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HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 _ _ . . �r��ts + Bc-ya,�� hcPeCsaS � TOWN OF YARMOUTH BOARD OF� �, ` ' ` ��";� ��� APPLICATION FOR LICENSE . 'y2 , Y �1�'ft% ` i ..,, ,-. a��% � ;.=�� �sb � b 4 zooq i * Please complete form and attach all necessary�Ocu�e�its y Dece er I S 2008 ? Failure to do so will result in the return c+f'yow applicahon pac et __ _:.�' :�_� NAME OF ESTABLISHMENT: � S ����/�,til �A�`C�LTEL. # ��- `�e d�/C(� LOCATION ADDRESS: rZ'"Z (,t/�1 l i'E ( p�.} , SU�,rf t�kr�m.�-x-rt MAILING ADDRESS: OWN�R NAME: - J TAX ID (FEIN or SSN): CO$d�+ORATION NAME (IF APPLICABLE): N�NA�iER'S NAME: � .S�S��S TEL. # S'��-'� �3[W Mt1ILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be cer6�ed as a Pool Operator,as requered by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. 1. 2. Pooi erat must list a m' um of tw mployees cun•ently rtified in b ' er sa e , andard First Aid and Commum y Cazdiopulmonary � ation(CPR). Please list the oyees below and attac ies ofemployee certifications to this form. The Health Department wiil not use past years' records. You must ide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Alt food seivice 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 Establishxnents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must rovide new copies and maintain a file at your establishment. 1. � Il.L1Qjl�,..� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - 1. �c4J ��tsl 2. VtTli,�1 �—+1'l�,uRc.ro 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 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 roust provide new copies and maintain a tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�iG: LICENSE REQU[RED FEE PERM[I"# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 � _CABIN S55 MOTEL S55 _INN S55 _CAMP S55 _SWIMMINGPOOL S80ea. _LODGE S55 _'IRAILERPARK 5105 WfIIItLPOOL 580ea. FOOD SERVICE: . . .--- --- ---- - - � .___ . LICENSE REQUIItED FEE PERNII'I# LICENSE REQUIItED FEE PERMIT# LICENSE REQIDRED FEE PERMI"1"# �0-100SEATS S8i �OR-l�l�' _CONTINENTAL S35 NON-PROFIT S30 _>100SEATS 5160 _COMMONViC. 560 WHOLESALE S80 RETAII,SER�'ICE: —RESID.KTTCHEN S80 LICENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQI7IltED FEE PERMIT# _bOsq.B. S50 _>25,OOOsq.ft. 5225 . VENDING-FOOD 525 _QS,OOOsq.ft. S80 _FROZENDESSERT �40 I'OBACCO S55 v.�:�cxnvcE: s�o AMOUNT DUE _ $ 8 s.o0 ***"PLEASE TUR:\OVER AND C0:11PLETE OTHER SIDE OF FOR'1�I***"• . . _ ADMINISTRAI`ION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAT'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. 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 MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: 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. 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 De�artment to schedule the inspection five(�days pnor to opening. PLEASE NO'TE:People are NOT allowed to sit m the pool azea until 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 Yannouth must norify the Yarmouth Health Deparhnem 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 Pemvt until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmem is prohibited. NOTICE:Pernrits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILTI'Y TO RETIJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQLIIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��(��� SIGNATLJRE: C� PRINT NAME&TITZE: �1 . �Al�v►'`� U1.'h"� ioniros � JY11�«.. ��«� t v�— �vt� t tJ��� o�o a The Cwnmonwealth of Massackuselts Department of Indumial Accidents �eiNiws�rs 600 Washington Sireet, 7'�Floor Bostoa,Mesc. 02111 Worken'Compe�aaHou i�sraice Ats�avik Boftdteg/Plrmbl�g(Eleetrical Cootractors �: ,�� � ����.