HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 �a � TOWN OF YARMOIITH BOARD OF HEALTHC�� w • �'�
��� APPLICATION FOR LICENSE/PERMIT-2009 � `� y
ti. . � �� �� 1 � «��
* Please complete form and attach all necessary docut�ents hy December S 2008
Failure to do so will result in the retum of youl�,ti�pli�ah8n pac et. r! ____' �� '''��'� " �
NAME OF ESTABLISHMENT: �tJ�✓ TEL. # '�J�7�0 ��
LOCATION ADDRESS: � o �k a.- a��+w p
MAILING ADDRE S: �6 �J � O
OWNER NAME: �`� ° TAX ID F or SSN :
CORPORATION NA A PLICQ$L : �S `ue✓ �
MANAGER'S NAME: �J'� TEL. # 7Fr
MAILINGADDRESS: u "7/�✓ � K de.� d� /�
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 Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a Gle at your ptace 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 Manaeer, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chaz-ge (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 Hennlich
Maneuver on the premises at all times. Please list your employees h•ained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Depanment 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
LODGL�G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERM[I'# LICENSE REQT.7IRED FEE PbRMIT€
B&B S55 CABIN S55 MOI'EL S55
INN S>j CAMY S5� SWIMMING POOL SSOea.
_LODGE S55 _1RAILERPARK SI05 WHIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQLJIRED FEE PERMIr# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIILED FEE PERMI7#
_0-100 SEATS S85 _CONI'INEN'IAL 535 NON-PROFIT S30
_>t00 SEATS 5160 COMMON VIC. S60 WHOLESALE S80
RETAIL SERVICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERMff# LICENSE REQU[RED FEE PERMIT# LICENSE REQIDRED FEE PERMIT#
�<SOsq.B. S50 �4-03� _>25,OOOsq.ft. 5225 _VENDING-FOOD 525
_<25,OOOsq.ft. S80 _FROZENDESSERT S40 I'OBACCO 555
VAbiE CHA�GE: 510 f�NIOUNT DLTE _ $ �n,p p
»'"*"pLEASE TL7L4 OVER AiVD CO.MPLETE OTHER SIDE OF FORVI*****
ADMIlVI5TRATION
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 haue a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHE
Town of Yazmouth taz�es and liens must be paid pno to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLYSHII�I�NTS
TRANSIENT OCCUPANCI': For purposes ofthe limitarions ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transiem 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 openu�g. Contact the Health Department to schedule the inspection five(�days
pnor to opening. PLEASE NO'TE:People are NOT allowed to srt 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 Yarmouth must notify the Yarmouth Health Departmern by filing the required
Temporary Food Service Application form 72 hours pnor to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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 woking, preparation, or display ofany food product by a retail or food service establishment is pro6ibited.
N01TCE:Pernrits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEIVIBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHI�NT, 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: SIGNATURE:
PRINT NAME&TITLE:
iorzvos
�\ The Commonwealth ofMassachusetts
Department of Industria!Accidents
M�caNA�r�
600 Washington Street, �"Floor
Boston,Mass. 011ll
� Workers'Compensadoa iasarance ABidavh:Baildiog/Plambiag/Electrical Contradors
t
name: �S `V.�✓� M-f.f/�� .
addass:� ��/0��q ��
clrv���` �'�""�"�l state• �" � ao�� d�Y9t' ohone#V��7�� �
�
vmrk site location(fiill�dressl: ��
❑ I am a lwmeowner perfornung all work myself. Project Type: ❑New Con�tn�ction ORemodel
❑ I�a sole��uoprie[or aad have no one woxkiog in any�ca�city. ❑Building Addition �
�I am an emp r providiog w�kecs'compeasati�for my employees wodcing�1Lis job. �
- . ! �'�, . . _ .___
< - _ . ._._._- -- ._ . . .. . ..
com umr. �.Ur�f �
.a : �- aW-�- I�1.
� : D- G.'�`ytia �1� Q �a:�� 7C�U ���'
,� �. ��.� e�. � �iS�X 7S
� � � � ,:, .. �.., ,. . .,,. a �� ;,�� � ���.
❑ I am a sole pr�rietor,8eneral coatraetor,or hameawwer(cirde onc)and Lave hiced U�e contrac[as lis[ed below wlp Lave
the following wakers'compensa4on polices: �
eomwav oaoe: . . . � � .
ad�[ss'. . . . � . . .
citv: � . �g• . � . - � . . . . .
ineaxe ea � .. . . �p � . . .
, ,�. ._ . .., . .. .. -
. . .. . - ,. . . .. . . - ,�.:-;- . , z� � sr<;.;
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ad�rps•
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Id p
�"�� `�' ,t �:.� _: ,,. ;, . ..y ., a. . _ ,. ,:c„ •.�. ,.,..;�u� ,�,�t
FaOme Oo xcme oavnage n rcqe6N udQ S[tlMa 2SA dMGL 152 0�Ind d Ne i�qdtl�a N'uidad pe�Wo da�e q�bf1.'f�4M�aN�r�.
ex ynn'loptbw�ent a w�9 a dN pe�Min�e t►e[�Ka STO�WORK ORDSR ud�Bee dS10�.N a dry��e. 1 odnahed tWt a
epy�WaW&mMmybe[arwaM[d4teeOmmlloveYlptlomN/0eDlAfiravmgevv�ntlw � � . .
!do hekby der tAe . d pe ojperJrry eAat H�e irjonnm�lan proddel ebove k dve m�l cerrect� �
Si . pere ra/ - (� ,
Print name � � � W � Phoce# cS�eS� 7�A��� �Yd'��2_.
oea�w.�owy do net w`ifc Y[6is am W he m�plefcd 63'dlY or 4wu s�dal
dtyarto�vn: � ��q nge����
❑cheek IffmmaBt&tepeme b rtq�ed � � � ����
❑Sdx�e�Y O�m .
mstact u. . ����+��
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLJMBER: #09-039 FEE: $50.00
In accordance with re�aUons promulga[ed under authoriTy of C6apter 94,Sec[ion 305A and Chapter
t 11, Section 5 of the eneral Laws,a permit is hereby grarted to:
Stephen E. Wolfe, 2 North Main Sueet, South Yarmouth, MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31_ 2009 BOARD oF IIEALTH: :�fePe�t S�, JZ.✓V., �aqvnaut
(,'&aur�ea ,`�.9CeffiRen Rlice C'R�ixnuui
` ext `3.�BKaura, (',�eXk
Cln,n(�'xeen6a�J�t..N.
�
Ianuary 9.2009 Bruce G.Mmph , , R.S., CHO
Director of Hea
$ y /
Jt y�k �r.�..
"J�,�• /�1 Ah7 ^
� 3 TOWN OF YARMOUTH BOARD OF AL'R� ^� [� C� � 0 M 'S Do
���_i APPLICATIONFORLICENSF¢@_ �������� �JAN 0 � 2008
* Please com lete form and attach all neces ' d ���
P sary¢ocil�e`nfs by Decemb 31 2007.
Failure to do so will result in the returmufyour application pack t.H�ALTH DEPT.
NAME OF ESTABLISHM �✓� TEL. # ��?�l�
LOCATION ADDRESS: �. D �ib�,, vti.0 UZ66�
MAILING ADDRESS: �
OWNER NAME: TAX F IN r N �
CORPORATION NAME F PLICA$I�E)j i� �,
MANAGER'S NAME: W��� TEL. # 4�
MAILINGADDRESS: a �uw a�G. d2 d o R7d'���Z
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required b��State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certification to tivs form.
1. 2,
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Departraent will not use past years' records. You mast provide new
copies and maintain a Cile at your place of business.
i. Z:
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 deSned 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 p�st ye�rs' records.
You must provide new copies and maintain a file at your establishment.
l. 2,
PERS9N�T CI�ARGE:
Each food establishment must have at least one Person In Charge (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 Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employeQ 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. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE OhLY
LODGING:
LICENSE REQUDtED FEE PERYiI I# LICENSE REQL'IRED FEE PERMT s LICENSE REQti IRED FEE PER�f77=
_B&B S50 _CABIIV S50 MOTEL S50
_INN S50 _CAtOIP S50 _SWI�4INGPOOLS75ea.
_LODfiE 550 _TRAILERPARK S10q R'HIRLPOOL S75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT� LICENSE REQliIRED FEE PER4fIT a LICEtiSE REQC'IRED FEE PERbfIT=
_0.100 SEATS S75 _CON'IINENTAL S30 NOti-PROFIT S25
_>100SEATS S1i0 _CO�f.YIONVIC. S50 N'HOLESALE S�5
REI'AIL SERVICE: —RESID.KITCHEN 575
LICENSE REQUIRED FEE PERMI'I�= LICENSE REQL7RED FEE PERWI7= LICENSE REQL7RED FEE PER4IIT=
I <SOsq.R. 54i � D —O��J >25,OOOsq.B. 5200 VENDING-FOOD S20
_Q5,000 sq.R. S75 _FROZEN DESSER'I S3i TOBACCO S50 �
VA:�CHA�'GE: S10 AMOUI�T DUE _ $_c�S�00
•"••PLEASE TL`R.Y OPER AXD CO�iPGE'IE OtHER SIDE OF FOR�i^`***
. r
ADMINI3TRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pemvt to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pemuts. PL.EASE CHECK
APPROPRIATELY IF PAID: ' /
YES V NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCi7PANCY: For purposes of the limitstions of Motel or Hotel use,Tcansient 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 six(6)month period. Use of a guest unit as a residence or
dwelfing unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as deSned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generatly be considered Transient.
* NOTE: Enolosed Motel Census must be completed and retumed w,t�t�s apP���at�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 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
closin�.
FOOD SERVICE
CATERING POLICY:
Anyone who caters wittvn the Town of Yazmouth must notify the Yazmouth Health Departmert by fifing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Deparhnent.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeatth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of azry£ood product by a retail or food serviee establishment is pro�ibited.
NOTICE:Permits run annually from January 1 to December 31. TI'IS YOUR RESPONSIBILITY TO RETIJRN
THE COMPLETED APPLICATION(S)AND REQUIltED 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. REVOVATIOVS MAY REQUIRE A SITE PLAN.
DATE: l.�/c�i'� � SIGNATURE: � <
T lx�, �. �� ��r��
PRINT NAME&TITLE:
io?om
� T/�e Commonwealth ofMwssachuset�s
DepaRmest of Industrial Accidents
N�N�
600 Washington Sfreet, f"Floor
Boston,Mass. 02111
wo�e�°Compe�eatioa Imarsace A�davk:Baildieg/Pl�mbi�g/Ekcfrical Co�Mctors
name: t V C✓ Gr/lan 1�'� .
aaa�s: 2 vv� �cc67.z -
i �f�� liiZd state: � zi ' h U '"� 7� ��
watk site lacati�(full addcessl:
❑ I am a hom�wner perfoiming all work myaelf. Project Type: ❑New Camstcuction QRemodel
❑ I am a sole proprietor and have no�e woiking in�y capacity. ❑Building Addition
Wiram an�plo provi ' workas'compensati�for my�pbyees working on 1Lis job.
f �,com noe: �� ��`f _.. . ._ . .__ __ _ _.
addras: L U- (G ' � t
d : D . ���2+.� 6 r:cS� �bd !��
a�1�1�w .Go 7w�leY�' � �u 6 —���?«�q-5�-0 7
,.�. ,.
❑ I am a sole proprie[or,ge�eral coetractor,or homcow�er(drde uneJ aed have hiced tbe con�trns listed below wlw have�
tl�e following wakers'compeagation polices:
wowuv ame•
addEps:
etR: o►we M:
lu�ake t6 ndtev#
�sy me•
�•
clts' � oWe#'
_ . . . _ __ _._ .. _- - - -_._. ____ .. .._. ....— � ------- —. _ . . - �--- . _. ..__ _
..-�eo. .. . odicv A
Jd1�d�it�YrK�f�Mrey:. . . . . . _ . � . .. . .
