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Home My WebLink AboutLicensing - 2000 and Prior ;i pw,Sr �L'Y;�y �'GIC,v1 �LiC I • P � >'�,'� ��ti G? C�' GI� � N/ [� DD , � TOWN OF YARMQL�T�i BOt�l�'bF HEALTH APPLICAITON FOR�I�LY�E/PERMIT- 2000 N 0 V 3 0 iggg '� �� HEALTH DEPT. * Please complete form and attach all necessary documents by December 31, 1999. Failure to d"o so wi resu i the retum of your application packet. ---------------------------- ----------- --------------------------------------------------------------------------____. NAME OF ESTABLISHMENT: R�1 C A v �M� QiA(st�(, TEL # LOCATION ADDRESS � fY1Ri � MAILING ADDRESS: QW�iER/CORPORATION NAME: IYIANAGER'S NAME: TET # MAII,ING ADDRESS: ---��----------------------------------_—_______----------------__-------------------� POOL CfiRTIFICATION�: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please Gst the designated Pool Operator(s) a�d attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currendy certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certiScations to this form. The Health Departmeut will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. i�FIIVILICH CERTIFICATION�: 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 emptoyee certifications to this form. TLe Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. i. 2. 3. 4. RESTAI3RANP�EAT�NG:- TOTAL# � I NOI�T-SMDKINC;SEATS>-'F4�4b#- `--- — _ _____--____------------------------------------____--•------------------------------------------_— 4FFICE USE ONLY LODGING: LICENSE REQUIILED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN $50 _CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 _SWIMMING POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# i 0-100 SEATS $75 y�K- �I_ _CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 ?.k.�20 WHOLESALE $75 RETAII. SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 TOBACCO $20 ' _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE = $ I Z�l "'•`pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"••• _ . _ _ _ E , ADMINISTRATION . UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIltED ; TQ hIOI,D,ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSOIV OR COMI'ANY 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 TA3�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILITY TO RETURN Tf� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISF�vv1EENT', MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMAqNG, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TI�WATER TESTED FOR PSEUDOMONAS, TOTAL C6LIFORM AND STANDARD PLATE COLTNT BY A STATE CERTIFIED LAB, PRIOR TO OPENIAIG, AND QUARTERLY THEREAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SWIlviR�IlNG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING Tf� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT Tf� HEALTH DEPARTMENT. k'1ZOZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WiLL RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TI-�ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES(i.e., OiTTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISI-IMENT IS PROHIBTTED. DATE: 3e SIGNATURE: Ytil�''/ P�rrr N�& TTTT.E: . I,�� l��wa� G,�„�. 11/12/99 ��y�0 ';s� a t£ZZ�86£ (SOS) :Nauoyd :uos�adiaaiuon luawLsd�d 971��H❑ aayp t,uamlaapSO I9Z pa�mba�n asuodsa�a�sipawwi��»ya p p��op 9msuaa��❑ �aamusd�p 8mp�mg M acaany�luuad . �QO��a :u.wol�o.y�� nay�o u,No��o�tp�Cq p��a�dmoo aq w on siy�ui a�u.�ou op ��uo asn �cnyo •'- M�� Nauo G�.�/�'�k� lkll�k{f� aweu�w�d �� o � / ainteu8is pwo�pw anq n anoqv papinaid vottmu�oJu�sy1 myl S+n/isd Jo s�p�ausd puo sv�nd�y�iapun.fJfus�.fqalay op� �wprayuae a7w,wa�oJ np aq110 wop�8pcaeu��o o�yp�q�o!P�p��+�o�aq esw ivawal��s yyt Jo,Cdoo t 1�p p�quapn� om papi�dtP�00'OOISIo„U�Po�Y34i10 7iMOM LO1S�Jo m�o��qi oi wp��uad�u�o n�p.