HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 � ~ � C�S
^� � TOWN OF YARMOUTH BOARD OF HE� N �� G 'z i, , � �u
�� APPLICATION FOR LICENSE/PERMIT=����� , � '� NO V 1 4 2008
~� * Please complete form and attach all necessary documeiits by�7ecember S 008.
Failure to do so will result in the return ofyow applicaUon packet. TH DEPT.
NAME OF ESTABLISHMENT:,�,[G��R,'S CFiCkfYyE �76R,� TEL. # .�GS 77S'G�/�
LOCATIONADDRESS: `rJ,� �d�17;�
MAILING ADDRESS:__ �SA.�E
OWNER NAME: f:NEp VL M� CA/2�/� TAX ID (FEIN or SSNI:
CORFORATION N_�IF APPLICABLE): [..lGf/�' SPI�� x� .
MANAGER'S NAME: CflEif.+�/L M�CA2.rEEN TEL. # b/7 g'/G / 6S
MAILING ADDRESS: 3/ �OLL� FlSk LAN� 'J76Niu1SL'd�7' Mq /1�39
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees cun•ently certified in basic water safety,standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a Gle at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service estabiishments 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 Heaith 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 establishmeut must have at least one Person In Chazge (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 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.
l. 2,
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGIVG:
LICENSE REQUIRED FEE PERMI"I# LICENSE REQUIRED FEE PERMI'I# LICENSE REQUIRED FEE PERNIII'�
_B&B 555 CABIN S55 MOTEL S55
_INN S5� CAMP S55 SR'QvIIvIINGPOOL 580ea.
_LODGE S55 _'IRAII.ERPARK 5105 WHIItI,POOL S80ea �
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIr# LICENSE REQUIItED FEE PERMII# LICENSE REQUIREb FEE PERMI?#
_0-100 SEA?S S85 _CONIINENI'AL S35 NON-PROFIT S30
_>100 SEATS SI60 _COMMON VIC. 560 WHOLESALE S80
RETAIL SER�7CE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERMII'€f LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT#
� <SOsq.B. S50 �0�!-t,v-� _>25,OOOsq.ft. 5225� VENDING-FOOD S25
_<z5,000 sq.ft. 580 _FROZEN DESSERT 340 LI'OBACCO 555 G(T-GY�
VA'1-IE CHArGE: S10 AMOIINT DLTE _ $ /d S.QO
�**"'PLEASE TLRV OVER AtiD CO.'VIPLETE OTHER SIDE OF FOR�1**•"'
�. . , s
ADMIlVISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STAT'E WORKER'S COMPENSATION INSURANCE
AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED "
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemrits. PLEASE CHECK
APPROPRIATELY IF PAID: , /
YES ✓ NO
MOTELS AND OTHER LODGING ESTABLISffiVIENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use, Transient occupancy shall be
limited to the temporary and short te�m occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any s'vc(6)month period. Use of a guest unit as a residence or
dwelling unit 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 CNIR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days
pnor to opening. PLEASE NOT'E: People are NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WA'I'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 gound 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 Yazmouth Health Deparhnent by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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 cooldng,prepazarion,or display of any food product by a retail or food service establishmem is prohibited.
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBIL.TI'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
� �C2'��
DATE: %/ 2 Sl SIGNATURE: � � �
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PRINT NAME&TITLE: �i � L- � C' �E � c/1>E�
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_ 11/4/2008 2:07:14 PM First Cardinal LLC. CC-Incoming£ax Page 2
CERTIFICATE OF LIABILITY INSURANCE °"ii�""'o ioe
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Wm F 8odwk Inwance A�enqr NEORMATION ONLY ANO COMFER6 t�RIGHTS UPON THE
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� ��
TOWN OF YARMOiJTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-009 FEE: $50.00
In accordance wit6 ce�u1ations promulgated under au[hority of Chapter 94,Section 305A and Chapter
111,Section 5 oft6e�'ieneral Laws,a permi[is hereby granted ro:
Twilig6t Spirits Inc., 55 Route 28, West Yarmouth, MA
Whose place of business is: Becke�'s Packatte Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31 2009 BOARD OF HEALTH: .�fefen.S��,�J,2,..aN- ., �afXntaet
�f�¢e .�. Ji.�l[l�PJIG, �lCe ��,�A'l�X/ItQ/t
a�s r�ucnox:M;�,iw�e,���gea�t,;�,�. `.Radext `3. `.,8�rouerc, '(,Pxx1E
Qen 'C�reen6aurn, J`Z..N.
F.i�ly�e �• .?Ea�eo
November 19.2008 B ce .Mu[p y,MP , ,
Director of Health
THE COMMONWEALTII OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #09-005 FEE: $55.00
ThiS�s to Cenify rhac Twili�pirits Inc. d/b/a Becker's Package Store
55 Route 28_ West YarmoutlL MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBAC('(� PRODi JCTS
AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
1'his�er�it ie�ant�i��for��'t�y with Article VI of the San����y Code of Ihe Commonwealth of Massachusetts,end
exp es ec er ssoonersuspended orrevoked.
November 19.2008 BOARD OF HEALTH: .`�¢e¢ft S�� ✓�..lV.� �p[MIItaK
C'Rn�cf¢0 .�f. .7Cellihe�, `UieR '(.hai�►tan
.%tal�rt 3.�f2Kow�c, ('lr�
Q�er�(�'xeendfauin, 52.N.
£�rdyn. �• .�fCu{eo
ruce . MuTP Y, � ,
Director of Health
1
� t3FCKeI"zS
V°` Y�s TOWN OF YARMOUTH BOARD OF HEALTH
r��y-5 APPLICATION FOR LICENSE/PERMTl'- 2�8 _�,�}�b��;
. r � (J��''� y� ,�OV 1 4 2u�i
* Please complete form and attach all necessary docuttt�nts by Decemb�er 31, 2007.
Failure to do so will result in the retum of yo�application packet.
NAME OF ESTABLISHMENT: ���,�£R 'S �''ii'C,�Afy� �7'Q�� TEL;#,j0,� '77S—OG ! I
LOCATIONADDRESS: �<; ,2y" � u' �,,��r�- 7�/,qR_nn�v
MAILING ADDRESS:
OWNERNAME:�'�/.�k,�/L� LYi�INSOP M�CA�R.� TAXID (FFINor 4�I1 �
CORPORATION NAME (IF APPLICABLE): � �G NT Sp/i2,i tN L
MANAGER'S NAME: � �� TEL. #�p� ��S Ob I I
MAILING ADDRESS:sSs 7� a-S'
POOL CERTIFICATIONS:
The pool supervisor must be certiTied as a Pool Operator,as required by State law. Please Gst the desienated
Pool Operator(s) and attach a copy of the certification to tlus form.
1. Z
Pool operators must list a minimum of two employees currently cenified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
eertifications to this form. T#�e Health Department will not use past years' reeords. You must provide new�
copies and maintain a file at your place of business.
L 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTffICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. 'fhe Health Department wi}l not use past years'records.
You must provide new copies and maintain a file at your establishment.
I. 2
PERS9N_IN CIIARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during houis of operation.
1. z
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 tnnes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQl11RED FEE PER'�9I # LICENSE REQL'IRED FEE PER�ll7 s LICENSE REQL'IRED FEE PER�IIT=
_B&B S50 _CABIN SSO M07EL S50
_INN 550 _CA.'�fP t Si0 Slk1YL4IING POOL S"ISea.
�"��,,"" _
_LODGE S5� _IRAILERP.�RE 5100 _RT-IIRLPOOL S75ea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT r� LICENSE REQL , D FEE PERI4IT s LICEtiSE REQtiIRED FEE PER�fIT=
_0.100 SEATS S75 _CONTINENTAL S?0 _NON-pROFIT 52i
_>100SEATS 5150 _CO:�L4IONVIC. S50 _R'HOLESALE 57i
RETAIL SERVICE: —RESID.KITCHE?� S7�
LICENSE REQUIRED FEE PERMlI= LICENSE REQL7RED FEE PER�III'= LICENSE REQC7RED FEE PER4f17-
/ <50 sq.tt. S45 �OS'OOa _>35.00D Sq.B. 5200 _�'ENDING-FOOD 520
_<25,OOOsq.N. S75 _FROZENDESSERT S35 �10BqCC0 S50 09
va�cxa_vcE: sto AMOUNT DUE _ $ 95,o�
"":"pLEASE TLRY OF'ER A\D CO\IPLE'IE OTFIER SIDE OF FORJi*^•'*
._.
-' -�
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transiem occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined io M.G.L. c. 64G or 830 CMK 64G, as amended, shall generally be considered Transient.
* NOTE: Er,�tosed Motel Census must be completed and returned.u;tn tn�s aPPu�at�on.
POOLS
POOL OPENING: All swimming,wading and whidpools which have been closed for the season must be ins ected
by the Health Department prior to opemng. Contact the Heakh Department to schedule the inspection five(�days
prior to opening.
POOL WA'TEHTESTING: 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 Depardnern by filing the re�uired
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Departmeni.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heakh
Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Pemtit urnil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior apprwalfromtheBoard ofHeahh.
OUTDOOR COOKING:
, . . . . .
-9ntdeer� ; . —
N01TCE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI-IE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MO'TEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), M[IST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEME�IT. REVOVATIO'_VS MAY REQUIRE A SITE PLAV.
DATE: I�I J �l�� SIGNATURE: � �L/�i'I/L//d'L—
PRI:VT:�1Ab4E&TITLE: � � 2 � /�SiJ�nJ T
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°`:r""o TOWN OF YARMOUTH BOARD OF�EAI.TH � � � � � � � � �°
�� ' -;s APPLICAI'ION FOR LICENSE/FERMIT-.20Qti'77�,�qs N 0 V 2 2 2006
�`�, * Please complete form and attach all necessary documents by Decembe 3��,�QE�:H DEPT.
Failure to do so will result in the return of your application pack .
NAME OF ESTABLISHI�fENT:B�",r�CE�,'S DRC+E?4GG�' c�'TORE TEL. #�O� 77S—D(o/l
LocATioN anv�ss: 3� �rrr� �-�- w, Y19R�ar1r�/ n?R Gb�67.3
MAILINGADDRESS: �Ti4/'i1.� �4-� ��O �
OWNER NAME:(1�'�fi�J�/✓Sd nl /b'� ��142.(,�JV TAX ID (FEIN or SSNI �
CORPORATION N (IF APPLICABLE). /UGHT �P/R.��' G�
MANAGER'S NAME:�°�(��,yL �CC/9/L�-�E TEL. #S Cab
MAILINGADDRESS: .R/ I�OLG�f"iSk LN ��NN1S�d2T /MYy19 [��9
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 minunum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach wpies ofemployee
certifications to this form. The Healt6 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-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertification to this appGcation. T6e Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment
1. Z.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CER'TIFICATIONS:
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 ceRifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a t"de at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQLIIRED FEE PERMIT# LICENSE REQUIltED FEE PF.RMIT tl LICENSE REQT.lII2ED FEE PERMI1'ik
_B&B S50 CABIN $50 MOTEL E50
INN $50 CAMI' $50 SWIIvIIvIINGPOOL$75ea.
