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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 , � ,7 TOWN OF YARMOUTH BOARD OF �r� ��S��CDu N�`t 5 2E � � APPLICATION FOR LICENSE �I�ID ' � � [J U� �� ;��1 EC l � * Please complete form and attach all neces ; cu�ients by Dec� �N�i. Failure to do so will result in the return of your application p . NAME OF ESTABLISHMENT: �uC=K /rua-n/� �'Gtin/�y,�jj,-rtB TEL. # � 8 7sla ��I.r LOCATIONADDRESS: .�a8 Bucree �st-.� �. wEsr y�emour�r�. m,� 6y6� MAILING ADDRESS: SsHn� Ar M�dv� OWNER NAME: E�A-2 iC'i/aT/ TAX ID (FEIN or SSNI: .� CORPORATION NAME (IF APPLICABLE): E Mp,LT� CdR.� /NC. MANAGER'S NAME: E.TstZ K<t2sJ TEL. # SOP �'fa j'� MAILING ADDRESS: _PM»t ,4� /h36Y� POOL CERTIFICATIONS: The pool supervisor must be cerrified xs a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. 1. 2. Pool operators must list a minimum of two employees cun•ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Piease 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 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 certification to this application. The Aealth Department will not use past years' records. You must provide new copies and maintain a Cle at your establishment. 1. �/� 2. PERSON IN CHARGE: - ----- __ _ _ _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees h•ained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIrG: LICENSE REQLI[RED FEE PERMIT# LICENSE REQiTIRED FEE PERMII# LICENSE REQi7IltED FEE PERMIT# B&B S55 CABIN 555 MOTEL S55 Nv S55 Cnl�� b55 SWIMMINGPOOL 580ea. _LODGE S55 . _'I-RAILERPARK 5105 _WfIIIZI,POOL SSOea. FOOD 5ERVICE: LICENSE REQLJIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# LICENSE REQiJIltED FEE PERMIT# 0.100 SEATS S8> _CONI'INENTAL 535 NON-PROFIT S30 >100 SEA'IS 5160 COMMON VIC. 360 WHOLESALE S80 RETAIL SERVICE: —RESID.KIICHEN S80 LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED .FEE PERMIT# _vOsq.B. 550 _>25,OOOsq.fr. 5225 _VENDING-FOOD S25 �QS,OOOsq.H., SSO �€b�-n�lo —FROZENDESSERT S40 I TOBACCO S55 #E69- 6�p �a�zEcxn�ce: sio AMOiJNTDUE _ $ 135-00 '"«"'pLEASE TURr OVER AA'D CO;VIPLETE OTHER SIDE OF FORR1'***** L Y ' •• � ADMINIST`RATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth 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 AT"I'ACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTAgLISHMENTS TRANSIENT OCCUPANCl': 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. Transiern 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 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 CMR 64G, as aznended, 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 NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of 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 Pernut until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOHING: Outdoor cookin�prepazarion,or display of any food product by a retail or food service establishmem is prohibited. NOTICE:Pemrits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMI'LETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI3E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. . � DATE: la- I� g SIGNATURE: �� PRINT NAME&TITLE: �S ��'> imu!as :. ,,,;•. � The Commonwealth ofMassachusetts Department of Indastria!Accidents �d� 600 Washington Stree� 7`"Floor Boston,Mass. 02I11 Workers'Compeasatioa iasm�ance ABtdavk:Baildiog/Plembieg/Ekctrical Coetnctors dterarlN�: Pleue PRmtT k�bh �: �'�Tq-� KF/�►-i✓ address: .So10 /'GK� �LA'11� /�+�/ siri Il/fdT Y�I�QZI�/ siate• /Y1� zio• OZ��S ohone# �� 7 /��'� work site location(full adJtcssl: �� ❑ I am a homeowner perfoiming all woik myself. Project Type: ❑New Constnic[i��Remodel . ❑ I mn a sole-proprietor and have no one wocking in any�capacity. ❑Building Addition LvJ i am an employer providing waicers'compeasation f�my�ployces wodcing�this job. . . . comoaavaaoe• /IIl� ��"�� / � .aar«.: f'.t�i� s1d A�-dv� . dc�• m��s• iasm..ee eo. ___peueti� :�. _. . . . . ,.-, �, .-� , . .�;, a„��a.e».� .,5t ❑ I am a sole proprietor,gea�al coatraeMr,or homeowser(cirde owt)a�have Lired the conhactas 1{s�d belo�•who have the following woikecs'compensation polices: � �dma- ci . � . � � . . �. � . . . . . . . � . . i�seaaee eo. � ��g . . . ,. � .. . . .._ ... . . . . ,. . x�. 5.t+.,�.`b`"�'i: WeDI�Y�!' i�dCtlb' �9' � . . ' . . �� . . � . _... .. ___ _. — _ . _. ._ __- .. . . __ . _ _. _ . _ _ _ _ ._. _. .. . . _ __.. __ __. . . . _ Inva�oe�,°i - ndievM ��ieeiilW� , .�., :< ,v. : .,,: ., �w �� ; �� ..._.M ,r. . FaY�ebsecmeea�e�enrtqdrad��dvSectlw25AHMGLLS3eukadbtYei�p�Jtlwdai�IWpeaNks�fa�e . , , �. . * . sae9nn'IsPeM��mtoweDudHpnaltlnlnthehr�Na37YXWORKORD&RaM�BeedS39�.M• RaS13M-MaoN�r.. npy o[IY6 NaieaeW my 6e forwarded oe Ne Omee a[IweNtgatlue at We DIA/r eawage ve�ntlsn. ��e. I mdenh�d tYu• I l0 6arby cerrify ander NYe patns wd peee(fies ojpujxryµd f6s infonndton prodded e6oae Ls b�ue a�l conrct . 3i%oaNrc�/ \1� DaM ��02-�6 . Prim name ��/�1— !�� Phone N ��r/ /�a �.) . o�dal me auly do oot wrke i Ws aru to 6e eonPleled b5 dlY x bwa s�tial � . . . cily°Tfawa' . . . PMdN�emeN Rie.i�.pep��ent ❑ehcek IC�e�f1e`eapea�e 6 reqai`d . � .. ��5� ❑Sdeetuea's O�ee . �LLeaHY Dqn��at ceMaQ pvaeu: �M, � tm:�a sm�mml EIG Fax Server 12/18/2008 2 : 00 : 24 PM PnGE 1/003 Fax Server Q�E�ste�'n InSut'�►nc�e 519 Station Avenue Yarmouth, MA 02664 TO: Town of Yarmouth Health Dept Company/ Insurer: Contact Fax Number: sos-�6o-34�z Contact Phone Number: From: cindy Jenke DirectFaxNumber: soa-64�-so9i Dired Phone Number: sos-39a-6o3a, iz Notes: Date and time of fax transmission: - Thureday, December 18, 2008 1:59:22 PM Number of pages including this cover sheet: 03 The information contained in this facsimile message is privileged and confidentiaL II is intended only for ihe use of the individnal nazned above. If you aze not ihe intended recipien�you are hereby notiLed ihat any distribulion or copy of tltis communication is s4ictly prohibited. If}rou have received tLis communication in error,please notify us immedialely at ihe above listed phone m�mber. Tl�enk you. EIG Fax Server 12/18/2008 2 :00 : 24 PM PAGE 2/003 Fax Server ACORQ CERTIFICATE OF LIABILITY INSURANCE �12/�18/2y008� PROOUCER SOS-398-6033 FAX 5p8-760-1667 THIS CERTIFICATEISISSUED AS A MATTER OFINFORMATION Eastern Insuran[e Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EIREND OR 519 StdtiOn Ave qLTER THE COVERAGE AFFORDED BYTHE POIJCIES BELOW. So Yarnauth MA 02664 Cyllthia ]enk5 INSURERSAFfORDINGCOVERAGE NAICf1 ixsuaeo We Mart Corporation Inc MSURERA'. [� 528 Buek Island Rd wsuaees_ Hartford West Yarmouth� � �26�3 INSURERC: iuwaeR o INSURER E: COVERAGES THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMEo AeOVE FOR THE POLICY PERID�INo1CAiEo.NOTWITHSTANOING ANY REaUIREMENT,TERM OR CON01710N OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN,TNE INSURANCE AFFORDED eV THE POLIGES DESCRIeED HEREIN IS SU&IECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS DF SUCH POWGES.AGGREGATE LIMITS SHOWN MAY HAVE eEEN REDUCED BY PAID CLNMS. INSR 0' TypEOFINSURANCE POLICYNUMBER �UCYEfFECTVVE OLITE EXPIOTiON LIMITS GENERAWABILITY 2077073SE8 Da��S�Z008 ��OS�z�09 EACROCCURRENCE 4 1�pQQ.QQ J( C�dMERCIFLGENERlLLLI0.BILRY O�OS�ZOOB O�OS�LLO DMAAGETORENTEC y 1(p�OO 0.PIMSMAOE �OLGUR MEDEXP�Mymepersan) S S�OO A PERSON?LBiICVINJURY 5 S�OOO�OO GENERPLAGGREGATE 5 Z�OOO�OO GENLAGGREGATEIIMITAPPLIESPEft: PROCUCTS-CIXdPlOPAGG 3 2�0�� J( PCUC� jRP LO' qUTOMOBILE LIA9ILITY CpV�BINE�SINGLE'�_IM'1 qJYAUTO (Eaecdhm) g FLL OINNEDFU'OS 60]IL�INJURti SCHEDUIED AJTOS (Pef�� g HIRED AUTOS BOJIL"INJURY N^N OIVNED All'OS (P��pe�� g PROPERTY�qMAGE g (Px ac��tlerY: GqpAGELIHBILiTY AUTCOM1LT-EAA�CIOENT $ ANYAUTO Ot�ERTFfJJ Epa« g FUTCOM1LY: qG3 3 EXCESSJUMBPELLALIABILRY EACHOCCURRENCe 3 OLCUR �LLAM�SMA�E AGSREGATE S 1 D°DUCTI�E > RETENTiON S l' l, S WORKERSLOMPENSATIONNND OSNECNKZZGS Os�OS�ZOOS Oa/OS�ZOO9 X 7'��yTMirs °E"' EMPIDYER4'11A814TV Ol/OS/2009 Ol/OS/1910 e.:.EncHacc�oeur a 100,00 B CNY PROPRIc ORiP0.RTNER/EXECUTiVE OFFICER.TAEVBEREXCLUpEOP E.:.DISEASE�EPEMPIOYE b LOO�OO 11 yes,rksuibe�ntler SPECIfLLPRO`4510NSC¢lav E.L.D�SEASE�PCLIGYLIAIIT b $��QO OTMEF OESCRIPTpN OF OPEPAT�ONS 1 LOCATIONS IVEWCLES!E%CLIISIONS�D�EO 8Y ENDOPSEMENT I SPECIAL PRDVI910N5 vidence of Insurarrce CERTIFICATE HOLDER CANGELLATION SHOUID ANYOf THE ABOVE OESCRIBEO POLIQES BE CANCELLEO BEFORE TME EXPIRNTqN D�TE THEREOF,THE ISSUING INSUREN WILL EN�EPVOR TO MAIL ZO OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLOEp NAMEO TO THE LEPT, BUT FAIIURE TO MNL SUCH NOTIGE SHALL IMPOSE NO 09lJGATION OR LIABW TY TQYO of Yarmouth OFANYI(INDUPONTHEIN3UpEli,I15AGENT50RREVRESENTATIVES. Heal th Department AUTHORIZED REPRESENTATIYE C nthia 7 )enks ACORD 25(200110H) FA%: (SOS)760-3472 �ACORD CORPORATION 7988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-040 FEE: $80.00 In accordance wi[h reRulations pmmuigated under au[hority ofChepter 94, Section 305A and Chap[er I 1 I, Section 5 of the�ienerel Laws,a pe[mit is hereby granted to: We Mart Coip. Inc., 528 Buck Island Road, West Yarmouth, MA Whose place of business is: Buck Island Country Store Type ofbusiness: Retail Food Service less than 25,000 square feet To operare a food establishment in: Town of Yarmouth Permit exp'ves: December 31. 