� �T-� t �: � -�-_���i� ��- uri �-�/l?�im�-vrrl_. �: iLUL�r vQ-�o,�7.io�'3 JSo,�r-�,u-�•ce� w__ork site lacarim(fiill addccssk � . . ❑ I am a Lomeowna pert'mming a�w�alc mysedf. Project Type: ❑New Canshuction❑R�odel ❑ I am a sole-p�ropaic9or and have no une woxicing in any capecity. ❑B�rildiog Addition �am an eanployer providing w�ke�s'compensati�far my�ployces workmg aa t6is job. � . ��.�: '0`��1,�_S � I���'v�\.1 .aa��• �z.� � lVl,� ,J �r a�.: 1,,1 �-t 1'Y�,�- U��3 �.: �.a�. �+2ti���T� .SY�-r� �1-ns:t�Lp� Ct �s W C�. �7q�"�-� `'� � _ _ - . — � �»w�-_� ❑ I am a sote pmpcidor,g�ad ewtraelet,or Yemeew�er(cucle awe)and have himd the mnuact«s lisred below wLo have ihe folbwin%wo�kas'cocopensetiou Pulices: mmv�: addreu• . � . ein' � oYaeN: � � .. . � � . . . ►�nenaoeea� . . . oaHe►/ . . . - . � . _ .,;� ., � , . .. � . .. . -, ...�. . . . . . .. ,:. . , . � .- . , . ...:�; . . ,�k•; z .es._�. amouv u� add�a• d�s' �s- � _ , . ._ -- ,- �:� ��;�,�,,,,;< �,�- Fa.e r+�.e e.�..�n.ey.�a..aQ sedw zs�.cMra.ux en wa a ue+�.,rw.raw..��+we.r,i.e�a siy�wM■.aar o.�y�•�..m�..wes o aw�a.rk.mree e.'a w.srorwowcortoeRa.a.�.tsieue.a.yaps�e.�. t mae�awu.e, e.pgKUBaheue�err6enewuaMeaNeommdl..eaU�w�sKtlkDlAMewnase.vi�ntls.. - /b 6ersby oertijy5`r�/••Ke prGs uwdF��+olPh1�Y tl�6�ks7nfenn�en prerided rbawe b awa rwd ewrec� � �) Sigustu,e �'Q�� . . � il��o F � erim� _ � �'+A�.�1�c-� rn�s Sv�-�9tl-F cu� .�w�by a.«.�r�m,...an�«.qaeanr�xr.�e..�.� ciyKGwa: - �p�i�es D�t . QIIes�4�Bnrd ❑cYa#N�le�npsoc b�eed � ❑Sdecm90�m . . QHpMh D�p� pshet paaw: pWe C: �OUQ tn.ia�mml . � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-144 FEE: S85.00 In acwrdance wi[h regulations promulgated under authorit��of Chapter 94,Section 305A and Chapter 1 I 1,Section� of the General Laws,a pernut is hereby granted ro: Jason Carvalho, 12-2 White's Path, South Yarmouth, MA Whose place of business is: Bagels& Beyond Exnress Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31. 2009 BoaRD OF HEALTH: ,��E�e_ee'"n��S� ��7a�li,ZJZ� .NQ, �!�� /a�Qet— SEA"IING: 0 l�.R�ly�W�"C'�p ,7�„�✓""1�.Q���"Q��lIIp^JL,� V�(,.CC l.lU!(J(ryt((/( RE57RIC110ti5: See re�'erse side. ./W.(,f�y �� ,/,�ry{µW�� (�(� QftfL �IIL, ✓Z.✓v. �(�ft 1L ACa'.'1.� Januarv 14 2009 Bruce G. Mwphy, H, . .,CHO Director of Health *Restrictions: 1 No fryers; 2 No stove; 3 No clothes washing machine; 4 No seats - take out only; 5 Singte service/paper items only; 6 Maximum daily water usage not to exceed 120 g.p.d.; a weekly log is to be maintained with a yearly report to be submitted to the Health Department on or before December 1 st of this year. If the weekly water usage exceeds 120 g.p.d., the Health Department must be notified immediately. If it is found the water usage exceeds the restriction, the Board of Health will review the violation when considering the issuance of the following year's food service pernvt. %��r�zs tQ�1oNo ;£ '�"S�s^ � TOWN OF YARMOUTH BOARD OF HEALTH ` C5 'i� L F��-� an�� ��y;- APPLICATION FOR LICENSE/PEIEMTJ;� - r � ��p N 4 zoos * Please complete form and attach all necessary do�rme�by Dece ber 31, 2�07. Failure to do so will result in the return of your