Faive i�aecve a�uaee n'eq�M odv Seetle�2SA NMC,L 132 eu led b IYe I�wMW Kvi�iW peoNie da Ae�bll�M.M aN`r�.
o'e ynn'hwpHwnmmt n wd n eM pn�ltln In Ue tarm eta 31Or WORK ORIIER aM a Bee e[Sl@9.N a day apiat ee. 1 odnsh�d that a
apy of fhh afatrant m�y 6e f�neaMrd b Ne Omee atl�veNiptls�s ot Me DIA[er ewcase�tln. �
/do hereby - er NYe pains ' oj tAm Me teforvudien pro�ddel aboNe 6 nrre m'd 4
ss �K l 3 �
Prim name � �, P6one# U"�7�d��0 0 l 7��o��7�?
a�w oee.ny ae aw wrae m lhis.rea n ae m�vkfal6r dlr er w.0 emaa�
cky or tewu: � perwiN.eene M ❑BeidinE Deparlment
❑eheek NlmmediNe reepemc 6 reqWM �Sdecda a O�te
❑HeMY Deprdst
cs°t�e[Pe+aeu. Piox M; �OWc
ln+��#�1
—�r—
� � The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-�900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
msuring with:
THE TRAVELERS INSURANCE COMPANIES �
NAME OF INSURANCE COMPANY
ONE TOWER SQUARE
HARTFORD CT 06183
ADDRESS OF INSURANCE COMPANY
(6KUB-894X579-4-07) 06-27-07 TO 06-27-OS
POLICY NUMBER EFFECTIVE DATES
JOHN F MARTIN INS AGCY 1023 ROUTE 28
= BOX 350
� 5 YARMOUTH MA 02664
= NAME OF INSURANCE AGENT ADDRESS PHONE#
'� BASS RIVER MERCANTILE , INC. 2 NORTH MAIN ST.
oC
o= SOUTH YARMOUTH
o� MA 02664
' = EMPLOYER er�r�nFec
TOWN OF YABMQUTH
BOARD OF HEALTH :
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #08-047 FEE: $45.00
In accordance with re arions promulgated uuder au[horiry of Chapter 94,Section 305A and Chapter
111,Section 5 of the�enerai Laws,a permit is hereby grauted to:
Stephen E. Woife 2 North Main Street, South Yarmouth, MA
Whose place of business is: Bass River Mereantile
Type ofbusiness: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31. 2008 sonRD oF HEnLTH: �fePxtc Sl�aRi, J2JV., C'�avurtatc
ClEaxeea .`�.:rCeP.�iR�e�c `11ice CR�aix,�naut
ZaBexE 3.f�3acocuit,L'�ex�
Qr�ri.C�,reen6auni, J2..N.
£.�eeeiyra:/'•.`�fay.eo
January 25.2008 Bmce G.Mwphy, .S.,GAO
D'uector of Health
Of.YAR � L� _ �. R�fl �;,.�,
2 � o TOWN OF YARMOUTA BOARD OF HEALTH
o��y APPLICATION FOR LICENSE/PEI�MI'�'- 2007 1 �D E C 1 8 2006
c�`� '$ * Please com lete form and attach all necess docu y
p ary m�ents� ece�b r �,QQ�i UEPT,__
Failure to do so will resuit in the retum of your application packet.
NAME OF ESTABLISHIv�1'T: � 1 �/ G�"l �� TEL. # �� ��% ��"�
LOCATION ADDRESS: � ��1 G ��'
MAII,ING ADD S: 1'l�
OWNERNAME�t Z�c� "� �/ TAXID r � ` �"/
CORPORATION N AEPLIC LE}�_
MANAGER'S NAME: �c/{�— TEL. # 7d���'�-�tiZ
MAII,ING ADDRESS: IV P,v � G+- dci�/ /}�/ . ��/C:,
POOL CERTIFICATIONS:
The pooi supervisor must be certified ac 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 oftwo employees cunently certified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to this form. The Hexit6 Department will not use past years' records. You must provide new
copies and maintain a fte at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment
I. 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 ia 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 Tile at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQLRRED FEE PERMIT t!
_B&B S50 CABIN S50 MOTEL $50
__INN $50 CAMP $50 _SWIIvIIvIIDIGPOOL$75ea.
_LODGE $50 1'RAII,ERPARK $100 WIIIRI,POOL S75ea.
FOOD SERViCE:
LICENSE REQUIltED FEE PF.RhIIT# LICENSE REQUII2ED FEE PERMII'# LICINSE REQIJIl2ED FEE PIItMIT#
_0-100 SEATS $75 _CONTININTAL $30 NON-PROFIT $25
_>100 SEATS 5150 COMMON VIC. S50 WHOLESALE S75
RETAII.SERVICE: _RESID.KITCIiEN 575
LICINSE REQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICINSE REQIJIltED FEE PERMI'P k
��50 sq.ft. $45 �� 1-b� _>25,000 sq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.R. $75 _FROZIN DESSERT $35 TOBACCO $50
NAMECHANGE: SIO AMOUNTDUE _ $ i(S.OQ
""`PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••"••
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
of any license or pernrit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSLJRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth t�es and liens must be paid prio to renewal or issuance of your 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 motel and hotei 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 whirlpoois 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(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 Fnust be drained or covered within seven(7) days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarnouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemvt until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heahh.
OUTDOOR COOKING:
Outdoor caoking,preparation, or display ofany food product by a retail or food serviceestablishment is�rohibited.
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMII�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
DATE: �- p � SIGNATL7RE: i;1�..C� ��
PRINT NAME&TTTLE: • � �, J�t�-- iQ �L S i r,� e�
ioii�io6
� Tlre Commonweahh of Massachusetls
Depa�tneent of Iedwstrial Accidentc
N�felNrw�s
600 R'ashingtoe Stree� �'F[oor
Bostat,Mass. 02I11
---- — Worlce�e'Com tio�I�sma�ee A�davlk B�il bi�glEteetrical CoNraelon
,,.,.,- ..... --.... . .,,.; , _ ... ., . ..
v-� .. '�5�a F,.-„ r';:'x - ' �-�s �r,^,�. y�s. ; -»�.� � `
�: , �t I Ue✓ ��uM, � o �t7 b'b�Co2-zZ�-
_ ,
�y o� �a 3�� i� 1� l� '��/�
�: � '
' ; ���,o- d4- � .G Z� S�'� ��i l��
wo,�S�m i '� rwt s: , z�
❑ I�a homeown�perfotming ali wak myself. Project Type: ❑New Caosfcucti��R�adei
I a sole 'dor aod have no ane w in� ca ❑Buil ' Addition
I am an e,mplo �aoviding o�cas' .. �m for my�. � loyees wodcing on tLia job. . . . ... .
. - �C�.� _ �(d�✓Gtt��C:�z.t�.l�� _ _ __
Ov (nl,
� LC; - ,�-7E,c� —1��_
. r✓ru o� �`Z r:
4K�a <i�/I' T �l�'".c,�--
❑ I am a sole propridor,ge�eral ewtrat[or,or lomeow�er(codt oAeJ and have hiiad 9�e coufextots listed below wlw have
the following wakeas'compensataon polices:
�
. eltv nirrM: �
M
addrns•
tHv: oMe 9:
-- - -- - -- - ----- -- �-----
. . _ _.._. --------- - --- -.._----------_ . . . . _ .
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Fa�e Y setve a�e n�eqdvell ude Seetlr 2SA�MC.L LS2 m Id b tYe h�i1W dat�i�d pmMe da is�p b SITIM.M�Afaf
��•�w...oa..oa,.a.��du�w..r,srorwowconnsa..a.e.�.rsioue.a.y�.r.�. i�.amc,
npy etltl�ttaieaent my 6e hrwnded M f0e Omee of Lve��Ne DIA tar es�e`age veelpeftls�.
/do herobq ler tAie aw� JDM+QY bi�t Mt iefa+e�fion provWeAabove ls awe od
Sig„mom. Dare ` Z/! � � 1�
PriMname � D . Phom# b�� �bo /fy� 4����`cZ�.
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cityortewn: pc�flioesN flB�iMaeDepar�t
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�tlnMY Dep�t
natM Petaea: phwe R: �OHQ
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' 12718/2006 09:54 508-396-2239 JOHN F MARTIN RE&INS PAGE 01
. IS9UE DATf(�M'DOM�'�
CERTIFICATE QF 1NSURA� �z�1 A i�6
��Ep i THIS GEHT�FICATE IS 155UED AS A MATTEp OF INFOFMATIIXJ ONLY AND CONFEPS NO
JOhn F. Martin Insurance Agency � RIGHTS UPON TME CEflTIFICATE HOLOF.R. THiS CEPTIFIGATE DOES NOT AMENO, EX-
� TEND OR A�TER THE GOVEFIAGE PFFORDEO BV THE POUC�ES B E�a N
1023 Route 2$, Sox 350 .._. ,._. .
South Yarmouth, MA. 02664-0350 i CpMPAN1ESAFFORDINGCOYERAGE
� _ _
508-398-2277/FA%: 509-398-2239 I��A .St.paul/Travelers
wle�cooi ' _ ......_. _ ,.. .. . � � � ,.�-� . .
woE � �uP,w�, � p_n-�'� �
.... . . ........ .__ ,.
..... ... . .._,— -- I LEYfER B 1 L^` � \
,� .. � 1 a 200
sasa River Mercantile. inc. �NWMERY � pE ,
2 North Main 5treet ,. __., ,... . ._.. .. U�pT.
120o xoute 26 � �q p �-IEh��N
South Ydrmouth, MA. 02664 „ _
cauvnwr
� �rrea E v
a
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TNiS IS TO CERTIFV THAT TFIE POUC�S OF INSUR 7NCEA�I�C�DRION O ANVECCN`�TRACDTTOA THER D�CUMEfn WROH AESP CTiTO WHICH THIS CE- g
JIG4TE0.NOTWITHSTANDMG ANV REOU�AEMENT, THE POLIC�ES DESCRIBED HEFE�N IS SUBJECT TO Al�7HE TEAMS,EXCLU- �
TiFiCATE MAY 8E ISSUE�OR MAY PfATAIN,THE INSURANCE APFOF�OED BV �
SKKJS ANO CONOI?IpNS OF SUCH POLICiEg.LIMITB�+'�WN MAY HAVE 9EEN REDUCE�6V PA�D GLAIMS. , . �
,....-.�... .._. .""" . -. ...,., u
. . .. .-..._ .._. -, ........_.. ,
F'OIJCY EFF�TIYE ��IX%MT10M KL LMM79 MLT7�IOAN� �
CO riPE OF IH9YR�MCE POLIC NIIIMER . �AIE�MM�D]M'� OIIE INRV��� . ,.. - .
LTA .. ... . .. ._ . � � :
...� ._....-_....,� ..�" """.. . ....,
.. .��. ..--- GENEPAL<GGRECi4YE �
pENEM\LWBI��T' . '�
0
PRODUCTS-GONP/CGSAOOREG�TE
� COMMEFC�lGENER4LI.��ILfiV �
ClAIMSMADE i O�CUR. . PEFi50Wa6�'�SINGINJUR�
�� � EACXOGCUAAENCE
ps.'��R58CONTA�CTa15PROT. ' •
FIREDAMAGE�ArryOl�BM9) �
-��� -' "" '"' . MEO.EXPENSF(!vry one pasc�) . j
. ...._.., .�.,.._. .. � ... .. . _ ._ .. .._..... . ... . ... .. ..... .. ,
. .. .. . .,.....:. . _....�...���.... .. . .
C0�'+Eo
M1TpADBILE WO��T�' SINGLE
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ALLONME�AUTOS � � �8001LY
INJUA'/
SCNEWLEDAUTQS ' ' iPpr�pmn) I
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NpN.pWN�AIITOA IPB�iadeM)
G�MGELIhBILT' � � PROPERTY
O�+WGE
,... ... . ..... .. ..._'__. ._..._..._... . ... ... ....._ .... . , . .. EACH AOOaEC1TE. .
qc�5 WBILffY OCCUAKENCE
OTMERTHIIN U.6AEUA FORM . . .
. .._......_ . .... ....,....,..,.... ....."_^_"_"___" .._.._..... ..,... .. .., . . ... .. . .