_LODGE $50 1'RAII,ERPARK $100 WIIIRI,POOL $75ea.
FOOD SERVICE:
LICINSE REQUII2ED FEE PERMI1'# LICENSE REQUIItED FEE PERMI'C# LICINSE REQUIltED FEE PERMI'L#
_0-100 SEATS $75 _CON1'QdENfAL $30 NON-PROFfC $25
_>100 SEATS 5150 COMMON VIC. S50 WHOLESALE E75
RETAII.SERVICE: —RESID.KTTCHEN $'75
LICINSE REQIJIRF.D FEE PERMI1'# LICENSE REQUII2ED FEE PF..RMIT# LICENSE REQUII2ED FEE PERMIT 8
( <50 sq.ft. S45 '�� _>25,000 sq.ft. $200 _VENDING-FOOD $20
_QS,OOOsq.ft. S75 _FROZENDESSERT S35 / TOBACCO S50 �00
NAME CHANGE: S10 AMOUNT DUE _ $ �JS QC�
•••••PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM"""""
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any 6cense 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 INSURt�NCE 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 permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotei use,Transient occupancy shall be
limited to the temporazy and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6) month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transiern. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�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 swiauning 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 Departmerrt by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a 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 Pettnit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited.
N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.iTY TO RE'I'CIRN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006.
ALL RENOVATIONS TO ANY FOOD ESTABLISI�fENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO CObIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
�
DATE: / �L� SIGNATURE -C iNNJ1�h-
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #07-006 FEE: $45.00
In accordance with re�ations promulgated under auThority of Chapter 94,Section 305A and Chapter
I I i,Section 5 of the eral Laws,a permit is hereby granted to:
Twilipht Spirits Ina 55 Route 28 West Yarmouth, MA
Whose place of busi�ess is: Becker's Packaee Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit eacpires: December 31. 2007 BonRD oF HF.AI,TH: ,B $, (�o�do�ay�q, `.15,, •
efeR��S'!r�ls, RJV., ?/!ce G�lu�iiru�
RFCTRICTION:Milk,juice,packaged chips,�da. Rp�pl[t�. Bqqwyy� �
n�.w�u
A.� �j�, R.N.
rro��t�za aoo6 y,� �
Director o Health� � �
THE COM1tZONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #07-006 FEE: $50.00
This is co ce�tify thet Twilieht Snirits Inc. d/b/a Becker's Package Store
_ 55 Route 28 West Yarmou MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PROD CTS
AS PER TF� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This�et$it i�s�rted i�i confor�iri wiih[�ticle VI of the S y�.Cale of The Commonwealth of Massachnsetts,and
� 31 007 e§s sooner suspended or reoked.
November 28.2006 BOARD OF HEAI,TH: B $, (�'y�,p�y,�Jj,� •
���`„s�, R�v, v:� e�
R�t�. a�, er�
A�tu�k�10�5�,.,�lt
A.��j�.,�, R.N.
L -
Director of H�e,alt2t� '
�`='"^R TOWN OF YARMOUTH BOARD�f)F S�A�.Tg �S�jg��S
o��,i� APPLICATION FOR LICENSE/PER14�T:-�'09G �� ��8✓
r = , < ,
�� • Please complete form and attach all necessary documents by December 3 ,
Failure to do so wiil result in the retuin of your application packet. - � � �''� -�'`� DD
NAME OF ESTABLISHNIENT:,B,E"C',eER1S PNC,e�46� S7nRF TEL. # 7'IS- •71
LOCATION ADDRESS: EPT.
MAILING ADDRESS: �T
OWNER NAME:�i�,YL JD McSON �! C" 1�RR.�r TAX ID(FEIN or SSN� (�' $' /�
CORPORATION NAME(IF APPLICABLE): UfGl ..T ,
MANAGER'S NAME: � � TEL. j
MAII,ING ADDRESS: /d D BOX oZ(o L!!�' ��/,�5��'d�'7` /YJ� 0�67a-.
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 empioyees currently 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 tlris fortn. T6e Health Department will not use past years' records. You must provide new
copies and maintain a fle 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-tune 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 IN CHAR�E: _ _ __
Each food establistunent must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2.
HEI1bg:FCH 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
attaetF 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 REQUIl2ED FEE PERMIT N LICINSE REQUIl2ED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
BBcB $50 CABIN $50 MOTEL $50
_INN S50 _CAMP �50 _SWIIvfI�fINGPOOL$75ea.
_LODGE $50 TRAII,ER PARK E50 WIIIRI,POOL $75ea.
FOOD SERV[CE:
LICINSE REQUIItED FEE PERM[T# LICENSE REQUII2ED FEE PERMIT tl LICENSE REQiJIl2ED FEE PERML'P#
_0-100 SEATS $75 CON1'INEN1'AL $30 NON-PROFiT $25
_>100 SEATS 5150 _COMMON VIC. $50 WHOLESALE S75
RETAIL SERVICE:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PF.RMI1'# LICENSE REQUIItED FEE PERMI1'#
I <SOsq.ft. $45 'OIIO >25,OOOsq.R. $200 _Vh'NDING-FOOD $20
Q5,000 sq.ft. S75 _FROZEN DESSERT $35 I TOBACCO $25 �EQ(_�
NAME CHANGE: S10 AMOUNT DUE _ $ '70.00
"•""•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM`••"•
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STA1'E WORKER'S COMPENSATION INSURANCE
AP'FIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED�
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ' NO
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2005.
SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-
10 DAYS PRIOR TO OPEIVING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMEN'T, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO
COMNfENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swiauning,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opemng.
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
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 Departmern by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untd the
above terms have been met.
OUTSIDE CAF`ES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmem is prohibited.
DATE: SIGNATURE: C-Ll�.�Gl'L�-
PRINT NAME&TITLE: C �R Di/NsoN cC���1✓
09/28/OS
1:;'.NI20ng 11:28 FAZ 7a129�1300 BqRB�C INS. �001
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aC�tD 24 RW7m8t ��CORi'i CORPOiiATON 7988
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMITNUMBER: #06-016 FEE: $45.00
In accordance with ceg�ations pmmulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the(ieneral Laws,a petmit is hereby granted to:
Twilight Spirits Inc., 55 Route 28, West Yazmouth, MA
Whose place of business is: Becker's Packa¢e Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut eacpires: December 31 2006 BoaRD oF�ai.'rx: B `15. /yl.`.15., '
� e�fea��5'luls, �rce L�lrain�xwc
RESIRICTION:Milk,juice,,���a�n;Ps,�. Rod�t 4. B�, �
nr�3t�Ma�eR�o�
��j� R.N.
January 10,2006 ruce G. u[phy,MP , ,
Director of Health
THE COMI140NWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #06-015 FEE: $25.00
'rhis��o Cenify that Twili ht Spirits Inc. d/b/a Becker's Package Store
55 Route 28. West YarmouttL MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER TI� YARMOIJTH BOARD OF HEALTH TOBACCO REGULATION.
Thisl��it is�ant�i�c�O for�t�with Ar[icle VI of the San�tar�Code of The Commonwealth of Messachusetts,and
eacp s s sooner saspended ot revo
Jaa,�y io.z�6 Bonitn oF�nr.�: B �5. !�'oado.�. M.$., '
���st�, a.�., v:�e�
R�t�. B� G1�6
P��.�la��
A.��j�, R.N.
v
ceG. mP >R ,
Director of Health
��
�$���Y��'�� TOWN OF YARMOUTH
� `� ll46 ROUTF.28 SOUTH YARMOUTH MASSACHUSETTS 026644451
� MATTqCHEES �
,�'+�a„a,�,�o,«�� Telephone (508) 398-2231, Ext. 24] — Fax (508) 760.3472
B O A R D O F H E A L T H
To: Yarmouth Board of Health Permit Holders i��``'��---
i ' '-
x =
From: David D. Flaherty 7r., RS. ;��� � � �_ -,
Heahhinspector ✓ � � ' l%,�s
Town of Yarmouth N�'q�TN, Q�P
T.
Re: Federal TaJc ID Number
Date: March 22, 2005
The Massachusetts Departmern of Revenue is �w requiring that we furnish detailed information
to tbem regazding all permits and licenses that we issue. One of the details that they requue we
send to them is every establishment's Federal Employer ldentification Number(FEII�ottterwise
laiown as your"Tax ID Number". This is purely for adminis[rative purposes only.
Some businesses use the ow�r's Social Security Number (SSl� for this 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
Yarmouth Health Departme�
1146 Route 28
South Yarmouth, MA 02664
1'hank you for yout anticipated compliance. If you have any questions regardiug this matter,
please do not hesitate to call. The office hours are Monday to Friday, 830 a.m. to 430 p.m The
telephone number is(508) 398-2231,e�rt. 241.
Establishment: /�L'�,��,5 PACkAG£ SJ?7R,� FEIN or SSN: ��
LocationAddress: �J ��/fE �� ��ST �Aa�tdvey
Signature: /'� G'�%�'L��%�srl./
rr;nt: GNERyr- A . �/tsHN.So� Title: OZ.t�NF2
�
L�� Printed on
( Recycled .�-�
3 Paper
„_'_ _' /��yI(/� f
� ��yA� �' O�� �'� � I� _ _ .. _. ��J
2 � a TOWN OF YARMOUTH BOARD OF;HEAL'f�
o ,y APPLICATION FOR LICENS - 2005 D E C 2 1 2004
"C�? ,.
* Please complete form and attach all necessary�cu�ients by Decem . DEPT.
Failure to do so will result in the return oFyow applicat�on packet.
NAME OF ESTABLISHI�IENT: .c�i��h.�R'S PAckAG-c �2E TEL. #�TDB� ?7S D 6�/
LOCATIONADDRESS: ,S�S Rnv7E' otR'
MAILING ADDRESS: �-S,S /QdU T'.E' oZ8 GuFS7' YAlLKCU77�1 /�ZA ('�Z( �3
OWNER/CORPORATION NAME: 7zd/u6 cS P/�e./TS TNL ,
MANAGER'S NAME: CHER-YG (JO/�N�SO TEL. #S4S� 7E0�4(o`I
MAILING ADDRESS: ��i Pa�c� F/Sk- LANE `��NNl�pDAT /dt,q D�Z�v3 9
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 safety, standard First Aid
and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of
employee certiScations 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.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fiill-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this appGcation. The Healt6 Department will not use past years' records.
You must provide new copies and maintain a t'�e at your establishment.
1. 2.
P�RSE}N IN CHA�tGE: - _
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.
1. 2.
3. 4.
RESTAiJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIl2ED FEE PBRM[T# LICINSE REQUIItED FEE PF,RMI1'# LICENSE REQUIItED FEE PERMI'P#
_B&B $50 CABIN $50 _MOTEL S50
_INN S50 _CAMP $50 _SWAI[vIINGPOOL$75ea.
_LODGE $50 TRAII,ER PARK $50 _WI-DRLPOOL $75ea.
