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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 � TOWN OF YARMOUTH BOARD OF HEALTH ��p� '� � er^" ..1� � �r -.; ;�� C � f�. [J � APPLICATION FOR LICENSE/PERMIT,Y�� \�r 5 �5 � � � -, ,(`� ` E(� ~ * Please complete£orm and attach all necessary documents y l�inber 15 271b81 5 2008 Failure to do so will result in the retum of your ap�anon pac H Lq��n pEr�T. NAME OF ESTABLISHMENT: �i a` a.2 i<s TEL. # �7Y 13 e o��7 LOCATION ADDRESS: 9d� 2wk Z Y> MAILING ADDRESS:_'� yt�MM '�. w. Y Rx„^�^ /ln/�- �ZG 73 OWNER NAME: 1,� �z C�1S�n� TAX ID lFEIN or SSN): �� CORRORATION NAME (IF APPLICABLE): �Q (_—��a,,,t,;�S•s MANAGER'S NAME: 1w�� G(S�N TEL. # 7�Y L3� Gbi� MAILINGADDRESS: `� YpQ.,�«n '�^ t.�. y�r��, ,�� oz�7 � � POOL CERTIFICATIONS: The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated i Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Caz•diopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments 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 tile at your establishment. � 1• � ��'�t LS�i.� �C��avs�4 2. � PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. � 1. P 1�c� �S�/� 2.��5��r� i HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and � attach copies of employee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a Cle at your place of business. 1. 2. � 3. 4. �' RESTAURANT SEATING: TOTAL# � I OFFICE i7SE ONLY LODGLtiG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIltED FEE PERMIT# . _B&B S55 CABIN S55 MOTEL $55 � _INN S5� GnMP 555 SW"LVNIITiG PGOi 580ea. _LODGE S55 TRAII,ER PARK 5105 WfIIRLPOOL 580ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIl'# I 0.100 SEATS SSS —/(� _CON711VENTAL S35 NON-PROFTI S30 _>100 SEA'IS 5160 � COMMON VIC. S60 �Q_�=�,5 _WHOLESALE S80 RETAIL SERVICE: —RESID.ffiTCHEN S80 LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERNfIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.B. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25 _<z5,000 sq.ft. S80 _FROZEN DESSERT S40 'IOBACCO 555 �n�7Ecua:�cE: sio AMOiJNTDUE _ $ �45•00 *""'"PLEASE TUR�I OVER A'VD CO.'1�LETE OTHER SIDE OF FORYI**••* ,, . _- ADMINISTRAI'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 AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR 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 MOTELS AND OTHER LODGIlVG ESTABLISffi1�NTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 generally refer to corninuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninery(90) days within any six(6)month period. Use of a guest unit as a residence or dweliing unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be wnsidered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ecced by the Heaith Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opening.PLEASE NOTE: People are NOT allowed to srt 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 closing. FOOD SERVICE I CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Deparhnent by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtau�ed 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,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits cun annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITI'TO RETURN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER I5, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENl', ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I Z �L G SIGNATURE� PRINTNAME&TITLE: �^�2c� �� r,w+�� io�zi�os �\ TI�e Commonwealtk of Massachusetts Deportinent of Industrial Accidents �fiQld� ' 600 Washington Streey 7`"'Floor ; Boston,Mass 02111 Workers'Compeesatios Idsoraaee A�davk:BaildSog/plombisg/Ekctrieal Coatnetors ��, MB�tNt.�a�'d�Ue�� PkaMe PR111P1'I.oiN.. . .. � aa�oc: '�-c��2' ��l�irJ � addass: 3 /tPc»nM� � . , � �w) 7 r'�.+r WI'� staM� Nl�' zio_ d1�7 Z ohme# '?7'f d,3 fi �v/) wrork site location(full addcessl: :. � . . '. ❑ I am a homeowner performmg all wock myae(f. Project Type: ❑New ConstrucRai❑Remodel ' ❑ I am a sole�proprietor and have no oce wocking in anY�capxity• ❑B�tilding Addition � � ❑ I am an employer providing workers'compensation for my anployces wodcing�this job. . . '' �m�o��: �NA�. �`�,i#ri�•--- _ _ �: y8� Qwk +3`1 Pv `�� rys7 , ac�-. _ So �nn�s ,IN4 oZ�rGo � r• S�J`G �f'�d-G66o �. � �M T s,�� : c�Gs7Cg5'6 �i ❑ I am a sole propridor,ge�eral ewtractor,or homeowwer(circle ane)and have hirod ihe conhxtas�listed below who have tl�following wotkeis'compwsatipn polices: . . � . m�v�me. . . � . . � ad�caf: . . . � � . � . � � . i �'� . . . . � o�o�e N• . . � . - � . . . . � hma�te eo. � . �p . . . . . . . ., .. . ._. _ , . . _ _ . . , wcvd",'��;f �YOl• I I �� I� �'�. . . . . . - �� - �e M' _ . . . : . _- �- --- - � - - _ . -_� .