application p lye�ALTH QEPT. NAME OF ESTABLISHMENT: � �jC��� C � S TEL. #�-�6U-�(O� LOCATION ADDRESS: � �' � � MAILING ADDRESS: Pcl n� OWNER NAME: �c � �� Prn v�-t� TAX ID (FEIN or Nl� / CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��.L.v� � TEL. # �;�-7�o i/c� MAILING ADDRESS: _ 12- Z W4���7 P'H S-I C� is��� POOL CERTIFICATIONS: The pool supervisor must be certified as a Poo(Operator,as required b��State law. Please list the designated Pool Operator(s�and�ttachasopy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently cenified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Heaith Departraent will not use past �•ears' records. 1'ou must provide new• copies and maintain a C�e at your place of business. l. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who is cenified 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 appiieation. The Health Department witl not nse pasi ti�e�rs'records. You must provide aew copies and maintain a file at your establishment Ce�� `.��JftL�t.4.z9 Z-�2c� � �'+�7 �--1 I. �`�'�;R�� 2. PER�9N IN�HAAGE:. -- --- _— _ - ------- — - - _ _ _ _ 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 establislunents 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 employce certifications to this form. The Health Department will not use pxst 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 PERb1II ?� LICENSE REQL'tItED FEE PER'4fI I= LICENSE REQtiIRED FEE PER�IIT= _B&B S50 CABIN S50 MOTEL S50 _INN S50 _CA1bfP � Si0 _S�b"IVLbfI1VG POOL S75ea � _LOIX;E S5� _TRAII.ERPARK 5100 R7-IIRLpOOL S75ea. FOOD SERVICE: LTCENSE REQUIRED FEE PERMIT� LICENSE REQL'IRED FEE P£R'�fIT� LICENSE REQL'IRED FEE PER�IIi? 10.100SEAiS S75 s'/�� _CON'IINENTAL S?0 NON-PROFI7' S?i _>100SEATS S1i0 _CO:�I.bIONVIC. S50 R'HOLESALE S7> RETAIL SERVICE: —RESID.KI1CHEti S75 LICENSE REQUIItED FEE PERMIT= LICENSE REQL7RED FEE PER�DI'= LICENSE REQL7RED FEE PERVIII'_ _<i0sq.ft. S45 _>25,OOOsq.d. 5200 �'ENDING-FOOD S20 _<25,000sq.8. S75 _FROZENDESSERI S3i TOBACCO S50 vn.�c�vcE: sto AMOUNT DUE _ $ �5•0 0 **«"*pLEASE TCR\OFER?L\D COJiPLE'IE OTHER S1DE OF FOR�i`""** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewa! 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 STA'fE 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 taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE 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, ordinarily and customa�ily 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 aggre�ate 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 de&ned in M.G.L. a 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * 1VOTE: En��os�d Motel Census must be completed and returned w;tt�t�s app��cac�on. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins � by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TES1'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 Yazmouth must notify the Yarmouth Health Deparhr►ent by filirig the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health DepartmenY. 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 Peimit 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 Boaz�d ofHeahh OUTDOOR COOKING: OutdooFcoeking, preparation,or dispiay ofany food product by a retail or food servic�establishmentis�rohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQIJIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISfIlv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMEVT. RE�IOVATIONS MAY REQUIRE A SITE PLAN. DATE: �/O��f SIG�IATURE:� PRRV'I'_VAME&TITLE: c I�kPT- _R�-vf�Ko (.