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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 3' � � Q. IZOOtCs71/�1 � � TOWN OF YARMOUTH BOARD OF H�ALTH ' `�j ( � APPLICATION FOR LICENSE/�R1� T-'200��,�� R' `'A� R * Please complete form and attach all necessatyt�ncu$r�nts"by Decemb 1 S ZU08. � � � Failure to do so will result in the retum of your applicahon pack ' - _.,� _, � �',:" _--- L1 NAME OF ESTABLISHMENT: � � ' �. TEL. #��,a LOCATION ADDRESS� :_-,_—��`a5� Q� lr, E�- ' MAILING ADDRESS: c4\I C! w.�,�c--��.c,o� � '(Yv'� . �ea:1n'7�' OWNER NAME: � TAX ID (FEIN or SSNI: CORFORATION NAME APPLICAB E): MANAGER'S NAME: TEL. # �043 36"7—aQg� MAILING ADDRESS�p. (�jjc �9 ��rnc�r-45�.n-;- rn�.. qa�-,-�a POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by Styte law. Please list the designated � Pool Operator(s) and atta a copy of the certification to this form. � 1. 2. �'f � Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cazdiopulmonazy 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 i copies and maintaiu a file at your place of business. l. 2. I� 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requn•ed 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. 1. �� Q��Q. �� 2. I PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. i. ��n r� .�4�e Q.�S z. HEIMLICH CERTIFICATIONS: All food service establislunents 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMTI# LICENSE REQTJIItED fEE PERNIIT# _B&B S55 CABIN $55 MOT'EL S55 _INN SS> CAMP 555 SWIMMINGPOOL SSOea. _LODGE S55 _TRAII,ERPARK �105 WFIIRLPOOL $80ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# � _0-100 SEA7S S85 _CONI'INEIVI'AL S35 I NON-PROFIT S30 �/ _>100SEATS 5160 _COMMONVIC. $60 WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 � LICENS£REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<jOsq.B. S50 _>25,OOOsq.ft. S225 VENDING-FOOD $25 _QS,OOOsq.ft. 580 _FROZENDESSERT S40 TOBACCO S55 � �n:ti7E c�n�rcE: sio AMOUNT DUE _ $ 30,o� ""**•PLEASE TUR\'OVER AND COMPLEI'E OTHER SIDE OF FORM*""'• ADNIINISTRA'I'ION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �1� OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED � � Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �� NO MOTELS AND OTHER LODGING ESTABLISHIVVI�NTS TRAN5IENT OCCUPANCI': For purposes of the limita6ons ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transiem occupants must haue and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vc(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transiern. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whiripools which have been closed for the season must be ins ected by the Health Department prior to opening. Comact the Health De�artment to schedule the inspection five(�days pnor to opening. PLEASE NOTE:People are NOT allowed to sit m the pool azea urnil the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total wliform 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 dosing. ' FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme�by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHeahh. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RETURN THE COMI'LETED RENEWAL APPLICATION(S) AND REQLJIItED FEE(S)BY DECEMBER 15, 2008. , ALL RENOVAITONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � �1 �� SIGNA 1 PRINT NAME&TITL :�-��Q� o �' • 10?21/08 . �\ The Commonwea[th ofMassachusetts Deparhneet of Industrial Accidents NiieiN� 600 Washington Streey 7`h F[oor I Boston,Maa�c. 02111 ' Work�s'Compe�sation I�saranee Aftidavh:Buildiog(Plombieg/Ekctrical Cootractors � °a�� ` �l.Q � T '� �A �.l ��l\\� ��I � iamcess � \o� ' . �`^-� I siN vr ,L��V"�Yll`l+n¢�""s�te� � � zio'�O/J ohoce# �0��e.� "d��a I � vrork �..-e locati� full addass. .. � . am a hom�wn�performing all woitc myse(f. Project Type: ❑New Constcuction�Remodel j ❑ I am a sole�propri�or and have no one woilcing in any capacity. ❑Birilding Addition . . i ❑ I am an employer�oviding wodce�s'compensation for my employees woiking�iLis job.. . � . � rn� � me: - � . ._ - . .__ . . . _ ... . . ..... . _._ . . _ . � adm'ess• � . . . � . � .. I �'' �eM• � � . las�avu ea. ,palkyM u � . .. . ... a , . _. � . ., . ,�,. . r�.: . .,, ze-„ ,e-. ,r...4 ,�n.us.,a:�va�n4�.4.ns��.x; ❑ I am a eole proprietor,ge�eral coetracMr,or Mmeow�a(cirde one)md Lave ltiied the contrxtas�lis[ed below wlp have tLe following workers compeagation polices: � d � . _ . �. . .. . . . � . . � co. � . . .. . .� . � . � - . . i�ea�axe �.k7 , . ., . ... ... . . _ , . ... . .. x:� s;�,_ . aaoouvune- �: �'. �, . . � . . � . o�l�- - . � � � . _..__ .. �� ., :.: . ., _, .��.� - ,,:q:xr�vs ,..;; ,� ;>f,:z,�°:..�;.a�F..�. . . FaYne Y xeve w�na�e n roqefaN odv SatlH iSA dMGL 152 m lead b tYe A�wMr Ke�L�WI pe�Nin d�4e�b S1,3M,M uN�r e�c ynn'Isptleswt a we9 a dd peeaMin 6 tYe 6�a Ka 31+Or WORK ORDEH�wd��5108.N a dty aph#ve. 1 ohnhaA 1rN a nppolh6�he�e�tdy6eterwardedblheOmeedlm�oflheDlAtarprenges�rl�ntlea � � � �� ea ewd penehlea oIPn7+�3'Aiet tGe informallon provldel abore B dv a'd . . . ad �� t�� PriM name��Q 1 � , � Plwne#S'C��^7�y� ^�a o�Yl ase aely de aM wrke i tOds�m b 6e co�Rktsd 69.d1Y ar Ywn e�Li . � . dly or tewa: � .��_ ��y��m t ❑ehedc��sNhie mpme b rtqmrM � . ❑Sdecde�'s O�te . uNactpeiaae: ��. . ��«�� l�s�mw� TOWN OF YARMOUTH BOARD OF HEALTII PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-141 FEE: S30.00 In accordance with regulations promulgated under authoriTy'of Chap[er 94, Section 305A and Chapter I 1 I, Section 5 of the Grneral Laws,a pevnit is hereby eranted to: Bass River Rod & Gun Club, Inc., 620 Route 6A, Yarmouthport, MA Whose place of business is: Bass River Rod & Gun Club, Inc. Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expues: December 31. 2009 BOARD OF HEALTH: 3Eefert SRalf, f/2..iV., ClfaNuttart CR�anc�eo 3E. 9CelfiRexe��ce �'Fiain�ncrn. 2Fsr2�crroNs: Wzll tested annuall}'prior to issuance of �p�e!!� `,;. ��dCR[elt� license. Outpost to hace limited cooking use of si�c tunes per year. QttfL CdXPRItBr�Q,U,�f�t�t��.✓v. F.(lCG�fL�• ""'"J'�"' Ja�man 12.2009 Bmce G.Mucp y,M .5.,CHO Director of Health � � _ .. • b.2 . 120� � 6unl °` r""� TOWN OF YARMOUTH BOARD OF HEALTH ��3 s�i � ' APPLICATION FOR LICENSE/PERMTl'-2008 '�`� �� ' � —T :r �i'y: �`."••� * Please co lete form and attach all nec ' mp essary documents by December 1, 2007. Failure to do so will result in the retum of your application packet � HEALI H ucr f. I NAME OF ESTABLISHMENT: \'��,� �� 7 = L,�C,�,I.jTEL. #�'�-�•1-o�lp°�a LOCATION ADDRESS: A MAILING ADDRESS.��. O . �y. a� OWNER NAME: _ TAX ID (FEIN or Nl� CORPORATION NAME (IF APPLICABLE)� MANAGER'S NAME:,�.�� \1+71n . TEL. #Sc�-31o'l-a b�ta MAILING ADDRESS:�'l�P�.�n�I'.��..� A. �C M�'r�4M�Mp�•va��"? POOL CERTIFICATIONS: The pool supervisor must be certiTied as a Pool Operator, as required by State law. Please list the desi¢nated Pool Operator(s) d attach a copy of the certiScation to tlus form. 1. �� 2. Pool operators must list a minimum of two employees currentiy certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee eertifications to this form. The Health Depert�aeat 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 - CERTffICATIONS: All food service establishments are required to have at least one fixll-time employee who is cenified as a Food Protection Manager, as deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wiH not nse past years'records. You must provide new copies and maintaia a file at your estabtishment. I.