__. _ -�---_ _� .. __._.__ . ._.. . �1��t - . . . . . . � . .ealiev# . . � .�. t� FaYme�� odvSxtlr75AdMGL152u�kadblYe4�nilWdabiYtpnfqb�fa�elpbfl,SKMmN�r '�I e�eYens'I�Ptieawt n w�H as dH pa�itlp h tYe fa�a Ka 3T07 WORIC ORDEA ud�Boe KS1N.N�day ap�t en 1 adaahM tMt■ apy�ux a.o�..y ner....,.a�e oe�ome�.r�u.�eru�nu�r��u... !do 6arby cakjy rnler tG anJpeneh}es ofperjrry tAiet Me iafara,aMn provlAel sbore ie bve m.l co+rect� . . Sigoazure . � Dste � 2�/Z�(�t? �� '�� c��,r� rno,K a 77Y a 2 it oc�� ) .mcw..e o.ry a.aat.rrke b w..re,a ee m-Wetal Dr dlr.r ww..�iat . . . . eHy ar fawe: � P�K I�IBvW�.e Depudeel ❑ehect HimseBale Rapme b m�Wxd . � � ' ��d ❑SdxbnY Omae . . QI�aMY Dmatdnt awhet poaen: �y. �p <s.aea srt maof TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-115 FEE: S85.00 In accordance�vith re¢ulations promulga[ed under authority of Chapter 94,Section 30�A and Chapter � i l l, Section 5 of the�,eneral Laws,a perniit is hereby granted to: i � TOP Enterprises, 928 Route 28, South Yarmouth, MA � i � Whose place of business is: Blondie's Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth ' Permit expires: December 31. 2009 BOARD OF HEALiH: .`�Eeeen SPtal�, JZ..N., Clfaixr►tan i C'lEauF.eo�. 9CeP�iPee�e��ece C'Peaixma�c � Seating: 12 .�O�PJIE .t. .�M4(WL� iQ.ruuc C�ceeraBaurn, J�2•N- i �ueP.��e `.P• 3Eat�e�r � � � Januarv 8,2009 � ruce �P Y, � , Director of Health ( THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-076 FEE: 560.00 This is to Certify that TOP Enterprises d/b!a Blondie's 928 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yamiouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .q`�E�e�Ce��r�t�S� Ptpa�Pt, JZ..N., CP!c�a�banan SEATIKG: 12 ULL(3ce0 Jf.. .7CP.C�.[PLP�X,j V�ICC �Q.IXI)lOff- .�aB4llt S_�KOUlIt, CCRXR Qitlt �(�CQft�c�Q,U,�I�1�L��✓Z..IY. �(JQ.�A�[-.�' """yu' Januarv 8 2009 Bruce G.Murphy, , .5.,CHO Director of Health • �` '�".".y TOWN OF YARMOUTH BOARD OF HEAL � `= �= �' '? � M '� DD r � ' APPLICATION FOR LICENSE/P �,,0 � � r��t s= ��`�' MAY t> 6 2008 * Please complete form and attach all necessary$�a�u m�t�y �� c�,�- Failure to do so will result in the retum o ur appl�cahon pac NAME OF ESTABLISHMENT: � l on�ie� 1 CoC.�,.v� TEL. # ��y Z��l �/7 LOCATION ADDRESS: �i� MA:,, 5� . MAILING ADDRESS: �/11oM n� �C 4��{ �a AiZMaAW M m2G73 OWNERNAME: �1�� a�� TAX ID fF IN or Nl� CORPORATION NAME (IF APPLICABLE): (Z�P n�,e��zes MANAGER'S NAME: ,jc�4„ (7�,�,J � TEL. # 77Y 23f1 MAILINGADDRESS:_�vvo�,�n,�,J �c �a�F �./�trn�,tf nn,tl� c>2�'7? POOL CERTIFICATIONS: T6e pool supervisor must be certified as a Pool Operator, as required by State law. Please list the desienated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently cenified 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 aad 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 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 certificadontothis applieation. The Health Department rvitl not ase pasi years'records. You must provide new copies and maintain n file at,your establishment. 1. Jv�,,,, Q�Sdn� 2. P�R��N�T C�GE: : Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.��sa r-� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to tivs form. The Healt6 DeparYment will not use past years' records. You must provide new copies and maintain a Tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # _/2 �I I OFFICE USE O1�LY , LODGING: LICENSE REQUIRED FEE PER'�9T# LICENSE REQIIIRED FEE PERyiIT= LICENSE REQL'IItED FEE PER'141i= � B&B S50 CABIN S50 MOTEL �SSO � INN � 350 - CAINP S50 SR'IYLb1ING POOL S75ea. LODGE S50 TRAILERPARK 5100 RNIRLPOOL S75ea. FOOD SERVICE: LICENSEREQUIRED FEE PERMIT# LICEI+;SEREQLIRED FEE PER'ki1T= LICEtiSEREQtitRED FEE PER�fIT= � I0.100SEATS S75 �{'0 — 77 _CONTINENTAL S30 _NON-PROFIT S25 , _>100 SEATS 5150 / CO:�L4ION VIC. S50 atdA�/07 _R7-IOLESALE S75 � RETAIL SERVICE: —RESID.Kt7'CHEN S7i LICENSE REQUIRED FEE PERMI7= LCENSE REQL7RED FEE PERbIIi- LICENSE REQtiIRED FEE PERbil7= ' <50 sq.d. S45 >35.000 sq.8. 