STAMOIIY
�Oltl[FR8 COINENS�11IX1
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500�000 io�sense—Pwc�.�M�*�
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OT/ER
UE9CPIPl10NOFOYFAAiR1NS�LOCAl1OX&YEX.•..•..•••..�••."«•"" ...••••.•.•.•••.••.••-.••. .,•,•• . . . .. .....� _..
IGLES�SPEGIIIL RIl14
CERTIFICA7E hIOLDER CANCELLA710N
Town Of Yarmouth SMOULD ANV bF THE ABOVE DESCRI6E� POLICIES BE CANCELIED BEFORE THE
� BOdrd Of Health @xPIpATION DATE TMEREOF, THE ISSUIryG COMPANV WILL EN�EAVOR TO
; 1 1 46 Route EB MAIL�O DAVS WRITTEN NOTICE Tp THE CERTffICATE HOLDER NAME�TO THE
� $OAtil Yarmouth� MI1, 02664 LEFT, BUT K�I�UFE TO MAI� SVCH NOTICE SHALL IMPOSE NO OBIIGATION OF
LIABILI F ANY KIN�UPON THE CAAAPANY ITS GENTS OR REPHESENTATIVES.
a �
�
�
TOWN OF YARMOUI'H
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHl1�NT
PERMIT NUMBER: #07-033 FEE: 5.00
In accordance with reaulalioas promulgated ander authority of Chapter 94,Section 305A and Chapter
� i l l,Section 5 of the�eneral I,aws,a pecmit is hereby granted to:
Stephen E. Wolfe, 2 North Main Street South Yarmouth, MA
Whose place of business is: Bass River Mercantile Inc.
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit e�cpires: December 31, 2007 BOARD oF HEALTI-I: B �a�r `.7�. (io3dok,dl?.$., '
d�fe&lP,�c Slscl�, QJK, ?hi;6 L�l�fiiisu.�s
Ro6oat 4. B�, U�
A��R.N.
Merch 23.2007 cuce G.Mtup S.,CHO
Director of Heal
: ' �� A T�E
3 o�e 2yc . TOWN OF YARMOUTH BOARD OF H��'H �6\� � '� � '-5 'J °�� �_ '�
��= APPLICATION FOR LICENSE/PER� ' 06� �� JA N 2 4 2006
��i'. "`'�'', � °" JN
* Please complete form and attach all neces`satj!.db c�,ments by Decem r���S H D E P T.
Failure to do so will result in the retum'o�your application pac
NAME OF ESTABLIS�IMENT:�p1y��,ff—' j u� �lev�� TEL. # �� �6� ��
LOCATIONADDRESS: 2 i{/ov-/� Glw .(' . .S'a ��� , �-t/� GZ�6jC
MAILING ADDRESS: ��' f'!
OWNER NAME: o TAX ID E r • �/
CORPORATION NAME LIC L 'rsc,� w C�
MANAGER'S NAME: �� ��� TEL. # 9� F� 222
MAILING ADDRESS:� �l.�c.� � .�l� lJl�/�
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 min;mum of two employees currently certified in basic water safety, standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a£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 full-time empioyee 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 wiR not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE: _ _--- _ .
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1. 2.
HEIA�;KH 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
at�acli copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERMI'1'li LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMII'#
_BBcB $50 CABIN $50 � _MOTEL $50
_1NN S50 CAMP S50 _SWA�IIvIINGPOOL$75ea.
_LODGE $50 _TR.AII..ER PARK $50 _WIIIRI,POOL $75es. .
FOOD SERVICE: �
LICENSE REQiJII2ED FEE PERM[T# LICENSE REQUIl2ED FEE PF.RMIT# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS $75 CON1'INENTAL $30 NON-PROFTT $25
>100 SEATS E150 COMMON VIC. SSO WHOLESALE E75
RETAIL SERV[CE:
LICENSE R&QUIItF,D FEE P�/,ERMIT!/ LICINSE REQUII2ED FEE PF.RMI1'# LICENSE REQUII2ED FEE PERMIT#
�<50 sq.ft. $45 'N�►'a�'. � >25,000 sq.ft. $200 _VE,'NDING-FOOD $20
_QS,OOOsq.ft. $95 _FROZENDESSERT $35 _TOBACCO S25
NAME cxaxGE: $10 AMOUNT DUE _ $ �}S•OO
"""""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM•""""
ADll�1VISTRATION
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 STA1'E WORKER'S COMPENSA'ITON INSURANCE
AF`FIDAVTP 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
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQiJIltED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISF�lENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEI�IING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOT'EL 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.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be insp�
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. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly�asis by aState certified tab. TestTesuits must be sent to the Heatth
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 Boarcl ofHealth.
OUTDOOR COOHING:
Outdoor cooking prepazation, or display of any food product by a retail or food service establishment is prohibited.
DATE: I� �' SIGNAT[JRE. �
PRINT Nr1ME&TITLE: � C• u �•
0928/OS
��� The Com�nonwealth of Massachusdts
�-:__
�d - _ neportnrart ojr»drrsnial Accidenrs
� - - �7N�
_- 600 R'sshingtoa Sdee� �'Floor
= Bosla�e,Mess. 02111
.•.
� Worlmre'Compe�ealio�I�sva�ce Affid�vf�B�7 b��g/Eketrkal Co�traetors
. u .. .;; .. �. � , . .�,r ,, .,„s ....,
,'�,.,., ,s�-� .,� �._`..;... +�}.H- �t.4�t�r�=»�...g�-v' . . ,
name: G/ (R�
�: 2 /�o �- ll��i
�� �e -y�,U��., �: l}'� �o: o7-�`F �# p���d� G22Z
��t�re i�n�rrou�Si: S'�hE
❑ I am a homeow�perfo�ing all wak myself. Project Type: ❑Ncw Caoslxuctia�DR�odel
I am a sole 'etor aod have m aae w in an &ril ' Addition
I am an�pb�`�xovi�' 1w�kess'compeesatim for my�ployees wohing on this job.
. l�s�c V`-i �evv�i�
�: G /V G(�l'�- v L.(Llw �.�.. y�_ .
��_`1�.��-� � h�' o�{G� .w.��: P�� G�G za`L
� �'r�uc�ws �.w Hw ��'.c: 6 t?� S s — -�65
❑ I am a sole propiietor,geasal eo�trxMr,or�emaw�er(arclt owe)aed have 1�¢ed Hx con4acWis listad below wla have
the following workets'compc�satiou Polices:
aon�v�_
�i�eu:
dlv nYae{:
N
aa�av a�c
�•
tA4s: oW�e/:
Fa9me i�a[eae ove�e n�eqetred dv SedM 2SA dMGL LS2 n�kW b He dp�itlw�f a�Id ps�Wp d a 6e�bf13M.M aMlv
anc ynn'hsptbwemt n wd n dN pmMlo 1�tYe 6'a K�31'O}WORIC OBD&A ud t me attiM.M�tlay a�et�e. 1 odenh�d 1�a
apy ottY6 Malesmt my he 6rwuded!s Ne O�e d1m�Ww atHe DIA tr ewe�age veel�ralW.
Siguaao�e �s e`\./G m�J�te.trtea ofD��xry aat xu u,�nwmtoe Ssovided A Is ar//�
D// / ,6
�_. �rrx _
Printname �-. � PhmeS � 3� �i �ep l���
e�ew we oery ae.et wA1e r tY.am ro ee nrpktd 6r dty ec e.w.aeaeial
dlyorfewu: perdflit�ecB r� "' U�vh�t
❑ekedc H1mse�aBe�eapee�e h req�nl �Sdxt�ea a O�ce
�ll�ar�f
coWet Penou. pYex�; �
l�s�.mao�
01/18/2006 11:55 508-398-2239 JOHN F MARTIN RE&INS PAGE 01
� CERTIFICATE OF INSURANCE ��EUIITE�MhVDO�'V)
PRODUCEP !I
1 /18/06
John F, Martin Insurance Agency 1 IGHTS UPION TMEICEFTIFICATE HOLDERR��S CEA7�FICA E DOES NOT A�MENDSEX-
� O L 3 ROIItQ Z 8� BOX 3 SO � TEN�OR ALTER THE COVERAGE AFFORDED BV THE POI�pES BElO�N
south Yarmouth, MA. 02664-0350 �- -
; COMPANIES AFFORDiNG COVERAGE
508-398-2277/FAX: 508-398-2239 �'�,,;M,;: • -•
cooe ��E f �T'ER A St.Paul/Traveleis
�. . �-
IN6uNEo . . � � ••� • _ � . ....__._....__. ' CQVPANY• . . . ..
"__ '..... ."� IEfTER B
Base River Mercantile, Inc. ' ��P,u,�; �: ;� � ,� L� ,
2 North Main Street � �ETfER C �
i 20o aoute ze � - � I�N 1 9 2006
South Yarmouth, MA, 02664 ; �E�rr�Pp"� D �
i ��EA"'' E l.,_,,�lFtii�f H DEPT. ..
COVERAOES �
THIS�S TO CERTIfV THAT THB pOUCIES OF INSURANCE LiSTED BELOW HAVE BEEN iSSUED TO THE INSURED NqMED ABOVE FOR THE POUCY pERIOD IN- �
DICATE�,NO7WITHS7ANDINO ANY qE0U1HEMENT,TERM OR CONpI710N OF ANV GONTqACT OR OTHER DOCUMEN7 W�TN qESPECT TO WHICH TNIS CER- �
TIFICATE MAV BE ISSUED Ofl MAV PERTAIN, THE INSURANCE AFFOqDED BY THE POLICIES P6SCRIBED HEREIN IS SU&IECT 70 ALL THE TERMS, EXG�U-
S�ONS AND CONDRIONS OF SUCH POLIGIES.LIMITS SNOWN MAY HAVE BEEN REDUCED BV PAID CIA�MS. S
� T'PEOFk�flUq�NGE "__...••••� •,.. " "' . , �
LTR •i POLICV NUMBER ...'.POLICY EFfECTVE POLICY 6XqM710N
' W7E(MALDww) w,7EIMAwOm1 �w.lNa791KSH0lIgAyQT �
. . ..__ ... .i.. ....__...._. ... .........
OENEI4L WBIDY .•. . . . . •••�
i 6ENERALA�REGATE �
' COMMEPC�AIGENERALLIRBILIT' i PRpD�I(',T$.COMplOPSRGGXEGRTE
ClAIM6MNOE OCCUA. �
� PEASONA�gqDVERTI5INGINIUR� °
OWNEp'6dCOfRqpCTOq'SPRpT. '' 'a
EACMOCCURRENCE �
. ". .'. . . � FIRE OIIAMGE INrry onP Mre) �
11VfOlAOBLEWeIUTP " .� . .�•��,.•••• .,... ........ . ,• .• . . . ..... .. MED.EXCENSEINrymepirsonl ?
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ceanflcc�„�Hao� CANCFLLATION "
Town of Yarmouth �
; Board Of xealth SHOULO ANY OF THE ABOVE DESCA10ED POLICIES BE CANGELLED BEFOFE THE
EXPIRA71ON OATE TNEREOF, 7HE iSSU�NG COMPANv WILL ENDEAVOF TO '�
; 7 1 46 Route 28 MAIL�O DpYS WRITTEN NOTiCE 70 THE CEF7IFICATE H�LD6q NqMED 70 TME �
� 5outh Yarmouth� MA. 02669 LEFT, BUT FAILUfiE TO MAIL SUCH NOTICE SHALL �MPOSE NO 08�IGATION OR �
' LIABILI F ANY KIND U�ON THE COM74NV, ITS GENTS OR qEPRE5EN7qTIVES. �
I e . $
0
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�
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTf TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #06-049 FEE: 45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a peimit is hereby granted to:
Bass River Mercantile Inc., 2 North Main Street, South Yannouth, MA
Whose place of business is: Bass River Meroantile
Type of business: Retail Food Service less than 50 squaze feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31, 2006 BonRD oF 11EEAI.Tx: B 95. �'io+�orc, i19..95., '
' ��' � .�, `�sl�, /l�v., v� e�
a�t�t.a� et�
nn��r��/�
fYifR B �LfNI� /(. .