�� A�� {L�q 5 2. PER�9N IN��IAAGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1.�1n R,^L��'C�Q.� 2. HEIlvILICH CERTIFICATIONS: All food service establislunents 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 tlris form. The Health Department wiR uoY use past years' records. You must rovide new co ies and maintain a file at our lace of business. P P Y P 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQiJIltED FEE PER:19T� LICENSE REQUIltED FEE PER�97T 4 LICENSE REQL'IItED FEE PER�fIl = � _BBcB S50 _CABIN S50 _MOTEL S50 . _INN S50 � _CA1�IP Si0 _SWI�L4IINGPOOLS7iea. � _LODGE S50 _TRAILERPARK 5100 _R7-IIRLPOOL S75ea. FOOD SERVICE: UCENS£REQIlIRED FEE PF,RMIT� LICENSE REQUIKED FEE PER'4It7= LICENSE REQtiIRED FEE PER�iIi= _0.100 SEAI'S S75 _CON'IINENTAL �530 LNON-PROFIT . S25 ��.Q�a _>100SEAT5 5150 _CO:bL'�IONVIC. S50 _R'HOLESALE 575 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUQtED FEE PERMI'I a LICENSE REQL7RED FEE PER�tIT= LICENSE REQtiIRED FEE PERbIIT= _<50 sq.tt. S45 >35.000 sq.8. 5?00 �'ENDING-FOOD S_'0 _<25,OOOsq.ft. 575 _FROZENDESSERT 53> TOBACCO S50 vn.�cx,��vcE: sio AMOUNT DDE _ $ 25-o0 *"+«*pLEASE TL'R.�O�"ER��"D COJiPLE'IE OTHER SIDE OF FOR�t"`""* 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 Compensarion 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 Yazmouth tazces and liens must be paid prior to renewal or issuance of your pennits. PI,EASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiJPANCY: For purposes of the limitations of Motel or Hotel use,Transiet►t accupancy 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 ofre�dence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirly (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transiem. * NOTE: En�losea Motel Census must be completed and returned w;t�,tn�s app>>cahon. rooLs POOL OPENING: All swimming,wading and whirlpoois which have been closed for the season must be' ed by the Health Department prior to opening. Contact the Health Department to schedule the inspection five�ys pnor to opening. POOL WATER 1'ESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterty thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE I CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by fiting 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 suspens�on or revocation of your Frozen Dessert PeRnit uatil 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 ofHeatth. OUTDOOR COOKING: flatdoor cooking;PreParatio�or�isp}aq of any feod prc�uef�ya retail oFfeod serviee establishrt�nt-igpre�i�ited. N01TCE:Pemtits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2007. AL,L RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW ', EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI3E BOARD OF HEALTH PRIOR ' TO COMME?10EMEVT. RE�iOVATIONS MAY REQUIRE A SITE PLAN. DATE: 1 O� t ��"C �� SIG�IATURE: � PRINT:VAhiE&TITLE: `�C�L 2 � S �J V+^� ��1� . ia so o� ' ' . � The Comnronwealtk of Massachusetts Departniertt of lednstrial Accidcnts N�C'�Niw� 600 Waskiegton Street, 7'�'F[oor Boston,Masx 02I11 Workera'Compe�satioe lasva.ce A�dsvH:Baildi�g/Plambiag/ElMrical Co■traetors �� (a-5S Q'.�.(l �' C'��n.-, L- �1.�c_ 8�I65: � ,— '�R �� C(i v�t;�� a- vV� 1� , �o�'�I°'7-S�'��a ��`'�i��.�? -ab�a � �«�;� r�u�: I�a homoowner petforming all woik myseif. Project Type: ❑New Camstrucxion❑R�odet ❑ I am a sole pmprietor and have no oce wo�cing in auy capecity. ❑Bwldiog Addition ❑ I am an employer providing wa�kas'compensation f�my employees wodcing�tLis job. com._ . _ _ _. .. _ . __ . .. . _ _ ._ - . _ _.-� . _ _ _ _ d�as: ..,�T,l�, �- ��- �a. �� , . ...; .., ,e..._,�.�.�w. . ❑ I am a sole{eopnietor,geoeral eontraetor,or iomeewoer(cirde one)and Lave Lired the�[as lis[ed below who have tbe following worke�'compensatioo polices: sQnouv roe• . c(ty: � ohuek• i�ea�ee� �y# oa�v r�e• 9d�os• � oYse$� ...—_ _ - ....—_. _ - __— ___—_ _—__ -_. _...—___ _._ _ ._.___ . _. —i4�aee eo. - ooliev$ .��.' . . . .. . .. FaY�e Y+eeme cwenµe n�eq�N oAQ Seetlr iSA NMGL LS2 en kW q 1Yc�da Wul p�Mn da Le�M t1.3KM a�N�r��. a�e ywn'Isprbw�t n we8 n dN pmltln Is t�e txe eta STOT WORK ORDBA uA a B0e af 3300.N�dry apM x. 1 adnah�d tW a npy K1Yb Wieacrt my be t�nraMetl b Ne Omce e[l�wntlp�K IYe DIA hrenerqe ver�nW�. 1 do hereby c wnJer tAe ptns an1 P��oIP�H+�T di�the iwfaw'eNon provl/el obeas la tr+re �� a�a�� p��-T�b.��- w�, . � p�M� »��3�� -aoSa eeaew as o.ry au a«.Mfe 4 mb,rea m ee cemqeted Dr�*r.r w.n.�w eHy'or tewa: P��# — ' De�'�t ❑eYMc if imueWie reapeme 6�eq�M Q��E Bmrd �3 Omoe tM1._.�m� , p4ue#; � ��8aes1 . Y �� A�'�o TOWN OF YARMOUTH 0 '� 1146 ROUTE 28 SOUTH YARMOUTII MASSACHUSETTS 026644451 � MFiTACMCES � �+�,,,�„�„�,� Telephone (508) 398-2231, Ext 241 — Fax (508) 760.347`L B O A R D O F H E A L T H � � � � � m � � M AR 0 ^ Z008 ALTH DEPT. January 16, 2008 Bass River Rod& Gun Club Attn: Robert J. White, Treasurer P.O. Box 29 Yarmouthport, MA 02675 Dear Mr. White, Thank you for submitting your organization's 2008 application for a non-profit food service permit I issued through the Health Department. However,please be a t there was no check enclosed to cover the fee. The non-profit food service fee amount is 25.00.� �«�LQ _��t_}y�{�j Also please note that for all food service permits, a copy of the Food Protection Manager's certification is required to be submitted with the application. All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as deSned in the State Sanitary Code for Food Service establishments, 105 CMR 590.000. Finally,please be reminded that,as a condition for licensing,well water testing is required to be done prior to issuance of the license. As soon as our office receives your payment,the above noted food protection certification wpy,and well water test results we wili be able to issue the non-profit food service pernrit to you. If you have any questions on the above, please feel free to contact our office at (508)398-2231, e�ctension 241. Thank you for yow anticipated cooperation. Sincerely, �� Mary Alice Florio Principal Department Assistant /maf cc: file �� Rv,cea o� Recycled L Paper TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�IMENT PERMIT NUMBER: #08-092 FEE: $25.00 In acwrdance witL reeulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�ienetal Laws,a pemut is hereby�anted to: Bass River Rod& Gun Club, 620 Route 6A, Yarmouthport MA Whose place of business is: Bass River Rod& Gun Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2008 BOARD OF HEALTH: .�fefen S�, JZ..N., �a C�axP.ea �.9Cel�i/fe,u,,� 9J^ice(.Rawwna�c RESIIucnox5: Well tested annually prior to issuance of ��If� 3.�KOIl1R.� l.[�� license.Outpost to Leve limited cooldng use of six times per year. (fr,f.t�rt,,M �ry�,l,!'(`lly6� f�„/v. `^`�"� `V"'��' January 16.2008 Bmce G.Murphy,MPH,R.S.,CHO Director of Health _ ��}�033 O`YqQ � .L ,,. 