5200 _YENDING-FOOD S20 i — — , _<25,000 sq.ft. S75 —FROZEN DESSERT S35 _TOBACCO S50 VAME CHA'YGE: SIO AMOUNT DUE _ $ /�5.OCJ � "•*"•pLEASE TL'R.\OVER AXD CO�iPLETE OTHER SIDE OF FOR�S••*•" 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 dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tazces and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES_�G NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCl': For purposes of the limitations of Motel or Hotel use,Transient acwpancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use: Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90)days within any si�c(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room OcCupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: Ea��osea Motel Census must be completed and returned w�tn t�is aPp�ioat�on POOLS POOL OPENING: All swimming,wading and wtudpools which have been closed for the season must be' ected by the Heakh Departmem prior to opening. Contact the Health Departmem to schedule the inspection five(�days ' pnor to operung. ', POOL WATER TESTING: The water must be tested for pseudomonas,total co6form 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(?)days of closing. ' FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departrnerrt 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 desseRs 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 Pernvt until 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 of Heakh. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits iun aru►ually from January 1 to December 31. TT IS YOUR RESPONSIBILPI'Y TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�v1EE1VT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMME?10EMEVT. RE�IOVATIO�IS MAY REQUIRE A SITE PLAN. �.---_.... -`� DATE: S i a SIGVATURE: �,rv,a r"- e PRINT NAME&TITLE: I U�c` C)I.�iN (k„n tR �o s�o� 1 � The Co�ninonwealth ofMassachuset�s 1)epartment oflndustrial AccidenLs N�'tN� 600 Washington Stree� 7`"Floor Boston,Mass 02I11 � Worlcers'Compeasatioa Insarantt Affi�vk:Buil�og/Plambiag/Electrical Coatnctors Aoolle�etSrfw'ia�Hs11• P�Sse PINPTI'kwiFlo name: �� •�)\ � I-� . ad�lress: � IC'G �M �� I �tv � ��/1�'t(�.Mac ri'u state• /�l� zio �'73 oh�e fe �� ,3 f y �p,S`�.�3 i �,t 5tm io�ea��rw�sr `�i'�41 �in s�'- 5 �r1'hEmo�'1�1 Mf} ozFby � Iamalameowna Petf°�n8 all work myself. Pr�o�ect Type: �New Constmcuon�Remodel �I�n a sole�proprietor and have�one wodcing in any capacity- ❑Buiiding Addition � ❑ I am an�ployer�oviding workers'compensation far my�ployees wodciog on this job.. amoavnmr ��t rKn l � I�t q� � . �m�..: k 4�c � i3y P o `�, iys� dtr: Srs �¢nni5 M� o�(o6U �s# ��' �yc� (vG'(nC) . iesmaeaeo. N�rM LhSvrnn4 ��_ �� g B l��G'17 ��/�,�yf-*� S F� ..v�c ❑ I am a sole . . ��.. � PraPn��.8��cas�aeMr,or�omeoweer(drdi onsJ and have hiied the con4actois lisled below wlw Lave , the foliowing workecs'comPensatioa Polices: rld'rss• . . eitv: �� iesmaece�. � . # . . ; . ..,. . .. . . .. �,_ . . . .. . . � <.;.. -. , _ , :.,�:. comm�v mme_ �: ells: � � . . �� . ipRaaeem. odiev 8 � PaQutebxeaewve�ea�re9drN�IvBWW2SAKMGL132enkadMlYelspytlyKcfi�bal - � � . � .�.. ��-��'. °HG Ypn'�-P��t a wri as dN P��Mks d��R 1e f1,3M.N aeder�. p�ltles la the fma e[a 31'OT WORC ORDLA nd�8u atS100.N a dq�t se. I�denhad lhat a ep�yotHhshteseWs�yheNnv�rdedmtheOmceotlaveNigUpddHeDtAfrcevenge�I9ntl�, � l Co henby cerdfy ander NYePvJes anApeaallira ojperjxry t/`�Mr infarwratlon provFded abnw!s trre and mrrect SiBoatme�>i�- �/�/G� � �— Date _ Printname_ I v1�i �')' rJ Phoae# 77Y Z3f9 GG!] o�clal use onty de eat wrke fa thb ero to 6e mnpkfal pY a�ly o*bwn e�ial . . . . . .. � . eity ar towu• �S ❑eheck Himantla6e reapeme m ❑��6��t . Ce9ofuM �BmM maNc[pmoa: �'a��ce c�e s�mw� v�K�; � �� , ACORD CERTIFICATE OF LIABILITY INSURANCE OPID RS DATE(MM1VDDM/YY) TOPBN-1 OS OS OS � PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bryden & Sullivan Ins Agency ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE of Denni s Inc. HOLDER.THIS CERTIFICATE�DOES NOT AMEND,EXTEND OR 4 SS Route 134, PO Box 1497 AITER 7HE COVERAGE AFFORDED