�
February 13.2006 Bcuce G. Murph , ,RS.,CHO
Director of Heal
�� �
����.Y��`�o TOWN OF YARMOUTH
� "j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451
� MATTACMEES �
�^�,,,�,,,�o,�P� Telephone (508) 398-2`231, Ext 241 — Faac (508) 760-3472
BOARD OF AEALTH r _--_
j ,� � —
�
i
To: Yarinouth Board of Heahh Permit Holders ? MHY 0 2 2005
From: David D. Flaherty Jr., RS. ;�D r �E��- � � UEPT.
Heahh Inspector �
Town of Yarmouth
Re: Federal T�ID Number
Datz: March 22, 2005
The Massachusetts Departu�em of Revenue is now requiring that we furnish detailed information
to tbem regazding all permits and licenses that we issue. One of the details that they require we
send to them is every establishmenYs Federal Employer ldentification Number(FEIl�otherwise
known as your"I'au ID Number". This is purely for administrative purposes only.
Sou� businesses use the owner's Social Security Number (SSI� for Uvs purpose. If this is the
case for your establishment, be assured that we will not allow this information to be public
record.
Please fill out the fields below and return this letter to
Yazmouth Health Depaztme�
1146 Route 28
South Yarmouth, MA 02664
Tl�ank you for your anticipated compliance. If you have any questions regazding this matter,
please do not hesitate to call. The office hours ate Monday to Friday, 830 a.m to 430 p.m The
telephone number is(508) 398-2231,ead.241.
Establishment: �SC ��v�v /�wc�,'��`� FEINorSSN: ��
Locarion Address: 2 ��D✓� l"�ci!ti J l � �o.. /�v�� �"!/¢ G ZG,6 3�
Signatur . �. (�t/
Print: ���1� �, wo r� Title: _���'�`�^
��
� Prin[edon �-,�s'
� � Recycled �r
Paper �`a
---,— �y�3�{�'� g2 M�mca�Nnu=
• °`��'°o TOR'N OF YARMOIITH BOARD OF HEALT'� ��3 = � ,2 ��,j 3
o;'�S APPLICATION FOR LICENSE/PERMTT- 2005
'`�y''� � � � JAN 0 3 2005
* Please complete form and attach all necessary docRments by Decemb r 31 2004.
Failure to do so will result in the retum ofyour application pack H�ALTH DEP7. �J
NAMEOFESTABLIS�IMENT: �� fla.v.0 /e TEL. #S'�� 76o-f�-�-
LOCATION ADDRESS: 7 ,{/�c�' Gi�, f'f S'� Y�'«w • _hfi1 c ZCE�f
MAILINGADDRESS: S�-f1� �
OWNER/CORPORATION NAME: `ue..- 4
MANAGER'S NAME: �� � TEL. # � � • 222
MAILING ADDRESS: , U `uer o uev�� �i U
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 emplo ees currently certified in basic water safery, standard First Aid
and Community Cazdiopulmoaary Resuscitation (yCPR). Please Gst 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£de at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
All food service establishments aze required to have at least one full-rime employee who is certiSed as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your establishment.
l. 2.
PERSON IN CHA�6E: — __ _ _ . . - - -
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 fde at your place of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICINSE REQUII2ED FEE PF,RMIT I! LICENSE REQUIl2ED FEE PERMI'I'M
_B&B $50 _CABIN $50 _MOTEL $50
_INN $50 CAMP S50 _SWIIvIIvIINGPOOLS75ea.
_LODGE $50 1"RAIC,ER PARK $50 _WHQtLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT if LICINSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
0-100 SEATS S75 CON1'INENTAL $30 NON-PROFIT $25
>100 SEATS $150 _COMMON VICT. S50 _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIl2ID FEE PERMTC#I'f LICENSE REQUIItED FEE PF,RbII1'N LICENSE REQiTIItF.D FEE PERMIT#
�<SOsq.ft. S45 7' O��D�NO >25,WOsq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.ft. S75 _FROZEN DESSERT $35 _TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ 7� UZ'
•••*"pLEASE TURN OVER AND COMPLETE OTHER SmE 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 permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Inswance. THE ATI'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 Yazrnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: . /
YES " NO
N01TCE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIIiED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISFIl�IENTS ARE TO CONTACT THE HEALTHDEPARTMQVTFORINSPECTION7-10
DAYS PRIOR TO OPENING FOR Tf� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISIIlbIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIVIENCEMENT. 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 POT.ICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
requued Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Aealth Department.
FROZEN�ESSERT� - _
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 of any food product by a retail or food service establishment is prohibited.
/ L"1 j �
DATE: I.� � �` SIGNATURE: L.l�/
PRINT NAME& TITLE: �-e,�� � �,✓o%/� v�' i'ed%�
10/22/04
_ 12/30/2004 16:36 508-396-2239 JOHN F MA�` PAGE 01
AC'Of�p_„ CERTIFICATE OF LIABILITY IN � ""E'"'"'"'"
ro4uc 1 �30�09_
JohR� F, Martln Insura[!Ce AgeflCy, Inc. TM�CEt QTEIIOFINFOflMAl10N
1023 Route 28 BOX 35� OI�YAh JNTItECE11TIFICAIE
r IIOLDEiI. �OT AMENU,EX7 ENU Ofl
South Yarmouth, MA. 02664 ��p�1� OYTIIEPOWCIESUELOW.
508-398-2277/FAx: 508-398-2239 nNacovenAoe
MWn6V --- --- ---� ------
Bass River Mercantile, Inc. "180=`-'="----- � � !� � � �% G DD
2 North Main Street """-'�'�---- -
South Yarmouth, MA. 02664 `�"�—"`-------� • •-- JAN D 3 2005
and 1200 Route 28, South Yarmouth, MA. -�� -
�uu�E:T=aveIers
eovenaaes
711F 1'OI.ICJF.S f1F INSUf1ANGE L191EO I�EIOW IUN/E 6[EN ISSUED TOT/E IN9UIIEU fMMED JIBOVE fU11711E POLICY PEIIpU INUICAICl/11()I WI I I Ci Il1rllllfl(i
11NY 17EWqiEMENf,IERM OR CONUITqN pF ANV CpN1pACT pq pTHEp ppqNAENt WIi11lIESPEC710 WI IICII 11119 CE1111FICAIF MI1Y Ilf:ISSUf:U 1�11
M�r�Ef1tA1N,111E MSVIIANCE AFFqiOEp BY TI E 1'OLICIE9 OESCRIBEO IIEREM 18 SUBJECT TO ALl 711E TERMS,ERCLUSIONS ANU C(XJIM�ttN�S Uf!;UU I
POl�C1E6.M36f1EOAlE LMM7S 6110YN1 MI1Y IUVE BEEN ItEDUCEO BY FND CIMA$.
. . . . . ..... .... ..."" ___ "'_—_'_—_ �..�..,""�... .__..._.. __ ... ... .
NRII 7�K Oi�IN111NIC[ �011CM d�lCNV! MLItt EAl'111A71d1 . . .
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E, lWqtNEP9'Luaun .... IWIY�R�NI6 EII
6KUB894X5794-02 6/27/04 6�27�OS E.L;EIq111Cca/ENf :100� 000
E.Lasense:E�eMtiurEl fSOO,OOO
on�ea E.4�MSFA6E-14A�C�Lp�11 t , o n n
�
oescmoiaM os oren�rroxxoe�noMwa�c�neiauwoN��wea�r aqo�wuv�rmeau rpo�ps .
CEIITIFlCATEIroLDER �ppn�ua �aw�unpk CANCELLATION
Towr1 Of YBT�IIOUt.Yl &bIRpNlPpphK�ppyg��ppp���BBECMICELLEUBEFd1E111��1M11A11U11
Roard O£ HEdlth dOf7Nl11[pF�T�1�q��q�ppp�p������p�OM�IL � O_ IM�9 MNI�EII
1146 ROute 28 xone[mriwcmrs�e��e��ocuEnxu�oiove�eFr.au�r■�w�e�o�row�siuu.
SoUth Yarmouth, MA. 02664 �xoo�uu�nononu�eninor�NrKwunu�neweunen,us�uunson
n an�rnEe.
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ACORD 25-5 pMI)
6 ACORb COfIPO11AT10N I9B!
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHIVIENT
PERMIT NUMBER: #OS-046 FEE: 5.00
In accordance with regulations promulgated imder authority of Chapter 94,Section 305A and Chapter
111,S�tion 5 of the Generat Laws,a petmd is hereby grattted to:
Bass River Mercantile Inc. 2 North Main Street, South Yarmouth, MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pemut e�cpires: December 31. 2005 BOARD OF HF.AI.TH: 8eiyc�nri�c$ 4oardosr, �1•$•
��,ya� v�e�.�
a�4. a� et�
eV�SlK.�, R.N.
A.�.� R.N.
Febivary 3,2005 Bnx;e G.Murp H,RS.,CHO
Director of H tli
._ _� �{�a�1���
6 � ,J� 5 ��.c�
�`�qy TOWN OF YARMOUTI-[�O`�.D E TH
3 � APPLICATlON FOR�,� �� � ���T-2004 J AN 3 0 2004
� y''? � X�=�
* Please complete form and attach all nec�"sary documents by Decem e DEPT.
Failure to do so will result in the return of your application pac et.
I�IAME OF ESTABLISHMFNT• cz�.v Cdz� i t- T # � ��� z'�t-�
LocATiorranD�ss• 2 �o�, �l� '., � ����.� �-i� ��s�
MAILING ADDRESS: ��at�
WN C T ON • �j ' " �iu,t. M��..f4- -=hc..
MANAGER'S NAME: �.. �� T . # �7� Gd�F�222
MAI IN . ADD F : '37� 'ue.- v� ac�e<, �-jft c%/�/c�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Poo] Operator(sl and attach a cogy nf the t�ertification to th�s forrn. .
1. 2,
Pool operators must list a minimum of two employees currenUy certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee cemfications 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 aze required to have at least one full-ttime 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' reeords.
You must provide new copies and maintain a file at your establishment.
1. 2.
- ER-S(JNZIV(;Hl�C7E: -----—- - -
. - _ ---- --__ _ - --- - -_ _ --- _ _
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 (east 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 REQU[RED FEE PERMIT H LICENSE REQUIRED P6E P6RMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S50 _CABIN S50 _MOTEL S50
_INN $50 _CAMP S50 _SWIMMMG POOL$75ea
_LODGE $50 _TRAILER PARK S50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICGNS&REQUIRGD FEE PBRMIT# LICENSE REQUIRED FEE PERMIT#
_0-IOOSEATS� S75 _CONTINENTAL S30 NON-PROFTT S25
>I00 SEATS 5150 � _COMMON VICT. S50 _WHOLESALE S75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE RBQUIRED FGE PERMIT tt LICENSE REQUIRED FEE PBRMIT#
�<SOsq.ft. $45 0�-Oc�JS _>25,OOOsq.ft. $200 _VBNDMG-POOD S20
_<25,000 sq.ft. S75 _FR07_EN DL'SSIiRT E35 _TOE3ACC0 $25
NAME�CH�N�F.� Sio AMOUN'I' DUE _ $ �''j,pp
*`«*'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 perrnit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE A7'TACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED V
Q$
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 annnally from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLiSHMENTS ARE TO CONTACT THE HEALTH D�PAR"IMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPEr1ING:All swima�ing,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
ON F.R VIGORY:
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 forrn 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
� Z .:�`33ES "ff'f : - - _ _ _ -
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.
OUT ID . FF`.4:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establistunent is prohibited.
DATE: 2,3 c SIGNATURE: ��. �� �
PRINT NAME& TITLE: ��hec,. �• �ufte— ,�ved',
10/22/03
. ' . �
• The Commonwealth ojMassachusetu
: Department ajlndustrial.-Iccidenrs
; omcea//eresaDsdais
- 600 Washington Slreel
' Bosron.Mass 01111
" "��' �ibrkers' Compensation lnsurance Affidavit
Analicant information: P►easePRINTTesGide
^
namc. .��iS�S l�lvW /7t�✓4�..��LZ� -�-�v�- .