FOOD SERVICE: �
LICENSE REQUII2ED FEE PERMIT# LICINSE REQUIItED FEE PF.RMIT# LICENSE REQiJIIZED FEE PERMIT'#
0.100 SEATS S75 CONTINENTAL $30 NON-PROFIT $25
>100 SEATS 5150 COMMON VICT. S50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIItED FEE PERMII'# LICENSE REQUII2ED FEE PERMI"P# LICINSE REQiIIRF.D FEE PERMIT q
��SOsq.ft. $45 ��'O�ja” _>25,OOOsq.ft. $200 _VENDING-FOOD $20
_QS,OOOsq.ft. $75 � _FR07..ENDESSERT $35 I TOBACW S25 �pS�aaS
NAME CHANGE: $10 AMOUNT DUE _ $ 70.00
••""•pLEA5E TURN OVER AIYD COMPLETE OTHER SmE OF FORM•••"•
1
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED l/
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth t�es and Gens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.I1'Y TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL ESTABLISHI�IENTS ARE TO CONTACT TI�HEALTH DEPARTMIIVT FORINSPECTION 7-10
DAYS PRIOR TO OPEIVING FOR TI� SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MiJST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR
TO COMA�NCEMENT. 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 standazd plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimrrilng pool must be drained or wvered within seven(7) days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishmem which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY:
Anyone w o caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DES9ERTS:
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 Pemrit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOHING•
Outdoor cooking preparation,or display of any food product by a retail or food service establishment is pro6ibited.
DATE: / �Z �7 SIGNATURE: � �
PRINT NAME& TITLE: � L 7� J�HNso.nl �j+�ucl�LrPJ�
10/22/04
. �.�,�
A�IIIt11. CERTIFICATE OF INSURANCE ���z'j��
n�ooucew THIS CERTIFICATE fS �SUE� AS A MATTER OF �NWpMATION
pNLV AND CONFERS q0 RiGNTS UPON THE CER:TIFlCNTE
First Cardinal Gorp. MOLDER. TM�S CERTIF�CATE DOES NOT AMEND. E7(TEND OR
10 BntiSh Afiefic2n BIVd. ALTEFI 7ME COWERAOE APFORDED 9Y 7ME P'O�tC1Ef% BE���
QOMPANIES AFFORD11K3 COVEMOE
L'ath8m, NY 12110 �uar Massachusetts Reail Merchants WoAcers Compensation
� A Group, lnc.
� ca+�r�n�t
B
Becker's Package Store ----
Twilight Spirits Inc. , ��
31 Po!ly Fisk Lane �,u,,,
Uennisport, MA 02639 �
COYEHICaEB . _...
WDICA DC�RHBTANDWG ANY RL-0UIREMEN�T.7ERM OA4WNDYTION OFBANY CONTMCTOORE 10THER EOOC MEM WITH RESPECT TO W ICH TH S
_. _.. CEpT�FiCATE GAAY 8E I�D O61 r.iAY PERTAW.TME IN3UAANGE AFFCdNDED BY THE POLICIES�EBCFtIBED NEREW 1S 6UBJECT T��ThE TEFMG _._
EJSCLUBIONS ANQ CON OF SUCH PO�ICSES.L:MRS 6FN)WN MAV HAVE BEEN REDUCEU BY pi11O CINIMS'._ .
TI PplCYINMlEN �9IXy�') `Y�n 1Y16
1YPlOf IBNIIfMIC[
�q/�LA(ppEp�17E i
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ovn�as s cows'vnor
FlPEp1i1AKiE�Myarenl� •
— M�IXP(M+YwG��I •
�p�t yy,�yry � co►�awEO e�xa�u�nr 1
ANY AUTO t
MLOWNFDMlTQS ���r �
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NON-0YMED�UTOB .
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0T11ER iMAN UMBFELU FOMI ,
BTA7UfORYlCMtB
MI01NW�IMl1oNAllc _—
p �'�''O''�"°�""°""�` 0140005023031Q5 Q1(01/05 01/09/06 ��^ � �
n�raaaw�row � o�e-rauc+ruwr � 500000
v,w7M6R�ExEwnve � a8FA8E-fAp�BwRovE! f
Q'i10EH8 ApE: �L
0111lR
09dP1f10X CF spEMnGMrIOCAl1otl W N W XGLMEdlL REl19
Coveree Location: 55 Ri 28
West Yarmouth, MR 02673
C£imRCATE r�OLDEA CANCELLATWN
Town of Yarmouth SN01M'D �"'� °FM`ABOY"��'� �'a �� ��
6XRRATION MTE T/IE580t� Tf1E 168tNN0 GOYYAN!' WILL OOFI�YOR TO IW. .
Attn: License Dept. ?5 osvs wwrrew xence To nE cear�ciurE�eo�nex xu�i�rt�n+E�sr,
1146 Rte 28 wq//i9,UpE TO IMit 6Ud4 MOTICH fXALL WPOlE MO OKIWl10N OR LINlWTY
South Yarmouth. MA 02664 os .rr wno ura+ me ca��xx r�s �oum a��tr�umo.
�iTqN2E0 RlPR!!lMMTVi
ncoao ass t� JUtiu,$?71�•��conwxt�noH tea
TO�VN OF YARMOUTH
BOARD OF HEAL1'H
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERNIIT NUMBER: #OS-032 FEE: $45.00
In accordance with regulations promulgated under authority of Ghapter 94,Section 305A mmd Chapter
111,Section 5 of the General Laws,a permit is hereby granted to:
__ TwiliQht Spirits Inc. 55 Route 28 West Yannouth, MA
Whose place of business is: Becker's Packa¢e Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yazmouth
Pemvt expires: December 31. 2005 BOnuD oF I IEni.1x: B�$. (�'o�doa,M.`.D. '
��.y�� v� e�.�
RESIRICTION:Milk,juice,packaged chips,soda. � ROI�e3t gp'B40[ws� �.�&31�L
a�{eleK c7ftG�t� Q./y.
�4.��j�, R.N.
January 31.2005 Bruce . M�ap ,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT NUMBER: #OS-025 FEE: $25.00
This is to Ce,tify that Twilieht Snirits Inc. d/b/a Becker's PackaQe Store
55 Route 28 West Yazmouih MA
IS HEREBY GRANTED A LICENSE
For _ SALE AND DIS ION OF TOBACCO PRODUCTS
AS PER THE YARMOUTA BOARD OF HEALTH TOBACCO REGULATION.
���S�it��s��ted_v���fo�l�ys�nAtticle VI o�f the SaniTsiv Code of The Commonwealih of Massachusetts,and
3� suspen orrevoked
January 31.2005 Boa�oF��,�: P��tf� e�
n�.r��� v�e�
2��. a�, e�
e�.��l,�k, R.N.
��i�, R.N.
s� .M,,�by,�
Ditector of Health '
ofl w
, _ �— ��l't ,p.� � ��` g�'s ��" -
pF fAq� TOWN OF YARMOUTH BOARD H A,UTH.
3=r � APPLICATION FOR L10E T�2�04 ��OV 2 6 2003 L
Y\�S �:�!t :.,,%�_'++S
* Please complete form and attach all necessary �',�' uments by December TH DEPT.
Failure to do so will result in the retum of your application packet. �
NAME OF ESTABLISHMENT• ��3ECk�P `S P�9Gt_AGE �`i'OFC.� T # 6�77 ��-06 J(
L�QCATION ADDRFSS• S�S '�r�t�T.E `'R' nJ,��T �/�`2Md:Jr�( �t�A iJ,�C � 3
MAILING ADDRESS: �SR n�e �
T ON : "-7.�1 r L�G.yT �S i P iTs 17�1 C_ ,
MANAGER'S NAME: �' r 2�[_ `)DF!N��O N TEL # C An1� �76c-rt�u
Iv�AILING ADDRESS• c�1 �'D�.c�v -�'isK ���n�N�S ,'a�T /�fA n� 3 9 �
POOL CERTIFICATIONS:
The pool su ervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
gool Operator s an�attach a copy of fhe ceRiYication to this form.
1. ��/ f1 2.
Pool operators must list a minimum of two empbyees 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 wi(1 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-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
i. N�R z.
P�RSON IN 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 establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B S50 _CABIN S50 _MOTEL S50
_INN S50 _CAMP S50 - _SWIMMiNG POOL S75ea
_LODGE S50 _TRAILER PARK E50 _WHIRLPOOL S75ea
EOOD SERV[CE:
LICENSE REQUIRED FEE PERMIT N LICGNSE REQUIRED FEE PBRMIT# UC6NSE REQUIRED FEE PERMIT#
_0-100 SEATS S75 _CONTINENTAL S30 NON-PROFIT S25
_>IOO SEATS $I50 _COMMON VECT. S50 _WHOLESALE $7S
l3ETAIL SERVICE:
LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED f86 PERMIT# LICENSEREQUIRED FEE PERMIT#
�<50 sq.ft. S45 y' � _>25,000 sq.R. 5200 _V GNDING-FOOD S20
_<25,000 sq.ft. S75 _FROZEN DBSSIiR'f S35 I T06ACC0 S25 �_�
NAME CHANGE: $10 AMOUNT DUE _ $ -T 0•�O
*****PLEASE TURN OVER ANU 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 pemut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION 1NSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
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 annually from January 1 to December 31. IT IS YOUR RESPONSIBILITl'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL F U ATION
POOLS
POOL OPEPIING: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 standazd plate coun[
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
CONSU_MFR Al)VISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATF.RNG POLICY:
Anyone who caters within the Town of Yarmoudi must notify the Yarmouth Health Department by filing the
reqmred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FR��EPd�ESSER�'S:- _— - - _
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.
OUT�IDF C�F�'S•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health.
OUTDOOR COOIKN •
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
�
DATE: l� �C^ C SIGNATURE: � �%� . � ��"
PRINT NAME& TITLE: LiHF� � � �I . � /�(/'✓ ��JjiJ ''/J�NT
10/22/03
. . �
The Commonwea/!h ojMassachusetls
= Depar�ment ojlndusrria/Accidexts
a Olnce ot/arasU�stliis
600 Washington Street
' Bnston, Mass. 01111
` �� '` W'orAers' Compensation Insurance Affidavit
Apnlicant information: P► n•cpRINTTeriida
namc �iy�iP�� lJ���l,�r)�`�I � �N%C�I('i-/�T SPI/Z,l/ � �l��i �
locati�n �__ �O[��i� LI Jl�— �n� � _
•i�t�_������� t ��or�T - — 1"lri ( /.�47 / j ehonea ��� /�L���'_D ��;��
� I am a homecwner performmg ail work myself.