2 e o TOWN OF YARMOUTH BOARD OF HEALTH�a L�� 2 0 2005 � �� APPLICATION FOR LICENSE/PE1�IVIIT�2(�q¢, * Please complete form and attach all necessary doc►� �by Dec�n� PT. Failure to do so will resuit in the return of yo�p icahon packet. NAME OF ESTABLISF�IENT�S� \`:�LQ I� �,fa t(,-�V n,( TEL. #��a LOCATION ADDRESS: MAILING ADDRESS: "�P. OWNER NAME: T ID E r S . - i CORPORATION NAME IF APPLICABLE): � PkS `� � L v„i �',� �' I MANAGER'S NAME:� \��:"� TEL. # ��a-4�1'�-�aoa ; MnII.,nvGAnnxEss:'3�'�.�n V` e� =� C a-s�.�, ��. �ate3� � I POOL CERTIFICATIONS: I 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. M�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 employce certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t'de at yoar place of business. 1. 2. i 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your estsb6shment. I 1. J`( \(� r.��'� � `�� 2. I` PERSON IN CHARGE: _ _ _ Each food establistunent must have at least one Person In Charge(PIC) on site during hours of operation. i, 1. 2. I �, HEIIt��CH 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 iattaeli copies of employee certifications to this form. The Health Department will not use past years' records. � You must provide new copies and maintaia a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiJIRED FEE PERMIT# LICENSE REQiJIItFD FEE PERMIT'# LICENSE REQUII2fiD FEE PF12MI1'# _B&B $50 _CABIN $50 MOTEL S50 _1NN� $50 _CAMP $50 _SWA4IviQdGPOOL$75ea. _LODGE $50 TRAII,ERPARK S50 WfIIRI.POOL S75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT N LICENSE REQiJII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0.100 SEATS $75 CONTINENI'AL $30 �NON-PROFIT $25 �6�� _>100 SEATS 5150 _COMMON VIC. �50 WI-IOLESALE �75 RETAII,SERVICE: LICENSE R6QUIItED FEE PERMIT# ISCENSE REQUII2ED FEE PF.RMI1'# LICENSE REQUII2ED FEE PERMIT t! _<SOsq.ft. S45 >25,WOsq.ft. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO a25 NAME CHANGE: $10 AMOUNT DUE _ $ 25. o0 '""•"PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM""'"" ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK APPROPRIATELY IF PAID: �` A NO YES NOTICE:Pernrits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN 'THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENII�TG FOR Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMl�IENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. � POOL WA'I'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. ' POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establistunent which serves or seils 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 Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: I Frt�z��-desserts must-be testgci e��monthly basisby a State certifie�laU, �'gst resuks must�sent to i�HealEh--- Department. Failure to do so will resuit in the suspension or revocation of your Frozen Dessert Pemtit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approva!from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. DATE: � � I � SIGNAT[� �- PRINT NAME&TITLE:1��!j e 2 T �S �� Y�� t�'./l� . 09/28/OS ----��-,---�----� T7�e CoMnronwcalth of MwssachusetGs _ - - _ Department oflndusdial Accidenic _ — �NIi� -_ 600 R'ashing�a Sfrcet, �'FJoor -�, Bostwt,Mass. 0211I � Worgas'Com�esatio�Lsea�oe A�v(� ' W�/Ekeldal Co�tracbrs �_.. �,.r_., > ,.�,�� « �� .�..... ,. , ._ . . � . "�S N-r- . e� �: 1 S5 ` � L� . � e�- b -- e �.�.Tqnhn�u�-�n�P�� amtr• 1 � �� ' zio�V��ihone S 3�n�"�1 aR �este locati�ffnll addresak ❑ a homwwna perfo�ing all work myaelf. Projed Type: ❑New Ca�nwKim�Remadel I�a sok and have m a�e in an B ' ' AddiRon . 0 I�an�loYer Ptm'idiog wo�ceas'compe�satim for my�ployees woticing oa this job. �• s14s: . aYsel: • ❑ I am a sole pcopridor,getaal eo�trxter,or homeow�er(�arde owe)�d Lave huad ihe cam4actas listed below who have the folbwing wakets'compeaeation polices: ��ae� �dd�d: dtv oire R: oatlev N �� +ea�• dh: a�re� F�s i�aecne evaade e�aqWd dv Sxtlr 2SA dMGL ISt eu kM b IYe i�prlir dvW W p�Wle�f a 1�e R b t1.1MM udhr �ae yeus'h�pMer�est n wd n eM pmMb 1�tYe[w�da S1'O�t WORK ORDBR atl a�e dSIM.M a dry a�t�e. 1�d tW a dpy�ttlh Maiesat my Ee fiewaMed b tYe Omee dLvntlpW�s KNe DIA hrewerage veApntln. �da Aeneey rnJe.the paf�a.ntv��alvaN�1'aYar dYe mfon.rins proaaet aae«e e av. s cnwe�ct S;goa�ure � \--- nate 1 \ 1"� I �� r.;��_1� �1rJe �� > �1 l P�# S�� -3�Z -a0ga •meld.sewy a...t.r.Yertw,re.Neees�WNMDrdls.ren.aa�tLl dlyortawv: �g ^— -- p�� ❑tYerk if f�!�me b re9�� SdecmL Omce 0�� cseM/Pense: P4�el; I� lM1.:�s�mm� TOWN OF YARMOUTH BOARD OF HEALTH I PERNIIT TO OPERATE A FOOD ESTABLISHII�NT PERMIT NUMBER: #06-124 FEE: $25.00 In accordance with regulations promulgated�mder authoriry of Chapter 94,Section 305A and Chapter 11],Section 5 of the General Laws,a pernut is hereby granted to: _ Bass River Rod& Gun Club, Inc. 620 Route 6A, Yazmouthport MA Whose place of business is: Bass River Rod& Gun Club. Inc. � Type of business: Non-Profit Food Service To operate a food establishmern in: Town of Yazmouth Permit expires: December 31_ 2006 BOARD OF HEALTH: B $. M�., ' I ��"f�"s`�„ rv., v�e� �sllucr[oxs: Well tested annually prior to issuance of /1o�r![t� B9payc, � licen.se. Outpost to have limited cooking use of six times per year. Q�/Np�� r�a„�y 3 i.zoo� ruce G. Mwphy, S.,CHO Director of Heakh � �- `� �3� 25 6d .RAD i GUN C,U� o�qa Gtf [n; f� a '? ,l ��^ �_ �, ! r �sa TOWN OF YARMOUTH BOARD OF 1'� °� ' APPLICATION FOR LIC�E/�ERAQTi'-2003 I e �x - 3 JAN 1 8 2005 I * Please complete form and attach all necess�ry:doc�Fnen`ts`Tiy Decemb 3-1 0�1ii pEPT. I Failure to do so will resuk in the retum of your application packet. � NAME OF ESTABLISHMENT� SS ` .�i� � -+�_,.,, C\.r� TEL # Sroc`�-3io'7 �i9 a. . LOCATION ADDRESS: lo .— A MAILINGADDRESS��.v �x �� cl2rno r�-.��e— rV�%k �a��) � OWNER/CORPORATION NAME: ' MANAGER'S NAME:� \ '��n`� � TEL #Sa�-`}�l'--�'lo� MAII.ING ADDRESS'3�l �cv.�O '�/ � r.� l�� C�n A"�rKw�c�. �YW�• aa b�� 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. �I,� 2. Y� I+�- Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation �CPR). Please list these empioyees 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 busiaess. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIF'ICATIONS: All food service establishments are required to have at (east one full-time empioyee 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 Healt6 Department will not use past years'records. You must provide new copies and maintain a t'ile at your establishment. ' 1. S�nl�.��c2v� 2. iPERSON IN CHARGE:- - - ! Each food estabGshment must have at least one Person In Charge(PIC) on site during hours of operation. � �.�4�a.1,��?