�n�uamuosudwi ,un�aoo ■o/p��pp�pps'IS ol de a�p��o app�ad�n}�ua�o�oqmd��aq�ol Pr+!��LSI'19W)�YSZ oouaag��pan pa�m6a�st a2uano�a�naas o�a�n��s� • :a u ' p• ! a a c�nzui •N .. � . un :sa�qod uouesuadwo� ,�ay�os �w��o��o� ay� a+ey oy+� Mo�aq pa�si� s�o»e�uaa at{�paiiy a�ey pue lauo a��iia)�au.Noawoy �o ��o��e��uo� �e�auao �o�audad a�os e we � ❑ - �Sn[1-,�c� - N�trJ n ! ��o� � •p �1�� }�rn :. 1. 1 , J�1- : SJJ�(1 '�J � . u . ue - --- --- - '.__ - -- - � of si �uo au� �om sab.�o dwa�w io uonesuadwo� s�a.�or 'aw i�o�d �a+o dwa ue wc 9 4 �I I ! . `I F I I .� .4uede�.iu¢ ui 3ury�o�� auo ou a�cy �� m�udad z�os e we � ❑ ��{�as.�w ��o.r ��e amuliouad�au.roawoy o wc � � cYJ�� [, " �� - �� 1 � �, .W � ��neP11d aaue�nsu� uopesuadwoJ ,s�ay�o,M .. � IlJZO •ssnfy 'uotsog ;" -� Jaal�S uot8u�ymM 009 s�ipLOpt�o//Oa�lll0 '. sluapr��t•lar.rJrnpuf jo luauq�ndaa � ; suarn y�nsmyy jo yl�aamuourruo,� a y,� , ' � � , TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-31 FEE: $75.00 In accordance with regulafions promulgated under authoriry of Chapter 94,Section 305A and Chapter l 11, Section 5 of the General Laws,a pertnit is hereby granted to: iacon (�arvalho,�27 Main Street Weet Yarmouth_ MA Whose place of business is: Bay Colony�aeel Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH: $d 71L�+. �ettea. L/kavu2xa�n SEATMG: 19 �O��Kp��G�• S�t• �iG•• �U(GC �OD�IL �. ��tOGVat, �/E�Pl�ik�� S '�rwYw 0' _ December 6 , 19 99 Bruce G. Murphy, M H, .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-20 FEE: $50.00 This is to Certify that Jason Carvalho d/b/a Bay Colony Bagel "� 7 Main 4tr t West Yarmnnth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2000 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 conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof,the undersigned have hereunto�xed their official signatures. BOARD OF HEALTH: $d 7J1C. �etYea. �(rai�a�c SEA77NG: 19 �.�j�gC--G.e 7$c[�GiqK, i�'1'�,. �/� (J�rq,y,r�qK �W�[l7• ��tOI�K. � �'lLCuC .SK�7CQl�'�OOJLCQ Kl� �CIL December 6 , 1929 ruce G. Murphy,M , ., CHO Director of Health � ' TOWN OF YARMOUTH BOARD OF HEALTH " � � C � M C� DD - � APPLICATION FOR LI AUG � 6 �99J * Please complete form and attach all necessary document y I, , 8. Fail HE LTH PT. � the return of your application packet. -------------------------------------------------------- --------------------------------------------- ------------- N E TABLI ' R"� C �, � (�- gSC� LOCATION ADDRESS� �7,� /�-�„ g T �� GL � 2 MAILING ADDRESS �� OWNER/CORPORATIONN MF� 1�}so G+��l.v�uiE� IVtA.�IAGER'S NAME• �f!'CG'�-� TFi # fPlJ -�CZ,n MAII.ING ADDRESS: 3 7�.�:n .Cd � �//If M bLS�N /y1,,4 l) � 7-3 -------------------------- -----------------________ -------------------- POOL CERTIFICATIONS• The pool supervisor must be certified as a Pool Operator, as rec�uired by new State law. Please Gst the designated Pool Operator(s) and attach a copy of the cedification to tivs form. 1. 2, Pool operators must list a minimum of twoemp loyees cwtenNy certified in basic water safety, standard First Aid and Community Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus form. The Health Department will not use past years' records. Yon must provide eew copies and maintain a file at your place of buainess. ]. 2. 3. 4, �Il�it ICH CERTIFICATIONS• All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-cholnng procedures below and attach copies of employee certi6cations to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Pde at your place of business. l. 2. 