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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 Y a � TOWN OF YARMOUTH BOARD OF HEA�,T� ` ` ` 'B*.�• PiZzA t�� APPLICATION FOR LICENSE/PE � � a� � l � , r � ~� * Please complete form and attach all necessary doci�nts� ec ��5�2�0��$ Failure to do so will result in the return of yo applicat�on ac ALTr Gti�l. NAME OF ESTABLISHMENT: r'Z TEL. #��`39 - a� LOCATION ADDRESS: / Z e MAILING ADDRESS: OWNER NAME:.�,'��r�[�' � /� TAX ID (FEIN ar SSNI: CORFORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus 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). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a flile at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requu•ed to have at least one full-time employee who is certified as a Food Protection Manaeer, as defined in the State Sanitary Code far 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 uew 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. L 2. HEIMLICH CERTIFICATION . All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1.�S.L'�'�_�� r � v iJ� 2. 3. 4. � RESTAURANT SEATING: TOTAL# ��Co OFFICE USE ONLY LODGItiG: LICENSE REQUIRED FEE PERMIT# LICENSE REQTJQiED FEE � PERMII'# LICENSE REQi7IRED FEE PERMIT# B&B S55 _CABIN S55 _MOTEL SS I1V1V S5� _CAMP S55 _SWIMMINGYOOL 580ea. LODGE S55 _TRAILERPARK SI05 _WHIRLPOOL �80ea. � FOOD SERVICE: LICENSE REQI.IIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMCI# � 0-100 SEATS S85 �(5`1—� _CON7INEN'IAL 535 NON-PROFIT S30 >100 SEATS 5160 �CONIMON VIC. S60 ��Q��' _WHOLESALE S80 RETAIL SERV[CE: —RESID.ffiTCHEN S80 LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERNII7# LICENSE REQiJ[RED FEE PERMIT# _vOsq.ft. 350 � >25,OOOsq.ft. 5225 _VENDING-FOOD S25 <25,000 sq.ft. S80 _FROZEN DESSERT S40 _'IOBACCO Si5 �A1•iE CHA�.VGE: S10 1�1VIO�T DUE _ $ I yS. Od *****PLEASE TIIRV OVER A:'VD CO.'VIPLETE OTf�R SIDE OF FOR�i*'•*" � . µ AD1�IIIVISTRATION 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 Ce cate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSA N 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 rior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHII�NTS TRANSIENT OCCUPANCY: For purposes ofthe 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. 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 dweliing unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. a 64G or 830 CMK 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. PLEASE NOTE:People are NOT allowed to srt m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 Yazrnouth must notify the Yazmouth Health Departmern by Eling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmern is prohibited. N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTl'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��r9 ' �� $IGNATURE: � a PRINT NAME&TITL . r ioiu%oa � The Commonwealth ofMassachusetts Department of Industria/Accidents N/ctNi� 600 Washington Sfreet, �"'Floor Boston,Mass. 011ll Worlcers'Compeoeation iasm�aece ASdavk:Boildiog/plumbing(Electrical Contnctors O name: � address: � zi : U ' work site lacation(full add�ess): �� ❑ I mn a homeowcer perfoiming all wak myself. Project Type: ❑New Construction QRemodel ❑ I am a sole�propridor and have no otie woiking in mty ca}�city. ❑B�rilding Addition � I am an employer Exoviding wockas'compeasali my employces wodciog on this job. � camoasv mme• �� I t-C�T - � � fl � : . ��: � y� e � ce. �C` M ..... �,._ . , . ..., .. :, .. �._. ,:� . . .,.,�r . r .<;:, V..» ,�.�,w�.r,...-;; ❑ I azn a sole proprietor,gwerai eaatractor, Mmeowwer(cirde one)and have Lired tbe conkac[as li�ed below who have tLe following wo[kets'compensation polices: � c000�uv�aue• � � . . � . � . . . addr�• � � � . dtv . . . . . �g. � . . . . . . � . . iasea�ce eo. � . .. �kq q � � � � � - . . .,. . . .. . . ,. _ . .. , . _ � . .e.�. . e�art�ume• �' �- -- -- - ----_. . ._ . _ _.. __—__ _ ...__ _--- -� - ..��5:- � ---.' .__ . .. __. .---_._. _ -_ __ _ ...._ . o�o�e#' - . . idqa�eee9. .. . � � pd�ey8 '. ' ' - ' ' :-'k-.. . S «. � . [.4 A. i �,.:. FaBvebxcoeonva6enrtq�hNodvSxtlr2SAdMGL152n�ktlbtYeirp�Kai�Yalpeal8nda8�eybil�LMuN�r � ex Yn�*'IuPtYan�t a we9 u dvi pmltln W tYe for�d a 31'Ot WORK ORDER ud�Hee d S160.N a Aay aplmt ae. 1�ed�t■ npg�tli4�laie-WmybefarwaM[dbHeOmee�InMIp�NHeDlAtareavmgevermnW�. � /lo hdeby n ' petns end jpeyrry N�at Me iejannmton prowided ebove Ls ave iwd cerrect� . . � g1�atuR �- `�- Date�-��_ � P� . .. G� � •. � PhoceH� � �� 7� emcLtex.ny a oof...iteswN,.rsmac .exy.rwMo�.mdai . � Wyortown: � Permifl�Ceeu■ �BoYdmgDeputment ❑eheek NmmaB�le mpme h rtqvued � . . �� 4�tm's O�ce . . . QLLeaNY De�N�t n�fui Pdaae: Plex M; OOf�C tm�asrimm) . . � . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-109 FEE: 85.00 In accordance wi[h regulations promulga[ed under au[horiry of Chapter 94,Section 305A and Chapter I 1 l, Section 5 of t6e General Laws,a permit is hereby granted to: Gerald A.Dowoing, Jr., 1311 Route 28, South Yarmouth, MA Whose place of business is: Bass River Pizza Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pennit expires: December 31. 2009 BOARD OF HEALTH: .�Ee�ett S�, f/Z..N.,C'l�wwnarc senr�rrc:36 C'IEaxl¢e .`�f. .?fePliliex, 4Jice C'hawtntaet a�srn[cnoxs: Paper service only,no&yolators,in compliance wi[h � �eXl�.�M�u(st� CtPx� agreement letter with Health Director Bruce Murphy,dated OS/28/98. QItIt�AfeenBli[ttn� �. No hamburgers,cheesebargers,chicken cutlets or veaL fAt¢(yn�. .�A�/ee January 7.2009 ruce G.Mucphy, H .S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-072 FEE: 60.00 This is to Certify that Gerald A. Downing, Jr. d/b/a Bass River Pizza 1311 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to t6e 6censing authoriries by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .�fePan Sllall, `JZ.✓V., C'haixman sE�rirrc: 36 e� .�. :rc�ee;��,l va� er�,►ta,� �PXE 3.�KOWlC� (;CPNR Qfl/! �lillfll� ✓�..JV. t11Q�ff. January 7,2009 Bruce G. Murphy,MP R. .,CHO Director of Health S fi V�. . , 2281 /�.�2. P!z-a.�l �"1�s^ TOWN OF YARMOUTH�r�� L�� s APPLICATIONEORLICEd i R NpV 1 5 201i! " �= I * Please complete form and attach all neces " uments by Decembec 31, 200,?. � Failure to do so will result in the r ' of your application-paeket: -� NAME OF ESTABLISHMENT: � �,�t- ��; � TEL. #508-39N-'7�Dn LOCATION ADDRESS: ��1 ��'�7�_�,;tS� ,,,�,..�,t, ,� d MAILING ADDRESS: OWNER NAME:� \--, � ° TA3 D - IN r Nl: � CORPORATION NAME (ff APPLICABLE): � MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operatoq as required by State law. Please Gst the desi¢nated Pool Operator(s) and attach a copy of the certification to this form. L 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Communiry Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee eerEifications to this form. The Health Department will not use past years' records. You must provide ne�• copies and maintain a fde at your place of business. 1. Z. 3. 4. _ _ _. _ _ ,��..�, FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who is cenified 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 ase past years'records. You must provide new copies and maintain a file at your estab6shment. I. � � . � PERSQN IN��IAI�CiE: _ _ __ ----__ __ _ — . Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � � 2. HEIMLICH CERTffICATIONS: 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 Cile at your place of business. l.�t_�.e l cQ � �,, ,,�� - � � r 2, 3. q RESTAURANT SEATING: TOTAL #� �; OFFICE USE ONLY LODGING: LICENSE REQUQtED FEE PER'�fIT� LICENSE REQL-IRED FEE PER�IIT= LICENSE REQL'IItED FEE PERbt17'_ _B&B S50 _CABIN Si0 _MOiEL S50 _�NN � S50 � _CAIbiP S50 _S�t'IYLbIING POOL S75ea. _LOIXiE S50 _TR4ILERPARK 5100 ��7-IIRLpOpL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER�4IT a LICEtiSE REQL7RED FEE PERbIIT= / 0.100 SEATS S75 0 �QO'7 _COMINEN'IAL S30 NON-PROFIT S?i _>100SEATS 5150 /CO:�L'140NVIC. S50 �,4—�(0 _�51-IOLESALE 575 REiAIL SERVICE: —RESID.KII'CHEN S7i LICENSE REQUIRED FEE PER'bIII= LICENSE REQL7RED FEE PERbIII'= LICENSE REQtiIRED FEE PER�II7= _<SOsq.B. S49 _>25.00Osq.R. 5200 _�'ENDING-FOOD S_'0 _QS,OOOsq.B. S75 _FROZENDESSERT S35 _TOBACCO S50 VAA�CH��iGE: S10 AMOUNT DUE = S_/2S�o a *w""'pLEASE'IL'R\OFER�\'D C031PLETE OTHER SIDE OF FOR)1'"*«* ADAIINISTRATION 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 W � -�-� gE CERT. OF INSURANCE ATTACHED �2oPPc-p aF�. ox WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid pri to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporazy and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintsin a principal plaee of residence elsewhere. Transiern occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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: Enolos�d Motel Census must be completed and returned�tb wis appticacion. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ed by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground 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 Departmetrt 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 certiSed lab. Test results must be sent to the Health Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Perniit urrtil 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: - Aet�eer�oekieg>PrePar$tian>er atsP1$Y of ' orfaozYservizx sstabiisturs�nt is�rohibited. NOTICE:Permits run annually from January i to December 31. I'I'IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. AL,L RENOVATIONS TO ANY FOOD ESTABLISf�1ENT, MO'TEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMME_VCEMEVT. REVOVATIONS MAY REQUIRE A SITE PLAN. � DATE: j► - 1 tl -�7 SIGNATURE: PRI:�IT NAME&TITLE• (Z , �o:o n� Client#: 67096 11 BASSRIVERPI ACORD.� CERTIFICATE OF LIABILITY INSURANCE 11N5/07D�n vrtooucea � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International NE(YCL) ONLV AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 437 Station Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. South Yarmouth, MA 02664 508 3940946 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: AIM Bass River Piva INSURER B: Gereld A Downing Jr INSURERC: 1311 Route 28 INSURER D: S Yarmouth,MA 02664 INSURER E: COVERAGES THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWI7HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC7 TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICYEFFECTIVE POLIGYEXPIRATION LIMITS L7R NSR NPE OF INSURANCE POLICV NUMBER DAT MM/DD OATE MM/ D GENERALLIABILITY EAGHOCCURRENCE $ COMMERqAL GENERAL LIABIIITV DAMAGE TO RENTED S CLAIMS MA�E �OCCUR MED EXP(My one person) $ PERSONAL 8 ADV INJURV E GENERAlA6GREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ POLICV PE� lOC AUTOMOBILELIABILITY COMBINEDSINGLELIMIT $ (Ee accitlent) ANV AUTO ALLOWNEDAUTOS BODILVINJURV $ SCHEOULED AUTOS (P8f�e��) HIREDAUTOS � BODILVINJURY $ (PeracdtleM) NON-OWNED AUTOS PROPERTVDAMAGE $ (Per accitlent) GARAGELIABILITY AUTOONLV-EAACCIDENT $ qNV AUTO OTHER THAN �ACC $ AUTOONLV: qGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ S A WORKERSCOMPENSATIONANO VWC6009682012007 �7��7��7 �7��7/Q$ WCSTATU- OTH- EMPLOVERS'LIABILITV E.L.EACH ACCIDENT $�OO OOO ANV PROPRIETOfLPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDEDI E.L.DISEASE-EA EMPLOVEE $�OO OOO Ityes,tlescnbe untler E.L.DISEASE-POLICV LIMIT $SOO OOO SPECIAL PROVISIONS below OTHER DESCRIP'f10N OF OPERATONS/LOCA710N5/VEXICLES/EXCLUSIONS ADDED BV ENOORSEMENT/SPECIAL PROVISIONS No.of Days; 10 PIZZA SHOP TOWN OF YARMOUTH CER77FICATE HOLDER CANCELLATION SHOULD ANV OF iHE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Yarmouth UATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �D DAYS WRfITEN Board of Health NOTIGE TO THE GERi1FICATE HOLUER NAMED TO THE LEFf,BUT FAILURE TO 00 50 SHALL 'I�4B M81f1 St. IMPOSE NO OBLIGATION OR LWBILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR S.Yarmouth,MA 02664 REPRESENTAi1VE3. AUTHORRED REPRESENTATNE ACORD 25(2001/08)1 Of 2 #8638 RT001 � ACORD CORPORATION 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMiT NiJMBER: #08-007 FEE: 75.00 In acwrdance with regu]ahons promulgated under authority of Chapter 94,Section 305A and Chapter 111,Secrion 5 of the�'ieneral Laws,a peimit is hereby granted to: Gerald A.Downing, Jr., 1311 Route 28, South Yarmouth, MA Whose place of business is: Bass River Pizza Type of business: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2008 BOaRD oF�nLTH: .