2009 soARD oF HEALTH: ,�fel¢n SIF�E J2.Ar., U'iataunait @lfaxleo �E. �JCelfilEr�c ?)ice U'Iaix�nan. ��e�.�, el� a� �,�, ✓�..�v. �3• � 7anuary 9.2009 iuce G.M hy, . .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #09-028 FEE: $55.00 llris is co Cemfy thec We Mart Corp. Inc. d/b/a Buck Island Country Store 528 Buck Island Road, West Yarmouth. MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This.�em'�t is�nte�jn�gpjomuN with Micle VI of tj�e Sanitery.Code of The Commonwealth of Massac6usetts,and expi es ec r I VVy unl�ss sooner susprndea ot revok2a January 9,2009 BOARD OF HEALTH: .�P.PRtt S�(7�� ..lv.� �QLIIItAf! �QX�RO .�. ��C�GAPII� �I[C¢ � JtoBent 3.�Baoutn, C.lenl� Clnn , 52.rV. Euel.� t.`P 3 gee B ce . Murp y,M . , Director of Health , � �% --, BJc.IL lsc .CovNr-RY S7a(Lt �` """�y TOWN OF YARMOUTH BOARD OF�#EALTH s� '� ' APPLICATION FOR LICENSFa/P�RMIT-2 �It ` ° � . �.� �� * Please complete form and attach all necessary doc�ttnents by Decem r 3�t;'zvo7.�28088 Failwe to do so will result in the retum o�your application pa t NAME OF ESTABLISHMENT: Bu�K LPLAn/� ��clrx.y �J'�2F TEL. # S0� �`Ia 8"�If LOCATIONADDRESS: _ Sd8 �S�uck /scs�,ve k0. ,�/E-dr y'sH2m0'k�- m.a azs�-3 MAILING ADDRESS: S'sNinE /�3 A-3�vc� ' OWNER NAM€: __ E�TsF2 ,4K9sH( KIr�/ T X ID (F IN or N�- CORPORATION NAME (IF APPLICABLE): /n/E MA-.eT Cl.�P. in/C• MANAGER'S NAME: c�Ts}� A• Kff�.-n/ TEL. # Sd P-�90 �� MAILING ADDRESS: .P�F ,�r sh3ctr� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please Gst the desienated Pool Operator(s) and attach a copy of the certification to this form. i. h! 2. Pool operators must list a minim of two employees currently cenified in basic water safety, standard First Aid and Community Cazdiopulmonary suscitation(CPR). Please list these employees below and attach copies ofemployee certificarions to tlris form. The Health Department will not use past years' records. You must previde new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued 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 ihis applieation. The Health Department wi}l not use past years' records. You must provide new copies and maintain a file at your establishmeut. I. /V �� 2. PE�tS9N ZN CJ�ARGE: _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. 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 tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your pl$ce of business. 1. �� 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER'19T# LICENSE REQIIIItED FEE PER'4i1'I= LICENSE REQL'IRED FEE PERbIIT= _B&B S50 _CABIN S50 _MOTEL S50 _INN 550 _CA.bSP S50 _S«'I�LbIING POOL S75ea. _LODGE S50 _TRAILERPARK 5100 ��7-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT g LiCENSE REQUIRED FEE PERA3IT= LICEPiSE REQL'IRED FEE PER4StT= _0.100 SEATS S75 � _CONTINENTAL S30 NON-PROFI7' S25 _�100SEATS 5150 _CO;�]:NONVIC. 550 R7-IOLESALE S7i RE'IAIL SERVICE: —RESID.KI7CHEti S7� LICENSE REQUIItED FEE PERMII'= LICENSE REQL7RED FEE PER�tIi= LICENSE REQLTRED FEE PER�III'_ _<SOsq.ft. S45 _>?S.00Osq.B. 5200 VENDING-FOOD S20 L<25,OOOsq.B. S75 0 'D`'�� _FROZENDESSERT S35 �I'OBACCO S50 , 3�GJ.� va�ec�,vcE: sio AMOUNTDUE _ $ /25.00 •"•**PLEASE 7'IIRY OVER A.\D COJfPLETE OTHER SIDE OF FOR\f•�*** . , ' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any ficense or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE A1"PACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transiern occupancy shall generally refer to continuous occupancy of not more than thiRy (30) days, and an aggregate of not more than ninety(90) days witliln any six(6)manth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: En��o�d Motel Census must be completed and returned w�m ttus app�icarion. POOLS POOL OPENING: All swimming,wading and whirlpools which have been ciosed for the season must be' 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 swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Departrnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Depariment. 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 wrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking;prepacation,or display of any food producE bya retail er food service establishment is prehibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIITY TO RET[JRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�lENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMME?10EME�tT. RE�IOVATIOVS MAY REQUIRE A SITE PLAN. � c DATE: I r� c��.__�___ SIGNATURE: "- PRINT NAME&TITLE: ��'� - �.' ioaoo, '�"\ The Commonwealth ofMassachusetts DepaR�nent of Industrial Accidents NMaNrw�Ms 600 R'ashington Streey 7'"F[oor Boston,Mass. 02111 Workera'Compeosatioe Ieseauee AiSdrvih BaildioglPlambug/Ekctricd Coelractora �. �.rs�-� K,waN ��►uc �,� Ce�.�ey .l'meF � M.a�, cnc� ,�s: sa a �s�+cee lt�� s�J . � kIEST Y�/hlti+7Jt �ate m�4- �o o� 63� on�n SQ � 3�i o 8�--� work site locatim(fiill addnssl• ❑ I am a homeowcer perFocming all walc myself. Projec[Type: ❑New Camstru�.Kion QRemodel ❑ I�a sole pro�ietor and have no one wodcing in aoy caPacity. ❑Bwlding Addition �] I am an employer provid'wg workecs'compensation f�my employees working�ihis job. comoavrme•. _. ... E.�'S I�T� /ilr,�GC7L.�ll�� .. . .. _ _.._.._ ._. _ .aa.�,.- S/9— S�d� A1�� - ��.- �r� _y�� p�-ai-66 y ��: sa� 39 �' da33 • ,..�. �!� N�?'�J/ �x D� /�ot 3 �(0 6 � ❑ I am a sole proprietor,geaersl eo■traetor,or yomeawoer(eirde oneJ�d 6ave hired�e ca�tractocs li�ed below wlw have t]ffi following woikas'co�npensation polices: tldrna• eito- oleae�: ��, odin# �- �y oYae#. . . . . irea�eeco. __ _. _ __ ___ __ .._._ ,.P�..'e�R _ ._ . _ . _ _.. ..._ _ ._ . . . . __ . . . . M6ili�111MiiYR�i1�MIr1'.1S . . � : .. . .. .. . .: . . .. � . �. Faive b�eeme aroadc n Rqdnd oda Satlr 2SA a[MGL 1S2 m led b He�p�Jtl��fui�i�l p�Mie d a 6�e+bS1,5KM a�N�r::. �y�,•�,ti...m�...b..dwa..awdu�w��t.srorwowcoeoea..a,eK.tsiee.a.e.y.��.�. �oadmwu.e, apy�t Ws Whmnt s�7 he brwaM[d m Ne Omce dlneM�a(1!e DIA hre�venge verMntl�e. . /do hereby cerbfy rnder tMe pates oad penehles of perjwry diet tAc i�fonwaatoe previded aboce is axe owArnrrcct �� cn/ �n �/y/ao-n� / Print name �1/�Z "T��V Phone# .S�O 7 �� /�+ e�eLl ex eely do aM w�Me i t6b un W h m�pk�ed W dly er Mwa a�ch� eHy ar tewa: P��# ❑�� DI.Icee�l�g Bovd ❑tYcd HlmseMat rnpemt 6 reqd�d ❑Sdeedee'a O�ee . . Q�N Ikpr�t m�Q penaa: P�� (mi'sd 5apt mm) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-041 FEE: $75.00 In accordance with reaulations promulgated under authoriry of Chapter 94,Secrion 305A and Chapter 111,Section 5 of[he�ienetal Laws,a permit is 6ereby granted to: We Mart Corp Inc 528 Buck Island Road West Yarmouth, MA Whose place of business is: Buck Island Countrv 3tore Type of business: Retail Food Service less than 25 000 square feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD oF HEALT[I: .�Ee�c SPtal$ `J2.N., L'�aa[�ruuc �r �Peeu��ce @Pec�ix�naua ��- January 23.2008 mce G. mph , ,R.S:,CHO Director of Heal THE COA�INiONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMTT NUMBER: #08-031 FEE: $50.00 Th;s zs to c�cify chac We Mart Corp Inc d/b/a Buck Island Country Store 528 Buck Island Road, West Yarmouth, MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. This�era�'teis�nte�}n2�ornu�' with Articl��o�'�t e Sanit�r�Code of The Commonwealt6 of Massachusetts,and ex s c er ss sooner s or revo J�,�23.Zooa sonxn oF�tv.�: .�fePea SF�aRy .12.�V.,L',�abuna,e C'�a�c[ea .�.9Ce�PiKerc�, `vice @�aw�man J2a6ent s. `.�t3�iarwc, C'Paxl� Qnn.Cdxeendatun, J`t..N. `.P..� ea B ce .MwP Y,MPA• . , D'uector of Health � =�°`e"o TOWN OF YARMOUTH BOARD OF HEALTH ° ��s APPLICATION FOR LICENSE/PERM�I'-200�� o D E C 0 6 2006 �;. '�` * Please complete form and attach all necessary doeuments by Dece�be 3��QE�H DEPT. Failure to do so will result in the retum of your application pack . NAME OF ESTABLIS�IMENT:�E MA�T C�X,U_ /,uc guuct/1tac.�e .1'/dKt-TEL. # -�d� �90 8� LOCATION ADDRESS: S�g �ctuc /c�.�.�a ,�tp W�� ,x oz6�3 MAILING ADDRESS: �'Mn� ,a� ,g�yc2 . OWNER NAME: __ ��A� !f_ ,E'y�l TA ID (F'EIN or SSNI � CORPORATION NAME (IF APPLICABLE): ,/,�/� /rlpveT C��. �,�r�-. MANAGER'S NAME: C�7�d-� �,�r�-rl T'EL. # ,53� 390��.T MAILING ADDRESS: AJ /�v� POOL CERTIFICATIONS: 1'he 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 certificatio�to this form. � 1. 2. % Pool operators must list a minimum of two employees currently certifi ' basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these ployees below and attach copies ofemployee certifications to this form. T6e Health Department will not us ast years' records. You must provide new copies and maintain a file at your place of business. l. 2_ 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full- e employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Foo ervice Establishments, 105 CMR 590.000. Please attach copies ofcertification to this application. The Healt epartment will not use past years' records. You must provide new copies and maintain a tile at your blishmen� l. 2. PERSON IN CHARGE: - - Each food establishment must have at least one Pers9 In Charge (PIC) on site during hours of operation. � i 1. 