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Home My WebLink AboutLicensing - 2003 and Prior . Ba�N"ts t 6E�oaD a OF Y'�R TOWN OF YARMOUTH BOARD OF HEALTH 32 d ^.c �n � � �", APPLICATION FOR LICENSE/P&1iM1'�"�,200,'�'r; � ' � M [� � r �;_ �y':�e �,, "� ..�. 'm�-�'��11 E Q(� � * Please complete form and attach all necess �y Dec m er 3�, 20�� Z�J� Failure to do so will result in the return ' w application p e#�E�_�?-�,-��T NAMF, nF F.STARi ISHMFNT• �L$ ��k...G� TFI. # '�G-a S� LOCATION AT)DRFS�• 27 V(��kla�) S`f Illl �4 W1.+r c��3 r,ren rtJr, ADD�SS• -- n�,cn.rFuirnupnuaTrn7.rN,�ME• �\ �'Icxua�� r,re�.renFu�crteraF• \ (�p-�.,�� TET. # r,ren rT.rr �DRFC4• S(�nl` POOL CERTIFICATIONS: TLe pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opeiator(s)and attach a�o�oflhe certificat�n ta Yhi�form. . 1. 2• Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cazdiopultnonary Resuscitation (CPR). Please list these employees below and attach copies of employee certificafions to this form. The Health Departmeot will not use past years' recorda. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. FOOD PROTECTION MASIAGERS - CERTLFICATIONS• 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 applicaiion. The Health Deparhnent will not use past years' records. You must provide new copies and maiutain a file at your establishmenk 1. V�f..� 2. _ _ kF_RS(a1>i II�I�F�R�t�__ Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. J. l-��n�e.�s� 2. HFT I H RTIFICATIONS• 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-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. z• 3. 4. RF.STA , NT SEATING: TOTAL# OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMI"C# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S50 _CABIN $50 _MOTEL $50 INN S50 _CAMP $50 _SWIMMING POOL SSOea LODGE $SO _TRAILER PARK S50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-t00 SEATS S75 aI�O"6�✓—Ol�' _CONTINENTAL $30 _NON-PROFIT S25 >100SEATS $150 ICOMMONVICT. $50 �6�—Dld _WHOLESALE $75 RF.TA 1 .RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# TOBACCO $20 _Q5,000 sq.ft. S75 _TOBACCO S20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAMECHANGE: $10 AMOiJNTDUE = S 12.5.00 **•**PLEASE T[IRN 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 � 21� 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 I to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHIvfENTS ARE TO CONTACT Tf�HEALTH DEPARTMENI'FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING 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 OPErTING: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 far pseudomonas,total coliform and standazd plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yannouth 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 Depariment. �ROZEN DESSERTS: Frozen desserts must be tasted on a monthly basis by a State certified lab. Tesf results musf be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COO iNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: � ' Z SIGNATURE: PRINT NAME & TITLE:_ �I. .,�is,� 10/18/02 ;.�o.lN ExWns on: r��b �(.W�.P �1Mu� Wip Number: 194594 12/05/02 7.W.3 Venlon Numb�r: t l0 GUOTE WORK $ NEET Insurer . GRANITE STATE INSURANCE COMPANY Unde�vri[er . C I FELL I , JEAN B►anch . ASSIGNED RISK 9rplcer . MARSM�IL K LOVELEITE INSURANCE JIGENCY Inaured . JASON CARVALHO Effecwe pate . t2/o5/02 Exp;ration pate . 