BY THE POLICIES BEIOW. . So. Dennis MA 02660 Phone: 508-398-6060 Fax:508-394-2267 INSURERSAFFORDINGCOVERAGE NAIC# �' INSURED WSURERA: NGIQ Insurance Company 14788 I INSURER B: � TOP Enterp riaes LLC �NSURERC: 3 Yeoman Drive INSURER 0: West Yaxmouth MA 02673 INSURER E: �. COVERAGES . THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOT`NITHSTANDING ANV RE�UIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUE�OR MAV PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH iPOLICIES.AGGREGATE LIMITS SHOWN MAV HAVE BEEN REOUCED BV PAID CLAIMS. I LTR NSR TYPEOFINSURANCE �� MILICVNFIMB6R LI YEFFE IVE PO Y PIMTI ... DAiE MMIDU DA:E M . . -.—._- . LIMLS GENERALLIABILRY EACHOCCURRENCE $ ZOOOOOO � A COMMERCIALGENERALLIABILIN $I�$R �4�15��$ 04/15/09 PREMISES Eaomurence a $0�0� CLAIMSMADE �OCCUR � MEDEXP(Anyoneperson) $ 5000 X BUS1IIE88 OWIl@IS - PERSONALBADVINJURY EZOQQQQQ GENERALAGGREGATE $ZOOOOOO , GEN'IAGGREGATELIMITAPFLIESPER: PRODUCTS-COMP/OPAGG 5 ZOOOOOO . POLICY PRO- JECT LOC � AUTOMOBILE LIABILITY � � COMBINED SINGLE LIMIT ANVAUTO (EaacdtlenQ E I ALLOWNEDAUTOS SGHEDULEDAUTOS BODILVINJURV $ . .. (Per person) HIRED AUTOS . BODILV INJURV $ NON-OW NED AUTOS (Per acdtlen�) ' PROPERTVDAMAGE $ (Pe�acdtlent) GARAGELIABILITY AUTOONLV-EAACCIDENT $ ANVAUTO OTHER THAN �pCC $ . AUTOONLV: pGG $ ' EXGESSIUMBRELLALIABILITY EACHOCCURftENCE $ OCCUR � CLAIMS MADE AGGREGATE $ � E DEDUCTIBLE S RETENTION $ a WORKE�COMPENSAT�ON AND EMPLOYERS'LIABI�RV TORV LIMITS ER A ANYPROPRIEfORIPARTNEWFXECUTIVE B=�gR OS�OZ�OS OS�OZ�OJ E.LEACHACCIDENT $ ZOOOOO OFFICER/MEMBER EXCLUDED? If yes,tlescnbe untler E.L DISEASE-EA EMPLOVEE $ 10 0 0�� SPECIALPROVISIONSbelow E.L.DISEASE-POLICYLIMIT 5 S00000 OTHER DESGRIRION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS AODED BV ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION YARMOSB. SHOULDANYOFTHEABOVEDESCRIBEUPOLICIESBECANCELLEOBEFORETHEEXPIRATION DATE THEREOF,TNE 15SUING INSURER N7LL ENDEqVOR TO MAIL ZO DAYS WRITTEN NOTICE TO TXE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL YARMODTH TOWN HALL IMPOSE NO OBLIGATION OR LIABILITY OF ANV KIND UPON THE INSURER,ITS AGENTS OR HEALTH IN3PSCTOR 1146 MAIN STRSBT REPRESENTATNES. SOIITH YI�MOjT'1'$ MA 02664 A� �OREPRESENTAT � � ACORD 25(2001/OB) OO ACORD CORPORATION 1988 , , TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-177 FEE: $75.00 In accordance with regulations promulgated under au[hority of Chapter 94,Section 305A and Chapter � (I(, Section 5 of[he Generxl Laws,a pennit is hereby gran[ed to: TOP Euteiprises, 928 Route 28 South Yazmouth MA Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food estabiishment in: Town of Yazmouth Permit expires: December 31 2008 BOARD OF HEALTH: ,`�E¢�¢ft $�[�, ,`R„N,� �n Glfaxf,ee 3f.:Keffi�c `11ice ('l�aiaanan seeen�: iz J`�a6ext s. `.,8�wuruc, @�exk ��«��, �..�v. May 7.2008 mce Director of He�alth' � ' i THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH I PERMIT NUMBER: #08-107 FEE: $50.00 � ' This is to Certify that TOP Enteroricec dn,iA RlnndiP'c ir r i ' 928 Route 28 South Yarmouth MA IS HEREBY C,RANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority grauted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: ,�EeP¢n$�q� ,`R.,A/,, C'��mcr�y SEAr[NG: I2 a� �� v� � �✓2a6ext 3. �B�,n, ('.�ex� �C�t' ee�� `✓2..N- May 7.2008 Director o He Ith � •,CHO i . _ �... . " " �{.s�'to� �(asm' - - - 3 oF�"�sc TOWN OF YARMOUTH BOARD Ol� �jI`� ;� �? r,� i� �' M r� � 2� APPLICATION FOR LICENSE/Ph'I7�q� � `��''_ `~" APR I 0 2007 * Please complete form and attach all necessary documents by Dece ber 31, 2006. Failure to do so will result in the retum of your application p c1E@�AL7 H DEPT. i NAME OF ESTABLISfIlvIEE1VT: �fO.Y/,�/.F.'.S .��CE C�.�6�jy! TEL. #SL '�7�.f17� LOCATION ADDRESS: g�Q�r �,v�,r� � B y,v,e,n�;rs� m,� i MAILING ADDRESS: .r/ /yJ O OWNER NAME:__ �i+/J9 /9'1i�i►6.C/G�'G'A TfL ID ((F�IN or SSNI� ��? CORPORATION NAME (IF APPLICABLE): y��/,��y��S��o �� MANAGER°s rra�:_C,.�-Ty �1.�.�u�� TEL. #��_D •7 -.S7'77 MAILING ADDRESS: ��,� .Q Y �� POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. �' 2. , � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The He�lth Department will not use past ye�rs' 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 establishmems 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. Piease attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a t"de at your establishment i. ��//fy/��.