation �
Law of[he following states: Massachusetts
i
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed �
in item [3jA. The Iimits of our liability under Part Two are: �
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease - each employee $500,000 �
Bodily Injury by Disease-policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any sta[e listed in �
item [3]A. and the states of North Oakota,Ohio, Washington, and Wyoming.
D. This policy inciudes [hese endorsements and schedules: �
See Extension of Information Page - Schedule of Forms 4
_ _. _ ..__ �,�
[4j Premium �
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subjed to verification and change
by audit. (Continued on another page)
Total Estimated Policy Premium S 857
7oW1 Surcharges/Assa�rnents S 36
Total Estimated Cost S 893
:o-eaNn�use Mz Page- 1 - Informati0n Paqe
�•�� : TTWC908992 WC OOOOOlA
Cn:e : 07/09/2008
"ANOTE
16 South River Street•P.O. Box A-H.Wilkes-Barre, PA 18703-0020.www.guard.[om
�! , j �D Workers' Comcensation and Employer's liabilitv Poliev
1,JH NorGUARD Insurance Company -A Stock Company
INSURANCE Poliry Number TTWC908992
����� Renewai of NEW
NCQ No.[25844]
Policy Infonnation Page
[4] Premium (co�t.)
Massachusetts
-- _.—--- —__ __ __
Ciassification Code Premium Basis. Rate per Estimated
ToWi Estimated ;100 Annual
Annual Remuneration : Premium '
: Remuneration
... . .__ _ __. !_ _._ . .._... .__..._- _i
�Effective: 07/02/2008-07(02/2009 � ' �� �
__. .._. . ..... _.._ ..___. ._ ... ,_. ..__ _._ _..._�
....-----. ,.- _.. ....._. . ._._ ._._.--<
RESTAURANT NOC �� ���� 9079 �: � 50,000 � 1.14 , 570 '�..
__.—_._ �._ .
Rate Deviation ..... ...... . � 9037...:. . .... . 8.000% ....... 4fi.-�-
--. ... ._. ._... _.._ ..__ .____ .__ ..__ . ....
_._ 9945 : .000% .. 0..��'..
. ._. _ __._ .__. .. ___� . _. __ .._.
Tot Est Premium 07/02/2008-07/02/2009 _. ...... . '... ._.. _ ; .. 524 .',
�Minlmum Premium� $219 � ' ' '�..
.__ __._ ._.---------_. .. .... _... . __ i.__ .._. .__ .....�
,Tot Est Standard Premium for Massachusetts � � 5zq '
_. . ._. ____ .__.. ....... . .. . . . . �i._ __. ._.. .._.:
Policy Totais
Total Estimated Standard Premium for Massachusetts 524 '
-
Expense Constant MA �900 318 '
, Total TRIA - Certified Terrorism Losses MA 9740 15 `.
Minimum Premium MA $219 ;
Total Estimated Annual Premium 857 '
' MA State Assessment 07/02/2008-07/02/2009 6.300°k 36 '
__ _. .
' Total Estimated Cost for TTWC908992 893
_ _ _ . . _ __ _
iNre2Nn� use Mz Page - 3 - Information Page
Mca : T7WC908992 WC OOOOOlA
�a[e : 07J09/2008
nn e n�n-r�
Policy No. MPR0502272 Mt. Hawley Insurance Company
�,- COMMERCIAL LINES POLICY
COMMON POLiCY DECLARATIONS
Renewal of Number
Named Insured and Mailing Address: Producer Name and Address: 38632
TTDK, LLC RISCO Inc.
Ann& Fran's Kitchen 60 Catamore Blvd.
4�7 Main Street East Providence, RI 02914
West Yarmouth, MA 02073
Policy Period: From 6/27l2008 to 6l27/2009 at 12:01 A.M. Standard Time at your mailing address shown above.
Business Description: Restaurant-Casual Service
THtS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS
PREMIUM MAY BE SUBJECT TO ADJUSTMfNT.
PREMIUM
Commercial Property Coverage Part �i36 _
Commercial Inland Marine Coverage Part Not Covered
Commercia�Crime Coverage Part Not Covered
Liquor Liability Coverage Part Not Covered
Commercial General Liability Coverege Part $�,sza
Employee Benefits E&O Coverage Part Not Covered _
"Coverage for Certified Acts of Terrorism Not Covered
Totai $3,464
Amount payable: $3,464 at inception;
FORMS AND ENDORSEMENTS
Forms and Endorsements made part of this policy at time of issue:
See Form MPPP 200-Policy Forms List
'H there is Covenge for Certified Aets of Terrorism, lossas eaused by aets o/terrorism will be partially reimbursed by lhe United States
Grnemmant u�dar a fommAa established by federai law.Under this formuia,the United States Govamm�eM pays 90%of covered Fertarism
losses exceeding a statutority estaDlished deduelible W the insurana eompany providi�g the eoverage.
Countersigned: By �
Authoriz Representative
THESE DECiARATiONS TOGETHER WITH THE COMAAON POLICY CONDlTIONS,COVERAGE FORM(S)ANO FORMS AND
ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
InGudes wpyrigMed matenal of Insurance Servicea Office,Inc,with its permission. CopyrigM,I�sura�ce Servias OTfice,inc., 1983, 1984
. .--- .__ ._ .._" o...... � ..s �
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISAMENT
PERMIT NUMBER: #09-049 FEE: S85.00
in accordance�cith reeulations promulgated under authorit�•of Cl�apter 94, Section 305A and Chapter
1 I l, Section 5 of the(',enrral Laws,a pennit is herzb��granted ro:
Debra Duarte 471 Route 28 West Yarmouth MA
Whose place of business is: Ann and Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yatmouth
Pernut expves: December 31. 2009 BOARD OF HEALTH: ,`/f¢Qen SRta/1�, .`/2.✓V., C'Rtqdx�nan
SE:1T1[.G: 30 � f7[, rU_ep.� p�� �C
7G J1KCL{ V
.`/2aBexE s. J`3xatwt, �
��a��2.✓v.
DecenzUer 4.2008
Bruce G. M phy, M H .S.. CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWI�i OF YARMOUTH
PERMIT NUMBER: #09-033 FEE: 560.00
This is to Certify that Debra Duarte d/b/a Ann and Fran's Kitchen
471 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 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 conforrnity with the authority eranted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersiened have hereunto affixed their official signatures.
BOARD OF HEALTH: .�feeen SRta/E �J2.✓Y., C�ayunpn
SE.47R�G: 30 nQ_..e_. f![ ft/�_QQ.Q__. n,� �t
l.luM.U�O .7L. JI.G[Gf{W,f,.� V"
.J2oBent �. �3noava, l.CexR
����✓2.rV.
DecemUer 4 �008 �/
ruce . u�p iy,
Director of Health
� ��� �
. �^��; TowN oF Yn�ou� son� o � r� � � e ,� �
s APPLICATION FOR LICENSE/PE � `
� � � �� � �d � L � 2�0�
* P iease comp l e te form an d attach all necessary documents by Decemb 31 2007.
Failure to do so will result in the retum of your applicario�pack t.H�A�TH �EPT.
NAME OF ESTABLISHMENT: NN 1�t V� tGh2 TEL. # SO�.��� 77�/
LOCATION ADDRESS: uJ,
MAILING ADDRESS: ' /
OWNERNAME: T r N � -
CORPORATION NAME (ff APPLICABLE):
MANAGER'S NAME: TEL. # � - (o(
MAILING ADDRESS:
POOL CERTIFICATIpNS:
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 f rm.
1. 2
Pool operators must list a minimum of two emplo s urre tly c ified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CP . eas list e e employees below and attach copies ofemployee
certificarions to tlris form. The IIealth Depart wi not ast pears' reeords. You must provede new
copies aad maintain a fiIe at your place of b si ss.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are requ'ved to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide aew copies and maintain a file at}�our establishment.
1._�-rGfNEl9 �AJ�a{Ll 2. l./�'DrCI, �Gil"Y` ( ,n lJroc�ss �
c
P�R�9N ZN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Hettnlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certificaYions to this form. The Health Department will noY use past years' records.
You must provide new copies and maintain a fde at your place of business.
i. I-��tr�eu �Ur;uh�" z. �ra �u�o ��
3. 4.
RESTAURANT SEATING: TOTAL # 3 Cv
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERtifIT# LICENSE REQtiIRED FEE PER�IIT= LICENSE REQtiIRED FEE PERbfIT=
_B&B S50 _CABIN S50 _MOTEL S50
_INN S50 _CA.M' S50 _S1'l'ILf\4ING POOL S75ea.
_LODGE S50 _T'RqII,ERPARK 5100 _R'I-TIRLpOOL S75ea.
FOOD SER�7CE: �
LICENSE REQUIRED FEE PERMIT= LICENSE REQIIIRED FEE PER\4IT a LICENSE REQtiIRED FEE PER�IIT= �
�0.10(1 SEATS S75 �0�'��y _CON7INENTAL � S30 NON-PROFIT S'_5
_>I00 SEATS 5150 eI/CO:�L'�ION VIC. S50 OS–�OS _R'1-IOLESALE S75
RETAIL SERVICE: —RESID.KITCHEN S7i
L[CENSE REQUIRED FEE PERMIT= LICENSE REQL7RED FEE PER\41T= LICENSE REQLTRED FEE PERbiIT=
_<SOsq.ft. S45 _>35.00Osq.ft. 5200 _VENDING-FOOD S20
_Q5,000 sq.R. S75 _FROZEN DESSERT S35 _TOBACCO 550
vn:�cttavice: s�o AMOU\TDUE _ $ I �S �
"`"•*pLEASE I'L'RY O�'ER A\D CO\1pLE'IE O'IHER SIDE OF FOR)f`****
AD1�IIl�TISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and Gens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRLATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCC[JPANCI': 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 elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
* NOTE: En�tos�d Motel Census must be completed and returned w;t�tn�s app��carion.
rooLs
POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be' ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days
prior to opening.
POOL WATER TES7'ING: 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 Departrnent by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuks must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernrit ucrtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior apprrnal from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is pmhibited.
NOTICE:Pemrits run annually from January i to December 31. TT IS YOUR RESPONSIBIL.ITY TO RET[JRN
THE COMPLETED APPLICATION(S) AND REQiJIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISffivfENT, MOTEL OR POOL (i.e., PAIIVTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMME?10EMEVT. RE>IOVATIOiVS MAY REQUIRE A SITE PLAN.
DATE: �{� ,2�i - � SIGNATURE: �,�N����L/�i/'.✓��
PRIVT:vAME&TITLE:�hY l�ee �ar-�- -��h�
io?o�,�
� The Com�nonweahh ofMassachusdts
Departrnent ojlnduslria[Accideiets
NfaN�
600 Washington Stree� 7'"F[oor
Boston,Mass. 02111
Workers'Compe�sation Iasm�a�ee Affidavk:Boildiug/Pl�mbisg/EleMrical Coetradors
�: i�e h�--a v ct►��
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sia� � - {'�M s�at • � zia �nC�nln/ °h."'"N `Z(L6--�-1-l� ��lo
work site locati�lfoll addressl� ' .