12/05/03 Mniversary Rate Date . Rating Plsn . RISK ID: COVER�GE A: YES EMPLOYERS LIABILITY: 100.000/ 100,000/ 500,000 CAUTION: This quotatlon is an estlmats based on ths representaUons of the named Insured, and Is subJect to all pollcy�ms and conditlons, ratas and underwAdny rules In efMct durinp 1he covenge period, fn conformriy to appllcable laws. LW0687 �. ¢�1) INSURED'S COPY o�'YqR �� ; '�o TOWN OF YARMOUTH � - - y 1146 ROUTI:28 SOliTH YARMOl17'H MASSACHL'SF.TTS 02664-4451 � � MFTTACHEES � C�, k,p.o �o�s�+�� Telephone (508) 395-2231. I:x[. 241 — Fax (508)398-2365 vJ� B O A R D O F H E A L T H November 20, 2002 ; �; , , :_ �� ; J. Carvalho � �'i� �� ,� � ��`� d/b/a Bagels &Beyond � I ,_, �,L,�,- �;i:_.`�`�� 327 Route 28 --�— ; West Yazmouth, MA 02673 Deaz Mr. Carvalho: Thank you for submitting the 2003 application for food service and common victualler permits. However, we are unable to issue your permit at this time due to your application being incomplete. All sections of the application must be completed in full, as required by the Board of Selectmen. The following question was not answered when you submitted your Application for License/Pernut: Town of Yannouth taxes and liens must be paid prjpr�to renewal or issuance of your pernuts. Please check appropriately if paid: Yes ��ZC No (If question is not applicable,please indicate such.) Please answer the above question, and return to the Heakh Office so that we may issue your 2003 food service and common victualler pernuts. Thank you for your anticipated cooperation in this xnatter. Sincerely, �� Mary Alice Florio Principal Depaztment Assistant /maf cc: file � Prin[ed on ! Recycled L 3 Paper TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-012 FEE: $75.00 In accordance with re�u1ations promulgated under suthority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of ihe�ieneral Iaws,a permit is hereby ganted to: J. Carvalho, 327 Route 28 West Yarmouth, MA Whose place ofbusiness is: Bagels&Beyond Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit e�cpires_December 31. 2003 soAltn oF HEni,1'H: �i(ra�rlec�f, zouGF�, � SEATING: 19 . • . D, �Op�t�.�� .�.. �/1CG �N4K .. � � ��0-�`'_/r�.y G��QOOWL. (icvNc � �R!/fCGIZ //LGf/OAMW� T1C�K S�. !G./L• November20 ,2002 ruce G.Mmphy,� S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH - PERMIT NUMBER: #03-010 FEE: $50.00 This is to Certify that J. Carvalho d/b/a Bagels&Beyond 327 Route 28, West Yar�uth, MA IS HEREBY GRANTED-A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only andexpires December thirty-first 2003 unless _ soo�er sm�gend�d or revok�l far vialation ofth�laws ofthe Ca�nonwealth respectuig th� -- - - licensing of common victualler's. This license is issued in confornuty with the authority granted to the licensiug authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo�the undersigned have hereu�o a�ed their official signatures. BOARD OF HEALTH: �iFa�io:f� z�. L/Fa:�w.c SEATiNG: 19 �D. CJ� 7lC,D., 'Liee J�O�tS�. �ROqYK, �(�tk �atiEek 711e2)auxetl �du S�ak. ,�.�1. November20 ,2002 Director of H IUi ' � . . BflG� + B"tY0N17 � ,/ TOWN OF YARMOUTH BOARD OF HEALTH - ,C�1'�' ` a;t"� ,�`,, PLICATION FOR LICENSE/PERMIT -2002 Cv , � ; �'� � '�� - J) � t � ��"� �� b �fli * Please complete foin�i ch all necessary documents by December 31, 2001. Fail to`do so wil�result i thereturn_cLfy��:a�pliea�q��ack�t� NEALTN DEP7. ,TL/ d" NAME OF EST LISHMENT• c5 �£�(ch-� TEL # SD�P�-74�-d� i n('AT1nN AnnRF S' �Z� (V��°n� W �� Md UL(o'�3 MATi ING ADDRFSS• pWNFR/CORPORATION NELME• MANAGER'S NAME• �l�S� C�x.vwc,h� TEL # ��79�-,rc� MAiT ING ADDRFSS' 327 fh�A-��1 t��. �`� C�Z�� POOL CERTIFICATIONS: The pooi supervisor must be certitied 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 forxn. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certifica6on to this application. Thc Health Department will not nse pa.�t years' records. You must provide new rnpies and maiataai s£�at your establia4ment 1.� Lk-,J��a� 2. ._ _ _ --- - ------ r_ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operadon. 1. �Z� �l-t-c.-✓A'l.tcri` _ 2. �t� 1�ki�r.nrM 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 empioyees trained in anri-chokuig 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. Z• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIlVG: '- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _ B&.B � $50 _CABIN S50 _MOTEL $50 INN $50 _CAMP S50 _SWIMMING POOL$SOea LODGE $50 _"I'RAILERPARK $50 _WHIRLPOOL $25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT t! I 0.100 SEATS S75 -�w� _CONTINENTAL S30 NON-PROFIT $25 >100 SEATS $150 I COMMON VICT. $50 #Od"O��J _WHOLESALE $'75 RRTAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# TOBACCO $20 _<Z5,000 sq.ft. S75 _TOBACCO $20 _<50 sq.ft. $45 _>25,IX10 sq.R $200 _FROZEN DESSERT S35 NAME CHANGE: $10 AMOUNT DUE _ $ IZS.OO - ****"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* � � - _. . _. ___ .__ �. � / `� � � r ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: - -YES - - _ N� _ NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMEiN"I'S 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 OPEPiING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 auimal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Depariment by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. -- -- - - - - - — -- - __ _- -- FROZEN DESSERTS: Frozen desserts must be tested on a monthly basi�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 unril the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. 4UTDOOR COOKING: Outdoor cooking,preparation,or display of any food.product by a retail or food service establishment is pro6ibited. DATE: SIGNATURE: �� PRINT NAME&TITLE: � �h ��/j1,vb9�w ch�c� 09/11/O1 , � _ ",�t",t i:� . , GRANITE STATE INSURANCE COMPANY � � 13102 703z7-0000 wt 899-56-40 /. - ------------------0�3-66-1201-O 1-- PENNSYLVANIA JASON LARVALHO 327 RTE 28 �� Member Companies of W YARMOUTH, MA 02673-0000 American International Group � EXECUTIVE OFFICES: � 70 PINE STNEET, NEW YOAK, N.Y. 10Y70 SEE NAME AND ADDRE55 SCHEDULE - WC990610 ' I.D# WORKERS COMPENSATION AND EMPLOYERS MARSHALL K LOVEIETTE INSURANCE AGENCY LIABILITY POLICY INFORMATION PAGE PO680X�836TREET WEST YARMOUTH MA 026 -0000 IIYSURED IS PREVIOUS POLICV NUMB@R INDIVI�UAL RENEWAL OOS 4 608 OTHER WORKPLACES NOT SXOWN AlOVE:SEE NAME AND ADDRESS SLHEDULE - WC 0610 � ITEM¢ PpLICY VER10012:01 AM.�tapdutl time at the Insurod's malllnp addreu �i+or 12/05/0l ro 12/o5/oz � �M 3 A. Work�rs Compensnion Insurance: Yan One of the policy �ppliss to the Workars Compsnsation L�w of ths statp Iisted hsro: MA B. Employen li�bility Insurance: Pert Two of the poliry appliss to Ms work in s�eh stats Ifsbd in itsm 3A. The Iimits of our Ilability undor ►art Two aro: � Bodlly InJury by Aceidant t 100,000 eech a�Gd�nt �. Bodlly In�ury by Dise�ss t 500.060 poliey timit Bodflv ��1ury bV Diswss f 100.000 e�eh amployee � C. Ot�er Spbs Insunncs: Part Thrse W ths po11cV appllss u the s4Ma, i} any, listed hsra: SEE ENDORSEMENT - WC200306p �M� Ths promium for ihis policy will be determined by our M�nu�ls of Aules. Clns�ffutlona, R�tas and Ratinp Plans. All information rpuired bslow Is sub�ect to verHlcallon and ehanys by