�� 2. PERSON IN CHARGE: Each food estabGshment must have at least one Person In Charge(PIC) on site during hours of operation. 1. C.ir�1�i _/yi�9ii�i.r/ 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich Maneuver on the premises at a(i 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 fde at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �_ OFFICE USE ONLY LODGWG: LICENSE REQilIRED FEE PF.RMIT'# LICINSE REQiJIItED FEE PF.RMI1'# LICENSE REQUII2ED FEE PIItMI1'# _BBcB S50 _CABIN �50 _MOTEL $50 _INN $50 _CAMP $50 _SWIIvIIvIItdGPOOLS75ea. _LODGE $50 _1RAII,ERPARK $]00 WFID2I.POOL S75ea. ROOD SERV[CE: LIC UIRED FEE PERMIT# LICENSE REQUIItID FEE PERMIT# LICENSE REQLJIl2ED FEE PERMIT# _al00SEATS $75 ��f– 7� _Cf�N17NENq'qI, E30 NON-PROFTT $25 / _>100SEATS 5150 Vco�oxvcc. sso �k6�—f65 _wxoLssas.E s�s RETAII.SERVICS: —RESID.KTTCIIIF,N S75 LICINSE REQUIRID FEE PERMIT# LICENSE REQUIl2F,D FEE PERMI1'# LICENSE REQIJIRED FEE PERMIT# _<50 sq.ft S45 _ >25,000 sq.ft. $200 VENDING-FOOD S20 _QS,OOOsq.R $75 � � _FROZENDESSERT $35 TOBACCO $50 �� NAME CHANGE: S10 AMOUNT DUE _ $ . ""•PLEASE TURN OVER AND COMPLETE OTHBR SIDE OF FORM""•"" /(/Q �G.1�/ ��C � ,-, ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CER'F. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yazmouth t�es and liens must be paid prior to newal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transiert occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Trausient occupams must have and be abie to demonstrate that they maintain a principal place ofresidence elsewhere. Tcansient 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 suf(6)month period. Use of a guest unit as a residence or dwe►ling unit shaii not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpoois which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate wunt by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool tnust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by Sling 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 resuk in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOI�TG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILdTY TO RETURN I THE COMPLETED APPLICATION(S)AND REQLJIItED FEE(S)BY DECEMBER 31, 2006. , ALL RENOVAT'IONS TO ANY FOOD ESTABLISI-IIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND ROVED Y Tf�BOARD OF HEALTH PRIOR ', TO COMA�NCEMENT. RENOVATIONS Q LAN ', DATE: �/O " D z SIGNA i � I PR1NT NAME&TTTLE: �omro� ` , � Tke Co�ruxonwealth of Massachuseris Department of Indusdial Accidexls �IM� 600 iVasHutgton Stree� 7`�F/oor Bostor,Masc. 02111 ..__ Worlcers'C� ' �Iisva�ce A�davk: 6i�g/Electrical Co�traehrs _ g� r*i' nsme: �-�//I'1� �/ +oC/�ICC+/� �: S/69' /l•.v.�J „�+SI� ciri �!�• y/Af�irlO�f�� state: /n/� ao:dc'GY�dane S ��1�s�� work site locatim/fvll addiessk ❑ I am a homaowar perfoimiog all wak myself. Project Type: ❑New Caostcucti��R�adel I am a sok 'dor and 6ave no a�e in� ❑B ' ' Addition I am an�ployer providing wakecs'compensation fa�my emp�yees wo�cing an fl�job. anaarv�me• L / 1� i1].�'�S � �i��CYJ�s.AI// _� . a�s: ��' I�/.r'/ uY�! ekv: �Lf♦ y/�iLd/7'ld!/� � aYsef: �1/��1/ �n. �—/,�F/�i�.c��i�B� s.GS � ..n�a O�- l.��G 11�!/ 35.�' ❑ I mm a sole pxrp�ietoy�SI catrxter,or romcsw�(arde owe)�d have hued the c�tas listod bdow who have the followin8 w�k�s'�mpe�taon Polices: n�e�t� �� : aire f: � / adiivr �Mv: nYa�eAk N FaYo+e r rene a�maae s nqWN uiQ SeWN 2SA dMC.L 132 en WA b IYe dpwMiw dai�Yd pYYe d�Le 3 bil ZMM uNr we yeu+'I�prir�nt n wd n dM pwltln 1�16e�ata 37'Or WOFK OBDBH uA a 9oe dfIM.M�dq aplet�e. I odenuW t�a apydtl6 he bHeOmcedL►�ndl6eDlAhras�evsrpintlM. /b A y cntlfy 1 Ma Me iwforwedw pnvlJel abaw h sae w�l csn�ect n� y id '07 Pcim Phoce N �7 Qa �� 5�� .�Yl.x wy a.sr w.�re r w�..r.�N e�o.pe�a br d�r.r r�.e.