The URL can be used to link to this page

Home My WebLink AboutApplications, WC and Licenses Prior to 2010 _ ' �.e .yaurr . _°`�"� TOR'N OF YARMOIITH BOARD OF HEALTH o � � � , 3 c ` ` � ^ � APPLICATION FOR LICENSE/PERMIT-2007� r�� * P lease comp lete form and attach all necessary documents b�Dec�m er 31 E�0 66 1 2 0 0 6 F a i lure to do so w i ll resu lt in t he retum o f your application pac e�EALT H C7EPT. Nt1ME OF ESTABLISFIIviENT:�,055 K, �22 �i'�c�Nr ((c, TEL. # �°�iS - �J7� / LOCATION ADDRESS: .2 y F2o rr�.,vGHAn� G.A.�i S: �i.Q:��..�� MAILING ADDRESS: •D• f3o , OWNERNAME: T.�X ID (FEIN or SS1Vl� O -2�9 �77 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAII..ING ADDRESS: POOL CERTIFICATIONS: T6e poal supervisor muat be certi6ed ac 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 oftwo employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certiScarion to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment 1. Z. PERSON IN CHARGE: -- - - __ _ _ _ _ __ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEII�IL.ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-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£ile at your place of business. 1. 2. 3. 4. RESTAtJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PF..RMIT N LICINSE REQUIItED FEE PERNIIT# LICENSE REQUIl2ED FEE PERMIT# _BBcB S50 CABIN $50 MOTEL $50 INN $50 CAMP $50 SWIIvIIvIlTTGPOOL$75ea. _LODGE $50 1'RAII,ERPARK $100 WIIIRL,POOL $75ea. FOOD SERVICE: LICENSE REQiIIRED FEE PF.RMIT# LICENSE REQUIRF.,D FEE PERMIT# � LICENSE REQUIItED FEE PIItMIT# -Q-100 SEATS $75� _CONTINENI'AL $30 �NON-PROFff S25 �t07"OgS . _>100SE�1TS �� $150 COMMONVIC. S50 WHOLESALE S75 RETAII.SERVICE; . —RESID.KITCHEN S75 LICENSE REQIIIRED FEE PF..RMI1'# LICENSE REQiIIItED FEE PERMIT# LICINSE REQITIRED FEE PERMIT# _<SOsq.ft. $45 _>25,OWsq.ft. $200 VENDING-FOODS20 _QS,OOOsq.ft. $75 � _FROZENDESSERT $35 TOBACCO $50 xnnte c�nrrce: a�o AMOUNT DUE = S 2S.o0 '"•"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM`"'•• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a CertiScate 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 �" v�C ��8-00- H/ Town of Yarmouth taaces and ►iens must be paid prior to renewat or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLLSHNIENTS TRANSIENT OCCUPANCI': For purposes of the limitations 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 have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generaily refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collecrion 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 whirlpoois 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(S�ys pnor to opening. POOL WA'TER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heaith Department by Eling the required Temporary Food Service Application form 72 hours prior to the catered evem. 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 untd 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 COOKING: Outdoor Cooking,prepazation,or display nfany food prosluct bXa retail or food senzice establishmentisprohibited N01'ICE:Permits run annuaily from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, MOTEI, OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR ' TO COMI��NCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. ' DATE: /2 - Ci- O G SIGNATURE: �=]�LJrw n� o� ��c-��w� PRINT NAME&TITLE: A 5s7: iTZL�Sc.:2 c2 iomroc f , . � The Commomvealtk ojMassachusem Departw�eet ojlxduserialAccideatc �7N� 60B IVashiagton Streey 7'"Floor Bosww,Mass 02111 __ ____— _ Workas'Com ' a I�svaeee A�davk: leetrleal Cwtraetors �: �A55 iVc`1t- yf+CNT CGGi3 �5: �O. �Ok /SZ- ' � ciri � ��ZMQt�(}.� spx: �'!A. zin: O�GG� ohose#7lJ� ' �70 ' % 7�� ' �sim�o�a�[rnu�r. 2� fi20i1�iN G NA�n �Ah . .S �f q ZM o�.G1�L 0.7G G 5� � ❑ I�a homaowra perfo�iog a11 wak myself. Pcojed ype: ❑New Cmau�uctio�❑Remode� I I am a sole and have no ace w in� ❑ Addition ! I am an�ployer providiog wadceca'�on for mY emPbYces wmkin8 on this job. .as��c: _ _ . . . . :- _ . . _. _.. _. ... `-. _ . _ .. .. . . . . . �t�ew: tltr:.. . W�e9: � . '�. LRaeec.. S�'+/Tlfw/GK'— /1'lAi'2/N[t/15 ... w�e.rtt GvC .'l fS 'OQ ' �'f/ � . i ❑ I am a sole praprietor,gAaal cootraetor,or Yemeow�er(rndi owe)�d Lave huod the coatcactas liated below wLo have I fl�e follo�vmB wo��s'�p�ation Potic�: ca�r� + � cLLve aiwe If: � � aomrv� ad�s: � dM OYa�e#: . -- -__-. _._— --. ..--- — - -_.-- � --_—.: . —_. ._..—.__-- FaYve►�ecae cwvsSe u rqid uiv SeetlN 2SA dMGL 152 m Wd M IYe I�prilir dai�Wt ps�Mo da dt�O S1.SMM�dhr e�e yeu+'6iptiw�at a,wd o eM peadtln 1�tYe E�d�310?WORIC 09D&R atl a�e df1N.N�Aay�aWt we I�denhW tYN a e�py d U6 Maieae�t dy Ee f�nrudd e�I�e O�ae d l�N�DIA twew�e widn�. I do Aenby csr�fify r,e�`�dYe piws a�JP�o1D�+�Y b'+a Nu 6fas�greddel abave B�re ad osm�c s��s... � �,..�i.��:_._. na� �� - S-d G r�;m� Srrz.=RMR,� L. l�i4/��.,� r��a �08- CiF-6 .m�l.xe.�y a.set.Mferw.arnt.eew�fedArdh.ren...mrLl �9m�� per�Y `-'" ' DryrOest ' ❑eYedN�se�le�enebre9� ❑Sd�'+O�ee �� " �P�� pYwei; C70Wv t��1 , i , � � � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffiVI�NT PERMIT NUMBER: #07-085 FEE: $25.00 In accordance with re�(ations promulgated under auThority of Chapter 94,Section 305A and Chapter � 11],Section 5 of the�,eneral Laws,a peimit is hereby gran[ed to: I j Bass River Yacht Club, 24 Frothinghazn Way, South Yarmouth, MA � Whose place ofbusiness is: Bass River Yacht Club � Type of business: Non-Profit Food Service ! To operate a food establislunent in: Town of Yazmouth i � Pernut expires: December 31 2007 BOARD OF HEALTH: B `.�. � M.$., ' � d�{se�c��i,. ./�., �/ice��ici3�c�C pa�lic�(a M� ►4.�.z lf�, R.N. � Febrnary 26_2007 I ruce G. Mu�phy, S.,CHO i Director of Health i � � i i I i' I �, I I I i � � i � � • �e R.s . TOWN OF YARMOUTH BOARD OT4�� " �s � 2 � APPLICATION FOR LICENSE' , '� �'�s . ��- �� DEC 0 5 2005 � � Please complete form and attach all necessary doeaments by D e �p5 Failure to do so will result in the return of your application pa . '�� H DEPT. I NAMEOFESTABLISFIMENT: RSS vLs c!J � � TEL. # 7j�JSr— �'I?D/ LOCATIONADDRESS:_�2y fllop).d„�/G't!A„n Ar� _ S. `�.�o.?fiot.P1-J MAILINGADDRESS: . $a t�3. �� o OWNER NAME: TAX ID(FEIN or SSI�� C9 - SS T'l 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-�perator(s}and attach a copy of the certifica�ion to this form. 1. 2. Pool operators must Gst a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees bdow and attach copies of employee certifications to this form. The Health Departmeut will not use past years' records. You must provide new copies and maintain a t'ile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one 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 appfication. The Health Department will not use past years' records. You must provide new copies and maintain a t'de at your establishment. 1. 2. PERSON IN CHARGE: - _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIg+g: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 ali times. Please list your employees trained in anti-choking procedures below and attacfi eopies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMI'L tt LICINSE REQiTIl2F.D FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _1NN S50 _CAMP S50 _SWIIvfIvIING POOL$75ea. _LODGE S50 _TRAII.ER PARK S50 _WI-IIRI,POOL $75es. FOOD SERV[CE: LICINSE REQiJIItED FEE PERMIT# LICINSE REQiJIRED FEE PERMI'I'# LICENSE REQUII2ED FEE PF,RMI1'# _0-100SEATS $75 CONTINENTAL $30 I NON-PROFTT S25 O� Ei—µ�'� _>700 SEATS 5750 _COMMON VIC. $50 _WHOLESALE S75 RETAIL SERVICE: LICENSE REQIJIItED FEE PERMII'# LICENSE REQIlII2ED FEE PERMIT# LICENSE REQiIIltF.D FEE PERNIIT# _<50 sq.ft. $45 _>25,000 sq.ft. 5200 _VENDING-FOOD $20. _<25,OOOsq.ft. $75 _FROZENDESSERT S35 _TOBACCO $25 IYAME CHAIVGE: SIO AMOUNT DUE _ $ ZS.00 "•"""pLEASE TURPi OVER AND COMPLETE OTHER SIDE OF FORM•••"" � s^- — _ � ! ADNIINISTRATION 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 STA1'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED -� w� 2�8-Do- �l Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yow permits. PI,EASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Permits run annually from January 1 to December 31. 