audit. CNssifiuliona RSmun�qlioo� ��OGlr Eslimebtl Cad�NumMr • f1000fly. P��mium .. � Annu�l 3 Ynr muneHflon �Annwl �3 Yur SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $41 DfGEN&E CpN$TAM la��WNERE AVVLICABLE BV STATEI 5 244 MA MINIMUM VpEMIUM S 2 I MA TpTAL E$TNATED PREMIUM S� I IO H�nEieaHtl bslaw, int�rim�tl�ustm�nig Oi pnmwm sMll b� m�6a: � bml-Annu�IlY � Quvt�rlY � Mont�lY DEVOSRPIiEMIUM ENDOpgEMENT$�FppqNUMBEP� SEE ATTACHED FORM SCHEDULE - WC99Q612 12/06/O1 ASSIGNED RISK 66 luue Dats luulnp Oflice AWhoeitetl Xeprsaantafhre wc o0 oa Ot 30Y!] TOR'N OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�IIVI�NT PERMIT NUMBER: #02-067 FEE: $75.00 In accordance with��atiansprom ulgated�mder authority of Chapter 94,SecUion 305A and Chapter 111,Section�of the General Laws,a permit is hereby granted to: 7a�nn rarvalhn_ 327 Main Ctreet/Rnute 2R West Yarmouth_ MA Whose place of business is: Bagels&Beyond Type of business: Food Service Ta operate a food establishment in: Town of Yarmouth Permit expires:December 31_2002 BOARn OF HEALTH: (�a3lra� z�, �adu�ra.s ssnru�r� ie D. � 71C.D., ?/!ei ekal,�wa« � �• � �a�rrek�Aeuxett � S �� Mm�ch 1 ,2002 Bruce G.M hy, .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #02-047 FEE: $50.00 Tlvs is to Certify that Jason Carvalho d/b/a Bagels&Bevond '�27 M in C P /Rn rtP R VJest Y rmo� h_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and ai that place only and e�cpires December tlurty-first 2002 unless sooner suspeuded or revoked for violation of the laws of the Commonwealth respec.�ting the licensing of common victualler's. Tlus license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �ifa�ia:i� Z�, (�jfadr.�ra.r ssa�ru�c: 19 D. � 711.D.. �/1ce � �raav�. L�lesk �a�rlak�aravotl Sk . ,��. March 1 ,200z vf phy, .,CHO Du�ector of Health December 4, 2001 Yarmouth Health Department: Attention: Peter Peter, My name is Jason Carvalho from Bagels and Beyond, 327 Main St. in West Yarmouth. I spoke to you the other day about getting the number to RJH Associates. My Food Managers name is Joeseph Chevalier and he took that course in Bari�,stable Town Hall. His certificate was filed here and when we were inspected over the summer, Hitlary saw the certificate and wrote on our report that we were cerfi64�d. Some how the certificate is missing and I have been in touch with the RJH to get a duplicate copy sent to us. The problem that I have run into is that Joe is not sure of the exact date of the course therefore a search under his name must be performed and duplicate certificate will have to be issued out of Chicago. This is according to Dr. Zadeh from RJH. I am enclosing a copy of the Heal#h Inspec#ion we received and will forward the copy of the certificate as soon as possible. My impression is that this process.will take some time therefore I am re-submitting my application so I can receive my proper permits in time. If you have any questions feel free to coiif�i�f iYi� �f �08-�90-a�00• . �"�:f'.)!!C`��l.,!� {±i j C�'at� lF,�C'.Y:��'� i...� C�� t.�"� ;i i^e i '�.r`r !iJ j.i,3;�= Thanks for your time, Jason Carvalho ��.d:�a M��e�H zooa a o Ntir � � u� d � � � � �� -� °,s -n �� .�.�.��T %�;S�-Pu� , Cf� n�:. 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I � e a: S� 1 `�' � '� � � a � � � � (/� i \ .� i z : p � � � � � � � � � � �.� � � " � � _ ti ¢■ � a 3 � B ' � � � T �+� O ❑ ❑ a O 0 O O ❑ ❑ ❑ O ❑ a q y$ O � � � y � � � N � �$� � � � 1V N � sz i o S� �� N N O !O m J O� fn A fJ N �•• � � 7F �i '� �� '" 0 � � � � � 9 <� N � � ��m. � �� ` � � � � . � � � � 3 Q m � a'� � � � = A � � m � -+ � � � �p� � � o(o� oaooj� n < � � ��m �.