�Li dtyort.wa: pe�C (�Ikpafwt �Bend ❑thak H�1e�seae b`eqdvN ❑Sdst�ea'f Omee ❑FIWIY D4a�� tasiffipe+een: piNel; � f101� cmw�a Syt mm) TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISffiVI�NT i � PERMIT NUMBER: #07-171 FEE: $75.00 In accoidance with reQulations promulgated imder authority of Chapter 94,Section 305A and C6apter 1 I I,Section 5 of the�'ieoeral Laws,a peimrt is hereby granted to: Blondie's Corporation, 928 Route 28, South Yazmouth, MA Whose place of business is: Blondie's Ice Cream Type ofbusiness: Food Service To operate a food establishmern in: Town of Yarmouth Pernut expires: December 31 2007 BOARD oF I IEnLTH: 8 $. M.�., ' ��`s� �., v:�e� � s�w�g:i2 RodeRt4. B�, �k PaLr:c�(a Mo.�..v.,co1� +4.r,,y lj�, R.N. Anri112,2007 ruce ,R D"uector of Healtli THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-105 FEE: 50.00 This is to Certify that Blondie's Comoration d/bfa Blondie's Ice Cream 928 Route 28, South Yarmouth, MA IS HERF.BY GRAN7'F,D A COMIIZON VICTUALLER'S LICEN5E In said Town of Yarmouth and at that place only and expires December thicty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victua(lers. Tlris license is issued in confornuty with the authonty geanted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B $. /x��'�/_,�l.`.�5., . sEnnrrG: 12 d�e&�$�i, KJY., 7/ice e�sai•4nru.�c Ro%+tt 4. B3ou� Gl� Pa�a Mc$�ott A.�� R.N Arnil 12.2007 ruce ., Duector of H�ealth , - �#'`��ZO..��66' N s � � ��^R.y TOWN OF YARMOUTH BOARD O�$EALTH ' L� C� CG � � M �� DD I o? � APPLICATION FOR LICENS`�I�ERMTl'-2006 Ap� 0 6 ZODS � ,i= * Please complete form and attach all necessary dobnYrients by D 31, 200� Failure to do so will result in the retum ofyour application ALTH �PT. i NAME OF ESTABLISI�dENT: �e i5 � TEL. �'1 - i LOCATION ADDRESS: � MAII,ING ADDRESS: � OWNER NAME: ` T ID r CORPORATION NAME (� APPLI ��j'E : I'1 12.S � (G. D� MANAGER'S NAME: ( '�Z�1l,l � r lQ�(}i'1 TEL. # . -31 MAIL,INGADDRESS: �YYi� K1S A13c�V1� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please Iist 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 of employee ' certifications to this form. The Health Department will not use past years' records. You must provide new ' copies and maintain a file at your place of business. 1. 1��c 2. 3. 4. I�' 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 tlris application. The Health Department wili not use past years' records. You must provide new copies and maintain a Tde at your establishment. �. !,2�h�a �1�.hn� 2. PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge(PIC) on site during hours of operation. �. r�-N�� I�Y�nn 2. I�G�h lee n ��t,! HEIA�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 attaeFi eopies of employee certifications to this form. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2, 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQLJIRED FEE PERMIT N LICENSE REQiJIItED FEE PERMIT# LICENSE REQITIItF,D FEE PF,RMIT# _B&B $50 CABIN $50 MOTEL $50 _INN S50 _CAMP S50 _SWII�IIvIQJGPOOLS75ea. _LODGE $50 _TRAII.ERPARK SSO WfIIRI.POOL S�Sea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQiIIItED FEE PERMIT# �0.100SEAT5 $75 �OG�I70 CONTINENTAL $30 NON-PROFTT S25 >100 SEATS 5150 I COMMON VIC. $50 OG � D_-1 _WHOLESALE S75 RETAIL SERVICE: LICENSE AEQUIItED FEE PERMI7'# LICENSE REQUIItED FEE PERMIT p LICENSE REQilIl2ED FEE PERMIT# _<SO sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD S20 QS,OOOsq.ft. $75 1FROZENDESSERT S35 ��6�� TOBACCO $25 NAME CHAIYGE: SIO AMOiTNT Di7E _ $ 1 LO. 00 "•"•"pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•"^*" ADMINLSTRATION Under Chapter 152, SecUon 25C, Subsection 6,the Town ofYarmouth 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 AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. Pi.EASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Pemuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TQ RETURN Tf� COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR TIIE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISF�IENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQIJIRE A SITE PLAN. ADDTI'IONAL REGUI.ATIONS POOLS POOL 6PENING:All switruning,wading and whidpools 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 aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Applicarion form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERT$: _ Frozen desserts must be tested on a 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 Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ' bu�rnoOx COO�vG: Outdoor cooking,preparatioq or display of any food a retail or foo ervice establishme�rt is prohibited. DATE: SIGN PRINT NAME&TITLE: I � o9izaios I ' . ,'! m �_--� The Co�nmonwealth of Massachuseds _ —_ Department oflndwsdial Accidente _ = N�erN� =- 600 R'ashiwgtoa SYrcet, �'F/oor .. Bostoiy Mass. 02111 Workers'Com�eaatio�Lsva�ee A�d�r(�Bo7 6i�/Eketrleal Co�trxlors ,...,_.. .. -'-<�. ��.