� I am a sole proprieror �r.,', ha�e no one �oorking in am capaein�
__ �I am�n emTloyec�cniidino wockers' compensation for my emplo}ea uorking o�this job.
comnan�� name• ��r'��r�7 �/�lh'.fTS �/'✓� ��(� � C,l�.-r/� �����Y�� ��l� Q�
nddrcss: �.J� �/�./�(�l L �JS
iife�QlL�% �"1.�✓]��l � II/t/Y (J�' l �� pheeeu. ���(� ��S (/(G� ��
insur�nce co L3�.r�� I ��✓1���.1C h"('� l�i�L' �A�CF C l� oolicv k �P� � `J In .�/7�
� I am a solz proprietor. _enerai contractor, or homeowner(circ(e onel and have hired the contractors lis[ed beloµ ��ho ha�e
the follu�cin_ «orkzrs ,ompensation policns:
s9moanv name: �
add ress•
sin�: Ahone p•
insur�nsc co. �o�i¢�•p
comoanv namr. �
tddress — _— __ _ _ _
�" yhoee M•
iniu[aacsso. �pn M
t
Failurc to secure covenee�s requircd under Secnos 25A o(MGL 152 n�ind W tYe inporiOw o(erid�l pqdtln oh Ou op to tl}00.00 a�d/or
oae yean'imprisonment u w�di�a civil penalHa iu the form oh SI'OP WORK ORDER��d a(l�t of SI00.09�d�r qdeft me 1 ndmta�d that■
eopy of thn statemcnt mar be for.v�rded to the 011iee ot larmti`�tlom o(Me DIA tor eoverqe verilkatlo�. .
� 1 do hrreby cr y nder the ms d p l�ies perjury that�he injonnation provided abovt is true and conect
Signatur /�.. � ,�✓ /�/�
Printname . Y � � oneM .�Qd �I�: `-[l��/
.• oRcial use onl. do not.ritt in this area to be compltled by tity ot Imvo ollltial
eity or town: Y�ODTQ _ permiNiteex M nBuildieg Depanmm�
� �Liemsine Bo�rd
� check if immediatc response i�required 261 �Stlettmen'e Oflite
(508) 398-2231 pat, OHdItE Depanment .
ron�ace person: phone M•_ __ _ nOther .
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLLSHMENT
PERMIT NUMBER: #04-013 F'EE: 45.00
In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the al Laws,a peimit is hereby p�anted to:
Twilip,ht Spirits Inc., 55 Route 28, West Yarmouth, MA
Whose place of business is: Becker's Packa¢e Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2004 BOARD oF HEAL'I'x: Berya«iir� `�. �o3�o�s, M.$. '
v�,Ha��u, v� �
RESTRICTION:Milk,juice,peckaged chips,soda. RO6N��. B�lWw/�t� �83�{6
��/tG�t� K./N.
\1 � ry
l !II
T)f_ ��
V- i
November 28.2003 mp ry,Mp . �—
Director of Health
THE COMI�IONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #04-008 FEE: $25.00
This is�o Ce�tify thac Twilieht Spirits Inc. d/b/a Becker's Package Store
55 Route 28. West Yarmouth. MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBiJTION OF TOBA . O PROD T
AS PER TI� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This. t is an t�with Article VI o the���y Code of The Commonwealth of Massachusetts,and
e�cp�es�ecz�ier�.��u�n e3s sooner s��spend�or revoked.
November 28.2003 BOARD OF HEALTH: po�lic�/�p�s9Nw�, �raviixaiy
�,a�� v� e��
R�1�. a�, e�,�
� S�, R.N.
�`/� M�" �,�,�� i
�� . Um ly, ,
D'u�tor of Health
/
~ 3�Fe q.yc TOWN OF YARMOUTH BOARD OF HF�,L�I � ; � � ' ; � �,
�t��� APPLICATION FOR LICENSE/PEIiiVil'I"+��0`l13
? � �, , : . ���� ' `( `bq�/ �E;' ' � � [°;,2 �;
* Please compleYe form and attach all necessary�cu�te �tS,�ISLcem�e�'31„��02,.
Failure to do so will result in the return of�r a�Iication packe�!�=-�� � t i ;:iEP7.
TABLISHMENT• � LC 'S Ck19�E S �'c,F TEL # 5v 77 -0 //
LOCATIONADDRESS• �i5 KTJ-8 /�UEr'T Yr42�'1G7il7N /WQ ��67 '3
LVfAILIIYG ADDRESS: SA M F_
OWNER/CORPORATIONNAI�LF•-7Zulu�NT CPi2iT` TnIL .
MANA .R' N MF.: CHERYL JvNnJsonl TFi # OFl�'(oO2YJ�O`�
MAILINGADDRESS: 3� Pot.Gy FISK L./9N� �CNNiSPO�T va�39
PO01. 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 certificarion to this form.
l. 2,
Pool operators must list a minnnum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attsch 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 piace of business.
1. 2.
3. 4.
FOOD PROTECTION ANAGER - R FI ATION •
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of 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.
1. Z.
PERSON IN CfLARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. 2.
�IEIMLICH CERTIFI ATT N •
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 pmvide new copies and maintain a file at your place of business.
1. 2.
3. 4.
F TA iR ANT ATIN .: TOTAL#
i.on,nvc: OFFICE U O .v
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_BBcB $50 _CABIN $50 _MOTEL $50
_1NN $50 _CAMP $SO _SWIhfMING POOL$SOea
_LODGE $50 _'I'RAILER PARK $50 _WHIRLPOOL $25ea
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-t00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT E25
_>]00 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75
RETAIi .RVI .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�TOBACCO �� � _q5,000 sq.ft. $75 TOBACCO $20
�<50 sq.ft. S45 #Q3�bZ3 _>25,000 sq.ft. $200 _FROZEN DESSERT S35
NAME HAN .F.s $IO AMOUNT DUE _ $ (� S,OO
•***•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"***
�
. �
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �`,/
OR
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 V NO
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002.
SEASONAL ESTABLISI-IMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PffiOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPEIVING: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 aze required to post
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yannouth 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 DESSFRTS;
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.
nUTSIDE CAFES:
Outside cafes(i.e.,outdoor seaUng with waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
DATE: /� D a- SIGNATURE: +.li' '��� . ����"��
PRINT NAME&TTI'LE:�N���L �'i �IDN SON ��cj�DF«
10/18/02
�\
. . The Conrnronwealt/� of Massachitsetls
- ' Depar�men�ojlndrestria/.�lccidenu
�lllcsell�lq�
, � 6b0 Was6rngton Streef
' Bos�on.Mass OZIIl
W'orkers' Compensation lasunnee Affidavit
Aoolicani information: PleauPRiRTTeriiJt
namc: (.�/t�/�-�� ��xl�i`(�IV � .
���[Qo:_,3l �DLc� F.Sk L,9n/�
���. 1��NNiSPORT 11i1lb dd-('�3�'j eno��w.'�O� 7G�0-OD��`l
� 1 am a homeowner pertbrtning all work myself.
� I am a sole proprietor=^� h��e no one ��orkine in an}�capaeih•
[�I am an emplo�er pro�iding workers' compensa[ion for my emplocees working on this job.
eomoan�same: ��1�1rN7� �SPI%lTS �/�C--
address: J� �� O?�
tih^ �����T Y��✓V��1/T�') M� O��J�i � ohanelh. .J06 �lv'(1���
e
insurnneeco. �/I' '�/ � �//�� ?'E'/ '�liii�.���1 nolieYM �"
Q I am a sole proprie[or. generai contractor. or homeowner(circle one! and have hircd the contractors listed below aho ha�e
the follu�sin��corker.' ,ompensation polices:
eomo�av namr �
address
citv: � phene M•
inc��rnn�e eo. _ peliev N
tomesnv name•
addre�r
p(y: R6eee M:
insarsnee co. naHer N
� , .
. Failurc�o xcure�eoverKe u required u�der Sadw 25A o(MGL ISl w led qt�e l�pNi4o�de�i�iW peWtla d��e tp to SI.S00.00 aWlar ���.:
we ynn'ispriaoamt�t��w�eN is dril pesdtln is t�e form o!a STO�WORK ORDFR ut�'Me dS10�.N a dq q�int K [��denb�0 Hata
� topy of tAh su�emeet m�v be fonrardM ro the 011ice of IproHp�u etl�e DIA fx edrera{e retienW�. . �. - � � �� � -� �
/ao herrby ce ' •under r pains d p a/tf�r ojperjury thm rbe injornntlon pmridtd abo_rr ts One awr corxa
Signacurc /' %�/,�Z/D,�
Primname GN£L�L . J��On� pf�one�t,�`� 7(�,D�-Ob6t{
ol6eial use ony� do no�w��e ia t6ia area to 6e rnmpleted by eitr a Pow�ollkfal �-- �� �
ei�y or towe: Y��T$ _ � pervilAkeme N nBuildiog Deparfaeo�
. OLleemiop Bwrd �
Q eheek if immedia�t raponx i�required 261 QSelettmn•a 011iee
�HealeA Dep�nmeat
eonmet pmon: � � p��N;_ �508� 398�Z231 ezt. nOther .
�,e.��iy:ar PIV � .
�
NOTICE NOTICE
TO - TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Sireet, Boston, Massachusetts 02111
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Se.ctions 21,22 &30, this will give you notice
that I(we)have provided for payment to our injured employses under the above-mentioned chapter by
insuring with:
ltassachusetts Betail Merchants iiorkers' Ca■oensation Group. Inc.
NAME OF INSURANCE COMPANY
190 Forbes Eoad - Suite 237 Braintree LIe O?1R6-7611
ADDRESS OF INSURANCE COMPANY
4024-01 10/21/2002-1/1/2003
POLICY NUMBER EFFECTIVE DATES
FIRST CABDIAAL CORPOBATIOH 10 British Aserican Blvd Lathaa HY 12110
NAME OF INSURANCE AGENT ADDRESS PHONE#
Twilight SpirYts,Inc. Becker's Package Store,46 East Main St,Hyannis MA 02601
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. 1'he reasonable cost of the seo-
vices provided by ffie treating physician will be paid by the insurer,if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention,employees are
hereby norified that the insurer has aztanged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
CLAIIiS OFFICS (800) 790-8877
� acoRv_ INSURANCE BINDER °"m s lo�l 02
THIS BINDER IS A TEMPORARY INSURANCE CONiRACT,SUBJECT TO iHE CONDfIIONS SHOWN ON 7HE REVERSE SIDE OF 77iIS FORM.
�� 781-293-6331 �� �� 3519
781-293-2171 g�t Aserican Insvrance Co.
innn
FIIi. F. Borhek Insurance Agency °p� � °A� n�
311 Plymouth 3treet � X '��
Halifax MA 02336 10/21/02 � 11/20/02 �+
Scott C Casa ande nasernet�sssu�roExremcove+�cewn¢nmveru�cawurv
woE: suacooe reeownwovaucvr. T�
cusro►mtw: SECI�-1 o�avavsu�no�snraaa.�r�a�mM
�NSUnEo
sroriiiynt spirits, Inc. ���= P� �0��
t/a Beckers Package Store
46 East Main Street
Hyannis hA 02601
COVERAGES LIAAITS
rneos�uc� covmnceww�s � cowsx nwauHr
P�'�TP c�rsoFass Actual Loss Business Inooae
easic �erw�o�R srEc Personal Property 500 $91,000
casn�w�eurr �ocCnr� s1000000 �
g �����,m �on�aeEwymeee) s300000
�� �� �owwyaePaaay s10000
X Li.quor Liability $ a/$2a re�sor+ni.anwru�er s1000000
c�r+n�nccre�cnre s2000000
�aooarerorewwsuaoe raooucTs-courro�acc s2000000
nvrawoeo-eunawm coMee�suaeuut fSOOOOOO
urvnuio eOoo.Yituuav(P'e.vanml S
nLLOwN�Aul06 � � 80DLVw1UtYlPer+citlN) S
SC11�IA�AIJIiDS . . .. PROPH(7YRRIN� S —
X M�q��N� . . .. . . . . . . � M�I(YJ.PAYIENT3 S . ... .
