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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 . " . .. _ �Ac�s f 6EYor��_. a � TOWN OF YARMOUTH BOARD OF HEALTH r j � �� APPLICATION FOR LICENSE/PERMI�,-Z� c '�'��l , 1 ¢ �� i .... , ,r � � �t��' ''' � � * Please complete form and attach all necessary doqa �I"it bp c�e er 1 Z 08. s� ne Failure to do so will result in the return of y , ppi�cahon pac __ ��=�=!��, NAME OF ESTABLISHMENT: �Z� G�`�� TEL. # SZ�-`�'i0-PJ� LOCATION ADDRESS: �J MAILING ADDRESS: OWNER NAME: c � TAX ID (FEIN or SSNI: �)�(— CORFORATION NAME (IFf�PLICABLE): MANAGER'S NAME: �! H�� TEL. # St�� -7��-�3T� MAILING ADDRESS: �QM�. POOL CERTIFICATIONS: The pool supervisor must be certi6ed as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certifica ' n to this form. 1. � 2. Pool operators mu list a ' oftwo employees c ertified in basic water safe dard First Aid and Community Caz•dio ulmo Resuscitation(CPR). Please list these employees below and attach copies o employee certifications to this . The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requn•ed to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide aew copies and maintain a file at your establishment. 1. 1 '\� 4'�"i A(wl 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �;��^^ � �✓W�c-w 2. HEIMLICH CERTIFICATIONS: All food service establis ts with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the pre ' s at 1 tunes. Please list your employees trained in anti-chokmg procedures below and attac copies of em yee cert' cations to tlris form. ea Department will not use past years' records. You ust pro ' e new copies nd maintain a at your pla e of business 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIrG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERNIlS k B&B SSi CABIN S55 MOTEL 555 INN S55 CAMP S55 SWIIvIIvIINGPOOL SSOea. _LODGE S55 _IRAILERPARK 5105 WHIRI.POOL 580ea. FOOD SER�'ICE: - --- - - — � � --- . __ _ .- _. -_ _ _ LICENSE REQUIItED FEE PERNIII# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'I# I0.100SEA7S S85 ��'"��'__�4(?j _CONTINENl'AL 535 _NON-PROFIT S30 _>100 SEATS 5160 �COMMON VIC. S60 �� _WHOLESALE S80 RE'f 41L SERVICE: � —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# _<50 sq.ft. S50 _>25,000 sq.R. 822i VENDING-FOOD 525 <25,OOOsq.ft. S80 _FROZENDESSERT S40 TOBACCO S55 v��cxa�cE: sio AMOIJNTDUE _ $ l�lS.Od ""•*•PLEASE TUR�OVER A1VD COMPLEI'E OTFIER SIDE OF FORitii**^** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISffi1�NTS TRANSIENT OCCiTPANCl': For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to conrinuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety (90) days within any s�(6)momh period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening.PLEASE NOTE: People are NOT allowed to srt m the pool area unril the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. 'I'hese 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 resuk in the suspension or revocation of your Frozen Dessert Pemrit until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Pernuts run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQLJIRED FEE(S) BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: �oauos � . � � �� ,��,S�S S' The Commonwealth ofMossachuselts Department af lndustria!Accidents N�YM� 600 R'ashington SYreeK 7`"'Floor Boston,Mass. 021II Workers'Compeesatioo Inaerana ASdavih BaildieglPlambieg/Elec[ricy�Contractors �: A�r�� w�.� address: � Q �d. � �,� / 1V (xJ � ciri `��/YkM�� shate• l/�i� zio� �1�-�973ohone# J��' /�U J 0 �/`'' work site locafion(fWl addicssY. �� . ❑ I am a homeowcer perfomring a11 wa�k myself. � Project Type: ❑New Constcuc,Kion QR�odel ❑ I�n a sole�proprietor a�have no bne wodcing in�y capacity. ❑Building Addition � �I am an anployer}sovidiog wa�ke,�s'compensation for my employces wodcing�this job. comoaevaame: � ;��-l�'1.��(/h,�.� � � . address: � ,�� .RI./ � � . � � . . . citr: y'� �{ IV\,�" � / 73 oYaee&• . ��.. �tZ�.r y T� S}�A sE,.�-ns�A�A� Cc� v�!;,_��.. �?9��-� "1 -- ---� � _- �, � � ,�x>�.��.�«� ..�� ❑ I arn a sole proprietor,gmeral co.tracMr,or homeawwer(cirde one)�d have hiced tbe conh�actots lis[ed below wla have the following wo�lceis'coinpeasation polices: 4nmmav�amt: � � . . . . . addr'as: . . . . . dt9' . . . . . o�a�elh . . - � . . � . . iwfvatoe oo. . .. . . ��d�p . � � . . . . eommvnue• � � ad�as• � : . � � � nYoee#- � . . . ��t . . palicy$ � .. _ .. . . . .� - . . � � ,,., FaBmt b�ecme wvuage��udc 9ectlw 25A dMCL 132 eu Ind b tYe�dtl�a N'ofieiaY �pm�Nin�f a B�e q b S1.3M.M anNsr..�: �r�+'mnr��a•�..awa..x�.du��..r.s�rorwomconoeem.e�.rsieo.waay.s.�.�. io.an,a■amu, eapy af lih s1tleneat my he f�nnrded b Ne Omte KLvnUptlsn�f IYe DIA/re�vera`e�criBntl�e. . . /!o Aarby cad'fy wler H1e paAu anJpent/dv ofPe JrJ+o9 tG�dYe Iwfora�mion provile(abnve&trre an6 corrxt . . . Si�atuce `—�%l� Dah �/�� Primname /_ � l �lA'l�.,V� Phom# SO�'�J�IU�P�r� � •�dal ese o.ry ao aa/w�ite b ws..ea lo ee cooqetd br dlr.r e.w.a�ci.� . � . eHy or tewu: �eru#IBeeax i 1-IR.�NM...p��t ❑eherk N�ie�e�eme b�eqeired � . ��x�� ❑Sdec�m's Omee . matact poaoc ��y. ��'�� t�su mm� �Q TOWPi OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-143 FEE: S85.00 In accordance with re@ulations promulgated under authorin�of Chapter 94,Section 30>A and Chapter I 1 l, Szction�of the Gzneral Law•s,a permit is hereby eranted to: Jason Carvalho, 311 Route 28, West Yarmouth, MA Whose place of business is: Bagels & Beyond Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2009 BOARD OF HEALTH: ,q�f�¢�Q¢""��l�$� �7� ,t7/JZ�.�✓ev�,��" na,wtttqta�it SEAiI1�G: 19 t��.lC�(NQ-R�.G�`O ,`7f.. ,/IQGWW{.�(CC l.!(p.f1(f1EQK RESTRICTIOI:S: Disposable sen�ire only:no sto��e or fnolawr, ✓WOXJLG �. �KOW�f. q�� Q_ f uo public toilets:hours of operation�+'itl be 6:30 am.l0 5:00 p.m. t�M��!p!Q[��y3� rC.lW(41lfIL� ��. �"_�"' �' � Januarv 14.2009 Bruce G. Murphy, ,R.S., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-091 FEE: 550.00 This is to Certify that Jason Carvalho d/b/a Baeels & Bevond 311 Route 28, West Yaz-mouth, MA IS HEREBY GR:�rTED A COMMON VICTUALLER'S LICE\SE 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 respectin¢ the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensine authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersiened have hereunto affixed their official sienatures. BOARD OF HEALTH: .ffeCen SKaR, J2.