� �� 4. � � � 6 ~ � � � � � � � � . �� . �� R � � . � � � � � z � � � � �$< �� ° W�� $� � � � � � � � i � � � $�� Y � _ � � � � � o �� s « � I�t� 0000p o y� � I �� 3 �m� � � � � L..1 LS�. � No�� ` �� M 1 � � �� .� e , � _ �� % � � � � � � � � � �� _ ��- � o _ _ _ _ _ _ _ _ _ _ __ _ � � o o � • m < • � � I � � i � I � ❑ ❑ � u 4 � R � � N � � i � � a � � � ❑ ❑ � �" r • r � � � � � `� � - � N � � � � Q a 00 � � � � N � I •- '�ry6�Ets � ��.^ra�.so j f��'-� GiL � L � M [� D TOWN OF YARMOUTH BOARD OF H APPLICATIONFORLICENSE/PF,Ii�N � � `�� DEC 2 8 20U� ;�� `�� EALTI DEPT» * Please complete form and attach all necessary documents by Dece�r 31,2000. Failure the return of your application packet. ----------------------------------------------------------------------------------------------------------------------------------- NAME OF ESTABLISHMENT: BPrE�E[,S $� 1�£�/u� TEL. # ?�/G—�SUU LOCATIONADDRESS: 2.�'� M+��J ST 1N. �GAx.rnuvrN Inh- oZtn�3 MAILING ADDRESS: SA� OWNER/CORPORATION NAME: MANAGER'S NAMF: JdtSG�J Lfl�t��.+.w TEL. # 74�-dS� MAii.INGAi)DRESS: 3Z7 MA,rI W_y. W�aA u-t1.7] ------'------------'-------------'----------------------------'-------- -----'--'-'- — - -- POOL CERTIFICATIONS: The pool supervisor must be certified as s Pool Operator, as reyuired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safery, standard First Aid and Community Cardiopulmonary ResuscitaUon(CPR). Please Gst these employees below aud attach copies of employee certifications to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintain a£ile at yoar place of business. 1. 2. 3. 4. HELMi 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 Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �Q NON-SMOKING SEATS: TOTAL# � /l�B --______------------------------�_________ __�..�___�____�______T___w�__.._.._.��_.W.��___r__,.--- 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. lWHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certitication is October 1,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $75 � 1— D _CONTINENTAI, $30 >100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 �OI�06� _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. S75 _FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ I 25.O o ••'"*PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM*«"•* j._.....�_.._. _.. . .. . .. _ .. e � � . f ADMINISTRATION ! i Untd�r�IiapteF„152t S�ction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �eny'-Hce�iise �-pee�nit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of 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 I5 YOUR RESPONSIBILII'Y TO RETiJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISfIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR TI� 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 REQIJIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEPIING: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,pnor to opemng,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effecHve date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establishments must have at least one person-in-chazge who is a certified food protection manager. �s pmvision 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 January 1,2001. Only establishments which seli or serve ready-to-eat, raw or undercooked animal pmducts aze required to have consumer advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must nodfy the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours priar to the catered event. Thses forms can be obtained at the Health Depariment. FROZEN DES5ERTS• 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 unUl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),mi sti have prior appmval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepararion,or display of any food pmduct by a retail or food service establishment is prohibited. DATE: IZIUU SIGNATURE: PRINT NAME& TITLE: �H1w FM.