X NON-0YVNFDNIf03 . .... . . .. . . . . . . . . . . . . . . . ... . PHtSON11LNJURYPROT S.. _ . ..
IIIIIlSLf�MOTOPoSf f
S
AUfORfYSCALDAMRfiE O�lIC7BlE ALLVB9QF.S �IA.�V6iC1FS NCiUl1LCASHVALUE
���ypH: 5fA7�AYO1R1f S
07F1HtTFNNCOI.: OTtiHi
RpAAOEIuenJrY MrtDIXLLY-EnACC�FNt S
ANYAUfO OlF�t7W W Mll'OON.Y:
FACHA�BiT f
AGGREGA7E _
EXGES.4LIP1BLLlTV EI1CH0�10E i
UMBR¢lA FORN AG(piEGnTE S
OiNHtTwWUYBRSUFORY RETRODATEFaRaAwSMwE: S[1F-eISIIRFDRETBiIqN S
YUC$tRMORY L1111TS
wow�nsco�e�sntax ELr�accoe�r SSOOOOO
nNo
ow�or�esuneum ELOISER�•EABAPLOYEE s100000
ELoisFwsE-ra.rt.wuwr SSOOOOO
� �s s
�°"s` T�s s
coveuwEs
�srau�roTaa�eew s
NAME&ADDRESS � �
X ►artrc�u',ff �mnprwi�
. . . . wssrnvff . . .
BIISII�S �s
Busiaess Loaa Center, Inc � �
ATIIlA, Servicinq Dept. ��A�
645 Madison Ave 19th Floor
Nex York NY 100�12
Scott C Casaqrande
ACORD 75-S(1PJ8) N07E:OiPORTANT STATE QIFORMATION ON REVERSE SIDE CORPORATION 1993
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #03-016 FEE: $25.00
'rhis is to Cenify tt,at Twili rt Spirits Inc d/b/a Becker's Package Store
55 Route 28 West Yazmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
AS PER Tf� YARMOUTH BOARD OF HEALTH TOBACCO REGULATION.
T'his�er�ieCie�ent�i��fior�it�with Article VI o�f the Sani�tar�Code of The Coromonwealth of Messac6usetts,and
eacp s r e s sooner suspend or revo e .
December 18 ,2002 BOARD OF HEAI.TTI: eifa�+lea'�. xdU�a, �radurra.c
b"e.aja.xl.s D. Cjezdas. 'jJl.?J.. ?/ice
,�.o6otl'�, b�aara, ela�k
�at�tek 71(,eDar.Kou
'� e SiEak .'jl.
ruce G.Mi y,MP
Directo�of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMTT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #03-023 FEE: 45.00
In accardance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
11 I,Section 5 of the General I.aws,a perntit is hereby granted to:
Twilight Spirits Inc., 55 Route 28, West Yarmouth, MA
Whose place of business is: Becker's PackaQe Store
_ _ =Fype ofbusiness:—Retait FaQ�Servic�tess than 50 square feet-_ _ _ _ ---- -_
To operate a food establishment in: Town of Yazmouth
Permit�pires: December 31.2003 BOARD oF HEA[,'I'H: (/,kanlia�. ze!llkec, �a�;�xa+c
���. c�, m.D., v�
� � RESTRICTION:M�lk,juice,packaged chips,soda � i�e�Crl�. S��aaac, �ai�
�aa�rte4�CDot.�ott
'+f� S'Eak. ,�?Z.
December 18 ,2002 Bruce G.M ,MP S.,
Director of Health
. . ���`�"
TOWN OF YARMOUTH BOARD OF � � �� �' 9 �� � DD
APPLICATION FOR LICENSE i�� O C T � O 2OOP
r �,
' Please complete form and attach all necessary documents by Dece 31, 2001.�ai1 re����s�alt
the return of your application packet.
NAME OF ESTABLISHMENT: F_ 5 C ,�A ST� TEL. # $ 77S'd6!/
LOCATION ADDRESS: NG �.S4STMA/N .S7kEf7" L,vFST YjIRMDIll7�1 �VIA
�uLitvGaDD�ss: SAM�
O T G.
MANAGER'S NAME: ��/Lc�C.�L c,DNNSO TEL. # �L�''7G�-riY3(i�
1�1au,itvG aDD�ss: .3i PD[.[_y �"tS/c. LANE �fNN/5/0�7- /1AA D�G3�_
POOL CERTIFICATIONS:
The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community 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 61e 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 applicarion. 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 Chazge (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 o�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.
_R_�STAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQU[RED FEE PERMIT# LICENSE EtEQUIRED FEE PERMI'C H LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN S50 _MOTEL $50
_INN $50 _CAMP $50 _SWIMMING POOL$SOea
_LODGE $50 _712AILER PARK $50 _WHIRLPOOL S25ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS E75 _CONTINENTAL S30 NON-PROFIT � $25
_>t00 SEATS $t50 _COMMON VICT. S50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N
�TOBACCO $20 �a'�Sr _<25,000 sq.ft. $75 TOBACW S20
1<50 sq.ft. $45 �dd-0�7 _>25,000 sq.ft. S2W _FROZEN DESSERT S35
NAME CHANGE: $10 AMOUNT DUE _ $ �S OO
*"***PLEASE TURN OVER AIYD COMPLETE OTHER SIDE OF FORM*•*•*
i k
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
• Goinpensatian lnsurance. '1`�I�L ATTA�HE'D S'FATE :WOR�KEIt'S'iCOMPENSATION INSURANCE
AFFIDAVIT MUST BE�dMi'LET.ED:AN'U SIGNEDi,t3K . '^ �,` -°°:: -;
' : �' ,
GE�tT.,�F IbISURANCE A"T�'A�HED
, . . . , • <
- ' � . � . ..�_ >V
-.�. � :'VV.ORK�R'S C(�°Ivl'P. rX�',EIDA'i�IT-4SIGNF,D,Ak�ID ATTACI�ED,
Town of Yarmouth taxes and liens must be paid pno to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET'URN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001.
SEASONAL ESTABLISFIMENTS ARE TO CONTACT Tf�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 OPEPTING:All swinuning,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 colifornt and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swnnming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
�ONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
(,ATF.RiNG POL.ICY:
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.
FRO .F.N D SSERTS�
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAF�S•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),m�1 have prior approval from the Board of Health.
OUTDOOR COOKING•
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited.
DATE: l v J�� ��- SIGNATURE:
PRINT NAME&TITLE F� L �V c��N ��5��€�-
09/11/O1
�\
�' The Conimanweal�Ir ojMassacbusetts
Deparlmen�ajlnduslria/�ccidenls
> 0//l60N�y1tlIlf
6b0 Woshinglon Sfree�
' Boston.Masc 021I1
W'orhers' Compensation Insunace Affidavit
Aoolicant informafion: Pke�ePRdV7'TerOdt
p�g;C�r{F�RyL A. cIDXNSo/J � �
lucation� . .
ci��- ehone M
� I am a homeowoer penortning all work myself.
� I am a sole proprietor_^,i ha�e no one �corkine in an}•capaeity
�"�I am an emploger pro�idine workeri compensa�ion for my emplopees working on this job.
eommnrname• ^TLtI�`��s�tNP ..$�p/ILdT,$ ',r/VG dbd ��.I�'.�ie�s �/9�/t�' a�/��
address: �G GJ1t�� /�'tAI� �STRnE�T �+
tib•: !/vza7�_ Y/�/�/h�I//f+ /�/� ohene M: S�O �7S�(/�/
insuraneeeo. �J{�AMEIC.IC/1N �NSURANGF Ce. eolieyp �� Q�-���•C'�G�
� I am a sole proprietor. �eneral contractor.or homeowner(circle anel and have hired the contractors listed below u ho ha��
the Follo�cin_aorkrrs' :ompensation polices:
� somosnv eame: �
address•
�
�v: � � ehene N• __
in���ranee eo. yoliev!f
tomeany name•
addresr
. ' �(y� ohaee M: � .
.¢,�
insuranee ce. .�._ mHn N �
- -� � Failure to xeun tmnte�s required wder SeeWs-25A of MGL IS3 m In�te Me i�a�af aiWY peWpe ot�A�e q p S1.SOOAO a�dlor �
. " i�e yean'iapriaosmnt u well n eivil penlHn i�the form ef�STOi WORK ORDER aN�Aie ef S10R0��8�r apiW�e 1 uders��1L�a
-� eoyy of thh sutemem mar be fonv�rded ro tAe OOfce of IaraHpObm d1Ye DIA for eeverqe veeillptlN, - _ � � � �
!du 6enby cea' •under tbe inr and alU ojperjnry 1hm rhe iejonmtlon prorfAtd a�ore b mir�d mrrnt
Signuum ���� ��
Printname L. a�el�� 7��W�T
oRcial use onl�• do not.rite in thia aro to 6e eo�npkted..6y eiry ar 1ew�allleld ��
eiry w�arn: Y��T$ _ persitAia�e N nBnildiog Depvrmmt
pLieemio�Bwrd
�ehe�k if immediate response ia required 261 �Selettmn'a Ofllee
(508) 39&-?231 ��, OHnlee Depirmiem
eonmet penoe: � pYaot M;_ nOther
�,e.nay:ac P11� � . .
. �,.;r.::��.
ACORD_ INSURANCE BINDER ' °�'° S 1"'i,o2
THIS BINDER IS A TENPORARY INSURANCE CONiRACT.SUBJECT TO TFff CONDITIONS SHOWN ON iHE REVERSE SIDE OF THIS FORN.
�100�� 7B1-293-6331 � �^� �0�• 3519
781-293-2171 Great Aaerican InA+,*-r++c:e Co.