❑ I am a homeowner petforming all woxlc myaetf. Project Type: ❑New Caos4uctiav ORemodel
❑ I am a sole�proptietor aod have no one wo�lciog in anY ca�city. ❑g��p�bpo
� I am an�p1oY�P�'��B wakecs'compeasation for my e�mployees wo�cing�this job. .
eomoaev afne_
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❑ I am a sole proprietor,ge�eral e�tracter,�6omeowwer(drdi awe)�d Lave hited tbe conhactas listod below who have�
the following waalceas'compensation polices:
ffi��v�mr• � . .
addr�s•
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�7e�'dprbw�t n wd u dvi pmltln is tre 6rn Na SfOr WORK ORD6A aM�8u KTIN.N a day�W1 ve. 1 odenWd IW a
aepy o[tlb fhOeoeW oy 6e hrwarded Y tYe Omce afl�wpliptlw of He DIA Rr aver�ge verienWe.
llo heirby�sertF e4r aYePa�s g� �fpeqwry dY�NYe iwfennaloe providel obeve h ove a/d/cor+ect
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Prietname i� � U Phone# ")/ JO ` ���[3 - / y�n�
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, n:Raymond Travers Mu6 Internatfonal To�,Town of Yarmouth Certiflcate Emailing: Debra Du15:07 04f25108GMT-04 Pg 02-08
' Cllent8:39209 11ANNPRANSKI
ACORDM CERTIFICATE OF LIABILITY INSURANCE a;;2uoe°'"rr"
PROpUCER THIS CERTIFICATE IS 1S3UED AS R MIATTER OF INFORMATtON
HUB In28I119CtOn81 NE(YCL) ONLY AND CONFER9 NO RI3HT5 UPON THE CERTIPICATE
265 O�feans Road HDLDER.THIS CERTIFICATE DOE8 NOT AMEND,EXTEND OR
AL7ER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
North Chathem,MA 02650
508 945-0446 IN3URER8 AFPORDING COVERAGE µq��g
IMSURED IN��ftERP' HBIWY!(I�ISUf817C0C0177F78tlY
Debra Duarte ;neuH�a. Ma na Carta
47� Main St �N'uc�a c
WestYarmouth,MA 02673 �N����nner�
IN'LHFR P
COVERAGE6
THE PU�ICIES OF INSURo.NCE LISTEG 8EL0`N HAVE BEEN ISP.UE�T�?HE�NSJRED N4WEn ABJVE FGR iHE POLICY FERIOC 1NOICATE�.NCNJITHSiANDING
4Y'R=00;RE^tEf1T,TER��^.CF.CaVCITION OF ANY CONTR4�70R�THEk C? UMENT 1^r1-M RESPECTTO 14HP H H!o�ER,IFICA�.�E fAAY BE ISSUEC OR
�tPY PER'41N T4_IN�JR4NCE AFFORDEO 8V-HE Po�ICIES DESCRBEC 4FR N i5 4UBJFC"t0 N!L TNE TE ��.rF,EX:;�t,5-0N3 CNC CGVJITIpVS OF 3JCH
POLICIES AGGREGPTE LIMI?S SHOWN MAF HA7E BEEn REDJCEC B"PND�1��:1.1&
LTR NSR TV°E OG IN6:FAACE POLICY NULI6ER >OLICY EFFERIVE PoUCY EXPIRATION
fd NJ IW LIP11T6
A GENERALLWBILITY "��QMN$jT$�JZ�j Q¢)O��Q$ QjiO�/W =aChOiCCRRENCc <,� OpQOQ�
ccMnae�cu!�eneau�>E��i,vi I narna�Eroaeo,"�.<ED�. � s�00000
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nNYPROFR�EiJR'PARTNER�EXECUTrvE ��i ELEPCNNCCIDEIVT ESOOOOO
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tt aem�ne,noer �
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OTHEH
I
OE9CR'PTION OF OPERATIOM9l LCCATOMS/VEH.�CLE9l EI(ClGS10N5 A4DE[2v;!�DORSENEM!S'ECip'.oq0Y5:CN9
No.of Days; 10 �
TNNN OF YARMOiJTH
CERTIFICATE HOLDER CANCELLATION
BNOUL�ANY OF TNE ABOVE DEBCRIBEO POLICIEB BE GNCELLFO BEF0A6 TFF EXPINRTION
Town of Yarmouth OATE THEREDF.TFE�SSUING INSCPER WILL ENOEdVOF?O M<�L ,�_ pLYS WRI!'EA
Aitn:Board of Health NOTICE TO TN�CE2TIF!CAiE HOLDcR N.1N?�i}TMe�EF'.BUT FPILtIR�TG CO SO SXALI
1 t46 Route 28 IMFO`Jc NOOBIIQATlON QRLIABILiT'JF A4Y 1aR0 UPOH THE k19URER,I'9 PGENTS OR
South Yarmouth�� 026� REGRESE4TATIVFB.
AUiNORIZE REPPE6ENTAiN_ E.
A� L�I'^�
ACORD]SIZW1/O8)� pF2 #37424
RT001 O ACORD CORPORATtON 1988
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHNIENT
PERMIT NUMBER: #08-174 FEE: $75.00
In accordance with regularions promulgated under authoriry of Chapter 94,Section 305A and Chapter
111,Section 5 of[he General Laws,a permit is hereby gran[ed to:
Debra Duarte 471 Route 2& West Yarmouth MA
Whose place of business is: Ann and Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 2008 BOARD OF HEALTH: 3EeQe�a SR�, `JZ..N., C'f�avanaa
SEAr[c.rrG: 30 (,��6 � ��� cU����
J2oBeJlt .�. �Bxau,ut, C�e�tP�
���J2.✓V.
Anri129.2008
ruce G.Mwphy, .5., CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER; #08-105 FEE: $50.00
This is to Certify that Debra I?uarte d/b/a Ann and Fran's Kitchen
471 Route 28 West Yarmouth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yattnouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authoriry granted to
the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: 3fefen SP�alt `JZ.✓Y., Clfaixman
sEnrarc: so CAa�teea .�. .�feP�iN�c 91ice Clfavuna�t
✓2�� �. ��„�, e�
���, �..N.
Anril 29.2008
D ector of Heal h '
�--�r... f}NN t FQaN�$'
�°' Y`�"s TOWN OF YARMOUTH BOA A� ' `, L� � (� � 0 �I C� DD
s� s'' APPLICATION FOR LICENS � ���� ,?'
` � �;'„�a ut� � 7 2007
* Please complete form and attach ali necessa'ry documents by Decem r 3 0 7�
Failure to do so will result in the retum of your application pac ���H DEPT.
NAME OF ESTABLISHMENT: �!/�(/ `,t�,�/,`(��r TEL. # l�J���6''��
LOCATION ADDRESS: i.d �'�� _ �,� ��
MAILING ADDRESS: _ d8��z s
OWNER NAM�:��S� �w�.�i9� TA ID /F IN or 4N)- .
CORPORATION NAME �IF PLICABLE):�r�,� T,�.
MANAGER'S NAME: i TEL. # 6�fC' �i��o�
MAILING ADDRESS: l �
POOL CERTffICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated
Pool_Ouerat4r(s) andati�ch�ss�py_af_ther.ertification to thi,s-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 ofemployee
/certificarions to this form. The Health Department will not use past years' records. 1'ou must provide new
� copies and maintain a file at your place of business.
1. 2:
3. 4
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fixll-time employee who is cenified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department witl not ase past years'records.
You must provide new copies and maintain a file at your establishment.
1.� �F� �[�� 2.��45'�`9i ,S<�_���•4- /�'
P�RS9N�N�HARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �
1. �
1�' z.�_�� �
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-cholung procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
- �
1. �% 2._ ��r=1�/�l/ �l6�
3. " 4.
RESTAURANT SEATING: TOTAL # `��
Loncnvc: OFFICE USE ONLY
LICENSE REQIJIltfD FEE PER\9T?� LICENSE REQliIRED FEE PER�III's LICENSE REQL'IRED FEE PER�III=
—.B�B S50 _CABIN S50
MOiEL S50
_� S50 _CA1bfP S50 � �
S�5'I�4INGPOpLS75ea �
_LODGE S50 TRAILER PARK 5100
�— WHIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQ[ARED FEE PERMIT s LICENSE REQLIRED FEE PER_\4IT a LICEFSE REQtiIRED FEE PER�IIT=
�0.100 SEATS S75 0�—�a-{ _CONTINEN'IAL S?0
NON-PROFII' S25
_>100SEATS 5150 /CO.'4L'4IONVIC. S50 OS�47�
�47-IOLESALE S75
RETAIL SERVICE: —
—RESID.KlICHEN S7i
LICENSE REQUptED FEE PERA9T= LICEI�iSE REQUIRED FEE PER�IIT=
LICENSEREQL'IRED FEE PER�III'=
_<50 sq.ft. S45 _>Z5.000 sq.8. 5200
VENDING-FOOD 520
_QS,OWsq.R. S75 _FROZENDESSERTS3i
TOBACCO S>0
vA!1�CHeLVGE: SIO AMOUI�T DUE _ $ / 2S. 00
wwR�:pLE4SE TURY OPER A.\D CO�iPLE7E OTHER SIDE OF FOR\i*"""*
, •
ADMINISTRATION .
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED��'
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pem�its. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short tenn 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 eL9ewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirly (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
* NOTE: En��osea Moted Census must be completed and returned.�tn r�s aPPucat�on.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opemng. Contact the Health Department to schedule the inspection five(�days
prior to openiag..
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
� by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yazrnouth must notify the Yarmouth Health Department by filing the reclwr�
Temporary Food Service Application form 72 hours prior to the catered event. These fortns can be obtained at the
Heaith Department.
FROZEN DESSERTS:
Departmente Failure to do so wi11 r sultt n�the su pensson or rev�oca on of your Frlozen Dessert Pemtit urnil t e
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board of Heahh.
OUTDOOR COOKING:
OutdoQr caoking,pre�arat�Qn>-or display of any food�roduct-by aretail or food service estabuShcne"t us-P'°h'brted'---
NOT'ICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILiTY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIlvfENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEAT-TH PRIOR
TO COMME:VCEME�IT. RE?IOVATIOVS MAY REQUIRE A SITE PLAN.
DATE:�`� SIGNATURE:
PRINT:�IAME&TIT . /�+'��� ��1�� �� b�'�'
�o?o o�
,p� ,�D� • Vy
�"\ The Commonwealth o assachus� /� ���
. Department of IedusTrial Accidents �V `� �� ��
N�ia�N�
600 R'ashington Slreet, 7"�'Floor
Boston,Mass. 02111
Workers'Compeeaatioe I�s�a�eye�A�S�d��vk}�:}B��ildi`o�g/Plumbug/Ekctrical Co�traetors
W�� • Y�� L�fLI{4\1 �tl�. �
L810L: �
atldress: `_ ,
--Sl
ciN state� zin• �h^^P# ��
wark site location(foll addressl' �
❑ I am a homeowcer yufocmiog all wak myself. Project Type: ❑New Cwsnucti�QR�adel
❑ I mn a sole proprietor and have no one wodcing in any capacity. ❑Building Addition
❑ I am an employer providing workecs'compensation for my employees woiicing on iLis job. (��., l
_. �- - --_ �_..---� --_.. --- . _ _ _ __. . - �,�J
---�� com �ne• .