>; � ., :r;�- .... .. . ,....,� ., .� , .. .=Y� x .,_ - _. . �: (�n�die.'S ('�rc�nrct ion a�: �j',�Y� 11'lain S�. �:�. �� Uarmaak6� �� YiI� ao� t��o��l �� (� 3�u 31UD ��«�8� ❑ I am a homeowner perfo�iog all wodc myself. Pcojad Type: ❑New Cmstrucam❑Remodel I am a sole 'dor and tmve m�e w m� B ' ' Additioe I am an eooployer prni�work�s'compeaaarim far my�pbyces wodcing m this job. �..,.�: �I�nat@.'S '�C�. �f2G1,Yr1 � rm �-IhM� O � 3� - Ol� U� W ECr ,3 " ❑ I am a sole propridor,geaa^al eo�trxter,or bemeaw�er(circlt owt)a�have hQed the�tas listod below who have the followmB woh�s�comPe�ation Po�ices: �� a/dre� dtr• orre Ii: �wv�e• addr�: dtv 0ire�k __. ____ _ . .. _.. ._ # FaY6e/ef[eresmye dv8edM25AdMC.LI3fn�kaiblYei�prlirdoid�dpeWindaO�e�pbfl,3M.MuiNr e�eynn' n ed�Ap9 �Iui�tYe6riKaSTOrWORICOSDSHatlaeoedSiM.Madya�t�e. toAnwWtht• npyNmeMa e�try udY1 heO�edl�WndHeDlA6ravvqevMpnlW. �s0 K/0�' ■ � ' iNd i�! ' A p/OVWCd BbOM!1T hY6 A � D e�� I rnoce a � - I .mad.:.wy ae..�..rkeruB,rr,o.eenrpkm+usdh.re.w..meLl �N.�: �g "' p�t ❑t►ett if f�h te�e+e b�eqired �'�O�m ❑�� nahel Pdas�. P6�re A; f�bUe lm:m sm��mm) I TOWN OF YARMOUTH ' BOARD OF HEAI.1'H PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-170 FEE: $75.00 In accordance with re¢ulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�ieneral Laws,a pecmit is hereby granted to: 7im M iocca/Blondie's Corporatioq 928 Route 28, South Yarmouth, MA Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernrit expires: December 31, 2006 BonuD oF HEni.'rx: L3 sis `.D. ,i19.95., ' �`sl�k� rv�., v:� e!�„� s�dag:�z Rod�t 4. B�„ � P�k.f4o.$� +4.� , R.N. Apri17.2006 Director of He � � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-170 FEE: 50.00 This is to Certify that Tim Magliocca/Blondie's Corporation d/b/a Blondie's Ice Cream 928 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2006 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomrity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: B $. �io�ws,M.$., ' SEA7'li,rG: 12 eN��i, ��./{�., �/ice e�[�lwsr.�t R�t� e�, Cl�r.& A��19�9s�ft �«��i� R.N. ADI71�.2� . � � P Y ,RS., A Director of H i THE COMA40NWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-014 FEE: $35.00 i This is to Certify that Tim Maglioc�a�3lnndie'c('rnnnratinn d/h/a Blnndie'c icr('re� j 928 Route 28,South Yazmouth,MA IS HEREBY GRANTED A LICENSE FOR TFIE MANUFACTURING OF FROZEN DESSERTS � AND/OR ICE CREAM MIIL � For the year commencing with March first 2006 � This License is subject to the Rules and Re�u1ations of the Massachusetts Deparfinent of Public Health Relative ; to the Manufactu�ng of FROZEN DESS$RTS and ICE CREAM MIX,to the Rules and Regulatians of the ' Board of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by ! Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with tTie provisions of Sectiaai � 65J said Chapter. BOARD OF HEALTH: B ' $. � M.$., ' *Regulation 105 CM2 561.009 requires $�u�i, ./V., �ioe� i ��3'Plate co�mt and colifrnm tests. Qo�it�.B3otwg � . /��iu�.�a/�e�e3�.o� � i � �j�, R.N. ; � �� Aprit 7.2006 ruce - �[ph I-]�R, _� Director of Heal � ' ; = tk.'�j443 8con�oiEs 3=°e^"�yc TOWN OF YARMOUTH BOARD O H�r4� r� � �N r, �,? ,� ;� APPLICATION FOR � � 5 �C�S ,�� .1: ' , �. ;� ..�� J i U;��n * Please complete form and attach all necess�d� y Decemb �1�ALTFi DEPT. Failure to do so will result in the ret�m of your applicauon pac NAME OF ESTABLISHMENT: O.GrLv�� c_� i�7 TEL_ #, ��J LOCATION ADDRESS: AS�� /�'�.�� 57.� D . .>�ti�!�br.7�F�F� /� MAII..ING ADDRESS: ��i�.L� .�A3 �f�r.� OWNER/CORPORATION NAME: /�Jfi�Y ol� s.r.�.. � MANAGER'S NAME: �.�I/Y/�iffr� � TEL. # 3��.3� i MAIL.ING ADDRESS: �Si�s� /rI3 i9,�'a�,� � � 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. I 1. /r��f� 2. i Pool operators must list a minimum of two emplo ees 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 oot use past years' records. You must provide new copies and maintain a file at your place of business. ; 1. 