2. HEIlvII.ICH CERTIFICATIONS: All food service establishments with 25 seats or more must h e at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your emp yees trained in anti-chokrng procedures below and attach copies of employee certifications to this form. The ealth Department will not use past years' records. You must provide new copies and maintain a file at y,ofir place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIIVG: LICENSE REQUIItED FEE PERMIT'# LICINSE REQUIItED FEE PERMI1'# LICENSE REQUIltED FEE PERM[T# _B�B S50 CABIN �50 _MOTEL E50 _RdN $50 _CAMP $50 _SWIIvf[�9NGPOOL$75ea. � _LODGE $50 _1'RAII,ERpqRK $]pp W[$tl,pppL E75ea. FOOD SERVICE: LICENSE REQUIItED FEE PFRMIT q LICENSE REQI.TII2F,D FEE PERMIT# LICINSE REQUIItED FEE PERMIT# _0-100 SEATS $75 _CON1'INENTqL $30 NON-PROFTT S2S _>100SEATS $150 _COMMONVIC. S50 WHOLESALE S'/S RETAII,SERVICE: —RESID.KITCIIEN $75 LICINSE REQUIRED FEE PF.RMI'P# LICENSE REQI7IItED FEE PERMIT# LICENSE REQUptED FEE pggTqT p _<SOsq.ft. S45 _>25,OOOsq.ft. $200 _VENDING-FOOD $20 / QS,OOOsq.R. S75 7^ 6 —FROZINDESSERT S35 / TOBACCO $50 �G7-pa-/ NAME CHANGE: S10 AM�UNT DUE — $ �25-�00 ""`PLEASE TURN OVBR AND COMPLETE OTHER 5IDE OF FORM•^••• . , ADNIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any ficense or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A1"I'ACHED STA1'E WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED / Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use, Transient ocwpancy 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 ofresdencc eLsewhere. Transient occupancy shall generaily refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereatter. POOL CLOSING: Every outdoor in ground swimming pool enust 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 Aealth Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State 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 Pemut until the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Boazd ofHeakh. OUTDOOR COOKING: - �utda � , ot display of any food product by a retai�or food service establishment is pmhihited._ . NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTl'TO RET[JRN Tf�COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATION5 TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMA�NCEMENT. RENOVATIONS MAY REQLJIRE A SITE PLAl�i. �� v DATE: b:' � , � (� fo SIGNATi7RE: PRINT NAME&TTTLE: ,�T�i-� Kd�s✓ /�i��1�itrfl� ioirnov ' . � � The Co�nnronweahh of Massachusetts DePartw�ent ojlndrrsdial Accidei+ls NbNi� 600 R'ashiagton Street, �'Floor Bostws,Mass. 02111 Wor��s'Compewdo�Irvuce AffiA�vik B� b��/Elxtrieal Ca�trae/ars �- - - � � <�;�.�� s �•.� �.� .. . �� - � � '�,�. . na�oe: .Lr'-�✓i�'� K� ad�ess: ..�y� �llCK. S/�-y✓� /'�l.' �;ty k1�Y..ARm�c�i �, �u✓� an: 112��3 �a SQ6'.�9a �'�—�� s�re�«aa�rrwt saa�sr. ❑ I am a homoowner perFormiug aR wak myaelf. Projed Type: ❑New Cmst�uctiao�R�tadel . I�a sole aod have no one w in� B ' ' Addition (�. I am an�ployer piovidiog wo�cas'compensation fac my employ�s wodcing on tbis job. . . _.._-_ ._ - - � �}� �!� { / a000av�e: ��' /Y)Fa"�% U.�� 7N`� . /.+t/�1�--�lll� �� ,.(�"�k''L� - � .aara.• �a�� .9s dY�aV�- - �• .r��: �� /�Taaa�� 4� k1CC N�C 2265' ❑ I am a sole propridor,ge�val eo�traetor,or komeow�er(dmele owe)�d Lave Iticed the contcacWcs listecl bdow wlw have the following wakas'compensataon polices: � � uMe li: �ea A addivr s�r dwe A: FaYae O�+ecae c�s Rq�d uAQ SeetlN 1SA dMGL 1�m led b He�W Ke'W W pmWn�f a�e�b f1,SNM aMl�r a�e ynn'i�pr6a�nt n wd n eM pwltln 6 fYe f�att 370t WORK ORD6R atl�9oe df1M.M a tlry�aMt�e. I udv�Wd tW• epy dtlb#�dy be firwaNM b tYe Omce dLveMipWr d1�e DIA hr eweeage ve�nlM. , /lo Aersby cer6fy rwdsr ale pfna mJpseki�o�-J='i f� fperJwry dYd Me ieforw�Gba providal eiove 6 we w�d cermt �'(% s�so�ure � neu /l�6�6 Ptint name �L�1�� 2�� P6oce# � .�� T/� ��S .mdVaxwry eo.M.o.uer�m.,rareae�.peeanr�*sxwma�l cHyarfewn: p�A f�D�t OLion�Beud ❑tY[cic Him�4�epane 6�eqWed �w'a O�ee ��prds� ushc[Pvsn. pYwelt, ❑OIYc (m'sd S¢30a01 . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #07-028 FEE: 75.00 Tn accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: We Mart Corp. Inc., 528 Buck Island Road, West Yannouth, MA Whose place of business is: Buck Island Countrv Store Type of business: Retail Food Service less than 25,000 squaze feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2007 BOARD oF xEALTH: B ►�G $. �'a�do�c, M.$., ' e�fe&le�c Slre�k, K./Y., 'Ui� G�Jsai� Rodr�4. B�, � P�k Ma��t a.�q� a.�v. January 31.2007 Btuce G. Mutphy,MP .,CHO Director of Health THE COD�IONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #07-021 F'EE: $50.00 r 'rt,is is to Ce,tify rhat We Mart Corp. Inc. d/bJa Buck Island Countrv Store _ 528 Buck Island Road West Yarmou MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCT AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This. t is o �1 wrth ARicle VI o �e Sani�.�Code of The Commo¢weakh of Massachusetts,and e�t�es�ece�n�er�1�2��utll�ss sooner suspen�ed or revok�d January 31_2007 BOARD OF HEALTH: B �. ��,, ' �a�s� rva�`., v�`� er� a�t�t. a� et� p�ic�.l�1�`5�a�ott � R.N. B . Murphy,MPH, , H Director of Health . _ -, '11� S�e =o`�"o TOWN OF YARMOUTH BOARD OF HEALT �� — � 3 ° APPLICATION FOR LICENSE R1H�T ` b °�i �, ;, '� � JAN 0 3 2006 �`� * Please complete form and attach all neces 2io � e�emb �'" �� Y� �I��H DEPT. Failure to do so wiii result in the retut�r.of application pack . NAME OF ESTABLISfIMENT: �t/E iVY�;QT �',� � 'rEL. # Sa�F�-�� '�fi LOCATION ADDRESS:�/ p �c, ,r /S4s�11 arru,v C�� MAILINGADDRESS: s2s ,�uc.� /s'cs�q� .�1 �/�te/xe'rl71i /rrs+- oL6�-� OWNER NAME: E,TA� A,�RA� Kl12tn1 TAX ID (FEIN or SS1Vl� � CORPORATION NAME (IF APPLICABLE):_ /�[� �y/q�r' �� ,cl�C - MANAGER'S NAME: E�-� q,e,rypA TEL. # SD�F 3`/0 8�.f MAiLING ADDRESS: A-S s4�,�E- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, required by State law. Please list the designated Pool Operator(sj and attach a copy of the certification to this rm. 1. 2 Pool operators must list a minimum of two employees c ently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Pl list these employees below and attach copies of employee certificatio�s to this form. The Health Department ill not use past years' records. You must provide new copies and roaintain a file at your place of busin s. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 application. The Health Department wili not use past years' records. You must provide new copies and maintain a fde at your establishment. I. 2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. Z HEIlbff;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 attacti copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY LICENSE REQUII2F,D FEE pERMI1'# LICENSE REQUIRED FEE PERMIT N LICINSE REQUIltED FEE PF..RMI1'# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIIvIIvIlNGPOOL$75ee. _LODGE $50 _TRAII.ER PARK E50 _WIIIRI,pppL S75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT k LICINSE REQiJIItED FEE PERM[T# LICENSE REQiJIItED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 _NON-PROFIT $25 _>100 SEATS 5150 _COMMON VIC. E50 _WHOLESALE S75 RETAIL SERVICE: LICENSE REQi)IItED FEE pERMPP# LICENSE REQUIItED FEE PERMII'p LICINSE REQUIItED FEE pggl�q�p tt _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD $20 I t15,000sq.ft. $75 � 06,DNa' _FgOZENDESSERT $35 ( TOBACCO S25 �#06-�29 NAME CHAIVGE: $10 AMOiJNT DITE = S 100,op "'",pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM^••^• "�- _ . ADMINISTRATION Under Chapter �52, 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. 'I'HE ATTACHED STATE WORKER'S COMPENSATION INSi7RANCE AFFIDAVTP 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 pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIITI'TO RET[JRN THE COMPLETED APPLICATION(S) AND REQiJIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISffiVIEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COD�IENCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. ADDTTIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which haue been closed for the season must be inspected by the Health Department prior to opening. POOL WA'I`ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by 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: F�oz�xi�csserts must bc-tested en a monthlY basis by-a State certified lab. Tesi resultsmustbe sentto Yhe Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pe�mit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromtheBoard ofHeahh. OUTDOOR GOOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: �2—d9— 0 S SIGrrATuxE: �-- - PRINT NAME&TITLE E�4� AKBA� �'e��d"� 09/28/OS • =� Tbe Caxnronwealth of Mossechusetts �� _ Department ojlndrtsl�rial Accid`ntc � -- = NL�IN� - a 600 Washingtoa Stirey f"F/oor Bostor,Mass. 011ll Wo�fas'Compe�satio�In�ce A�d�vlt Bdldi�g/PI�mIx�JEkNrkal Cootracters � �� , �� ,. �� e �, �:�� ,.., x. name: add�ess: siN � smre•'�� zio• dti...P# wark site lacffi�(foll addcessY. � � ❑ I mm a homeowna performing all wak my�1f. Project Type: ❑New Camstcucdon❑Ranadel I mm a sole and have no me w in�y Buil ' Addition .