+lVri,ko u.vy�c,,ti 11/16/00 � � � The Commonwea/th ojMassachusetts : Depnr�men�ojfndustria/AcciAents a 9lflceel/svesUystliis 600 Washington Street Bnston, Mass. 01111 " W'orkers' Compensation ►nsurance Affidavit Apolica��f�rmation: PfesuPRllaTTt�'ida namc: �A{x21 � ��4�� T• — — � location' � Z � m �']�✓ . . �,. k/ �AI�-n�.�-�l W1/� [12co �3 ono��a ��!/��'� Q 1 am a homeowner ptrtorming all work myself. � I am a solz proprietor�r.d h�cz no one ��orkine in am capaciry �I am an employer pro�iding workers' compensation for my employees aorkine on this job. com�ana name• �AG'CZ� 7� ��'"�L�"� ,aa��t5. 327 /'h<f-r�/ �e� ��" 2 �7q,�I ��nI �y.• V� . �� /�� i� � J ohoneq• ! /(T�l.IV�/ insur�nceco U!G'/N� JT�f�L� ��1 policy# ��O�Ly � I am a sole proprietor. general contractor, or homeowner(circle onel and hace hired the con[ractors lisred below �cho hace thz follu�cin_ «orkzr_ ,ompensation polices: comoanv name• -- ^a�ress• ��- � phone q• insur�ncc co � policr# tomoanv name• - - . .. __— - - - - - -----._ -- -_.. -- __ . . _--�- -- - - _ ____. .___. addres • �• � phoee8• insunnte co �M Failurc to seeure covenge as required under Seenoo 25A of MGL 152 n�Ind to IYe iepaitloa of erisiul padtla of a��e ap W 51300.00��d/or oae ycan'imprisonmen�u w�ell u civil ptodNn io the form ot�STOP WOItK ORDER��d�6ee of 5100.00�day a�dwt se [��denta�d that a topy ot thh shtement mar be fonv�rdM to the ORct of lovotig�liom ot tst DIA for eovera�e veri6utlw. /do hrreby certij}•unde�tC�d penalties ajperjury thm 1he injorrrmlion providtd above is but and corrceL Signaturc Dau /2�/7�C� Printname ��`N ""'�-�A9"AwA9�Y.d Phone# 7�lU�FJ� ., olTicial use onlc do not w rite in this area to be completed by eity or towa oflitial - city or town: Y�MD�T$ _ permiNiceex k nBuildiog Departmmt � �Lictosiog Bovd ❑check if immedia�e response ie requirtd � 261 �Sdectmen'f OlTee ❑Hci1tA Dep�rtmee� coa�act person: phone p;_ �508� 398=2.231 eat. nOtAer IronN i;05 P1AI � r THE COMMONWEALTFI OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #O1-064 FEE: $50.00 This is to Certify that Jason Carvalho d/b/a Bag�ls&Beyond 't27 Main Street/Route 2R, West YarmoLth. MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2001 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in confomrity wrth the authonty granted to the licensing authori6es by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed the'u official signatures. BOARD OF HEALTH: �d�11. �etua, (�alr�uu SEA�G: �9 G��. z�, v� e��« ��3 �. � �x�e o:� � , m. . March 2 ,2001 ruce G.Murphy,MP R. . HO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #O1-107 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 pertnit is hereby granted to: Iason C'arvalho �27 Main StreP /RontP R Wect Yarmo � h 1��A Whose place of business is: Bag�ls& Beyond Type of business: Food Service To operate a food establishment in:_ Town of Yarmouth Permit expires: December 31. 2001 BOARD OF HEALTH: �d�11. �etlea, �uin�xa�c SEATING: 19 �,C��` �l, z�pY. �/� �q,�y . . J�04� �. �'tOWK. �[k �iekaeC d :L' �eu�a.,u�D. , �Jl.D Mazch 2 ,2001 Bruce G. Murphy, MPH, .S HO Director of Health