�Ee�ea S�aly J2.N., '�w+unaa ssnniu•�c:36 C'Piavtfee .�. .7CeffiRrex, `Utce e�taixnta�n xEsr[t�c1'toxs: Paper service only,no fryolators,in compliance with Jto84Xt�.�Kotlan.,� agreement letter with Health Director Bruce Mucphy,dated OS/28/98. Qaut�jareen�a[tm.� �../v. No hamburgers,cheesetnugers,chicken cudets or veal. November 16.2007 �=` ' � Bruce G.Mu�p H,RS.,CHO D'uector of H th THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-006 FEE: $50.00 This is to Certify that Gerald A Downin¢ Jr d/b/a Bass River Pizza 1311 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMDZON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensmg authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .�EeBerc Sfia�, `Jt..N., C'�aixmauc sEnrirrc: 36 C'�axFee .�. .`/C�fiP�i ?Jice CR�abuttan Jto6ent �. BKaw.c, (',�lt Qnrc � November16,2007 Bruce G.Mucphy ,R.S.,CHO Director of Heal r�? � �__. .� , _� o °`e'°�s TOWN OF YARMOUTH BOARD OF HEALTH �` • o=�� APPLICATIONFORLICENSE/PE$M1T;200'f �tC O 7 2006 c�� /s * Please com lete form and attach a11 neces ' �� DEPT. p sary,do�u[tt�nts b}� ecem Failure to do so will resuit in the return of your application packet. Nt1MEOFESTABLISFA�ENT:��)A� ��v,p_'��7ZA- TRT". #5o�-.�9� -�02� LOCATIONADDRESS: �3�� n,7-t'F 2S3 , 4�armn,lrh �� C1��(¢� MAILING ADDRE S: OWNER NAME: TAX ID IN CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a t"de at your place of business. 1. 2_ 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certiSed as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this appGcation. The Health Department will not use past years' records. ' You must provide new copies and maintain a fde at your establishment � I. +r (' . 2. - ,, r----r�R�AN�*}�HA�iGE: -- .,t; , - —�-�r� —�_� _ _---, Each food establishment must have at least one-P�rson In Charge(PIC) on site during hours of operation �i c� rn��'J-- 1�C7 \ • 1. u1�f11 Ol �!': 2 HEIMLICH CERTIFICATIONS: ��— Ail food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. l.f��-1 '7 � i1�ll ��`i 2. 3. � 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICINSE REQiTII2ED FEE PF..RMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQLJIl2ED FEE PERMIT# _B.&B SSO _CABIN $50 MOTEL $50 INN $50 , _CAMP $50 _ _SWIIvIIvIING POOL$75ea. - _LODGE $50 1'RAII,ERpARg $100 WIIIRLPOOL $75ea FOOD SERV[CE: LICENSE REQUIRED FEE PFRMI1'# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# � 0-100 SEATS $75 �Q7-d�_ _CONTINENTAL $30 NON-PROFTT E25 . _>100 SEATS $150 ! COMMON VIC. S50 �d_��o� _WHOLESALE $75 RETAII.SERVICE: —RESID.KITCI��N $75 LICINSE REQi7IItED FEE pF,RAqT q LICINSE REQiJIItED FEE PERMI'C# LICINSE REQiJIl2ED FEE PERMIT# `<50 sq.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. S75 _FRO'LENDESSERT 535 TOBACCO S50 xeMe cHnxcE: sio AMOiTNT DUE = S /2S. 00 "•'•PLEAS�TURN OVER AND COMPLETE OTHER SIDE OF FORM'•^•^ ADMINISTRATION � Under Chapter 152, Section 25C, S�bsecuon 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 A1"TACHED 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 Yazmouth taaces and liens must be paid prior to renewai or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO MOTELS AND OTHER LODGING ESTABLISHMENTS 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. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit 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 aznended, sha11 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 piate counf by a State certified lab, prior to opening, and quarterly thereaftert_ 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 Department by filing the required Temporary Food Service Application foRn 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor searing with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor conking,_prepaxation,-or-display ofany food product by a retail or food service establishment is pro6ibited. N01TCE:Pernuts 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, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISI-IMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIviENCEMENT. RENOVATIONS MAY REQ A SITE PLAN. DATE: ,� ° �� CO SIGNATURE: 1 PRIN'I'NAME&TITLE �o�� ou�nef c� d� O� Y�R �� '�p TOWN OF YARMOUTH � �r��- y ll46 ROUTF. 28 SOUTH YARMOUTI-I MASSACHUSETTS 02664-4451 N MATTACHEES � ��+,,,,ap��tp,s,� Telephone (508} 398-2231, Ext 241 — Fas (508) 760-3472 B O A R D O F H E A L T H Februaty 22, 2007 Gerald A. Downing Jr. dlb/a Bass River Pizza 1311 Route 28 South Yarmouth, MA 02664 Dear Mr. Downing, Thank you for submitting the year 2007 applicarion for your establishment's food service and common victualler permits issued through the Health Department. However, prior to issuing the license, we need you to� ' " ' �es's c�o�►��. Please complete the tughlighted section of the enclosed form and return it to our office at your eaiiiest convenience. As soon as our office receives the completed affidavit form,we will be able to issue the licensesto you. If you have any questions on the above, please feel free to contact the Heakh Department at (508)398-2231, e�. 241. Thank you for your anricipated cooperation. Sincer� Mary Alice Florio Principal Department Assistant /maf enc. cc: file � r-ri�x�e3 or, � � Recycled Paper , 4. ; � Tke Coramonweahlh oJMassachusdts Depaitment of Indr�serial AccidenLc �N� 600 Washiagtoe Stree; �"'Floor Boston,Masc 02111 ---- Wodcas'Com ' e Lsuam A�d�vl�607 bi�glEleetrical Cwtraetors __,, ... . �:�.s= �, :.r � �,, ,N �;�; �� `��c� � •,.,,�; � ��r . ngr� �,Lc��{�� .,�� : 1�11 �1 e z�b , s��r`�'j YRJw�,�,Tf� smm �!� aff ozr Cd-.I.,n�a `��8� 3�� —'7� work site locati�(fnll add�essl: � ❑ I am a homeownet perfo�ing all woh myself. Projxt Type: ❑New Cmsuvcum ORanadel I�a sole and have no aoe w in� B ' ' Additioa � I am an�ployer poviding wa�ice�s'compensati�fa�r my�ployees working�this job. _ . .. . . . . . . . . rn��s• ■idtas• . . � . dh: � . . oYsel; � z.,>.. ❑ I am a sole propxietor,8ae+a1 ewtrxMr,ot 6o�eaw�c(drafe owe)aed have hued ihe�fisled below who have tLe followmg wadcas'comP�u�o P�� aema��wes � � �9: nirr�- � . � . # K�IYYL�e: � f�: �': p�pk Q- . Falhre r+eeee e�+vge a rq�6ad aMv SeUW 2SA dMC.L Iffi m led b Ik BapwNW daW W peaNtlo�f a`e e�e7'+o'IwPthw�atawe/udHpwltlnlatYe6s'sKaSTOrWORICOADSRaM�dx�tflN.MaM�rt� vdvsh�dtYNa npy atNb Maleae�my be twwuded i�IYe Omea�Iave�Wr�[He DIA fir cwerage vr.r�e�Ysa I do henby etr4ffy rnlsr NYe pdna a�lPeetlfiea ofPerj/vy tMt Mr iwferinsBee provldel ebeve ia trae m'/onrrect �� #` '1` � . �+� � --A�A� .m�w.x.wy e.�...uerw...�m�eo.p�nrdir.rwm� cky.rwn: �M ^- --- p�� ❑eheck Nio�ed6b�npeas is'eqahal �BmM OSdMd's O�m �P�� ph�ae#; �� lm�sa s�.mml F TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHII�IENT PERMIT NUMBER: #07-079 � FEE: 75.00 In accordance with re ations promulgated imder authority of Chapter 94,Section 3b5A and Chapter 111,Section 5 of the�eral Laws,a perntit is hereby granted ta Gerald ADowning Jr. 1311 Route 28 South Yarmout MA Whose place of business is: Bass River Pizza Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Pemut eacpires: December 31 2007 Boa�tn oF I IEnI.'1'x: :?5. f��,�,�",��,',�,� M.:15,, G�l�r.i�,s sEnru�c:36 N��l�ak, K✓�., vics�rr�u,�c�s xEslluc�rcoNs: Papea service only,no fiyolators,in compliance with Ro�eitl�.B�mouwy � agrecment lett�with Health Director Bruce Mu[phy,dated OS/28/98. /�cbeic�/�o�5stwro� No hmmburgers,cheeseburgeis,chicken cutlets ai veal. fQ�uc�au�c, /l./�. Febmary 22.2007 iuce G. urphy, RS.,CHO Director of Heal THE COMIVIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUI'H PF1tMIT NUMBER #07-054 FEE: $50.00 This is to Certify that Gerald A. Downin�, Jr. d/b/a Bass River P17�A 1311 Route 28, South Yarmouth, MA IS HEREBY GRAN'1'ED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and e�cpires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of wmmon victuallers. This license is issued in confornvty 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: B �B. �'a3do�,M.`.D., ' SEATING. 36 . . � � . e/�� t �i�i, Q./V./,��/�ic/e G�ls�xa�c � � . I�000¢L� B/IO[MIb� (�fPZ6 ��M�S� , FeUruary 22,2007 Bmce G. Murphy, ,RS.,CHO Director of Health �� C.�1Sb3 �•R.Pizc.n OF YqR �� 2 � .yo TOWN OF YARMOUTH BOARD OF HEALTH 3��° APPLICATION FOR LICENSEIPERMTT- 2006 r '_ � �, �� • Please com lete form and attach all neces ^ � p sary docitments by Decem er 31, 2005. , Failure to do so will result in the retum of your application p et. I f NAME OF ESTABLISFIMENT: � '� � TE . I LOCATION ADDRESS � MAILING ADDRESS: owrr�R rr�:�' � T�ID�nJ or ssr�� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAII.ING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated Pool Operator(s) and attach a eopy oFthe 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 wdl not use past years' records. You must provide new capies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wiR not use past years' records. You must provide new copies and maintain a file at your establishment. �.�+r�l c \ � � �� ^�,tic �. 2. PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. e 1. � 2. HEIll�;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 attae}i 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.r12 d fl-�G �1 �� J�C � ��(�� 2. 3. --�1 4. RESTAURANT SEATING: TOTAL#�_ C�_ OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERM11'# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PF.RMI1'# _B&B $50 _CABIN $50 MOTEL $50 _INN $50 _CAMP $50 _SWIIvIIvflIIGPOOLS75ea. _LODGE $50 _TRAII,ERPARK $50 VJHIItI.POOL S75ea. FOOD SERVICE: �. LICENSE REQTJIItED FEE P�yERMIT# LICENSE REQUIl2ED FEE PERMII'# LICENSE REQUIItED FEE PERMI'C# J_0-100 SEATS $75 �"OIO�008 CON1"INENTAL $30 NON-PROFIT �25 _>100 SEATS 5150 � COMMON VIC. �50 G—OO8 _4VHOLESALE $75 RETAIL SERVICE: LICENSE R&QUIItED FEE PERMII'# LICENSE REQi)II2ED FEE PERMIT tl LICENSE REQL7IItF.D FEE PERMIT# _<50 sq.ft. E45 _>25,000 sq.ft. $200 VF.NDING-FOOD $20 QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $12S.OO '•"""pLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM'••^" ADD�NISTRATION 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� OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHE Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. TI'IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQLJIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT THE HEALTA DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, 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 have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or selis ready-to-eat, raw or undercooked animal products are rec{uired 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 3ervice AppGcation form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must i�e tested on a monthiq basis by a State eertified lab. Test results cn�sf be sern 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 CAFES: Outside cafes(i.e., outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. ^ OUTDOOR COOKING: Outdoor cooking prepazation, or display of any food product by a retail or food service establishmern is prohibited. � � DATE: �1-�, -�5 SIGNATURE: - r PRINT NAME&TITLE: ` G 09/28/OS TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLISHMENT PERMIT IVUMBER: #06-008 FEE: 75.00 In accordance with re�(a[ions promulgated�mder authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�Ueneral Laws,a pennit is hereby granted to: Gerald A.Downing, Jr., 1311 Route 28 South Yarmouth,MA , Whose place of business is: Bass River Pizza Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31_ 2006 BOARD OF I IEAI.TH: Ba�c�r.c `.B. �M.`11., �us ssa'rm�G:36 I�cAic/a Ma$e.swrol#� �/ios e�rci3ixc�. xESTx[cr[oxs: Paper service only,no&yolators,in compliance with Ro�aat�.,Buorwt, � agreement letter with Health Director Biuce Mutphy,dated OSJ28/98. �e�e�w�$'�ic�r, /l./� No hmmburgers,cheeseburgers,chicken cuUets or veal. A�ua(�.t«u6asu� R.N. November 15 2005 Bruce G. M�up ,RS.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMI"T NLTMBER: #06-008 FEE: $50.00 This is to Certify that _ Gerald A. Downine, Jr. d/b/a Bass River P;,,� 1311 Route 28, South Yazmouth, MA IS HEREBY GRAN'I'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornrity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official signatures. sEArmrG: 36 BOARD OF I-FEALTH: �� C�'cYidar, M.