� . __ _ . . �_I am an�Yer providing wakeas'compensatia�fac mY�PbY�W'�B on th�job.. coeorr�c �/l�� /1�Y1CT �. �/(�'� . �s.s: S2-8 /�roLGtc LSL.shrtl I� .Qk1 • �_. /.�!€�T �/.��e�a�, �.: �a-�' �1� s'�-9.t— u.�.�. T� ,�r�T r . vfi dc/�c ,vK zi 6s' ❑ I am a sole Propii�or,8eoera�e�tractor,or homeowoer(enrJe owe)md Lave h'aed ihe�tois lis[ed bclow wlw have the following workets'compea4atfon polices: fn �t uee: �: �A uYwe 6� N u�r bec �: dtf' � nYa�e#� � . Faive 0�aeeee smqe s reqded uder SaYx 2SA dMGL 152 m Wd b He�W dvlNtl peWOo�fa Le�N A3M,M aedhr o�eyan'I.prY��nntnwdndNp�Itlplatiebr�ata37V?WORICOBDERud��dflM.NadryapWt�c lodvs6Mtl�a npy af Itle Wle�e�t ry be ferwardtd�b Ne O�.e�l�e�NMe INA frpvenee ve�nlM�. r do haray ce,tljy,ale.Me pasa.ea pendffes@jpafwy tMd tbe a,(or.eften preaasl.enre 6 ave a�d rn�k Sigoatu�e _.__ _ ! Date � � � /� PriM name F�� Phone# S7� �d � emew ax o.�y ae ea wrke r ub,re.b ae os�WMsd bs�*r.r wva.mcLl dlyortswv: !�_ ^— ' �� ❑eYeek ifi�t mpeese b'eqalred �'�� n's O�cee � De��dnf 1�� #' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #06-042 FEE: $75.00 In accordance with re ations promulgated under auihority of Chapter 94,Section 305A and Chapter 111,Section 5 of the eral Laws,a pern�it is hereby granted to: We Mazt Corp. Inc., 528 Buck Island Road,West Yarmouth, MA Whose place of business is: Buck Island Counhy Store Type of business: Retail Food Service less than 25,000 square feet To operate a food estabfishment in: Town of Yarmouth Pernvt expires: December 31, 2006 BoalzD oF I�ai.'rx: 8 �15. ,M.$., ' �t�, �., v�e� aoa�t�.a�, et� p�k Mo2� ��i , R.N. March t6 2005 ce .Murphy,MP , .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH , BOARD OF HF.ALTH PERMIT NIJMBER: #06-029 FEE: $25.00 ��5 to cenify�hac We Mart Coro. Inc. dlb/a Buck Island Country Store 528 Buck Island Road_ West Yannouth. MA LS HEREBY GRANTED A LICENSE For SALE AND DISTRIBTTTION OF TOBACCO PRODIJCTS AS PER TFIE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. ��e�i�$n�te�}n2c�or�wi�Articls�s�IIo�t o S�anitarv_Code of The Commonwealth ofMassachusetts,and k8d February 3.2006 BOl1RD OF HEALTH: � �. �o3do�t, /H�., ' ��s`�, a�v., v� e� a�t�. a�, er� n�� '3 ��uniy R./�. tuce G. M p y, ., H Duector of Health �� $ �� Yq�� TOWN OF YARMOUTH �{� �''� 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 • Mr1TTACHEES � ��„� �o,bn� Telephone (508) 398-2231,Ext 241 — Fa�c (508) 760.3472 B O A R D O F H E A L T H � � � �' � To: Yarmouth Boazd of Heahh Permit Holders A�R i 1 2005 From: David D. Flaherty Jr., RS. �D r H�AL? ' '-=''T. Heahh Inspector Town of Yarmouth Re: Federal Taac ID Number �ate: Mazch 22, 2005 The Massachusetts Deparhnent of Revenue is now requiring that we furnish detailed information to tl�em regarding all permits and licenses that we issue. One of the details that they require we sencl to them is every establishme�'s Federal Employer ldentification Number(FEIIV)otherwise I�own as your"I'aic ID Number". This is purely for administrative purposes only. Some businesses use the owner's Social Security Number (SSl� for tUis purpose. If tUis is the case for your establishmem, be assured that we will not allow this information to be public record. Please fill out the fields below and reti�m this letter to Yarmouth Health Depar[ment 1146 Route 28 South Yannouth, MA 02664 'I'hank you for your azrticipated compliance. If you have any questions regazding this matter, please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m to 430 p.m. The telephone number is(508)398-2231, ext. 241. °�b�A �'� Establishment: �r b � ��..\� :.+.�,�� FEIN or SSN: � �pQs Sr�F Location Address: 524 /.A�uc,t� /SL,CrnrD R.D. lnl�&j �/�n`fiu TH mA- oZ6 '�3 ,.._.__..-- , Signature: __�=---- Ptint: ��i� Kf7/X�/ Titie: ��s�/��% ��? n�s�j' Cc+.�'p, ING . �,'� � Printed on �� Recycled ,�.s " L� Paper -„ry TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHMENT PERMIT NUMBER: #OS-030 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Genaal Laws,a�mit is hereby ganted to: We Mart Corp. Inc 528 Buck Island Road West Yazmou MA Whose place of business is: Buck Island Country Store Type of business: Retail Food Service less than 25,000 square feet To operate a food establishment in: Town of Yarmouth Permit eapires: December 31_ 2005 BOARD oF HEALTH: Be�NriH.�5. go3dorr� �$. ' P�M�� v��an R�t�. B�, Gl�,,b � Sl.�., R.N. Q��i� R.M. € ��J I March 16:2005 Biuce G. Murphy,MP .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-023 FEE: $25.00 This is to Ce,vfy that We Mart Corp. Inc. d/b/a Buck Istand Countrv Store _ 528 Buck Island Road West Yarmou MA IS HEREBY GRANTED A LICENSE For_�ALE AND DISTRIBiTTION OF TOBA O PROD T AS PER TI�YARMOUTH BOARD OF HEALTH TOBACCO REGULATION �s. � t is te�fn confoimitv��SlWs�of tho Sanitarv Code of The Commonwealth of Msssachusetts,and 2005 unl8 ded k8d March 16.2005 BOARD OF IffiALTH: Be��1�c�1. y'o3c�as,/��1., ' �Ma�� v�e�� R�t4. B� � �8!� R.N. /�iuc y'�t .rcns, /�./�. A�-�` ruce G.Miuphy, ,R ., H Director of Heal •. . , �.�>pq4��% °`�"o TOWN OF YARMOIITH BOt4R11 O�HEAL� � !'�` ' = � L, � r R , ��; APPLICATION FOR LICENSE/PE 2005 �y .� - JAN 0 3 2005 * Please complete form and attach all necessary documeii�' Y, be 3�..��$Q4rH DEpT. Failure to do so will result in the retum of yow appl��ack . _ ; NAME OF ESTABLISf��NT: �ucic /S�.arv v E TEL # So��90��o LOCATION ADDRESS: 528 Bz, d. /s�,,,,, ,20,.,�, w�tT ��,�,�� m,,� a Z6 �-�3 MAILINGADDRESS• S.t-w. s�s .9-i��vF OWNER/CORPORATION NAME� 1'�� A K//.��n� MANAGER'S NAME: £ Lr� A - Ki/".A*/ TEL #�-a��Io ��I U MAILING ADDRESS: cA-•i.- � st��Y� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,a quired by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ' form. L 2. Pool operators must list a minimum of o emplo ees currently certified in basic water ety, standard First Aid and Community Cardiopulmonary suscitation �CPR). Please list these employees elow and attach copies of employee certifications to thi rm. The Health Department will not use p years' records. You must provide new copies and mtain a fde at your place of business. 1. 2. 3� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS� All food service establishments are required to have at least one full-time e ployee who is certiSed as a Food Protection Manager, as defined in the State Sanitary Code for Food Se ' Establishments, 105 CMR 590.000. Please attach copies of certification to this appGcation. The Healt6 De rtment will not use past years' records. You must provide new copies and maintain a fde at your es �shment. 1. 2. PERSON I�i CHA�iGE: _ Each food establishment must have at least o erson In Charge (PIC) on site during hours of eration. I. Z HEIMLICH CERTIFICATIO : All food service establishm s with 25 seats or more must have at least one loyee trained in the Heimlich Maneuver on the premis at all times. Please list your employees trained in -choking procedures below and attach copies of empl ee certifications to this form. The Health Departme will not use past years' records. You must provid ew copies aud maintain a fde at your place of busi ess. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# LODCING: OFFICE USE ONLY LICENSE REQUIItF,D FE& p$gl�qT g LdCENSE REQIJIItED FEE PF.RMIT# LICENSE REQiTIItED FEE PERMI7'# _B&B $50 _CABIN $50 _MOTEL $50 _1NN S50 CAMP S50 _SWA�IIvfII1G POOL$75ea _LODGE $50 _TRAn FR pARg $5p WIIIRr pppL $75ea. FOOD SERVICE: LICINSE REQUIRED FEE PERMIT# LICENSE REQ(7IltgD FEE PERMLI'# LICENSE REQUIItED FEE pF,RM(T# _0.100 SEATS $75 _CONTAIENTAL $30 NON-PROFIT $25 _>]00 SEATS $I50 _COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUII2ED FEE pERTq1'# LICENSE REQUII2ED FEE PF,RMI1'# LICENSE REQiARED FEE pggTqT q _<50 sq.ft.� $45 >25,000 sq.ft. $200 _VENDING-FOOD E20 IQS,OOOsq.ft. S75 OS� _FROZENDESSERT $35 / TOBACCO $25 �'OS�na� NAMECHANGE: S10 AMOiJNTDUE _ $�p,�p . ,""""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 Worker's Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES � NO NOTICE:Permits run annually from Januazy 1 to December 31. TT IS YOUR ItESPONSIBILTI'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLISfIMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION7-10 DAYS PRIOR TO OPENIlVG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISffi�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTITONAL 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 WA'I'ER 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 w o 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. FROZEPT-DESS�RTS: 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 Pernrit until the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOIQNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: SIGNATURE: PRINT NAME& TITLE: 10/22/04 C,��"�u^R °�n" l.