✓V., C'(lavtmtut SEA7ItiG: 19 ��p��"'�a `�. �e�px,�� a� RES7RICI701�5: DisposaAle senice ouh':no stoce oe fn-olaror .q/µ"q""r"�/�{ty�nn,,�lr(!((yj `�� ' no public Iuilels:hours of operaiion��'ill he 5:30 a.m.m 5:00 p.m. �{,((,/(. �� „/Y� Januarc 14.?009 ruce G. Murphy, PH, R.S., CHO Director of Health � � ��ts� (��yoN�J °` '�"k� � TOWN OF YARMOUTH BOARD OF HEALTH� ' �� APPLICATION FOR LICENSE/PERMiT-200� '�'�� ` C � '� � ��' � / c �+r � t' `, * Please complete form and attach all necessary� * e��y�ci�nb 31;��T. 4 Z008 Failure to do so will result in the return o �a�licat pack t.�EALTH DEPT. NAME OF ESTABLISHMENT: t �jA( TEL. # t41F-7gn_p!�Z,O LOCATION ADDRESS: �11 ,M oc�� ,rx �,Lf 6M.ak c3Z(,7� MAILING ADDRESS: OWNER NAME: A�v�t.a-�o T X ID fFEIN or Nl� CORPORATION NAME (IF APPL CABLE): MANAGER'S NAME: c�Su� ��A�v�9�xo TEL. # 62�d'-79U� MAILING ADDRESS: SA(tiz. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool_Dgerator(s) andaYtuha�o�7cnf�hereriification-to this form. 1. 2 Pool operators must list a ' imum of two em oyees curre y cenified in basic water safery, standard First Aid and Community Cazdiopulmona Resuscitation PR). Please li these employees below and attach copies of employee certifications to this form. T e �ealth De rtment will not e past year ' reco s. Pou must provide new� copies and maintain a fde a our place f business. � l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certi&cation to this application. The HealEh Department will not nse p�st years'records. You must rovide new copies and maintain a file at your establishment. l. � �� 2�. P�R�91V_I.N��RGE: _- — __ _– _ --_ ___ _ ----- ____ _ - __ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operarion. I. � �$_^— �%�J�v�.t�.� 2. HEIMLICH CERTTFICATIONS: 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 tnnes. 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 $nd maintain a fde at your pl$ce of business. 1. !V ��' 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LiCENSE REQUIltED FEE PER'bf1T# LICENSE REQL-IRED FEE PER4IIT t LICENSE REQL7RED FEE PERbfi7= _B�B S� _CABIN S50 _MOIEL� S50 _�NN S50 _CA.'�RP S50 _Sl�l7�tYIINGPOOL575ea. _LOIXiE 550 _TRqILERPARK 5100 _��7-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LICENSE REQL7RED FEE PER�SIT= LICENSE REQti IRED FEE PERbt1T= I 0-100SEAiS S75 ��`{� _CON'IINEN7AL 530 NON-PROFII' S25 � _>100SEATS 5150 1C014LYIONVIC. S50 �a9-aR�J _��HOLESALE 57i RETAIL SERVICE: —RESID.K(TCHE\ S7� LICENSE REQUIRED FEE PERMI"I= LICERSE REQL'(RED FEE PERbIIT= LICENSE REQtiIRHD FEE PER�III'_ _a50 sq.ft. S45 _>25,000 sq.R. 5:00 �'ENDING-FOOD S?0 _<25,OOOsq.tt. S75 _FROZENDESSERT S3i TOBACCO Si0 �iA.�CHeLYGE: SIO AMOU\T DUE _ $ /2S.00 •w�w»pLEASE 7'L7R.\O\'ER�1\D CO�[PLE7'E OTHER SIDE OF FOR\f**""" � , -.--� ,� ADMIlVISTRATION � \ Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON 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 permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinazily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofre�dence elsewhere. Transiem 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 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. * NOTE: En��osed Motel Census must be completed and returned.�;th t�is applicarion. POOLS POOL OPENIIVG:All swimcning,wading and whirlpools which have been closed for the season must be ins by the Health Department prior to opemng. Contact the Health Department to schedule the inspection five( days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and 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 Yannouth must notify the Yarmouth Health Departmerrt 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 resuit in the suspenswn or revocation of your Frozen Dessert Pernut urrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeakh OUTDOOR COOKING: Outdoor cooking,preparationror display of any food product by a retail or fnoci service PMAhl��hme�±_is prohihited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETCJRN THE COMPLETED APPLICATION(S) AND REQiJIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�ICEME�IT. REVOVATIO�iS MAY REQUIRE A SITE PLAN. DATE:_��F/��_ SIG�IAI'URE: � PRI�IT:�IAME&TITLE: �� 1i�?u n- � �,. �. . �'\ The Commonwealth ofMassachuselts DepaKment of Industrial Accidentc N�eIN� 600 R'ashington Streey �"Floor Boston,Mass. 02111 Workers'Compeesatioa I�seraaee AtHdavk:Bolding/Plembug/Eketricai Coatractors tls: Plpse i1NT lux.l. . . . �: �" d �' � C��C,f st ��r✓iti.� � a�: �l�/'Y�Po;� f�. cirv I.t� ��11�Y�UCJ�1'l shate• L�� zio•dLb�1� ohoce# "�'�' � ��'0 S�� wrork site location(full addressl: ❑ I am a homeowner perfom�ing all work myseif. Project Type: ❑New C�sttuc4��R�ode1 ❑ I mn a sole pro�ietor and have no one wodcing in any capacity. ❑Bwlding Addition �I�am an employer providing w�kecs'c�p�pensation for my employees wodcing um tltis job. _ � - — 1 . aonw.v.�me• 1 i IL h+L'CL �r tZ1 ��Y`'"� S ,�p '�'2 � : —�u .: c7u— 6 5� �. .� u s l. < ,. <:.. < ,: . ❑ I azn a sole proprietor,ge�eral eo.tractor,or homeow�er(cire%oweJ aed have hired the con4ac[ocs�listed b¢low who have the following workers'compemsa[ion polices: �mur unc- adNna- city niaee#• �44'��tt�. oollev N d��4B' �" nia�e#- " . ._ . . . . _ ____.._-___—_________.___._. - .—___—__._—_. .—_— _—.. __ t�sQa�cew. �g_ __ — . . .. _. .. ♦fYdriii�lrl'if�efi�r�w�. . . . . . . : ... ... .. . ..� :. �. Fa9ve e..eene w.afge n reqdrea oae seelw ssn e[n1cL lSz m Ina a ue isp�..raf�rd pn.Min.ra�R a s1,sM-M+.dNr: ..er�,�+'�,i.w.m�■.w.a..dvr�nu�r.rn.[asrorwowcoenea.w,�etuee.�eaa.y,pm.�ea �oaenu.dmu, eapy NtY6 fl�traeat my be ferwardM b tAe Omee af IavntlptN�at IYe DIA far pverape azrMntlx. 1�o hereby certljy e paGu anl peneldee ojperjrry M�Me iwjonw�tan prodded ebone 6 vve and cormt Si�at°`e-- Date ��$�OS Prim name_�SC� C•'i`^'rtcKJ Plwce# 'S�-�7QV a O'^' amew ese oury ae aw wrfle s lw,rea f.ne eovWetW�r dtr er m.m.mrL� � eLLy or tawn: ��K ❑��Depvtnenf ❑cYeck If�se�Be'eRame 6 ieqohed �� ❑Sdsdn'a O�oe coNaet paaoa: ��. ��d�� c .