1T IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2005. , SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�iING FOR THE SEASON. : ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO C011�NCEMENT. RENOVATIONS MAY REQiJIItE A SITE PLAN. ADDTiTONAL REGUI.ATIONS POOLS POOL OPENING:All swimming,wading and whidpools which have been closed for the season must be inspected by the Health Department prior to opening. I 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 swirruning pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Aealth Department by Sling the required Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtau�ed at the Health Department FROZEN DESSERTS: Frazen dessert�must t�teste�an a irranthly basis b�a S'f�te c�rtified lab. `I est resuifs musf�e senfio ffie I�ea�th Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , DATE: /2 - ! — 6 J SIGNATiJRE: ��jy,,,,„ � I�....Q�� PRINT NAME&TITLE: �J ss7": i n��s� Rc.`r� ovnaios , . F .�� ---_� TTie Coninwnwealth of Massachusetts ! _ -= Dcpartment oflxdystrfal Accide�+Is ' _ — �eIM� - - 600 R'ashington Smey �"'Floor - , Boston,Mass. 02111 � Worhen'Com�s�tio�Ls�ee A�vl� 6i�gJEkelrkal Co�traetora .._ ._.. � n,g,�,^,� ''3 <a*��>r;��" r,.- � - .., .,. . .. . ._ . ,. � �: �Ass �„«. �'Al'NT C�`a add�ess: ��. �X / �l Z �n� S. `�,�+��.o�c� �: !'h.e. ri�o2LG� �x Sa� �3gF •�i�e) wo�t�uio�;��rnu�gr .25( T'l1o'7f�•,•G<JAm �.a�, � �1i9�l�a61.G'}d� /ylA fQ,7�G� ❑ I am a homeownv perfotming all wak myaelf. Ptojec[Type: New �Rmrtodel I�a sole and have no aae w in ao Addition am�employer ptoviding warkeas'comp�setian f�my�byces wodcing m tbis job. . .. . oaoorv�e: I �� idri: . vY�e/: ' ��_ S�„�► �.,�K . I�,Q2.NrKs . wc �rt g -ao- yl i ❑ I�a sole prop�idor,ge�eral estractor,or homeewoer(arcle ow�)md Lave hinod the co�actaa listed below who Lave the following w�kas'compeosaaon Polices: �t vee: �: �w oire�: 0 �t�e; sddrew• t$s: ore!_ � . .... . . _ . . _ ____. . __. ___ _ . . -. . .___-_—_ _ __ -__ . ___-. . _ . . ._. . _.. ._. . __. . . _ . _-.__ ._ _ . / FaYu'e 1�attoc ems�e tl�eqbd dQ SediN 2SA�1qC.L LS2 m lud b IYe bIp�I1W d e'W W peWn K�ie�p bA 1MM aMhf �eyeve'leeptiw�ntnwdudMpwMbltllYttx�Ka31WWORICOBDEBda6edS1M.M�day�ahN�e. ladnahW�a � mpy afNb�ry 6e t�e�r�ndN Y tYe Ometa dl�n�tHe DIA hrsMvqe vvNatlN. . 1�o Aersby et��fy �NYe pdaa m�d/rnehta of0e�ry diat Me7sfonwdJoe prorldd ebepe 6�e m�d earroct .. gi�atore �5�/�,Jr�,.... e�. �..��•- • p.os /2-/'O s p�c� S�'.�a.r„�,� � . /?i�G,7a��, en�a H - �. -G � a�ad.x.nly a..at.rtkertYi.,re.r.eeea�plued9rdlr.rr�.n.mrL1 �9�*�� ps�lBeeati I-lBeNb�pipglM� ❑cYed if IwmpWle�eapsea b�ahed ��Hsud ❑SeJx��'�O�m o.�ePe.aoc pY..es; I-bue �� t�a s.�.mw� TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-101 FEE: 25.00 � Tn accordance with reaulations promulgated under authority of Chapter 94,Section 305A and Chapter j I I I,Section 5 of the�ieneral Laws,a petmit is hereby granted to: i � Bass River Yacht Club, 24 Frothingham Wav, South Yarmouth, MA Whose place ofbusiness is: Bass River Yacht Club I � Type of business: Non-ProSt Food Service i To operate a food establishment in: Town of Yarmouth j Pernvt e�cpires: December 31 2006 BOARD oF I-IEnLTH: Be �c�5. o+rdo�cy M 91., ' ; a��"`sl�k, �rv., v�ek�.� Ro6�t�. B� Gl�k ��R.N. � �anuazy 26.2006 ruce G. Murphy, H,RS.,CHO Director of Health 1 j /�ah-Pre�:f o�..y,�� d S� . �� '�o TOWN OF YARMOUTH � � y 1146 ROUTE 2S SOUTH YARMOUTH MASSACHUSETTS 026644451 H MqTTACMEES � �+o,,,,,,�o,�� Telephone (508) 398-2231, Ext. 241 — Fasc (508) 760.3472 B O A R D O F H E A L T H To: Yarmouth Board of Health Pertnit Holders �,f Fmm David D. Flaherty Jr_,RS. ;1D� ' k' 9 9 2005 � Health Inspector � ! TownofYarmouth 1 HEALTH C�EPT. Re: Federal Ta1c ID Number i Date: March 22, 2005 i � ' The Massachusetts Department of Revenue is now requiring that we fianish detailed information � to them regarding all permits and licenses that we issue. One of the details that they require we se�to them is every eskablishme�'s Federal Employer lde�ification Number(FEII�otherwise lrnown as your"Ta�c ID Number". Tlvs is purely for administrative purposes only. � So� businesses use the owner's Social Security Number (SSl� for tUis purpose. If this is the , case for your establishmern, be assured that we will not allow this information to be public record. , Please fill out the fields below and return this letter to I j Yarmouth Health Departmem 1 1146 Route 28 � South Yarmouth, MA 02664 Thank you for your a�icipated compliance. If you have any questions regarding this matter, please do not hesitate to call. The office ho�s are Monday to Friday, 830 a_m to 4:30 p.m The telephone number is(508) 398=2231, eart.241. i Establishmem: Q�tss R�✓�C )p�wr Civa� IN�. �irr or ssrr: a� — �37�g7� /tsesc�Hc /a 6�x ��✓ LocationAddress: 'i''�' �.`�h��H7tM I^/R� <S�. �q�n.nta,��N. �cq arL��— oi��' c�b. ��.,.�, M.¢ e'Y6L� Signature: � Print: �.qZr,rE.c � ��lG/f�'a.f Title: /u.�•�. � �� Printed on � � Recycled Paper � � e.a.Ynnrrcu,g ,iFYq 32 � Rsc TOWN OF YARMOUTH BOARD OF�AI.'I'H� G3 � � i� � �^ f� � o y APPLICATION FOR LICENSE/PE -2005 '�D E C 0 7 2004 � .;S ` ' '+ .F: . �C. • Please complete form and attach all necessary do ��t �� DEPT. Failure to do so will result in the return of y ap n pack I NAME OF ESTABLISHMENT: i ifT �.i3 TEL # ��f&'- R'!D/ ' LOCATIONADDRESS�.?� .�97+G�✓�s�m �,.A� �`7.9,'2nio�G}!, aa6Gs1 ! MAILING ADDRESS: �3oX /Fl� S y,4it�.,o�.Ci7b� a 2 G L� ; OWNER/CORPORATION NAME: � MANAGER'S NAME: TFi. # MAILING ADDRESS: i POOL CERTIFICATIONS: T6e pooi supervisor must 6e 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. l. Z. . Pool operators must list a minimum of two emplo ees currentiy 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. T6e Health Department will not use past yeaes' records. You must provide new copies and maintain a file at your place of business. i. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail 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 of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your establishmenL i 1. 2. PERSON IN CIIABGE; -- _ _ _ _— _ __ ----- � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I � 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your empioyees 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. i 1. 2, 3. 4. I RESTAURANT SEATING: TOTAL# i ; OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE P�RMIT# ISCINSE REQUIItED FEE pER2�q'['q LICENSE REQUIl2ED FEE PERMI1'# � _B&B $50 _CABIN $50 _MOTEL S50 _INN S50 _CAMP S50 SWIIvIIvIINGPOOLS75ea. _LODGE $50 _TRAII,ER PARK $50 WI�RLPOOL $75ea. FOOD SERVICE: - LICINSE REQUIl2F.D FEE PERMIT'# LICENSE REQ[IIItED FEE PERMiT# LICENSE REQUIl2ED FEE PERMII'# . _0-100SEAT5 S75 _CONT'INENTAL $30 �NON-PROFIT S25 0� �Ob✓ >I00 SEATS $150 _COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSE REQIJIItED FEE pERMiT# Y LICINSE REQIJIItED FEE PERMIT# LICINSE REQUIltED FF� PERM[T'# _d0 sq.R $45 - ' - � '>25,000 scj.ft. �� $�00 VENDINd-FOOD S20� . _Q5,000 sq.ft. $75 ' , _FROZEPI DESSERT S35� _TOBACCO $25 NAM&CHANGE: $]0 � .. � - � AMOUNT DUE _ $ ga�.0(� ••*""PLEASE 1'URN OVER AND COMpLETE OTHER SIDE OF FORM••••• � � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ' AFFIDAVIT MUST BE COMPLET�D AND SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII,ITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISFIMENTS ARE TO CONTACT THE HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIl1�1EEIVT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIv1ENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDTITONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department pnor 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 quarteriy thereafter. POOL CLOSING: Every outdoor in ground swimrrvng pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food estaUGshment wtrich serves or selis ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY• Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly 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 ha�e prior approval from the Board ofAealth. ��! QUTDOOR COOKING: ', Outdoor cooldng,prepazation,or display of any food product by a retail or food service establishment is pro6ibited. , DATE: /�-�s- O -7 SIGNATURE:��j�w.