�
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ea #
.:.. _ . ,�: . �. t'- . . .d.:nfie.xR '� �� �
❑ I am a sole propri�or,Se�eral ewtraetor,. � bome��n ( ��� � ]tiiad We contcactots listed bebw who have
the following woike�s'compensation polic _
V
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ex yefn'6aptlroawt af wd n cM pwMn in tht fer�Na 3T0�WOBK ORD6R nd�Bee KS10�.N a day apint�e. 1 odenhad tlut a
d�y a[We#aBewt my he tWwaNed b the Omae o/lnntlpW�t af Ne DIA tar tsvera{e verlAddw. .
�do Aeneey cerhfy rnAe.NYe y.r,w+mrpeud(ia nlveN+�l'���e refonw�ton Proadeaa6nv�e is a�ue w�a on.rocc
�� Date
Print name Phone#
e�d�l me anly de eat wrNe Y tNs arca b be mrPkted bY d�S or Wwn a�rrht ..
eily or town:
PermiU6eeme M Departmmt
Qlkeedms BeaN
❑ehaf ifimmdi�h`eepame 6 reqdnd O�'��t
co�d perwa: ��: �Q
(.�dsp.mm)
� Dec�2i-2DOT 04:D1pm From-HUB International NE LLC 5087601401 T-T50 P.001/OOt F-037
ACORD,� CERTIFICATE OF LIAk31L11 Y INSUKAN(:t �zniro�
vRonUCEit THIS CER7IF�CATE IS ISSUED AS A IqA7'7ER OF INFORMATION
HUB Intema8onal NE(YCL) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDFR.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
437 Station Ave ALTER THE COVERAGE AFFORUED BY THE POUCIES eELOW.
South Yarmouth, MA 02664
r�pg ggq-0g� IN3URERS AFFORDING COVERAGE NA1C#
,usu�em irvsuaea n: Hanover Insurance Company
Ann&Fran's Kitchen iNsuR�ee: AAagna Carta
Illusion Property Trust iNsuRExc:
21 Brookhfll Lane iNs�rtEao:
West Yarmouth, MA 02673 INSURER E:
COVERAGES
THE 70GIGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAAAED A6DVE FOR THE POIJCv PERIOD 1NDICATFA.NOTwITHS7ANDING
ANY REQUIftEMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER D�CUMENT wITH RE3PECT TO WHICH 71i15 CERTIFICATE MAY BE ISSUED OR
MA�PERTAIN,THE INSURANGE nFFORDED BY71iE POLICIES DESCRIeED FIEREIN IS SU&IECT TO ALITHE TERMS,IXCLUSIONS AND CONDITIONS OF SUCH
POLIC�ES.AGGREGATE LINITS SHOWN MAY F44VE BEEN REDUCED BY PAID CUIMS.
� vou erive voucrowru� uwirs
LTR. NSR T�PE�INSURANCE �a.wV NUMBPA pAiE DATQ NMID
/� GpNERALL1ABRrtV OHN5928392 OM01/07 04/01I08 F.�cnxwpaer+ce s1000000
x °^'.^�E'o RE„TE°, 5300 OOO
COMMERCIlLL GENERAL LIABIL1i'�
cwas Maoe �X occup Meo�cv�n�y�o wr�l s5 000
vErssorva�aaov�rv�uav s1000000
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ENDLOYERS'W19rt.RY E.LEAGHNGCIDENT S�OOOO
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pFFICER/MEMBER FJ(LLUOEOT
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DE9CWPTION OF OPERA110N9�LOCATONS I VENICLES!RCW610N6 ADOEU BY ENDORSEMENT I SPECIAL�AO�lSiDNS
Harvey&Ginny W�9ht are covared by the Workers compensatfon pollcy_
CERTIFICATE NOIDER GINCELLATION
SHOULD ANV OF T1E AeOVE DESCRI6E0 POl1C�ES BE C+�NCELLEC 9PfORE lXE DIPiRl�T1oN
TownofYarmouthAtfn: Boardof MTETMERE�F,TNEISSUINGYlSURERWILLENOFAVDRTOM1Ul �jL �YSWRITfEN
Neaht�DepL NOMETO TXE CERTIflC0.T2 MOLpER NAMED TO THE I.ERT.9UT FNILURE TO DO SO S11ALL
1146 Mein Street �MiOSE 1'ID OBlJGA170N OR LYBILITT Of ANV IQND UPoN THE INSUIi¢R,ITS nfEMT3 0R
South Yarmouth,MA 02664 �P��ATME3'
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ACORD 25�2001l08)� of 2 #18561 M5002 0 ACORD CORPORA710N 7988
• Dea-27-2001 D4:01pm From-HI1B International NE LLC SOBT601407 T-754 P.002/002 F-037
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the poii�y(ies)must be endorsed. A statement
on this certificate daes not wrrfef Aghts to the certificats holder in lieu of such endorsement(s).
If SUBROGATION tS WAIVED, subjed to the terms and conditfons of the policy,certain policies may
requlre a� endorsemeM. A statement on this certificate dces not confer rights to the cert�cate
holder in I"�eu of such endorsement(s).
DISCLAIMER
The CerGficate of Insuranee on the reverse side oi this form does not constit�te a convad between
the issuing insurer(s), authorized representative or producer,and the certiFcate hokier, nor does it
affirma[ively or negatively amend, extend or alter the coverage efforded by the policies listed thereon.
ACORD 25S(20Ut108) 2 of 2 #16561
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NiJMBER: #08-121 FEE: $75.00
In accordance wiffi re�u1arions promulgated uuder authority of Chapter 94,Secfion 305A and Chapter
I I 1,Section 5 of the�'ieneral Laws,a permit is hereby granted to:
Salty's Inc., 471 Route 28, West Yarmouth, MA
Whose place of business is: Ann& Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2008 BOARD OF HEALTH: ,q�E�e_Pe""r6t"S" lt�f� , J2..N., eR�a"vuna�n
SEAiING: 30 � �v[WK('q ,7G„ ��R�I�RAG �ICQ�QIXI►iQf1.
✓`2e.�ext s. `.�3�uurt, C'�exPt
Qnn.C�x' eerr�acuri, flt..N.
£�ePyn. `.P..�fayea
January 23.2008
Bruce G.Murph ,R.S., CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #08-075 FEE: $50.00
Tlvs is to Certify that Salty's Inc. d/b/a Ann& Fran's Kitchen
471 Route 28, West Yarmouth MA
IS HEREBY GRANTED A
COD�VION VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in conformity with the authority granted to
the licensing authoriries by Generat Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOi1RD OF HEALTH: q,��Ee�P,"e"��t�"S�qL �t,J,26.6JVQ., CR�arixmaut
SEATING: 30 � � uuy[C�p .7G. ,%�Qf.(�%RQ/( �ICC�Xl/l�/y
`J�aBe�tt 3. `.�iacaufrz, '(.�
���✓�-
January 23.2008
mce . , .
D'uector of Heal� �
� fINNt F2AN5
_ `YA . ..�� 1 103 � �v
20 � R Q TOWN OF YARMOUTH BOARD OF HEt1LTH
���$ APPLICATION FOR LICENSE/PERMTT- 200'7 ' ZA �
� � � o � � �
* Please complete fonn and attach all necessary documents by Decem er 31,�0�.
Failure to do so will result in the return of your application pa etp E� 2 g Zp06
NAME OF ESTABLISHIviENT:��nJ y- �i2�¢�,S' ���(�� � p� ,z
LOCATIONADDRESS: " S��/ I11�¢TN ST /�J��vn�ru�����3
MAILINGADDRESS: o�/ d2r�aA' j¢i�� ii���� ya.2v„n � Y7v14 o�G � 3
OWNER NAME: H/�R L[_� /�>�PiG/f T" T,�iX ID (FEIN or SS1�: �
CORPORATION NAME (IF'APPLICABLE): Sp� r�/ 's �N C,
MANAGER'S NAME: , R ve l i TEL. # ��- �,%-�9�7�
MAILING ADDRESS:�/ � / `//n�t=, ��1�i�y����, ���, _,,�i �3
POOL CERTIFICATIONS:
The pool supervisor must be certiT as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a cop of the certification to this form.
l. 2.
Pool operators must list a nunum oftwo employees currently certified in basic water safety, standazd First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. T6e Health Department will not use past years' records. You must provide new
copies and maintain a file at y ur place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certi8ed as a Food
ProtecUon Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertification to this application. The Health Department wilI not use past years' records.
You must provide new copies and maintain a 61e at your establishment
1.��.PUE�/ ���«-C�i Z.
PERSON IN CHARGE: _ _
Each food establistunent must have at least one Person In Charge(PIC) o� site during hours of operation.
�.��1►�,��r--� z.�g , r.��s
HEIMLICH CERTIFICATIONS: �/P�T'",E�LS�iGT/D ��'��"NT"urs�l�
All food service establishments with 25 seats or more must haue t 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.
1. ��•ed�_�1 �.�/lZl6�fi 2. �U��u�- Lr/�e/�-di
3. t ,�,�/.•v ���s,-� � 4.�re1 e< OL.ii"F;2.4
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGRVG:
LICENSE REQUIl2ED FEE PERMIT tt LICENSE REQUIItED FEE PERMI"P I! LICENSE REQUIltED FEE PERMIT#
_B&B S50 CABIN $50 MOTEL S50
_INN $50 CAMF' $50 _SWA�IIvfIIdGPOOL$75ea.
_LODGE $50 TRAII,ERPARK $100 WIIIRI,POOL $'/5ea.
FOOD SERV[CE:
LICENSE REQiIIRED FEE PFRMIT# LICENSE REQUII2F.D FEE PERMIT# LICENSE REQI1tRED FEE PERMIT#
I 0.100 SEATS $75 �67 y��' _CONl'INE,N'PAL S30 NON-PROFfL S25
_>100SEATS $150 / COMMONVIC. $50 �6� _WHOLESALE S75
RETAII.SERVICE: —RESID.KTTCHEN $75
LICINSE REQiJIltF.D FEE PF.RMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQIJ7RED FEE PERMIT#
_60sq.ft. S45 _>25,WOsq.ft. $200 _ _VENDING-FOOD $20
_QS,OOOaq.ft. S75 _FROZ,INDESSERT S35 TOBACCO S50
NAMECHANGE: S10 AMOUNTDUE _ $ IZS�00
"••"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""""
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'ued to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/ '
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PL,EASE CHECK
APPROPRIATELY IF PAID:
YES_�� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations ofMotel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
agg�egate 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 collecrion 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.
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 Yamiouth must notify the Yarmouth Health Department by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthiy basis by a State certified lab. Test resuits must be sent to the Health
Department. Failwe 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 COOKING:
Outdoor cookin�zprepazaUon or display ofany foad�roduct by a retail or food service establishmern is prohibited.
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIITY TO RET[JRN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�vviENT, 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 REQUIltE A SITE PLAN.
DATE: g SIGNATURE:
PRINT NAME&TITLE: A���'z/�l/6�s1'i.