FII4. F. Horhek Insurance Agency oa� � w� n�
311 Plymouth Street ^w X �r°i nu
Halifax MA 02338 10/21/02 � 11/20/02 �+
Scott C Casa ande ����Tpo�e�cov�rsnsEwnfneovew��coururv
c� suscooE: vaeowwncraicrs �
cusro�R� HECHI:-1 o�roNosocexnnor�ve�rr0�c�a�aneml
xisunEo
Twilight Spirits, Inc. ���r � ���
t/a Beckers Package Store
46 Sast Main Street
Hyannis 29� 02601
coverencEs u�s
�vaeoFsmm�wce � omuc� coasx nwurr
�P� uusesoFwss Aatual Loss Busiaesa Eacoae�
ens�c ��ono Q� Persoaal Property 500 $91,000
ce+ee��weanY Fwa+o�+cE s1000000
g Nw�acuuco�+utuenm . �o�►uceWya�ere) 5300000
aauasw� �X occ� , � u�owwwa�evasml i10000
X Liquor Liability $ /$2m -� �anwwuer s1000000
ce+e+��cer+�cnre s2000000
r�nmo�tewrtcwusunoe: vnooucTs-ca.wrorncc s2000000
p����' co�r�oswc�Euur s1000000
anwro eoo�reuxnr(rga�l s
ALLONmEDAUf05 eOdLYNaI1Rir(PBraWaa�i) S
SClEOIxIDAUf05 PROPH(tYOMWGE S
X HWWAUf05 Y�ICALPAYABffS f
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11UTORIYSICALORYKiE O�UC7BLE ALLVE!/QES �i�IRIDV@if1ES ACTWLCIISFIVAWE
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UI�RFJIAFORM AGCaREG�TE f
on�etnowu�uFowa rs�mow�Fweciwwsw�: saF-wsur�rsEra�rrow s
WC5fATUI'ORY1.911T5
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�nseasE-raucruar s500000
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p7��� TA�S S
COVERAGES
ES7Wn7ID70TILLPRBYUY S
NAME&ADDRESS �
X � �oomaw-ru�
�s rnvff
� BIISINBS Wlwa
Business Loaa Center, InC "
ATIt�, 3ervici.ng Dept. ��A� �
645 Madison Ave 19th Floor �
Nen York NY 100�12
Scott C Casa snde
ACORD 75S(1198) NOTE:INPOKTANT STATE 9iFORAMTION ON REYERSE SIDE CORPORA710N 1499
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #02-067 FEE: $45.00
In accordance with reaulations promulgated imder authority of Chapter 94,Section 305A and
Chapter 111,Section 3 of the General Laws,a permit is hereby granted to:
Twilight Snirits inc_ 46 Rast Main Stree�, West Yarmnuth_ MA
Whose place of business is: Becker's Package Store
Type of business: Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yarmouth
Pernut expires: December 31.2002 BOARD OF HEALTH: �i4anlea r?�. z�. (�.�al�rca�r
' D. �, �K D., ?/u:e
RES7RICTION:Milk,juice,packaged chips,soda � �7oct�rt, �,�0't�
pa�rtek 7X�etntatt
� Sks�4, �?Z.
October 31 .2002 ruce . ur y, , Ff�
Director of Health
TI�E COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #02-051 FEE: $20.00
Th;s is to Certify that Twilight Snirits Inc. d/b/a Becker's Package Store
46 East Main Street. West Yarmouth_ MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PRODU TS
AS PER THE YARMOUTH BOARD OF HE T TH TOBAC O RFGULATION
This permit is granted in confonnity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires T�ecember 31.2002 unless sooner suspended or revoked.
October 31 ,2002 BOARD OF HEALTH: ��, i�e(�t�pa, ��ut�a�C
�uja.Ki.c D. C�midoK, 7K.D.. 2/lee
�o6e�t'�. �wmv�. �
�aarlek'lXXcDararotl
`�ePew S . .?Z.
ce . urp y, , ,
irector of Health
, ' '� gE��KERs PAGKAG-E
OF YARMOUTH BOARD OF HEALTH
/a�,T�p� �` ICATION FOR LICENSE/PERMIT -2002 �;� [� (�; [� [; \�J I� f�
* Please complete form and attach all necessary documents by December 31, 2001. Fail e t`�'dia se�i1Q�ult '
the return of your application packet.
HEALTH DEPT.
AME OF ESTABLISHMENT: r TEL. # /
TIO S: �
MAILING ADDRESS:
OWNER/CORPORATION N,�1�F. �� P� �tTS 1�/�-
MANAGER'S NAME• —JOiv ,!� HP TEL. #
MATi ING ADDRESS�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community 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 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-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 certificaUon to this applicaUon. The Health Department will not use past years' records.
You must provide new copies and maintain a 51e 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. Z•
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $50 CABIN $50 _MOTEL $50
INN $50 CAMP $50 _SWIMM[NG POOL$SOea
LODGE $50 'I'RAILER PARK $50 WHTRLPOOL $25ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMTT# L[CENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $75 _CONTINENTAL S30 _NON-PROFIT $25
>t00 SEATS $150 COMMON VICT. $50 WHOLESALE $75
FTAI RVI .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#� LICENSE REQUIRED FEE PERMIT#
_TOBACCO $20 _<ZS,OOOsq.ft. $75 1TOBACCO S20 Oa�B
�<50 sq.ft. $45 Qe1 _>25,000 sq.ft. $200 _FROZEN DESSERT$35
NAME CHANGE: $10 AMOUNT DUE _ $ 6S.O�
***"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•"
ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Warker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �N �b�'
Q� 1i,.i� [.�qru•rrt.LlCe-[a&c.
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth 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 RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2001.
SEASONAL ESTABLISF�;NTS ARE TO CONTACT TEIE HEALTH DEPART'MtsNT 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
_—_ ._ _ PQOLS __
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
CON U R VISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post
Consumer Advisories.
CATERING POLICY•
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departrnent 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 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: I L SIGNATURE:
PR1NT NAME & TITLE
09/11/O1
�
The Commonwealth ojMassachuset[s
= Departmenl ojlndustrial.-Iccidents
a Olflce sl/arestlyst/ais
600 Washington Street
' Bosron.Mass. 02111
� W'orkers' Compensation Insunnce Affidavi[
Aoolicant information: Plea• �
n�mi� ����� 13t fS 1� �(-�Y�� C �flCli �V�
locmion. �/ IL-f .
�t` � ��' ✓ phone a / iC1 !�(o' C/
� I am a homeowner pzrturming all work myself.
� I am a sole propriemr �r.,', ha�e no one norkin� in am capatin�
� I am an emplocer pro�iding workers' compensation for my emplocees uorkine on this job.
comnanv name: ��y�e�
�ldress:
titv': /� /� ehon e•
iosur�ntt co � YL�IA1 I �FQGLI' �� ll1ti� � � oolicy N �'-�y�C�f) � �
� I am a solz proprietor. _eneral contraetor. or homeowner(circfe onel and hace hired the contractors lisred below ��ho ha�e
thz follu�cing ��orkrr_ ;ompensation polices:
comoanv name:
re
ciR': nhene p• .
insurancc co peliev p
S2mnanv name:
address
vh" phoes M• �
insurance eo. � poRev N �
t
Failure�o scoure covenge�s«quired uoder Secnon 25A o(MGL 153 a�lad to t0e ieporitloe o(ensiW peultla of���e ap a 51300.00��d/or
�one yean' imprisonment n w�ell a�civil pemitln ie the form ot�STOP WORK ORDER nd i 6ae of f10D.Oe�d�r K�imt me I ndenfa�d tLat■
� eopy ot�hy etatemem may br fonv�rded to the ORee o(Invn�ipuom of tbe DIA for eoven�e rerilfntlo�. �
/do�hrr ertijp under rhe pain penatria ojpery'ury rhaf�he injormafian provided abovt is nae and con�et
Signaturc � J/�/� �G�
Print name � �/O�✓ /" "�i90.k4i� Plione X .7D�� 77�d�� �f
.. oRcial use onh do not wriu in�his arn ro be tompleted by city or lown o0leial
city or town: Y�M�IIT$ _ permilAieeau N nBuildiog Departmeot
. OLierosios Board
� check if immedia�e response i�required Z61 �Stlettmen'�Ofiiet
(508} 398�2231 pat, �Health Dep�rtmeet
conroct penon: phont M:_ __ _ nOtAer
� Participant: D D S SpiHts, Inc.
Becker's Package Store
Certifieats Numbar. 0760-11
Coveraps Period: January t, 2001 to January 1,2002
Additional Named Insureds: Locations:
Becker's Package Store 460 E. Main Street, Hyannis, MA 02601
D D S Splrits Inc
Schedule of Operations:
�, Code � EsGmated Rate Per Estimated �Effective �
;Number:i Ctassification: �Total Payroll': � $100: Fee': � Date: j
8017 Store: retait NOC 584,474 1.28 $1.081 1/1
Total for period: 1/1/01 to 1Hl02 $1,081
15% Rate Deviation: ($162)
Increased Limits Fee: S�
Merit Rating Credit: .950 ($46}
A.R.A.P.: 1.000 SO
Total Mod�ed Fee fw period: 1/1/01 to 1/1/Q2 5873
Total Modifled Fee: 5873
Fee Discount: SO
EsGmated Certificate Fee: 5873
Note: Payroll data antl Feea may reflect pro-raW valuea il applicable period is oNer Vian one NII year.
Reason: CeRlficate renewai
Issued: December 3. 2000
Towiv oF Ya�moirrx
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT Ni7MBER: #02-009 FEE: $75.00
In accordance with regulations promulgated�mder authority of Chapter 94,Section 305A and
Chapter 111,Section 5 of the General Laws,a pemut is hereby granted to:
D1�S S inn 'tc inG„ 55 Route 2R Wect Yarmnuth_ MA
Whose place of business is: Becker's Packa�e Store
Type of business: Retail Food Setvice less than 50 s�uare feet
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2002 BOARD OF HEALTH: (�4aalea�. Zeflrlraa, �ifaur�a�c
D. �. '�l D., `U�ee
� �. G�
P���
:3�eEe.� Skak, ��P.
March 8 .2002 ce . urp ry, ,
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NLJMBER: #02-008 FEE: $20.00
This is to Certify that DD S�rits Inc d/b/a Becker's Package Store
55 Route 28 West Yatmouth_- MA
I�HEREBY GRANTED A LICENSE
For SAT E AND DISTIZiRUTION OF TQBACCO PRODUCTS
AS PER THF Yt�RMOUTH BOARD OF HEALTH TOBACCO REGULATION.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Mac.sachusetts;aad
e�ires December 3l.2002 unless sooner suspended or revoked.
__ �n s ,zooz so�oF:����: _ �w�a�. Zdl�, eka�r,�aK
E�e�rj�Gc D. CJmrdaa. 'jK.D.. 'Ulee
,�o�t'3. 8'zavac. L�fatk _—
�aarlek'iXeDraexetl
�efe� S/rak. ,�7Z.
ce . urp y,
Director of Health
. .;
�-��., �.,,, ,,,, ,,,,,, ,��`B��Ec.l�ERS PRGKR6ESla2F
� . /
TOWN OF YARMOUTH BOARD OF HEAL�H G3 �f° ��" I�' Il r,�j (�� L�
APPLICATION FOR LICENSE/PERMIT-2001 L'"E:� O 4 2��0
' Please complete form and attach all necessary documents by December 31, 2000. Fail d i�i,�h�bl�ilff��ult 'n
the return of your application packet.
-------------------------------------------------------------------------------------------------------------------------------------
S Sdb� 1
LOCATION ADDRESS: l�U r
MAILING ADDRESS: ttjF, G Mq�wl n vi:tn
OWNER/CORPORAITON NAME: "��S S�� �z-�rr � n�c.
MAIdAGER'S NAME: �[�.� l`a�RPrv�v.S TEL. #
MAILING ADDRESS: �nn�
-----------------------------------------------------------------------------------------------------------------------------------
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 ttus form.
1. 2.
Pool operators must list a minnnum of two employees currently 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 file at your place of business.
1. 2.
3. 4.
HEINILICH 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 ail times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Deparlment will not use past years' recorda.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL#
-_ ------- -•--_- ----- -----_-- ------ --_------------- --------- -----_--- -------- -------------- -
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT#
B&B $50 CABIN $50
_INN $50 _CAMP $50
_LODGE $50 _TRAILER PARK $50
Mt3'I�L' � ' .$50 SpJIMMII�7G`i'OOL $SOea.