�2aS 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 a11 times. Piease list your employees trained in anti-choking procedwes below and attach copies of employee certificauons to this form. The Health Department will not use past years' records. You must provide new copies and maintaiu a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQiJIl2ED FEE PERMIT# LICINSE REQLIIRED FEE PERM[T!k LICENSE REQi7IltED FEE PERMI'1'# _B&B $50 CABIlV $50 _MOTEL $50 - _INN $50 _CAMP S50 _SWIIvII��IINGPOOL$75ea _LODGE $50 TTtaTt.Fu p,�RI{ $50 WI-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE pERMiT# LICINSE REQiIIltF.D FEE PERMIT i� _0.100 SEATS S75 _CONI7NENTAL $30 � NON-PROFIT $25 �D,}'��{D _>100 SEATS $150 � _COMMON VICT. S50 WHOLESAi,E $75 RETAIL SERVICE: LICENSE REQUII2ID FEE PERMI'P# LICENSE REQUII2ED FEE PERMII'# LICENSE REQtIIRED FEE PF,RMIT# _<SOsq.R $45 >25,OOOsq.ft. E200 VENDIN(}-FOOD S20 _Q5,000 sq.R. S75 _FROZEN DESSERT S35 TOBACCO $25 xnM$c�xcE: a�o AMOUNT DUE _ $ 25.00 ••••"pLEASE TORN OVER AIYD COMPLETE OTHER SIDE OF FORM••"•` . �- ` M .�. � I ADMIlVISTRATION 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 haue 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 V,•• WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth tvices and liens must be paid prior to renewai or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES `/ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT TI�HEALTHDEPARTMIIVTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TAE BOARD OF HEALTH PRIOR TO CONIl�IENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTl'IONAL 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 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 arumal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Appfication form 72 hours pnor to the catered event. Thses forms can be obtained at the Health Department. FRAZE�T DESSERTS: _ _ , Frozen desserts must be tested on a mo�thly basis by a State certified lab. Test results must be sent to the Heaith Department. Failure to do so will result in the suspe�sion or revocaUon of your Frozen Dessert Peimit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service establistunent is pro6ibited. DATE: � ��I �1J SIGNA • � � _�--� PRINT NAME 8c TITL��c�Q" "S \t�11n �� *uA�'� 10/22/04 _ � The Co�neronw`alth ofMassachusdts -- -__� �{1 _ _— _ Depariment of Indusfrial Accidents 1� N�e/M� � - 6Bb Wos6ugton SYrce; 7'�F/oor —-, Boston,Mass. 02111 Worlcas'Com�nnsatb�Lsea�ce Affid�vk: ' bi�g/Elettrical Co�Uxtors _ �,. :.,� ,� �- �,.,��, .. .,_ n ; � � name J 7�� `�\ � Q � �D "' Ill�1r�A C.\y„� �•�lC .. eaa�8: (o '0 �CL .— c�, �,,, Q�n��r—�,�e; � rnf� a� oab7s��S��-3�o��ga .��«�r ❑ I am a homoowna perfo�ing all wadc myaelf. Projed Type: ❑New Caoatmc4on QR�odd I am a sole aod Lave no oce w in� B ' ' Addition p i mm an mw�r�o��s wodcas•�;on f«mr�v�r�w'�B an iltis jon. �• \ Ic'� e�r st�M: �s ❑ I am a sok propiietor,geaa�al co�traeror,�remeaw�er(cirde owe)�d Lave lrirod the conaactas listed below wla have tffi followiog waicas'compeosation polices: moa�..r�: tltr ahre i: �ea. M ad�aa: eilr: .ire�k Faive Oo xene a�mye n rtq�6N oiQ SMW 2SA�MGL 132 m Isd i�He�da�Y pm10n�fa Le�b S1.�MM udNr ..eye�.��n.w..a.r�..r�du.b...r,srorwonxoeoen..a,e�.rsieu�,a.y�.e. i�wuu, espy�IY6 Wie�a1 my 6e fiewudW b Me Omca d1�Wn dUe DIA/raven`e vxMnWa /lo Aarby csr6fy rn6er t6eYdw8 adl�n�hka ofDe�wr}'d1a Ms 7wfonuatow provldel ebore k px oud �;� \ �— �_ 1� �`-��4� p��—r-��: � ��;, p�� 5��-3�-� -a�� a .manme.wy a•�..�+rerw.a.ao.a�m.p�ausair�rw.amdd � atyaraw.: pc�tlicme= ��t ❑eYed if f�!�re 6 rcqa6M �'a O�ee OHnMh Dep� aafae[peses: pYwe g; ❑OUa lmird S¢IOR11 ( TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�IENT PERMIT NUMBER: #OS-140 F'EE: $25.00 1n accordance with reg�ations promulgated under authority of Chapter 94,Section 305A and Chapter I 1 I,Section 5 of the(ieneral Laws,a peimit is hereby granted to: _ Bass River Rod& Gun Club, 620 Route 6A, Yarmouthport MA Whose place of business is: Bass River Rod& Gun Club Type of business: Non-Profit Food Seivice To operate a food establishment in: Town of Yarmouth Permit e�cpires: December 31. 2005 BOARD OF HEALTH: Ba�wxi.s `11. �M.2. ' �� v�ef� xEs'nuc�r[oNs: Well tested annually prior to issuance of Qo��. 83�t�wc, � licen.se. Outpost to have limited cooking use of six times per year. e�e�e��rals„ /l./�! f4iut(�'3ee�d�wwi R./�. February3_2005 Bnuz G. M�uphy,MPH,RS.,CHO Director of Heakh �.-Pr� OF�Y`�k f� SJ� ' ; �� ,� TOWN OF YARMOUTH � "j 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 � MATTACHEES ,�'�o„�,,,�o,�*� Telephone (508) 398-2231, Ext. 241 — Fa�c (508) 760.3472 B OARD O F HEALTH � � �� i; ,' . i - � To: Yannouth Boazd of Heahh Permit Holders MAY 1 1 2005 From David D. Flaherty7r., RS. ;�D� HEALTH DEPT. Health Inspector � � Town of Yarmouth Re: Federal Taac ID Number Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we fiunish detailed information to them regarding all permits and licenses that we issue. One of the detaiLs that they require we send to them is every establishmern's Federal Employer ldentification Number(FEIIV)otberwise laiown as yow"1'a1c ID Number". This is purely for administrative purposes onty. Sorr� businesses use t}� ow�r's Social Security Number (SSl� 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 Yazmouth Health Depaztme�rt 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to call. The office hours are Monday to Friday, 830 a.m to 430 p.m The telephone rnimber is(508)398-2231,eact. 241. Establishmern� Q�.�ie �� vr ,.A��or SSN: CV..�� , .i�c� . Location Address:��."� Q-� ( �c3�Q iMp�nT�n�Q.�.,M la , �a b'� Signature��,_ Print . �a e� j �� Title.'^�S�(��. :� �� Printe Recy P �� - \ � ^ ! ` r�rr�WNOd d0 BUIS 113H10 3.L8'IdWOJ QNV N8A0 NNf1.L 3Stl31drrrt• oo� $ _ �na .i.unowv o�s ��s�we� . 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N2If1.L�2I O,L�I.LI'IIfiISAIOdS�2I iIIIOA SI.LI 'I£�aqwa�aQ o� i ,C�nua f mo�,Cilenuue ucu sjiuuad ��I.LOAi ON S3A �QIt�d 3I A'I�.LdI2IdO�Iddt� ' �I�3H� �Sd3'Id 'SiluLad mo,C3o a�uensse io �en�aua� ol loud p�ed aq �snm suai� pue saxe;y�nouue,i;o umoy ' Q3H�`d.LLd Qidd Q�NrJIS ,LIAd'Q13dd 'dY�IO� S�2I�I2IOM 8�5 a�x�v�.r.��K�xnsnu 30 �ixa� xo`a�H�is aHv a�i��a�o� �g .tsn�iinvar�v ��l�i�I(1S1�tI I�IOI.LVSrI�dLHO� S.2I�}R[OM �.LV.LS Q�H�d.L.Ld �H.L 'aauemsui aor��saaduzo� s�iaxaom 3o als�gty�a� a aneq 3ou saop �itaEdu�o� io uosiad e 3� ssaa[snq e a�e�ado 03 ;rwaad io asaaar� ,fue;o jemauai io aouenssT pioq ol pannba�n�ou si�nouuE�3o umoy aqa`q aoi�oasqnS `�SZ uoR�S `ZSI �aid�[��apufl AIOI.LV2I.LSIAIILIIQE� . . . , . . _ ; � The Commonweolth ojMassachusetts � Department ojlndustrial.-1 ccidents ; Ol//Ce01/OPCSUOfWIf 600 Washington Street ' Boston. Mass. 01111 " W'orkers' Compensation Insurance Atfidavit Aoolicant infarmallon: PleasePRiNTTerGide ��m �� ,� V Q Q K3�YJ ��lV� ��A`�^ �.Ne ��,�,�� t�a� tz: � .a. 4,r '*�a(L�cv�o� ,—�'�c,K ,— rv� !� - �1�� one��x 5��=�� –0�9 a � I am a homecwner pen�rtning all work mpself. �f am a sole proprie[or�r.,', ha�e no one ��orkin� in am capacin� � I am an employer pro.iding wrorkers' compensation for my employees working on this job. comnan�� name: adAresr titv: ehone M• . insur�nce co yolicv M _ - � I am a sole proprietor. _eneral con[ractor. or homeowner(circ(e onel and hace hired the contractors listed belou ��ho ha�e thz follu��ing ��arkrr>' ,ompensa[ion polices: tempanv nome• address• cin'• ehone N• insurancc co oeliev# tomnanv name• addrc�•• �}y• � ehoeeM• � Inet�renrwPn. � OQRry* . F�ilure to seeure corenqe�s reqwred under Seeaoe SSA of MGL I52 n�lead W the i�po�idw of tri�i�l pndtln of�O�e�p w 51300.00��d/or ooe yan'imprnonmmt u w�dl a�eiril pendtln ia the form ah STO�WORK ORDER asd�Ifet of f100.6!