3. q. RESTAURANT SEATING: TOTAL #�� NON-SMOKING SEATS: TOTAL#�/ -�f' ----------------- --- ------------------------------ --------------------------------- OFFICE USE ONL.Y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 CABIN $50 _INT1 $50 _CAMP $50 _LODGE $50 TRAII.ER PARK $50 _MOTEL $50 _SWIl�Il�IINGPOOL $SOea. WHIItLPOOL $25ea. FOOD SERVICE: — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-]00 SEATS S75 q�9� _CONTINENTAL �30 _>100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 �y _WHOLESALE $75 RFTA I. RVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO �20 _<ZS,OOOsq.ft. $75 FROZENDESSERT $25 _>25,000 sq.ft. $200 LYAME CHANGE: $10 AMOUNT DUE _ $ /aS, 00 ""•••pLEASE TURN OVER AND COMPLEI'E 01'g6R SIDE OF FORM•""•• - ADMINISTRATION ` . UNDER CHAPTER 152, SECTIOI�25C, SUBSECTION 6,TI�TOWN OF YARMOUTH IS NOW REQUIltED TO HOLD ISSUANCE DR REIV��JAL OF ANX 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 Q$ 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�PROPRIATELY IF PAID: YES Np 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 DEC$MBER 31, 1998. SEASONAL ESTABLISf�IEE1VTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASOIV. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION i- F 1i ATION POOLS POOL OPENING: ALL SWINIMING, WADING AND WHIItLpOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI-IE HEAL'I'H DEPARTMENf, A1VD THE WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlv1��IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. FOOD SERVICE CATERING POLI Y� 'ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY Tf� YARMpUTH HEALTH DEPARTMENT BY FILING TI-IE REQUIltED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERT � FROZEN DESSERTS MUST BE TESTED ON A MONTHL,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMEIVT'. gAII,URg TO DO SO WII,L RESULT IN Tf�SUSPENSION OR REVOCATTON OF YOUR FROZEN DESSERT PERMIT UNTII,Tf�AgpVE TERMg HAVE BEEN MET. OUTSIDF [' " S• OUTSIDE CAF'ES(i.e., OiTTDOOR SEATING WITH W,AIT'gg/WAITRESS gERVICg��j��Hpy�p�OR APPROVAL FROM TI�BOARD OF HEALTH, OUTDOOR OOKTN['- OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHIvIENT IS PROHIBI'fED, DATE: � �� SIGNATURE: �-7�� PRINT NAME & TITLE: �F}-lc-ti (�y1�/J/}-c� Uci/1.2r _`�'� �\ ' The Commonwealth ojMassachusetts s = Deparrment ajlndustrial.-Iccidents ; Omceol/avesa►ystHis 600 Washixgton Slreet � � ,,:' Boston. ,tilass. 01111 " '"� �1'orkers' Compensation Insurance Atfidavit n�mc- - �LA^ c•� �V"�K�� _ � . (oc�ti�n' �� tJ�/ II\ �1.A) S`� �� ity��,"�1� {V\� U�� ehonea �L'� �G—�� 0 I am a homeoµner pzrt�rming ail work m}self. ;J I am � sole propriecor _r,', ha�z no one �corkin_ in am capacin• �] I am an emplocer pro�idino µorkers' compensacion for m}employees uorking on this job. comnam� name: � � ��.U>1.0 `-u-�"vL� � � �Jdress• J�' � l�� I,�11\/�LV� � V _ citv• W ' lF:�-�fYl/l �-I �l �1� V 4tJ�� ohone M: ��i'� �%cJ-8 SW insur�nce co A.C� �� oolicv# �i � _ �j I am a sole propriecor. _eneral contractor. or homeowner(circ%one! and haee hired the contractors listed beloH ��ho ha�e the follo��in_ ��orker .ompensation polices: companv name• � address• ��n�• ehone k• - insur�nccro ooliev# eomnanv name• iddre«• u}y: phove M• ine��ren��rn OO�([r K • F�ilure to seeure covenge�s reqwrrd uoder Seenou 25A of MGL 132 u�lad[o t6t iepaido�o(ttisiW peedtln of�6�e op m f1�D0.00 ud/or one yean'imprisonment i�w�ell ae civil pendHa io thc form o(a STOP WORK ORDER�ed�Oee otS100.00�d�r�pimt ma 1 a�denb�d that a � - copy of IAy sutement m�r be lonvvded to the ORce of Inveetig�Gom of the DIA for emra�e veri6atia. /do hr�eby cenij}•under rhe pains and prnalfier ptrjury tha rhe injormafion provided abovt is trr+e and eorrr� Signaturc _� _ � �� / S � 0 Prin� name�;��N-- ��--� Phone B 71� - 'r� .. oRcial use only do no��rite in this trea ro be eompleted by city or tmvn ollleial cirv or mwn: YA��II� _ permitAiteeee n nBuilding Department � �Licensiog Bo�rd � check if immediau response i�required 261 QStleetmen'f ORee �HaItA Departmmt conuct penan: phone N:_ �508} 398�Z231 eat. nOther • TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVIENT PERMIT NUMBER: 99-196 FEE: $75.00 In accordance with re ations promulgated under authority of CLapter 94, Section 305A and Chapter 11 I, Section of the General Laws,a permit is hereby granted to: Iacon Earvalhn� 'i27 Main Street Wect \'armnnth MA Whose place of business is: Bay Colony Bagel Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernvt eacpires: December 31. 