�.- � ��r�. PRINT NAME& TITLE: Sf/x.=RihA.v L• �AL��/�` .�,� ssr, r�zc-.qs�rz�.. 10/2z/04 : . -. , .. . . -. � �m GRANITE STATE INSURANCE COMPANY 60302-0000 WC 431-74-70 i31oz ' --------------------------------------------- ot3-66-0704-00 •••• � . . PENNSYLVANIA . • . ..• . . . ' BASS RIVER YACHT CLUB, INC. PO BOX 182 �� Member Companies of SOUTH YARMOUTH, MA 02664-0182 American International Group � � EXECUTIVE OFPICES: � � � 70 PINE STREET, NEW YORK N.Y. 70270 SEE NAME AND ADDRESS SCHEDULE - WC990610 � , I.D# M I : � ••�� . . , SMITHWICK � CLARKE INS INC , WORKERS COMPENSATION AND EMPLOYERS 400 COMMERC I AL STREET LIABILITY POLICY INFORMATION PAGE PORTLAND, ME 04101-0000 INSURED IS � PREVIOUS POLICY NUMBER � CORPORATION RENEWAL 008163830 ' OTHER WORKPWCES NOT SNOWN neOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 � ITEM 2 VOLICV PEfl10D 12:01 AM.atandartl tima at the insuretl`s � maflingadtlress FROM 07/O1/04 ro 07/O1/05 , REM 3 p, Workers Compensation Insuronce: Part One of the policy applies to the Workers Compensation Law of the states listed hBre: i MA � -B. Employers Liability Insurance: Part Two of the policy applies M the work in each state listetl in item 3.A. � The limits of our Ifability under Part Two are: � Botlily Injury by Accident $ 100,000 each accident Bodily In(ury by Disease $_ 500.000 policy limit ; Bodily Injury by Diseasa $ 100.000 each employee C. Other SWtes Insurance: Part Three of the polfcy appiias to iha statas, if any, listed hare: �' SEE ENDORSEMENT - WC200306A i � REM� The premium for this policy will be datermined by our Manuals of Rules, Classifications, Rates and Reting Plans. i All Information required balow is subject to verification and changa by audit � � Estimated Total pg�e pa� Estimated Classitieations CotleNumbar Aemunarotion St000FflE Premium � ❑X A��+I ❑3 Vear munentfon �p��ual �3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $$ . EXVENSECONSTANT�IXCEPTWHEflEAPPLICABIEBVSTATE) $264 MA � �� MINIMUM PNEMIUM S ZO� MA TOTAL ESTIMATED pREMIUM S(F A H i tl cetad below, iniarim atl�ustmentz ot premium shall be mada. � Semi-Annually � �uarlarly � Monthly DEPOSRPREMIUM ENDORSEMENTS�FONMNUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 . 05/19/04 ASSIGNED RISK 66 Issue Date - Igguing Offlce Authorized papresentative WC 00 00 O7 3996] Ipicl mrn�n nr�ri�i TOWN OF YARMOUTH BOARD OF HEALTH PERMiT TO OPERATE A FOOD ESTABLISHII�NT PERMIT NUMBER: #OS-068 FEE: $25.00 In eccordanoa with re ations promulgated�mder authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�Laws,a peimit is hereby gianted to: Bass River Yacht Club, 24 Froth�Qh�n Way $outh Yazmouth,MA Whose place of business is: Bass River Yacht Club Type of business: Non-Profit Food Service ; To operate a food establishmem in: Town of Yarmouth i Pemrit expires:_ December 31. 2005 BOaRn oF HF.ALTx: Baya�$. (�'o+tdoa,M$, • i Patnicw6�la.b` ?/ics C�rar�iaia+s Ro6e�et 4. B-Qarw.,�� S!� RrV. ��j� R.N. '; a�zi_Zoos � Bruce G.M � Director af�,�(� S.,CHO � � I I i i c v � �t' 19�7 (,QS 1� B•e YacdtT ��_°`�"o TOWN OF YARMOUTH BOARD OF ��" 3 ° APPLICATION FOR LICENSE/PE�1I �2004 ,� � 'n - ° ; ;J � ! .��, '+ � _, ' Please complete form and attach all necessary¢�ctimehtsby becember 3 , 2�� 1 0 Z003 � Failure to do so will result in the return o��qur application packet. HEALTH DEPT. S i✓�=,'2 ACN L T A RE : 0 0}I v� S � � �vIAILING A D F.�R� . �. �X /�Z ; QWNER/CORPORATION NAME• MANAGER'S NAME• TFr p MAII,ING ADD FS • � j � � The pool supervisor m be certiTed as a Pool Operator,as required by State law. Please list the designated + Pool Operator(s) and attach y of the cerkification to this forrr. 1. 2. Pool operators must list a minimum of two emp o currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CP . lease list tliese employees below and attach copies of employee certifications to this form. The Health Depart will not use past years' records. You must provide new copies and maintain a file at your place of busin 1• 2. 3. 4. � i EOOD PROTECTION M NA ,FRS - RTIFI ATION�• All food sexvice establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000. Please attach cop�of certification to this application. The Health Department will not use past years' records. You must pmvidei�ew copies and maiutain a fiie at your establishment. 1.— 2. –PERSON IN CHARGE: --- _ _ _ – Each food establishment must have a east one Person In Charge(PIC)on site during hows of opecation. ' 1• 2. FI T.ICH CERTIFI ATION : All food service establishments with 25 seats or more st have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your em ees trained in anti-choking procedures below and j attach copies of employee certifications to this form. The Heal epartment will not use past years' records. I You must provide new copies and maintain a Cle at your place business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# w�wc: OFFICE USE ONLY L[CENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERM[T# _B8c6 $50 _CABIN 550 _MOTEL $50 _INN S50 � _CAMP S50 _SWIMMING POOL S75ea. _LODGE S50 _TRAILER PARK S50 _WHIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICGNSE REQUIRBD FEE PBRMIT q LICENSE REQUIRED FEE PERMIT R _0-IOOSEATS S75 _CONTINENTAL 530 1 NON-PROFIT S25 �b`F�I03 >I00SEATS SI50 _COMMON VICT. S50 _WHOLESALE S75 RFTAIL SERVICE: UCENSE REQUIRED FEE PERMIT# LICENSC RCQUIRGD FEE PGRMIT# LICGNSE RGQUIRED FEE PERMIT# � _<SOsq.ft. $45 _>25.00Osq.ft. 5200 _VGNDING-fOOD S20 _<25,000 sq.ft. S75 � � � _FROZEN DESSERT $35�" _TOBACCO S25 LVAME CHANGE: SIO � �� "- � � � � � AMOUNT DUE _ $ 25.O p «•••*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'"*•" , F e 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 CompensaUon 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES ✓ NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITl'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. 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 OPEIVING: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 sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporary Food Service Application form 72 hours prior to the catered event. "fhses forms can be obtained at the Health Department. F�t6Z�N DES3ERTS: � 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 waitedwaitress service),p�have prior appmval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establistunent is prohibited. DATE: /%t' /D'03 SIGNATURE: CF_��•..._ �. ��.J �e1G w_. PRINT NAME&TITLE: 5r+'•---�../ L. /?f+ �w�n/ ASsi. Tr1c:ASc-/2,�,2_ 10/22/03 - ° � The Commonwealth ojMassachusetts = = Department ojlndustria/.-lccidents ' a 011/eeal/snsstl�srJ�is � - ! 600 Washington Slreet � Bosrort, hlass. 02111 I ` ��•` Wbrkers' Compensation Insurance AfQdavit � Aunlicant information• p► , pR�_,�s.n. j; �� /� /�/ nam�� ,qs5 .C�VE/L— % GN% C/C.�.a L�i ' �� 7�f2o??,li�/Gh�Ai+�► �n.A�i �� O!( /�2� i � � u�� S�ARiMOuG}+l I�►A D eZ GG cl no� � �oSl 3 98 �i'?D I � � I am a homecwner pznortning all work myself. � I am a solz proprieror_r.d ha�e no one ��orkine in am capacin• � I am an employer pro�idins workers' compensation for my employees workine on this job. tomnan�� name: 8(�(�fC45' �a��"C fit�': phene B //_�� ..