$. ' � v�e�n R�t�. e�, et� �Sl�k, R�� November 15,2005 �' , , � % Bruce G. Murphy, ,R.S.,CHO D'uector of Health ; � S� � OF�Y'`�� '�� TOWN OF YARMOUTH ll46 ROUTE 2S SOUTH YARMOUTH MASSACHUSETTS 026644451 H MATTACMEES � ��o.,��,�,�,n� Telephone (50S) 398-2231, Ext. 241 — Faac (508) 760.3472 B OARD O F HEALTH — ; �-� ,. .".� G 2025 To: Yarmouth Board of Health Permit Holders HEiaLTH DtPT. Frota David D. Flaheriy Jr., RS. ;�D� Heahh Inspector � Town of Yarmouth Re: Federal Taac ID Number Date: Mazch 22, 2005 The Massachusetts Department of Revenue is �w requiring that we furnish detailed information to them regazding all permits and licenses that we issue. One of the details that they require we send to them is every establishmeuYs Federal Employer ldemification Number(FEII�otherwise known as yow"Taic ID Number". This is purely for administrative purposes only. Sorr� businesses use the owner's Social Security Number (SSI� for this purpose_ If this is the case for yow establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Heahh Departa�rn 1146 Route 28 South Yarniouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, gIease do not hesitate to call. The office hours are Monday to Friday, 830 a_m to 430 p.m The telephone number is(508) 398-2231,ext. 24L Establishment: ��S��i�C" P( ? � rSSN: �� Locarion Address:� 0 , S`��'��"" \ ^ Signature: 4 � Print: 2'� i Title: �A7�Q � L�� Printed on '�� Recycled Paper • • �.#Ub� �(2� � = s'"�s TOWN OF YARMOUTH BOARD �T.�H � �J C� DD o ,` APPLICATION FOR LICEN$�, �20r15 " •'�' � DEC 0 S 2004 * Please complete form and attach all necess�tjt`tloc��ts by Decem er 31 2pp4 Failure to do so will result in the retui+�$f your application pac e �ALTH DEPT. NAME OF ESTABLISfIMENT• � I .L �a 2�l- TEL #g'D� 39L1�7 LOCATIONADDRESS: ��(1 i�VCJt- Z.� S� �l,�.,r�. Y• t,— lz1A _ MAILING ADDRESS: OWNER/CORPORATIONNAME: C' �_r � � � � , MANAGER'S NAME: S?�^-�--� TEL. # Sif�--. MAILINGADDRESS: G.�w�� 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 certiScation to this form. l. 2. Pool operators must Gst a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (vCPR). Please list these employees below and attach copies of empioyee 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 busiuess. 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 3ervice Establishments, 105 CMR 590.000. Please attach copies of certification to ttus application. The Health DepaRment wiil not use past years' records. You must p vide new opies and maintain a file at your establishment. 1. � (f � 2. PERSOAi-IN CI�.4RGE: _ __ _ - -- _ Each food e$tablishment must have at least one Person In Charge(PIC) on site during hours of operation. ` \ � L F Y'�Q'\(� r�s�._Y�(2 � 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. 3.��e�-f-a3S.9�.�� 4. RESTAURANT SEATING: TOTAL#_� OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERM[T# LICINSE REQi7Il2ED FEE PERMIT# LICINSE REQUIliED FEE PERMI'I'# _B&B $50 CABIN $50 MOTEL $50 INN S50 CAMI' S50 SWIIvIIviING POOL S'/Sea. LODGE $50 _TRAII,ERPARK $50 _WI3IRI.POOL $75ea. FOOD SERVICE: LICINSE REQiJIItED FEE PERMII'# LICENSE REQUII2ED FEE PF.RMIT N LICENSE REQUIltED FEE PF..RMI'L# �0-100SEATS S95 �DS�T� _CON'1'INENTAL $30 NON-PROFIT S25 _>]00SEATS $150 �COMMONVICT. S50 OS'O� _WHOLESALE $75 RETAII.SERVICE: LICENSE REQUII2ED FEE PERMIT# LICINSE REQUIItED FEE PERMI1'# LICENSE REQUIItED FEE PERM[1'# _c50 sq.ft � $45 >25,000 sq.ft. 5200 _VF.NDING-FOOD $20 _Q5,000 sq.ft. $75 FR07,EN DESSERT $35 _TOBACCO $25 NAME CHANGE: S10 AMOIJNT DUE = S I2S�0 •""••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•"* ADMINIST'RATION 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tarces and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY 1F PAID: YES NO NOTTCE:Permits run annually from January i to December 31. IT IS YOUR RESPONSIBILITl'TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONALESTABLIS�IMENTS ARE TO CONTACT T'FIEHEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, M01'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDTI'IONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whidpools wtuch have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 estab 'shment wlrich serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN 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 Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � DATE: ' � — O SIGNAT'URE: � PRINT NAME& TITLE: � � 10/22/04 _='� The Co�n�nonwealth of Massachusetts —_� '� _- nepa.rMa�tofladuslria[Acdde��tc _ — N�wNrwu�i = 600 Washingme Smet, �'F[oor = Boston,Mass. 02111 ... ' wo.t«s�cam�...r�■i..Q..«w�m.�s�um.�m�.m��.�ca.r�mn � _�. ;.� � F�� .�_ . .�. .. . ,....�_.:� .. ,.,.i -.n.'x . �•-�k.a5'a ' ' �� s�s . ;, � LBmt: � e(dICSS: � � "� —�"ZC�C� work site locati�rfoll a�essY . ❑ I am a lamaowner pedoming all wak myself. Project Type: ❑New Caosavcdan�Ranodel ❑ I am a sole 'dor and Lave�aoe w in anx ca ❑Buil ' Addition � I am an�P�Y�Ro"��%wadce�s'compensatim far mY�PbY�woilcinB m tbis job. . . -..'--'a• cbv- �M: ieBf�otca. ❑ I�a sole pro�i�or,geaenl co�trxtor,or Yameow�er(drde awe)�Lave hiiad 1Le contcacwis liared below who have the folbwing wakas'compeneation polices: .a�.... .u.- ninaed: d ai�en: .a10- oYwe/: FaYve 6 s[eae sveade n�eqdrN dc Sa1M 2SA d MC.L 152 m kW b tYe hpitlr d e�d Ps�Nn d a ie�p bS1.1M-M aMhr . etiy�,+•n�rw.o�..�s..aw�dm�6r..r.srorwowcosoae..a.ae.ruM.�eaa.y.�.r. ioeew■amc. apy�[ub wrae�t..y he bewaM�A ee me omce�Im�ef ue D1A travenge ve�mnu... . ��ti�eey ,�� M Gu Pl � �IP�N�O'tAd MeTnforw�tow provlAel abeve la 9xe awAasrrect �;� /v� '/- �'-� p� C✓� Phoce# � IJ 3 g� " 7�� o�Wnesaly deaatwrkeY/WanabkwpMedb7dtyNMru�ial eHyarfewa: P�g �D�� ❑tYeek if f�me�ie�e�eee 6�e9�M ❑��N� tetlut peteoa: P`��+ � t��mm� CERTIFICATE OF INSURANCE 'SS"E°A�`"'""°°,""> PRODUCER 7'EQS CERTIFICATE IS ISSUED AS A MATTER OF Q]FOR111ATION ONLY AND CONFERS NO RIGATS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE C J MCC3RIly IDSUianCC DOES NOT A11�ND,EXTEND OR ALTER TFiE COVERAGE AFFORDED BY THE POLICIES BELOW. Agency Inc . 437 Station Avenue COMPAIVIES AFFORDING COVERAGE South Yazmouth, MA 02664 uvsuaen Gerald A Downing io TrERxv A A.I.M. Mutual Insurance Co dba Bass River Pizza 50 Lake Road West Yarmouth, MA 02673 COVERAGES � � � � .. . .. .� .. . . � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEBN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWTTHSTANDING ANY REQUIltEMENT,TERM OR CONDTTION OF ANY CONTRACT OR OTHER DOCUMENT Wl1'H RESPECTTO WHICH TEQS CERTIF[CATE ivIAY Bc ISSL�D OR h(AY PnRTAIN,i"tIE INSuRAIvCE AIFORUED�BY-THE YOLIC�S DESCIUBLD F�cRcIN IS StiS�CT T'v eilL�Tf[E TERi.iS; - EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMTTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS . CO TypgOFINSUAANCE POLICYMIMBER �LICYEFFEC'1'IVE POLICYEXPOlATIO LNitTS L� DATE(MMIDD/Yl� DATE(MM/DD/Yl'� GENERALLIABILITY GENERALAGGREGATE 8 COMMERQAL GENERAL LIABILITY PRODUCI'S-COMP/OP AGG. 5 LAIMSMADE�CCUR PERSONAL&ADV.INIURY 5 OWNER'S&CONTRACTOR'SPROT. EACHOCWRRENCE I FIREDAMAGE(Anyocefire) f MED.EXPENSE(Anyoreperwn) S AllTOMOBiLELGBILITY COMBMEDSINGLE $ ANY AUTO LIMIT ALLOWNEDAUTOS BODILYINIURY $ SCHEDULED A Vf05 «�� HIREDAUTOS BOOILYINIURY f NON-OW NED AUTOS (��) GARAGE LIABILITY � PROPERTY DAMAGE 5 EXCESSLIABll.ITY EACHOCWRRENCE f MBRELLAFORM AGGREGATE S THERTNANUMBRELLAFORM .� X w v NER � � �. ORICER'S COMPENSATION AND YERS'LIABILITY ELEACHACCIDENT f IOO�OOO � A 6009682012004 07/17/2004 07/17/2005 . 1:�PROI'R1EPP.Rt--� f:JCL-- � - - -- - -- tL UISEASE-POLICY LIMPf�-� 3 SOO OOU �ARTNERS/EXECUTNE EL DISEASE-EACH EMPLOYEE S IOO OOO FFICERSARE: X EXCL OT�R ESCAIPfION OF OPERATIONS/LOCATIONS/VEAICLES/SPECIAL ITEMS CERTIFICATE HOLDER � CANCELLATTON�� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF YARMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WII.L ENDEAVOR TO MAII. 15 DAYS WR11"fEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE BOARD OF HEALTH LEFf,BUT FAIGURE TO MAiL SUCH NOTICE SHALL Q.SPOSE NO OBLIGATION OR 1146 MAIN STREET LIABILTTY OF ANY KIND UPON THE COMPANY. TTS AGENTS OR � REPRESENTATIVES. AUT}IORIZED REPRESENTATIVE SOUTH YARMOUTH, MA 02664 � Dec-02-2004 05:45pm from-NORCROSS LEIGHTON 5087601407 T-630 P.UO2/UO2 F-97B ""'"^�' a.�r� � �rit,.�a � t Vt LIAF3ILITY INSURANCE oa io s °°TE�"""v°°"�.� PRODUGER Sr1SSR—B S,'Z OZ OQ THIS CERTIFICATE 13 I$SUED AS A MAT7ER OF INFORMATION FiOB Intez�national Mev $n laad ONLY ANp CONFERS NO RIGMTS UPON THE CERTIFICAT� 437 Station Ave g NOLDER.THIS CERTIFICATE pOE3 NOT pMEND,EXTEND OR ALTER THE COVERAGE AFFORDEO BY TF1E POLICIES BELOW. So.Yarmoubh p�. 02664 Phone: 508-394-p946 Fax:508-760-1407 INSURERSAFFORDINGCOVERAGE IN341R�D NAIC�F insursFxn National 6r e Mutual Ins. Co INLURER9: LTM �tval Ins. Co. Basa River Pizza Insu�xc: 50 Lahe Roaa W. Yarmouth MA 02673 ��a INSURER E: COVERAGES 7HE POLICIES OF INSURANCE LIS7E0 BE10W HANE BEEN ISSUm Tp 7HE INSURfD NqMEO A80VE FOR THE PO�.IGV PERIOO INOICqTED.N07WRH6TANDING pN'�REUu1FiEMENT,TERM OR CONofnON OP ANY LON'(qpC7 oR 07H�R DOCUMFM W11'M p6SpEC77p y�l7�CH TXIS GERTIFICRTE Mqy BE ISSUF�OR AMY PERTNN.THE IN$URANCE AFFORDF�BYTHE POLICIES OESGRIBF�HER�IN IS 9U&IECTTp pLL 7{{E TEW�$,�[��pNS AND CONOffIONS OF SUCH POLICI[$,p(;GREGA7E lIM?&SHOWN MAY HpyE gE@N{i�pUCED BY PldO GU11M5. LTR NSR 7YPEOFINBURANCE POLICYNUMBFJi pp7E y�yp ONTE NWDO/yp 11Mf§ GENERAI_IJqBILiTP FscHoccuwaEucs s 50000a A x coMMertnucEu�unei�m HP860434 07/01/04 07/Ol/05 P�E�,re„m� s 100000 CuiM5M111nE X� OCCUR MEDFXP(Myaneporsonl 55000 aeasoNua�oviwuav s50D000 GENEWLLAGGREGATE S 1000000 GEN'�qGGRE0A7ELIMRApP��ESPER PROWGTS-GOMP/OPAGG ESDOOOOO POLILV �� AUTOMOBILE uABIUTY �yA�O COMBINEOSINGLE�IMIT E (Ed 9RWBnl) ALLOWNFAAUTOS SCHEDULFDAVTOS BODIIYINJURY E (Perpereon) HiREDntrtos � NON-0WNF�AI7TOS BO�IIYINJURY S (Pe�BCitlenQ PROPER'ry DAMN6E S (Peraedaanq GAWIGE LIABILRY AI7f0 ONLY•Ep q(',(,'�OENT S ANY AUTp afMERTHqN �ACL S nUTOONLY: qr,G S IXCESSIUMeReun u491LIN ERCn OCCURRFNCE f OCCUR � (`jpIM3 Ml�E A06�� S f DEOUCT191,6 S RE7ENT�ON 5 E WORI�RSCOMPENSATpli/Wp X TORYLIMRS ER $ EMPIAVEps uABIu7Y arvvPixovwerowaatrNeq�cvrn� �6009682012004 07/17/04 07/17/05 e.�.eacHnccioErrr s100000 OFFICERIMEM96R FXCLUDED7 u aosmoeunaer E.LDiSense-EnFMPwvEE S 100000 s�w�raowsiomseeio. E.LDISEASE-POLICYUMIT s500000 on�a :. . .. �_ . � S OED BY ENOORSEMENT/SPECIAL PROVIGONS �EStltIPTION OF OPERATIONS/L f�y � i PIZZA S�OP .. . . . .- DEC 0 3 2004 HEALTH DEPT. CERTIPIGTE HOLDER CANCELLATION ______]_ SHOULDANYaFTMfp9pyEOE3cHIeEDPOLICIESBEcuNCFJ,LED9EFOREiX�p(p�qp7�px OATETHFIlEOF�TXEISSUNGINSIIREqyy�L{,ENDFAVORTpMWL I.O OAYSWRRTEN TOMI o£ yarmouth NonceTon�EcertnFicarexo�oeawweoron�e�F7,avi'Fa�uxer000sos�u« Hoatd of Health " ],J,Q 6 jYfgin „yt. IMP0.RE NO OBLIG0.TION OR LJABILIry OF RNY qND IIPON THE INSIlRER,RS/W EM'S pq 3• rarmouth h�, 02664 aEPREsaramr�.s. oUIHOfSEo NEPRESEMrYrnE 3cott A.Tr�bla /�CORD zs(20oi/oe) 0 ACORo cORPORATION 1988 Dec-02-2004 05:44pm From-NORCRO55 LEIGHTON 50876014U7 T-630 P.001/002 F-8T8 HiJB International New England, LLC 437 Station Avenue, South Yarmouth,MA 02664 Phone: (508) 394-0946/(S00) 649-0946 Faz: (508) 760-1407 FAX COVER SHEET DATE: �2 ^ 2— Q �}- NUMBER OF PAGBS: [a � �a.unING THIS Cov�t s�� TO: TOWn � YAN�r1,00'H� � �Ob� 0`�� : 5as -3q�r—og3b `� FROM: J� x�: C�,,��. o-.g ih�� - i��t P�•Lzo�. In case of a problem: (508) 394-0946 NOTE: THISII�ESSACrE ISIN7�NDED ONLPFOR THE USE OF THE ATDIVlDUAL OIt EN77TYT0 WHICHIT WASADDRESSED,ANDMAYCONTAZNINx'ORMA770NTHATISPRIYILEGED. CONFIDENTIAL,AND EXEh�TFROMDISCLOSURE UNDER APPLICABLE.LAFY. IF THE RF.f1DER OF THISt1�SSAGEISNOT THEINTF.NDED RECIPIF.N'lOR THEEMPLOYEE OR AGENT RESPON.SIBLEFOR D,ELII�ERIIVG THE.ME9SAGE TD THE INTENDED RECI'PIENT, POUAREHEREBYN077FIED THATANPDISSEMINATl'ON, DIS7RIBUTION, OR COPYING OF THIS COMMUMCA770NIS STRICTT,Y.YROHIBITED. IF YDUFIAVE RECFlVED THISCOMMUMCATIONINERROR, PLEASENOTIFYUSI�EDIATELYBY TELEPFIONEAND RE771RN THE ORIGINAL MESSAGE TO USAS THEABOVEr1DDRESS VlA THE U.S POSTAL SERVIC� THA.NKYOU. TOWN OF YARMOUTH BOARD OF HEALTH PERMTl'TO OPERATE A FOOD ESTABLISffiYIENT PERMiT NUMBER: #OS-071 FEE: 75.00 1n accordance with reQulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a pemut is hereby ganted to: Gerald A.Downin�, Jr., 1311 Route 28, South Yarmouth, MA Whose place of business is: Bass River Pizza Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut expires: December 31, 2005 BOARD oF�nI.TH: B.