�a syr.mm� OF�Y9� �� '�o TOWN OF YARMOUTH ��A `j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 ` MqTTACM[FS � �<,,,a„�,,.r� Telephone (508) 39&2231, Ext. 241 — Fas (508) 760 3472 B O A R D O F H E A L T H 7anuary 28, 2008 Jason Carva(ho d/b/a Bagels&Beyond 311 Route 28 West Yannouth, MA 02673 Re: 2008 Pernut ApplicaYion Dear Mr. Carvalho, Thank you for submitting the 2008 application for your establishmenYs pemuts issued through the Hea(th Departrnent. Please note that, since yow establishment has a food service license, a copy of the Food Protection '� Manager's certificarion�'or your establishment was supposed to be submitted with your application. All food service establishments are required to haue 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 provide a copy of the above certification at yow eazliest convenience. If you have any questions on the above, please feel free to contact our office at (508)398-2231, e�Rension 241. Thank you for your anticipated cooperation. Sin� , � r MSIy E�ICC FIOLlO � � • Principal Office Assistant � /maf cc: •. file �� Printed on � R�`led 4 • THE COMMONWEALTA OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #08-093 FEE: $50.00 Tlus is to Certify that Jason Carvalho d/b/a BaQels& Bevond 311 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonweakh respecting the licensing of coinmon victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3EeBe�t Slfa�, �J2.JV., @f�auxman sEnr[tsc: 19 nC'R-,cQv-[�-�e`d .�E!.�9��i'e��P�P�.�ifl�e�i `UiCe '(.l�alxni(xrt RESIILICI'IONS: Disposable servim only,�siove or Syolaror. .q/W��a�� L �. .�VwW�4� � no public[oilets;hours of ope�ation will be 6:30 a.m.to 5:00 p.m. � fM[!G �[P.QfL�tj[�1�l,l,�/�►,t,��.�..�. . "�"�' January 28.2008 Bmce G. wphy , .S.;CHO Director of Healt TOWN OF YARMOUTH BOARD OF I3EALTH PERMIT TO OPERATE A FOOD ESTABLISfIlYIENT PERMIT NUMBER: #08-148 FEE: $75.00 In accordance with reeularions promulgated under authority of Chapter 94,Secrion 305A and Chapter I 11,Secrion 5 of the�ieneral Laws,a perntit is hereby granted to: Jason Carvalho, 311 Route 28, West Yarmouth, MA Whose place of business is: Bagels & Beyond Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2008 BOARD oF HEaLTH: .q�f2e_ee""e�t"S" Rrt7a�Pc,7/J2� a.a.N@.-, C�patvunqa¢n SEATING: 19 � tC7,fll�l�Vi�(�,r��p ,7L!.d�rICGLlf[l^'lL�} (/,%,fQ{..7[Q%lN1�Q(b RESIRICIIONS: Disposable service only;no stove or fi}rolator, ✓nW---U_Y7iL�._J�Jt_KO��WfL�t7I�,CP,�Ir[2 no public toilets;hou�of opeiarion will be 6:30 a.m.to 5:00 p.m. Uj`'�•[,�,�,�'„X4KfLV[ll.I/fL� .IL.✓Y. . �"�^'�'��'�' � . {. � JeDll&i)'2g,z�0$ � mce G.Murphy, .S.,GHO D'uector of Heal . F_,.,, ck�tata5�r� f g�roNa 2° e R o TOWN OF YARMOUTH BOARD OF HEALTH � �su ,JAN 0 4 2007 ��;? APPLICATION FOR LICENSE/P��IIT-200'7�17�0 9 �`� * Please complete form and attach all necessary d'o"cu�nents by December 31, 2006. Failure to do so will resu(t in the retum of your applicat�on packet. NAME OF ESTABLISfIMENT: � � TEL. # �7��ZqU��Uv LocATiorr.�nv�ss: �l�=�i�.�S� MAILING ADDRESS: OWNER NAME: l.PC11,�l�ftvt-Gv TAX ID(FEIN or SS1Vl CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: ��,h (,{�,�,��F; TEL. #�-79U-dSW MAILING ADDRESS: �\\ �Md� N POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum oftwo employees 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 tlus form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establistunents, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishmen� � � �� c� 2. PERSON IN GHARGE: . Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIF'ICATIONS: 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 Cde at your place of business. 1. 2. 3. 4. RESTAiJRANT SEATING: TOTAL# �QI OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMI'P# _B&B S50 CABIN S50 MOTEL $50 __INN $50 CAMP $50 SWIIvIIv1IIdG POOL$75es. LODGE $50 1'RAII,ERPARK $100 WIIIItI,POOL $75ea. FOOD SERVICE: LICINSE REQUIl2ED FEE PF.RMIT# LICINSE REQUIItED FEE PERMI1'# LICINSE REQiJII2ED FEE PF.RMIT# I 0-]00 SEATS $75 ,/� _CONTINENTAL $30 NON-PROFIT $2S _>100 SEATS 5150 / COMMON VIC. S50 �'�7�F(� _WI-IOLESALE E75 RETAII.SERV[CE: —RESID.KITCI��N $75 LICINSE REQiJ7RED FEE PERMI1'# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# _<50 sq.ft. S45 _>25,000 sq.R. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 __ _FROZEN DESSERT S35 TOBACCO S50 NAME CNANGE: E10 AMOUNT DUE _ $ /2 S•00 "'•"PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••"'• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A1"I'ACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCP: 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 motei 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 uait shail not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in MG.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whiripools 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 Sve(�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must norify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State ceRified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,prepar_ation, or displ�y of any food producthy a retail ocfood service establishment is prohibite�. NOTICE:Pemrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLIS��IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:_ SIGNATURE: ��//�� PRINTNAME&TTI'LE: c �f�cfcn.�t ( h�t.u.9c_rt�. '�`�-`'^-c� iomio6 IL'LirUO Il��Yp� �fUIrAIY rsro aa� wea i-wi �.�vvuua r+u - yI �.��i��ai;;w N.jE'.ts.� '.`4"'��':i::�e�J.. .J �� `}n� ' 4�f'1� :�. -. ry .T�u - �"=�'^4�a'' �&� `:t;1�c, _v��:;'��;:•,�:, .a: "-`�•`-'r`�i"•:;-;>'�"`'' '.�.�.�;�,,k'v ,`„': '• '�' i> t�'..,; w.� �::' r:-.;` . " $M :�'r t'�.(.. I � r � r" r' 'f''-':."' . t. ';.. :�Y.:., ':'.'j.'�{ l �•�� li �A� 'Ery.�� Q�$ r(.C�SY,< ::�•i'.y. ��lC.� �: 'i »C.'; 'f! y r.��r. �4.�b��3.� nM�./�` �LY � �!�;� r� ' � �'°. :. '` �'y:�]: s � r•K�. =3 ;• ;l2/Y7�'10o:'i : ., �. _ .S�. in .':e P�"S' �'• r��a��"�S.P.': ^ n � ^' �r� : Y .. � 4. :'�' - ��y� K+�. r:. n ♦_ " :• . ..[�r.�, .. .� al�u:y�'. . . . M.�..w x .rJ'�,�'�' . . ,fq y� - q- .:- 1. .;.:�:.�i':.�::. . °q:_ dT..?Lrny�Nin�';_a:::, nt. . .�{�'�;.r^7Y.1'�ej�•`ar� .�w�;'y::��a.�. PROpUCER Y 7HIS CER'fIFICAT�IS 16SUED AS A MATTER pF INRORMWTJ�N (3WCY AAID CpNFERg NO RIGN'fS UPON THE CERTIFlCATE �arehad K�ov/1e�e�ns�°�9��c HOIAER.TH(S CERI'IFlCATE DOES NOT Ab1�ND,EXTEND OR 386 Route 2B AI.'PER TME COVERAGE AFFORpED BY TNE PpUGIES aELOW West YartnaaEh,l�Ap,p2873 COIRPqN1ES AFFORDING INSURANCE COMPANY A 6RANITE S7ATE INSURANCE COMPANY INSUREp Jason CaryaVn 311 R�te 28 West Yarmouth,run a2673 'r''Ci0 IViVF.�i.}I�j:.`j ,.H •p��!'.'ry�' .ii +'^��.�q -•;.1�.- . , :I�I. .. •.(„ ., �'�}��_ . ;'�F}�r,^... ,+.I{;..�J4!..._.'%�Y..:p�r:':.l�ti�i: I.)!.�:?''