�/ -� IOSur1nce co �/•n'N�n �/TI(i 1/y� �Q nnl� �1 QQ��G3 7��" � I am a sole proprietor. general contractor. or homeowner(circ%onel and have hired the contractors lis[ed beloµ «ho ha�e the follo�ein_ ��orker ;ompensation polices: cumoanv name• address tia: nhene M• insurancc to. poliev# comoanv name: � address: �� yheee� insurance eo. �Rn.� ■ Failure to secure coven`e u required uader Seeno�ZSA of MGL IS3 u�Ind w the i�paidaa W ui�i�i peultle�oh O�e�p ro 51�00.00��d/or one ye�n'imprisonment a�w�ell u eivil peeNHa io the torm o(i STOP WORK ORDER�ed i Ilae ofS100.00�dar K�iut me. I�Wenu�d Wt a copy of�hh sntement m�y be fonwrded to the Oliiee o(lave�tig�tlom of Mt DIA tor eovera�e veriflpUe�. !do hrreby certij}•u er rhe pain�rtd pen '�pery'ury�hm 1h�injormatlon provided obove is p�e and correct � Signamre C�l.�.:..� p� /2 �/O - Q3 Print name �HG°�i2/hAw! � . �blti i� Phone M 7 1/S• 3�7�—�e 5f Z 3 . olTioial use onh do not r rite in�Ais arca ro bt tompleted by ciN or lowv o111Na1 ciry or town: YA��DTQ _ permifAieeeu N nBuildio�Dep�rtmeet � �Lieemieg Board ❑cheek if immediatt response i�required 261 �Seieetmen'�Ofliee �He�lt!Departmtet � contact person: phone N:_ �508� 398�2231 est. nOther Smithwick & Clarke Insurance, Inc. Local Knowledge • Experience WorldwideTM Telephone:?A7-761-1636 400 Commecrial Street Facsimile:7A7-761-2045 Portland,ME 04101 Toll Free:1-800-3741883 August 5, 2003 Bass River Yacht Club, Inc P.O. Box 182 Bass River, MA 02664-0182 j RE: Workers Compensation WC8163830 Dear Treasurer: � Unless mailed directly by the Insurance Company, we enclose your Workers i Compensation policy renewal. The Insurance Company will invoice you directly for any � future installments. I � We urge you to review your entire policy carefully, noting the limits, conditions, exclusions, and endorsements. Higher limits of employer's liability, for example, � $500,000 per accident or disease, are available for a very reasonable additional � premium. � Workers Compensation policy premiums are subject to audit and may change based on � your actual annual payroll. With this in mind, please notify our office if you expect your � payroll to differ substantially from estimates noted on the policy declarations pages. iShould you have any questions regarding this matter, please do not hesitate to contact me at (800) 370-1883. Thank you for allowing Smithwick & Clarke to meet your insurance needs. We truly appreciate your business and look forward to being of service in the future. Sincerely, -__.. __.__ __. _—� ._ �-_._-,�. Deborah White, CI�_�� cc: Chris Noll 835 Mt Hope Street#43 North Attleboro, MA 02760 Website:http//www.smithwick-ins.com . : . . . . � -� GRANITE STATE INSURANCE COMPANY 60302-0000 wC 816-38-30 13 i o2 ..,.�, r, ' ��'7:'.------------------------------------------- �� .��..� , . _ „ 013-66-0703-00 ' •••.• . . - . PENNSYLVANIA A . • . ..• . . . , BASS RIVER YACHT CLUB, INC. PO BOX 182 Member Companies of ' SOUTH YARMOUTH, MA 02664-0182 � American International Group . . � EXECUTIVE OFFICES: . 70 PINE STREET, NEW YORK, N.V. 70270 SEE NAME AND ADDRESS SLHEDIiLE - WL990610 I I.D# . � ,��. SMITHWICK S CLARKE INS INC WORKER$ COMPENSATION AND EMPLOYERS 400 COMMERC I AL STREET LIABILITY POLICY INFORMATION PAGE PORTLAND, ME 04101-0000 i INSURED IS � PREVIOUS POLICY NUMBER � CORPORATION RENEWAL 002163444 � OTHER WORKPLACE5 NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 � ITEM 2 VOLICV PERIOD 72:01 AM.atandard time at the insured's � mailinflaAAress FpOM 0]�0��03 TO �]�0��!{ i � ITEM 3 p. Vyu�kero Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states Ilsted i here: MA I B. Employers Liability Insurance: Part Two of the policy applies to the work in each atate listed in item 3J►. �, The limits of our liability under PaR Two are: godily Injury by Accident $ 100.000 each accident i Bodily Injury bV Disease S 500.000 policy limit , Bodily Injury by Disease $ 100.000 each employee � �I C. Other States Insuranca: Part Three of the policy appiies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A rt�M< The premium for this policy will be determined by our Manuals of Rules, Class'rfications, Rates and Ratfng Plans. - All informetion required below is subject to verification and change by audit Estimeted Total pa�e pa� Estimated Clessi/ications CadeNumber Aemuneration E7000FRe- Premium � Annual ❑3 Year � m�^e�� ❑X Annual ❑3 Year SEE EXTENSION OF INfORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $�p IXPENSECONSTANT�IXCEPTWNEPEAPVLICABLEBYSTA7E) $2�{�{ MA MINIMUM PREMIUM S�q2 MA TOTAL ESfIMAlED VHEMIUM S�l7S � H Indreatetl below. interim adjustmenis of premium shall 6e metle: � Semi-Annually � Uuerterly � Monthly DEVOSITPREMIUM ENDORSEMENTS�FORMNUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 � . ✓��/� ✓/�� 07/26/03 ASSIGNED RISK 66 Issue Oate Issuing Office Authorized Representative WC 00 00 Ol 39967 TOWN OF YARMOUTH BOARD OF HEALTH . PERMIT TO OPERATE A FOOD ESTABLISHMENT PERNIIT NUMBER: #04-103 FEE: 25.00 In accordance with re2ulations promulgated imder authority of Chapter 94,Section 305A and C6apter 111,Section 5 of the Z`ieneral Laws,a permit is hereby gmmted to: Bass River Yacht Club, Frothin�ham Way South Yazmouth, MA Whose place ofbusiness is: Bass River Yacht Club Type of business: Non-ProSt Food Service To operate a food establishment in: Town of Yarmouth ' Pemvt expires: December 31_ 2004 BOARD oF HFALTI I: �� , (josdors, �$� ! Ro�isat 4. B6��awr�� d� S/�lt. R./V. Jmmuary 29.2004 j ruce G. Mtuphy, , S.,CHO ! Director of Health 1 i ! I � r�.R.vR�T cWe -� aFr R.y TOWN OF YARMOUTH BOARD OF i= � _ G,? C� C�c.. � APPLICATION FOR LICEATS� -. � � M G DD rC�s a �#g 42' M�p� " Please com plete form and attach all necess a i�`documents b y Decem 31;�U�� Z��3 Failure to do so will result in the return of your application pac et�,�E�� -� DEPT. N T � ' k� � # fr- o I�OCATION ADDRESS: � S• I S� OWNER/CORPORATION NAME: � 71 ."v.w_ bIANAGER'S NAME: l° ,�,J�1e.41� / TEL.. #�'�r-7�/G s� �vfAg,IL�IG ADDRESS: POOL.CERTIFICATIONS: iThe pool supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated __ .P_aol Operator(s)and_attach a ennT�f the cQrtification-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 fde at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIF'ICATIONS: 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. Piease attach copies of certification to this applicadon. The Aealth Departmeut will not use past years' records. You must provide new copies aud maintain a file at your establishment. ' 1. 2. i i _ PF_i�en.�T�I+�EF�A-$GF: _ _ - - --- _ _ _- -- - Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. 2. HF�T�yff,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee irained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anri-chokmg procedures below and i attach copies of employee certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a File at your place of business. i 1. 2. j 3. 4. � RE4TA TR ANT ATIN : TOTAL# i OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S50 _CABIN $50 _MOTEL � $50 _1NN S50 _CAMP $50 _SWA4MING POOL SSOea � _LODGE $50 'I'RAILERPARK $50 WHIRLPOOL $25ea I � FOOD SERVICE: � I LICENSE REQ[JIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# I _0.100 SEATS S75 _CONTINENTAL $30 �NON-PROFTT $25 O� 3-(C� >100 SEATS 5150 _COMMON VICT. E50 WHOLESALE $75 ' RETAII.SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT i! _TOBACCO $20 _<25,000 sq.ft. $75 �TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft $200 _FROZEN DESSERT S35 NA F. sNGE: S10 AMOUNT DUE _ $ 25.00 *•'*'PLEASE TIJRN OVER AND COMPLETE OTHER SIDE OF FORM*•:" ' + ADMINISTRATION Under Chapter,152, S�ction 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license'or peFtnit 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 o3�w�� ,lJ I(.