Loc�tion� !� �v0�'-f� �Ct��� .S� .
crt. SJ• 7�.�"�'12„��X'LI / /lf d�'T ohonea iUk-7Lu /�d�d=
� I am a homecwner pen�rming all work myseif.
� I am a solz propriztor _r.d ha�e no one �.orkin� in any capacin�
�am an employer pro�idins workers' compensacion for my employees working on this job.
7 ��
comnan�� namr. �JS,ti� �`"l�/'L`� ����l�t-�r.
adAresr. � /Uv�'�`^ ��Y�, �' �
[ity: �D "4�i`��ho�.T�n. L' G/7- d ��� phoneM. J V(1 � "/�0 �cF7f�
insuranceco. �✓�tJ�w.f oolicy# �l��I" ��T/` V /S-� �U�
� I am a solz proprietor. general contractor, or homeowner(circle ond and hare hired the contractors listed below ��ho ha�e
the follo�cin_ «orker compensation polices:
comoanv namr. �
address:
cin�: phone p:
insurance co Dolie�•H
comoany �ame:
addres3•
tiN• ehoee M•
insurance co. eo6ev M
t
F�ilure ro accure covenge as requ�red under Seedoa SSA of MGL 151 u�Ind W the i�paidw of eri�ivl pndtle ot�O�e ap�o Sl¢00.00��d/or
ooe ynrs'imprisonment u w�ell n civil peedHee io t6e(orm ot�STOP WORK ORDER aed�6ee o(SI00.00�dry qdort mo 1 ndmhW N�t�
eopy of thy statement may be fonv�rded to the ORee of Inve�tfa�tiom of Me DIA for toven�e vMflatlw.
� /da�hrreby ce ' •under thr paint and prnaltirs ojperjury�hm�he injormation provided abovt is aue and correet
Signature � � � Z �
Print name � �- ��� one M 760 ���
.. olTicial use onl�� do not•rite in this arra ro be completed by cirypNorvn ollltial
ciry or town: y�ODT$ _ .permitAicceae N nBuildioe Departmmt
�Lietesio`Bo�rd
�cheek i(immediale response ie requirrd 261 ❑Selettmen'�Oflice
(508) 398�?231 p�t, �He�lt6 Depanment .
conroct person: pdone M;_ _ _ nOther
i1GOR._D„ CERTIFICATE OF LlABILITY INSURANCE uAIE(WNWIIY�
1 /23/04
• PnO�Ep TH18 CERTIFICAtE IS IS6UED AB A MATTEA OF INFOI7MA710N
JOhA F. Martin Insurance AQeIICy� II1C. ONLY AND CONFERS NO RKiHT3 UPONTIIE CEATIFICATE
1 O Z 3 ROUt2 Z 8� $OX 3 S O MOLUER.THIS CERTIFICATE UOES NOT AMEN6,EI(i END OIt
South Yarmouth, MA. 02669 JU.TEpTHECOitERA6EAPFOqIDEU9Y171EPOl.IC1ESBElOW.
508-398-2277 f FAX S 508-398-2239 INSUREf19 AFFORDING COVERAGE
1NSUqEO -.. .. . _.___ ..._.._. ...___...._.__. _ .
`___'_'_'""___"_..._.___...._.__. .
��€R�_Staveler's Property
Bass River Mercantile, Inc. ���&
2 North Main Street —` -"'-"""-
ttsimenc:
South Yatmouth, MA. 02664 --""'-'—"-�""' ` - '
n�stx�n u:
_ �-------__ ._
_
IN9Ui�l1 E: -
COYERA6ES . ,
11iF.POI.ICIFS OF INSUMPJCE IISTEO AELOW NAVE BEEN ISSUEb TO Tl1E tNSLM#ED NAMEb ABOVE FOR If IF POLICV PEfAp[I NJDICA�F11 NO!WI I I IS IANUING
M7Y R£WIf1EMENf,IERM ON GONURION OF ANY CONTRAC7 OR OTHER DOCUMENT WfTN RESPECT TO Wt11CFt TH13 CEFl71fiCAf F MAY F7F ISSUEU C.NI
MAV PER1qIN,111E MSINiANCE AFFORDEb BY Tf1E F'Ol,lGIES OESCRIBEO HEREIN IS SUBJECY TO AlL 7NE TERMS,EXCWSKNJS ANU CONIN7fUNS UF SUCIt
POlIC1E5.A(i6REGAIE LMII IS SIiOWk MAY HAYE 6EEN REDUCEO BY PAlO CLMMg,
.._._.____ _' _____�_'_' ._.._..""_.
Mi9R IYPEOipISNINICE YEfFFCT1Y6 ROIICYEl11'piR710N .-' . .
VOIICY NUMBFII LMWIS
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6RUB894X579-4-03 6(27/03 5J27J04 ELFM;IIACCN1ENt : 100, 000.
E.I,INSFNSE,.EM1EAiIYVfkE S rjQQ� �OQ.
.. . E.L.UISEA5E-I'OLICY 4Mtll f .
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r
CE�TIfICATEt10LDER �on�rorutiuuwceo.►�sua�nurran: CANCELlATION
. BNOlRO ANY Of iNE JIBCY@ DE9Cq�9E0 pOlIC7E9 9E C1INCELLEQ BEfO1iE 111E EXMIIh71011
Town Of YdrfiOUth �t�t���.mu�#��NBUflENWM.LEIKIERVOR70M�A �_Q OAYS WIIIIfEN
1146 ROute ZS MQTICf1QT11lCEf1TIfICAIElqLOEqNRMEOtOlOELEFf,BUlfNIIUNElolfo5flS11AU.
South YdY'm011th� MA. 62664 ��� �T�a+u�ekrtroc�Nr�rc�uww�n�er�sunen,�is,�ueNrsai
nernEean mae.
1W/ BENT iv4
ACORD 25•S(T197j
�ACORD COfIPORATION 1888
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #04-058 FEE: 45.00
In accordance with ce hons promulgated under autbority of Chapter 94,Section 305A and Chapter
111,Section 5 of the�eral Laws,a pemrit is heceby granted to:
Bass River Mercantile Inc., 2 North Main Sueet, South Yarmouth, MA
Whose place ofbusiness is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishmern in: Town of Yarmouth
Pemtit expires: December 31. 2004 BOARD OF I IFAI.TH: Berya�ei�a.�. 4o+ldoK, �$. '
P�t�:�4 M�, 9i:� ef�.�
Rode�at 4. BAow.i, elas�i
� sl.�. R.iY.
A.�.�lj�b�, R.N.
Mazch ]0.2004 ruce G. M�up , ,R.S., CHO
I}irector of He th
�'��9t� 1'TV �� B.K. MERCANTI.E .
�' YAR TOWN OF YARMOUTH BOARD O�.IIEALTH �- �
2 s � � p �2 "�O :
3 °c APPLICATION FOR L�(.-'ENS�/PERMIT-2003 " �°' ' � ��� �'=' � �
�C�? ��r � 2
* Please complete form and attach all nece'�sary�cumen'ts by Dece ber �2 p �002
Failure to do so will result in the ret`um of your application p k��qLTH DEPT.
T I � /-� 7rv-
S : o �f� �t'i- a.< O
DRESS• �
TI °
G ' o ' . #97�«` �
D •370 1ue.� o,reY l� �
POOL CERTIFICATIONS:
The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated
Pool Opectatar(s}�-attacha cogy ofxhe.certificarion to tlris fotm, _ . _
1. 2.
Pool operators must list a minimum of two employees currendy certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certificarions to this form. The He$lth Department will not use past years' recorda. You must
provide new copies and maintain a fde 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 Health Deparhnent will not use past years' records.
You must provide new copies and maintain 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 opera6on.
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-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMI'T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $50 CABIN $50 _MOTEL � $50
_INN $50 _CAMP $50 _SWIMMINGPOOLESOea.
_LODGE $50 _TRAILER PARK $50 _WHIRLPOOL �25ea
FsOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CON'I7NENTAL $30 _NON-PROFIT $25
_>]00SEATS $150 _COMMONVICT. S50 WHOLESALE $75
AETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_TOBACCO $20 _<25,000 sq.ft. $75 _TOBACCO $20
�<50 sq.ft. $45 �03�6�( _>25,000 sq.ft. 5200 _FROZEN DESSERT$35
�iAMECHANGE: $10 AMOUNTDUE = S �5.00
:..:.pLEASE TfJRN 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 C�ENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHEL� �
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarntouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES V/ NO
NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISHIv1ENTS 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 OPEHING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WAT'ER 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-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 DE�SERTS:
Frozen3esserts must be tested on a monthly basis�y a State certified lab. Test results musfbe serit to the Health
Department. Failure to do so will result in the suspension or revocation of yow Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
DATE: � �- °� SIGNATURE: � W
PRINT NAME & TITLE: f2et, �' J r�r.
10/18/02
, . �\
The Commonwealth ojMassachusetu
, = Depar�ment ojlndustria/,-fccidents
; Omceo//sresaosWis
600 Washington Street
' Boston. Mass 01111
` '� ,` �i'orkers' Compensation lnsurance Affidavit
Anolicant informa/Non: / � P► AseYRiNTTes.7dr
nam����L� !�{��'v 4 ( a�l/uwl�.
� . u� U ( -�'ie ���
• � cYa6ca �� d�o� a��/�d (�U
� I am a homecµner pzrforrtting all work myself.
� I am a sole proprietor �r.� ha�e no one norking in any capacih•
((�1'am an emQlover ro�idins workers' compensation for my empto}ees wodcing gn tt+is job.,- -
_
comnanv aame• �'S C�— � � �!� � - - � � - � - - - �- -
aJAress:2 �U' ' `� ��I(S �� �
iit�� �-�e!/!//itd U � ��—`�"T phene • � �00 <U a �.
insur�nce co. ( �4�'l.�S `V� �iz lT.(/z4�/.�f eolicy k � /�C.�� 0 � 7"�` ��s�— U Z
� I am a solz proprietor. general contractor, or homeowner(cirde one! and hace hired the contractors listed belou ��ho ha�e
the follo��in_ �corkzr ,ompensation polices:
companv name: �
address•
c�,y: ohone N:
insurance co. oolie�•#
cnmoanv name:
addrcs�-
� e�: ehoee M• � '
insuraneeto. eeRev�f� .
a
Failurc ro secure covenge u required under Secdoe ZSA of MGL IS2 u�Ind to ne ieporifio�of eridvl pndtla of�O�e ap m SI,500.00 a�d/or
oae ye�n'imprisonment u w�ell u eivii peadtln io the form of�STOP WORK ORDER��d a Il�e otf100.00�dry K�ion m��[��denu�d Mat a
eopy of thia sntement may be for.nrded to�he 011iee of Invotig�Gom of IEe DU for emerate veriflutlo�.
�. /da�hrreby certijy under the par and penaltier ojperjury that the injormotion provided above is aue and corrcd
I l
Signatu �. �''� r'Z le1-�.Z-`f�Z
Print name �i 0 one N J`�—�6a /��
., alTitial ust only do nat write in this area ro be eompleted by eity or imvv ollleial
ciry or rown: Y�M��TQ _ permiNiteex N nBuilding Departmm�
�Litee�io`Board
�theck if immrdiate responst if rcquired 261 �Seitetmen'f Olfiet
�Hedtb Dep�rtmmt �
connct person: pAonca:_ �508) 398�2231 eat. nOther
12/24/2002 13::8 508-398-2239 JOHN F MARTIN RE&INS PAGE 01
. ACOt�.U� C�RTIFICATE OF �.IABlUTY INSURANCE � zY'�4"1'�'�'"'
Jonn F'. Markln InBurance AgenCy, Ina. YFMBCEqT1FICATE1813SUEDA3AMA1TE11UFINfUhMAiION
7023 ROUC@ 28 BoX 350 ONLYANIICONFEOSNOIlIO11T9UPONYIIECE1tlIFlGn7E
r IIOIOER.TIN9 CEpnsICAtE[IUES HOT AMENb,E1t7ENU Vle
SOUYh Yarmouth, MA. 0266d A4TER7F�F COVE11Asi�AfFORUEU DY lllE PUUC�S UBLOW.
508-398-2277/FAX:S08-398-2239 �Nsunsna�Fvonallocovennue
MfUqt.0 � _ ......._. . . .. . . -....__ :_..�....._._......