�sjomi.s 2S. �iuda.s,M.$., L�l.a:3«rc.� sEwTING:36 /�cttic�/�c$sewro�, �/sw�raiR�xc�s xEs'rtucnoxs: Paper service only,no fryolators,in compliauce with Ro/e+r��s.BRoum., � agreement letter with Health Director B:uce Mucphy,dated OS/28/98. d�e/as�lialir /l./{! No hmmb�agers,chceseburgecs,chicken cuUets or veal. f4iui �� /1./�. January 21.2005 ruce G.Miaphy, , S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-O50 FEE: $50.00 Tlris is to Certify that Gerald A. Downine, Jr. d/b/a Bass River P;,,� 1311 Route 28, South Yarmouth, MA IS II�RRF,BY GRANTED A COMMON VICT[1ALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornrity 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: Be��s�. �, iN.`.D. ' san'1'irrG: 36 p��1�� v�ef,�.L Qo�wJit�. B3orws, �e3�c e� Sl�k, R.N. �Q.t.z R.N. 1�,�,y Zi,Zoos Bnxce G.Murphy, , S.,CHO Director of Health � �vARy TOWN OF YARMOUTH BOAR�',�F I:TH��" �f �3 p 2 0 APPLICATION FOR LIC �2004 °�? � � C� � nC9 � D * Please complete form and attach all necess cuments by Decembe 31,�� 5 2004 Failure to do so will result in the return of your application pack . NAME S MENT: � E . L CAT N A DRES : I ` r ` ADDRE 3 ZoJ S rw�sc�n. RPORATION NAME: p - A ER'S NAME: TEL. # - 1�17 IN ADDRESS: � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. � 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. " 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: / All food service establishments aze required to have at least one full-time employee who is certified as a Food JProtection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. PIease 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.C7PU'A�G\ 1-�rn�v�� K1C �� 2. JP��E:._ . _ - --- -- --- --- -- Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. � 1.C'1 P r v�1(� � ��, *� fl�✓I� 2. JH�IMLICH CERTIFICATIONS: Ail food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Tile at your place of business. 1.�'�2rv��. � ��n.v�s ��r 2. 3. 4. RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&.B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SW[MMING POOL$75ea. _LODGE $50 _TRAILER PARK $50 WHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT f! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 10-]00 SEATS a75 �o�� _CONTINENTAL S30 _NON-PROFIT $25 _>100 SEATS 5150 1COMMON VICT. $50 �0��( _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZEN DESSERT S35 TOBACCO $25 — � �iAMECHANGE: $10 AMOUNTDUE _ $ � •-� ••":*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••**• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yattnouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED 2� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth ta�ces and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLIS�IMENTS ARE TO CONTACT T'HE HEALTH DEPARTMENI'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 swinuning,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total 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 utimal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth 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 Department. FROZEN DESSERTS: Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Deparnnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/wait�ss service), nx ust have prior approval from the Boazd 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: f 1� �'r 10/22/03 MA33ACHU3ETTS WORKERS'COMPENSATION ASSIGNED RISK POOL APPLICATION FOR WORKERS'COMPENSATION INSURANCE MAIL TO: The Workers'Compensation RaGng 3lnspection Bureau oT Massachutttts P.O.Box 8006 Boston, MA 02206 (817) 439-9090 IMPORTANT Th�appOwtlon must be ryped or pririled and filed in duplicete wilh Me Burcau. M orlginal b4fdtl fo�m must be used. � A separate aPPlleatlon muat be f11eA for each Ipal entlty. Encbse ehock meds payable to: The AAessxhuaetls Wwkem'Compensalion p,aaigned Rkk Paol (MWCARp). cove�nee v�u ne�emm�vey nou�Proaaea ma�.won rewew.eureau s�an rmes mn m.aaMksuon wes ssaaraawuy oomP�ea. n,e eantea�dece covxaae can be cow�d u '. at 12:07 AM the day afler tlie applfaation arM depoeu premium are rxeived in the olfice W Me Bureau. Under rro Wrcumstenee vrill wverage be bouiW H:payma�t ar depoeil yremium doea rid aarompelry ihe applicadon�ihe declhmlion requiremanls are rrot met�drere is e temrd of wve�age In torce for Me eMily meld�sipPlte�on:or.Ihe applkaM k in de(autt d piemium for priwwoAcbs'mmpematlon coveraga. The undenig�red emplcy�er ia umhle to purdiase woilrois•compensetlon arid empbyers'tlabiHy inwre�rcs in the voluMary me�kel aM hereby applies for wch i�urance In ihe Mesaachuselle Assigned Risk Pod and a�resely represenb ihat auch i�ura�we is soupM in pood hilh. Requested I.. GENER`AL INFORMATION Eifective Date:7'� � 1. GLe � C)IVNi�I/� � �i > l� /�2-� NAME OF E�MqPL/OYER (Name of sok proprietor,general partrxr(s)a truatee(s)muat be g' n �C�e hade name o(yie busin�s,) Z, p�v/�g 3��O O PENOING FEDERAL EMPLOYERS IDENTIFICATION NUMBER (If pending, a copyof the IRS appMatlon,) � / �, 3. �JVG�E/C.� � G N�ur S � ^ �� 3C'� �e ^� �P dO P9�/�� 4. /.3�/ t�«,S� aP �5"= 5�.a ��,,,,� •'r�4 �a 6�� <��5/ 7�it-� MASSACH SE 5 LOCATION Number Street Cdy State Zip pry� 5. �J �-- OTHER S.LOCATIONS Number Street City Sfate 7�p /'p� (A�aeparate sheet H necessary) / e. 7CJU R�r�S� �'�'iPCc� Ol/0 `l�S� LOCATION OF RECORDS Number Street State Zip p� 7. LEGAL STATUS de Pmprietw ❑ par6�ership � Trust ❑ Limded Partnership ❑ Corporation ❑ Other(e�tWain) II. CORPORATE INFORMATION L1st the Nartie,Duties,PerceMage of Oxmership arM Armual Salary of each ot(�er GsMd in the Corporale Artides c{Organizatlon. NAME DUl'IES %OWNERSHIP SALqRY PresldeM Treesurer Clerlc NOTE: Corporate oMkers cannd elect to ha macluded fiom coverape in Massechusetls. See the MeaseMusetls Rate Pagas fa�corporate aK�cer me�dmum/ minimum pnyrdl limilatlons. Sde propklors and par6ro�s cannd ekq to be eovered In Maesechueelts. III. INSURANCE COMPANIES WHO REFUSED TO WRITE VOLUNTARY COVERAGE AawMing ta Messaehusetts Generel Law�Chapter 152,Seetion BSA�an ampbye�may obtaln wakera'canpensation coverage through the MeasachuseGs Workers'ComPensatlen Assigned Risk Pool H tlxy have been relected M'lwo eompames licensed to write workers' canPensatlon insurance in the Commornveafth of Massaehusetls. 1. Att�h N✓o letters o/dedinaGon from'visurance companies who t�ave declfned to write voluntary coverege. The letters must be submflh.y on qiginal lettert��; p��,m��pe��moro U�an sbAy(60)days prior to submission; tliey muat have wigirwl signat�rea; and,Mey muat be signed by earrier personnel aulhor¢ed W 6irW eoverage. � NOTE: If ycw are currently(naured in yx ye�uMery market�o�e a the decqnatio�$must be from your present eertier. q eopy W the eancd�a nonrenewal must be allaehed M the applieatlon. / 2. Have yau recehred y�ny Mf�s o/rWuMary coverege9 (Include muaFNne w retrospective ratfig tertns.) ❑ YES N�Cf 0 V. BUSINESS OF EMPLOYER (continued) 5. Completety deseribe all opere6ons o/the employer by locadon. Also,campletety deaeribe airy changes tl�t t�ve Taken pla ming the Misirress of the empbyer oi the�ture o/the aperation. Attach e separate sheet if necessary. ��.�1 �'/�o,o VI. MASSACHUSETTS CLASSIFICATIONS, PAYROLLS, AND PREMIUM CALCULATIONS Payrolls of axporate ottfcers must be included. Adach the four most receMty flkd Pwm 941's w DET Farm 1's. la and classifieallons on the a katlon wNl 6e com red M r audits and I reeorda submNted. D�cribe the Dutles of the Empbyeas by Lceatlon Class Number of Tofal Rate Premium Cade E Remuneratlon� ��r-xavY2�d.t�eT .CJv C O�'"j / r,3� �7� `� Clerical NOC 8870 Outside Sales 8742 Drivera,NOC 7380 Employers'LlabilHy / / - TOTAL PREMIUM " ExPerience Ratin9( )a Merit Ratln9( ) ' ArtassaehuseRs ConsWction Credit( ) " Loss Co�refard �.�.� STANDARD PREMIUM ��G � � •• Deductibb Credk( ) VII. DEPOSIT REQUIRED : • Rqp� � �-�2a.�2Jn-�j�n��. ta.� .�• (7d �• �^��^�0�$ """ Inwrance Charge( 10% ) Eatimated InatallmeM Minimum �I'�I � Expenae Consfant � ' Ud. PremWm 8asis De ' UrWer Annualty 100% r�e TOTAL ESTIMATED ANNUAL PREMIUM At I�t Semi- 75% ona DIA Assessment(�,� %)of Standard Premium �/ b Q 55�000 Mnual At I�t �uarterly 50% fhree TOTAL EST.ANNUAL PREMIUM AND UTA ASSESSMENT �r7 $10,000 U /�� At I�st Mantl�y 25% nine DEPOSIT PREMIUM 325,000 2. Enchsed is eheek number �the amouM o/S �T/ (�G�made payable to the Massachusetts Workers'Compensatlon Assig�red Riak Pool(NNUCARP). A single eheek must be submitted. Amr bindirq�of coverage is based an the assumpllon tt�at the dreck is negatiable. If the d�eck ia non-negotiaW ,the assignmeM will be rescirMed. 3. Is the promium 6eing fi�nced7 ❑ YES NO � If YES,then 700%of the Total Estimated Nmual Premium and Massachusetts DIA AssessmeM must be seM wilh the application aloRg witli a signetl copy of the finance agreement. � KaPPikable. '�R Refer ro the Masa.pages oi tlro Basb Manuai(or Worke�s'Compensation a�M Empbyen'Liability Inwrance for deqils. �� ApWi�onty m Former Self I�rourers. R�x b Ihe Pracedures Manuel tor delalls. IV. INSURANCE RECORD YES NO ' 1. Haa the applkaM previousy had Massaehuaetts workers'cornpensatlon Insuranee 9 2, If YES,complete the folbwing fw the rtast reeeM Nree years: INSURANCE COMPANY POLICY NUMBER POLICY PERIOD PREMIUM 3. It NO,complete: ew Busin�s ❑Self Insured ❑Otha(e�lain): 4. Former Self Insurers are subject ta Mie PrertYum Determination Endorsem�t-Famer Self Irreurers-1.M audN must be completed before eoverage can be bourM. Reter to the Procedures Manual la ddails. If self Msured vaitli�tlte last twelva tnanMa�Pmvide the tenrenatbn daM: 5. la there any�paid wo�rs'comper�nation premium due from y�w or�y other commony amed or merreged enterprise9 It YE3,provide Me entlly name,bala�e and pdicy num6er(a)bebw. If the premium is beirg disputed,attseh an e�ryknedon for Bureeu consideratlon. If an arrangemmt for peymeM has been made�attaeh a copy M Ne signed�raemer�t. - 6. Ia the empbyer in banlwptcy7 If YES,attaeh a copy of tl�e approved banWuptcy tlkng. 7. Does thia e�tity or any eommony managed w axned e�ty have operations in stat�ofha ihan Mass.? If YES,attach a Iist of employer remes,slates,carriers and IMersfate or inVastate ID numbera. 8. Has Mere been a rreme change wilhln tt�e last five years7 9. Has there b�n a ncerger a wnsdidatWn w&hb tlie Mst flve y�rs9 � 10, Has there been a sale,transfer w comeyance of ownership IMerest within ihe last frve ye�ara7 11. DW the applleaM purehase a oUrerwise acqWre the physieal asseis of anotlter�wlwse operetlona ticey took over wiThin the Iest five y�rs1 �2, Have Uie axmers or otficers ever had oxmership interest in arry otl�entity,either curreNty w prevbusly e�dstlng'J COMPLETE AN ERM FORM AND ATTACH TO THIS APPLICATION IF THE ANSWER TO 7,8,9, 10, 11 OR 12 IS YES. V. BUSINESS OF EMPLOYER YES NO 1. Dces the epplicant suppty employees to oUm businesses7 If YES,canpkte and allach tlie suppkmantal appdcation,Side A,antl refer to Me Procedwes Manual fa Natnietim�s. 2. Does Uie appliqrd regularly have empbyees supplied to tl�em from dher businessea? If YES,complete and attach the suPplemeMal applkalbn,SMe B, and refer to the Proeedures M�ual la insWctions. 3. Mass.law provW�tlret you,the employer,are fable for injury ot empbyees of uninsured subcontractws. Premlum will ba eharged in the absence of a cerMfieale of Insurance from subcontractas. Is d andcipated that aubconVact labor will be udSzed dur'sig the pdky term7 If YES,estlmate payrolis made M subeontractara wiqwut eerNfxetes of insurance. $ Transfer this amouM to Seciion VI and Identiry by Gassification of work peAortned. � 4. Do you use InUependent contreetws9 If YES,you must maiMain documentadon which aupports that they are,in fact,indapendent contraetora. If such documentetion is not ava�aabk,or if tlie designated earrier Mds evidence of an empbymeM relatbnship, then premium may be charged as if the in�d�ls w�e employees. . , • , VIII. APPLICANTS STATEMENT The undersigned hereby cmtifies that hdshe has reatl arM understands tha atatemeM in this applketlon. Purthertnore,in eonsiduation of the issuanee of the poliey of insurance,he/she also certifies tt�at the statem�ds made In this application are true and agrees: 1. To maiMain a complete record of all policy transactions in such lorm as the imurance eompa�ry may , reaaonaby require and that all sueh records wiA be avai�We to Ne eompamr at Me d�ignated address. 