�C Q f�'�",..""' � TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NUMBER: #OS-030 FEE: $75.00 In accordance with regulations promulgated under authoriTy of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the�eneral Laws,a permit is hereby granted to: Iiaz A Khan, 528 Buck Island Road West Yazmou MA Whose place of business is: Buck Island Country Store Type of business: Retail Food Service less than 25 000 squaze feet To operate a food establishment in: Town of Yarmouth Permit eacpires: December 31_ 2005 BOARD oF I�'ALTH: Be�aNrsr�.`?5. (�o+tdoy,�11.�. • n�� v�ef� a�t�a.� e� �S!�!� R.NR.N. Januacy 31,2005 ruce G.M�uphy, RS.,CHO Director of Health THE CONIMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-023 FEE: $25.00 'I'his is to Cemfy thac Ijaz A. Khan dlb/a Buck Island Countrv Store 528 Buck Island Road West Yazmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBAC O PRODUCT AS PER THE YARMOUTI-I BOARD OF HEALTH TOBACCO REGULATION �Si�es�'�e�n��2603 uNe�so nar��s sp�ended o Sr�k&1Code of The Commonwealth of Massachusetts,and January 31.2005 BOARD OF HEALTH: Se�a�L�$. �joadok, M.�f., • p�Mo� v� er� Rod�t� B� Gl�k d�.� S�lt, R.N. �� .n, R.N. D�or.oM�ea(h� ., H 1 = .: �,�$��oo� _ _BucK ls�.caoN�2y Sron� �`�Ra TOWN OF YARMOUTH BOARD OF HEALTH 3=C � APPLICATION FOR LICENSE/PERM O'�y Y� � � % A p � ^�� _� �� 1_�J�� , * Please complete form and attach all necess�'}t. ��s 1'�eceehber��09�, .cF, i Failure to do so will result in the retuna `o�o appli �ion pac�- I — _ NAMF OF ESTARLIS MFNT: ,�i � ivi / f� LOCATIONADDRESS: saB- �Cilis.csr,�i'7 R,�� _ YAo��,�isi, M•� �a,I73 MAILING ADDRESS' fs}m�s J�/sev,c OWNER/CORPORATION NAMF• �� 'J .�E( mR.PT /NF � MANAGER'S NAME: A.c Fm ,��tv.aaos�n'I TFi # �A_ �60- 3,'t37 MAILING ADDRESS: S'A-n-r� A-t g/3oVf • POOL CERTIFICATIONS: The pool su�ervisor must b_e 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 th�s form. 1. 2. �--�--_. Pool oper must list a minimum of two employees currently cert' ��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 fortn. The Health Department will not use past years' rewrds. You must provide new copies and maintain a file at your place of business. .r f"_�__ 1.— ---- 2. /� 3. 4. " � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies ao/d mai�n'tain a £tle at your establishment. i. ,/ 2. �._,.-,_-- - - -��-�� _ PERSON IN CHARUE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. � 2. �=�'�� —J— x HEIMLICH C�IFICATIONS: 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. T6e Health Department wilt not use past years' records. You must provide new copies an�ain 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# _68cB $50 _CABIN S50 _MOTEL S50 _INN S50 _CAMP S50 _SWIMMING POOL S75ea _LODGE S50 _TRAILER PARK S50 _WHIRLPOOL 575ea FOOD SERVICE: � LICENSE REQUIRED FEE PERMI'C# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS S75 _CONTINENTAL S30 _NON-PROFIT $25 >I00 SEATS 5150 _COMMON VICT. S50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. S45 _>25,000 sq.ft. 5200 _VGNDING-FOOD $20 �<25,000 sq.ft. S75 � -6� _FR07.EN DESSF.R"f S35 LTOBACCO S25 6 -Q� NAMECHANGE: $10 AMOUNTDUE _ $ IOb.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 SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED_� Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS 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. f1DDITIONAL REGULATIONS POOLS POOL OPEiVING:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depaztment 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 quarterty thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE CON5UMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FR0�1�[BESSERTS: _ ___ _ _ 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 resutt in the suspension or revocation of your Frozen Dessert Permit until the above tenns have been met. OUTSLI)E Ct�F�'S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board of Health. QUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establislunent is prohibited. DATE: � /—�6— ��f SIGNATURE: �� PRINT NAME&TITLE: ,�F�n a�i.yu�lzA1�'/ P ��,c� � 10/22/03 . '' � The Commonweallh ojMassachusetls : Deparrment ojlndustria/.-iccidents ' ; Ol1IC001//I'CSU�ftl/K 600 Washington Slreet Boston,Mass. 02111 ` �� '` wbrkers' Compensation Insuronce Affidavit ARplicant informaHon• Pf +��epR '�•sy nam�� ,/J1/�/� ls/�AsV/� C_.F'JIIN�/�� /�� . location� �.— ��iS.�LFni� �/� ..��_.�.�_� cit� UI—��/'c�//IJ�fL ��/�� /��p7� ehonep S0d — / 90 /i77�: � I am a�iomecµner pzrtortning all work myself. � I am a sole proprieror ar.� ha�z no one norking in am capatiry __ � i am a_n emplo�e�ro�idin_w_orkers' compensation for my employees uorkin¢on this job. comoan�� name: �i.!/n/ ��/(�K /�'J,�,F'/ �N(° " ,��.5: �A� — t� �� ..�„� titc ,Q�� iit��: ��A tiTi� /Y/f� n n�(�� ehone p• �,((� �— 3 7�7--H�/Y i � / / > iosurance co. �f /f�A✓F.[LQ,S policv p n�U� q9� X q��—OT � I am a sole proprietor. general contractor, or homeowner(cire%onel and hace hired the contracrors listed below �.ho ha�e thz follu��in_ «orkzr ,ompensation polices: �moanv name: � � re • ' a i s nncc � •p m n ._. . ._ . . _ _ ..__ ._. _ _ . address: t1LY' 6 ; nheee�• insuraneeco. � � ��n.� � F�ilure�o secure covente�s requirtd under Seenoo 23A a(MGL 152 n�Ind W tYe inpo�iOw W erisiW ptedtln of�6�e op ro SI�00.00 a�d/or one yean'imprisonmmt u wzll�t tivil prndHe�ie tAe torm o(a STOP WORK ORDE7t�W i 1i�t of SI00.00��da)qdost m� f��dmta�d that a eopy of tAy sntemen�may be for.v�rded to the 011iee of Ievati��tiom otMe DIA for emera{e verilhatlw. �. !do�hrreby cenij}•u er the paint and penal�ies ajpery'ury�hm�he injornmtion provided above is dut and eorrcet Signaturc ate !� /—!� � — O `7 Print name pM K .- olTiciat use onW do no�w rite in thie tro ro bt tompleted by eih or lowa ollleial ciry ar town: Y��DT$ _ peneiNiteex M nBuildioe Departmeu� pLieeosine Bo�rd p cAeck if immediate response ie required 261 �Seleetmen'e Oflitt (508) 398-2231 p,at. OHeNth Depanmmt . contact person: phone N•_ _ _ nOther � a TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-055 FEE: $75.00 In accordance with re ons promulgated under awho[ity of Chapter 94,Section 305A and Chapter ]11,Section 5 of the e�nexal Laws,a peimit is hereby granted to: Town Quick Mart Inc., 528 Buck Island Road, West Yarmouth, MA Whose place of business is: Buck Island Countrv Store Type of business: Retait Food Service less than 25,000 square feet To operate a food estabGshmeat in: Town of Yarmouth Pernvt expires: December 31. 2004 Bo,4RD oF HEALTH: Be�yr.�i�s `.D. �, M.�,l,.f ' pa�YJc+�s�, �/ice C.liaN�rc� Roda+lt�/. BaorWt�. � � �l.al., R.N. �.�.�+�d�, R.N. l��-✓ i March 5 2004 Bruce G.Murphy, , . CHO Director of Health � THE COMI4IONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-038 FEE: $25.00 Thi31s to eertify che� Town Ouick Mart�ne. d/b/a Buck Island Countrv Store 528 Buck Island Road West Yarmouth MA IS HEREBY GRANTED A LICENSE Far SALE AND DISTRIBUTION OF TOBA('CO PROD T _ AS PER Tf-IE YARMOUTH BOARD OF HEALTH'£OBACCO REGULATION e�acpi�es�e�i�etr�� ml�ss��s�o�ed orSre�vo�CedCode of The Commonwealfh ofMas.gachvsetts,and March 5_2004 BOARD OF HEliI.TH: Be�iia�1. (�ou�ok, M..21., " �.a�s,� v:� �� a��. a�, � � �r.� R.nc �i�a.!ja 6.�, R.N ruce . MnTP Y> H, > Dir�tor of Health - . � F r � -' ✓��p I��----�- -----� �°`;'`R a TOWN OF YAR ,�H BOARU OFA��EALTH ��= APPLICATION F � t� '�I,,SE/PL�'RIVIIT = t.i�v iu � 7�ijj,^r I * Please complete form and attach all necessary documents by December � ___v =:�'`t'. � Failure to do so will result in the return of your application packet. �` I�IAME OF ESTAT3LISHMENT• ue f SA�v>7 Cvuiv�RY SJo.PF T # s-a 790 A79'.� LOCATIONADDRE S-ad l�v�Xss..¢ivs/ .Pr7 �u-Y,q�.��.�'1� ,tnA, �a�73 MAILING ADDRESS: SRr�F a i .ari.�v � � OWNER/CORPORATION NAME• <t> FFir� ��.,P/.?�ln'/ MANAGER'S NAME• A.�EEM /(srun6'.P�iyi TEL # 6' 'i 9c5� jf4�j�f' MAILING ADDRESS• S.2A- t3 u��S.tAs✓� /?/7 w �i9/�n�n ,u MA i),��7 s� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. ,-�� 2. _----.'.""""..__.� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary 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. _� _ ______ __ -.._._. . L '" 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, ]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. 1.� �--� 2. "----. ---.. ---. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � � ___._--- 1. �f�✓'� K�lu,ll,PA71'1• 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 Healt6 Department will not use past years' records. You must provide new copies and intain a Sle at your place of business. J y�,_...----''- 1. 2. .�".--- 3. 4. .