�.�1�/ i o so o� , , • ,p� � �\ The Cominonwealth of Massachusetts Deparfinent of Industrial Accidents N�feaN� 600 Washington SYreet, f°Floor Boston,Mass. 02111 Workera'Compeesatioo Ieseraace A�davk:BaildixglPlambi�g/Eleelriesl Contrsdora name: �s: /'� '�'Z-2 �.(�rti� dz city O' �41IL�7't slate� IVV6' zin� U�P�9 / o6me# V�+O - 7 �d'�,yCl� work site lacation(full adMxsl: t�-'2� W�"��.T C�r"'EI � ❑ I am a homeowcer perfotming all w�k myself. Project Type: ❑New Ca�nstnrc[im�Remadel ❑ I mm a sole Tuo�aiexor and have no one wodcing in any ppxity. ❑Building Addition �Tam an employer providing wakets'compeasati�f�my employces wodcing am flds job. . . . ._ .. - - - - - -- .._ _ . _ __..... wmaav�e: ��C2S � � '�CCi+ti�.� �ff ��,.: ��,-� : �� �-��� pA� a�- � `-faa.n.wrn u►v� ��• 'SbF- 2�-3t�r1 ,..�� �,lz�n� .�nr� �cnuaa-�� ,�,� �-lS(�t� _ _ -,--�,�_ ,a�� .. ❑ I am a sole proprietor,geoeral eoatracMr,or iomeowwer(circle oneJ and have h�red U�e con��tas listed below who have the following wakers'compeasation polices: c�p�v une: adNesa: dtv nYo�e f6 ieseaKe co- �# suo�ar we• +�sfM• e�tY• oia�e 8• . . __ . ___ _- ._ ._ -. _� - .___ - -_.._. —_—_--_._�.___ . . .-_- _ ._- _-___-_ _ _ �M14!lllel!ea . _ mL_ # . .__._ ._. . . _. AlYdfilMYrl�liW�R*�M�r',Y�'. ': .� . , � .... .. .. . FaBve r aame wveade a rtqetrN�tlQ Seetln iSA KMGL 152 eu Ind b IYe dpr�lY�da�IW peaMn Na 8e�p b SITTN.N aWhr��. ene ynrs'1eptLaeeest u wea n dN pnaltln 1�t6e fir�of a 3101 WORK ORDEA ud�Bee dS1M.N a dty apint.e. I mdvatud tY�t• npy Htlb thtraeN my he[erwaMeA m tAe O�x a[Ine�m o[Me DIA tertrrenge vert6nlNe. /lo hereAy re�peins cnJpenaHies ojpaJwry ehat Hie infennaMn provldel obnre is pve a�6 co,vrct / /� s;gnah„e L�G�` nan Il�/��f Print name �S 1/�— �f�-tX�ti10 P6oce# ��� �� 0 '3l cU e�l ux only da aM wrke Ie thM arri 4 be co�pktM 6y dry er Nwn s�rLt � eity or tewu: p�p �ge�E p�a� ❑eheek Iflmmedi�le me 6 �Bmtd � R9o� �nY Omte ❑FIe1H Deprda� enafacl pvsen: pY�g; �p�yQ lnvad 5�yt mm) � O��Y`�R �� '�o TOWN OF YARMOUTH � �'� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 M/TTACry[ES ��e,,,,,,�,,.�� Telephone (508) 398-2231,Ext. 241 — .Fa�c (50S) 760.3472 B O A R D O F H E A L T H 7anuary 28, 2008 Jason Carvalho d/b/a Bageis&Beyond E�ress 311 Route 28 West Yarmouth, MA 02673 Re: 2008 Pemvt Applicarion Bagels&Beyond E�cpress, 12-2 White's Path, South Yazmouth Dear Mr. Carvalho, Thank you for submitting the 2008 application for your establishmenYs permits issued through the Health Department. Please note that, since your establishment has a food service license, a copy of the Food Protecxion '' Manager's certification for your establishment was supposed to be submitted with your application. 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 provide a copy of the above certification at your earliest convenience. If you have any questions on the above, please feel free to contact ow office at (508)398-2231, eactension 241. Thank you for your anticipated cooperation. Sincerely, ��2Z Mary Alice Florio Principal Office Assistant /ma€ cc: file - , ' �� Printed on �( Recycled L►} Paper TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHD�NT PERMIT NIIMBER: #08-148 FEE: $75.00 In accordance a�th regularions promulgated under authoriry of Chapter 94,Secrion 305A and.Chapter ' 111,Secrion 5 of[he General Laws,a permit is hereby granted to: Jason Carvalho, 12-2 Wlrite's Path, South Yarmouth, MA Whose place of business is: Bagels &Beyond Express Type of business: Food Service � To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BonRD oF HEALTH: .