��.�ES S-9�n/1-Z-v�
�o,nroc
ruouc aervice iviutua� insurance company
One Park Avenue
New Vork,N� �0016-5807
I WORKERS GOMPENSATION INVOICE (
JPolicy Number: WC 006754
BillLng Address:
Salty's In�d/b/a Ar�n & Fran's Kitchen Named Insured: Salty's Inc d/b!a Ann & Fran's Kitchen
21 Brookhill Ln Producer. HUB Internaticnal New England, LLC:
West Yaimouth, MA 02673-4826
_ _ _ _ __ _ __-- — POLICY INFORMATION _ _ _
_.__ __—
('oiicyperod: 1/1/2007 tc 1;7/2068
Invoic�s#: 75633C
Tctal Premii�m: $854.00
Paynient due by: Ot/04/2007
T�pay in tuil: $854.00
'Mlnimum.�mountdue: $213.50
'If your ,�olicy is on inslallments the amount due includes a $6.00 service charge.
It is important t� r.ail your insurance paymen',s on time to avoid possible cancellation of your policy
and related servics charges. We ezpect to receive your payment on or before the due date. Ya�
sh�uld allo�ro 5 business days for mailing.
Ta avoid 3n unnecessary cancellation, pay minimum amount due as shown. Any changes to your
policy will be refiected in future billings.
For billirig inquiries please call your producer. (978) 458•6801
� _-�-���c-�.Ezc-:� L[L� ��i�y( c�f�/
4
.� RETURN THIS PORTION WITH YOUR PAYMENT
MGke cneck payable to�� Public Service Mutual Insurance Company �
Poli�y Numbe�r; 'WC 006754 Payment due by:_� /O--Ui q/2pp7
Pulicy period: 1�'f�007 to 1/1l2008 Total Que: $854.00
Invoice �: 7563'3p "Minimum amount due: $273.50
Tote.i Premiur�: $854.00�� Amount Enclosed: _
.�
To ensure proper�redit please.write the poiicy number on your check.
if��
F'ublic Ser✓ice MutuaPlnsurance Company\
One Park Avenue��'� � �
�lew York, NY 10016-5802 \
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #07-126 FEE: $75.00
1n accordaIlce wiffi re�uiatioas Piomulgated under authoriry of Chapter 94,Section 305A and Chapter
I 11,Section 5 of the�ieneral Iaws,a permit is hereby granted to:
_ Saltv's Inc. 471 Route 28 West Yazmouth, MA
Whose place of business is: Ann&Fran's Kitchen
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31_ 2007 BOARD OF HEALTH: B �. /x��,'���, �J.�y,, •
sEn�rtrrc: 30 �es�s�iali, KJY., 7/ics�raid�x�,rc
Rode�t 4. B� �n.6
/��ic�.�'fo�e+�co�
� � fQ��IL 4'dee�c�.�slur /l./V.
March 28.2007
ruce G. M
Director of H�e.al�th� -,CHO
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #07-082 FEE: 50.00
This is to Certify that Saltv's Inc. d/b/a Ann&Fran's Kitchen
471 Route 28, West Yamiout MA
IS I�REBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless
sooner suspended or revoked for violauon of the laws of the Commonweakh respecting the
licensing of common victuallers. Tlus license is issued in confornuty with the authority granted to
the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affi�ced the'u offrcial signatures.
BOARD OF HEALTH: B $. , M$., ��
SEA�G: 30 �r��s�, ��e�
Rode�it 4. SRow�, Gle�r,b
n�M�,�
�r�, R.�v.
March 28_2007
Director of H�ealth�
�. � . rg��1�f6 � � G3 � �� ���
�Fe R.y TOWN OF YARMOUTH BOARD�F
3 � APPLICATION FOR LICEft5EfP�f ' 6; DEC 2 9 2005
Or�j'1 �
r�iS � 4 E `
* Please complete form and attach a11 nece�sar�'dbcn�ents by Dece , DEPT.
Failure to do so will result in the return of yow applicat�on packet.
NAME OF ESTABLISf�IENT: ���5-�f/G '1711�1 �,�,rV f fiv°1x/_t TEL. # J� �/
LOCATION ADDRESS: —�,J ` --i F-S�-T �..r/ 7
MAILING ADDRES : 'C/ - �"o�fc �
OWNERNAME: TAX IN r - / �
CORPORATION NAME ( APPLICABLE):�l��y,1- �'.,,�c .
MANAGER'S NAME: ! — TEL. # l�-�a�+�
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pooi supervisor must be certified as a Pool Operator,as required y State law. Please Gst the designated
Pool Operator(s) and attach a copy of the certification to this form.
1.
Pool operators must list a minimum of two employees en ce ' ed' asic water safety, standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR) 1 s st th e s below and attach copies of employee
certifications to this form. The Health Depart nt ' not e st ears' records. You must provide new
copies and maintain a tile at your place of b siness. � � � � p � � D
1. 2.
3. 4. "
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fiill-time employee who is certi8ed 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 appiication. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishm nt.
�.��� P��v �._������
rERsorr nv c�GE: ___
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. �/,�24- �.��,'v 2.�sEJ2l�7 � Lc�
HEIlbfE;�H 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 ali times. Please list your employees trained in anti-choking procedures below and
attaei4 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.��'-� �.t�(.br4i� 2.�rZJ`�43�4 �Cv .
3.�A.l�g�l,� 1� B � iILF,._�1� - 4. S7n:L.�'�vF'�9�E-G I
RESTAURANT SEATING: TOTAL# � UV�� �'"� A �� Q-��'°�-- -
OFFICE USE ONLY
LODGIlVG:
LICENSE REQUII2ED FEE PERMIT�t LICINSE REQUIl2ED FEE PERMIT# LICENSE REQUIl2ED FEE PF.,RMIT#
BBcB $50 _CABIN $50 _MOTEL $50
INN $50 CAMP $50 _SWIIvf[vIlNG POOL$75ea.
LODGE $50 TRAII.ER PARK $50 WHQ2LPOOL $75ea.
FOOD SERV[CE: �
LICENSE REQUII2ED FEE PERMIT# LICINSE REQUII2ED FEE PERMI1'# LICENSE REQUIl2ED FEE PERMIT#
� 0-100 SEATS $75 �iD6.-�� CON'PINENTAL $30 _NON-PROFIT $25
_>700 SEATS 5150 �COMMON VIC. $50 �()6-08� _4VHOLESALE $75
RETAII,SERVICE:
LICINSE R&QUIItF.D FEE PERMI1'N LICINSE REQiIIItED FEE PF.RMIT It LICENSE REQUII2ED FEE PERMCf#
_<SOsq.ft. $45 >25,OOOsq.ft. $200 _VENDING-FOOD $�0 .
_QS,OOOsq.ft. $75 _FROZENDESSERT $35 _TOBACCO $25
NAME CHANGE: S10 AMOUNT DUE _ $ 12 S•00
""•"PLEASE TURN OVER AND COMPLETE OTHER 51DE OF FORM"*"""
ADIVIINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAViT MCTST BE COMPLETED AND SIGNED, OR _ , /
CERT. OF.INSURANCE ATTACHED
1�
OR
WORKER'S COMP. AF�'IDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
N01'ICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RE'I'CJRN
TI� COMPLETED APPLICATION(S) AND REQUIKED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISFIlVIEENTS ARE T.O CONTACT TFIE HEALTFI DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEIVING FOR THE SEASON.
AI,L RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COMl�lENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which haue been ciosed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required
Temporary Food Service Application form 72 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 Pemvt until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress service), must have prior approval from the Board ofHeakh.
OUTDOOR GOOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
�
DATE: � SIGNATURE:
PRINT NAME&TITLE: ��'� �'I/��1� ��I�i's`.vi -
l
09/28/OS
. : Public Service Mutual Insurance Company
• One Park Avenue
NewYcrk.NY 1C016-5807
WOfiKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
INFORMATION PAGE
NCCI Compa.ny No:t 6152 Prior Policy Number. WC 006754 4
RENEWAL Policy Number: WC 006754 05
1. Named Insured and Malling Address: Producer and Mailing Address:
Salry's Inc d/b/a iann & Fran's Kitchen HUB IMernational New England, LLC
21 Broc>khill Ln 170 Appleton Street
WestYarmouth, MA 02673-4826 Lowell, MA 01852
Tel. (978)458-6801
The Insured:Corporation
Other wo�kplaces not shown above:
2. The policy period is trom 1M/2005 to 1/1/2006 12:01 A.M. Standard Time at your mailing address shown above.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the
stat�;s listed here: Massachusetts
B. Em��loyers Li��bility Insurance: Part Two of the policy appiies to work in each state listed in Item 3.A. The limits
of our liability under Part Two are: Bodily Injury by Accident $ b00 000 each accident
Bodily injury by Disease $ �4.P149Q policy limit
Bodily Injury by Disease $ �00.000 each employee
C. Other States Insurence: Part Three of the policy applies 10 the states, if any, listed here:
D. This policy includes the following endorsements and schedules:
See Extension of Information Page
4. Th�s premium for+:his policy will be determined by our Manuals of Rules, Classitications, Rates and Rating Plans.
All infornation recauired below is subject to ver'rfication and change by audit.
Premium Basis Rate Per Estimated
�oc. Code Total Estimated $100 of Annual
Cltissifications St. No. No. Annual Remuneration Remuneration Premium
See Extension of Information Page $654
Loss Constant: $0 Expense Constant Charge� $264
Minimurt� Premium� $217 Deposit Premium $91 B Total Estimated Annual Premium: $918
Premiurc Adjustmc:nt Period: Annually
Seniicinct Office: New England 8ranch
Counter.signed 2Jt 6/2005 at New York, N.Y. by tw. _ _
Authorized Representative
THIS INFORMATON PAGE WITH THE WORKERS COMPENSATION AND EMPIOYERS LiABILITY INSURANCE POLICY AND
GNDOaSEneEN7S,IF ANV,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POUCY.
Edilion 10/97 page 7 cf 5
Copynght, 1987 National Council on Compensallon Insurance
•, � Pubiic Service Mutual Insurance Company
One Park Avenue
New York, NY 10016-5807
WCiRKERS COMPENSATION AND EMPLOYER'S LIABILITY INSUqANCE POLICY
EXTENSION OF INFORMATION PAGE ITEM#4
NCCI C;omF�any No:16152 Prior Policy Num6er: WC 006754 4
REPlEW.4L Policy Number: WC 006754 OS
1. Named Insuretl and Mailing Address: Producer and Maitlng Address:
Saity: Inc d/b/a Ann & Fran's Kitchen HUB Internationai New England, LLC
21 Br<okhill Ln 170 Appleton Street
West'/armouth, MA 02673•4826 Loweil, MA 01852
Tel. (978)458-6801
2. The policy period is from 1/1/2005 to 7/1/2006 12:Oi A.M. Standard Time at your mailing address shown above.
4. Premi�m
Premium Basis Rate Per Estimate�d
Massar.hus>tts Loa Code Total Estimated $100 of Annual
Classifications St. No. No. Annual Remuneration Remuneration Premiurn
Restaurant �JOC MA 1 9079 ^�32,094 1.85 $594
Total Manual Premlurti $594
Premiuin for Increased Limits Part Two (9607) $6
BalancFa to Alinimum for Increased Limits (9848) $44
Total Pn�mium SubJect to Rating $644
Experience !vlodification of 0.000 $0
Total Madified Premium (9885) $644
Policy Esalance to Minimum (0990) $0
Totat Es�zima+:ed Standard Premium 5644
Rate Deviation of 5A96 (9034) ($32)
Expense Constant Charge (0900) $264
Premiwr for the Terrerism Risk Insurance Act of 2002 0.03 $10
Total Estimai:ed Premium $886
Massachus�•etts Assessment of 4.9% $32
THIS INFQRMATICN PAGE WITH THE WORKEflS COMPENSATION AND EMPLOVERS LiABIUTY INSURANCE POLICY AND
ENDORSEMEN7S,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY.