�,'�i�Tti��. . : .... _ . �'�%"; .. A.v . _ ThR61S TO CEPtIIFY TNAT 7HE P4LJC�5 OF fN56lqANCE Lt51EP BELOW HAVE BEEp1 ISSI�TO THE NSlAi�D Npk�DqppNF FpR � TFIE POI.ICY PERIOp N�CAT�.NOTUIIITHSTAhblf�ANY I�QtARE11ENT.TERM UA CONOlTiDN OF ArIY OONfRAC7 OR OTHER oacUM6NT Wf(li RESPECT 70 WFRd'171�US CERTIFlCAIE MAY�168UE0 OR MAY PEttTiW,7HE INASURANCE AF�oRpE�7HE POLICIES DEStai�Ep HEREIk 18 SUB,lECf TD qI.L THE TERMS.EXCWSId�IS AND CONDI'f10N$OF SLICH POLIGES.LiA�'f3 SHOWN MqY kAVE�EN R�pUCSP BY PAI�q1A1MS. m �m arsw�axc� ew� ra�cr w Exryaa�oxo�� q e coppFA&. dM'40YER�'W61L1iY �� 5: �j'�''} 'L r^l7 BMEI ` , $��i�at,4 �'. OExcL17 �,�0� ��0� �2rorJ��7 rAMONY� j: �v � 'G��,�y�"e�U� ��9a�w4M10�eNN�uro CM'. ttACCIOENNr 0 'IOQ "'-�lICYLWIP f �� YEE f 7 IDNOF I If[M$ CERT�ICATE HOLDER kCElt_ATION TOWNpFYARPAOUTH sHae.oanoFna+uaTo�earauciaeecu�,meE��in+r 11C8 RT 28 �a�ror�o�r¢r�aeoF.nie iasuuoGcanwnyrwa�sio�wp 70�� SOUTHYA1iMOU7M, MAQ2fi44 wvswrsrrtexwn�Tot�c�mrr.a�r�ocoEr+r�aa�arorne�sr,eur vMaine iow1LL euLT1 p�&at6 p1�G6E Noa�IGa71�+a+tw�tm aP ANY NMb UP�N TNE CatqPANM.ltB ASRi�B d!R�9BftAinres. AUniaRIZ�REPREBF�vra7NE ��^ l/l 'd IQ�L '°N Aauaey aaueansui a} �a �ano� � Wy�5 �6 C00� 'Z 'ue� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-094 FEE: $50.00 This is to Certify that Jason Carvaiho d/b/a Ba�els&Bevond 311 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COD�IlVION VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and e�cpires December tUirty-first 2007 unless sooner suspended or revoked for violatron of the laws of the Commonwealth respecting the licensing of common victuallers. Tlus license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B ic 2. , M.$., . S�,�G: �9 ��' - j/`s/�, �`.J��v�� e� RESTRIC7'IONS: Disposable savice ody,no stove or&yolator, Q/O��t?��'Y.�,B/R�(y!GNly (iLB3� �public toilets;hours ofopecatiw will be 630 am W 5:00 p.m . //�G/[�ffC/6/Y(13JJ6?/NO�/� . fYlL/L g I(�. E�p1713,2�� Bruce G.Murphy,MP .,CHO D'uector of Heaith _ __ __. __ _ TOWN OF YARMOUTH BOARD QF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #07-148 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of tl�e Zieoeral Laws,a pe[mit is haeby granted to: Jason Carvalho, 311 Route 28, West Yarmouth, MA Whose place of business is: Bageis&Beyond Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Pemrit eacpires: December 31, 2007 BOARD oF I�ALTH: B pus `.1/5. G{�o3d�n,�M.n`.15�., G�kr.i�i�xwc SEAITNG: 19 �/�� s�s7�GNy K�yn'�/-(C,B IiNG($INGIL RESTRICTIONS: Dispersable service mly,�stove ar&}rolator, �/C�O(si¢�x� ��. 83h01Wi� �itf�B�R �public toil�x;hours of op�atio¢will be 630 am to 5:00 p.m /�O[asCla�OdJB�lll[OW A.��, R.N. Apri13.2007 � t Bruce G.Murphy, S.,CHO Director of Health ��S��IZ.��°� (�c�,Ets tgeYoNtj � 320 :"R�sc TOWN OF YARMOUTH BOARD OF HEt�I.; , ��i APPLICATION FOR LICENSE/PE1tMi1'-�� p�0 V 2 1 2005 * Please complete form and attach all necessary doc6ments by December 31, 2005. Failure to do so will result in the return of your appGcation paeket. NAME OF ESTABLISHI�IENT: �'I ,��,�A� TEL. # �,F7�j0 -�SZO LOCATION ADDRESS: ' MAII.ING ADDRESS• OWNER NAME: c ��`- TAX ID (FEIN or SSNl• � CORPORATION NAME(IF' AP�LICABLE): i' MANAGER'S NAME:_�a�,y� eflx.�.tte,s-�,� 'I'EL. # MAII,ING ADDRESS:__ C Rm L POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please fist the designated Pool(lper�toF(s}an�attach�seg}Lo€th�certifieat�on-to-t�is forrn. 1. 2 Pool operators must list a minimum oftwo empioyees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employce -T certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a t'de at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this application. The Health Department wiil not use past years' records. You must provide new copies and maintain a t'�e at your establis6ment. 1. 2 PERSON IN CHARGE: _ . Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. �\��U��,LIA�uJ 2. HEIR�.IeH 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 attacti copies of employee certiScations to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGINC: LICENSE REQUII2ED FEE PERMl1't1 LICENSE REQiJIItED FEE PERMI'1'tl LICENSE REQiJIltF,D FEE pgRTqT tl _B&B $50 CABIN $50 _MOTEL $50 _1NN S50 CAMP E50 _SWIIvIIvIING POOL$75ea. _LODGE $50 _ _TRAII.ERPARK $50 WIIIRLpOOL $75ea. FOOD SERVICE: LICINSE REQUIItED FEE PERMfP# LICENSE REQiJIItED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# �0-]00 SEATS $75 ��0 CON1'II�N1'AL $30 NON-PROFIT S25 _>100 SEATS 5150 I COMMON VIC. $50 '06�O�e7 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQ[JIRED FEE PERMIT# LICINSE REQUIRED FEE PF.RMI1'H LICENSE REQUIItED FEE PF.RMI1'# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 _TOBACCO $25 NAME CHANGE: S10 AMOIJNT DUE _ $ � ?�,p a """"pLEASE TURN OVER AND COMPLETE O'1'HER SIDE OF FORM•^^*^ - f ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLJRANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paad p or to renewal or issuance of your pemvts. PLEASE CHECK APPROPRIATELY IF PAID: yE NO NOTICE: Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILd1'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQIJIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISEIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENIIVG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. ADDTTIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heakh Departrnem 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 desserCs musTb�tested an a monthfy basis by a Statceertifieh lab. Test reselts must be sent to-the�-IcalEl� Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparatioq or display of any food product by a retail or food service establishmern is prohibited. DATE: Z 2- SIGNATURE: - PRINT NAME&TITLE: If�"1...h /�"��/o ��- 09/28/OS . ,.� "Y u...l : �F .. _ . I -4 ':,. .