�dq qdo�t m� 1 ndmta�d that■ eopy of tAia entement m�y be for.v�rded lo�de Oltiee of lovestfatuom ottht DIA far eoven�e verillutla. � 1 dn hrreby certijp under the pains and prna((i�s o�perjary that the injorrnatlon provid[d above is we and rn Signaturc��—�. .�..9------+ 1 Date ��O I 1�f�0� Print namc��O�� \ �� . \ � P'hone R ��—3b�-- �� c�— ., oRcial use onl.� do no�,.ri�r in�his arca ro be eompleted by�ciry m Imva ollletal city or town: Y��DT$ _ permiMieeme M n8uildioe Dep�nm�ot . pLiceosiog Bovd �eAtek if immedi�tt respoase i�required 261 QSelee�men'e Olffee �HealtEDepanmeat ,. contact penon: phone M:_ �508} 398--2231 eat. nOther ' �. - , , , K i i � TOWN OF YARMOUTH � BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT I PERMIT NUMBER: #04-116 FEE: 25.00 I, In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter i 1 I 1,Section 5 of the Laws,a permit is hereby granted to: Bass River Rod& Gun Club, Inc., 620 Route 6A, Yazmouthport, MA Whose place ofbusiness is: Bass River Rod& Gun Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Pennit expires: December 31. 2004 BOARD OF HEALT'H: Beir�ri�c `.a. C'joado�c,�1.`�. ' ��a� v:a e�.� ttEs'rn�crlotvs: Well cested�nually prior to issuance of /lo6a+e�g. Bdoaws, �e3� license. Outpos[to have limited cooking use of siac times per year. d�e�t ��y R./V. � January 30.2004 ' ruce G. Murp ,MP ,R .,CHO Director of Health � . �ps�33s3�25'Y B.Q. 2oo+ ��N ��e R.y TOWN OF YARMOUTH BOARD OF HEALTH 3r � APPLICATION FOR LICENSE/PERl��=20Ui� ' '�{ rC�s �,_ _ I �+ � � L , * Please complete form and attach all necessary dacyhtents by I2eee'�ber�31,2002. ' Failure to do so will result in the retutn of yout ap�lica$on pa¢ket. !. ; � `w�i. ".• - - - NAME OF ESTABLISf�vvIENT: 1�':V ee 'S3oo < v,�..� C-�,.�b �L. # 3�a-s�a4 A I S • �a�o '"'�+ bA � � � iA i•iN[', ADDRESS:'P. O. � o'1g ' C � MANAGER'S NAME:T-?c�tQ.'s' \�h. c �L. # qy5-�a�a MAILING ADDRESS:31�fl�l'�cw A-1.� C�.a�nn .r, �MA.. �ab�'� � ' POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by Stete law. Please list the designated � Pool Opeiator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two empioyees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitadon (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 maintaiu a file at your place of business. 1. 2. 3. 4. i FOOD PROTECTION MANAGERS -CERTIFICATIONS: ! All food service establishments are required to have at least one fuil-time em�loyee who is certified as a Food ; Protection M811'dger, 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' recorda. You must provide new copies and maintain a file at your establishment. 1. Sh a� � '1��Qos 2. PERSON IN CH,4BG�: _ -- -- Each food establishment must have at least one Person In Charge(PIC)on site during hours of operaUon. � 1. ��A�_. '��e2oS 2. HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have aY least one employee trained in the Heimlich ' Maneuver on the premises at all times. Please list your employees trained in anri-chokuig pmcedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATIlVG: TOTAL# OFFICE USE ONLY Id��ING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H _B&B $50 _CABIN a50 _MOTEL � $50 _INN $50 _CAMP $50 _SWA�A�IING POOL$SOea _LODGE $SO _1RAILER PARK S50 _WHIRLPOOL S25ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTqL $30 I NON-PROFIT S25 .�o3�ll!? _>IO(1 SEATS $150 _COMMON VICT. S50 WHOLESALE $75 RETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.ft. S75 _TOBACCO $20 <50 sq.ft. S45 _>25,000 sq.ft. 5200 _FROZEN DESSERT E33 NAME CHANGE: $10 AMOUNT DUE _ $ ZS.00 **'**PLEASE TURN OVER AND COMPLETE OTI�R SIDE OF FORM*•••* ADMIPIISTRATION Under Chapter 152, Section 25C, Subsecrion 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 ATTACHEB OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: �- YES � e�� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISI-IMEN"I'S ARE TO CONTACT'TI�HEALTH DEPARTMEN'I'FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING: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. i 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 Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. _FRn7.FNIlFCCFRTR• _ .---- _ _ - - - -_. _ - --------- - --- '�. 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: i Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ' OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. � DATE: `� ' 0�3-�a- SIGNATURE�� PRINT NAME & TITLE��e2� 5 ��. � � iZ.�� _ 10/18/02 . , � The Commonwea[th ojMassachusetts s � Depar�men! of Industria/.accidenrs ; OlAcsol/orestlOsahis 600 Washington Stree1 Boston. Mass. 02111 ` '��,` Wbrkers' Compensation Insurance Affidavit Aoolicant information: PfessePR[IVTTed�7dt n�mi�. 1. J�-4�� 1 � \� C�4� '` �'"')V.c� � �l� � �r�C�. . ��,�� a� -� � �, cin Y�w�r�hE1\1 ` �1�e.� � �� a�o�� ehone k ��1-�Iv,—1 O��ot � I m a homecµner pznorming all work myself. �I am a solz proprietor _r.d ha�e no one ��orkin� in am capaein� � I am an employer pro�idine workers' compensation for my employees aorkin¢on this job. comnanv name: 1/�(�fC53' eit��: nhone p: insur�nce co ooliev lt � I am a sole proprietor. _eneral contractor. or homeowner(circ(e on�l and ha�e hired the contractors listed below «ho ha�e the follu��in; ��orker; ,ompensa[ion polices: vn addres�• �n.. phene N• . insurincc co oeliev# _ _ __ . _ __ .__----- -- - --. ___ __.__.. .. - - -. ._ _ _ addre•<- �• � _ nhoee X• � �.�...�......, oolier M t Failure to eeeure covenge as requfred under Secnoo SSA o(MGL IS2 ea�Ind to Ne iepailio�ot erisi�Y peultln of�O�e op to 51300.00 a�dlor oae ye�n'{mprisonmmt u w�ell u eivil pendHn io the form of a STOP WORK ORDER��d a R�e orS100.00�dar K�fut ma [��denu�d H�t• eopy of tAy sntemrn�may be fonv�rded ro the Oliiee of Invatipuom of IEe DIA tor eoven�t verilfatla�. � � !do hereby certijp undu rhe pains and pertaltieJ ojperjury�ha�!ht rnjannatlon provided obavt is trne and cor►ect Signaturc—��*�--,.�1.� � �a-a� -oa Print name��ee.� S W�``�C Phpne N S�� 4 y� —,a�a .. oRcial use onl� do no�write in�his arca to be tompleted by tity m Imre ollltial ciry or town: Y��DT$ _ permitAitenae N nBuildiog Dep�rtmeat � �Liteesiog Bo�rd �cheek if immedia�e response if required 261 ❑Seleetmen'�ORce OHedtA Depanmeet . contact penon: Ppo��p;_ �SOS) 398-2231 eat. nOthcr I TOWN OF YARMOUTH ; BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT i PERMIT NUMBER: #03-112 FEE: $25.00 � In accordence with regulations promulgated under authority ofChapter 94,Section 305A and Chapter � 111,Section 5 ofthe General Laws,a permit is hereby ganted to: i Bass River Rod& Gun Club, 620 Route 6A, Yarmouthport, MA Whose place of business is: Bass River Rod&Gun Club Type of business: Non-Profit Food Service � � To operate a food establishment in: Town of Yarmouth � ' Pernrit expires: December 31. 