Edition 10/97 Page 2 of!i
CopyrigM,1987 National Council on Compensation Insurance
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NIJMBER: #06-137 F'EE: $75.00
In accordanc¢with reQulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�ieneral Laws,a peimit is hereby�anted tp:
Salty's Inc 471 Route 28 West Yarmouth MA
Whose place of business is: Ann&Fran's
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Percnit eapires: December 31 2006 BOARD OF HEALTH: B `�, ��y,� •
5�,�,,G: 30 - ���s`�, �., v�e��
��M�
��� a.n!
Febniary 2 20� �`
Bruce G. Murph , H,RS.,CHO
Director of Health
'I'HE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #06-084 FEE: $50.00
This is to Certify that_ Saltds Inc. d/b/a Ann&Fran's
471 Route 28 West Yannout MA
IS HEREBy GRANT'ED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2006 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. Tlris license is issued in confomvty with the authonty granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affuced their official signatures.
BOARD OF HEALTH: B��rrt,s$. �i'o+�orC,�jq,$., e�r�r�
sea'r[rrc: 30 e�fele�a c4�u/i, a./�., ?/i�G��i�uxw�
Rode�it� Bao�w�, �le�
n����,u
����, a.n!
Febrvazv 2 2006
�r,— "
Director of H�ealth� ,
OF Y`�� �
�C �
�� - '�� TOWN OF YARMOUTH S
�, — �_ $ 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451
�nwrrAcnccs� Z'elephone (508) 398-2231, ExC 241 — Fax (508) 760-3472
"t^ro�.no�"'"
B O A R D O F H E A L T H
To: Yarmouth Boazd ofHealth Permit Holders
From: David D. Flaherty Jr.,RS. ;�D r —�
Health Inspector ✓
Town of Yarmouth ' '%
Re: Federal Tax ID Number ' HEALTH DEPT.
L�ate: March 22, 2005
The Massachusetts Department of Revenue is now requiring tUat we furnish detailed information
to them regarding all permits and licenses that we issue. One of the details that they requue we
send to them is every establishme�'s Federal Employer ldentification Number(FEIIV)otherwise
lrnown as your"I'�ID Number". This is purely for administrative purposes only.
So� businesses use the owner's Social Security Number (SSl� for this purpose. If this is the
case for your establishment, be assured that we will �t allow this information to be public
record.
Please fill out the fields below and return this letter to
Yarmouth Heatth Departmern
]146 Route 2$
South Yarmouth, MA 02664
Thank you for your anticipated compliance. If you have any questions regazding this matter,
please do not hesitate to call. The of�ce hours aze Monday to Friday, 8:30 a.m to 430 p.m The
telephone number is(508) 398-2231, ext. 241.
Establishment: ���,�/.3' �_�,Tij/,f��or SSN: � ` ��,/ �
.
Location Address: y�/�-,,G�'��"����.i' �/i���� �
i
Signature:
Print: ��'!I`-��1G7�� Title: ��'-,T'Y✓ �
, ;---
'�
� Prin[ed on
L � Recycled
Paper
�.
��
' G1-�'���� / A�v,v �FkaN s
°`%'R�so TOR'N OF YARMOUTH BOARD OF LTH ��� i rs -„_ ,
o,?��i APPLICATION FOR LICEN�E �005 - `,
��' �" �` IAN 0 3 2005 �
* Please complete form and attach all necessary docum y ecember 31 2004.
Failure to do so will result in the retum of your applicat�on packet. HEALTH DEPT.
NAME OF ESTABLISFIl�IENT: . c ,� TEL. #
LOCATION ADDRESS: / ��r-' - �i��S% �p
MAILING ADDRESS: O " � -
OWNER/CORPORATION N ` ^'
MANAGER'S NAME: TEL. # Z
MAILING ADDRESS: < - ��s�_
POOL CERTIFICATIONS:
TLe 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.
i.
Pool operators must list a minimum of two currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resusci ' l�i�j:-z;ease Gst these employees below and attach copies of
employee certifications to this form e Health Department will not use past years' records. You must
provide new copies and main ' a fde at your piace of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS�
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertification to this application. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
1. � �L`Y'.�c� G�I � ��//--
2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1.-�j . ��1��/'% 2. ��i92L�z S ��/�"�Z�
HEIMLICH CERTIFICATIONS ,,
All food service establishments with 25 seats or more must have at least one employee trained in�the Heixnlich
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.
�. � � -�� d z.---���r���
3. !./=� � f- 4._v .✓��_T �r!s-.,,��-,�t
RESTAURANT SEATING: TOTAL#
LODGING:
OFFICE USE ONLY
LICENSE REQUIltED FEE pBgl�q1�g LICINSE REQUIItED FEE PERMIT# ISCENSE REQUIItED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL S50
_�N S50 _CAMP S50 _SWIIvIIv�IGPOOLS75ea.
_LODGE $50 _T'RAII,EgPARK $50 _WI-IIRLpppL E75ea.
FOOD SERVICE:
LICENSE REQUIltED FEE pEItM[�p p LICENSE REQUJRgD FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS a75 �o` s ral'r _CONIINENTAL $30 _NON-PROFIT $25
_>1W SEATS $150 1 COMMON VICT. S50 OS�08Ce _WgOLESALE $75
RETAIL SERVICE:
LICENSE REQiJIRED FEE PERMI'C# LICENSE REQIJIItED FEE pERM[1•7i LICENSE REQi7IRFD FEE pggTqT g
_<SOsq.R $45 _>25,OWsq.ft. $200 _VENDING-FOODE20
_QS,OOOsq.ft. $75 _FROZINDESSERT $35 _TOBACCO $25
NAME CHANGB: $]0 AMOUNT DUE _ $ /25,00
'•"`"pLEASE TUR1Y OVER AP1D COMPLETE OTHER SIDE OF FORM•••••
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR
r/ � �
CERT. OF INSURANCE ATTACHED �(����5 ��/����
OR _.
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �� �j�y,r��
Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES �� NO
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTHDEPAR'TMENTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and wtrirlpools 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 i�ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishmem which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY•
Anyone w o caters within the Town of Yazmouth 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.
FR(17FN DFCCT,R�'S�-- - - _ _ _ _ __ _
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: � � SIGNA V�� \
pRINT NAME& TITLE: .�i,�.Z1 ��'�,i--�s�' � `�'�/'
� _
10/22/04
ACORD CERTIFICATE OF LIABILITY INSURANCE OPID J DATE�MM/DO/YYVY)
ANN&F-1 O1 03 OS
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONPERS NO RIGHTS UPON THE CERTIFICATE
HUB International New England HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
So.Yarmouth MA 02664
Phone: 508-394-0946 Fax:508-760-1407 INSURERSAFFORDINGCOVERAGE NAIC#
INSURED INSURERA: MdCJIId Carta Ins
INSURER B:
AIlII & Fran's Kitchen MSURERC: _ � — ,, r�
21 Brookhill Lane iNsuaeao: �-� — " -' - �-�
West Yarmouth MP. 02673
INSURER E:
COVERAGES � '
THE POIICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PER � T 1 � DIN
ANVREQUIREMENT,TERMORCONOITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHISCE TI�
MAVPERTAIN,THEINSURANCEAFFORDEDBVTHEPOLICIESDESCRIBEDHEREINISSU&IECTTOALLTHETERMS.EXCLU IONSANOCONDITIONSOFSUCH
POLICIES.AGGREGATE LIMITS SHONM MAV HAVE BEEN REDUCEO BV PAIO CLAIMS.
LTR NSR TVPE OF INSURANCE POLICY NUMBER DATE MhUDU/YY DATE MM/ODm 11MlT5
GENERAL LIA&LITV EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) E
CIAIMS MADE ❑OCCUR MEO EXP(Any one person) S
PERSONALBADVINJURY S
GENERALAGGREGATE $
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $
POLICV PR� LOC
JECT
AUTOMOBILE LIABILITY GOMBINED SINGIE LIMR $
ANV AUTO (Ea acciCenQ
ALLOWNEDAUTOS BODILVINJURY a
SCHEDULED AUTOS (Per person)
HIREDAl1TOS BOOILYINJURV $
(Peraccitlenq
NONAWNEDAUTOS
PROPERTY DAMAGE $
(Perecdtlenp
GARAGELIAB�UTY AUTOONLY-EAACCIDENT E
ANVAUTO OTHERTHAN �ACC E
AUTOONLV: qGG $
IXCESSNMBRELLALIA8ILITY EACHOCCURRENCE $
OCCUR � CLAIMSMADE AGGREGATE S
$
DEDUCTBIE � $
RETENTION $ a
WORKERS COMPENSATON AND X TORY LIMITS ER
A EMPLOVERS'LIABILITY . yjQOOG7S4� O�.�D�.�OS � OZ�OL�OG E.L.EACHACCIDENT $ rj0�00�
ANV PROPRIETOR/PARTNEfLEXECUTIVE
OFFICEWMEMBEREXCLUDED7 � � . E.L.DISEASE-EAEMPLOVEESSOOOOO
ttyes,tlescnbeuntler E.LDISEASE-POLICVLIMIT $ �j�0��0
SPECIHL PROVISIONS below
OTHER
DESCRIPItON OF OPERATIONS/LOGATIONS/VEHIGLES/IXGLUSIONS ADDED BV ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
TOWN-63 SHOULDANVOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORETHEEXPIRATION
UATE TMEREOF,TME ISSUING INSURER WILL ENOEAVOR TO MAII 1 O DAVS WRITTEN
T091I1 oP Yaxmouth NOTICE TO THE CERTIFICATE XOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Attn: Soard OP Health IMPQSENOOBLIGATIONORLIABILITYOFANYKINDUPONTHEINSURER,ITSAGENTSOR
1146 Route 28
South Yarmouth MA 02664 REPRESENTATIVES.
AUTHORIZED REPRESENTATNE
Bob Lind ist
ACORD 25(2001108) OO ACORD CORPORATION 1988
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-125 FEE: $75.00
In accordance with re ations promulgated under authoiity of Chapter 94,Section 305A and Chepter
1 I 1,Section 5 of the�al Laws,a peimit is hereby granted to:
Salty's Inc., 473 Route 28, West Yarmouth, MA
Whose place of business is: Ann&Fran's Kitchen
Type ofbusiness: Food Service
To operate a food establishment in: Town of Yazmouth
Perntit eacpires: December 31. 2005 BOARD OF HEALTH: Be.yawriu$. l�mrd.ru�,M.$. '
S��,r�G: 3o p�k M� v�e�
Rode�it 4. B�, Gle+t,4
�Sl.�k. R.N.
�lf� R.N.