2. To wmpty substar�ially with all laws,orders,Mes�d reguladona In Mree and effeU rt�de by the public authorities relating to the welfare,h�Mh and safety of employees. . 3. To wmply wHh all reaao�ble reeommendatlons made by Ua insuranca eomparry reletlng W Ue welfare, heaith arM safety of employeea. This I�uranea is being provided through the MASSACHUSETTS WORI�RS'COMPENSATION ASSIGNED RISK POOL,and r�U�rough Me voluMary market. NOTICE: MASSACHUSETTS GENERAL LAW,CHAPTER 152,SECTION 14�5)PROVIDES: 'Nolwkhstanding any provision of sectlon ona hundred a�M deven A of chapter lwo hundred arW sintyaix W the eontrery,any person . who �mowingty makas any false w miskadi� statament, represaMadon or w6mission w knowingly auists, abets, solkits or conspires in tl�e making of any hlsa a misleading statemenf,representatlon or submiubn,w knowingty coneeals or hils to discloae Imowkdga o(the oeeurtenu of arry avaM aftaeting the paymaM,coverage a other beneflt/or the purpose of obtaining w danying any payment, coverege or other beneM umkr this ehaptar; u�d arry person m employer who knowingly misclassiRes a�ployees w engages in deeeptive empbyee leasing pnetices for the purpose of avotding NII payment ot inwrance pramiyms...slull ba punishad by hnprisom�eM in the state priwn tor not more Man flve years or by inpNsom�M in jail Mr nM less than six months nw more than hvo and onefialf years or by a /ine ot than one thousand n more than ten thausan rs, or by b�h such fltre arM mneM^ �rSS ' ` �e ��0 � �i`a� (Business Name of Empbyer) signaa,re ropr�e�w, co r � IX. AGENCY INFORMATION AND PRODUCER STATEMENT The produear hereby certlfles Mat the i�ortnafion provided,ineluding prerNmn Infarmation,is Uue to the best ot hislher knowledge and be . � �� ^,� AGENCY � � �� ._!J ADDRESS N �� GC� D"4 "v ��/r N� ^C��,6 Street Cily 'p Code V Te�p h� / PRODUCER � L ' �G � Name(Pri ed) SI e . Agency License Number MASSAGHUSETTS WORI(FRS'GOMPENSATION ASSIGNED RSK POO:_ RULES AND PROCEDURES PLe-3E R�eg GARfFIlLY 1. Applkatlais will rrot be aeeepted by FAX machine. 2. An addRional or replacemeM eMay cannot be endaraed oMo an e�dedng assigned risk policy as a named insurod uMess an appikatlon�d cheek are submRted and covwage Is assigrred by tl�e Bur�u. Refer to the Procedures Manual for instn�etions. 3. The Pool is able to prcAde coverage ony fa Massachusetts empbyees. If an emqoyer has operatiorre in a�ry stffie other Uian Massachusetts,a crommences oper�ions in such state after policy inception,applieadon for coverage for those operaBona must be made to the appropriate Bureau a Mlrer ageney adminlstering the Residual Market in that state,ff vduntary coveraga s not available. 4. If wluMary coverage haa been cancelled a nonrenewed at tlre irreured's request,fhe insured is nd eHgible Mr assign�risk 5. VV�hen a pod podcy has been cancelled hvbePfor nai-payment of premium�a at the requeat o!the flnance�mpany,the dnpbyer must reapply to the Pool for subsequeM eoverage aRer atl aWtanding balances Imve been paid. � 6. Applirations fw joint vmturca must include a eopy of tlie JdM venhve agreemeM. 7. Payrdls and elassificationa are subject M review by Bur�u StaH arM may be charged. 8. The Waiver of Our Rights to Reeover(rom OOiers EndorsemeM,WC000373,ia available W empbyers who require the endorsemeM by eontract. Reler to fhe Procedures Manuel far detalls. 9. AgeMs are rwt ageMs of the Mass.Workers'Compensatlm Assigix.y Risk Pool arM cann�issue Certiflcat�of Insurance. 10. If yau have arry questions about the rules goverNng the Massachusetts Workers'Compmsatlai Assigned Risk Pool,refer W Me Proeedures Manual. If addilimal Infortnation is requlred,contact the Workers'Campe�adon Ratlng 8 Inspectlon Bur�u of Mass. at(81�439-9030 w write to eitlier P.O.Bm�9005,BosWn,MA 02205 a 101 Arch Street,Boaton,AAA 02110. mmax i�as �ACORD INSURANCE BINDER OPID S �A� 06/25/04 THIS BINDER IS-A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS PORM. PRODUCER � ac,Ne,�: 508-394-0946 COMPANY BINDER# 32263 508-760-1407 National Grange Mutual Ins. C Norcross & Leighton Cape Loc. E �cPiw,n C.J.McCarthy Ins.Agency,2ne. oare TIME DATE nrne 437 Station Ave X nM X iz:oi u,n So.Yarmouth MA 02664 07/O1/04 12:01 PM 07/31/04 Noon Scott A.Trembla THIS BINOER IS ISSUED TO EXTEND CAVERAGE IN THE ABOVE NAMED COMPANV CODE: SUBCODE: PERE%PIRINGPOLICV#: BINDER CUSTOMERID: �SSR—B DESCRIPTIONOFOVERATIONSNEHICLES/PROPERTV�Inclutli�qLoeation) INSURED Location: 1 Suilding: 1 PIZZA SHOP Bass River Pizza PIZZA SHOP/ OPERATIONS 50 Lake Road W. Yarmouth MA 02673 COVERAGES LIMITS T'PEOFINSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CqUSESOF�OSS BUS PER$ PROP SOO �IGOOO BASIC � BROAD � SPEC BUS INCOME Glass Coverage FOOD SPOILAGE 5000 GENERALLIABILITY EACHOCCURRENCE ESOOOOO X COMMERqALGENERALLIABILITY FIREDAMAGE(Anyonefre) SZOOOOO CLAIMS MADE � OCCUR MED EXP(My one person) $rj0�� PERSONALBA�VINJURY $SOOOOO GENERALAGGREGATE $].00OOOO RETRODATEFORCLAIMSMADE: PRODUCTS-COMP/OPAGG $LOOOOOO AIJfOMOBILE LIABILITY COMBINE�SINGLE LIMIT $ ANVAIJrO BODILYINJURV(Perperson) S ALLOWNEDAUTOS BODIIVINJURV(PeractlCent) E SCHEOULEDAUTOS PROPERTYOAMAGE E X HIREDAUTOS MEDICALPAVMENTS 5 X NON-0WNEDAUTOS PERSONALINJURVPROT 5 UNINSURED MOTORIST $ $ A11T0 PHVSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE CALLISION: STATEDAMOUNT $ OTHERTHANCOL � OTHER GARAGELIABILITY AUTOONLY-EAACCIDENT E ANV AUTO 07HER TMAN AUTO ONLV: EACHACpDENT $ AGGREGATE g ��ry EACH OCCURRENCE $ UMBRELLAFORM AGGREGATE § OTHER TMAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION E WC STATUTORV LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYER'S LIABILITV E.L.DISEASE-EA EMPLOVEE $ E.L.DISEASE-POLICYLIMIT $ CONO�7�I ONS/ FEES $ OTHER TAXES § COVERAGES ESTIMATEDTOTALPREMIUM $ NAME&ADDRESS MORTGAGEE ADOITIONAL INSUREO LO$$PAVEE LOAN# AUTHORIZED REPRESENTATIVE . /� ` ACORD 75S(1/98) NOTE:IMPORTANT STATE INFORMAT ERSE E pACORD C RPORATION 1993 ,;;�.- , --,=E, �r�€s.�,..,, -'r� t` � ?' «m��':y:_....�._ — � �n � . a. - - � �.�'R-"",' �+ i��- _.��- � �.. � �� . :, �� + �+�.� {��t " .. :::�E� �7 'aU"`-��.,. a . � � �� „ � �" a _ �> __. m.. z...._.n � .__�¢ , »r�:.� ___-�.m��,�� ._,�"�,, ,n.��'_`�_� �m�, s�.. �ax-,,._t�� Co�erc,�al Property Section - Additional Subject of Insurance COVERAGES/FORMS DEDUCTIBLE COINS 8 AMOUNT MEPSB THE COMIIZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT 1VIJMBER: #04-I l l FEE: 50.00 This is to Certify that Gerald & Tracy DowninQ d/b/a Bass River Pizza 1311 Route 28, South Yazmouth, MA IS HEREBY GRANTED A COM1140N VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirly-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto a6'viced their official signatures. BOARD OF HEALTH: Bsal�i.c�. �„M.$. " SEA�,� 36 p�.aa��rt v�ef� a��a� ef� �� a.�r. ��.w.�, a.n�. July 2,2004 � Bruce G.Mucphy,MP S.,CHO Director of Heahh TOWN OF YARMOUI'H BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NCTMBER: #04200 FEE: $75.00 In accordauce with reaulations promulgated undes authority of Chapter 94,Seclion 305A and Chapter 111,Section 5 of the�ieneral Laws,a Perndt is hereby granted to: Gerald& Tracy Downing 1311 Route 28, South Yamiouth, MA Whose place of business is: Bass River Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Peimit e�ires: December 31 2004 BOARD OF I IEAI.TH: Be�.$. lfatda�,.M.$., C�a�.� s�,��:36 �,y� v:�.e�.� �srluCTTONs: Paper service only,no fryolators,in compliance with Ro6sst�. �tow�w,. � agreemert letter with Health Director Bruce Murphy,dated 0528/98. d�i�ik �'�c�r. /l./�. No hamburgers,chceseburgecs,clucken cu[lets or veal. 14itk '�o�rwry Q.l�! 7ulv 2.2004 tuce G.Murphy, H, S.,CHO Director of Health � � �i e��P�� . _�`:""o TOWN OF YARMOUTH BOARD OF HE � � ;S APPLICATION FOR LICENSE/PEI�I ,. i ' .' ( '� Please complete form and attach all necessary 4 aments �y � c�embe� � ti i�� PT. f �-3-�;�3.-- Failure to do so will result in the return ot �ur�ppGcahon packet. S T # �IU '12pU �QCATION D FS : (�\t Rol►zE o2sc SO �fA vS(i-1 t,L� c�ZC'-,F,c-J MAILING ADD FS�• 131� 'Ro�'TF-- � So- �As�a.�c, ��c-�, o.aQ cSZ.p,ry 4WNER/CORPORATION NAMF• '��SS eZZ,I��Q �fZz.�p 3 �� 1�LANA ER'S NAME• �y To�p�.y �LA^c�� -cc, ��,S T r # `7C-z�-.� i � MAILING ADDRESS• t-F25 -c�E �4��—�f�v�,.ot,�x kA' 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 attaah a cop;�of the certif:caiion to fhis form. 1. 2 Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this forrn. The Health Department will not use past years' records. You must provide new copies and maintaia a tile at your place of business. l. 2. 3. 4. FOOD PROTECTION MANA RS - C RTIFI ATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maiutain a file at your establishment. 1.�1«A'`Q:��..)�!- -(C�ul�\`i 2. PERSON IN C AR — _ _. _ - __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �-RPrO.��Pr �o� �'��S 2. �sr�� -101.1DL� HEIMLICH CERT FICATION�• All food service estabiishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �1.� "Coi.s.��s 2. t��'Cov��lT— 3. 4. F TA A1.IT ATIN : TOTAL# C--�S OFFIC . . nNi y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FL•G PERMtT# i.ICENSE REQUIRED FEE PERMIT N _�� $50 _CABIN S50 _MOTEL $50 _MN S50 _CAMP $50 _SWIMMMG POOL$75ea _LODGE S50 _TRAILER PARK S50 _WHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PER�M/,IT M LICGNSE REQUIRGD FEE PGRMIT# LICENSE REQUIRED PEE PERMIT# I 0-IOOSEATS S75 �'T'�EI _CONTINENTAL S30 _NON-PROFIT S25 _>100 SEATS $I50 f COMMON VICT. S50 �O`F�O � _�yyOLESALE S75 RFTAII RFRy�(`g• LICENSE REQUIRED FEE PERMIT# LICENSE RBQUIRED FGE PBRMIT q LICGNSE RBQUIRED FEE PERMIT# _<50 sq.ft. S45 _>25,000 sq.ft. 5200 _VLNDING-FOOD S20 _<25,000 sq.ft. S75 _FROZEN DGSSGR'P S35 _TODACCO $25 HAME C AN('F• $�Q AMOUNT DUE _ $_ � 2,5 ,p "•"`*PLEASE TURN OV ER AND COMPLETE OTHER SIDE OF FORM"*'•• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED 2$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits nut annualty from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCIRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE 1'O CONTACT TH�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Heaith 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 ADVISOR • Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. �AT . rN POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Tempo Food Service Application form 72 hours prior to the catered event. Thses forms can be obtazned at the H�th Department. j`iu117ctv�F�C�RTC� - . 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 teims have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: OuWoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: 11�5�� SIGNATUR�: .C,/.,,,a� ��.:1�'_ PRINTNAME& TITLG: �C,R2�NP< -tc:,�� / "r��e��D��x�r 10/22/03 . _ � The Commonwealth ojMossachusetts = Department ajlndustria/.-lccidents ; Olflieoll�s�lysWis 600 Washington Slreet Bosrox.Mass. 01111 W'orkers' Compensatian Insurance Affidavi[ ApQlicant information: PI nicPRfl�TTeeGi�Fp � nam� �� QI1�YZ `�Vl�,1n lucation� �s�1� �4"C�� a'Z� crt� `-in.��Qk�c5l1..`CF� phonep 4Wll ��ti -lZ�C� 0 I am a homecwner pzrtortning atl work myself. � I �m a sole propriator_r.d ha�e no one «orkin_ in am capatin• � I am an employec pro�iding workers' compensacion for my empioyees workine on this job. tomnanrname: g�s �\\)U� P1� �JAress: `� I��. �U.,-Cre �-� titv: jl� • Y�'��.�"� � ehoneM• (�� J��:��7 insuranceco. �J�A�(1hA1Ptl, C�s'tZ��C� l�.l�'CV.�1N$Cf)oolicva \Alfs-1530� � I am a sole proprietor. _eneral contractor. or homeowner(circle onU and hace hired the contractors listed below �tiho ha�e thz follo�.in_ ��orkzr> compensation polices companv name: address• cf,y: phone p: insurancc co. politr# comoanv name: addrese• �: ehoee M• insunneeco. eoiievi! � • Failure to fecure covenee as requved under Seenoa 25A o(MGL 112 n�lad to Ne inpo�idw oterid�l peWtln ot�O�e sp lo f1,500.00��d/or oae ye�n'imprisonment af w�e11 n eivil peodHn io tht form of a SI'OP WORK ORDER�ed i Oet ofS100.00 i A�r q�iat me [��denn�d th�t a eopy of thy statement may be for.v�rded to the Oliiee of laveetig�tiom of Me DIA tor eoven�e verillntla�. �. /do-brreby cenij}'under the poinr and pmal�ies ojperjury that tht injornmtion providtd a6ovt it true wd correee r . t� Signamre� i. �.v� Da�e �1 65(C3`T Prim name l�1 IP,1,0.1A.