2003 BOARD OF HEALTH: (�a�rlea�. ZelPs�4ec. � ' $uc�a«a«D. �, ill.D.. 2/ice i rs�s'ra�c'r�oNs iF nxY: Well tested annually prior to issuance of �o�att�. �u�, eferk ilicense. Outpost to have litnited caoking use of six times per year. �aatiek�� i 'r�de�c$ksk. �'jP. I � � ! .r�„�y».2oos i ruce G.Murp ,MP HO � Director of Health �I r � -. � ��a B.R. �fl �-�N � „ TOWN OF YARMOUTA BOARD OF HEALTH '£�� ` PLICATION FOR LICENSE/PERMIT -2002 * Ple�co e e form and attach all necessary i�cuments by lecemtier 31, 2001. Failure to do,so�will result in the retum of your application packet. +-'`�l. � $ �sn�y� ��, NAME OF ESTABLI HI�tFNT•� �-�'.L�2 2 0o L��,^, e.wl� i.�� TEL # 3�a �ae�. • �a� �r ea � MAILING ADDRESS:�•o. �ox 'aq . aer.,o,�..-4,-P44..:.w.a. oa�-�S' E: 5"1�` 2 "� � L �,.-.r C\,..+� —�t c... 1�VANAGER'SNAME Zac �r: T # g`�5 �`23R$ ' MAILING ADDRF,SS: 3"l-Pv�a� �I:�..� AJ� .C�r.a .—hc�cv. ,�tv��a . =i a��-i POOL CERTLFICATIONS: j The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated i _ pyvftiiecertification to thts form.__ _ _.—_ ,. __ i l. 2, � Pool operators must list a minnnum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies aad maintain a fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS• All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishmen� 1. 2. PERSON IN C�IAR�iE: - _ _ . Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HFTMT ICH CERTIFICATIONS: All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the�remises at all times. Please list your employees irained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new� copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: 'FOTAL# OFFICE USE ONLY I ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _s�a aso _cnBna $so _Mo�L sso _INN $50 _CAMP S50 _SWIMMING POOL$SOea _LODGE $50 _TRAII,ER PARK $50 _WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0.100 SEATS $75 _CONTINENTAL $30 I NON-PROFIT $25 :�QOI� _>100 SEATS $I50 _COMMON VICT. S50 WHOLESALE $75 RFTAn SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACW S20 _<25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.R $200 _FROZEN DESSERT$35 NAME CHANGE: a10 AMOUNT DUE _ $ ZS,OO `**"*PLEASE T[JRN OVER AND COMPLETE OTHER SIDE OF FORM*•*•• . - ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a 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 Yazmouth ta�ces and liens must be paid prior 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 RESPONSIBILI'I'I'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MLJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION i REGULATIONS _ POOLS POOL OPENIIVG:All swimming,wading and whirlpools wtuch 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 swinuning pool must be drained or covered within seven(7) days of closing. FOOD SERVICE ['nNS 7MF.R 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 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 Depaztment. _ -- - - -_ _ - _ ._ _ FRn7F1V DFSSERTS• 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),�have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: ��o `�o� ( �o � SIGNATUR •��1.�`1C� PRINT NAME&TITL��oc2:�W�r.�.�-e �+..A�. 09/11/O1 �3 � ` �\ The Commonwealth of Massachusetts � Deparlmenr ojlnduslrial.-fccidents ; Omceo//aresU�sW�s 600 Washington S!►eet Boston. Mass. 01111 " "��'` �L'orkers' Compensation Insurance Affidavit Apolicant informaHon: PlesseYRdVTie�ia nim�� ' �J"*�S-T�� l L. Q ��aF7 'c L^1V� l.�V�h �--�'� �- 'on� � � �� 14 • �� CI `l�l"C��.l \ r \-��.�Q_.�� '��. '� �� ehonep �OV- c��o�-3o�a � I am a homeoµner pert�rming all µork myself. �1 am a solz proprieror �r.,'. ha�z no one �corkin_ in am capacin• _�art�_an EmpinteTnro�_idia�µockecs_c�tnpensa[ion fot my emplorees workiae-on this job. - an n tJdrear {jty• ohene p• -- insur�nce co poliey M � I am a solz proprietor. ;enera� con[ractar, or homeowner Icircle onel and hace hired the contractors listed below ��ho ha�e the follo«in; �corl:ar> ;ompensation polices: m vn ^adrcss• - -- �R�� ohone N• insur�ncc co ooliev H m e• addres • . _ . _ ._.__ .__ . ._ . _ . . . . . �,• yhoee M• insurance co ��M e F�ilure ro secure coverqe as reqwred uoder Seenoo 25A of MGL 152 w iad to tYe i�pri�w W eri�inl pndtln ota d�e ap eo 51�00.00 a�d/or one ye�n'imprisonment��w�ell u�civil pemlHa io tht[orm ot�S70P WORK ORDER aad�Il�t of SI00.0p t d�y qtlest m� [��denh�d tr�t a topy of thh sutement m�y br fonv�rded to the Ofite of InvaNg�tiom of Me DtA for eovera{e verillutfw. I do�hrreby cerrij}•under the pains end prnal(ies o/pery'ury that�ht injormarinn provrdtd above is ant d eo SignaturcT��?�� Nd�i— Date �o1�eZb�o 1 Primnam��i �- �l� r\.�e PhoneM Sb�-3�Oa —�a�`q � .. olTiaial use onh do not r rite in this�ro ro bt eompleled by tiN or fmvn oflleial �' city or town• Y�M�DTQ _ permiNfeeeu M nBuildiog Departmeu� ' �-- �Licemio6 Bo�rd �eheck if immedi�le respome i�r�quired 261 QSeleetmen'�011fee � �HnItE Dep�nmmt con�ac�person: pbone M:_ �508� 398�2231 eEt. nOtAer TOWN OF YARMOUTH � BOARD OF HEALTH i PERMIT TO OPERATE A FOOD ESTABLISHMENT '; PERMIT NUMBER: #02-005 FEE: $25.00 i ' In accordance with regilatioas promulgated under authoriry of Chapter 94,Section 305A and � Chapter l 11,Section 5 of the General Laws,a pennit is hereby granted to: Racc River Rnd& C;un C luh 620 Rnute 6A Y rmo� ynnrs, MA i iWhose place of business is: Bass River Rod&Gun Club � Type of business: Non-Profit Food Service I � To operate a food establishment in: Town of Yarmouth i Pernut expires: December 31_2002 BOARD OF HEALTH: (�,kaalea� xelluies. (� ' �j"a�+c D. Cjmrd.ors 'IK D.. `Uiee � xss'ra�cnONs 1F'wv: Well tested annually prior to issuance oF �a�ert'�. !a'�atevs, �k license. Outpost to have limited cooking use of six times per year. �afilck�euxatt � Februazv 24 ,2002 ' ' ruce G. Murphy, S.,CHO I Director of Health i I i I ; i I I , � PX'' o � c� f� � M � Do � � �1 . r Ci� � > TOWN OF YARMOUTH BOARD OF HEALTH JQ N O 3 ZOOO APPLICATION FOR LICEN9E/PERMIT-2000 �e�� HFALTS-1 DEPT. ' � ��;s ___ ___. �' * Please complete form and attach all necessary documents by December 31, 1999. Failure to do so will result in the requm of y4ur ap��cauon packet. r.. ,� . - , '�".._�.�.+.."::�_'-�.�.�.c.�:�C. :^ .:f-+q:s+�r..,+�.-sr- ' 1 a aw<�t ay�-,-r�-.-.._,�..:*h„v fis, r I�y ,y � r` � �".. `N�-^er,T_..— . � I y L AME OF ESTt1$�:I� '��a � � ��e�rt1 �'S � r i'�#` �%��3 ` ,. �- ��-�8�,.�!---^--�--�-- i L D -P.p. o,l , , oa � MANAGER'S NAME: � a��2T 5 \►�h. �r�.. # �ea.-s�aq MAILINGADDRESS: '3"'i`1�a.�0 V: �� A-,1.�. ,Ck+A:'�awt Ttr.�a . ��"},'�_ POOL CERTIFICATIONS��_________��___�_�w__�___w_�_w_________,___�__��. The pool supervisor must be certified as a Pool Operntor, as required by new State law. Please list the designated Pool Operator(s) and attach a copy ofthe certification to ttus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safery, 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. I HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I Maneuver on the premises at ali times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. � RESTAURANT SEATING: TOTAL# - NON-SM9KING-SEATS: TOTAL#--------- -- -- - ______—____-------------------------------_______----^-------------------------------------- ' OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE . PERMIT# LICENSE REQUIItED FEE PERMIT# i i B&B $50 CABIN $50 I nviv sso caivrn $so j _LODGE $50 _TRAII,ER PARK $50 � MOTEL $50 SWIM1vIING POOL $SOea. WHIRLPOOL $25ea. �'OOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 I NON-PROFIT $25 2 � � _COMMON VICT. $50 _WHOLESALE $75 I RETAII. SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 ; AMOUNT DUE _ $ Z`j— I I •••••pLEASE TURPi OVER AND COMPLETE OTAER SIDE OF FORM••••• l�/� __ .. _. . __ ; ,_� � � � � _ _ ADMINISTRATION IJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�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��Qlq.rc,(�S QR 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�jtc�.