Februacv 3_2005
Bn�ce G.M�p RS.,CHO
Director of Heal
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERNIIT NUMBER: #OS-086 FEE: 50.00
This is to Certify that Salty's Inc. d/b/a Ann&Fran's Kitchen
471 Route 28, West Yarmouth, MA
IS IlEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless
sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornuty with the authority granted to
the licensing authoriries by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
Boa� oF�tu,�: B��. M.$. l�.�
s�,�� 3o p���a� �e!�
a����c�
�4.r.��d�, R.N.
Februazv 3.2005
D'uector of H�e,alY, ,
� fYq ���J�{�, �� RNIU'YF�4AN$
r �o y � TOWN OF YARMOUTH BOARD OE HEAf.T ;, � _, �,
` APPLICATION FOR LICENSE/P��IIT-20 � �'' LL `� r ��' � D
/y
�' • ,: . ' ` �'t��l d � ����
P lease comp lete form an d attac h all nec��i''y�ents by Dec mber 31, 2 0
Failure to do so will result in the r o your application a��-�-� ���T
T T # ��l� ,z��i
N D �J ��Yt-yc' ' Lv �
MAi .IN D_ F �• � r �P� /r'f!i -�t i�vS� oG?G��
O T N • S�GT-� `� -�.�� �
ER' E: �� l�yi�i� �j GS,
.ADD S : - !/C • Gr� d G�3
POOL CERTIFI ATIONSjY f����
The pool supervisor must be fied a P ol Operator, as required by State law. Please list the designated
Pool Operator(s) and attach cop the c ification to this form.
1. 2
Pool operators must list a minimu� f two e oy es currently certified in basic water safety, standard First Aid
and Community Cardiopulmona Resusci ion PR). Please list these employees below and attach copies of
employee certifications to this rm. Th ealth Department will not use past years' records. You must
provide new copies and ma' ain a file at your place of business.
1. 2
3. 4.
FOOD PROTECTION MANAGER C RTIFI ATION •
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 certifica6on to this application. The Health Department will not use past years' records.
You must provide aew copie nd mai ' a file at your est lishment.
I. , . �.�/�`i`_. �j�. �� /���� 2. C� � �li���/✓2 �SG
!
PEiiSOi�f Hd�i��#i2��. _ -_ ___ _ _
Each food establishment�must have a one Person In Char C)on site during hours of operation.
1. 2
I�-EIMLICHCERTIFI ATION4•
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 busiaess.
1. f/1/Z/�of�/ 2. �.� %/�iv��1/�
3. (a��,�2��ff 4. �c/%��/
�
RESTAURANT SFATIN(': TOTAL#�
��M,��z OFFI . ON Y
LICENSE REQUIRED FEE PERMiT H LICENSE REQUIRED F8E PERMIT# LICBNSE REQUfRED FEE PERMIT H
_B&B "a50 CABIN S50
— _MOTEL $50
—� $50 _CAMP S50 _SWIMMING POOL$75ea
_LODGE S50 _TRAILER PARK 550 _WHIRLPOOL �75ea
FOOD SERVICE
�� LICENSE REQUIRED FEE PERMIT# UC6NSE REQUIRBD FEE PERMIT# LICHNSE REQUIRBD FEE PERMIT#
I 0.100 SEATS S75 �-0� _CONTINENTAL $30 _NON-PROFIT S25
_>IOOSEATS 5150 I_COMMONViCT. S50 �� _W��OLESALE $73
RTAIL RVI
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE6 PERMIT It LICENSE REQUIRED FEE PERMIT#
_60 sq.ft. S45 _>25,00(1 sq.ft. E200 _VENDMG-FOOD S20
_<25,000 sq.ft. S75 _FRO'LEN DGSSER'P S35 _TOBqCCO S25
NAMF� $�p
AMOUNT DUE _ $ 12,5 .Oo
""•"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"""•
;, :
�- - y - --�_ ..,
ADMINISTRATION � , �",,�
Under Chapter t 52, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or permit io 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 C/
Q$
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEH---
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 cun annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL E3TABLISHMENTS ARE TO CONTACT TH�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR"TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATiONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPEIVING: Al1 swimming,wading and 'rlpools ch have been closed for the season must be inspected
by the Health Depaztment prior to opening.
POOL WATER TESTING: The water must be ste or pscudomonas, total coliform and standazd plate count
by a State certified lab,prior to opening, and erly thereafter.
POOL CLOSING: Every outdoor in gro swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVIC�-
CONSUMFR AAVISORY:
Each food establishment which serves or sells read -eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must if e outh Health Department by filing the
required Temporary Food Service Application form 72 0 ' o the catered event. Thses forms can be
obtvned at the Health Departrnent.
FItOZEN DESfiF'ItTS: -- -
Frozen desserts must be tested on a monthly basis by a St e '� e� b. Test results must be sent to the Health
Department. Failure to do so will result in the suspensi or r on of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress servic , u prior approval from the Boazd of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by re�ood service establishment is prohibited.
DATE: SIGNATURE:
PRINT NAME & TIT :��q�-������`f��� f�S .�/�.i.�<<
10/22/03
From:67aurabeth Ch�bon CIC At:7he McCerthy Compenia FezID:97B80BOD38 Ta:Ginny NkigM Detr.11/25fZ003 12:09 PM Pege:t oi 1
ACORD_ CERTIFICATE OF LIABILITY INSURANCE OPID °���M�°°^�
ANN68-1 11 25/03
rRODUCE� TNIS CERTIFICATE IS ISBUED AS A MATTER OF INFORMATION
NOscsoss & I,Oiq6t06 Cape Loc. ONLYANDCONFERSNORIGXTSUPONTHECERTIFICATE
C.J.MeCaithy Ins.Aqeacy,Iac. HOLDER.THISCERTIFICATEDO�SNOTAMEND,EXTENDOR
437 3tatioa Aw ALTER TX!COVCRAGEAFFORDED BY TXE POLICIES BELOW.
Bo.Yarmouth 29� 02664
Phone: 508-394-0946 FaX:508-760-1407 INSURERSAFFORDINGCOVERAGE NAIC#
iNeuReo iNsuaean: Haaover Inauraace C aa
wsuaea e: yaagaa caxta xne
llaa G Fraa�a Kitchen ��suReFc
21 Ssookhill Laa� iNsuaeao�.
p►est Yaxmouth DA 02873
INSURER E�.
COVERA6ES
THE PJUQES OF INSURANCE LISIEC BELU1'H4VE BEE�ISSUED TO iHE NSIFED NAMED A30YE'OR THE POLICI P9RIOD INDICAiED.NOTtiIhSTRJDMG
ANY FE]JIRENENL TERM CR COIVPTION J=PNY CCNiRHQ OP 9 HER DOCUMENi N/ITH 4ESPECTTO WHIGFi TMI:CEPiIFICATE MMY BE ESU'_D OR
NAV PERTAIN 'ME IV3URANCE FFFJ'.DED BY THE POLICIE9 DE3CRIBEC MEFEIn IS 9UBJEC t0 ALL iFE TERVS EXGU,6 ON9 MD GONDI79N9 OF SJCH
POLIQE: 4iGREGhTE LIMITS sHOWN MAY HFbE BEEN FEIXIC=D BV PAi�CLpIMS.
LTfi 1YPEOFNSURANCE �OLICYNUNBER OAIE(MM'00/YY) WTE(MM'WIYY� UN�
GENERALLIABILRV EPC}1GCCLRRSNCE 6IOOOOOO
A X oou�M=_aa4�Newauneiur� OFIN592839203 04/O1/03 09/01/04 PFanises eaoo����,�a s 300000
cuiNs�aaoe X�occua . ti�e�exe�noy o�e ce5o�� s 15000
� � Peas�wua�din.uzr s1000000
cermuaseRec-are s2000000
� I 6EN'LAGGREGPi=�iMITAPPLIESPER: I �.FFppUCiS-COMF/OPPGG 5 'jODOOOO
� �OLICY jECT I ��
IUTONOBILE LI4BLf1Y
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EOCILY INIUPY �S
9CHEDULEJPUfJS I (Pe�persoN
iIREJ PUlOS
BGCILV INJVR�
VON-OVMECFU'� I (Permciaert) 5
^FOPERT1DPhNGE 6
� (Pareccidck)
OARAOlLI48LITY I AI,TOCKV-�1ACOIDEM S
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EXCE98NMBRELLRLIGBILRY EPCHOCCl4Xt=NCE S
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WGItl(GRCCd.P6N8ATi0NM1D X TJR't�INIT° E3
B �r�oveRe•�ueam y�00675902 O7/O1/03 01/O3/04 E.�.en�ancaoentr s500000
PNT PROPFIETOR�PPRTNEWEXE0.�i16E
OFFICEPRAEMBEP EXC�LCED9
E1.CISEPSE-E4EMFLJYEE SSOOOOO
If yes,Eescrbe wEx
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #04-088 FFF": $75.00
In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter
I 1 l,Section 5 of the Z�eneral Laws,a permit is hereby granted to:
Sa1ty's Inc. 473 Route 28 West Yarmouth MA
Whose place ofbusiness is: Ann&Fran's
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pemrit expires: December 31 2004 BOARD OF HEALTH: Be.ywxl.c `�. (�'o+ulo�,, �1.$, •
sEn�r,rrc: 3o Pcb�ia�Mc.b` �co� ?/:ce �r�vxa�c
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Jea�zs.zooa ��
Bruce G. Murphy,MPH, S O
Director of Health
THE COMMONR'EALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NLTMBER: #04-066 FEE: $50.00
This is to Certify that Salty's Inc. d/b/a Ann& Fran's Kitchen
471 Route 28 West Yarmouth MA
IS HEREBY GRANTED A
COMbION VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2004 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victualler's. This license is issued in 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.
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. . ,
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-041 FEE: $75.00
In accordance with re¢ulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�ieneral Laws,a permit is hereby granted to:
Sattv's Inc 471 Route 28 West Yazmouth, MA
Whose place of business is: Ann&Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yannouth
Permit expires: December 31. 2003 BOARD OF HEALTH: �e;y ,��, ��
SEATING: 30 e� p'
� m�_w`O!R-L��y. ��iiObpql�(i� L/.. (�(CC
nr,aJt�_(��G1G I[I(�.C�.(/�fIMIfO�/�
. !�'LLGIL�1iQ�i. �,L• �
December 10 ,2002
Bruce G.Murphy, .,CHO
Director of Aealth
THE COMMONR'EALTH OF MASSACHUSETTS .
TOWN OF YARMOUTH
PERMIT NUMBER: #03-025 FEE: $50.00
This is to Certify that_ Sakv's Inc d/b/a Ann&Fran's Kitchen
471 Main Street/Route 28 West Yarmou MA
IS HEREBY GRANTED A
COA�MON VICTUALLER'S LICENSE
In said Town of Yazmouth and at that place only and expires December thirty-first 2003 unless
. __ _ _ —sooner suspe�e�orrcv�k�d forviatntiasafthe-}aws ofthe Commonweattlrres�rectmg th�
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 Testunony Whereo� the undersigned have hereunto affixed their o�cial signatures.
BOARD OF HEALTH: �;{[, z��. ��
SEnTnac: 30 �� ��oec �D, , �f/ite �Ctur�raa
����
� S/ ��1.