(, �-� CERT. OF INSURANCE ATTACHED C��_ dF (NS. OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ✓ NO YES NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETCJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2002. SEASONAL ESTABLISHMF,NTS ARE TO CONTACT'TE�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 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 animal products are required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �N D � �RTS:-- — - __ _ __ — -- - —_ ---- rozen esserts 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), us have prior approval from ihe Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: -3//d f03 SIGNATLJRE: /i.,+i � // �inBiv✓ PRINT NAME & TITLE: �,U c� n d a �l i e h n s n n/ �'e n�rre o A e r� 10/18/02 05/09/2003 12:05 5083987139 JAMES F LEIGHTON CPA PAGE 01 ,GRANITE $TATE PNSURANCE COMPANY , 603a2-0000 WG 216-34-44 13102 ----�•---•------------•--•---------------- 0�3-6F-07o2-43 PfNNS;YLVANIA Bp55 R I VER YACHT' CIUB, I NC. . Metilb8r COrtlpBnieS Of PO BQX. 782 �� American International GroUp SOUTH YARMOUTH, MA 02664-0182 . ' � � ' . � EXECUTIVE OFFICES: � � � ' � . � � � � TO PINE STREET, NEW YORK,�N.Y. 70270 SEE NAME AN�..AD�RESS SCHEDULE = WL9906T0 7.DA� ' SMITHWICK 6 GLARKE INS INC, ' WORKERS COMPENSARION. AND EMPLOYERS k00 GOMMERGIAL STREET : . .lIAB1UTY POLIGY INFORMATION.PAGE . PORTLAND, ME 04101-0000 INSUREQ IS � . . . . . PREVIOUS POLICY NUMBER � . CORPORA7i0N RENEWAL 008 4659 �OTNER�VMOHKPLACES NOT SNOWN�ABGVE:SEE NAME AN� A�DRfSS SCHEDULE - WC 0(10' �TEM 3 ' POLIC�Y PEWOU 12p1 0.M.�slAndard time al fM Inwiad;s , ' � mamna�aar�s F� 07/O1/02 To 0]/Ot/03 rt�r a A. Workers Compansadon In6unnCe;Pe1't One af tbe policy applies to tha Wcrkars Compenaeuon Law of tha sta[os listed � . hero: � � . , � � ' � , . MA , �B. Employers Liabllity'Insurmix'Part Two'of the policy appUes to Sba work in eaeh state listad in itan 3.A-' � �Ths�llmhs of our Ifa6ility under Part'7wo are: eodilv�Injury bv ��M S 100,000 weh seeidsnt � � . . � 8odily injury by DisO�so S �+00.000 poliCy limit ,. � � � � �� . 6odily Injuhl by Olasf�a i 1'D0.000 ach employee C. Other States Insurance: Pqrt Three ot thb policy applies m the statas, if eny, listed here: SEE ENDDRSEMENT - WC200306A rtEµa The premwm for this policy will'be CbLe►mioed bv our Manuals of Rules. qasSiflCetions, Ratss and Retlng.Plms. ' All informat�bq r�qu�red bNew is subi� 1c verificaeion and change by aad�t- , EstimHeA Teta1 pale Par EcUmapd ' �II . . . .. . � RlTUnenllen 57000FNb Ramlum dassilicafioec. Loda Numbe� �mUneNUOn . . . . � Annual❑3 Ywr ��nuel ❑7 Yee1 SfE EXTEN516N OF INFORMAT,ION PAGE - WC7754 $� � 7AXES/ASSESSMENTS/SWRCHARGES ..q1P,918E COMSfAtR IaL�T��E 4PPLICABLe BV STATEI� ' ' Z A�1 MA , . M�NIMW1 vP2111UU S�92 MA TQfAL ESnMA7ED PpBA�UM � S�+TS '11'indiulW Eelow. inlarim aAju�lmaap'of OroTIUm sh�ll be lnatls: .� . . � � seml-4nnuHtY.. . �. Quuudy . �.� ' � Mon1h1Y . OEP09RVNEMIUM �+oonseweas�wnMNUMeew 5EE ATTACHED FORM SCHEDULE - Wt990612 0']/03/92 ASSIGNED RI.SK. 66 � . �a.uma auca nuthmwea w'vresannare wc o0 on o, , luue De�a � . . . . . i � - ' TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-168 FEE: $25.00 �I In accordance with resulations promulgffied under authority af Chapter 94,Section 305A and Chapter i l 11,Sectioo 5 ofthe�ieneral Laws,a permit is hereby granted to: j Bass River Yacht Club Frothingham Way, South Yarmouth, MA Whose place of business is: Bass River Yacht Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yar�uth 3 � Permit expires: Decembet 31.2003 sonxn OF t-�EAI.Tx: (�iEaxlea'+f�� ,��, �ar � � `D. .�jmrdo� '�AG.D.. ?/tee ,�a�. �xoa�. � �a�'�DouKett � Sksk. . '� � March 10.2003 nuz G.Murph ,MPH ,CHO Director of Health I I i i i , :' - � Gi. 2. YRu+T Cc..Ug . ,� .� £ € i� � �'N OF YARMOUTH BOARD OF AEALTH ¢'�7�� aS � LICATION FOR LICENSE/PERNIIT -2002 � �'� (? �a �i �,r i�„ D • Please complete form and attach all necessary documents by December 31, 2001. Fail � s�avi��ult n the return of your application packet. AL7N DEPT. AM EST ISIIMENT: TEL. T D MAILING ADD SS: $ 2/�! C T E: � A E 'S N � ' SeTI . # S - � MAILING ADDRESS: POOr CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated POoi"OPeratar(S�and atta�kacoPY-ofthc�ertifcatiantathis farm.- _ _ - 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 Fde at your place of business. 1. 2, 3. 4. i i ! FOOD PROTECTION MANAGERS - CERTIFICATIONS• j All food service estabiishments 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 certificafion to this applicafion. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a£de at your establishment. 1. Z, ' PERSDN IN CHARGE: _ _ _ - - - _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operaUon. 1. 2, HEL1�fLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2, i 3. 4. I RESTAiJRANT SEATING: TOTAL# i — OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&.B $50 _CABIN $50 _MOTEL $50 _INN a50 _CAMP � $50 _SWIMMING POOL$SOea i I _LODGE $50 _TRAILER PARK S50 _WHIRLPOOL S25ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT q LICENSE REQUIRED FEE PERMIT# _0-]00SEATS 575 _CONTINENTAL S30 LNON-PROFIT $25 �hOZ-07Q >I00 SEAT'S SI50 _COMMON VICT. $SO _WHOLESALE $75 AETAIL SERVICEa. LICENSE REQU[RED � PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 �`�'�.,�„ _<25,000 sq.8. $75 _TOBACCO S20 _<50 sq.ft. $45 ��'--��;�;:.. _>25,000 sq.ft. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 AMOUNT DUE _ $ 25.00 '"***PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM**•** , : . __ ;� ADMINISTRATION Under Chapter 152, Secfion 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 Certificace of Worker's Compensation Insurance. THE ATTACHED STATE WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Q8 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:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'URN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISF�v1FNTS ARE TO CONTACT TF�HEALTH DEPART'MENT 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 REQUIItE A SITE PLAN. ADDITIONAi_- RFGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departznent 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 ('nNSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal pmducts ate required to post Consumer Advisories. ('ATF.RING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. - __ _ FROZFN DESSERTS• Fmzen 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),m t 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:�a�`!�o� SIGNATURE:� -' �1 • �•Y,e.s„> PRINT NAME& TITLE:�j�_m,;i /it/�. 09/11/O1 { '__ i - ,- " '" � iThe Commonwea/th ojMassachusetts = Depar�ment ojlndustria/.-�ccidenrs � y Of/Icea//erest/Ostli�s _ a - 600 Washington S�reet Bnston.Mass. 02111 W'orkers' Campensation Insurance Affidavit ARniican[ informaHon: p1 +�aepRiNTTwwcti.sK ! n�m��'L.h.�20i .Ciir�PA) �L.�.� i.rii,�, � y `, p location� �t.�.hTAin�.��i.l �l.1.l.� . . . � . j cm .� � '�ntim,�.�,rd{, Qno��a 39i�-�17o i ;� � a meoµner penorming all work myself. I am a solz proprieror ar.� ha�z no one��orkin_ in anc capaein• I �aru an emplo�upco��din�workerc' rnmp�sarinn �m1 emplo�ees uorkiae on this job. — _ ( comnanr name: 8f�(�fC55' � ' - ��'� nAene M• insur�nce co. yolicv M � I am a sole proprietor. general contractor, or homeowner(clrc/e onel and have hired the conttattors listed below aho ha�e thz follo�cin2 �corkar_ compensation polices: comoanv nnme� � � � address• ��N: nhene d• insurancc to. nolie�•# [omoanv name: _ . _. . _ . . ._ . . _. . _ _----- - --� - --- . . . . _ - - -- � --- --- — ---_ . �d resr �"— ehoe M• � insunneeco. ��n.M � � • . F�ilun m secure coverqe as required usder Secnoo ZSA of MGL 152 u�lad to 16e i�poritlo�o(crid�l peedtln af�p�e ap to f1,500.00��d/or ooe ycan'imprisonment as w�ell n civil peadtlee io�ht(orm of�STOP WORK ORDER asd a 6x of SI00.00�d�y q�iott me. 1 ndmb�d that■ eopy of thn etatement m�r be fonrvded to�Ae ORce of Invntlgniom of the DIA far eoven�e veriliutlo�. /do hrreby cenijp under rhe pains and pexalties ojperjury thallhe injornmlinn providtd above is put and eorrcet Signamre .P(�J�dit/�7 �i�„2rv� (' irnA./a.f/ p�, O�a3 �� 2 ✓ Printname �,.