-r; NO ar � NOTICE: PERMITS RUN ANNiJALLY FROM 7ANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMI'LETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION�-10 DAYS PRIOR TQ OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHI�fENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENl',ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMA�NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS ' POOL OPENING: ALL SWININIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED I,AB, PRIOR TO OPENING, AND QUARTERLY Tf�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWARvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WFIO CATERS W1THIN TI�TOWN OF YARMOUTH MUST NOTIF'Y Tf�YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TF� CATERED EVENT. THESE FORMS CAN BE OBTAIlVED AT Tf� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS SY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII.URE TO DO SO WII.L RESULT IN Tf� SUSPINSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTII,TI-IE ABOVE TERMS HAVE BEEN MET. - _ _ _ _ OUTSIDE CAFES: OiTfSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MCTST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OIITDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIvIENT IS PROHIBITED. DATE: Ia SIGNATUI��. �, PRINT NAME& TITL� � Q"; J �J��f'1�� e � ►�LW� 11/12/99 , - � The Commonwealth ojMassachusetls � s = Deparrment ojlndustrial,-lccidenrs ; Olflceof/anssalDsdiis .- 600 Washington Street Baston, Mass. OZlll � w'orkers' Compensation Insurance Aftidavit Anniicant information: Pf n.eP1[INTTer.7.iy o�m� �"�(�1��?��l � ��-of� � �7�1� �Wb —1--r.1 Cs � �- F� �""'�rl S�la . oa -� _' • , '-' x3 �3014 � 1 m a homeouner penurming all µork myself. �am � sole proprietor �-,�, ha�e no one ��orkin� in am capacin� � I am an employer pro�iding uorkers� compensation for my employees workine on this job. comnanv name: address• tity: ehone N• iDsurance co. yolicv a � I am a sole proprietor. general contractor, or homeowner(circle onU and have hired the contractors listed below ��ho ha�e the follu�cin_ ��orkzr compensation polices: comoanv name: - ad d ress: cin�: phone a• � insuranceco. nelicrN � eompanv name: �. . .. .. address . . . . _. . � ciri• �hoee ih. insuranee co. eeliev M t Failurc�o seeure covenge u reqwred uoder Seenoe ZSA of MGL I53 n�iad to We iaporidw of eridW pndtles ota 8�e ap to SI,SDO-00��d/or one ye�n'imprisonment u w�e0 u civil pendtla in�he torm of�Sl'OP WORK ORDER�ed�fiae otS100.00�d�r q�i�st ma 1��denn�d thu■ �opy of thy sntement mar be for.varded to�he Olifee of Invntipuom olMe DIA for eoven�e verieutlo�. /do�Arreby certij}•under the point and prn Uier ojperjury�hm the injormation prorided abovt is dnt and rnr►eet Signamrc 1 �T��1 . \�►�^� _ Dsre � I31 �q � I, Print name��7"�]C.Q, .~I —� W�ll y� � PhoneN ��"�S^ 31r+�'l'�� j . oRcial use onk do no��ritt in this area m be comple�ed by tily or tmva olfleial eiry or town: Y�M�DTQ _ � permiNieeaee M nBuildiot Departmea[ � QLicrosiog Bo�rd � �check i(immedi�tt response ie required 261 QSdeetmen'e Olfiee �Hea1tA Departmeat eontact person: phoneM;_ �508) 398—?231 est. nOther TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-144 FEE: $25.00 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 1 ll, Section 5 of the General Laws,a permit is hereby grented to: __ Raes River Rod& (;un ('lnb_ 620 Rnnte 6A Yarmn � hnort MA Whose place of business is: Bass River Rod& Gun Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yazmouth Pertnit expires: December 31. 2000 BOARD OF HEALTH:�d�n/. .�natt�g, C'�a/�w,q,,��/.nq� n �oan G. Ju�Civan� K.//., Vice C.�irma ' aes iwcTTONs �F ewv: Well tested annually prior to issuance of license. l�o�erl�p�i�own, C�e.� ' Outpost to have limited cooking use of six times per year. a6.ie!`e Ja�o��y-�✓� pes �ic � ou��li ; Januarv 25 ,2000 — — ; Bruce G.Murphy, MP , ., CHO Director of Health An en�pl�»'er is detined �s an man iauai. parcncnn�p, a�w��.�.,��. ...,�N��a.�..�. ... ....._. --o---�- --- --- . __ the (oregoin_ en_�a__ed in ajoinc en[erprise. and including the le¢al representatives ofa deceased employer. or the recei�er or trustee of an indi�idual . partnership. association or other legal entiry, employine empio�ees. Ho«ever the u��ner of a d«elling liouse ha�ing not more than three apartments and who resides therein, or the occupant of the d��ell;n= house �f another��ho emplo}s persons to do maintenance , construetion or repair work on such dwellin¢ house .x ��n �ht _rounds or buildimz appunenant [hereto shall nut because uf such emplo}'ment be deemed to be an emplo�er. \1GL �h�prer I _= ;ection _> �Iso s[�tes that even state or local licensing agencc shall withhold the issuance or renc��al of a license or permit to operate a business or to construct buildings in t6e commonw�ealth for an}' applicant �cho has not produced acrrptable e��idence of compliance with the insurance coverrge required. Additionalh. neither [he �ommrm�ealth nor am of its political subdicisions shall enter into am� contract for the performance of public ��ork uncil acceptable evidence of compliance with thz insurance requirements of this chapter ha�e bcen presen�ed to the convsctin_ �uthurit�. .�ppli..:nts Please flll in the ��orkers' compensation affida�it completely, by checking the box that applies to)�our situation and suppl�ing cnmpan. n�mes. address and phone numbers as all affidavits ma�' be submitted to the Deparcment of lndus[rial Accidents for contirmaiion uf insurance covera¢e. Also be sure to sign and date t6e a�da�it The affida�i[ should be returned [o the cit} or town that the application for the permit or license is being rcquested. not the Department of lndustrial .�ccidents. Should cou ha��e am•questions regardin¢the "taw"or if you are required to ohtain a «orkers' compensation polic}. please call the Department at the number listed below. City or Towns ��..__., �,e ..,,.e .ti�. ftiP �ffidavit is complete and printed legibly. 'ihe Department has provided a sPace at d►°bott°m of . .-- ---'r:�..A.. ennlicant_ p�[IISt r � � P.�� Raver R�r_1�Gu n „ ,, _ U�� r�; ,r� {` � `;7'�4�V OF YARMOUTH BOARD OF HEALTH ` r �qry 0 6 19�p CATION FOR LICENSE/PERMTT- 1999 2� ' Please com 1 �qy ai necessary documems by December 31, 1998. Failwe to do so will result in the return of yo�a pac et. - ------------------�------------------------------- ----- -------------------------------------------------------- NAME OF ESTABLISFIlVfENT��l�� J..iQ �Q� L'1\w��,.,,b�L # 3ea 3a9a LOCATION ADDRE4S �oao�� te Q MATT IN ADD F.