_ WHIRLPOOL $25ea.
�QOD SERVICE:
NOTE: Per the new 105 CMR 590.000 State Sauitary Code for Food Establishments,the effective date for
food protection manager certification is October i,2001.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
_COMMON VICT. $50 _WHOLESALE $75
BETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
I <SOsq.ft. $45 �DI-DOZ �TOBACCO $20 �0/-dp/
_�L5,000 sq.ft. $75 _FROZEN DESSERT $35
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOiJNT DUE _ $ (o S•00
••*•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•«"*
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND 5IGNED, OR
CERT. OF INSURANCE ATTACHED
�
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taues and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ✓ NO
NOTICE:Pemuts run annually&om January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000.
SEASONAL ESTABLISHIv1ENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENII�IG FOR THE SEASON.
ALL RENOVAI'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department,and the water 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
NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS•
The effective date for food pmtection manager certification is OMober 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 wnsumer advisory is January 1,2001. As stated in 105 CMK 590.000(K), enforcement
of Conswner advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell
or serve ready-to-eat, raw or undercooked animal products are required to have consumer advisories.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Deparhnent by filing the
required Temporary Food Service Appiicadon form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitzess 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 pmhibited.
DATE: �� �'I � SIGNATURE:
PRINT NAME & TITLE: -�,�U ( ,H�Mrw,�.✓ ���
11/16/00
. . �
The Conrmonwea[th ojMossachusetts
3 Deparlment ojlndustria/flccidents
; //llce ol/sresf/ystliis
600 Washington S�ree1
Boston,Mass. 01111
" Wbrkers' Compensation Insurance Affidavit
Apnlicant information: PleaieYRIIP1'Te�'LTa
name� �� S �7 �I K 1"fS � NL- .
location� r','�o '� {�/���N S"� � '�T � . �
��� �j,� lA K� GZ Cr-7�J ehone q S�CnJ 77�D L !/
� I am a hameowner pz formm�all work myself.
� I am a sole proprietor ard hace no one��orkin_ in am capaciry
� I am an employer pro�idine wnrkers' compensation for my employees workine on this job.
com�anc name• �S� S �7f V� Tl � ^�
�ddress� 'T'�C � N���� S) � —
��• �t ) VI fl�YV��I.I {'�� �hone k• � `77SOb I/
ipsur�nceco � 5�"7'19�i� ��Lfi WdiLw l'L��(� �2i� ool�# v��'�p� �
� I am a sole proprietor. _eneral contracmr, or homeowner(circle anel and have hired the contractors lisred below �cho ha�e
thz follo�cin_ «orkzrs compensation polices:
comp�nv name•
address•
��• phone k:
insur�ncc co Dolicv#
n n m :
address — - _ . __
.�'.�,,.e.�,- phooe M•
C9�£Y#
Pailure to steurt covenge as required uoder SetHoo 25A of MGL 152 u�kad lo the i�poeiaoe of erimiW pe�dtla of a O�e ap to SI,500.00 a�d/or
one yean•imprisonment is wxll a�tivil penalHn io the form ot�STOP WORK ORDER aed�6ot of f100.00�d�y af�io�t�e 1 r�denta�d ehat a
eopy of thh stuement may be forwarded to the ORce of Inveatigaliom otthe DIA for eovenge veri6utlw.
!do hrr ijy under nc�pains a na(ties ojperjury 1ha1 tkt injormatian provided abovt is but and ror►ect
Signamrc ate �����
Print nam �Q p73/r0 �./f71�YV�AN Phone M S� ���' ��
., oRcial use onh do not wria in tAis area to be completed by city or rowa oflltial
- city or rown: Y�M��T$ _ permitAicenu M nBuildiog Departmeo�
� pLiemsiog Bo�rd
� check if immtdiate responst ie required 261 �Stlec[men'f ORet
❑Hnith Departmeet
contactperson: Pppo�g�_ �SOE� 398t2231 Cat. nOMer
Ire.�sN;;a5 P1A1
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: #01-001 FEE: $20.00
This is to Certify that DDS Snirits Inc d/b/a Becker's Package Store
55 Roure 28 West Yazmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIB TION OF TOBACCO PROD JCTS
AS PER THE YARMOUTH BOARD OF HEAi TH TOBACCO REGU ATION
EFFECTNE NLY 1. 1996.
This permit is ganted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2001 unless sooner suspended or revoked.
December l2 ,2000 BOARD OF HEALTH: �� �eLYCd, �e{�t
�Q�l�ed?�. /�d�. �/iCe �,lsQdlntQ�
�oBad`�. �7aeswc, elaik
�ia4a� d:C'ouglr�
�� a. �. � ;t
« . � y, , ., .�
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #O1-002 FEE: 5 0
In accordance with regulationspromulgated under authority of Chapter 94,Sec6on 305A and
Chapter 1 I 1,Section 5 of the General Laws,a permit is hereby granted to:
nn4 4niritc inc 55 R�?R �IJect Yarmrn�th 1��A
Whose place of business is: Becker's Packa�e 4t�,v
Type of business: Retail Food ervice less han 0 s��are feet
To operate a food establishment in: Town of Y o h
Pemut expues: December 31 2001 BOARD OF HEALTH: L^d 711C, �ettea, �;r„raK
�iFa�lea'+� zeillikm. �/r.'ee L�ka�i.Kwc
,�oBait'�. S�ioeavs, (�en(t
�aaC O:�oaqlr(Gc
� D• � . �K D.
�`1
December 12 .2000 �
D'rector of H ae ltt�i ' �
j�zz'�ev� f�;cuc��_Sfcrr-_.
� � TOWN OF YARMOUTH BOARD OF HEALTH G� C � C� 17 M � �
4 " APPLICATTON FOR LICENSE/P�RI�T�'=`.2000 N 0 V 2 6 1999
�, '�
* Please complete form and attach all necessary documetrt3"�iy�Dece�ber 31, 1999. aiMfie�th�BH� It in
the retum of your application packet. �,��1'�
, �
, _:� , . - q�
--------------------------------------------------------'��.----=----�0=---------------------------------�-----------
NAME OF ESTABLISI-�1ENT� �� P0l.(c�OE+C S?t�tz� TEL #�I7.S�-�o r/
�.00ATIONADDRESS 5� .�� 2v /.r� �l,o�
LIN D � n1 ,
N • S�2rr) c.
MANAGER'S NAME: 1 Biv L�' sOP�I 't'FT. # ?�D6 //
MAILING ADDRESS: �!P C JJ'/9 i�✓ �,o.�v�v.�
/ - —
------------------------------------------------------------------------------------- �_ ���_.
POO . RTIFICATIONS
The pool supervisor must be certified as a Pool Operator, as required by uew State law. Please list the
designated Pool Operator(s) and attach a copy of the certification to t}us form.
1. 2.
Pool operators must fist 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 certiScations to this form. The Health Department will not use past years' records. You must provide
oew copies and maintain $fite at your ptace of business.
1. 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 file at your place of business.
1. 2.
3. 4.
REST�LIR€�i'P SEA�'II�TG:TOTAL# — —�ION-SMOKING SEATS: TOTf1L #
-------------------------------------------------------------------------__—__--_----------------.______—
OFFICE U�E ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT#
_B&B $50 _CABIN $50
_INN $50 _CAMP $50
�. .. , ',L9�'iE ' $�SA ;�T�IT.�R P�: $�a„_ ;
g �MOTEL $50 SWIMMING POOL $SOea.
WHIRLPOOL $25ea.
FOOD SERVICE•
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $75 CONTIlVENTAL $30
>100 SEATS $150 NON-PROFIT $25
_COMMON VICT. $50 WHOLESALE $75
RETAII. SERVICE:
LICENSE REQITIRED FEE PERMIT # LICEN3E REQUIKED FEE PERMIT #
�<50 sq.ft. $45 �7 �TOBACCO $20 Y2K-5
_<25,000 sq.ft. $75 FROZEN DESSERT $35
_>25,000 sq.R. $200
NAME CHANGE: $10
AMOITNT DUE = $ �--
•'•••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•^••"
_ _ . „
,
ADMINISTRATION
UNDER CHARTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NbW REQUIItED
TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A
PER,`SO�T OR 'COMI't1N3� 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 �N ���/
� G1c2f*dc
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH T.AXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES � NO
NOTICE: PERMITS RUN ANNUALLY FROM JANLIARY 1 TO DECEMBER 31. IT IS YOUR
RESPONSIBII.ITY TO RETURN TFIE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMIIVT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATION3 MAY REQUIltE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPEIVING: ALL SWIIvINIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR
TFIE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND TF�WATER TESTED FOR
PSEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPElVING, AND QUARTERLY TI-�REAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlviNIIIQG 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 NOTIE'Y Tf�YARMOUTH HEALTH
DEPAR'TMENT BY FILING THE REQUIltED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72
HOURS PRIOR TO TI� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� HEALTH
DEPARTMENT.
FROZEN DESSERTS:
FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST
RESULTS MUST BE SENT TO Tf�HEALTH DEPART'MENT. FAII,URE TO DO SO WII,L RESULT IN Tf�
SUSPENSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE
BEEN MET. _. __.__ _ _ _
QiJTSIDE CAFES:
OiTfSIDE CAFES(i.e., OIJTDOOR 5EA'TING W1TH WAIT'ER/WAITRESS SERVICE), MCTST HAVE PRIOR
APPROVAL FROM THE BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISHR�NT IS PROHIB
DATE: ]/ � ///, ��I� SIGNATURE:
�-T-r�-�
PRINT NAME& TITLB. '�U>✓+�?�h0 ���)0<l,�I �A.e'1
11/12/99
�
� � The Commonwea/!h ojMassachusetts
= = Deparrmen! ojlndusrrial.accidenn
_ a 0/1/C00//LYRStly�W/f
600 Washington S1reeJ
q Bosron, Mass. 02111
" Wbrkers' Compensation Insurance Atfidavit
ARnlicant information: P1 o.epRilVTTed.-1,�p
mm � �`,,� -- �
�:C%KG/LS ����C,1(.G ,�'�
luc�tion� �� � /d?�lRf
ut� �l�/J/2i! / G� ehon a
� I am a homeoµn r pzn�rming all aork myself.
� I am a sole propriemr �-,', ha�e no one �vorkin_ in am capaein•
� I am an emploper pro�idine µorkers� compensation for my employees workine on this job.
tomnaar name: %//7 Z l�l�
�dAress• Tpff1A ��lL
citv' �LLG/.//� /� nhene u• �Z � �79 d(o //
�sur�nceco �S vrila+�� �S YV�{ULI.F;Ll�+(� nolicytt �J(JV�
� I am a solz proprietor. _eneral contractor. or homeowner(circle anel and ha�e hired the contractors listed below ��ho ha�e
thz follu«ing �corker aompensation polices:
comoanv nnme:
address:
tih': nhene M•
insurancc_co. yoliev#
tomoanv name:
addre3s:
Uh" pheee Ih
insuranee co. pogn.*
�
F�ilure to aeeure covenge u«qufred uuder Seetlon 25A of MGL 1S2 n�Ind to tbe iepaiOw of erisi�fl pesdtln oh Ou ap lo 51,500.00 ud/or
ooe yean'imprisonment��w�dl af tivil pentlHa io the form of�STOP WORK ORDER aed i Oet ofS100.0p�dar q�imt me [udmh�d Nat a
topy ot thia statement m�y be fonv�rded to�he Olticr of Invatig�tiom of fAe DU far eoven�t veri6uW�.