. .._.... . . .
BasB R1ver MeicantilB� Inc_ �°A-���•----- � - �
2 North Main Street "'�'!x!'�"----�-�- .
south Yarmouth, MA. 02664 "�"�1°
__..__..._,..__._._._ . .
and 1200 Route 28, South Yarmouth, MA. -`�"-0i---
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CE(IllF�CATE NOI�ER ,�ow„oh�i„p,�p.w.,�u � CANCELU1T10►1
Town of Yarmouth �dxn�xranr�eweoeecmrtnra�setcexcEucuecrunc�i�rErrma��
Poard Of EI@alth a�a.ne�ea,nKrowYwww�ie,n��ExuE�va,�ornn 1 O__ ���rs .mi��er�
1196 Route 28 1b/1C�1O11qCFR11pt�IkIKKUlHNAME010tItr�Efl,WIIµ1mE101niSu5�4�U.
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-044 FEE: $45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General iaws,a permit is hereby ganted to:
Stephen Wolfe, 2 North Main Street, South Yarniouth, MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December _3_1_2003__sonitu oF�ni,'1'[-i: ?�. Zdlikac. (�aoa.xaK _
- - _ _ _ __ _ _ _ . D. C1e�rdaa. ��.�tea_
,� �. b��roaw�c. (�la�k
�attta6'�XCDr�arott
sf�e4«S R.?t.
January 23.2003 ruce G.Murphy, .5.,CHO
Director of Health
� .
^*' � (3. 2. ME2.cRN'Tltk'
` .� �� `,� ��,,,�TOWN OF YARMOUTH BOARD OF HEALTH
` ���jp �!/�(-p�PLICATION FOR LICENSE/PERMIT -2002
* Please complete form and attach all necessary documents by December 31, 2001. Failure 2¢_r�u qo�vi�l;�sult in
the return of your application packet.
AME E IS NT: /G TEL. # - Ga-
LOCATION ADDRESS: `� c> i �� ✓� � C�2G6g-'
G ADDRESS: �
C O U�i - ���i'�/7/LF
MANA ' NAME: o TEL. # 4 �' 222
LING ADD o ivGv O! o
POOL CERTIFI�ATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
�oo�rator(sj�dattach a copy ofthe certificarion to this form.
1. 2.
Pool operators must list a minunum of two employees cunently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION 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 Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON I1V CHARGE: "
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service estabiishments 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 FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWIMMING POOL$SOea
_LODGE $50 _TRAILERPARK $50 _WHIRLPOOL $25ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT tl
_0-100 SEATS S75 _CONTINENTAL S30 _NON-PROFIT $25
>100 SEATS 5150 COMMON VICT. $50 WHOLESALE $75
RF.TAII,SERVICE:
LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 � � _Q5,000 sq.ft. $75 _TOBACCO ' ;��$2B � �
I <50 sq.ft. S45 �0 a�OO.S ', _>25,000 sq.ft. ���5200�. _FROZEN DESSERT$35
�iAME CHANGE: S10 � - AMOUNT DUE _ $ �S.OO
**•**PLEASE Ti7RN OVER AND COMPLETE OTHER S[DE OF FORM••***
. ' :�
,
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of anylicQnse qr�permit to operate a business if a person or company does not have a Certificace of Worker's
Compensation Insurance. T�1E ATTACHED STATE WORKER'S COMPENSATION INSURANGE
AFFIDAyIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED '
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taaces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
__ _.._ __ ___._ _ YES NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'1'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISI-IMENTS ARE TO CONTACT Tf�HEALTH DEPARTMFNT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ES�'ABLISHMEN'f;�MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE R�T�OkTED TO AND APPR�OVED BY�'HE BOARD OF HEALTH PRIOR ,
TO COMMENCEMENT. I�ENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
- POOLS
POOL OPEI�IING: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 plata 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:
—
Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,preparaUon,or display of any food product by a retail or food service establishment is prohibited.
DATE: � U SIGNATURE:
PRINT NAME & TITLE: � ✓�i��, �
09/ll/O1
WQRKERS COMPENSAT'ION AND EMFLOYERS LIflB�LI7'Y INSLi�,:iL L POLICY
�� INFORMA'AYl)n i',�i,r
NCCI(o.M1u
- — -� -� � � Folic No.
10901 � � V �� L WC6-0932466
!. INSURED: F3ASS RiVER MERCANTILF. !*'C Renewal o(Polic No.
W C."��'2466A
The Insared,'Mailing address: ` �
2 NORTH MAIN STREET �:'�di���t:.1 ❑Parmership
SOUTH VARMOUI'H, MA 02664
�;�crpor .tl�r�or
Other workplaces not show�above: lu:•�a�rd's I.U. '!.;-).(if applicabte)
See WC W W oi F.E.I.N.#043459481
_ - _ Risk !D# -
2. PQLICY PERIOD: The policy period is from 06;27/2G'Y. '.0 06/27/20 2 I'< 01 A.M. Standard Time,
at thc �murcd's mailme address
3. COVERAGF.:
A. Workers Compensation Insurance: Fart(�ne of the policy applies to the N,'erkers Compensation l.a�a of the states
listed here: Massacbusetts
Q. Empluyers Liabitiry lnsurance: Part Two of the policy applies to�sork i�a each statc listed in item ?.A. Thc limits of our
liabflity under Part Two are: B�iily Injury by Accident$I OO.WO esch accident
Bodily Injury by Disea.se $5(�SM70 policy limit
i Bodily Injury by Disease $IOQ.(�0 cach employce
C. Other States Insurance: Part Three of the policy applie,to the states,i£any, listed here: SGF.GU207F.
� p: This policy includes these endorsements and sche:Iules sFe cu2o'a
i 4. PREMIUM: The premium for this policy wip be determined by our bNar.uals of Rules, Ciassifications, Rates and Rating
Plaos. All Information required below is sub�ect to venfic�tion and chan�c by audit.
Code Premium Basis Rate Per F:stimated Annual
Ctassifications No. TotalEstimated I $IOOof Premiam
AAnual Remuneration Remuneration
S1C Code : 651 Z
See W C 00 00 01
lf indicated F>eiow.intertn edjustments ofpremium remium for Increased Lirrits paR Two, if apri�c&nfe A
sAall bc made-- lotai rremium 3�, ��- . : �:^^^�^^^ Mr!e5canon
yi� , ,,_....._.
�'- � �"'� remium Modified to Reflect Expenence Mod. ot'
�Semiannually; � (luarterly; �Monthly
otal Estimateo Standard Premiam
romiuii� D�;caa�:;i uyYL'C�~I:
MA-DIA AssessmeM S21 � �xp�ense Cor.stant Ct�arge
t,� � �...:......va ern�:�: p.,,.,,ium
;�3inimum Premium �17i :�zonsit Premiur.: ���� Totai Estimated Annual Premium 5736
_. —�_ - _.,_ _
Name of Producer: 10HN F MARTIN INSURANCB AGENCY � ,F,����
''J��'�'� - 04l t 3/2001
Sen�icing O�ce� Smaii businnao Ui�;c:.-..e,-s �'o��++rersivned Bv .-�----�
TWO PARAGON WAY,FREEHOLD,N.J.0772R nothonmG Ret,��x�;:.,;,t Date
THIS INFORMATION PACE W17H THE WORKERS wmrBN�n7ia,�:,;� :,�,`.1PL01'FRS t.lAR[LITY INSURANCE POLICI'AND
EtiDOR5FMENTS,IF AVy,1SSUED TO FORM A PART THEREQF.�OMPLE7��;HF. ���TO'�E P�';��Y��RF.D POLICY.
COPYRICHT 1987.NATIO�IAL COUNCIL ON CO PFNSATFON I�SURA�ICE . �
aiocoi�eo.�.vern wceeeoe�w,
. _ . . . � . .. . . .. .. . _. . . . _ .. iMA-0EQI0�38 �.
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISIIMENT
PERMIT NLJMBER: #02-005 FEE: $45.00
In accordance with reQulations promulgated under authority of Chapter 94, Section 305A and
Chapter l 11,Section 3 of the General Laws,a pertnit is hereby granted to:
Stenhen Wolfe Pres. 2 Nnrth Main Street South Yarmouth_ MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 sauaze feet
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31_ 2002 BOARD OF HEALTH: �(ia�e¢:�. Zdlu(rex, ekaLrrxa+c
�ja.�:.�D. �m�C. �D., `U�ee
,�o�ert� �or�e, �P�k
P���
'�felea Slu�k. ,�?Z.
-G.v
March 1 ,2002 Bruce G.Murphy, ,R.S,CHO
Director of Health
� � , ;� . ass ��v� ME2ca�r��
, . �'i�, =`s""` G�3 [� C� [� � MCDD
TOWN OF YARMOUTH BO ' ,�AN O 9 ZOO�
APPLICATION FOR LICENS E ' �Ol
� HEALTH DEPT.
* Please complete form and attach all necessary documents by December 31, 2000. Fait in
the return of your application packet.
--------------------------------------------------------- ----------------------------------,.�-------------------- -
T • ICJC�L G+¢N7/LL� ShF 7����"
o �� �, o
o c� 6
0
' u�
MAILING ADDRESS: �7 n �v �r� O/�/O
------------------------------------------------------------------------___---------------------------------------------------
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as reyuired by new State law. Please list the
designated Pool Operator(s)and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minnnum 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 fde at your place of business.
1. 2.
3. 4.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich
Maneuver on the premises at ali times. Please list your employees trained in an6-choking procedures below and
attach copies of employee certifica6ons to this form. The Health Department wiil not use past years' records.
You must provide new copies and maintain a fde at your place of business.
L 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
---------____--------------------------_--�-- ------------�---------------------•--------_--------------_--------------
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
_B&B $50 _CABIN $50
_INN $50 _CAMP $50
_LODGE $50 _TRAILER PARK $50
_M01'EL $50 _SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE:
N01'E: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,t6e effective date for
food protection manager certification is October 1,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAI, $30
>100 SEATS $150 NON-PROFTT $25
_COMMON VICT. $50 _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I <50 sq.ft. $45 �f��Q _TOBACCO $20
_<25,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ �5 .�O
«'"•'pLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM*•*"'
!__ _. _ _
,� _ ,, `
� ADMINISTRATION
Ur�der:ChapiGr 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 mus be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
NOTICE:Pennits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTTNG, 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 whiripools which have been closed for the season must be inspected
by the Health Department,and the water tested for pseudomonas,total coliform and standard plate count by a State
cert�fied lab,prior to operung, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swuruning pool must be drained or covered within seven(7) days of
closing.
FOOD SERVICE
NFW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS•
The effeMive date for food protection manager certificarion is October 1, 2001. As stated in 105 CMR
590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protection
manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000.
The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement
of Consumer advisory,Food Code 3-603.11,wiil be implemented January 1,2001. Only establishments which sell
or serve ready-to-eat, raw or undercooked animal products aze required to have consumer advisories.
�ATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heatth Department by filing the
required Temporazy Food Service Applica6on form 72 hours priar 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 waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
OuWoor cooking,prepazation,or display of any food product by a retail or food service estab(ishment is prohibited.
DATE: /2�7-r��vo SIGNATURE: ` �lti/
PRINT NAME & TITLE: S� �s�c, L`—. �'✓� � �`�' T�
11/16/00
, . � n . r
The Commonweallh ojMassachusetls
: Deparlment ojlndust�ial.�lccidents
s o OlflCe 0//OY@SUy!/llft
600 Woshington Slreet
Boston, Mass. 02111
"•y`'y Wbrkers' Compensation Insurance Affidavit
�'��, �/l��;l�
i„ / A>O�^ / ` 'b�K V I
�•,,^^' � Y G r/Wco c.�/�'(/-f' d�T phone M J�6�-7�6���"
� I am a homeowner pzrforming al�work myself.
� I am a solz proprittor �cd hace no one ���orkine in any capacih�
(� I am an employer pro�idin� workers' compensation for my employees working on this job.