--ZOl-\n� �one 8 �.d��'� 1 3a1�1�C�U .. olTicial use only do not�rite in�his arn to bt eompltled by eiry w tow�a ollltial ciry or rowe: Y��DT$ _ permiNieeex N nBuildine Departmmt � �Lietosioe Bovd � check if immediat�response ie required 261 �Sdeetmen'e ORcr �HealtE Department cOntact person: phont N:_ �SOS� 398�2231 eat. nOther TOWN OF YARI4IOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #U4-151 FEE: 75.00 In accrn,dance with re ations promulgatecl�mder autharit}'of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a permit is hereby granted to: Bass River Pizza Inc. 1311 Route 28, Soath Yazmouth, MA Whose ptace of business is: Bass River Pizza Type o€business: Food Service To operate a food establ�shment in: Town of YarFnouth Pemtit ezpires: December 31_ 2004 BOARD oF HEAI.TH: B..cjan.r.a$. lfo+�oK,M.9l., � sEa�ruac:3s " 11aA:e1(..l4o�5ww.o�, ?lic.C�.oia�.o.a �s�r2ic1'torts: Paper service only,�&yolafois,in compli�ce with /lo/wt�.�.fsaws, � agrecment ietter with Health Director Bnice Mu�phy,dated OS/28/98. e�i�s� /2./�. No hmmburgers,cheesebisgers,chicken cuttets ar veal. �i+u fjaaerr�arserY IQ./Y. Apci15.2004 Bn�ce G.Murp 1 H,RS.,CHO Direaor of H tli THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-095 FEE: $50.00 Tlris is to Certify that Bass River Pizza Inc. d/b/a Bass River Pizza 1311 Route 28, South Yazmouth, MA IS HEREBY GRAN1'ED A l , COMMON VICTUALLER'S LICENSE In sa�d Town of Yarmouth and at that place only and e�cpires December thirty-first 2004 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuby with the authority granted to the licensing suthorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official si�atures. � so�n oF�Eu,�: B�$. ��,d�, M..�. • SEATING: 36 p�.sfa�u, v;� ef�. Ro6wt 4. B3«wc, Gl�srb �k Sl.ak, R.N. February IQ 2004 Bruce G.Mwphy, IP ,RS.,CHO Director of Health . �.a�at�s �iaS% e.2.�,7�0 �f�"R.y TOWN OF YARMOUTH BOARD O�k`�IEALTH 3��° APPLICATION FOR LICEN�/I'�RMI'�-2003 (n� � � I� Q �/ � � °. . s a�.t, 2003 ��'' .-, ��ao�. * Please complete form and attach all necessary documents by Dece ber� , Failure to do so will result in the re#um ofyour application pa k HEHLTH DEPT. NAME OF ESTABLISHMENT: P�A� Q1 U� 'D 1 TEL. #f�S�Y, +�9�71t� LocaTiorrA�n�ss: i3ri ��.aur� 2s� �o. y�2Mauzr-� az��y ` MAILING ADDRESS: SGttit� OWNER/CORPORATIONNAME: P�rSs �rv�i'1 �Orz2/f Zn�L MANAGER'SNAME: j�r.yn/ TouDLj/,Ufl�//U11 TOGi/�/S TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �. ��rn�ry� ldLi��s z. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 Fd��/Nr'J ?ot-/�js 2. /"f�L�N 7oLi�/� 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 certificarions 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. M��v f 7oZr7>13 2. ��[,�n� To�iv �c 3. 4. R�STAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSF,REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN $50 _CAMP $50 _SWIMMING POOL$SOea. _LODGE $50 _TRAILERPARK $50 WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# I 0-]00SEATS $75 6 -V`IS _CONTINENTAL $30 NON-PROFIT $25 _>]00 SEATS $150 � COMMON VTCT. $50 �CS�7 _WHOLESALE $95 �FTAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. $75 TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ I 2;j.0i> *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION �Tnder 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 Warker'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 t renewal or issuance of your perrnits. PLEASE CHECK APPROPRIATELY IF PAID: YES I NO NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPON5IBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQLJIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparhnent prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application Form 72 hours prior to the catered event. Thses forms can be obtained at the Health Deparhnent. FROZEN DESSERT5: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. DATE: ��22'��7 SIGNATURE: ��Z-�-, ��"� PRINTNAME & TITLE: d.�.A�iuA 7ot-»1S PR.Es ��e�.-3C 10/18/02 : • �\ The Commonwealth ojMassachusetts � Depnrlment ojlndustria/.-lccidents ; 0I1/Ce01/sres!/Osali�s 600 Washrngton Slreet Bnstan.Mass. 02111 ` '�� '` Wbrkers' Compensation Insurance Atfidavit Annlicant informaHon: P►easeYR[iV7'TesGi.Ta �;,m< �A�� Qi� ��2z�-Ztit- ,� (q�i� 7o�rDiS -- ,�ifl�r�vA-ro u��s ��„� �� Q�z��- s�- v��r cit� �O-�t1�R.�fiIITl,A' ehon M So 3�{`F �Z�O � I am a homecwner pznurtnin,all µork m}self. � 1 am a sole proprietor_r.,a. ha�z no one ��orking in am capatin� � am an employer pro�idino workers� compensa[ion for my employees workine on this job. tomnam� name: ad d ress• iitr: phene�• insuranceco. f�O�CiLS A'ND C31t�'fY/B�I��DG�T�CON oolicvfl Q C'� C�� I-F 1� SS[7 �72 � I am a sole proprietor. general contractor, or homeowner(circle onel and hace hired the conaactors listed below «ho ha�e the follu��in_ «arker ,ompensation policas: comoanv name: �ddress• tsy': phone M: � insur�ntc co. Deliev M eompanv name: addresr �y: phoee N: insurance co. ooliev M t Failure to�eeure covenae a�«qmred uoder Secnoe ZSA of MGL I53 u�Ind W tht i�poridw of eridW pndtle of a O�e op to S1,500.00��d/or ooe yan'imprisonmenl�f w�AI u eivil peadNn io the form of�STOP WORK ORDER aed�6ee o(5100.00�d�y qdott me 1��denta�d H�t• copy of thia statemrnt m�y De lonv�rded to t6e 011fee of Investlqtlom of Me DIA for eoven�t reritlutfw. � /do hrreby ctrtijp under rhe parnt and pena(lieJ ojptrjury�hw 1ht injormNion providtd abovt is true and correet � Signaturc _ .��i �� Mrc 01�23�U "3 Print name � ��-� ti� -Yo�.1 p I S phppe N ��c�� .�i 9�-I 72b� - aRcial use anl. do not nrite in this arn ro be completed by ciry or tmvn o0leial city or town: YARMODTQ permiNieeaae N nBuildiee Departmeut �Lieensiog Bo�rd �cheek i�immediate response ie required 261 �Seleetmen'e ORee (508) 398—?231 p�t, �HealtE Dep�rtmem - contact person: pAone M•_ __ nOtAer ' ' �� OneBeacon � I N 5 l� k A N C F. INSTALLMATIC DATE PAGE NO. WORKERS' COMPENSATfON PRENNUM AUDIT INVOICE `70NTHLY 05/�bl/02 1 PI�nNCH OFFlCF PREMIUM AUDIT GENTEF AUDItOR AGENT CODE BUREAU I.D.A SOURCE OF INVOIGE REX NQ � UXPOROUGN OXBOROUGH 1111 �-�2887 51 TELE 9DSA59 �� ' POLIGY NUM6CR �CK POLICV PEPI00 CANCELLATION�ATE PERIOU GOVERED 6V THIS INVOICE WCP PLAN FROM TO FROM TO Ll (Q�c> HS7 B� 7G � �ISJIQ�S 3ISJI�Dc^ 3ISSIQIS .3IIJI�� HRSS ftIVER PIZZA INC � � '+ ROGERS GRAY INS AOENCY INC 1.311 RT28 ; � 4 P. O. ROX 303 SO YfiRMOUTH� MA 026E4 ' ; ORLEANS MA 02653-03a9 _, i ; i, � __." '3079 RESTAURRtJT 66, a40 �. 06 1� 374 INCRER5ED LIMITS EMPLOYERS LIABILITY 1. 00 X 5� TO1'AL ERRNEd STANDF�RD PREMIUM . 1, 42k PREMIUM DISCOUNT ��> MR ASSESSMEIVT CHARGE 4. S�OY. 57 EXGENSE CONSTRNT ^c14 STRTE TOTRL 1� 6'35 J�1 WORKER'S COMPENSATION 1, 695. @0 YOUR UNL}ERWRITER - 1� ^c18. 0Q� 477. 0@ -r 05/01/0�: 122�3 02 2 501 2@ COMRLET G441W 0601 i[;;��;;I[��jti. . � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #03-089 FEE: $50.00 This is to Certify that Bass River Pizza Inc. d/b/a Bass River Pizza 1311 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December tivrty-first 2003 unless sooner suspended or revoked for violation of the laws of the Commonweahh respecting the licensing of common victualler's. Tfvs 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 affuced their official signatures. BOARD OF HEALTH: �(ra�lea�, iCdlikaa, �ifrarsma.c . SEATING: 36 ��. �OK �.�., �/�CG �OB��, b'2oG�K. � ' �aarick'�Kc�Jawratt '��c S/�E. �yl. January 27.2003 ruce G.M y, .S.,CHO Director of Health TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NiJMBER: #03-145 FEE: $75.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 l,Section 5 of the General Laws,a permit is hereby ganted to: Bass River Pizza Inc., 1311 Route 28, South Yannouth, MA Whose place of business is: Bass River Pizza Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31 2003 BOARD OF HEALTH: e(�a�lec'�. zeUdkvt, e�iyFaGuxwnc SEATMG:36 S'C4JqUt1K�. �aK. //4.`D., !/ftt �QI/L�JQ�c aESTR�CTTONS: Paper service only,in compliance with �o�wiet`�. Sxokvc, � agreement letter with Health Director Bruce Mu[phy,dated OSl28/98. �a0tick'I1��JrnrrotC 9felerz ,$/rak. �1Z• January 27,2003 ruce G.Murphy, ,R.S.,CHO Director of Healt ' 3. {Z. Pi zmq 4 ' TOWN OF YARMOUTH BOARD OF E[�� _ . .___, APPLICATION FOR LICENSE/PE �� I JJ �, ��"� � '�;� Z 1 2t��2 * Please complete form and attach all necessary documents by `� , 2001. Faikure to do so will resul in the return of yow application packet. � l " _�, s_ `1_��', O ST LIS ENT: e. T . # o - dp LOCATION D F.SS• J� J � � 2 �Y e 5/`��u.�o c�l�„ IL G A S: OWNER�C0�1'ORATIONNAMF• f?r �LE� 7'OGi f��SS62�i'�Y i22� kG- MANAGER'S NAMF• ,/{��r��l�_��L 1 �� q TEI # MAILING ADDRFS • �T�i/..e� POOL CERT FI ATION • The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �o�i�P�ratar(�d-attacir�capy afYhe�erti&cation ta titis farm -- - _ ---- 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGER - 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 applicarion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. i. � �Ni'��f T�/ia,is 2. PERSON IN CHAR �� . — Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. '�� `r0�1��/�S 2. �/U�faY'1�L/�G�,�l�"f'��fiC HEIMT ICH CERTIFICATIONS• All food service establishments with 25 seats or more must haue at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anfi-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. ��t� � o�/GI/� 2. 3. /!L(�r/hGl Te /�' �4 4. RESTAIIRANT SEATINC'�: TOTAL# �,oDGmic: OFFICE i.SF nNi,Y LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN E50 _MOTEL $50 _INN $50 _CAMP $50 _SWIMMING POOL$SOea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $25ea. FOOD RVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N �0-t00 SEATS $75 Od-6�B _CONTINENTAL $30 _NON-PROFIT $25 _>I00 SEATS $I50 I COMMON VICT. $50 �.-�,� _µ�-�pLESALE $75 RFTA►� SERVIGE• LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAMECHANGE• $10 AMOUNTDUE _ $ lZS.00 "•*"+pGEASE TiJRN OVER AND COMPLETE OTHER SIDE OF FORM•*••• , t ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,ihe Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a busine�s if a person or company does not have a Certifica:e 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:Pemuts 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 ESTABLISI�vIEN1'S ARE TO CONTACT TI IE HEALTH DEPART1v4:NT 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swinuning pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER AAVISORY: Each food establishment wtuch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF,RING POLICY: Anyone who caters wrthin 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. FRn7FN 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 CAF�`S• Outside cafes(i.e.,outdoor seating with waiter/waitress service),ml�.t have prior approval from the Boazd of Health. nTrTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: c� � � SIGNATURE: l�i� DY'Pi5>��P f�r� PRINT NAME& TITLE: �E��1—� o�/� /�S 09/I 1/O1 _ • �\ The Commonwea/th ojMassachuset[s � Departmenl oflndustria/.-Iccidents a OIJIce e1/sresdOsaliis 600 Washrngton Street Bosron. Mass. OZIlI � W'orkers' Compensation Insurance Affidavit ARplicant infarmallon: p1 Ase� n.m• � � tirt� ehon p VX 7i� 7�-Q� � I am a homeoµner pzrtbrtning all work myself. �I am a solz proprie�or �r.,', ha�z no one «orkine in am capacin� - - kaman-empleyer-�cei+�ins-�sr4�ers'-cemgensatieFrfor-my-em�letiees�erlett�onthisje�-- . r o m n m • YPif/ dAres : S �iLi�fJf-� (/�i(� p. Q � �� insur�nce co. CI'.�'.��1. r�/�'� �� 1 oolicvk {��7 $�072 -ri 4�Y- 2 55��1 0 ' � I am a sole proprietor. _enerai contractar. or homeowner(circ(e anel and have hired the contractors listed below ��ho ha�e the follu�cing �corkers compensation polices: comPanv name: address: cin�: phone M• � insurantc co ooliev# � S2maanv name: addre�z• �'� phoes�• iesurantt co. pog�p t Failure to�ecure covenge as requ�red under Seenoo 25A o(MGL 152 u�iud to t0e i�paidw of erisiW pndtln of�O�e op m f1300.00��d/or oee ynn'imprisonment af w�dl a�eivii pendNn io tht torm of�STOP WORK ORDER aed�Ilee of SI00.00�d�y qNoft m� I��denh�d th�t■ topy of thia sntement m�y be fonwrded to�he ORee of Inr�ftia�tioe�of Mt DIA for toven�e verillntlw. 