!do- reby c ij}•unde ains a a/�ies ajperjury thm�ht injorrnalion provided above is tnit and corrcR
Signature� � y� ^��l/frlJ�
�
Print ame U oneM � � O �
.. olTicial use onl. do not wriee in this arn ro be completed by eity w tmvn oflleial
city or town: YA��IIT$ _ � permiNitce�e p nBuildine Departmeat
pLietasine Bo�rd
� check if immediate responae i�required Z61 OSelectmen'e Oflice
_ �HealtA Drpartmeet
con�actperson: - phoneM:_ �508) 398�Z23I" e3t. nOtAer
TOWN OF YARMOUTH
' � BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: Y2K-7 FEE: $45.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
11 I,Section 5 oFthe General Laws,a permit is hereby ganted to:
nDS S iri s Tn ._ 55 Ro �t R West Yarmouth_ MA
Whose place of business is: Becker's Package Store
Type of business:_Retail Food Service less than 50 square feet
To operate a food establishment in: Town of Yazmouth
Permit expires: December 31. 2000 BOARD OF HEALTH:�d��/.+�et�p0.,, C�at.�q//� ^ '
�oa/a C�.c�7unllivan� n�a//.� Vics ��irma
RESTRIC770NS [F ANY: Milk,Juice,Packaged Chips,Soda �obart J//. /,rown/� C.[er�
a6.eelle�a�o/a�y�oapae
;��lOoCouy���,.
December 1 . 1992 Bruce G.Murphy, MPH, R.S., CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: Y2K-5 FEE: $20.00
This is to Cert�fy cnat DDS S}�irits Inc d/b/a Becker' Package St�re
55 Route 28. West Yarmouth MA
IS HEREBY GRANTED A LICENSE
For SALE AND DISTRIBUTION OF TOBACCO PROD T
AS PER THE YARMOUTH BOARD OF Ai TH TOBA CO RFG JT ATION
EFFECTIVE NLY 1. 1996.
This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
expires December 31.2000 wless sooner suspended or revoked.
December 1 , 1929 BOARD OF HEALTH: G�� �s�, C'�i,,,,an
�oaa C..c 7�u[Guan� K.//.� Vica �hairmna
Ko�rrt..t. O�rown
�a6rre�[e�a�OU�y-�ooPa:�
///ic��o eCouyhlin
Director of H�e,a(Ui � '
gec itzr's Vac v.rac��`�e��
TOWN OF YARMOUTH BOARD OF HEALTH p � �' � � � � �
' APPLICATION FOR LICENSE/PERMIT- 1999��5"�° p�.i; 1 1 �ggg
Ch
+� Please complete form and attach all necessary documents by December 31, 1998. Fail 1
the return of your application packet.
---------------------------------------------------------------------------�s ---------------------------------------------------
NAMF OF ESTABLISfIMENT �S ��e-.�A6t JTL�'Cc' TEL # �T7,i UL%�
ATI N D SS: �� � m4 i�i
I�LAILINC. ADDRFSS• �/��2y + Q �cr/
RAT N N � S�i /iirt lnr c.
MANArF.R'S NAN1F' �/ o.vsi�A�l -,�iRPm9nJ TEL. # ?zb�Z Sz�
MAii ING ADDRESS �3- �u-�t r /-�-�.��,b
------------------------------------�L�_r.�Z1__l��--------------'-=--------------------------------------------------
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the
designated Pool Operator(s) and attach a copy of the certificarion to tlus fonn.
1. 2.
Pool operators must list a minimum of two employces currently certified in basic water safety, standard First Aid and
Commumty Cazdio�ulmonary Resuscitation(CPR). Please Gst these employees below and attach copies of employee
certificahons to ttus form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your ptace of business.
1. 2.
3. 4.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach wpies 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# NON-SMOKING SEATS: TOTAL#
----------------------------------------------------------------------------------------------------------
_- - -- --_ _ O�FICE�tS�BNLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
' B&B $50 CABIN $50
INN $50 CANIP $50
LODGE $50 TRAII,ER PARK $50
MOTEL $50 SWIMIVIING POOL $SOea.
_WHIILLPOOL $25ea.
FOOD SERVICE:
LICENSE REQLJIRED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT #
0-100 SEATS $75 CONTINENTAL $30
>100 SEATS $150 NON-PROFIT $25
COMMON VICT. $50 WHOLESALE $75
RETAIL SE�tVICE:
LICENSE REQLTIRED FEE PERNIIT # LICENSE REQUIRED FEE PERMIT #
�<50 sq.ft. $45 �Z �TOBACCO $20 ���
_<25,000 sq.ft. $75 FROZEN DESSERT $25
_>25,000 sq.ft. $200
NAME CHANGE: $10
AMOUNT DUE _ $ 1 ��J —
""'""pLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM•^•"
. .. . .. . . . . I
ADMINISTRATION �
LTNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TF�TOWN OF YARMOUTH IS NOW REQUIItED
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 INSLJRANCE ATTACHED /
2
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF
YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID:
YES ✓ NO
NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR
RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY
DECEMBER 31, 1998.
SEASONAL ESTABLISF�IENTS ARE TO CONTACT TF�HEALTH DEPARTMENT FOR INSPECTION
7-10 DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIlv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: ALL SWIMNIING, WADING AND WHIltLPOOLS WHICH HAVE BEEN CLOSED FOR
Tf� SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND Tf�WATER TESTED FOR
PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB,
PRIOR TO OPENING, AND QUARTERLY THEREAFTER.
POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING POOL MUST BE DRAINED OR COVERED
WIT'HIN SEVEN (7)DAYS OF CLOSING.
FOOD SERVICE
CATERING POLICY:
ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH
HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION
FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT Tf�
HEALTH DEPARTMEN'I'.
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. FAILURE TO DO SO WII.L RESULT IN
T�T�P�TSIQnIDR-AE-VOCATION OE Y4UR FROZEN DESSERT PERMIT UNTII,TEIE ABOVE TERMS
_ . —
— _ _ -- -
HAVE BEEN MET.
OUTSIDE CAFES:
OiTfSIDE CAFES(i.e.,OiJTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR
APPROVAL FROM TI�BOARD OF HEALTH.
OUTDOOR COOKING:
OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD
SERVICE ESTABLISfIMENT IS PROHIBTTED.
DATE: L � �� SIGNATURE: -"
PRINT NAME& TITLE: �Di✓AT�/Ar/ ( fiADirt��J �wN�`�'
a
. �
The Commonwea/th ojMossachusetts
= Deparlment ojlndustria/.-Iccidents
_ o OMce oJ/erestlystliis
' 600 Washington Street
Boston,Mass. 01111
" '� • W'orkers' Compensation Insurance Affidavit
Aoolicant information: PI�sePRINTTidGi�
mm�� T�� J�l1�Ll� �/�G- C�'�l9�Lt ��'z�E)L4 �L'�.L�A�t`�
location: 'i�lo � �/�/ �
cit�� /5``?.�GVIi2CS ///" �7�i o� phoneA.S����J-06 !/
� 1 am a homeowner pzrt�rming all work myselE
� I am a sole proprietor�r.d hacz no one ��orkin_ in am capacin•
�I am an employer pro�idins µorkers' compensation for my employees workine on this job.
comnanvnamr �7t�1-��� (f`iQe-�'id�sE S
adAress: 7� � /Vb�sV�
sitv: /`T�1Ct.KKGt ohone a. �76 O G //
ipsur�nce co mA5$ ��'Tqil ����.6g�.�{ �,U/���.�/,�P �� policv a /J7(a G�
� I am a sole proprietor. general contractor, or homeowner(ci�cle onel and ha�e hired the contractors lisred below ��ho ha�e
thr follu�cin� ��arkzr compensation polices:
som{Lan,v name:
addresr
sity: phone M•
in�urancc to. politr p
eamppny name:
address•
c�: phoee p:
insu[anee eo. eotiev M
Failure to secure coverage as required under Seenoo 25A o!MGL IS3 n�kad lo the iapaidoo o(erisiW peultln ot�B�e op to f1�00.00��d/or
ooe ytan'imprisonment n w�ell af civii pen�IHn io tAe form of a STOP WORK ORDER�W�Ifae of SI00.00 a dry qdott me 1 a�denaW N�t�
eopy o(ihie satement may b�forw�rded to the Oflfee of InvotiQ�tioot of the DU for toven�e veri&�tlw.
/do� rre ¢rlijj ande��he pains a!lier ajperjury that fht injormalion providtd abovt is t�ut and cor►tct
Signaturc � /��S ���
�
Printname PhoneM J� 7��0� r/
� otlicial use onh� do not.rite in this area to be aompleted by cih or lown oflltial
ciry or town: Y�M��TQ _ permiUlieeoee M nBuilding Department
�Lieensiog Bo�rd
0 check if immediatt response ie required 261 �Selectmen'�01liet
(508} 398-2231 eat. �Htilth Dep�rtmeo�
contact person: pAone M:_ _,_ _ nOther
�m�nN;,os vinl
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT NUMBER: 99-6 FEE: $20.00
This is to Cenify chat DDS Spirits Inc. d/b/a Becker's Packa,ge Store
_ 46 East Main Street_ Hyannis_ MA
IS HEREBY GRANTED A LICENSE
For�A�E AND DISTRIBiJTION OF TOBACCO PRODUCTS
__ AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION_
EF'FECTIVE JiJLY 1 1996
TLis permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and
e�cpires December 31. 1999 unless soouer snspended or revoked. n c7
December 15 , 19 98 BOARD OF HEALTH: C.d��/P. Jellapee� C��iairman
�oaa G. �ul[ivan� K.//.� Vice l,hairman
�o6a.t e�� [l3�,�wpz /,
�abrieL(e Ja�oGtky-.htooPe9
�.e�0' o ���
ntce . �P Y, ,
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLIS�NT
PERMIT NUMBER: 99-7 FEE: $45.00
In accordance with regulatious promulgated under authority of Chapter 94,Section 305A and
Chapter I 11, Section 5 of the General Laws,a permit is hereby ganted to:
n1�C Cniritc Tnc 46 Fact Main Ctreet,jjyanni5,MA
Whose piace of business is: Becker's Package Store
Type of business: Retail Food Service less than 50 s�uare feet
To operate a food establishmem in: Town of Yarmouth
Permit e�cpires: December 31_ 1999 BOARD OF HEALTH:�d�(/.���e7tteag�, C'�(,��.q.ta//nn / /J
. � �[�oa/n G. Jnu[livaa�/K�e.//l.� Vice C,�irmart
RESTRICITONS IF ANY: Mllk,Juice,Packaged Clups,Soda. Kobert� /�rawn� l�Larh
a6.w�sa�o��y�.VoaPa�
��e� �o ��
December 15 . 1998 tuce G.Murphy,MPH, .,C
Director of Health