�. �� ._-.L. . ._ � American International Companies Specialty Workers Compensation 300 Interpace Parkway, Bldg C, 1st FI PO Box 409 Parsippany, New Jersey 07054-0409 Phone: 800-645-2259 Fax: 973-331-8599 Jason Carvalho 311 Rte 28 W Yarmouth, MA 02673-0000 October 13, 2005 Re: Renewal Quote - Policy 6808643 � Re: Expiration Date - 12/05l2005 �� \`�� 5� C � � �IN � Dearinsured: , Enclosed is the renewal quote on your expiring policy. Please note the foflowing instructions if you wish to have us renew your Workers Compensation policy. You must pay the premium in full, which is$1,314. Please return the remittance advice and your check tor the required deposit premium to American International Companies, 22427 Network Place, Chicago, IL 60673-1224. Please include your policy number on the check. H we do not receive your premium by 77N 512005,you will not have any Workers Compensation eoverege. Payment of the deposit premium will wnstitute the employer's acceptance of and agreement to the terms of the poliey. {f we can be of further assistance to you now or in the future, please call our Customer Service Department at B00-645- 2259 between the hours of 8:30 A.M. and 5:00 P.M. Eastern Scandard Time. Sincerely, Underwriting Department cc: Marshail K Lovelette Ins Agcy Inc Notice about the Office of Foreion Assets Control (OFACI This orouosal or resultina binder the continuation of anv bound insurance and pavments to vou to a claimant or to another third oartv mav be affected bv the administration and enforcement of U S economic embaraces and trade sanctions bv the Office of Foreian Assets Control (OFAC) 'rf we determine that anv such �artv is on the "Sceciallv Desionated Nationais or Blocked Persons" list maintained bv OFAC Member Companies ojAmerican International Group Ine. .9meriran Nome Assurance./nc.,R1U/ttsurance Compony, Granile State/nsurpnce Company, /!linois No�iortq!Insumnre Co., New Hampshire /nsurance Company, Narinnal Union Fire Insurance Compuny. lrouranre Compnnv oj�he State o/'Pa TOWN OF YARMOUTH BOARD OF HEALTH PERMI'P TO OPERATE A FOOD ESTABLIS�NT PERMIT NUMBER: #06-090 FEE: $75.00 In accordance with re�u1ations promulgated under authonty of Chapter 94,Section 305A and Chapter 111,Sec[ion 5 of[he�eneral Laws,a pemut is hereby granted to: Jason Carvalho, 311 Route 28, West Yarmouth, MA Whose place of business is: Bagels&Beyond Type of business: Food Service To operate a food establishment in: Town of Yaimouth Pemvt expires: December 31 2006 BOARD oF I�sAI.TH: B ix$. (�atdag�25., �tn�rc ssnT�c: i9 elj�� tS�aelr,, K.N.n,'v�ic'e e�a RESTRICTIONS: Disposable service only,no stove ar&yolator, Q/�WtIB�f�L��./63h0(rML� C:[�l�6 no public toileCs;hours ofoperatimi will be 630 am to 5:00 p.m NGI?[l71&/I/O�[1B31rt0� a.�g� a.n�. January 23.2006 ruce G. Murphy,MP , S.,CHO Direetor of Heaith THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-067 FEE: 50.00 This is to Certify that Jason Carvalho d/b/a Ba�els&Bevond 311 Route 28, West Yazmouth, MA IS HEREBY GRANTED A COMMON VIC'I`[JALI.ER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-Srst 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B o' $'. �io+r�o��1s,�M.`15., . SEATING: 19 � . a��P.�� t�cN/ feG�L� Q�f.j�V�I�(?P.�.�LGfhIN41G RESTRICTIONS: Disposable setvice ody,no stove�fr}rolator, QnO4�� /'Y.��A3l� � l�+t[s6/N6 ia public toilefs;hours of opecali�will 6e 630 am.to 5:00 pm YfWUCA M6lJPJf!lWfb A.� l�' R.N. � January 23,2006 Bruce G. urphy, P .S.,CHO Director of Health OF�YA� � ��, o� '�y TOWN OF YARMOUTH 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MRTTHCXfES � Telephone (508) 398-2231, Ext. 241 — Fax (508) 760-3472 ��Pown�t`6�9� . B O A R D O F H E A L T H __ _ . . .. __., To: Yaruiouth Boazd of Health Permit Holders From: David D. Ffaheriy Jr., RS. � ; i Health Inspector � �� ,�.- I Town of Yarmouth ,_-' "="'-' � � ��_' i - I Re: Federal Tax ID Number Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. One of tbe details that they require we seud to them is every establishmenYs Federal Employer ldentification Number(FEIIV)otherwise ]rnown as yow"Tas ID Number". This is purely for administrative purposes only. Sov� businesses use the ow�r's Social Security Number (SSl� for this purpose. If this is the case for yow establishment, be assared that we will not allow this information to be public record Please fill out the fields below and return this letter to Yatmouth Health Departmern 1146 Route 28 South Yazmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regarding tUis �tter, please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m to 430 p.m Thz telephone number is(508) 398-2231, e�. 241. Establishmerrt: �t 1,�� I��`fCAt� FEIN or SSN: � Location Address: �� l�� S`r Signature� \ /V Print: ��'P�-- l._Rx-i..�A-e-k.� Title: �wP-C`uL- � Printed on �� { Recycled L 3 Paper � . ' (:h��24 �P�i r E4oNB °`�"o TOWN OF YARMOUTH BOARD OF H�AL s 'V - ' ,'i '-s -� ? APPLICATION FOR LICENSE/PE 2 OS ' � ��-��,_,-: , � NOV 3 0 2004 * Please complete form and attach all necessary doc�i�s by Decem e��0�.p�pT. Failure to do so will result in the retum�yoih`application pac . NAME OF ESTABLISf�iv1ENT: TEL. # LOCATION ADDRESS: '�(_�1 A�n+ 5'f U-�– MAILING ADDRESS: ' OWNER/CORPORATION NAME: � un �-co MANAGER'S NAME: � C r"� ��.�U– TEL. # MAII,ING ADDRESS: C' /1 � ,,� a-c POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certiScation to this form. I. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certiEcations to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years'records. You must provide new copies and maintaiu a fde at your establishment. 1. � - ��Lt�1V�(.U.v 2. i:*� es—� �-ert ' P�xsorr nv c�GE: �fl-� �=i E��-��' Each food tablishment must haue at least one Person In Charge�PIC) on site during hours of operation. 1.�- �b�)(-t�1Q'(/7�c� 2. � �d�2A/it-r� HEIl��L,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employe� e 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 Departmeut will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. Z. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT'H LICENSE REQUIItED FEE PERMI7'# _B&B $50 _CASIN S50 _MOTEL S50 _INN $50 CAMP $50 SWIIoII�fII1G POOL S75ea. _LODGE $50 _TRAII,ERPARK $50 WIIIRI,POOL $95ea. FOOD SERVICE: � LICENSE REQUIRED PEE PERMI1'# � 3,ICENSE REQ[JIl2�D FEE PERMIT-Ii �--IICHNSSIiE(�IIIItED FEE PERMIT H I 0.100 SEATS E75 0 5�b� _CON1'INENTAL $30 NON-PROFIT $25 _>100SEATS $150 �COMMONVICT. $50 dS�O�fa _WHOLESALE $75 RETAII.SERV[CE: � LICENSE REQUIl2ED FEE PERMI'P# LICINSE REQ[JIItED FEE PERM[T# LICENSE REQiTIItED FEE PERMff# _<50 sq.ft. $45 >25,000 sq.ft. 5200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZEN DESSERT S35 TOBACCO $25 NAME CHANGE: S10 AMOUNT DiJE _ $ 125,00 '`••*pLEASE TURN OVER AIVD COMPLETE OTF[ER SIDE OF FORM^^^*^ `�4 f ��r ADMINISTRATION . ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or 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 ta�ces and Gens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETiJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTIVIIIVTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTI'IONAL REGULATIONS POOLS _ __ POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be inspected by the Hea(th Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total colifonn and standard plate count by a State certified lab, prior t4 opening, and quarterly thereaftec 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 establishmert wtuch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters w�thin the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service AppGcation form 72 hours prior to the catered event. Thses forms can 6e obtained at the Health Department. FROZEATDESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES• Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display ofany food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: PRINT NAME& TITLE: � CJUJ 10/22/04 , ' ' �-�,�' �� ;.�. ^ I �, : �`�� -,--' _ � GRANITE STATE INSURANCE COMPANY 70327-0000 WC 680-86-43 ' t3102 --------------------••---....--------------- 013-66-1204-00 PENNSYLVANIA JASON CARVALHO 311 RTE 28 Member Companies of W YARMOUTH, MA 02673-0000 � American International Group EXECUTIVE OFflCEB: 70 PINE STREET, NEW YORK, N.V. 70Z70 SEE NAME AND ADORESS SCHEDULE - WC990610 I.DX MARSHALL K LOVELETTE INSURANCE AGENCY WORKERS COMPENSATION AND EMPLOYERS PO BOX 836 LIABILITY POLICY INFORMATlON PAGE WEST YARMOUTH, MA 02673-0836 INSURED IS PREVIOUS POLICY NUMB R INDIVIDUAL RENEWAL 00� 06 O1 ortiER WORKru►CES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 ITEM t VOLICV PEPIOD 12:01 AM.�tanE�rO Hma N 1M Inwrod's ina01opi0°n" crror 12/05/04 To 12/05/05 �M� A. Worken Compsnsetion Insurance: Pen One oi the poliey epplies to the Works�s Compana�tion Law of tAe stMss IlstsA hers: MA 6. EmploYers Li�blllty Insurance: Part Two of Ms policy applip to the work In eeeh atate Iistetl in ISem 3.A, Ths Iimits of our Ii�bilky undar Part Two aro: gotllly InJury bY A��dent t 100,000 �n �� BoAily In�ury bv Dis�eu f 500.000 polley Ilmli Bodily InJury by Dissns 5 100.000 s�ch smployes C. Qeher Stetes Insuranea: Part Three of ths policy appliss to ths atabs, If env Ifstsd hem: SEE ENDORSEMENT - WC200306A �M� Ths promium tor Mls policy will bs detsrmined by our Manuels o} Rulss, Gessl4lcatlons. Ratss anA Ratinp Plans. All InformMlon roquirod bslow {s sub�ect to wr�ficatlon and chenps by �udit. . _ .. - Estimrt�y tot�� --p�pe�pN- � Est�mm0 qassilic�tion� �p�Numb�r Pemunentlen ft��p� Vnmium x AnnuN ❑3 Y��r mUM�i�1011 X q�nuN �3 Ywr SEE EXTENSION Of INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $55 E%PENSE CONSTANT(IXCEVT W11ERE AVPLICABLE 8Y STATE� 2 �{ MA � MINIMUM PNEMIUM S Z�7 MA MTAL ESTIMATED VREMIUM S� LOZ N IntliubA Mlow, inbrim�OI��mMts oi pnmium s��l be m�tl�: � S�mi-AnnuallY � pu�rtblY � MonlhlY DEVOBRPqEYIUM ENDORSEMENIS�FORMNUNBER� SEE ATTACHEO FORM SCHEDULE - WC990612 � TOWN OF YARMOUTH BOARD OF HEALTH PERNII'P TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #OS-O51 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is hereby ganted to: 7ason Carvalho, 311 Route 28 West Yannouth, MA Whose place of business is: Bagels&Bevond Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2005 BOARD oF I IEALTH: B�u�c$. (jwcd.otiy i19.`.�. L�� SEATING: 19 p�.�fa� v�ef�.z RESTRICITONS: Disposable aervice�,,��.e a�� Rad�t 4. B�/� Ll�.6 m public toilets;hours of opeaation will be 6:30 am to 5:00 p.m �� R� A.��, R.N. J�„�y i9.2oos ' Bruce G.Mtuphy,MP S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-040 FEE: $50.00 This is to Certify that Jason Carvalho d/b/a Baeels&Bevond 311 Route 28, West Yazmouth, MA IS I IF.REBY GRAN'I'ID A COD�VION 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 violation 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 authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Bs��n 2. �j'o�idwry M.`�5. ' SEATING: �9 �p��"�n�cfpa��v�ef� RES7RICIIONS: Disposable savice only,no stove or fiyolat� I�ol,o�'sb yp, 01Ip{Y/l�y�A� no public toileb;hours of operation will be 6:30 am to 5:00 p.m. OIC�L c7�� K✓I, ��i� R.N. Januazv19.2005 Bruce G. Murphy,MPH,RS.;CHO Director of Health ��'a'�,g'�.a�°� i°`,r""o� � TOWN OF YARMOUTH BOARt?OF H�ALTH I�; I? � � u 0� I� o o y APPLICATION FOR LICENSE/P��'l11`- 2004 �`�� N0� 2 6 2��3 * Please complete form and attach all necessary doC'uments by Decemb f1Q3 Failure to do so will result in the return of your application pack ��l � H ��PT. NAME OF ESTfLALI4HMFNT• TFT # � ')qc�-F'cZs� LOCATION ADDRFS • �� (Y�W��I S ��—Cr � l�y(�,��,yl�. 1�1AILING ADDRESS: 4WNER/CORPORATION NAME• tl�R�r�n CA91�l�k.{/L1 A E ' AM : T Iv�ALI.ING ADDRESS• POOL CERTIFICATION • The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ___ 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - C RTIFI ATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide ne/w� copies and maintain a file at your establishment. 1.�. l.-'i/1 A.��i) 2. F�tt��nr�r e��t�� _ _ - - - ---- _ _ -- - - - . --- — - _ _. Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �� (�A7u,tiwcuJ 2. HEIMLICH CERTIFICATIONSc. All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. /� 4. �1 RESTA A1.TT S ATIN : TOTAL# Louctnc: 9FFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _6&c6 S50 � � _CABIN S50 _MOTEL S50 _INN S50 _CAMP $50 _SWIMMING POOL S75ea. _LODGE $50 _TRAILBR PARK $50 _WHIRLPOOL S75ea ._- � --..—--. _ . ..---- . _ __ - SERVICE: .. _ . . - - __ --._. _. ._ _ . . . . . .. LICENSE REQUIRED FEE PERMIT# LICGNSE RGQUIRED FCE PERMIT# UCENSE REQUIRED FEE PERMIT# �0.100 SEATS S75 O��OS3 _CONTMENTAL S30 _NON-PROFIT S25 >I00 SEATS S150 �COMMON VICT. S50 ��Ft3 _WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT q LICBNSE RGQUIRED FEE PERMIT# � _a50 sq.ft. S45 _>25,000 sq.ft. 5200. � _VENDING-POnD 520� � _<25,000 sq.ft. S75 _FROlEN DIiSSGRT S35 � _TODACCO � ' $25 . NAME CttnNCF� sl0 AMOUNT DUE _ $ I 25.00 "••:*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• ---,. . s L a. . ' a ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO NOTICE:Permits run annua�ly from January 1 to December 31. I7'IS 1'OLJR IiESPOP+iSIBILTCl'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLtSFIMENTS AR�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 REPORTGD TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WA'TER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-cat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth 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 DES3�R'PS: 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 CAF�S: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approvai from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE:�� SIGNATURE: `M' PRINT NAME &TITL�: �� }au�lo 10l22/03 �►°�n�00v�i[ii1'��ICAI�TUFrLIA61LITYINSURANCE N0.525�P.1i1 DATE(MWodyyYY) P SUd)7 5-4559 �% (508)775-4577 IS IFICA ISSU A A R pF 11/21/2003 MaMShal i K� Lovllette Ins. qgCy� , IIIC. ONLY AND CONFERS NO R1GMT5 UPON THE CERTIFICqTE 396 Mei n St�lEt H��DER,THIS CERTfFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE OFFORDED 9Y TFiE POLICIES BELpW. P.O. Box 836 West YarmouYh, fAA 02673 INSURERS AFFORpING COVERn6E NqIC iF '" � Jasan ca�va o P�R�. lianovar Inaurance canpanies Oooz DBA: DBA Bagels & Beyond neµa: Granite Stdtt Ins, Cos. 0006 311 Rt 28 ir�su�na West Yarmouth, MA 02673 IN4URFR0: INS i COVERA�ES NE POLICIES OF IN9U E ll9 D BE�OW MAVE BE N 166U@D TO TME(NSl1RE�NAMED ABOVE FOR TNE POLIC WOp INDICA7ED�NOPNITMS7ANDIN ANY RECUiREM[N7,TERM OR cONDITION OF ANV CONTRACY OR OTFiHR oCCUMENT wlrH RBSpeCT'r0 WMICw THI9 CERTiFICATE MAY EE isSUED OR MAY PFRTAIN,THElNSUPqNCE A�FORDBD BY THE POUG89 DRSCRIBED MHRE�N ie 9U9JEC7 70 NA 7HE 7ERM9,F,fCLU610N3 AND CONpTIONS OF SUCM POLICIlS.AGGREGATE UMITS SNOWN MAY HAVE BEEN RffDUCEp BY PAIO q.AIM9. ry� T'PE O�INauRANCE tOUCrNUMlER OATE YM' MMI00 4MT! °EXE"^�"""�°'' OHN594703 os ia�zoos osiia/zooa �+�+a�+Rn� 5 soo ao camnqenewaeN�a�uneiim a 300,00 ��E O�� nrtFnnis .e omiro e MEoe%P(ArornoneMroonl i 15,�0 A X I peasoroc��nwiwuRr a 500,00 OENRRAI.A00R6GpTfi E 4 �0 � CaENLAGOPE0AT6pyRMp'1''MPLIEiAER• wiOpUCTE-COMP/OPA60 S 4 OOO OOO MlIC1' �� LOC AUTOMOBIL84.�&LITy Ar,n,A�� COMB!NEOSINOu�LIMR E � (Fa Acudsnn I ALLOWNFA�yTpB SLNEWLED7�UTOs p001LYlµlUftY s ( erpxwN MIREO A�706 NONUWryQDAUfO$ DII.VIN,tUpy i xqtlotNl PROPEf1TY0r1MF0E S tPwecqtlsnt) �M��p�� AUTOONLY• MlYAUTO EAACCIDEM E O7HERTHAN �`ACC 3 AUTOONIY; A06 3 FxCRiiM1NA0pEµ4WpiU1Y WCHOCCunRENGE S OCCU� �CtAIM&MADF AOOREGATE f f ofiouC?IB�E RETENTION i d t C�E�pg�� WC8 6301 12/OS/2003 1Z/OS/2004 . T M • E B OFF�Epry.��9��y�j`�c"�rvc E.L.FACHACCIORNT s 100 00 „y�,��bauneer I E.1.D16EI8E•EAENPLOVE 4 100 QD sPEG1AtPRON$�ONBEN� � E.LDIBEA4F•POUCYLIMR i SOO OOO � NOpOPEq►TIONi�LO sl�ONi/ EwC�( Aoo�D! EN nTl V IAL rtoNS�ONb C�RTIFICA7E HOIDER CANCEI.LATON SIqUTA YNY oF TME 4BOVE 006CpIBED PpGIqE!6E CM'CELIEp 0@PORE T11E FaPF4TqN 0.4147NEPEOi.TX81i6U1Nc INBURER YYILL FN�CAVOR 7o MNL ,,Q�DAYBVAyTRH NO17CE TpTHlCERTIflCATE HOLDFR NAMEO To TMi�fiFT, Town of Yarmouth eurrni4uacror�vv�sucnnonceswu�MrweNooeucnnoNoau�eiun 1146 Rt 28 or nwr wNo usoN na ixsu«en,rts�aerty oa ncrnFs�rarnes, South Yarmouth, MA 02664 � nu�a PRESENTATIYL" ��' 7ohn Mc e�a 7pHN ACORO P5(20D1/08) F'AX: (506)398-2365 �ACORD CORPORA710N 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #04-083 FF.E: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permi[is hereby granted to: Jason Carvalho 311 Route 28 West Yarmouth, MA Whose place of business is: Baeelc BeyQnd Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31_ 2004 BOARD oF HEALTH: Bnex�anu��r,./�. �'jdrelac, /��. L�li4in�xwa SEATING: 19 H/�� ♦�1�I//a��i v�� RESIRIC7TONS: Disposable service ody,oo s[ove or&yolator, KOO@�fi 'Yp. BdOYf/N�L��1'� no public lodets;lrows ofoperetion will be 630 a.m.to 5:00 p.m � e7�� /C✓r- January 23.2004 Bruce G. Murphy,MP HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-063 FEE: 50.00 This is to Certify that Jason Carvalho d!b/a Bagels& Bevond 311 Route 28, West Yarmouth, MA IS I�REBY GRAN1'ED A COMMON VIC'I'UALLER'S LICENSE In said Town of Yarmouth 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 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: Bewya�sl.c `�. CJmrdo.s, M..�`!. ' 5�,�,G: �9 n�� s ,N�al��^' v'� e�.� RES7RICTTONS: Disposable s�vice only;�w stove or fiyolator, QOOH?�[��. 030[WL� (.[i3�6 �public toilets;6aus of operatimi will be 6J0 am to 5:00 p.m d�@ItK �� Q�. January 23.2004 Bruce G. Murphy, H ,CHO Director of Health � �-Nic�� lt� � � � �,�;^Ryo TOWN OF YARMOUTH BOARD OF H�d� a [� (� C � M [� D °�yr s APPL[CATION FOR LICENSE/PER,MP�,' p� MAY 0 7 20�3 , _�.; ��'��a*,��5 ' Please complete form and attach all necessary�C��m� 19ecem6er 1�9a�:TH D�PT, Failure to do so will result in the return o .�pur pl�cation packet. �a�P NAME OF ESTABLISHMENT• P ( e��,,.n TFT # �� v-zP�tr' e— - LOCATION ADDRESS: _�1�_;IV� �4- MAILING ADDRESS: W��r ��v.�s�tM ,M,�4 I �v1ANAGER'S NAME• �Ho TfiL # 1�AILILYGADDRESS: 3tl MA-r�-+ s� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2• . Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary'ResuSCi#ation (CPR)r' Please list these employees below and attach copies of employee certifications to this form. The Health'Department will nut 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 wha is certified as a Food Protection Manager, as defined in the State Sanitary`Code for Food Service Establisfunentz�; 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use piast years' records. You must provide new copies and maintain a file atyour establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. L `2: HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below a:;d, attach copies o£employee certifications to this form. The Health Department will not use past years' records:'. You must provide new copies and maintain a file at your place of business. ' " L 2. =, 3. q. ; RESTAURANT SEATING: TOTAL#� � OFFICE USE ONLY 40DGING: . . . . . � LICENSE REQUIRED� FEE PERMIT# LICENSE RGQUIRBD FGE. PERMIT# .LfCENSB REQUIRED FEE PERMIT t! _B&B $50 .. .. . �. .'.� �'_CABM..� � ._�E56� .. � .. _MOTEL $50�. _iNN S50 . _CAMP�� S50 � -� � � � _S141MMING POOL S75ea _LODGE S50 _TRAILERPARK $50 WHIRLPOOL $75ea. FOOD SERVICE: . . . LICENSEREQUIRED FEE PERMIT# 'I LICENSGREQtlIRED FEE PERMITp LICBNSEREQUIRED PEE PERMITH �100 SEATS $75 . �a� 0318Y � _CONTINF.NTAL� � S30 ' � _NON-FROFtT� S25�. � � � _>t00SEATS SI50 �COMMONVICT. S50 �Q — I�7 _WHOLESALE 575 R .TAI RVI � � � � - � . , .