1 do�hrreby certijp un� d/r r pains and pertaltier oj erjury�ha��he injorrwtion providtd above is b�t and e n�e�. �/�, �j' //////� � �7 � Signature ��;Y/,� I"rOa��7 M.. �� C./ -T� /� �„/ , �o� Print name -r� (/ � �/I �//7 f�d,� / S Phone N 1 .• aRci�l use onh do not wite in this arca to br tompleted by cih or tow�e ollleial rin or town: YA��DTQ _ penniNieeex M nBuildine Departmee� � �Lieemieg Bovd �check if immtdiate response if required 261 �Stlettmen'f ORce �Hulth Dep�rtmtet � contactpenon: phoneN;_ �SOS� 39$—�31 eEt. nOther THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-051 FEE: $50.00 This is to Certify that Helen Tolidis d/b/a Bass River Pizza Inc. 1311 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December t6irty-first 2002 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 confornuty wrth 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: (�4azlec�f. Zdllke�, �a.� sEn'1'wc: 36 �„c�anius D. � 7J9.'.�.. 2/lee ��aSest� �. QF�nk �a�riek�erAKotC �da� Skak .?P. March 13 ,2002 , Director of Health TOWN OF YARMODTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #02-078 FEE: $75.00 In accordance with regularions promulgated�mder authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: Helen Tolidi5, 1311 Route 2R, Snuth Yarmouth, MA Whose place of business is: Bass River Pizza Inc. Type of business: Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2002 BOARD oF HEALTH: �//Fa�rlr.a� zaf[�4oc. �a�c SEATING:36 �e.cja.�D. C�da+�. �K D., 2/ree �Far,�a.c xEs'rR�CTTOxs: Paper service only,in compliance with �o6ett� ?rs'oavs, elmk agreement letter wiW Healt6 Director Bruce Murphy,dated OS/28/98. �a�tek�Dexrxofl �S�ak. ,��l. March 13 ,2002 Bruce G.Murphy,MP , CHO Director of Health � �v�x��- • TowN oF YA�ou�Bon� oF aEA�.�rH i p (� C� C� � N! � D APPLICATION FOR LICENSF,��R1�T-20011 MQR 2 3 2�� q��, �b�� * Please complete form and attach all necessary documents by Decemb�er'31, 19�9. �'ail q-�p�p�g��1ffF��Euit n the return of your applicaxion packet. --------------------------------------------------------------------------------------------------- ----------------_ N F E S - "S � U� I NL # 7a6O �.00ATION ADDRES4 /�// .rIO(/T£ a R' - Yp R �Ua?,�rN nv D OWNER/CORPORATIONNA1vtF'� j� SS �/I/t,� 7�/2Zl�I �NC �vIANAGER'S NAME� l�FEL�/✓ 7UGiI�)S TET # �9�/ 7�00 �I�iGADDRESS� /'�// R�TE a �. .5'd • Y� �M�t T�! -------------------------------------------------------_____________-------------------_______—_. POOL CERTIFI ATIONS� The pooi supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(sj and attach a copy of the certification to tlus foirn. 1. Z, 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 certi&cations to ttris form. The Health DepaHment 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. HFi_i� I H RTIFI ATION All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. - D��1�FRAI+FT SE�TB*iFi-TAT�4f.-#-�---------�i�N-SMAI£ING SE�S��'-@�"A�#�------.—.. . . . ------_---_-----------------------------------_----_-_�_____________—__--------------------�� OFFICE USE ONLY I.ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 _INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIMMINGPOOL $SOea. WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $75 ?,K��O _CONTINENTAL $30 _>100 SEATS $150 NON-PROFIT $25 �COMMON VICT. $50 y�-9 'rj _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIItED FEE PERMIT # LICEN3E REQUIKED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 aMotnvT nuE _ $ �25 �- '•'•"PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM'•"•" 4 � ADMINISTRATION ' LINDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIItED 'T,O HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A P�RSON OR COMl'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 ATTACI�D � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID: YES NO NOTICE: PERMITS RUN ANNiJALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBII.TI'Y TO RETURN THE COMI'LETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENI1�tG FOR TfIE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIlvINIING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TI-IE WATER TESTED FOR PSEUDOMONAS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY Tf�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMIvIING 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 NOTIF'Y Tf�YARMOUTH HEALTH DEPARTMENT BY FILING THE REQUIltED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CA'IBRED EVENT. Tf�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. FAILURE TO DO SO WII.L RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZENDESSERT PERMIT UNTII,Tf�ABOVE TERMS HAVE BEEN MET. - . _ OUTSIDE CAFES: OiJTSIDE CAF'ES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM TI-�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBITED. , nA�: 2 31 Z�B1� slGrraTuxE: �� n PRINT NAME& TITL.E: �2-G G' vJ TO /i p�/ � - C��,�n�,�� 11/12/99 ��O�Y MRR-24-2W0 09�34 ROGERS & GRRY� ORLERNS P.01 A�NRI� ��E a••��, wrraroo � TH13 GERFIFIGATE IS IS%lE� AS A MATTER OR INFORMATION IIOOplS 8 ORA7' INl. AOiN07� INC '� ONIV�AND�CANFER3 NO R1GHT9 UPON THE CERTIFICATE 4f� ROYi� /7� . . . . � �� HOLDEA: THIS CEf�TIFlCATE DOEB NOT AMENU� EXTEND OR R0. BOY1�01 . . � � �. iW7N OINNW M1 OftiF1W1 . � ' . . . . � . . � . �- . � INSURERS AFFORDING COVERAC,E � __..... f61�Bi A �NY��. UA� �s. CQ __...... /�ai /�11�I MR1 MIC. � ...._ . .�. .... . N911�i.B:�..... �d�LO�E1Q fl� �S. rro. 1lf7 Ilwq R� �� r�mi�c: -- ...... '---............--'— SwN 11r�01rM YA 02M�0000 � �m�ui � _. ....., .. .'-' - R811F6i E . . ..:. THE PqJpIE3 pF INSUWWCE LISim BaOW HAV�BEEN ISSUE7 70 7HE INSUiED NAMED ABOVE WH iHE PIXJCY PEIiO� INOICAIED. NO7YYITNSTANOING AM' REOUIREMENf.7EAA1 IKi CONOff10N OF ANY�CONIAM.T OH OTiER OOCUM@R WITH Fl�SPBCT TO WHICH THI$C6RIRCATE NUY�ISSUm OR NNY P.ERfAIN, 7HE WSUWIfBCE AFF01iDED BY�T11E POLICIF$�pE$CPoB��HEfF1P1��IS SUBIECT 70 ALL iHE i6IM5, FJICW90N3 AND CONOfIION$ OF$UCH � _.....�: .,,. . . _ � 1YPE OF M9UHO/10E . .. � �pptx,ry Mp,� " POl1CY E�IAIIpN �� B ��'�� 8BZQ31o8bQ c;; .,-..:�' :io3/15/ob o9I15/o1 �-� i soo,000 x CM�6ACNL f1BbANL LL�B0.11V � � FME DMMIiE ane ih i0u�ooa � , o- _ ., v. . . . QdC��MOE �OIX� ;Y n Y�` '. �£'_�'i'r ,r �� . u ah� ' i�.Y�,S`•' _._ MEU F� are.�B,�cnw,�_ t 5 000 _ ..._ .. .�� k. : ., :� .. _ . � . �., Y�` PH60NIIL6ADVItiIIIRY 1 _.... 500�000 � �� c�e�iK�oora��E � 1,000,aoa f)BILA60�i�lELMR:WR�P9t . . . � � . �:C�l: �.-. PlprnlC�S-COMPIOPA09 7�..._.. 1�OOO,oOD VOLC1' LOf: .. . _ �Y �$M[iE L.Mf __ . .___. .__.. ... . ..... .. ' IWY IUiO . . . Al1 OMR�D MJ�OS . � � .. . . . . _ _ . . . . . �80�LY KFd1Y sa�aFn�uros �. 1�w�t s w��WroS . . . = .:-.. . __ . . ._ _. . ,,..;; �. �_ �. _ eoo�r rtwn s NOt+pxR��Vr06 � 1�'�odq�N . ..._.. __., . ...._ ... .. . _ _ _ ."'__ _._._ , _.... .._: _. . ... . ...... . ._. __ s la.�acda9� (111RR9E IURIIT . , i��. . � . . . Nf10 dlY-FA ACI71D@R 9 ANY IlRO . t .. .� . . . � , ., .. " i� . ... ..... d�101 7X�l/ FJ1 ACC S ' ' . ' . _ . NRO OPLLY: ABO S EkCE99 LWBiJ1Y , ... . , , . � EIuCJI OCWfi81fE S OCCUR �tXAMB MWF . - .. •s. .., ,. . • . .. . ' ' I0f3PC-047E f - S . . � . .,.. . . , ..,. _,_ . ,. .:. .. . ...:: .. . .. . . . . . ... .:. ..... _. O�IIC7BLE _. . ... i iE1BiTI0N ! . . � .'..._•— i wdiOB COMPBBATIOI�i AND . � . . . .. WC A 4 �Y�� C89178072 . A3/IS/OU '. "��b3/75/O1 EL EACN ACCO�Nf i 500�000 .. .. � ...__'_ . . ___r: .. ... .. __. .. .. _. .. _ . . � � Ey,pgEpAE_Ep 500�000 . . . _. ., ..__ . .... . . _ . """ . ,.._�. � E.Lo�-POLJCYLIMR a 500.000 OIl61 . . . .. ot�d�wnoH oF a+evmoxav�nasna+a�cavsaa�oo�er euaeaerte�a.�rirov�s _ _ .. .� __ a , � . _ ;. . . _. i:.00muw.ra�ea��... . : , .��::�-. .�, . . ... .. .. . . 910ULo I�Nr OF.T7E n90uE UF9CP6�POIIG�BE GNCa6ED 860HE hE F7�M7Wx �. � � � � M7E 7119EOF.1fE�II�IO.�M�Y'A.L HIOFAVOR TO MII� �. ONY9\YRITIB) rown or raimealh � 1f�6 Yaln i1r'�et " ! -... . . �� xar�ro nE.�rrr�are xa�wrm To n��.eur FkuFlE ro oo so s�wi. /TTNr N�NW O�f . . � _rw�no oa�annnw on u�e�nr oF an iwo n+e On iw 1Mf�oWa MI _, _...._.��._ ...,. _....;._.. ,._._.., .. Oa a S�"CiRAY INSD& C�A8�7�,� ACOBD 2fs plB� J. ----_. _ _---._ _._ .., , _, ;., _...: . _ � ACORD COHPORATION 1898 � OYt TOTRL P.61 . 0 °' � U o � ^ s v� c� � vi � � a w � � � �� w `W` o �"�,;� � �� x � � � � �w 0 a ° `� � N � U HxH �s a w�A o F"�'' W �.� � x ,�jF�jp �o � � � w � a! xw �� Q o w �L � �" � � p � W �� a, ° p s � � F �O � � � � 3r � Q �a 'ry7 � F�-� � � . Ow � ' � y _ � E" p e 3 � 0 0. � c� Gq w .�' o o g O .� N � aa � A'i Q� 'y .G Q . ~ � G F � = c � � m �; � . �� 'y ..a'. a� o p � r�.« y ,n �' c°�i ,�, . ' o . Z P" w �v, � a�'i a�i °y' x o ❑ .d Q � o 0.1 �,o_ ��„ y G a,s N � '�," a�i p � w 'v, a 3 r� U V] V •y cd � y � ^ Z �� a� 'a z ,d v F- �� a '° � aKi M °�r�r s F�1 O � O y �� C � . lJ al > C � a F � � PW. � F F� P. � � � i � h y a� � � p c �� , v o•� o � `� � �c�c ? � � � a w `� �'.�� °° �''k, � v' w �''�� ,� �, .c� H ��3 � � �'x � rj? Ao�p o � � � o �o U � W o � p � ,� tl� " c�i a��i � ��$ r�'isF � ¢a Q ,v, $� k W �+� �� a1Ca �' ►� ° Qv� .��.�o c� � � o � H C4 x o'o v `'� x O � "' '� �'a '° 3 � ; � � � � '� � �^:•� ty � w � o � ��.�� x E"' �„ a v� �F �� NV ,� w o w a� O � O > N �V � � � �' � ^7 y � C .. c� s"„� iC � � o �z a�.�'""7 y � ?�i 0 �"' � � F" � � y•��r a� .� oa � � � cdo� °' ' �n � .b�,,, �C7 ^o � � � .��. .C'� T � W N � Q +-' N 'J x � o >.�•.: F F >�q `'" a,' ,� � o c� °,.' � o � � O� � � � N � �W u� C U � y o � o M a F" o F. y eu� � _ � :° i•��a� •� z `�' v`�, g a�i'� F� ¢ � PW.. [�-� � rn�J^. � .�7 h Kl VC.7 Y amu" TOWN OF YARMOUTH BOARD OF HEALTH. APPLICATION FOR LICENSE/PERMIT - 1999 �� 2 1��9 * Please complete form and attach all necessary documents by the return of your application packet. -----------------------------------------------------=----------------------------------------------------------------------------------- ! _jr-j _�l n OLA iu. , MANAGER'S NAME: 0,,e -!l dao ( d vi TEL # 3 6j 4 7dr9 O t� MAILING ADDRES S : C Ao ---------------------------------------- I 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 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. 1. 2 3, 4 HEIlVILICH 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 3 RESTAURANT SEATING: TOTAL A. LODGING: LICENSE REQUIRED B&B INN LODGE MOTEL FOOD SERVICE: LICENSE REQUIRED _1_0-100 SEATS >100 SEATS (_COMMON VICT. RETAIL SERVICE: LICENSE REQUIRED <50 sq.ft. <25,000 sq.ft. >25,000 sq.ft. 2 4 NON-SMOKING SEATS: TOTAL # 1 ------------- -- - - - OFFICE USE-ONTLY - NAME CHANGE: $10 FEE - -- PERMIT #_ _ LICENSE REQUIRED $50' IND ' V ? ;ABIN $50 - �ej m�✓ AMP $50 - e3b ,�al � l TRAILER PARK $50 not �s5uc C SWIMMING POOL FEE PERMIT # $75 $150 $50 -lO WHIRLPOOL LICENSE REQUIRED CONTINENTAL NON-PROFIT WHOLESALE F FEE PERMIT # $50 $50 $50 $50ea. $25ea. FEE PERMIT # $30 $25 $75 FEE PERMIT # LICENSE REQUIRED FEE PERMIT # $45 TOBACCO $20 $75 FROZEN DESSERT $25 $200 AMOUNT DUE = $ 1 ZS * * * * *PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM* * * * * Y v 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 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 It 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, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL 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 PSEUDOMONUS, 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 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 _REVOCATIOIV OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e., OUTDOOR SEATING WITH WAITERIWAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: /P0 4vSIGNATURE: G� PRINT NAME & TITLE: r � � The Commonweo/th ojMassachusetts : Depar�men!ojlndustrial,-1 ccidents s - 0/1/CO0//OYaSI/y�UI/f 600 Washington Street Boston, Mass. 01111 �� 'y W'orkers' Compensation Insurance A�davit ARplicant information: P► 9erpRilPPw.'hTa namc: � F1 R�_�i/ �nr � 1 22 Jj -_ � IitiC� . � lucation � �i � �_B I rL.� ci[� �P� 1 r� 1N� l�l..t..'