1999 BOARD OF HEALTH:r^,d�ll, �etlea, ��a.c SEA'I'IIac: 19 �.+�$�. �. Y/ice �� s �� 0:c' Au¢ust 23 , 19 99 ' Bruce G. Murphy, MPH, . , CHO. � D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-112 FEE: $50.00 This is to Certify that Jason Carvalho d/b/a Bav Colony B�pel 327 Main Street West Varmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only andexpires December thirty-first 1999 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 conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have herewrto a8'ixed their officiai signatures. BOARD OF HEALTH: G�d 71C. '�eusc eiFatn.xax ��'�"�� SEATAIG: 19 . �RKK ,T^i�• 7.Sie�laells. �J��e.4�L.,. �/[f•C L.ravn+s4�t . �,• �. (,;�� IAueust 23 , 19 9�' i Bmce . Miup y, MPH, R:S., CHO Director of Health • P�a y colony r'x�g�� • " ,, ;,� ��3�2 �_____-.._.__ �Q W OF YARMOUTH BOARD OF HEALTH � T ��t• � � y"rYPPL CATION FOR LICENSE/PERMIT- 1999 � ' � ;�-n,�_�iiLItPT. * Please compleEe £irn'fn"an attac all necessary documents by December 31, 1998. Failure to do so will result in the return of your application packet. --------------------------------------------------------------------------------------------------------------------------------- NAMF nF F.STABLISHR� T' B�1Y �Ol.onY �A�E[. TEL. # 7�b+�500 T OCATION Ai�DRFSS �a'1 /17A��t/ �ST RT af1 I RA N N el2ne ; ER' N oeizne ��; L # o D C1a'n r GU� YQr O __----------------------------------------------- - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. - - - - 1 _ -- 2. Pool operators must list a minimum of two employces currently certified in basic water safety, standazd First Aid and Commwuty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificahons to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your ptace of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place ot business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ��------____ _—___--_—_—___—_—__—___----------------------------------------------------------- -- OFFICE USE ON�Y LODGING• LICENSE REQUIItED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# B&B $50 CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlvINIING POOL $SOea. _WHIR,I,POOL $25ea. FOOD SERVICE: LICENSE REQUIltED FEE PERNIIT # LICENSE REQUIRED FEE PERNIIT # � 0-100 SEATS $75 ^(,�j _CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 1 COMMON VICT. $50 Q�t-B O _WHOLESALE $75 RETAIL SERVICE: LICENSE REQiTIltED FEE PERMIT # LICENSE REQUIILED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25;000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNTDUE _ $ iZS.� "*""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF F�""* � - � 3,'"'"' �-�� .. 'S�i�� _.__...___.. 1 � r ADMINISTRATION ' UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-IE TOWN OF YARMOLITH 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 STA'I'E 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 TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK A,PPROPRIATELY IF PAID: YES � NO N01TCE: PERMITS RUN ANNUALLY FROM JAIVUARY 1 TO DECEMBER 31. TT IS YOUR RESPON5IBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMEN'I', ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMA�NCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT,AND Tf�WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNl'BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlvIl�fING POOL MU3T BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WI'THI1V TI-IE TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI�SE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL TI�ABOVE TERMS HAVE BEEN MET. _ _ _ _ _ -- OUTSIDE CAFES: OITTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. 4UTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII. OR FOOD SERVICE ESTABLISF�IENT IS PROHIBTTED. DATE: I�I�'''r[g SIGNATURE: �'�l,kc.ez�xz �� PRINT NAME & TITLE: NQe/,2�r� C--��;n t�Lts�, _ _ �-__ __ � , • � , . � , The Commonwealth ojMassachusetls : Departmenl ojlndustria/.-iccidents ; OMce el/erestlostliis 600 Washington Street Boston. Mass. 01111 Wbrkers' Compensation Insurance Affidavi[ Aonlicant intormation: PlesuPRD�7TT� /� _ � . nam�: NOCl2n2. C-e6J�/I ��XAJ-� �L�.�rt� �EC- localian: �T/7 m�/A/ 45� � ��. GU• YCc rrn ou�Fh ehone k /7U J�00 � I am a homeowner pzrtorming all work myself. � I am a solz proprietor �-d hace no one �corking in an} capacih �am an employer pro�idin� workers' compensa[ion for my employees µorking on this job. - - - _ �AY Cuu��v- - - - — -- -- — - — companl name: y ��6��- ..�� aJAress: �a7 �"/GLI1 �T. � �. tity: �- 7�MOfR'�'h � /�Q oam�3 Dheneq: 05��-'90 �� insurnnce co. �.J�QLO �nSU�Qrt� l--D, Dolicv f! 130l�r�Joi�a 3 � � I am a sole proprietor. general contractar. or homeowner(circle onel and hace hired the contractors listed beloµ «ho ha�e the follo�sin= �corker_ .ompensation polices: companv name: �� address � � c�': phone N: � i ran li �N an n rddress. _ - -- - _-_ _ - - - - - - _ _ . cijy: phoee 1t• insurance co. poliev M F�ilure to secure covenQe as required under Seceoo 2SA o(MGL IS3 ue Ind to the iepaido�of erisiul pndtla of a O�e�p ro 51�00.00��d/or oae ynrs'imprisonmeat u w�ell a�eivil peodNn io tht form at�STOP WORK ORDER aed i Oet of 5100.00�d�y q�io�t�a (ndenh�d Hat� eopy o(tAH statemcnt m�y be lonvarded to Ibe O�ce of(ovntipdom otthe DIA tor emen�e reri(iutlo�. 1 do�hrreby certijp under rhe puins and prnaUies ojperjury�hat the injorrrmNon providtd above B tnrt and eorrcet Signamrc � `� Due �a/��/Qa � Print name NO��n� C�� "`� Phone M /�O J�� _. ., . , olTcial use onlc do not w rite in this arn to be tomplehd by tily or town oflleial � ��. �� -� ' eiry or town: YA��DT$ _ permitAicceu M ' nBuildioe Dep�rtmmt � — ❑ �ceosm; ard p check if immediate response is required Z61 ❑Seltetmen'�011iee QHeiItE Dep�rtment contact person: phone a:_ �508} 398-?231 eat. �Other Ire neC iA�p1A1 TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-134 FEE: $75.00 In accordauce with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a pe�mit is hereby gan[ed to: Noelene C' .rviny 327 Main Street� West Yarmonth�MA Whose place ofbusiness is: Bav Colony Ba�el Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 1999 BOARD OF HEALTH:�d�/. �ett�p��, C'�./,�:,��na,.� / /J SEATII�IG: 19 `��jnoart��7�nullivan�/KJa.///.� Vice l,�irmart Ko�/ rt.1. O,rowan� l.(e,r/k � abr/ie�p�a�i/o1/e�ry/-e..JVooPee ickae! dau klin Febrvarv 9 , 19 99 Bruce G. Murphy,MPH,R .,C Director of Health THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-134 FEE: $50.00 This is to Certify thax Noelene Cervin d/b/a Bav Colp�,�aggl 327 Main Street West Yatmouth MA IS HEREBY GRANTID A }� COMI�ION VICTUALLER'S LICENSE � I In said Town of Yarmouth and at that place only and expires December thirty-first 1999 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 conformity with the authority granted : to the licensing authorities by General Laws, Chapter 140, and amendments thereta In Testimony Whereo� the undersigned have hereunto affixed their official signahues. � I so.�n oF�.�,�: �'d n'l. .�eup��,, C�[��///�an , /J � 3EA1'ING: 19 . �(�oan��7anl[wan�/KJe.�//.� Vice l,�irman Ko�ert J. /�rowa� (�[erk a6.al�sa��y-�l�Pa� ��f ' Co, � Febmarv 9 , 19 99 ��G. Mutphy,MPH, .�O Director of Health