�,(,Gt/{ila N �{]/1u/1 i9�pneM o�`18"7y/rf .• oflicial use only do no�r rite in�his tra to be completeQ by cih or rowa ollleial city or rown: YA��DTQ _ � permiNfteeu M nBuildiog Departmem �Lieensios Bo�rd ❑ cheak if immediatt response ie required 261 OSdtetmen9 Ofliet contact person: phone N:_ �508} 39$��31 eat. �Othe�h Dep�nmmt � JUN-25-2002 11�23 SMITHWICK & CLRRKE 207 761 2045 P.01 A_ CORD�, CERTIFICATE OF LIABILITY INSURANCE °�� 06 25 2002 vaooucc-� TNI9 CER7IFICAiE FS ISSUED AS A YATTER OF INFORMA710N Smithwictc 6 Clarka in8ur�n�� _� ONLY ANO COMFERS ND FdGHTS UPON THE CERTIFIGATE 400 Commercial 3treet ��ER' �� N07 AMEND, OREND OR ALTER TNE COVERAOE AFFORDED BY THE POLlCIEB BELOW, Portland 2+� OY101- �5��5��'��+E ixsu�o ttxa��FxaMASS 1P/C POOL HA83 RIVER YACHT CLUH, INC ius�ae: P O HOX 182 � INSURERt: � HASS Rivax � ao: MA 02664- i�� COVERAGES TNE POLICIES OF INSURqNCE LISTEO B�OW HpVE BEEN ISSUED TO THE INSURED NAMED A60VE FOR THE POLICV PEQ10�INOICATED.NOTN�ITHSTANOING ANV REOUIRFlu1FNT,7ERM pp CONDITION OF ANY CON7AqCT OR OTMER DOCUMEM W�TH RESPECT TO WHICH THIS CERTIflCATE MAY BE ISSUED OR MAV PERTAIN, THE.IIVSUR�WCE AFFORDFA BY TTiE POL1qES UESCRIBED NEREIN IS SUBJECT TO ALL TFiE TERM$, E7(CI,USIONS AN� CONDRIONS OF SUCH POLICIES. AGGREGA7E LIMfTS SHOWN MAY NAVE BEEN REDUCED BY PAID CUUMS. �N9R 7YPEOFM9�1RiNCE POUCYMM9EA W17�EYEFFECTNe POLICVP%PIRA7ICN LIMRS GENERAL IJABILRY I I I I FAGH OCLIIRRFNCE f mtiwEnca�o�eau�waiurv [� � (� f� � �!/ (�'s' � CWM9MnDE CJOCCUR � KIt�MMIAGE awM i ��.. �1�i9 L .1 2�+'+� / / � � NEU E1a ms S � PERSONALepDV@uURY S GEN'�AOQREGn7EUMRAPPLIESPEft: . H��LTH DFPT. I I I I OENERAL4F6RE�Gd'fE E p�p .—,.<�. PROWCTS•f70MP/OPAOfi S POLICV .iECT lAC � � � AUTOMO&LELu6WfY / / / / qNy AIfIp Cdi18REU SINGLE LIMR (Eaeetllenl) ; /�LL OWN�AUNS I / I I SCNFDULE0IUTOS BO�N.Y INJURY �� S HIfiEOAUip$ / / / / NONOWNEOAUTOS BOORYMJURY fPorecmeny S �i / / ' / vFOPE7ifY0AAlAGE tE'a.aaanu s GANAf�114BRRY auroau�r•w�caoan s ANVAUTO / / / / O7HERTFYW �nce s AUTOOAR.V: AGG S IXCESSWBIuf7 I � I I CUIiRENCE 9 OC[UR �CUIN6 MhDE iC,!',qEWTE S DEDUCfIBLE ' / / 5 IffTEpfIION a / a � a EMPL�OYERY�TIONAND , / / / / s .E.t-E4u1ACCI0ENr E 100�000 svic es4 s5 93 07/O3/2001 07/Ol/2002 E�o�s�-��r�.cr�Ea io0,0o0 MIIFR ELDI9E0.SE•POLIGYL9AIT s 500,000 � � � � OEdCfUPT10N OF OPFRA710N&LOGAilON.41VFM4_E&O(CLIIEIONBADCFb 9Y ENOOR6lMENT/9P�ULL PRONSIONB BROOB OF � CERTIFICATE FIOLDER nocmowu wu�n�x�r�: CANCELLATION aHano uw aF nie neovE oenaeeo vouc�s ee cAwceu.m BEFORE 1HE ovn�now mrE nirneos� n�e �ssurpo meuaa� r�� uoenvoa m wu� Ol D owrs wwrteN Nonee ro n�e cam�c�te iawEa nartv m nre��r.eur TWdd OF YARMOUTH, I+plSS FAILtIRE TO DO 90 SIULL�MPOSE NOOBU0111qM OR W1BN.f1Y OF AMY IOMD UPON TIE ATTN: DAVID FLAHERTY JR I RSAGENTSORR9RE9EMATN68. �� 1CORD 25S(7/97) �n IN50253�es�o�.o� aeCmorHc ueER Foru�s,iwC.-feoo1s27ae4.S m ACORD CORPORATION 1888 aape t e�z TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISfIl4IENT PERMIT NUMBER: #02-070 FEE: 525.00 In accordance with�ations prom�gated'�mder authority of Chapter 94,Section 305A and Chapter 111,Section of the Gen La permit is hereby ganted to: Raas River Yach C:1 �h Fm hi gham Wa� Sn � h Yarmo�th_ MA Whose place of business is:_ Bass River Yacht Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth Permit e�[pires: December 31_2002 BOARD OF HEAL'rH: eka�ea� �d�li�, �(/Fadr�c : D. �mrda�c. �AG.D.. �/�ee ,�. �, Gr� �� +'f� Skak .�1. � ��h i ,2002 ' ruce G.Murphy, .,CHO Director of Heal j i ; I I � � i i -r - _ �,,.� �-, �, �,, ,�aass R�v�,z Ya�+T cws , � TOWN OF YARMOUT RD p�H�. H�� ' � � d � � APPLICATION FOR LI��ExNnT-2ooi DEC 1 1 2000 • Please complete form and attach all necessary documents by December 31,2000. Fai the return of your application packet. ---------------------------------------------------------------- -----------------�---------------------------------- � � ,� � � �� —� �. O . U GZ Co MANA R' N ME ��,�j&� � � Lih/ql� ` .4��s�a, TEL #Tv� 3,qJ�-rYu,�,� IvIAILING ADDRESS: -------------------------------------------------------------------------------------------------------------------------- POOL CERTIFICATION : The pool supervisor muat be ceriified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2, Pool operators must list a minimwn 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 uae past yeara' records. You must provide new copiea and maintain a file at your place of business. 1. 2. 3• 4. . MT.I H .RTIFI ATION • 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 ttris form. The Health Department will not use past years' recorda. You must provide new copies and maintain a file at yoar place of business. 1. 2, 3. 4. , RESTAURANT SEATiNG: TOTAL# NON-SMOKING SEATS: TOTAL# j _ __...t_�----- r=-- 3---�------`--�----- ----=-_------ ---------�,__��.�_��------------- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 _TRAILER PARK $50 i _MOTEL $50 _SWIMMING POOL $SOea. � WHIRLPOOL $25ea. ' FOOD SERVICE: — I NOTE: Per the new 105 CMR 590.0011 State Sanitery Code for Food Estabtishments,the effective date for i food protection manager certification is October 1,2001. LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $75 _CONTINENTAL, $30 _>100 SEATS $I50 I NON-PROFIT $25 ( � _COMMON VICT. $50 _WHOLESALE $75 RFT t . .RVI . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 TFROZEN DESSERT $35 _>25,000 sq.ft. $200 N MF.['NA �.• $]Q AMOUNT DUE _ $ 25.00 •*'•*PLEASE TURN OVER AND COMPLETE OTHER 3IDE OF FORM••*"* :� ; " - ' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of.any'�ie�'ar�Letiriit�to operate a business if a person or company dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSLJRANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ,�' NO NOTICE:Pemuts run annually&om January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETCJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLISFIlvIENTS ARE TO CONTACT TEIE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVAT'IONS 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. AnnrTr NAr REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Heaith Department,and the water tested for pseudomonas,total coliform and standard plate count by a State cerhfied lab,pnor to opening,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swinuning pool must be drained or covered withiu seven(7)days of closing. FOOD SERVICE �c� eT,►�r� cswrTeuv rnnF F(lR FnnD FSTARLISHMENTS• The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-chazge who is a certified food protection manager. This pmvision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for consumer advisory is January 1,2001. As stated in 105 CMR 590.000(K),enforcement of Consumer advisory,Food Code 3-603.11,will be implemented January 1,2001. Only establishments which seil or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATFIZiNG POLICY• Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service ApplicaUon form 72 hours prior to the catered event. Thses forms can be obtamed at the Health Department. _ FROZN DESSER7'S• Frozen desserts must be tested on a monttily 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 unril the above terms have been met. OUTSIDE C�FFS• ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),�S have prior approval from the Board of Health. nITTDOOR COOHING: Outdoor cooldng,preparalion,or display of any food product by a retail or food service establishment is prohibited. � 'l DATE: ��r C__ >/ �r�72� SIGNATURE: ! �' , l�� PRINT NAME&'I'ITLE: ��-lCl rz-��n , G��>r i i� % 11/16/00 � ` � The Commonwealth ojMassachusetts : Depnrtmenl ojlndustrial,-iccidents � ; 0ll/Csol/eresll'falns 600 Washington Slreet Boslon, Moss. 02111 W'orkers' Compensation tnsunnce Afftdavit A..niironk infnrmofinm �P93l��Tl�i��1�11. oY 1 mm�� j Gt5� � ��1.0 ✓ l� iC� Fl �' r" � ��3 loc�tion �� n� �/ ln �/� �n U �. � J'f� � ;•r„ "K a;�Cn . �SL��T�Qhone N �(� �%� ��b'-�70 � � 1 am a homeowner pzrtortni g all work myseif. � I am a sole proprie[or�::d ha�e no one �corkine in any capacih� � I am an employer pro�idin�workers' compensation for my employees working on this job. comRan� name� ��(iS�_�6t��1�" C 'L '� _ . �Jdress [ �} �i 2-.....