��'�,c,.(�.oy, aq T N R° ,— # a -�G aq nv . --� �.► ' � a , ,q ----------------------------_----------------_______—_--------------------------------------------------------- POOL CERTIFICATIONS The pool supervisor must be certified as a Pool Operator, as re�uired by uew State taw. Please list the designated Pool Operator(s) and attach a copy of the certificarion to tius form. , _ ---- _— ---- --- - - - ---- _ -_ . 1 2. , Pool operakors must list a minimum of twoemployces aurently certified in basic water safety, standard First Aid and ; Community Cardio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to t}us form. The Health Department wilt not use past years' records. You must provide new copies and maintain a Tile at your place of business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: Ali 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-cholang 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 t"ile at your place of business. I � 1� 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# ---------,��----____��___---___----------------- -- - -------------------------------------- . __ __ __ _- - ---9�FI��I7SE-ONLS� LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# � B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 TRAII,ER PARK $50 MOTEL $50 _SWIl�IINGPOOL $SOea. FOOD SERVICF.• —W�LP�OL $25ea. LICENSE REQUIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL $30 _>100 SEATS $150 I NdN-PROFIT $25 Q9-t�3 _COMMON VICT. $50 _WHOLESALE $75 Rr.TAif.SFRVi[`F• LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NA F, C'AA $10 AMOUNT DUE _ $ z�j - '•"•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•^•" �� ADMINISTRATION ` s LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,TF�TOWN OF'YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMI'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED ATTACHED '�/`a l2s C.�o �-��A�l..�. ��1 o�. TOWN OF YARMOUTH T.AXES AND LIENS MUST BE PAID PRIOR TO RE1VE��AL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES NO v�t�-a w�^�►-r� �x��,?� NOTICE: PERMITS RUN ANNiJALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILIT'Y TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISfIMENTS ARE TO CONTACT TI� HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�TING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQiJIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. AnDiTiONAT_,REGULATIONS POOLS POOL OPENING: ALL SWIMI�IING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY TEIE HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEtJDO14IC)N�S,TUTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY Tf�REAFTER. , POOL CLOSING: EVERY OUTDOOR IN GROUND SWIl�IlvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE ('ATERiNG POLICY: ' ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT BY FIL.ING Tf� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FROZFN DESSERTS� FROZEN DES3ERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN TI�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS — - __ ----- — - - - - ___ — ___ - - HAVE BEEN MET. Oi1TSIDE CAFES_ OiTI'SIDE CAFES (i.e., OUTDOOR SEATING W1TH WAITER/WAI'1'RESS SERVICE),1�jZ�T HAVE PRI�R APPROVAL FROM Tf�BOARD OF HEALTH. OUTDOOR COOKING_ OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBTfED. DATE: �I�I I Q�i SIGNAT[fkE� � ��'1��,T�1._� PRINT NAME & TITLE�-2c�jcR��J V.'1 h .T e ��cPD. _^,w--_ The Commonwealth of Massachusetts Z W Department of Industrial Accidents Ofllee 011AVOS IS&Ois 600 Washington Street ,•� Boston, Mass. 02,111 W 6rkt rs'. Compt*nsation insurance.,A(fidavtt 9RDlant information: `.ti. l�IeassPRINTi'iitr` location: Q:—A `3A ,7 M I am a homeowner performing all work myself. M I am a sole proprietor and ha%e no one working in any capacity ❑ I am an employer pro% iding workers' compensation for my employees working on this job. company name address: city: insurance co. lam a sole the folio« company name address: cites insurance co. company name: 3 Failure to secure coverage as required under Section 25A of MGL 152 an lead to the imposition of criminal pesaides of a floe up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a floe of 5100.00 a day against me. I ooders. and that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage vtrilfeadon. I do -hereby certify under the pains and pen; 'sof perjury that the information provided above is true and eonecL Signature ate Print name 1 Phone N Official use only do not write in this area to be completed by city or town official city or town: YARMOUT11 _ permit/license q nBuilding Department OLicensing Board O check if immediate response is required 261 ❑Selectmen's Office contact person: ('roe-med 3,95 P1A) oHealth Department phone q; _ (508) 398-2231 ext. r7jOther OF•Yqht '�� '�o TOWN OF YARMOUTH l l�"t(� R�OTE 28 SOOTN YARD70UTH �(ASSACHCSETTS 02C>(i4-d4�1 �nw�r.nen�� Trlephune ��08) 398-2231. E�t. 241 — Pax 1�08) 398-236� +r�u,�o B O A R D O F H E A L T H To: Bass River Rod&Gun Club P.O. Box 29 Yarmouthport, MA 02675 From: Kelda G. Welsh, Health Inspector Date: Mazch 15, 1999 Subject: Annual Well Water Test 1 we aze unable The Health D ent has received your 1999 permit application. Unfortunate y, ePartm to process your application for the following reason: 1. Your Food service Permit requires that your drinking water,which is obtained by private well,be tested for coliform by an indep�dent laboratory. Please provide this office with proper documentarion for water testing by March 31, � As a reminder, the Health Department will not use past years' records in order to process � applications. You must provide new copies and maintain a file at your place of business. I Businesses which are unable to produce such documents are encouraged to contact me at(508)398- ' 2231,ext 241,or stop by the Health Department between the hours of 8:30 a.m. to 430 p.m., and iI will assist you in any way possible. Please be advised that your establishmc�t cannot legally open until the required information is obtained by this department and a permit has been issued. Thank you for your time and anticipated cooperation in ttris matter. KGW/maf cc: file I i � � � �� Printed on � Recyded Paper TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-143 FEE: $25.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 11 I,Section 5 of the General Laws,a pemut is hereby ganied[o: Rass River Rod & ('�m (�lnh 620 Rnirte 6A Yarmnirthnort MA Whose place of business is: Bass River Rod & Gun Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Pertnit eacpires: December 31, 1999 BOARD OF HEALTH:�d�/. .�nettaega, C�a/�:,�Q.,/�/Rn / /7 . �oaa �c 7Jnullivan�/K�g.�/•� Vice C.�irman RES7RIC1'IONs [F ANY: Well tes[ed aunually prior to issuance of license. �o�rf.}. /,rown� (..ter� Outpost to have limited cooking nse of s'vc times per year. 4Y///J�a�rie�a�a�/oIPa�ry�e/�oopea � ///ic�ia OoCou��lin February 11 , 19 99 Bruce G.Murphy,MPH, .S., O Director of Health I I � � � I i