�Eeee�t S� J2.,N., C'I�aiwnaa I senrmrc: o CC��f�a�ut¢�e�e�ae .�!.d�JCeP,�iPien `vice CPcauxntan RESIRICI'IONS: Seereverseside. - ✓IYVGIL 3. .�frMOlI1fL� � . � . . � . (.IIC�/f.�.i"sy'`.a'.��.IV ��. January 28.2008 ' Bmce G. Murp y, .,CHO i Director of Health I *Restricuons: 1 No fiyers; 2 No stove; 3)No clothes washing machine; 4)No seats-take out only; 5) Single service/paper items only; 6)Ma�mum daily water usage not to exceed 120 g.p.d.; a weekly log is to be maintained with a yearly report to be submitted to the Health Deparhnenf on or before December 1 st of t}us year. If the weekly water usage exceeds 120 g.p.d.,the Health Department must be notified 'unmediately. If it is found the water usage exceeds the restriction,the Board of Heaith will review the violation when cons�dering the issuance of the following year's food service permit. �.� =°`e"o TOWN OF YARMOUTH BOARD OF HE ��, � oF�y APPLICATION FOR LICENSE/PE � 'z "�Df/ ��-'s � �;�' �'I`� ocr 2 5 2ooi * Please complete form and attach all necessary docti�ient y ecemb�r 31, 2006. Failure to do so will result in the return of yo'�ir applicahon pac k�g t�__:; rr� oF ESTa,�Lis�rrr: �6�,Z. � � �� TEL. # ,;i7�'1 ic�-d'S� LOCATION ADDRESS: � -� lNN 1 TF. � y M,a- MAILING ADDRES : 1 wn c.r., OWNERNAME: ".fl-c-wo r � �/ CORPORATION NAME (IF�PLICABLE): MANAGER'S NAME: �JC-�•I �Nfiv� TEL. # MAII.INGADDRESS: ce�cl,..�ood 2D l�e�.,�.-5 � Yv�•h POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees curtently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee ceRifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t"de at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail food service estabGshments 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. Flease attach copies of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a£de at your establishmen� ]. � r�,& �.10 �LTU� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. L 5��t�Ja P.lu�a.� ��,1� �,�ce� 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 t"de at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICF,NSE REQUIItED FEE PERMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PF,RMI'L# _B&B S50 CABIN S50 MOTEL $50 _INN $50 CAMP $50 SWIIvIIvfII1G POOL$75ea. LODGE $50 1'RAII,ERPARK $100 WHII2I.POOL $75ea. FOOD SERVICE: ..___ LICENSE BEQUII2ED FEE __PERbIIT� --LICFNST�REQiJ1RID FEE- PERMIT# --� LIG&47SE REQtRR�D F&E-- PERMIT k -- � � � �0-100 SEATS $95 �'��/(T _CONTINENTAL $30 NON-PROFIT $2S _>I00 SEATS SI50 COMMON VIC. � $50 � WHOLESALE � E75 RETA[I.SERVICE: —RESID.KITCI�;N $75 LICINSE REQLJIRED FEE PERMI'P# LICENSE REQUIItED FEE PERMIT'# LICENSE REQiIIRED FEE PERMIT N _<SOsq.R. $45 >25,OOOsq.ft. $200 VENDING-FOOD $20 _Q5,000 sq.ft. $75 _FROZIN DESSERT $35 � TOBACCO $50 NAME CRANGE: S10 AMOUNT DUE _ $ ^J S •:•"•pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••••' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pecmit 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 AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLJRANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be aid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: S NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotei use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and 