� e�, �laYr�
o an �
2 ,� ��� �
a dresr
. � d C�.�6f20v�/ / � � �"`�'��phonek• �l KT "/�o�-�(���
insur�nceco !QS�� k .LhS�v4k�e-- C�a oolicyk w �� � ��-32Y"�
� I am a sole proprietor. general contractor. or homeowner(circle anel and have hired the contractors lisced belou �cho hace
thz foilu�cin_ ��orkzr_' �ampensation polices:
m anv n m :
address•
citv phone q• -
insur�nce co Do�Y a
m n me:
. . ... . . _____._ .. .--- - . ._ _.
-�dres •
�. phoee M•
insuraneeco iL°rsCY�
Failure to secure coverage as required uoder Seetioo 25A of MGL 152 eae lad to the inpaitloa of trisiW pesaltln of�d�e op to f1�00.00 aW/ar
one ye�n'imprisonment a�w�ell aa civil penilHn io the form at�STOP WORK ORDER�ad�6ae o(5100.00�d�y q�iost me 1 a�dent��d��t■
eopy of thia sOtement may be(orwarded to the ORiee of InveaNgatiam of the DIA for rnvenge verilfe�aw.
1 do hrreby ce ' •under the pain nd pe lties ojperjury tha�1he injormalian providtd abovt is dut md corrcd
Signaturc � � �T��6
�l l �^--• /
Printname O°�M �,v�_�v �^/
., official use onh� do not w rite in this arra m be completed by tih or lown oflftial
- eiry or rown: YARMODTQ _ permiMicenu p nBuildioe Departmtot
� �LIC[OSIOg BO��d
p eheck if immediate response ie required 261 ❑Selectmen'�Ofllee
�H-aleh Dep�nment
contac�person: phone M:_ �SOS� 398-2.231 eat. nOther
UnnM b95 P1A1
� `WditKERS COMPEb'SA'1'30N A.'vD EA�IPIAl'ERS LL4BIL1'!'Y INSORANCE POLIC4'
�� INFORMATION PAGE �
'"`�"� "' L E G ! � N
ia9�a :vc>:^�aa��, � q
�
1, 1NSURLD: frASS R€VER MERCRNTILB 3NC Reeew�el of Po1ie Plo.
NEW -�]
T'ne Insured/hdailing uddcess:
2 TdORTN bL�IN STRFiE"f �lrtdiridual �Pum�.ash�p
SOLJTH YARMOUTH,MA G3G64
�X Coryoraaan cr
pUur wockplaas nar showv above: tns�ed's I.D.No(s}.(sf nppliaablej
See`WC 00 09 61 F.E.IN.#043457481 �
Rzak ILbt -
2. POLICY PERIOD: The poiicy period is from O6/27/2900 to 66/Z712001 l2:(%! A.T4. Sz^rndanj Ti:ne � �+y
at tlie Ins�ued's mailing_��.,._.�..
:S.~COVERAGE: -. .._._.� ___.� __._.��.._.
.4. Workers Compensation Ins�irance.Part One nf the policy applies to the Workers Compensati;m Law o:the stst::s
lis,ed here: Massachusetts
B. Employeas Liability Insurance:Purt Two of the pulicY upPlies to work sn each state listed in itert;3..4 The.iunits cf our
liabiliry under Fart Two are: �otSily lnjmy by Accidenr Sl�J0,000 each accidrnt
�odily Injury by I?iseas�e f500,OW poticy limit
Hwlily lnjury by Disease 5100,000 each employee
C. Other States Ir.scrar.ce:Fart Thrc�e of d�e poli�v apgties�o:he states.if atty,listed her��� �£E GU2(}7E
D:This pnlicy incb�des these endorsements and schedulcxs_Se�GuzOtn
d. PRE1HIl?M: The premium for this polic�•wi11 be detertnined by ow Manuals of Rulas,C7assifications,Rates nnd�tating
Plans. All Information re uirod below is subject W veri6r.afion and c e by auld�
Code Premium Basis ltatc Yer � Estimated Armusl
Classifica�ons �Io. Total Estimated S'Oli oi Fr+smi�m
� _�_ � �ua{A�nunu��atio, RamuneTation
SIC Cilde: 65}.2
� . ._. .. ._ �x"d'L36__"'vtiir5 - � - �— . _ . . __ . _i . ..
1
�
� .__ .�__.�. __ .a,_. _�=. a,Y. .._. . _.,. .__,. __���.�....._
If indicated below,intetm adjustrnents of premium remium for lncreased Limita pact Twa,If applicable
shal!be made- �tal Premium Subject to the Experience Modification �
remiam Modi6ed ro Refte:t Experience Mod.of
❑Semisnnually; � Quarterly; ❑MomFily
dal Estimated Standard Ptemium
diun Discount,if applicable
MA-DLA Assasszsient ,t2', tnse Constant Charge „
ofsi f.stimated Annual Pre�tuum �
�
:Ninimum Premiwn SS72 �l�[)eposit Premium S",36 Total Estim�ted Annuai Premoum_ �3736
Name of Producer: IOHN F MART'IN INSUTtANCb AGENCY _�`��_
Servicing Ofiico: Sma11 Buau�ess Uaderw:iters C:auntersignW By �
�_ 'TWO PARAGUA(�YAY FREEHOLD TI.1.�7728 Auth«ized Repmsc�wiae uate
TIt1S 1NROR�1'tAT1fIN YAf.F.WiTH 7HF.N'ARKRPS 1'Y)MPF�NSATi61Y AND F.MPI.bYl!RR I.IABILTI'Y INRIiqANfF.MIJf7V AVD
ENDURSEMF.NTS.1F ANl".ISBUED TO FORM A pAY1T]'HEREUF.COMPLETES TIIZ ABOYE NUMBER@^�!F[.IIC1f.
COPYRiCN7 1487.NATIU�IAL COUNCIL ON CORIPENSATION IN5URANCE
BIOWI:FA.�-4)M.II WCtlYdYYI A,
!n1l.STf�}III98
`:*'
:�,
:'�
�� TOWN OF YARMO[JTH
,�
PERMTT TO OPERATE A F OD STABLISHMENT
PERMIT NiII�IgER: # 1-050
; In accordance with reg�]ations promulgated under authority of Chapter 94,Secti nE305A y�d 00
< Chapter 111, g��on 5 of the General I,aW,s�a per���s hereby gren��to:
: Whose p]ace of business is: B Riv r Merc i1e
�,
Type of business: Ret '1 Food rvic 1 s than 5 s
To operate a food establishment in: To�ofi, feet
���. h
C�' Permit expires: D��emi�er 31 nni
�" �� BOAItD OF HEALTH: �� �1�.
{ L� �i�, x�'racL��avr�a�
`. �o�it`� �rotvic, �,�
�'e�ja�r�c D. �Co,d,�. �Z.D.
Mar�h ,2001 �.tc.u�,
Bruce G. Murphy, MP , R.F , CHO
Director of Health
�.�> fZr�.��' Nte rr���ti i�
� ? TOWN OF YARMOUTH BOARD OF HEALTH �, p � � �� � �''� C= °
' APPLICATTON FOR LICENSE/PERMIT-2000 ��'1��/ �p N 0 3 20�0
� C�v��
' Please complete form and attach all necessary documents by December 31, 1999. Falure to do`so will tesd�£:i�i T� I
the return of your application packet.
----------------------------------------- ------- _�T_____ _._- � -------- �----------------------�y-�-- --
NA.� OF ESTABLISHMENT P3�A'� �I V�� M����7I.L�TEL # �C�� "-IO ��
LOCATION ADDRESS: ov�f� lyci rir . G�'r+* ��6�
D '
0
R' # 2
D d Ou� U 6
__------------------------------------------------------------------------------_---------------.
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to tlus 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 DeparGment will not use past years' records. You must provide
new copies and maintaia a file at your place of business.
l. 2.
3. 4.
HEIMI.ICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a fde at your place of business.
1. 2.
3. 4.
RESTAURANl' SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# -
-----------------------------------------------------------------------------------------------------------__.
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50
_INN $50 _CAMP $50
LODGE $50 TRAILER PARK $50
MOTEL $50 SWIMMING POOL $SOea.
_WHIRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERMIT # LICENSE REQU]RED FEE PERMIT #
0-100 SEATS $75 CONTIlVENTAL $30
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAII. SERVICE:
LICENSE REQUIItED FEE PERMIT # LICENSE REQLTIRED FEE PERMIT#
I <50 sq.ft. $45 Zy K_5o _TOBACCO $20
_<25,000 sq.ft. $75 FROZEN DESSERT $35
_>25,000 sq.ft. $200
N,4ME CHANGE: $10
AMOUNT DUE _ $ �—
"••'•pLEASE TUR1V OVER AND COMPLETE OTfIER SIDE OF FORM••••"
V�
� .
ADMINISTRATION
iTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQi}TREA�
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 COMI'. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES �NS MCTST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERNIITS. PLEASE CHECK PROPRIATELY IF PAID:
YES � NO
NOTICE: PERMITS RUN ANNUALLY FROM JANLJARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENII�TG FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOT'EL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE�tEPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWIMNIING, WADING AND WHIRI,POOLS WHICH HAVE BEEN CLOSED FOR
THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND TI-IE WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPEIVING, AND QUARTERLY Tf�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIv1A�IING POOL MUST BE DRAINED OR COVERED
WITHIN SEVEN(7)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH
DEPARTMENT BY FILING THE REQUIItED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TEIE CATERED EVENT. TI-�SE FORMS CAN BE OBTAINED AT 'I'I� HEALTH
DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN Tf�
SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE
BEEN MET.
-- — — — —
OUTSIDE CAFES:
OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), M[JST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
OiITDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISfIMENT IS PROHIBITED.
DATE: I2 Z � � SIGNATURE: ���
PRINT NAME& TITLE: �'� OIJLte✓
11/12/99
, , �
The Commonwea/th ojMassachusetis
. = = Department ojlndustrial.-Iccidenrs
; Of/Iceo//srestl�sdiis
600 Washington Street
Bostort, Mass. 01111
� v� ', W'orkers' Compensation Insurance Affidavit
Annlicant information: pl +�. �
namcr � �1U�. ��".�.C�J7<�
�� ` �`��� ��<� .�
��U �C�v.�, �. �� UZ� , �,/��
ut� � phone p � ��C.-���/
� 1 am a homeoµner pzrt�rming all work myself.
� I am a solz proprietor ar.,', ha�z no one «orking in am capacin•
� I am an employer pro�idino µorkers' compensation for my employees working on this jab.
c2mnanv name:
aJAress:
sitr ehon
�suronce co. policv p
� I am a solz proprietor, general contractar, or homeowner(circle onU and have hired the contractars lisred below ��ho ha�e
the follo�cing ��orker compensation polices:
comoanv name:
address•
��n�� phene q•
insurancc ro. nolie�•#
iomoanv name:
tddrsss:
�': �hoee M•
insuranee eo. po��*
t
F�ilure ro sceure covenee a�requircd uuder Secnoo 25A of MGL 153 n�Ind to t6e iepaiao�of crisiW pndtln of���e op�o SI�00.00��d/or
oae yan'imprisonmen�aa w�ell n civil prndtlee io tAe form of�STOP WORK ORDER�ad�6ae ot3100.00�dar q�iart m� I a�denu�d Hat a
eopy of tAb sntement m�r be fonwrded to the Oliite of Inve�tlg�tiom of Me DIA tor eovm�e verilkado�.