Decemberl0 ,2002 � ,
Director of H�e,alth� ' � '
� r $ -1 ANN + FRRNS
� ' . TOWN OF YARMOUTH BOARD OF HEALTH
� APPLICATION FOR LICENSE/PERMIT -2002 —_
� G� � i� l '' �� I�; '�
" Please complete form a� � , ocuments by December 31, 2001. Fail e t�dQ sp Wil�zg$ult n
the return of your apphc n ' �L y 1 � C li U i
82 /:1'l5�
O E ABLIS ENT: :i � � /
[ wu..v r�sr — _.� e�a�., — �r - oa�
MAILING ADDRESS• p� 8/l00� i U �Qo�sO - G/��.sr Y.azs+va,��s wso o� ��
OWNER/CORPORATION NtLME: S�JLTyJ' %.u4.
MANAGER'S NAME: /-/�92uts f �u2%dA'T T .L. #3bS- ��G p��
MAILING ADDRESS: �/ aQook� hi!/ ,�i+sD � kie�T�.f�i2nvi�/ _ l�fi! _ �'G�3
POOL CERTLFICATIONS:
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 tl certification to this form.
1. 2.
Pool operators mu t list a mini of tw ployees currently certi i in basic a safety, standard First Aid
and Community C diopulm ary Resu tation (CPR). Please list ese emplo es below and attach copies of
employee certificat ons to 's form. e ealth Department ill ot use as ears' records. You must
provide new copies n aintain de at our place of business.
1. 2,
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1.�94UE-/ � �j�l61f! 2.�i�pP1�'S Gf/ET�E'.C.3�'v'
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation.
1.��,�t� Lvf?�✓b�YT' 2. /o�2�6S !�/,�7.�_2�oic`
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. �/,v.�ri Gr/'.2/`✓sT� 2. �.�dis4/ /�.,/is'�
3. ' 4�
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN S50 _MOTEL $50
_INN $50 _CAMP $50 _SWIMMING POOL SSOea
_LODGE $50 _7'RAILER PARK $50 WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT!1
�0-]00 SEATS $75 03��8� _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $I50 � COMMON VICT. $50 �O o�-Oba- WHOLESALE $75
RETAIL SERVICE:
LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 TOBACCO � �$20�
<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAMECHANGE: $]0 AMOUNTDUE _ $ /QS.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*«•
. � `
. _ � .
T
ADMINISTRATION
Under Chapter I52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certifica.e of Worker's
Compensation Insurance. THE ATTACHED STATE WORKTR'S G'OMPEN5ATION 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 permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'1'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPARTMF,NT 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.
A DITION i F ULATIONS
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: T'he 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
C'nNSUMF.R ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATFRING 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. Failwe 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 haue prior approval from the Boazd of Health.
OUTDOOR COOKING:
Outdoar cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
�
DATE: l�r'.T!!J� SIGNATURE:
PR1NT NAME & TITLE: ��,pU,� ��d�YT /��QES �, r 1.v�
09/11/O1
� �
y The Commonwealth ojMassachusetts
�s : Depar�ment ojlndustrial.-lccidents
� ; Of!/ce o1lsr�stlOsllais
600 Washrngton S�reet
Bnston, Mass. 02111
' � °� ' Rbrkers' Compensation Insurance Affidavit
Aoolicant information: PfessePR[IV7"iedGida
nam�- //�F�%C.� f L/l/ C . ��i�Q ��/.v 9 /��'/�S �%C/yi'�
_'f
luc�tion� 7 Tl /�7/l �� 'ST�e� ` �/G i R�/ ��Q� G�s��.QF� �
�� ��� �/9�.N1�L6 � �A �O�li� 3 ehone p�vN��+���r7��
� I am a homeoµner pzrt�rming all work myself. ,�O$ �y�/ ��7.
� I am a sole proprieror �-,'. ha�zpo one norkin_ in an} capaein�
�I am an employer pro�idino workers' compensation for my employees uorkine on this job.
eomnanr name• 1' ���� /TL'/yf�•�/ _
I�ress• y�� ��l7/.� �T��%�
{jj�• �j�S' �i¢12�'�l� /���� ohonep• V"Y` J��S ��57�
insur�nce co �1.C�.�`L �IIF. �LM'f �� oolicv M �.�/� ✓���
� I am a sole proprietor. general contractor. or homeowner(circle ortel and hace hired[he contractors listed beloµ ��ho ha�e
thz follo�cin_ �corkers compensation polices:
vn
re •
f p.
insuran '�
m an n m :
insuranceso ��n K
_ 1
P�ilurc to ucure coverqe as required uader Seenoe 25A of MGL IS2 u�lad to the i�po�iliw of crisiW peedtle of�O�e ap m f1,500.00 ud/or
ane ynn'imprisonment u w�ell aa civil pendHn io the form af�STOP WORK ORDER nd i Ilx of SI00.00�d�r q�imt ma I ndenu�d Nat■
eopy o(thh sntemcnt m�y be lonvarded to tAe ORcr of►nvenig�tiom of tse DIA for emen{e rMfluUw.
l do-hrreby certij}•under�he pains and rna/�i�_ es ofperjury that�he injornmlinn providtd above rs trrt md coneeL
�'1y
Signature � . �'�/��
Print name �,.Qo�� /isyT� � � Phone M �' ��l �/'��
.. olTicial use onh do not write in this�rta to be completed by ciry or tmrn ollltial
citv or rown: Y�M�DTQ � permiNieeeu N nBuilding Dep�rtmmt
' --- �Liceesiog 8oard
p check if immediarc response i�required 261 p5electmenb ORce
�Hea1tE Dep�rtmem �
contact person: phoneM;_ �508) 398—?231 eat. nOmv
12l13t20@1 98:29 5087601407 NORCRO5S & LEIGHT6N PAGE 01
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�
ACORD 26S(TIl� RATION 1it/
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-002 FEE: $75.00
In accondance with re ations promul under authority of Chapter 94, Section 305A and
Chapter 11],Section�f the General aws,a permit is hereby granted to:
Sal},y's inc 471 Main Street/Route 2R West Yarmnuth_ MA
Whose place of business is: Ann&Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31. 2002 BOARD OF HEAI,TH: � zo[fu�, (�,�fav�a«
sEn�ra,rc: so D.�do�C 7 D., `Liee
�a8ott� �wavc, elark
�a�hiu�� sMrett
Januarv 24 ,2002
ruce G.Murphy,MP .S., O
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NtJMBER: #02-002 FEE: 550.00
This is to Certify that Salty's Inc d/b/a Ann&Fran' Kitchen
471 Main R Pt/Rnnte'JR Wect Yarmrnith A�A
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 violation of the laws of the Commonwealth respecting the
licensing of common victualler's. Ttris license is issued in conformity w�th 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: �lianfea�f, �d�'rez, �r�.c
sEn'�'¢vG: 30 S'P�1� `�. C�do�. �`j�. . �f/lte �ialnacax
P�� �ott�
Januarv 24 ,2002 �
ruce G.Mu hy, , .,CHO
Director of Health
_ ,�.y.¢�`P �ANN � ;, �-- : -�- .
" _ . a � c� c� ue � �
. • c1� ?��.
Towiv oF Y�ouTx sc� _ '��,,� DEC 2 1 2000
APPLICATION FOR LICE ,�, � � HEALTH DEPT.
* Please complete form and attach all necessary docutnents by December 31, 2000. Failure to do so will resu t m
the return of your application packet.
----------------------------------------------------- —�_----------------------------------------------------------------------
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a,r n rr n.T� n nnn�c c �! L�4w lL /f!/Q✓J L/CS�" ri�M-+PII� � e .`L_�
----------------------------------------- -
POOL CER'TIFICATIONS:
The pool supervisor must be cerlified as a Pool Operator, as reyuired by new State law. Please list the
designated Pool Operator(s)and attach a copy of the certification to ttus form.
1. 2.
Pool operators must list a minimum of two employees currendy certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certi£cations to this form. T6e Health Department will not use past years' records. Yon must
provide new copies and maintain a file at yoar place of bueiness.
1. a.
3. 4.
�rMr ICH CERTIFICATIONS•
Ail 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 empioyees trained in anti-chokmg pmcedures below and
attach copies of employee certifications to this form. The HeattL Department will not use past years' reeorda.
You must provide new copies and maintain a file at your place of business.
1.� �� 2.
3. ,� �' � — — 4-
RESTAURAN SEATING: TOTAL# 3C� NON-SMQKING SEATS: TOTAL#���
-�-- --------- __------- --------- --------- -----_— ---_----- -------- -------- - �---------- -- _
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 _CABIN $50
� $50 _CAMP $50
LODGE $50 _TRAILER PARK $50
MOTEL $50 _SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE:
NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Estabtishments,the effective date for
food proteMion manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $75 �6 I-b�g _CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 � � '� WHOLESALE $75
RFTrLiL SFRVICE•
.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $2�
45,000 sq.ft. $75 _FROZEN DESSERT $35
>25,000 sq.ft. $z�
NAMF.CIiANGE: $10
AMOUNT DUE _ $ I 25• 00
••*•*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM`«"`*
_ � . �,r.
.....�...._,,...__.�� . �' Y
.....�___...._.._� . .
` . • •
1
ADMINISTRATION
Uhder�haj�t@r_7�2,S�c1�on 25C, Subsecrion 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 t4TTACHED STA'PE iY4?AKER'S COMPENSATION INSiJRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED '
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taz�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: � /
YES v NO
NOTICE: Pernuts run annually&om January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2000.
SEASONAL ESTABLISF-IMENTS ARE TO CONTACT'TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPEI�IING 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.
ADDITION�i. RFC-tn ATION
POOLS
POOL OPENIING:All swimming,wading and whirlpools which haue been closed for the season must be inspected
by the Health Department,and the water tested for pseudomonas,totat coliform and standard plate count by a State
cemfied lab,prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered wiUun seven(7)days of
closing.
FOOD SERVICE
�TEW STATE SANIT RY COD FOR FOOD E TABLI H FNTS
The effective date for food protecrion manager certification is October 1, 2001. As stated in 105 CMR
590.003(A) 2), food establishments must have at least one person-in-charge who is a certified food pmtection
manager. �is provision is effective one yeaz from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement
of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell
or serve ready-to-eat,raw or undercooked animal products aze required to have consumer advisories.
CATERiNG POLICY•
Anyone who caters wittun the Town of Yazmouth must notify the Yarmouth Health Department by filing the
reqmred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZ .N D . S .RTS•
Fmzen desserts must be tested on a monthiy 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.
OUTSID �. C F� •
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKIN •
Outdoor cooking,prepazation,or display of any food product by a retail or food service establistunent is prohibited.
DATE: /� o�i �u SIGNATURE:
PRINT NAME& TITLE: /.,/�v�yC,/�y— �/,����
�
11/16/00
. � , _ ,,,,_ _ _
. �
The Commonwealth ojMassachusetls
� Department ojlndustrial.-iccidents
; O/flcsol/sresd'sUais
600 Washington Street
Bosron, Moss. 01111 `
" W'orkers' Compensation Insurance Affidavit
Aaolicant information: PfeasePRIPTTedGLTa
�^� � � �`%�/.1/ � /�`�
oamc: Gl�'� �.�f�..l�G � � � � :r--���"i{/.� 1L//���%✓�/
location: y,�� . �- //// ST�/2s�i-... .. .
cit�� ��) / Vi92«'f/Lf� N//7 ��G �_phoneM��/� ����..