� tii� � ��/� rwv�n� ll/lu� phonel��_�� i � -r� 9q � insur�nce co ��_� �� '� � � �� policy k �� - I 1�5 -�� R'' � I am a sole proprietor. general contracror, or homeowner(circle onel and ha�e hired the contractors lisred below ��ho ha�e the follu«in_ �corkzr .ompensation polices: vn m • r � phone N• '�sur�nce co Do�Y p � � phoee IE• in rance co Q�M - Failurc m secure covenge as required under Secuoo 25A of MGL 152 n�lead to tYe i�paitloa of eridul pe�dtln of a O�e�p w SI,S00.00��d/or ooe yean'imprisonment�f wtll at eivil penaltln io Ihe form ot�SfOP N'ORK ORDER aod a Oee of SI00.00�d�r K�iott me. t a�denn�d tlut� � copy of thh satement may be forwarded to�he ORte o(Invntigatiom of the DU for eovenge veri0utlw. /do hrreby cenij}•under the pains and pena/�in ojperjury�hat!ht injormation provedtd above is t�ue and eorrea. � y �- Signaturc��.e.�_Q, ' 's,�/�• •�:ay Dau l� � �2E�17J Printname in �,U-�_� ri' L�co PF'u"eIt ��" 3Ga • �/y/j— .. oRci�l use only do not w ritt in this area to be completed by tity or town olfleial city ar town• Y�HODTQ permiNiecox M nBuildiog Dep�rtmeut ' � pLieeosiog Bovd �chetk if immediatt responae ia required Z61 0��«1Oen'�Olii[e j QHcalth Dep�rlmmt contact person: phone a;_ �508} 398-2231 eat. nOt6er i „n�,�e i,05 V1A1 , . , _. . . _ . .. , ... _... .� .., �., , , . , ,�.. _ _,. . . . . . . . . _ ._ _ . � .;; � � i � , o � � U N � �• � i � ,� � � E- W � ��c( -� �;� ', � w � �,��o A q �,x I � aY � � ■. „ C7 o y , � �d' r� � � ' � � � � � � oa G I � F � ° � � p .7 A .�L � � wo ��y x dxw � @ c`' �" �" a a w � p �O d' � � EW„ b3 w � d � ``" O � aa O � W 6 � � � � .� , F � ''� C� � O C � e' F •�$ � F o =`" � � � " .� � . a�. Q y 4 ;$'� C � a C� 3y� '� d � . i . . � U � A y � � . '� . � y"i N 'O� p � �O v� t�� 'y � �7.. " . � . z �� M�e �0. ` /. i'� � ! .s,� . . . E'� ..�.0 a W � � %� �a�' {�t��i,a �� .:�f � y 0 ..�i �`I e'�� , '- s • � � � o � w � a H E° a , , �. , i .* . .+. � � ; . , , .� , •� , � �, , , . . , < � rsr � �'�- r �: �' F -r' � . 4 F . +e . �- 4 �� ` �. } � � i � �t <a 4 . ` . t � � 'f . f r ._ I [ i _ ' ¢ � '� f� ��. yD d � � j� 4 3�` �� ' t�. f t �f�,��it � �•` 'if �vt{� )t e .rk' .?��.3' s�- s� �'� �'.� i�. a rr it 1 't'�� €a ��f ��p ' y r �� -� �� 'o .+.s�i ,.h N j°.<°X'1F '4 7 �s�:��/K >kR`H �, a .� 4 t i'. �f .b a r �• x�' �`t li 1 3� # ±. # ��„• y, �N �r . �s�: ,{� .� _:` T'�"`��;�� ;; - _ � e � :. �°=f � . _ . r s � ; ,. d'X.a 55�F2i��i' y�C�'l� C' 11,(�J . � TOWN OF YARMOUTH BOARD OF HEALTH p � � r� � M � � X , APPLICAITON FOR LICENSE/PERMIT-20000 � D E C 1 3 1999 * ��'18� �� T;; ;�.:: .. i Please complete form and attach all necessary documents by December 3 , 1999. Fail w9N result in the return of your appiication packet. --------------------------------------- ------------------_��---------------------------------� F -� L # - a I I. TI �— q c D % �1ANAGER'SNAME F^�lT.i��vs�r� ns�n �lj'GP 3gL �l— �.ING ADDRESS� POO ��RTIFI ATIONR�____��__��____��w�_�___`----------------- ----- The pool supervisor must be certified as a Pool Operator, as re�uired by new State law. Please list the designated Pool Operator(s) and attach a copy of the certi&carion to tius form. 1. 2. Pool operators must list a minimum of two empioyees curretrtly certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certiScations to this form. The Health Department will not use past years' records. You must provide new copies and maiotaia a tile at your ptace of business. 1. 2. 3. 4. F7FiMT I .H . .RTIFI ATIOIQ All food service estabGshments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at atl 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. 1. 2 3. 4. RESTAURANT SEATING:- TOTAIr# - AIUN-SIVIOKING�A�'S: TO�AL� —_—___--------_----_------------------------------- -------- --- i,�M,IN� OFFI E SF nNi.v LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# _B&B $50 _CABIN $50 ` _INN $50 _CAMP $50 _LODGE $50 _TRAILER PARK $50 MOT'EL $50 _SWIMMING POOL $SOea. i � WHIItLPOOL $25ea. , FOOD .RvrrF• I LICENSE REQUIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# _0-100 SEATS $75 CONTINENTAL $30 , , . I -�rOQ _>100 SEATS $150 I NON-PROFIT $25 �-�Y _COMMON VICT. $50 _WHOLESALE $75 R�T ii SERVI E• LICENSE REQLTIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $Zp _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,000 sq.ft. $2pp NAME AN �.� $10 AMOUNT DUE _ $ L i'- """PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM••••' � ADMINISTRATION - UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI�TOWN OF YARMOLJTH IS NOW�EQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS tF A PERSOlV OR COR�Pt1NY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPEN5ATION INSLTRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTf MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA}�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK A�PROPRIATELY IF PAID: YES_� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILTTY TO RE'TURN Tf� COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHI�4ENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIlVG FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. Ai�DTTIONAL REGUi ATIONS POOLS POOL OPEMNG: ALL SWIl�A�IING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSfiUDOMON.AS,TQ'�AL COLIFORM AND STANDARD PLATE COUNT BY A STATE-CERTIFIED L.A�,-- PRIOR TO OPENING, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIbIlvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE ('ATFRiN POLICY• ANYONE WHO CATERS WiTHIN THE TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING TI-IE REQIJIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TE� CATERED EVENT. TF�SE FORMS CAN BE OBTAINED AT TF� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS M[JST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. 'I'EST RESULTS MUST BE SENT TO Tf�HEA1-T'H DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN Tf� SUSPEN3ION ORREVOCATION OF YOURFROZEIV DESSERT PERMIT UNTIL THE AB�VE TERMS HAVE BEEN MET. �iTSIDE C?LF'FS: OUTSIDE CAFES(i.e.,OiJ1DOOR SEATING WITH WATI'ER/WAITRESS SERVICE), MCTST HAVE 1'RIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTI>OOR COOKING: �, OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD , SERVICE ESTABLISHMENT IS PROHIBTTED. DATE: l_�3�I/Tq �.�SIGNATURE: �.-�l'7�i ,��ss-�g.�— PRINT NAME& TITLE: '"�^• . U�� 7�'� »� 11/12/99 � , The Commonwealth ojMassachusetts s = Department ojlndustrial,-iccidents ` z ; Ofllee o/%rastlOsWis 600 Washingtox Street Bnston.Mass. 01111 w'orkers' Compensation Insurance Affidavit Aonlicant information: PlessePRiNT'TesGi� n J � namr: "'�I�.LF�K�'liY.- �� C.h�- � �G[�i • Lacatian� �>� �'G, z� �pfi W � c�t� � 1�� .Vr.. �n� �� ehone M �S'�L` -� 9 y- 970 l � 1 am a homeoµner pzrformin all work myself. � I am a solz proprieror ar.d ha�z no one «orkine in am capatin• � I am an employer pro�idine workers' compensation for my employees workine on this job.__ _ _ comnan� name: �C�SS ��'�,�- ✓ �,S_hh � �la,�7 � �JAress: � i��' ��2— ��: S ��Cl �7')')!