/do�hrreby ceni •under rhr pains an pmaf�ier ajpe�jury thm�ht injorrnatiort providtd abovt is tnre and enrie�
Signaturc �� ����j
Print name i — ad—�- one N �V���GG l�`� �
.. oRci�l use anl�� do not+.rite in�Ais aro ro be completed by eiry w tmro ofll[ial
ciry or town: Y�M��T$ _ � permiNiceaee M n8uildiog Depanmea�
� �Liemsiog Bo�rd
Q check if immediate response if required 261 �Selectmen'�ORee
(508 3 ❑HedtO Dep�rtmeat
contact person: phonr M;_ __� 98-2231 eEt. nOther
/
TOWN OF YARMOUTH
' BOARD OF HEALTH
� PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-50 FEE: $45.00
In accordance with regulations promulgated under au[horiTy of Chapter 94,Section 305A and Chapter
111, Section 5 of the General Laws,a pertnit is hereby granted to:
Stephen Wolfe, 2 North Main Street, South Yarmouth, MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yannouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�d �/. .�etta�g, C'�a[�irmq�ann / /J/
�Noa/n�c 7�/u�llivan�nKa.///.� Vica l,hairma
Koberf Jg .�O�irowgn� l.(erk
a6rialle Ja�oU�y-✓�oope:l
;� l0o('a,��ln
Ianuarv 27 ,200o ruce G. Murphy, M .S., CHO
Director of Health
---••-• •'•"•�� �' �+n ���a���auai , pannership, association or other legal entiry, employing emplo}ees.cHoaever the
u��ner of a d��ellin�_ liouse ha�ing not more than three apartments and who resides therein. or the occupant of the
d��ellin: house c.f anotlier..ho emplo�s persons to do maintenance , construction or rcpair work on such dwellin¢ house
or ��n �he cr.�wid; �r building appunen�n� thereto shall nut because of such emplocment be deemed to be an emplo}er
�1GL �hapter I:= ;«��,,i� _: al;�, ;���es thu e�en state or local licensing agency shall w�ithhold the issuance or
rene�cal o(a license or permit to operate a business or to construct buildings in the commonwealth !or anc
applicant a ho has not produced accrp[able e��idence of compiiance with the insurance coverrge required.
.�dditiunalh, neither the common��ealth nor am of its political subdi�isions shall enter into an}•contract for the
performance of public ��ork until acceptable e�•idence of compliance with the insurance requircments of this chapter ha�e
hc�n preseneed to the con[rac[in= �uthurin.
Appli�.:nts .
Please till in the �vorkers' compensation affida�it completely, by checking the box that applies to}•our situation and
suppl�in�_ compan. names. address and phone numbers as all affidavits ma�• be submitted to the Department of
Induscrial ,�ccidents for contirmation of insurance coverage. Also be sure to sign and date t6e altidacit The
aftida�it should be recurned to thz cit} or town that the application for the permit or license is being rcquested.
not the Dep�rnnent of Industrial .�ecidents. Should cou ha�•e any questions rcgardin¢the `9aw"or if you arc required
to ohtain a «orkers' compensation polic�, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The De
the affidavit for you to fill out in the event the Office of investigations has to coetacc Pro��ded a space at the bottom of
be sure to fill in the permidlicense number which wiil be used u a rcf�n.,,.. .,.,..,�_ ,,,_ _�,__ ..
Yaa rogarding the appiicaat Pleue
�ti. n..,,.....__. �-. _ . — � -- .
(pe�vouS�y 19„ C��Q4 r�c�2cAr11'n�>
` � TOWN OF YARMOiJTH $OARD OF HEALTH p � � � � b � �
APPLICATION FOR LICENSE /PERMIT — 199�, FE B 0 4 1999
` ` HEALTH DEPT.
* Please Complete fotm and attach all necessary docwnents by D�ett 31; 1997. Feilure to�
so will result in the return of your application packet.
---------------- -----------
-- ---------` -------
N F - --------rs�.o-----T; �----DZGG
.2 1` 24Ce,.Hti� ----'�--..�'-'�_�._.._
c..
S 6 f r /ue✓ � �
�
: r - �
' � c:�j
�
M___�._�w_______._________._ �u�naNs
POOL/�.C��RRTIFICAT�I:O�NS: �����"��-��-""�"""" coa��//p ��,���/j1 �
P3�;iJFiviGililS LT1UJ� YJL P{r�{IIIIIUIII O�YWO i0 �M I�`!G l I�"'_I N:
eDl� }'CCS CUTfOtlthj+CCIhr1Cd IQ�0S1C WRtt7$SfCtY� � ��{�{'+
�r�a�a s� �a�,a e:,:esir:unity:,�sdia,�ul...:�;ja,y:'.ese�:Naft�m;Cd'Itl.Please list these 358
employees below and attach copies ofemployce certiScations to this form. The Heskh X��
Department will not use past yesrs records, you muat provlde new copies aad msintain a
fik at your piace of bosinesa.
1. 2.
3. 4.
I�Fi�I,ICH CERTIFI ATION •
All food service establishments with 25 seats or more must have at least one employee trained in
the Heimlich Maneuver on the premises at all times. Please list your ewpbyeees trained ia ant;_
choking procedures below and attach copies of empioyee certifications to this form. T6e Health
Department will not use past yeara recorda Yon must provide aew copies and maintxin a
file at your place of business.
1. 2.
3. 4.
RESAURt1NT SEATING: TOTAL # NON SMOKING SEATS: TOTAL#
- -----------------------------------...__...__-�-__--------------
OFFI I . ONLY
LODGING:
LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT#
_B&B $50 ,_.CABIN $50
_INN $50 �CAMP SSQ .
_ LODGE $SO _TRAILER PARK �50
_MOTEL $50 _SWIM POOL $SOea
' _WHIRLPOOL $25ea.
FOOD �.RVI .
LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT#
_0-10(!SEATS $75 _CONTINENTAL S30
_>100 SEATS $150 . _NON-PROFIT S25
_COM. VICT. $50 _,WHOLESALE S75
BF�T�Ii�
SEBYL�E:
�•��8t1--. - FEE PERMIT# LIC. REQLTIRED � FEE PERMIT#
'��50 sq. ft� S45 �t-S?v _TOBACCO S20
_<25,000 sq, ft`.� S75 _,FROZ. DESSERT S35
_>25,000 sq. ft. $200
AMOUNT DUE _ `/s�
. . ADMINISTRATION • .
UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS
NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT
TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A
CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. TIiE ATTACHED
STATE WORKER'S COMPENSATION INSIIRANCE AFP'IDAVIT MUST BE
COMPLETED AND SIGNED.
TOWN OF YARMOUTH TA7�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR
ISSUANCE OF YC?UR PEItMITS. �GEASE CHECK APPROPRIATELY IF PAID:
YES ✓ NO
NOTICE: PERMITS RLJN�NN[JALLY FROM JANtJARY 1 TO DECEMBER 31. IT LS
YOUR RESPONSIBILITY TO RBTURN TI�COMPLETED APPLICATION(S)AND
REQUIRED FEE(S) $Y DECEMBER 31, 1997
SEASONAL ESTABLISHMENTS ARF T!� rn�'F,q,�T;'d�;�P.;,;fd��AR'I'Iv1�N"P Fa7R
INSPECTION 7-10 DAXS PRIOR TO OPENING FOR THE SEASON. ' �
ALL RENOVATIONS TO ANY FOOD ESTABLI3HMENT, MOTEL OR POOL (ie. ,
PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APl'ROVED BY
THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY
REQUIRE A SITE PLAN.
�
�
,epDITIONtLi. I�F.(iLn.ATIONS �
POOLS
POOL OPENING: ALL SWIMMIN(3, WADINCi AND WI�IIRLPOOLS WHICH HAVE BEEN
CLOSED FOR'I'I� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,
AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO
OPEIVING.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvffNG POOL MUST BE
yp,�,*;�rc�n r�_u.rn�rF�t.��vY1�IIN SEYEN(7) DAYS OF CLOSING.
FOOD SERVICE
('ATERNG POLICY:
ANYONE WHO CATERS WITEIIN THE TOWN OF YARMOUTH MUST NOTIFY TF�
YARMOUTH HEALTH DEPARTMENT BY FILING 'I'HE REQUIRED TEMI'ORARY
FOOD SERVICE APPLICATION FORM 72 HOUR3 PRIOR TO THE CATERED EVENT.
THESE FORMS CAN BE OBTAINED AT T'HE-HEALTH DEPARTMENT. �
FROZEN D���_F_.�TS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE
CERTIFIED LAB. TEST RESULTS MUST BE SENT TO 'I'f�HEALTH DEPAR'TIVIENT. �
FAILURE TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR
FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET.
Oi ITSIDE CAFES:
OUTSIDE CAFES (ie. , OUTDOOR SEATING WITH WAITFR/WAITRESS SERVICE),
�,T HAVE PRIOR APPROVAL FROM Tt�BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR C�O�+Oc�KING, PREPARAT♦IpON, OR DISPLAY OF ANY FOOD PRODUCT BY A
10E 1 A1L�f V VIB '�JG��1�1�L LS�Tt117LiSi$�ua'�,�`r'i�'�'::.�.ur�IIT..'�'.B. -� � �
DATE: ����55 SIGNATURE:� � �
PRINT NAME&TITLE:St�""`� �, ����— `'�"�`�'
10/97
page 2 of 2
. . �\
The Commonwealth ojMassac/rusetu
3 � Department ojlndustria/.4ccidenu
; Omeea/IerasUostliis
600 Washington Slreet
Bosmn, blass. 02111
wbrkers' Compensation lnsurance Aftidavit
(��'y;�>� p/�� � �J � / /��y'.. �/` /A
namc� F✓� 1� i(�✓' /,'�✓'�N`///� ) /�� .� c'l/�-� �4�hr�r.-
�on: �1/'c� i�/t1 � CG�i�h �1/i . ��' /�iUG'✓ /�✓�
. , 4��� �Z�G G►d�'�, ���/� c�7� - ��-��2z
� I ^m a homeowner enorming all work myself.
[� � am a sole proprittor ar.d ha�z no one ��orkine in am capacin•
�am an emplo�er pro�iding uorkers' compensacion for my employees w�orking on this job.0 UP��- �u�'�`�d o�'���
�a��a,, �.��: i3s,s R;� ���-����
JAr c : O1�'([�I C't�ls � �
� 'v'dyyyi
. 'D (jE Q� U�' t 4� U /l� O
ranee '�+ Si #
I am sole propriet . general eontractor. or homeowner(eircle onel and hace hired the contractors listed below «ho ha�e
the follo�cin_�corkzr compensation polices:
comQanv name• �
addrcs�•
��• � ohone M• _
incn��nce co pelier#
eomoanv name• �
addrces
�v: ehoee N•
ineu�nn�w rn pp�N*
e
F�ilure to sceure cover�Yt�a required under Seetloo 2SA of MGL 153 u�lad lo the iepaitlw olerisi�tl pnaltlef of�O�e ap ro SI�00.00��d/or
ooe yein'imprisoemeet a�w�dl u eivil peedHa io tAe form o(a STOP WORK ORDER a�d�Il�e of S100A0�dq qdo�t s� 1��denn�d ehat a
mpy of thy sutemeet mw De fonv+rded ro tbe ORiee of lavatlq�tlom otthe DIA fx eoven�e vMtiatlo�.
I do hrreby ce 'p under rhe pain and p Uies ojperjury rhm�he injornufion providtd abewr is bue md rnrrca
Signaturc G ��/�y
Print name � one M � /t�"'�t7H �b�2 Z
.- oR�i�l use onl�� do no�.rite in this area to be completed by eiq or tova ollltial
eity or town• Y�M�DTR _ � .permiNiteeu N nBuiidiog Departmeot
. . �Liernsiog Board
�cheek if immediate response ie required 261 OSeleetmen'e Offitt
. �HuItA Dep�rtmmt .
contact penon: phone M:_ �508� 398�?231 est. nOtAer
' .,. .m. ..v���
'
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NLTMBER: 99-56 FEE: $45.00
. In accordance with regula[ions promulgated under authority of Chapter 94,Section 305A and
. Chapter 111,Section�of the General Laws,a peimit is hereby ganted to: .
Stenhen Wolfe 2 North Main Street So � h Yarmrnrth MA
Whose place of business is: Bass River Mercantile
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yazmouth
Pernut expires: December 31 1999 BOARD OF HEALTH:�d�n/. �et�ap�, C�a/�M„/J��z � / /�
/(/�ooan C��.'�7 /u�llivan�/K7/J.//.� Vice l,�irrrusa
. /Co�er[��p},[p,�rowpn/� („Le/r/�
�� - ��/./�a//�rie[[ep�Ja�noG�hr�-�/dooPee
. ///ic l�oCou9�i
� L
Febmatv 24 , 19 99 B[uce G. Mtuphy,➢IP .5.,CHO
Director of Health
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