� I am a homeowne pertormin�all work myself.
� I am a sole proprieeor�-d ha�r no one «orkine in an} capacin�
(�I am an employer pro�idino workers' compensation for rm�v, employeesworkine on this job.
com�an}' name: �(/�? f Y�S T WI (// / (��
.Jdr ss: '-T ���/ 1 �
S D � ��
�05����� r a
� I am a sole proprietor. general contracror, or homeowner(circle one� and hace hired[he contractors listed beloµ ��ho ha�e
thz follu«in= ��orkers zompensation polices:
�om{�nv n+me•
address•
�• ohone k•
insur�ncc co policr#
m an n m :
-_ _ _.—_ . . _ . _- -- . ._.
-- ---.._._—
address•
�: yhooe p•
inanranrw rn. ��
Failure to secure coverage as required uoder Setnoo 25A of MGL I53 u�Ind to the inpaidoe of trisiW pndtla of a O�e ap to Sl¢00.00 a�d/or
one yun'imprisonmeat i�w�dl a civii.pendNn io tAe form of a STOP WORK ORDER�od�6oe of 5100.00�day q�imt ma I aWeofa�d tlat a
topy of thH statement m�y be forwarded to the 01liee of Invntig�tiont of the DIA for eoven�e verilintlo�.
/dn hrre e p ' tie j thal the injormNion provided above 6 tntt�en � �
Signatu
Print name �C.A v Q /1/1 ��U ✓ C� � Phone# ��v� `� v 9�
� oRcial use onl�� do not wri�e in�his area to be completed by eiN or town oflieial
city or town: Y�M�DTQ _ permiNieenu M nBuildiog Dep�rtmeo�
� pLieensing Board
� theck if immedialt rcsponst ie required � 261 ❑Sdectmed�Ofifee
OH�alth Dep�rtment
contact person: phone a;_ �508} 398t2231 eat. nOther
pmsN iA5 P1A1
� - -�
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMITNUMBER: #01-050 FEE: $50.00
This is to Certify that Saltv's I_nc d/b/a Ann&Fran's Kitchen
471 T��ain 4trert/Rnnt 2R �IJeet Yarmrnith R�A
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yannouth and at that place only and expires December thirty-first 2001 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 signatwes.
BOARD OF HEALTH: $d�K �etleo, �ain.xa�
S��G: 3o e���. z�, v� e�,�
���. �, e�,�
��co :�
� . .D.
February 15 ,2001
ruce G. Murphy,MP ,R .,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMITNUMBER: #O1-078 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Sec6on 305A and
Chapter 111, Section 5 of the General Laws,a permit is hereby ganted to:
Salty'c�� 471 Main 4tree /Ro rt R Wect Yarmonth A�A
Whose place of business is: Ann& Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31. 2001 BOARD OF HEALTH: $d f1L, `�etYea, ��nc
SEATAIG: 30 ��e���� �, z�, v�L
�t,O,��/W-��e /. {�, �fR.
�/(GG�QR V � �
�ee.r� D. � 711.D.
.
Februarvl5 ,2001 � t�cp;'1' p�Z
Bruce G.Murphy,MP R.S.; HO
Director of Health
' �P1V1 c''� �'I'ZiV�IS �1�C��GI
� • TOWN OF YARMOUTH BOARD OF HEALTH�--�r�� � i: ;�;; I^ �� ���n '��� ����
APPLICATION FOR LICENSE�,�'�2�00�� /
�r� ;; � 3 c��JU
w?�,
#�lease complete form and attach all necessaxy documents by D�be�i��Fail e�sa��tJ�tlb�zilt i
the return of your application packet.
----------------------------------------------
-- ------ - ----------------------------------------------------------------
NAME OF ESTABLIS�IMENT- /IN�I �f�'/f.(ItSR��lee`��..c' TFL # 1�7� ���
L TI ! H'1�9/.J �Si R8�_ LV�ST a tt. — . d c�(o7�3
LIN D / OK ' / 0– 4J sT o o�
T ' .�.vc. �v ,i Kic �,v
' .vec�,c' 4J�f2l6N� TE # - !o
D QaoK l•1�'// < rT �v - - U 6 3
---------------____----------------------------__--__
-----------------------------____—___-----
POOL CERTIFICATION��
The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please Gst the
designated Pool Operator(s) an attach a copy of the certification to tlus form.
1. �l
Pool operators must list a minimum of two employees cunentl rtified in basic water safety, standazd First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certiScations to this form. The Health Department will not use past years' records. You must provide
new copies and maintain a le 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 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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# �� NON-SMOKING SE?�TS: TDTA�.# �
_ —___—_------------------------------------------------------ ----- ----------_—_____—_
OFFICE USE ONL.Y
LODGING:
LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 CABIN $50
_INN $50 CAMl' $50
_LODGE $50 TRAII,ER PARK $50
_MOTEL $50 SWIMR�IING POOL $SOea.
_WHIRI,POOL $25ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT # LICENSE REQUIRED FEE PERMIT #
�0-100 SEATS $75 YZK.'I�3 CONTINENTAL $30
_>100 SEATS $150 NON-PROFIT $25
�COMMON VICT. $50 YZ�'HI WHOLESALE $75
RETAII. SERVI E:
LICENSE REQLJIItED FEE PERMIT# LICEN3E REQLIIltED FEE PERMIT#
_<50 sq.ft. $45 _TOBACCO $20
_<25,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.ft. $200
N�,ME CHANGE: $10
AMOUNT DUE _ $ I Z� –
•"••"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••••
�
i ,
ADMINISTRATION
iJNDER CHAPTER.1�2, SECTION 25C, SUBSECTION 6, Tf-IE TOWN OF YARMOLJTH IS NOW REQUIltED
TO HOLD ISSUANCE QR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PERSON OR COMI'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPEN5ATION
INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTI'
MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�
TOWN OF YARMOUTH TA3�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPRO TELY IF PAID:
YES NO
NOTICE: PERMITS RLTN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHIVIENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENII�TG FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
CONIMENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN.
Ai)DITIONAi REGtn ATIONS
POOLS
POOL OPENII�TG: ALL SWIl�IING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR
TI-IE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR
PSEUDOMONAS, TQTAL COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEIVING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvIlvIING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN (7)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN TI-IE TOWN OF YARMOUTH MUST NOTIFY TF�YARMOUTH HEALTH
DEPARTMENT BY FILING TI� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO THE CA'I'ERED 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 Tf�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN Tf�
SUSPENSIONORREVOCATION OF YOURFROZENDESSERTPERMIT UNTIL TI-IE ABOVE TERMS HAVE
---
BEEN MET.
�TI' IDE F'F' :
OL)TSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �,�HAVE PRIOR
APPROVAL FROM Tf�BOARD OF HEALTH.
OUTDOOR COOI�iNG�
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE EST?,i�3LIS NT IS PROHIBTTED.
DATE: 1��� p� SIGNATURE:
PRINT NAME& TITLE: ��/��C�i��
�
11/12/99 �� ,� �g���f ��G.
�
� � The Commonwea!!h ojMassachusetts
= Department ojlndustrial.-Iccidents
_ b O/JIC001/OYCStly�//I/S
600 Washington Street
Bosron, Mass. 01111
� �� • W'orkers' Compensation Insurance Affidavit
Aoolicant informaHon• p► n p[ZIpTTndai,FK
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n�m��. S/-�L�. (% � ,_�/.�[' .
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urS�JLo�tY � �l/��� ���, / ��C �" /
t tt_.�_�� �—� .Q�{�lt[J t/�/fY" G�7`6�`.6���Chone a �`�8 �7L (i'���
� I am a homeowner enorming all work m}self.
�] I am a solz proprieror �c,', ha�z no one ��orkine in an} capacin�
�i am an emplover pro��ding unrkers' compensation for my employees uorking on this job.
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comnan�� nam : �`� 1�,� / .A /L . ��' J [��,�'�!� Y�< / �'llF.�/
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citv."V�S��lQ�c�</Lc��/�T L��/ d-�(o�3 yhensu. Jz�O ��/ V/ °��
insurance co. oolicv p
� I am a sole proprietor. qenerai contractor, or homeowner(circle onel and hace hired the contractors listed below ��ho ha�e
thz follu�cin_ �corker, compensation polices:
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insurancc co ������.p
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insuranee eo. � eeRev M
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Faiiun to securt covenQe as required uader Seenon 15A of MGL IS3 a�iad/o the i�poritloa Meri�iW pe�dtln of a O�e ap m SI,500.00 a�d/or
one ynn'imprisonment u wxll u eivii pendtln io the torm of�STOP WORK ORDER asd a 6ee ofSt00A0�dar qaio�t m� [��denn�d that a
topy of Ihy sntement may be fonv�rded to the ORce of InvefNQuiom of Me DU for eovera�e reritlutlo�.
/do hereby cer�ij}•under rhe poins a ' o erjury thal fh[injormaNan pmvided above is fnrt and eorrctt,
Signaturc /�/�Q�p�
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Print name � ' ; �{- p�e K ��� �f.�jZ
.� oRci�l use onh do not rrite in this arn to be completed by tiry or fmvv ollleial
eiry or town: YA�DIITR _ � permi�/lieeeae N nBuilding Deqrtmeo�
� ❑Licensios Bo�rd
� check if immediate response ie requirrd 261 OSdectmen'e Ofliee
�HealtA Depattmeet
con�act person: phoneN;_ �SOS� 398�Z.231 eat. �Other
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-143 FEE: $75.00
In acwrdance with regulations promulgated under authoriry of Chapter 94, Section 305A and Chapter
11 l, Section 5 of the General Laws,a pertnit is hereby granted to:
Raltv's inc" 471 Main Street Wect Yarmn �� MA
Whose place of business is: Ann& Fran's Kitchen
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires:_December 31. 2000 BOARD OF HEALTI-I:�'��f. .�atf�, C'��,„a,.
SEATING: 30 �y�oan�c 7s�u`��a�, ,�0�/ , v�e c��,�
Ka�er�/.}.n�ro/u,gn/� clO/.,k
a��/6eC�JakoG�cky�g/doop e
u'�ae e att��Cin
7anuary 25 ,2000
Bruce G.Murphy, MP R.S HO
Director of Health
THE COMMONWEALTH OF MASSACIIUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: Y2K-81 FEE: $50.00
This is to Certify that Saltv's Inc d/b/a Ann& Fran's Kitchen
— 471 Main S rePt �xJect Yarmouth h�A
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yazmouth 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 confornuty 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: �y{'Jn. .�ot�@.,/, C�[��.,„q�� q � /�
SEATIIJG: 30 �oan G. �u[livan� K.//.� Vice C,�zairman
o6a.r.�/ n/3rowA�, CL/„lG
a6.ia�leg Ja�pol��y-.ghtoopee
ic�aal d �Cin
Ja�uary 2�,2000
Bruce G. M y, , R HO
Director of Health