--"'�- RRSTAURANT SEATIN : TOTAL # OFFICE USE ONLY LODGING: � LICENSEREQUIRED FEE PERMIT# LICENSERBQUIRED FBE PERMIT# LICENSBREQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL S50 _INN S50 _CAMP $50 _SWIMMINGPOOL$75ea _LODGE $50 _TRAILER PARK S50 _WFIIRLP(H)L $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE RGQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERM[T# _0-100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT S25 _>IOOSEATS 5150 _COMMONVICT. E50 _WHOLESALE S75 RETAIi C RVI . � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k _<50 sq.ft. $45 _>25,000 sq.ft. $200 VENDING-FOOD S20 ,LQ5,000 sq.ft. $75 �Y D3-037 _FROZGN DF,SSERT E35 / �TOBACCO $25 �Q3-6alp NAMECHpN(' ; gio AMOUNTDUE _ $ i00,pp *""'*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 Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/ Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: /' YES �/ NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT TI-IE 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 REGULAT10N5 POOLS POOL OPEPTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL 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 �ONSUMER A9VISORY: Each food establishment wtuch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERIN[' POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health DepaRment by filing the required Temporary Food Service Application form 72 hows prior to the catered event. Thses forms can be obtamed at the Health Department. FROZEN DESS .FRTS: 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 waiterlwaitress service),mt sti have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparahon,or display of any food product by a retail or food service establishment is prohibited. DATE: /�` — �2 3 —02. _SIGNATURE: , �� PRINT NAME & TITLE: � 10/1 S/02 � The Commonwealth ojMassachusetls = Deparlment ojlndustria/.-iccidents ; O/11C00//II'6SUo/dI/f 600 Washington Slreer Bnston.Mass. 02111 ` ��', w'orkers' Campensation Insurance Affidavit ARplicant intormafion• Pfe±�sePR1NT7..d.'i�F�r oam�� yl.��/� /�11-1�.RR�I� � lucatian� �L�C.L3��,c,.s✓i/Jy ri/7!?F / crt� U/-�L21� /'l�/f � : ehon p � I am a homecµner pert�rtni(g all work myself. � I am a solz proprie[or �c,', ha�z no one �.orkin� in am capaeity � 7 am an emplo}er pro�iding w'orkers' compensation for my employees workine on this job. � //1 �/ -- tomnanvnamr. f�iuiN ( Xv:h6C MA,,P/ /dV� . adAress: .S 3�- /� r�L�� u/n/ f/f /�� tih': �'n '�A-J4 /n/J V//� mft. n 2 phone p• �i� � .- � - � ! � �� , insuranceco. /'\.9�/Y//�T1t policvM � ��7�� I am a sole proprie[or. _eneral contractor. or homeowner(circle onel and ha�e hired the contractors listed below aho ha�e the follo«in_ ��orkar> ,ompensation policas: � .�' � m vn �� a�dress: cin: � phone N• insurancc co. polie�•q . �! tomoany name: _ . . _ . . . _ . . . . . _ __ . . . ____._ _ addresr [iLY' pheee M• � insuranee co. eeliev N ■ Failure ro seeure covenee�s required uoder Seenoo SA of MGL 153 u�Ind a the i�poridw of criW W pe�dtlea of��e ap m fl¢D0.00 a�d/or ooe yun'imprisonment u w�ell n eivil pteNtla ie the form of t STOP WORK ORDER ied�Ilee of SI00.00�dry qdmt ma [��denn�d M�t a copy of thia shtemcm may b�fonv�rded to tAe 011iee of InveniQuiom otthe DIA far eoven�e veriliutlw. - l do�hrre6y nni nder the painr and pena!!ia ajperjury�hm rhe injormatfon provided above is nue and conect Signaturc `�`� � fo7 - 02 �- � . Print name one N S i�i�_ .`��/��_ �l/"9iU . oR�i�l use onh do not�ri�e in�his area to be completed by cih or fmrn ollleial city or town: y�M�DT$ _ pemiNieeeu N nBuildinL Dep�rtmeet � pLiceosiog Bovd Q check if immediate response i�required Z61 QSelectmen'e Oflier �Health Department contactperson: phoneN;_ �SOH� 398-?231 eat. npiher .. _� ♦ ;� (' � ,, ♦ - , ° ' I .-�r..,, , �, � TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-037 FEE: $75.00 In accordance with re ations promulgated under authoriry of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a permit is hereby granted to: Aleem Khurram, 528 Buck Island Road, West Yarmouth, MA Whose place of business is: Buck Island Country Store Type of business:_ Retail Food Service less than 25 000 square feet To operate a food establishxcient in: Town of Yatmouth Permit e�ires: December 31_ 2003 soARD oF HEALT[i: �iFw,leo ,'f�, z�lika�, � — __ _ _ _ -- ,�� .?�.. `t/iee _ __ �adrtek�e:.xotl '��uc .S/�a�E. R?P. January 17.2003 ntce G.Murphy,MP , R.S HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN O�'YARMOUTH . BOARD OF HEALTH PERMIT NUMBER: #03-026 _ FEE: $25.00 This is�o cerefy w�t Aleem Khurram d/Wa Buck Island Country Store 528 Buck Island Road_ West Yazmou - MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBt1CC0 PRO�UCTS • AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION ��er�'t is�nte��n��'urmi �with Article VI o�'�t e SaniE�Code of The Commonwealih of Massachusetts,and , e s ece er s soonersuspen orrevo Jan��ry 17.2003 BOARD OF HEALTH: �a�tlea r�. iCd(GEpn. �k �ur�«�S D. �. �.a., ?/ree �e6ert�. B�, Ll� p��tt � �k. .�t. ruce G.MurP Y,MF' Director of Health � Ls�ND �Ur�Y Sro2s . � � ,� . e��. �`�j �� TOWN OF YARMOUTH BOARD OF HEAI.TH �'� � �� ' � }�J� 7 G 'j5• °Z' �PLICATION FOR LICENSE/PERMIT-2002 I�;r.:(, Z % Z i;E�i " Please complete form and attach all necessary documents by December 31, 200L Fail ef1�.aFd_�oti�till�IC�itlt the return of your application packet. NAME OF ESTABLISHMENT: ULK c v Fs-�aP.c TEL #300" o$7Qij LOCATION ADDRFSS•41b' R� �cK i��Y„�2 O -�2rn�„ii� ✓I A n� G 7 '; MAILING ADDRESS• �,r.mci s}/3tc 4WNER/CORPORATION NAME� 22.2Ai !�a�� MANAGER'S NAME: 9r TEL # �c.Q �Gc� 6.R9Z MAILING ADDRESS: POO RT FI ATION : 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 th�s form. l. 2. Pool operators must list a minnnum of two employees currently certified in basic water safety, standard First Aid and CommuniTy Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a £ile at your place of business. � 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Deparlment will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSIIN IN CHARGE: . Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAiJRANT SEATING: TOTAI� T 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 $50 _SWIMMING POOL$SOea _LODGE $50 _TRAILER PARK $50 � WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS F�:_,$75 CONTINENTAL $30 _NON-PROFIT $25 ry.. _>l00 SEATS $ _COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 � , sq.ft. �75 l��0/ / TOBACCO $20 �-oa-oia _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ qS•OO *"•"*pLEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM*'*** f` � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarxnouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED L--''�� Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ��'r NO NOTICE:Permits run annuaily from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'CJRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHIvIENTS 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. ADDITIONAi REGULATIONS POOLS POOL OPE1�iING:All swixnming,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 swimining pool must be drained or covered within seven(7) days of closing. FOOD SERVICE ('nNSUMER ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked aniinal products aze required to post Consumer Advisories. ('ATFRiNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _ FROZFN 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),mus 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:/'�' R' d� SIGNATURE:�� PRINT NAME& TITLE: % "� A � � A f � �H!n�ei�.� 09/I 1/Oi , � The Commonwenith ojMassachusetts = Department ojlndustrial.4ccidents a 011lce ol/eresUy�IHis - 600 Washington Slreet Bnstort, Mass. 02111 � �� '` w'orkers' Compensation Insurance Affidavit Apolicant information: Pt n. INTT/r.7s�r � .. n'Im •� ��^ � � � /�� 'L� t�c�ann �� ,�' i�r � 1� r �� i9.�]11 i�4� WE�l- �.q �l�l n�s� i-� � cit� 1� I 0'-i ' � ./- (J �� ehon p � I am a homeouner pertortning all work myself. ..:�,�7,�"1,�aiafOg,��taC ,•.� h]ie ee:me.r�.iww.:`�� . ._ _ , � 1 am an emplocer pro�idine µorkerz' compensation for my employees workine on this job. comnanr �ame: �JAress• titr: ,�hone p• insurance co. yolicv tt � I am a sole proprietor. _eneral contractor, or homeowner(circ/e onel and hace hired the contractors lisred below ��ho ha�e the follo�cin_ oorkzr, ;ampensation polices: �smpanv name: address: ciR�: � ohone M� insurantc co. Dolicv# tomoanv name: _ _---- - � - - .__. _------ - --._- __. addresi: �" p6oes�• insuranceco. __pQ�n.p F�iiure to sccurc covenge as required uader Secnoo 25A of MGL 152 a�Ind lo tbe iepaitio�of eriW�l peedtln of a Ou op to f1,500.00 ud/or one ynn'imprisonment af w�d1 n eivii pendNn io t6e(orm of a STOP WORK ORDER�ed a Ilx of SI00.00�d�r q�iott m� 1��dmta�d H�t a eopy of thy sntement may be fonwrded to the ORcr of Inve�tigtuom of the DIA for eoven�e ve�0utlw. /do hrreby ce '}•under.rkr pains artd perta!!iv ojperjury�hat rht injornmlion providtd above is d�t and eorrcet Signaturc p�� ? - � L� v� Print name �+one M - oRcial use onh do not rrite in this arn m be completed by city or tmvn oflltial ciry or town: YA��IITQ _ permitAiaeu N nBuiidiog Dep�rtmeot �Litemiee Bovd � chrck if immediate response i�required Z61 �Selectm�n'�ORce �Hcdth Departmeet <on�actperson: phoncN:_ C508� 398-2231 eat. nOtAtr TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMTT NUMBER: #02-016 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: T��at RaiS, 52R R ick icland Rna� �xle t Y rmn � h A�A Whose place of business is: Buck Island Country Store Type of business: Retail Food Service less tha�25 000 sque feet To operate a food establishment in: Town of Yazmouth Pernut expires: December 31. 