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 five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered witkun 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 Heaith Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Aealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut untii the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,prepazation,or display ofany food product by a retail or food service establishmem is prohibited. NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQiJIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. DATE: �2Z/U7 SIGNATURE: PRIN'1'NAME&TITLE: � �-�kSW �� iomio6 I � � GRANITE STATE INSURIINGE LOMP/�NY 72529-�000 WC SMS'�0-06 ' t;io2 � oig-6b-tio6-oo � PENMSYLYANIA � Jg�SON LAR�ALHO �mp�r�Ompyroes o( � G�YARRMOUI'H. MA OZb17'�� � ��n�)�� �� 70 ryNE ST11�T.pEYy YpNK N.V. fOrio SEE NAME AND ADDRESS SCHEDULE - MC990610 MABSNAL4 K LOYELE7TE 1N5 A6CY INC YVORKC�iS OOI�NSA'fION AND lMPLOVFRS 396 ROUTE 28 �IA�YJ�y ppuCy I�RMpTp�1 PA6E 1IEST YARMOUTM. MA 026T3'4713 I DUAI �L�Y 00 1 Npr 6r�oM1N ANO ADD f t E ULE - �i �aucr�io�rr.�ewwrau»u.a.sy s�or 12/05/06 m 12/OS/�7 �a A. WoAawa OuniwaMbn�hK O�r N tlr p9q MNd u Ma MM�Y�ri Csm�r�Nn 4w M tlr stNes Wntl Mrr M11 t. EnC�tMWM aawr� M Tse M M�Oe1M�PNM�tn tlr waNc M wtl�auu IMM M Iwn 9.A. TM rrMb a1 aur IIeWILLy un�w tMl Tr0 Mk �MNNY W Aed�R� .. 100.000 s�eA dNwt �etlMy M�xy br Ok«w i _ 4QQ,000 puq Mmn bWl�Mpiry p Chrs f IOQ_0� uoh amplo�r c ouw am.aru�e«w/e tw�a a uu pxq,�pdhs�o tln eer.. a wn uaew�r.c SEE ENDORSEMEN7 - 1K2o03o61t Hsi• 1tl IM�s�natlon ewi�lro/�bd,b au�e!m•eM�Nen'tMwMt�M Go�NIe�No�Rws�e/�4�r'wn.. ewi.w.e..w pN.e« uw+.w awa�euw. a..nw�w �"'" aw a�. Y a.n�w �wn 'w"°'�0^ �..ur � . SEE EXTENSION OF INfORMATIQN PA6E - NC7754 Tl1XESJASSESSMENTS/SURCMAR6E5 $41 e�aweeo�nwrreoesrr�e�t�rwiarcws��1 2 NA rrYwwsr�iw � wr�►�isu�Mdixw 1' 1 n IM1sw Mww.N�M.•M.a�wa a Aw.wi+.wM r.de � sxN-MnuaM ❑ �I ❑ Ma+uM Od�OM111�Y� �wppN�"°�n SEE ATTACNED F�tM SCHEDULE - �990612 ; � O1/OB/0� ASSIGNfU RISX 66 • �uwOw w.w^�aniw Nplarm.e�aa�w.+l.liw wcawo� • � C TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO APERATE A FOOD ESTABLIS�IMENT PERMIT NUMBER: #07-190 FEE: $75.00 In accordance with re�u1adons promulgated under authoriry of Chapter 94,Secriou 305A and Chapter I 11,Section 5 of the�eneral Laws,a permi[is hereby granted to: Jason Carvalho, 12-2 Wlrite's Path, South Yarmouth MA Whose place of business is: Bagels&Beyond Type of business: Food Service To operate a food establislunent in: Town of Yarmouth Permit expires: December 31. 2007 Bon1t�oF IIEaLTH: p������ Q_�, �i �f !�� qgY. SEATING: 0 - J�[.e�[�¢"f"f".`SfUM�DL�""�✓"�".""✓"Y.� VICC l.lLN{XIM.IYK RES7RICIiONS: See mverse side. ,i��y�_,�ry� � ��FNCNP��CCICIftQJ(�• � November 5_2007 mce G. Murphy,MPH, .S O D'uector of Health *Restricrions: 1 No fiyers; 2 No stove; 3 No clothes waslvng machine; 4 No seats-take out only; 5 Single service/paper items only; 6 Ma�nmum daily water usage not to exceed 120 g.p.d.; a weekly log is to be maintained with a yearly report to be submitted to the Health Department on or before December 1 st of t}us yeaz. If the weekly water usage exceeds 120 g.p.d., the Health Department must be notified immediately. If it is found the water usage�ceeds the restsiction, the Board of Health will review the violation when cons�dering the issuance of the following year's food service permit.