�l� '• I '! d��y Chone k � ��'f 7 �.C7CJ � 1 am a homeowner pzrtorming all work myselE � I am a solz propriemr,-d ha�z no one «orkine in am capacih� � I am an employer pro�iding workers' compensation for my employees workine on this job. comnanv name: �Q S �q Y PA/' P i^2Z2 � I 'Lt�. address: � �i I I �1 � � :. titv J�_�U(/v` �A .l7C.t71 I/L '•I � ��eN nhenep• '�'�1"�'""�'� ��"f 7 �LbO ssur�nceco �O1�I� � P,V^CaI�� (� � �(� yolicyp FgL.CJ 31O g�0 � I am a sole proprietor. _eneral contraetor. or homeowner(cirde onel and hace hired the contractors lisred beloµ «ho ha�e thz follu��in= �corker> ,ompensation polices: �p �p;� 3�lS�SS Ta 3�S/o0 companv name: addresr. � � � � � cisy: ohone p• insurance co. po�i��•p eompgg,y name: � � . . . ---- - -- ---_- -------_._ _ . .._.____. _. address• c�y: phoee N• insunnee eo. eoikv N F�ilure to seture covenQe as�equired uoder Secnoo 25A of MGL 152 ns Idd to IYe i�paidoa of erisi�l pedtln of�O�e�p ro SI,500.00��d/or ooe ye�n'imprisonment a�w�ell aa eivil pendtla io the form of�STOP WORK ORDER�od�6oe of SI00.00�day qde�t�a I a�denn�d Hat a eopy of thie statemeo�may be for.r�rded to the 011fee of Inveuig�tiam ott6e DU for emerqe veriOutlw. /do-Arreby cenij}•und/er/the pains and penallies ojpery'ury�hat lhe injonnalion providtd above is nre and rnr►at Signaturc �g,�G�- Yd•�!'� � Due ��, . /�, 9 9 Print name e I /� phpMX �94 � `Z t9CJ .. oRcial use onh do nat wri�e in�his�re�ro be tompleted by tity or lown oifleid tity or rown: Y��DTQ _ permiNiccex N nBuildioe Depirtmm� pLiceesios Bo�rd p eheck ilimmediate response i�required 261 OSelectmen'�ORiee pHealeh Dep�rtmant con�act person: pAont p;_ CSOH� 398-2231 eat. nO�her tr�,.�a;,vs vu i � o o ,a � v� � � �� x z w ° � o a W � �� o �� ao �tlj� ,�� p �� s w � � � � � � H w� H �a � ° � 0aw c� .� �¢ � � WO �, � N � kq rp N� � O o WW �� N � � � � A � `�-� � v 0 �, F a'`33 a' � c � '� �a; O 30 � '3� � E-� � � � O W p, � „ o. g N O a� at � � 0 2 c � m w •� �' E o 0 E" °° "o � ri 2 � � � o a �' ._ .� ~ Q rn � c � a` .c ° m � � .S a p; ��n � N � � °� W Y3.: �'3 .ts �1 �'i'� al � �.. o d w y °�' � a' �a � •y �a � y � � �s � � ;; 'a.�, z � F .�.U G. � � 'k' c�' � " N � � O � Y � U � E a � F PWi � E+ F� p. �rwi �a � . b � � x � �� V � �I �� 0�.��-,•o � , R'i .+ N�L' � � i� � `�". . W �P-�. � � y C � � � `� �" � T y [� w X.''� +'G.+ .� � � � ,�p,,� • �~ +�.+N y y •U \ �xr 1.'l. V1 � 03 � O � � � � � �� j.,'`Q � � � �. � � � A � � � .� � �� A . � � g Q � ��o� k � 'o.w..a do." x G�, O G �. W aki �� F" O � ~ '� � ^ Ci � V�J Y ^��f �rq=' • m � � � C7 � iO^. ^ R� N W a w a v°z � F �y•�v � w . o c„ d 0 N � U � o G �; � � � z � � � � � � ^ 3 � , 3 � � z �.°�a � o � � ��•N � o � H � � � ��H� .� � r. ., a N �" �" � a �; i O '" a`" �i� c U � O id��p � R7 � y � �'�' � E" � ., � �'>� a I.n � W .� � O O Y � �I , � � �� y O N J.� >, c� � o,o, � ❑ � . D � py O�+ fn r F � H y �Q,ti ^ N � y .a 4,.��".-� �N �U'/'j�. LN. y � d y F Q /-+ . -�1 L� F�-I �OA'.� O F��V VU] : „ 4?5-C�I�I�t 4Ckip�,�_ $5G . , p � � �� `v7 ,= � TOWN OF YARMO B ALT MAY 1 8 1998 APPLICATION FOR LICENSE /PERMIT - 19 8 _ . HEAL.' �_ i1't�T. # Please Complete form and attach all necessary documents by December 31, 1997. Failure to do so will result in the return of your application packet. ----------------------------------------------------------------------------------------------------------------- ��,rnn� cc�renTrec.t�.rcl.rr• f3gSS 921I�E�R �122/i TEL # 3947200 ADDRF��• 431 � FlT 28 So- Y�:tr winta ^f-1� V� a �2 � r g s s Y/�` �vz—�- p 7�.fAA�A!!�D�CA]AI�.iR'_ _ �� L/ D� TEL.�37�7Z6-v ��en r?5Tr�^,.^„�.`eg• �,'3!� ��-L� S� Y,42112o-Gu1-69— 02 661i/ -------------------^-----------------.__•.__.__---'-_. POOL CERTLFICATIONS• ` ' ` ' Pool Operators must list a minunum of two employees currently certified in basic water safety, standard first sid and Community Cardiopulmonary Resuscitation(CPR).Please list these empioyees below and attach copies of employee certiScations to this form. The Healt6 Department will not use past years records. You muat provide new copies and m$intain a file at your place of business. L 2. 3. 4. HE lvn I H RTIFI ATIONS• 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 tLnes. Please list your employees trained in anti- choking procedutes below and attach copies of employee certiScations to this fornl. T6e Health Department wili not use past years recorda You must provide new copies and maintaiu a file at your place of business. 1. 2. 3. 4• RESAURANT SEATING: TOTAL# 3 G NON SMOKING SEATS: TOTAL#� -------------------------------------------------------------------•--------------------------------------�---- OFFIGE USE ONLY ` LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# B&B $50 _CABIN $50 _nviv aso �ca� sso _LODGE $SO _TRAILER PARK $50 _MOTEL $50 _SWIM POOL $SOea. _WHIRLPOOL $25ea. �10D SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQLIIRED FEE PERNIIT# �100 SEATS $75 .�� _CONTINENTAL $30 _>100 SEATS $150 _NON-PROFIT $25 �COM. YICT. $50 � _WHOLESALE $75 BF�TAIIa �EBYi�E: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq. ft. $75 _FROZ. DESSERT $35 >25,000 sq. ft. $200 AMOUNT DIIE _ ADMINISTRATION � LINDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NQW REQUIRED TO HOLD I3SUANCE OR RENEWAL OF ANY LICENSE OR PERMIT --�'O OPERATE A BUSINESS IF A PERSON OR COMf'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. 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 RLTN ANNZJALLY FR�M JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DBCEMBER 31, 1997 SEASONAL ESTABLISHMENTS ARE TO CONTACT'�HE HEALTH DEPARTIvfEN'I'FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD E3TABLISHMENT, MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMlv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. AnDITIONAL REGULATIONS POOLS POOL OPEI�IING: ALL SWIMMING, WADING AND WHIRLPOOLS WHICH HAVE BEEN CLOSED FOR 1'HE SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAY5 OF CLDSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FILING "tHE REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPAR.TMENT. FItOZEN 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 REVOCA'I`ION OF YOUR FROZEN DESSERT PERMIT UNTIL THE ABOVE TERMS HAVE BEEN MET. OUTSIDE CAFES: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WA[TRESS SERVICE), M�T HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�IENT IS PROHIBITED. �— � �� DATE: S � F� `�� SIGNATURE: �Jo��-�-u�"``7 PRINT NAME 8c TITLE:��e 11 �d/»f>S DLt?��' 10/97 page 2 of 2 — _ _ -�.- _ � ` � The Commonwea/!h ojMassachasehs : Deparlment ojlndustria/.-lccidents ; O/1/CeOI/IYCStlOflll/f 600 Washington Sbeer Boston, Mass. 01111 " �� 'y W'orkers' Compensation Insurance Affidavit Aoolicant intormation: Pfeas�PR[NT'ied�dt nam�: /7�A-S C �� f Y�IZ� '�l Z 7�-� � �-� � location: 13 [( (Z�'—L��y/Y/L 'vvLc� r1�J- '�1/� eC O L C 6 y cih- � phone N � I am a homeowner pzrt�rmin�all work myself. � I am a solz proprietor�cd have no one��orkine in am capacih� j'y(I am an employer pro�idine µorkers' compensation for my employees aorkine on this job. �� comnan�� name: nddress: � � tity: yhone p: � insurance co policy# � 1 am a sole proprieror. general contractor. or homeowner(circ(e onel and have hired the contractors lisred below ��ho ha�e the follo�vin� «orkzr, ,ompensation polices: m n n address• c'Si y: yhone N: insurance co policr# . comoany name: addrcss: [1y: Q6oee 8• insurance co.� � ooliey N � F�ilure to sccurc covenee�s required under Seceoo SSA of MGL 152 u�lad to tYe i�pwidoe of erisiul peultln of�B�e ap a f1�00.00��d/or ooe yean'imprisonment�a w�ell af civil penalNa io tht torm of�STOP WORK ORDER�ed�6x of f100.00 a dry tpimt me 1��dentaW th�t a � eopy ot�hif statemmt moy De for.wrded to the 011ite of InveeNgadom of Me DIA for eoveragt verifteatlw. � � 1 do hrreby certij}•under the pains and penaf�itt ojperjury�hat�he injormation providtd abovt is dut and co�d /� Signamrc ��[-O^2—� Dsre �/�'�/ � Printname 7`�` ��eh � '��/C1 /� PhoneN -�7� 720� , , oRcial use onh do not�rite in this area to be tompleted by eiry or tow�n ollleial eiry or town: Y�DTQ _ permiNiteme N nBuilding Depirtmeol ❑Lieensiog Bo�rd p eheek it immediate response i�required 261 pSeleetmen'�011iee pHea11A Department con�act person: pAont M:_ �SO8} 398-2231 eat. nOther Ue.ueE i,o5 Plnl ��; . � $b . ' 7S5[ifi DAT6 pflUDD/YY) �� ' �v`.. � � �Y � �:.s:sx� t . �' � °�.:� a z 5/76/88 �� ...: . ..::. . � ...... . �,. . � �� .:�, �OM� '1'HIS�iT3FICAT6151StiTJID AS A M.fATF.R OF➢VFCIRMATION ONLY AI'ID Brewer& Lord L�P COYFENSNORI40TSUPONT9ECf:RTIf7CATHBOLD6R.]ffiSCSBTTFICAT6 � 1>OPS NOT AMEND.E%TElID OR AL'IER T9fi COVERAG6 AFFORDTilI BY T86 PKILICIES H6LOW 777 Main Street COMPANIElS AFFORDING C � � GE Falmouth, MA 02540 .-. CJNPANY � 508-546-1130 �'rrEx � Traveler's Ins. Company . 1 !CO^ COMPAM' INSURID � cerrex B Commarcial Union Ins. Compeny COMPANY �_ (L:, �,� Bass River Pizza, Ina �� C � � 1311 P,oute 28 COMPANY � S. Yarmouth, MA 02664 �� D Traveler's Ins. Company COMPANY n . � . ., t LE'ITER L '� '�� \v�\�\\��::5\�. � S ':i ��.?SK:.. .. . . . . ..... . ..:. ... ..:::....:........<...... ... . . 1'�S IS TO CIDtTIFY THAT 1ffi POLICIliS OF QiSUMNCE LIST&D BS1AW BAVE BEEN ISS[IGD TO THB Qi50R�NAM6D ABOV6 FOR TH6 POLiCY P&RIOD N'DICAYED.NOTWITHSTAHDINC ANY R6QUIXfiM1�NT,'1TspM OR COHINTTOM OF ANY CONIRACT Wt 07HEit p(KU;1ffiNY'Wfl�p RHCpgC[Tp W�pCg 7�S CER77FICATH MAY BE ISSUED OR MAY P6RTAIIY.'I't7E 7NSUAANCE ANb'OBUBp BY THG F'OLIC�S D&SCRDED i�RER715 SOBJECT TO ALL T9B T6BM5. '�fiXCLU90NS AMl CW�IDITSONS OF SUCH POLICIGS.LIMI'CS ffiOWN MAY BAV6 BEfiN R6DU(:m BY PAm CI.AIMS. CO TYPBOFINSUAAIYC6 YOLICYN1P.41HER POLTCYEFF. POLICYS%P. I.QA7,5 TR M]E 41Qd/DU/YY) DATE Q�U�1/pD/Y1') q cs�x.�Li'u°u,��rx TBD 04/21/98 04121/99 GSI�tALAGGREGAIB 1000000 X COlAt.GEI�RALLIABILt7'Y PRODC�IP/OPAGG. If1CI CLANIS MADB �O(:C. . PERS d ADV.PDURY incl ._.... ownsa•s e ca:rrxncr•s mm ence occ[mx�cc � 50000 flRH DAMAGE(Ooe Flre) M1�.HRP.(Ooe g evraaoeae[ansam� TBD 05/21/98 05/21/99 ��sc+sia 1000000 ANY AUTO L�11�T ALL 0�5'Nm AUTOS . eODQ,V LY]URY �DUf.ED AUTOS IPer Pasm) . x RAtED AI11'QS UOD�.Y INJURY NONOWN6U AU'COS (W acddmll GARAG6 LGBO.ITY YItOPERTY D.NfAG& .C EX(�S5 LLIB�LTTY EACfl OCCURRENC6 UA�B6IJ.A F'ONM � AGGREGATE OI'!�t'1'HANUMBRF'.LLANVRM .::d'H, ,P�''.r:�" � D TBD 05/21/98 05/21/99 �'�'NT�vt.ma�rs ' '�•;,� ��,. z.;4 WORHERS'COMPEN&�TiON � encxeccmerrr 600000':.. kMC1AY6A5�1A61LITY DI66A56-POI.ICYLNUT 6�00 D�"'"`"�'''��• 500000 E or�¢ DESCRID'f[ON OF OPEBATIONS/IACA730N5/VffiCLESISpECtAL ITEMS Pizzeria ��'��:��, �;} :.,: ... ... .��. ��p� . �.< o .. . �z . � . ° �.i. :JKw� �� `..H�9.%.{ :: SHOUID.ViY OF l'�ABO�'G DBSCRIBSD tp,ICPfS B6 C�FI�.IBD 9EFORH 7HB .Q £: 6XP�tAT10[i 6ATE T�.+R60F.T96 LSSUQ7G COMPAM'W�.L&�IDHAVOB TO � '�': MAIL 1� DAYS WRITIisN NOTICB 707'�('&RY'/p�CA1'g HOID�t NM�TO'1'9P, � Town of Yermouth � LEFf,BUS FAQAAB TO MAD.NCH NOT[CE 91ALL U80S8 NO OHLiGATION OB YafTDULh� MA 02664 � LIABR,1'IY OF ARY�.`D UPON 7HE COMPANY,115 ACEM'S OA RHPAE6�lfA77V&S. .... �..�.�� AIffHORPIDRfiPRHSENTA7'IYE , � �cu�nzs�s z�rs�y B � �U�a,�,C�� , : < ;;„ ,.< � � ,.. . .:. .. .:. ie.A. .e. ':.. y� '..v THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-109 FEE: $50.00 This is to Certify that Bass River Pizza Inc 1311 RontP 28 Cnuth Yarmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 1998 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 affixed their official signatures. $�E�D �F' �Eu.�: �d //P/. Ja�pe�d� l.ha(�irm/�nan1/ SEATAIG: 3() �oan G. �u[livan� K.'/•� Vu'e ��H'�n ,�o6a.t � r�ro,.,R� ��.� a6.;�P�g sa�/o1��/� l�Pe� it�eL oCoughlin Mav 27 , 19 98 %1{ ruce G. Mwphy,MPH .S., HO Director of Health � TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 98-185 FEE: $75.00 In accordance with re ations promulgated under authority of Chapter 94,Section 395A and Chapter 111,Section�f the General Laws,a permit is hereby granted to: Bacc River Pi��a inc 1 11 Ro�te Z,�„ 4o rth_ Y�, armout_h MA Whose place of business is: Bass River PiLa Inc Type of business: Food Service To operate a food establishment in: Town of Y outh Permit expires: December 31 1998 BOARD OF HEALTH:�� a�ae�, C�(��q//nn / /� SEATING:36 �noan �c�7nuLlivan�nK.1/.� Vice C.�ir'rru+n xEsriuc'rtorts: Paper service only,in compliance with Ko6ert J. /,rown, 1.�.� agreement letter with Health Director Bruce Murphy,dated OS/28/98. Cy(�a/�6ra��e�a�o��y-.�oopee � /I/{C� OU(�� June 2 , 19 98 Bruce G. Murphy,MPH,RS., HO Director of Health