/Gl � ��/��' ' phone N: ; O Y- ��C� �'7�l � _ � inc��rnnceco � ! m � j �f � ry;Si�ine��e oolievlt ,��Q1L �-2��14J � I am a solz proprietor. general contractor, or homeowner(circle onel and ha�•e hired the contractors listed beloK ��ho ha�e [he follo��in; uarker; ,ompensation polices: m vn ad d ress• cin'• ehone k• -- ��r�n ce co polie�•# comoanv name• - - ---- - addrc�•• u�• phoee Ih. _ insyrartceso ��n'M 1 Failure to�eeure covenee�s requved uoder Seenoo SSA o(MGL IS2 n�lad to tYe i�paiCw o(tri�i�l pndtle of a O�e op m 51300.00��d/or ooe ye�n'imprisonment u w�ell aa tivil peadHa io Me form o(�STOP WORK ORDER aW�6�t of f100.00�d�r q�inst me. f a�denta�d that a eopy of thn sa[ement m�y be fonv�rded to the Ofiee of Inva�it�tiom otthe DIA tor eoveri�e verillutfe�. 1 do hrreby cenijp under rhe pains and penafties ojpery'ury that rhe injor�on providtd above is bnt and rnrrcet $ignaNrc �7J'/�//i� .� � i �/i�ii3"-- Date �1-J/3 �9�i. Print name ��l�LpQ��"��L4�j'�i�S�. •�� Phmrc N �S'/lF� -� -ri f<. �v l� .• otTcial use onl�� do not write in this are�to be eompleted by eih or towa olfleial � tily or town• Y�M�DTQ _ � permiNicenx M nBuilding Depirtmm� - - �Lieeosiop Bovd ' � cheek i(immediate response i�required 261 pSeleetmen'e Oflict '� �HnItE Dep�rtment �; conroct persan: p6ona N:_ �SOH� 398--2231 est. nOtAer TOWN OF YARMOUTH � ' BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: Y2K-65 FEE: $25.00 In acwrdance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter I 1 I, Section 5 of the General Laws,a permit is hereby ganted to: Rass River Yacht Ch�h Frothing am W South Yarmouth MA Whose place of business is: Bass River Yacht Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yannouth Permit expires: December 31. 2000 BOARD OF HEALTH:� �/. .�at��/�, C'�,a�.q,��aq � n �oan.� �u[[ivan� �//., Vica C��drma ,�oca.�.� t�„�,�, c�,� a6.i.�.�a��,&y-Jdoo� �� 0�('0��1,� December 22 , 19Q� Bruce G.Murphy,MPH, .S., O Director of Health i ' i i i � a '�nssRioeryc�+tClub �s3� � . ��. � . TOWN OF YARMOUTH BOARD OF HEALTH _„ APPLICATION FOR LICENSE/PERMIT- 1999 � �:: +,; �j � � D • Please complete form and attach all necessary documents by December 31, 1998. Fail re�o� S�o 2vi�ult the retum ofyour application packet. NE;\i. %+ DEP - - - -------------------------------------------------------------------------------------- T•-- - � . # -970/ O A I D � titu�� 9WNER/CORPO ATTnN NAMF LVIANAGER'SNAME: C�NiarrV�SON - L�i �N�A Tntl�u BpJ TFT # 87r8-39' 7�6r 1�AII.ING ADDRFSS� ------------------------_____-----_—__---------------- --- - -------------------------------------------------------- POOT CERTIFICATION The pooi supervisor must be certitied as a Pool Operator, as required by new State Iaw. Please list the , designated Pool Operator(s) and attach a copy of the certification to t}us form. , 1. __ 2. Pool operators must list a minimum of twoemployces curtently 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 tivs 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. q. HEIMI,ICH CERTIFI ATTnN4 '' 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-choldng 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 maiatain a t"ile at your place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# i ------------------�_��_..._�_��_----------------------------------------------------- , - _ _ _ _ O E .flNLI�__ _ - - - -- LODGING: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $50 i _INN $50 _CAMP $50 � _LODGE $50 _TRAILER PARK $50 I _MOTEL $50 _SWIl�INIINGPOOL $SOea. i _WHIRLPOOL $25ea. FOOD SERVI E• � I LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # ' _0-100 SEATS $75 CONTINENTAL $30 i — _>I00 SEATS $150 I NON-PROFIT $25 �-/(ea _COMMON VICT. $50 _WHOLESALE $75 RFTAii•SERVI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 TOBACCO $Zp _<25,000 sq.ft. $75 _FROZEN DESSERT $25 _>25,000 sq.ft. $200 1�1AMF f AA $10 AMOUNT DUE _ $ Z'rj "•"""pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••••• .� -. : ADMINISTRATION • � LJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-�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 STA'1'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK PROPRIATELY IF PAID: yES� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. iT IS YOUR RESPONSIBII,ITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIvfENTS ARE TO CONTACT Tf�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQiJIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CONIIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAi RF_(} TI�IONS POOLS POOL OPENING: ALL SWIMNIING, WADING AND WHIRI.POOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY TI-�HEALTH DEPARTMENT,AND Tf�WATER TESTED FOR PSEUDOIVIONUS,TOTAL COI:IFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY Tf�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlvIlvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE ('ATERTI�IG POLICY_ ANYONE WHO CATERS WITHIN TI-� TOWN OF YARMOUTH MUST NOTiFY Tf� YARMOUTH HEALTH DEPARTMENT BY FILING Tf� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TF�SE FORMS CAN BE OBTAINED AT Tf� HEALTH DEPARTMEN'1'. FROZ�N DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEAI-TH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL THE AB�VE TERMS , - — -- - -__ - - - HAVEB�EN 1�fET. Q_i1TSIDE CF��S_ OUTSIDE CAFES(i.e.,OUTDOOR 3EATING WITH WAI'I'ER/WAITRESS SERVICE),�T 'C HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. , Oi1TDOOR COOKIl�I�: QUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY POOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISfIMENT IS PROHIBTTED. DATE: �f17�99 SIGNATURE:��LL� �/�� '"�"J PRINT NAME& TITLE:�/.v°w �•vp� -` i _ . , � I The Commonwealth ojMassachusetls � : Departmen!ojlndustrial,accidents ; 9lflce o//iresUislJiis ' 600 Washington Slreet ' Bnston.Mass. 01111 " W'orkers' Compensation Insurance Affidavit �A�n�lir�nf infn�m�Hnn• �e9fCp��N� n�m•. �,.�, ��af-cc� �. Inr�linn' � A�t� A/XN/ �iUQ�.�' . `77l,� a �f�51�r - 9�lI / � I am a ho eoµner pertorming all work myself. � I am a solz propriemr�cd ha�z no one��orkine in any capaciry � I am an employer pro�iding workers' compensation for my empioyees workine on this job. __ �Jdress• 7�-/� �SS� � �.R . �� sunnce co � .9 fl'7 �/7LL�U+�� oY -�� /- oolicy�� 4'��-ao`20 / 4_1 � � I am a sole proprietor. _eneral contractor, or homeowner(circ/e onel and have hired the contractors listed below «ho ha�e the folluwin� «orkzrs compensation polices: vn �'dress• �� yhone N• � � i sur�ntc co oelicr# �, o�oee M• - � �; 'ns�rance co ourtev M i �, Failurc to�ecurc covcnge as required under Seerioo 25A of MCL 152 n�lad to the iopaidw of eri�inl pwdtla of�6�e�p to f1.500.00 a�d/or ooe ye�n'imprisonmrnt a w�ell u eivil penalHa io tht form of�STOP WORK ORDER�ed�Ilot of SIOO.OU�d�y Kd��- ��nb��t a � eopy of thh statemrnt m�y be fonvarded to the 011ice of InvesNa�tlom of the DIA for eoven�e vedBu�iw. 1 Ao�hrreby certijy unde�rhe pains and penalNa ojpery'ury�ha��he injormation providtd abovt is t►rt ard eorrtet Signaturc��..,� ' Due �/»/9 9 � ' Print name�tL.0 '^1 �� /1� Phone M S7� h�-�/fs - 74ti i � I . oRciai use only do not write in this�re�to be tompleted by eity or towa oflleial ei or town• Y��Q _ permiNieeex N nBuildiog Dep�rtmeet 4' pLiceesioe Bo�rd �ehetk if immcdia�e response ie required 261 �Seleetmto's Ofllee �He�lth Dcpartmeet pnone a:_ (508) 398—?231 eat. naner � coo�act person: — Uo�isM i,a5 PIAI TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-168 FEE: $25.00 In accordance with requ1ahons promulgated uuder anthority of Chapter 94,Section 305A and Chapter 111,Section�of the General Laws,a permit is hereby gra¢ted to: Raac River Yacht C'lub Frn hing]�gp1}�Sy,Couth Y rmn � h MA Whose place of business is: Bass River Yacht Club Type of business: Non Profit Food Service - To operate a food establishment in: Town ofYarmouth Permit ea�pires: nP��ber 31. 1999 BOARD OF HEALTH:�pd�/. .�at�pe�, �'�(�:�Q/a�.. � / /� `��joan. �c�� /u�llivan�/KJa.///•� Vice 1.��''�n' � lCo�ert J.�O�7rouipn� C.[e/r/k � a6rie�Ja�rol��ry-JdoaPe! �kl �0'o('ouy��n Febmarv 24 , 19 99 Bruce G.Murphy,MP , .,CHO iDirector of Health i i � � � I i ; i � � �