2002 BOARD OF HEALTH: 'a�, iCel(ik�, ��D�.�Cjoadn.c.�.D�`�/lee �a�tek e:oxotl .�1. March 15 .2002 ruce G. Mwp�}i Mp , R.S., CHO Director of Health O THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMII'NLJMBER: #02-012 FEE: $20.00 Th;s is to Cemfy that Izzat Bais d/b/a Buck Island Countrv Store — 52ft Buck Isl nd Road West Yarmouth_ MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRiBUTTON OF TOBACCO PRODUCTS AS PER THF YELRMOUTH BOELRD OF i-iFAi TH TOBAC O REGULATION This permit is grarrted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31_2002 unless sooner suspended or revoked. Mazch 15 ,2002 BOARD OF FIEALTH: �an�'�f, i�q(�'tet, �J,�ut'p�q� Geala�rGs D. CJozdoK. 'yll.D.. ?/lee ,�o�ett`�. �ota�c, ela�rk �a0riek'IJ�euxotl � S . .?Z. ruce . i Director of Health � ' �� Buckls�a,ND CounnYz S�azE `ii. ` S�'� JL.lIA� r�i � � �s � � � � ' TOWN OF YARMOUTH AL.TH � DEC 1 2 2000 APPLICATION FOR LICENSE/PERMTT-2001� H ALTH EPT. * Please wmplete form and attach all necessary documents by December 31, 2000. Fail the return of your application packet. ��_��_��_��_��__��_�_G__��_��'��_�_��__��_�__��_��_��_�_� I�1AME_OFESTABLISHMENT: I�jtJGk I�j�:v�� '„�,nr,lf�/' �1„�y TEL. # �79o -c97fc LOCATION AT�D�SS: �� ,��,o� �S, P,.i� e�,ai� �_,c-S; A2�+-+0,,�9- N/-� 0 2i�;� MAILING ADDRESS: s�r�r ic �,-�Y OWNER/CORPORATTON NAME: �22R T/3A�i�' MANAGER'S NAME: T7 z�1 T � n �s TEL. # 7�f o 874� MAII.ING ADDRESS: �aA�c' is .9n� --------------------------------------------------------------------______----------------------------------_------------- POOr. R'I'IFI ATION : 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 thts form. 1. 2. Pool operators must list a minimum of two employees currenUy 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 Henith Department witl not use past yeara' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department wili 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 REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food pmtection manager certification is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# _0-100 SEATS $75 _CONTIlVENTAI, $30 _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMI'I'# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 I TOBACCO $20 �'�� -0 I I <25,000 sq.ft. $75 �01-01 TFROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOiJNT DUE _ $ �I5 •00 *•*•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• r.._. � - _ : __. ._ . � v . , i ADMI�IISTRATION Under;Gha�t�r 1,52, 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 Worker's Compensation Insurance. TFIE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISHIvIENTS ARE TO CONTACT TI-IE HEALTH DEPARTMEN'T FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,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 NFw STATE �ANIT?�RY CODE FOR FOOD ESTABLISHMENTS• The effective date for food pmtection manager certiCcation 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 protecdon manager. This provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented Januazy 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 Yarmouth must nodfy 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 . SERTS• Frozen desserts must be tested on a montlily 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. O T DE C�FFS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�t have prior appmval from the Board of Health. OUTDOOR COOHING• Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: \ �� \� � �` SIGNATURE: ` PRINT NAME & TITLE: ��2 AT_�'�A 1 g o\�l^t �� 11/16/00 _ , �\ The Commonwealth ojMassachusetts W Department ojlndustria/,-iccidents � ; O///CS 0//OYCS!/OfWIf � 600 Washington Slreet Bnslon,Mass. 01111 " W'orkers' Compensation Insurance Aftidavit Bpplic��r information: PieasePRllQ'1`i�it � n�m.•' \ ] ��0�- � �13 �'1'�/1 J e!9 L ri��! C� � l9"K1� Inc�iinn� °�-� /�r Ir).L •��A-N/� � o A� � gjt r C3t �AQ�n��1-1 M/� Q o '� �i7� ohoneM 7e8•7�o • R74,i � i am a homeowner pzrforming all work myself. � I am a sole proprieror ar,d hace no one «orkine in any capaciry i-yr,pb.s� i-c„j,t�- 0�4�//(� � I am an employer pro�idinsµorkers' compensation for my employees workin¢on this job. om n n aJdress: cih^ Dhone M• — insur�nce co QQlicv M � 1 am a sole proprietor. general contractor,or homeowner(cire/e onel and hace hired the contractors listed below ��ho ha�e thz follo�cin_��orkzr_ ,ompensation polices: som r�nv name• -'dress• �.. phone k• insur�nce co Dolicy# m n - - - -. . _.. .. --� -- ddress• - -- ----.� . . . cilr � yhoenll• insurance co po�M F�ilure to secure coverage as required uader Setrioo 25A otMGL i52 na Ipd to tYe inpaitloe o(erisiW peultln ot�8�e op to f1�00.00 a�d/or one ytars'imprisonmeot u w�ell ae eivii pen�INn io the form of a SI'OP WORK ORDER�od�6ee of 5100.00�d�y qaimt me. 1 a�denh�d H�t a topy of thh sntement may be fonvirded to the ORte of lovotig�tiom of t6e DIA for eoven'e reriflutlo�. /do�hrreby cenij�•under the pains and penafties ojpery'ury�hm 1he injornmtion providtd abovt is nue and corrcd ' 12 . � Signaturc �ate J Print name �22.�a��t,� ` Q Phone M ��i�� 7e1 S� - oRcial use only do not w rite in�his area to be tompleted by ciN or town ollleial - ciry or town: Y�M�OTQ _ permiNiceou p nBuildiog Depirtmeet � pLiceosiog Board �check if immediah response is required � 261 ❑Sdectmta'�Ofliee pHcalt6 Dep�rtmeet conroct person: � pAone M:_ �508} 398--2231 eat. nOther bmuM i;95 FIAI , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-014 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 I,Section 5 of the General Laws,a permit is hereby granted to: T��at Raic 52R Ruck Tcland RoatL West Yarmouth MA Whose place of business is: Buck Island Country Store Type of business: Retail Food Service less than 25 000 sauare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 2001 BOARD OF HEALTH: $d� �ettea. �raduxa+c ��. z�, v� �� 3 �. � �aeE d :@�� j� D. . �K. 4 �hu�- <. Februazv 6 ,2001 Bruce G.Murphy, MPH,R.S C Director of Health THE COMMONWEALTH OF MASSACHUSE'I"I'S TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #O1-014 FEE: $20.00 This is to Certify that Izzat Bais d/b/a Buck Island Countrv�tore 528 Buck Island Roa� West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCT _ AS PER THE Yt�RMOUTH BOARD OF HEAi_.TH TOBACCn RFc;i Ti ATION This pernut is ganted in conformity with Article VI of the Sanitary Code of The Coromonwealth of Massachusetts,and expires December 31_2001 unless sooner suspended or revoked. February 6 ,2001 BOARD OF HEAL1'I-I: �� '�Ctr'¢d, �Grax�toy �rwrlea:�, zdli�. 2/iee Lflavroxa.� ,�o�t� �io�v.c, �k �lfiekael 0 :t'arg� a.x:,�c D.��doK. �l.D� �.� D'rector of Healtyl'i � Y� _ � �__ ,. _ L� C� t�; • TOWN OF YARMOUTH BOARD OF HEALTH �� 3 � �999 APPLICATION FOR LICENSE/PERMIT- 2000 HFALT!i p PT. �* Please complete form and attach all necessary documents by December 31, 1999. Failure o o n the return of your application packet. ----------------------------------------------------------------------------_---------------------------------- F N fft2d" L. #� oa' f/1- LOCATION ADDRESS S,�l� s3/,ac/l �G�d l�r�4 t. LIN �r OWNER/CORPORATION NAME� �/Z'u"/l�Li - ' ` � ' ' # 7 G� MAii ING�nD1ZF.SS� . —_--------____—__—_-------------------_---____—__--------------------------------------- -- POOL CERTIFICATIONS: The poot supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to t}us form. 1. 2. Pool operators must list a minimum of two employees cunently certiEed in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Cle at your ptace of business. 1. 2. 3. 4. HEA4L.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 a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health DepaRment will not use past years' records. You must provide new copies aad maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---_��-------------------------------___---______---_------------------------------------ OFFICE USE ONLY i3ODGING• LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlvIl��tG POOL $SOea. WHIItLPOOL $25ea. FOOD SERVICE• LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIKED FEE PERMIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 I TOBACCO $20 Yzk-3$ I <25,000 sq.ft. $75 Y2r_Jt� _FROZEN DESSERT $35 >25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ 9C� , O� ••`"`PLEASE TUR1V OVER AND COMPLETE OTHER SIDE OF FORM""'"" ADMINISTRATION i7NDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOUTH IS NOW REQUIltED 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 AFFIDAVTI' MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND CHED TOWN OF YARMOUTH T.AXES AND LIE MUST BE PAID PRIOR TO NEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK AP OPRIANO Y�P��U/.