� . UCENSE R6QUIRED FEE PERMIT N LICENSG RGQUIRED �GE PERMIT Vl UCENSE REQUIRGD�f EE PERMIT# _<50 sq.ft. $45 _>25,000 sq.R. 5200 _ _VENDING-FOOD S20 - <25,000 sq.ft. $75 _I'ROZC•.N DF,SSERT S35 _T013ACCb E25 NAME CHANGE: $10 � �. - � � � � � AMOUNT DUE _ $ I Z�� ••"•*PLEASE TURN OYER�AND COMPLETE OTHER SIDE OF FORM"**•" _ _ _ _ __ _ ' + ADMINISTRATION Under Chapter 1!5�2,,5ection 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 Compensa6on Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED��( ��P�9 Town of Yannouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT TE�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• RFGULATIONS POOLS _ _ _ . ------ — --- — - -- - --- _ __ - _ POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openmg. POOL WATER TESTtNG: 7'he water must be tested for pseudomonas, total cotiform 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 C�NSUMER ADVISOAX; Each food establishment w}uch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ['ATF.RiNG 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 DepaRment. FR07.F.N DE SERTS: 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),�have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: S � SIGNATURE:�--,%';�� J PRINT NAME&TITLE:—�� I,�c u� ( `"�-N�tit2[-�Cr> 10/18/02 O co, N W a 0 X a J J O G )WN OF YARMOUTH BOA ALTH Q fir' PPLICATION FOR- 200 APR 19 2003 CA5If Wo form and attach all ssa ocuments by Decembe rjQffH DC�3-, to so will result in th urn of your application pack . 'ired by State law. Please list the designated AX r CJ�� ;d in basic water safety, standard First Aid 7� �ese employees below and attach copies of f /� not use past years' records. You must C� i 4, CERTIFICATIONS: aired to have at least one full-time employee who is certified as a Food Aate; Sanitary Code for. Food.Service Establishments, 105 CMR 590.000. us application. The Health Department will not use past years' records. __lintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have' at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti -choking procedures below and attach copies of employee certifications to this ,form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. _. 2• __. 3. _ 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING. F- N � o LAJ Z r N FEE W PERMIT # LICENSE REQUIRED FEE PERMIT # QNWx W $50 - � F— _MOTEL $50 INN $50 CAMP $50 _SWIMMING POOL $75ea. C $50 TRAILER. PARK $50 _WHIRLPOOL $75ea. Q1 �00 0 PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # y0-100 SEATS Qp � y � NON-PROFIT $25 >100 SEATS ui o W _WHOLESALE $75 RETAIL SERVICE: W U W 'ired by State law. Please list the designated AX r CJ�� ;d in basic water safety, standard First Aid 7� �ese employees below and attach copies of f /� not use past years' records. You must C� i 4, CERTIFICATIONS: aired to have at least one full-time employee who is certified as a Food Aate; Sanitary Code for. Food.Service Establishments, 105 CMR 590.000. us application. The Health Department will not use past years' records. __lintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have' at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti -choking procedures below and attach copies of employee certifications to this ,form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. _. 2• __. 3. _ 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING. LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED PEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $50 - CABIN . $50 _MOTEL $50 INN $50 CAMP $50 _SWIMMING POOL $75ea. LODGE $50 TRAILER. PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # y0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 >100 SEATS $150; COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIREDFEE PERMIT # <50 sq.ft. $45 >25,000 sq. ft. $200 _VENDING - FOOD $20 <25,000 sq.ft. $75 FROZEN DESSERT $35 _,TOBACCO $25,� NAME CHANGE: $10 // �) AMOUNT DUE _ $ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal of any license or, permit to `;operate a business if `a'person or company does not have a Certificate of Worker's Compensation .Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND. SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE 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 OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING:' 'The'water must be tested for pseudomonas, total coliform and standard plate count by ;a State certified lab;, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat, raw or undercooked animal products are required to post Consumer.Advisories. , CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms: have been met. OUTSIDE CAFES: Outside cafes (i:e., outdoor seating with waitedwaitress service), must`have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or, food service establishment is prohibited. DATE: SIGNATURE: PRINT NAME & TITLE: 10/18/02 ti � , � Ms. Shah asked the Health Director what kind of restrictions he would place upon the operation of the restaurant. The Health Director recommended that only paper service would be allowed, there would be no stove or fryolator, no public toilets and hours of operation will be 630 AM to 5:00 PM. TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT Ni1MBER: #03-184 FEE: $75.00 In accordarwe with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of tLe General Laws,a permit is hereby granted to: Jason Carvalho, 311 Route 28, West Yatmouth, MA Whose place of business is: Bae.els&Beyond Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit eaipires: De�cember 31. 2003 BOA1tn oF��v.'r'x: �,si�. �elltkat. �a.r SEATING: 19 � � � � D. C�de.� �.D.. 2/�ee �4f/tnYQ�L . . .. � RESTRICTIONS: DisposaWe savice aoly;no s[ove or&yolator; .. 1�E��. �701�Y. �,�Plt�_ . . .. no public roilets;hours of op�aOon will be 6:30 a.m to 5:00 p.m �Q�tlC��MIAW� . . . . . � �f� .SI�R�. J�.,`. . . Mav 7.2003 ruce G.Murphy R.S.,CHO Director of Hesl THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMITNiJMBER: #03-107 FEE: $SO.OQ This is to Certify that Jason Carvalho d/b/a Ba�els&Beyond 311 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTIJALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-Srst 2003 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authonty granted to - the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereo� the undersigned have hereunto affviced their official signatures. BOARD OF HEALTH: ekanlea if�, xdltket, ekad�aa SEATING: 19 .r� �. CfARdO�G �C.T�., �I/[CL RESTRIC770N5: Disposable svvice only;�w stove or fryolator; 1C �• �70AW1. � no publ�todels;hours ofopecation will be 6:30 a.m.to 5:00 p.m �Q.�iC��O'tNtOtl � s�C�dic.5'�e, i�� May 7.2003 � ruce �P Y> > • , Director of Healt