�- �� NOTICE: PERMITS RUN ANNUALLY FROM JANLIARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILTTY TO RETURN TF� COMI'LETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPAR'TMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, 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 REQUIltE A SITE PLAN. DITION i F n ATION POOLS POOL OPENING: ALL SWIA�IING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY TFIEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvID�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS W1THIN'THE TOWN OF YARMOUTH MUST NOTIFY TI�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM ?2 HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS M(7ST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE BEEN MET. QUTSIDE CAFES: OtITSIDE CAFES(i.e., OUTDOOR SEATING W1TH WAITER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM Tf�BOARD OF HEALTH. 4UTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOO PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIv1ENT IS PROHIBTI'ED. � DATE: ��- 3� � � '1 SIGNATURE: /� PRINT NAME& TITLE:� %�/Ut ��Z, 6 lJ,ti.Q/� � 11/12/99 TOWN OF YARMOUTH BOARD OF HEALTH • PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-46 FEE: $75.00 In accordance with regulations promulgated under authority of Chap[er 94, Section 305A and Chapter ll I, Sec[ion 5 of the General Laws,a permit is hereby granted to: 4tPven M Kat� 52R Rnck Tcland Rnad Wect Yarmnuth R�A Whose place of business is: Buck Island Countrv Store Type of business: Retail Food Service les than 25 000 quare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:�� n/. ��aJt�g/s, C'�[�irmQ/a�n � � /J �//�oa/n C�c.7J/u�llivaa� Kg.//l,� Vica C,�irma Koberf/J/ .n6�row0n, �lerk a6.ial[e Ja�oU�Zy-�oap¢e r��lOo('o�y�ln � �« Januarv 25 ,2000 Bruce G. Murphy, MPH, . ., HO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: Y2K-38 FEE: $20.00 This is to Certify that Steven M Katz d/b/a Buck Island Country Store 528 Buck Island Road. West Yazmouth. MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS — AS PER THE Yt�RMOUTH BOARD OF HEt�i TH TOBACCO RFGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. c7 n Januarv 25 , 19 99 BOARD OF HEALTH: C�t� � Je�, l��tairman �oan C.. JuL[ivan� K./l.� Vice l.�irmaa �o�,t.� �rown, c�,� (�'a6.ial�e S'a�ol�y-.�oopa� //,(iChaelOe[�aµg�Cire ' �iL..c,;,�.eifi�� tic ruceS�i. urp y, , Director of Health " �k 1si a nd cau�+ry �-� " � ': ` ` �� '` r '�(5�1 F YARMOUTH BOARD OF HEALTH ' ` I � I ATION FOR LICENSE/PERMIT- 1999 �� :::: 3 1 `1'�' ��,� * Please compleke��',�'iNi�'ft6�H' ecessary documents by December 31, 1998. Failure to do so will result in the return of you`r app icaUon packet. --------------------------------------------------------------------------------------------------------------------------------- TAB I N uu S .� - L # 0 I 4CATION ADDRFSS c�f� r{, iit T�PCq.✓�, r2 1 MAILING ADDRESS S/� �= OWNER/CORPORATIONNA1�tF S'TFu'�� ,C�j /)�q ER' N =,,. � L # _ � LvIAII,ING ADDRESS� �r��r ~--------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATIONS The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tivs form. L 2. _ Pool operators must list a minimum of two employees ciurertly certified in basic water safety, standard First Aid and Community Cazdio�ulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certifications to t}us form. The Health Department will not use past years' records. You must provide new copies and maintaiu a file at your place of business. 1. 2. 3. 4. HEIl�ILICH CERTIFI ATinNS 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 £�le at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# - ---- ____—____-------------- -- -------- - ---------------------------------------------- _ -— - -- — - —- f3FFI�E I3SE ONL� LODGING: LICENSE REQUIItED FEE PERNIIT # LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $50 _1NN $50 _CAMP $50 _LODGE $50 TRAILER PARK $50 _MOTEL $50 _SWIl�A�IINGPOOL $SOea. _WHIItLPOOL $25ea. FOOD SERVICE• LICENSE REQLTIItED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 _WHOLESALE $75 RFTAii CF Vj LICENSE REQUIItED FEE PERMIT # LICENSE REQUI1tgD FEE PERMIT# <50 sq.ft. $45 �TOBACCO $20 � �<25,000 sq.ft. $75 Qq�37 _FROZEN DESSERT $25 _>25,000 sq.ft. $200 DTAME �'AAN $10 AMOUNT DUE _ $ q�'j — �;�� """""PLEASE TURPi OVER AND COMPLETE OTHER SIDE OF FORM•^••• ' � l ADMINISTRATION iINDER CHAPTER 152, SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOLTTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLJRANCE ATTACHED 18 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 1VO�CE: PEF�MI-TS �i3i*i--r1FI�VU?r�b3' FROM JANLJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILIT'Y TO RETURN Tf� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIvIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISf�vtvtEEN'T, MO'TEL OR POOL (i.e., PAINTING, NEW EQiJIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAi.RE TI ATIONS POOLS POOL OPENING: ALL SWIMNIING, WADING AND WHIIiLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TF�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMN�tG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. FOOD SERVICE ('ATERi�.tG POLICY ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING Tf� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TF� HEALTH DEPARTMENT. FROZEN DESSERTS� FROZEN DESSERTS M[JST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAII,URE TO DO SO WII.L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERMIT UNTIL'TI�ABOVE TERMS HAVE BEEN MET. __ - _ - ni TTSIDE CAFES: ��p�OR OUTSIDE CAF'ES(i.e.,OUTDOOR SEATING WITH WAITER/WAI'TRESS SERVICE),N�iZ�T APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKiNG: OUTDOOR COOKING,PREPARA'PION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. , DATE: ��; -2 �� SIGNATURE: pRINT NAME& TTTLE: S'%Z-G'ti �.�1 l��/� L�r.��_ • i _ � ' The Commonwea/th ojMassachusetts � Departmen!ojlndustria/.-Iccidents ; Of//C001//Y6SUOfU//f 600 Washington Street ' Boston, Mass. 02111 W'orkers' Compensation Insunnce Affidavit Aoolicant informaHon: PfeauPRiNf`i�r.�.F: n m.: �%��C/LJ .�� l Z. �11C! ��t-.��/,R/� O L�-� �' TIl ZC ��;� .�a� F'G��e x�'G�.,,� /C d .cit�� 1�� y/T�-�Z��G�/L 11i1 ehon tl �O� �70" ��L 0 1 am a homeowner pzrtormin�all work myself. � I am a solz proprieeor_rd hace no one«orkin_ in any capacin+,�,>.,�rc, � I am an em lover pro�iding workerz' ompensation for mkemployees uorkine on this job. �_ , u' C� _ tci�_i�.t_ C '2�! o m � n - T''� - . ,aa� ts: 3�25 oN L Ud . tih': ��GJ��O/QULII��y,� Dl7S�_phoned• insurance co. LG��(iV Cf�Sj�� C1� oolicp k Urc � �o a 9 ro y � I am a sole proprietor. _eneral contractor.or homeowner(circ%anel and hace hired[he contracrors listed below �.ho ha�e thz follu�cin_ �corker, ;ompensation polices: comoanv name: address: cih�: phone q: insurancc co. polit��R i2moanv namr. � addrees:- -� --- -- -- -----��-----.---.. _------�— -- - c�: phoee M• intu[znce co. eeliev N F�ilure to secure covengt�s required under Setnoo 25A of MGL 152 ut Ipd to tYe iepaido�o(erisiol pt�dtla of a��e op to f1,500.00 a�d/or ooe ynn'imprisonmeot u w�ell u civil penalHn io tAt form oh STOP R'ORK ORDER ied a Ifet of 5100.09�d�y qaiert se. 1��dennW N�t a topy ot thie satement may be fonv�rded to the 011iee of Inve�Ng�uam of t6e DU for tovera�e veri6e�tlw. . /do hrreby cenij�•under tke pains and prna(lies oj er' tNm thr injannation provid�d above is dut and cor►ed SignaNrc �, pate %�, 02 �%`CS Print name . �TC"�i�.%`f /,�4 ��/f'l G Phone MSO�f'- '7�`Q � .4%1�_S" . oRcial use onh do not�ri�e in�his�ra to be eompleted by eiry or town ollleial ciry or town: Y�D�TQ _ permilAieeme M nBuildiog Dep�nmeut � �Liceesiog Board 0 check if imm�diate response is required 261 �Selectmen'e Oflfer (508) 398�2231 e%t. �HealtA Department contact person: phone N;_ � _ _�Other ^ ae,isM;,05 v1A� \ \ TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NLIMBER: 99-37 FEE: $75.00 In acc;orda¢ce wiW regulations promul@ated uuder authorily of Chapter 94.Section 305A and C6apter I(L Sectiou 5 of ihe General Laws,a pecmit is hereby granted to: 4tPven M Kat�, 52R Rnck icland Rnad, Wect Yarmouth MA Whose place of business is: Buck Island Countrv Store Type of business: Retail Food Service less than 25_000 square feet To operate a food establishment in: Town of Yazmouth Pernut expires: December 31_ 1999 BOARD OF HEALTH: �d�P/. �et�p��, C�a/�M,�n/a/,. � / /�/ � �(�oarz C�c. 7�/u�llivan�/K�e.//l.> Vice l,hairman Ko�er(p��}.�O�irow0a/� (..[erh a�riella�Ja�oG1k�ooPee � ' e�O�C'ou�� Februan�9 . 19 99 Bntee G.Murphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 99-31 FEE: $20.00 1L;s is to certify�hac Steven M Katz /a Buck I 1 nd o mtry Store 528 B�ck Isiand Road WeM Yannouth MA IS HEREBY GRANTED A LICENSE For _ SALE AND DISTRIBLTTION OF TOBA O PRODU TS _ AS PER TF� YARNrnr 1TH BO RD OF HE T TH TOBA .['O RE Ti ATION. 11is peimit is granted in confomuty with prqcle VI of the Sanitary Code of The Commonwealth of Massachusetts,and expues December 31. 1999 unless sooner suspeuded or revoked. Februazv 9 , 19 99 BOARD OF HEAI,TH: C�� ettee, l..�ia;,•nu,n � �oart � Ja�ivan� Kp.//.� Vice (..�irman � Ko�rt� C�rown� l.lark �a6.;�P�S'a,Go��y.�l�Pe� � �.e�0' ou�l� Director of H�ealth' '