2. 3. 4. j FOOD PROTECTION MANAGERS -CERTIk'ICATIONS: All food service establishments aze 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 certiScation to this appGcation. The Healt6 Departmeat will not use past years' records. You must provide new copies and maintain a t'de at your establishmen� ; 1. �ir��/JQJ�t'� 2. PERSON IN CHt1RGE: - Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. i. �•�/�'l�l.s►.�trx� z. �i�,�r� _ iHEIMLICH 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 employces 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 ptace of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL#�i OFFICE USE ONLY LODGING: LICENSE REQTARF..D FEE PERMIT# LICINSE REQUIItED FEE PERMI'P# LICENSE REQUII2ED FEE pERM('p# _B&B S50 CABIN - $50 _MOTEL - - $SU _INN S50 _CAMP S50 _SWIIvII�fII�G POOL S75ea. _LODGE $50 T'RAII,F.,R PARK $50 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIItF.D FEE PERMIT# LICENSE REQi)IItED FEE PF.RMIT# LICENSE REQUIItED FEE PERMIT# I 0.100 SEATS S75 O5"I7� _CONTINENTAL $30 NON-PROFIT S25 _>100SEATS 5150 j COMMONVICT. S50 �i, 'j0� _�p�gpl,g $75 RETAQ.SERVICE: LICENSE REQUII2ID FEE PERMIT ti LICENSE REQ[JIltED FEE PERMIT N LICINSE REQilIl2F,D FEE pggM►T# _<SOsq.ft $45 � _>25,OOOsq.ft. 5200 d VENDINQ-FOOD S20 � _QS,OOOsq.ft. � �� $75 LFROZENDESSERTS35 9�05'�13 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ Jbd.DO ""•"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""^•' . < < . ADMINISTRA'ITON Under Chapter 152, Section 25C, Subsection 6,the Town of Yazrnouth is now required to hold issuance or renewal ', of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEA5E CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Pemuts run annually from January 1 to December 31. TT IS YOiIR RESPONSIBIL,ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTHDEPARTMIIdTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. AT"T" RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMI�IENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department 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 estab ishment wtrich serves or sells ready-to-eat,raw or undercooked animal products are 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 required Temporary Food Service Application form 72 hours pnor 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 resu►ts must be sent to the Health Aepartment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazatioq or display of any food prod etail or food service establishment is prohibited. , DATE: �'�`O � SIGNA PRINT NAME& TITLE: �L/� � . 10/22/04 � --�`�--� TTie Commonwtalth o Massachusetis �_ =-= f --= Deparlment oflndaslrial Accidehts - — N�'1N�M�r = 600 R'asbingfoe SlreeR �"FJoor — ,- BosWx,Mass. 9ZIIl � Wortas'Com�asatioe I�svuce A�d�rit Boil Cwhaclas name: �{�r/.CiC.. emre�: Q�Q� /Ylwv.r� �S%P. c1N ��• ��•6 sate: �� zio'I�Y �me M �-.s�':j<ad � ��re i«�rrou�x �,/�,r.�w�F'�.� �c��Pdf�'1 ❑ I am a homaown�perfocmiog ell watic myxlf. Project Type: ❑New Cmslcuctim�Remodel I am a sole a�have m aoe w m ' Addition I am an�P�Y�P��'��j wa��s'�m fa mY�P�Y�wmlcin8 an iLis job. �rvmG L /J'�l� �C� �..: 9�� />'1.�►i.r� � �m: . ` 50 . Y.�is�cr� _ �'1.v �a: Sos= 3�3/Q� ��_ �Y.��T.�a i.r�s l'e . ...�.: i.�.�.►�iY3�.3� ❑ I am a sok praprietor,Se�val ea�traeter,or 4oscowaer(cirde aweJ a�have lenod the com�sct«s listed below who 6ave the followmg wohe�s'comp�ation Polices: �t r�e: �: ekv: N�e i: �� : S�P: oYe�eN: _.__ .__ _ _ __ . __-___ _ . _ _ _ _ . _ _. .. .__. _ _ _ _.. _ .. .. i . FaYue Y aarc env�e n teq�6ad Wc S�etlr 2SA dMC.L 152 m kfd 0�IYe I�i1M de�YY perlin�fa is�b tI.SNM atdhr e�e ynt+'IeptMa�t aa wd n eM pmltln 6 Oe[w��t�S7'OT WORIC OBDER ud�me dSIM.N a dq aphN�e. I odnshW IW a cpyN06MaMae�1 bf�eOmeedl�tlp�NraftleDlAtrCSYengew�ntlN. � /b rtljy rnAer w Mt lefwa�dhn provirel ebope fa brs a�d orrrnct �� Prim name �/J7 �U�CL'�13� Phone# .SD�.�.�/L� .mcW.xa.ry a.iat.rtkertY,arnNeeos�WMM6rdls.renres�thl �lKvwe= petoWie�ei ^" ' p�p� ❑ehe�Nl�h � mM�b R9� �'s O�m �� a��P�� pr�n: flOme c,�sm�mw� TOWN OF YARMOUTH BOARD OF HEALTH PERMI'P TO OPERATE A FOOD ESTABLIS�NT PERMIT NUMBER: #OS-172 FEE: 75.00 In accordance with regulations.promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a permit is h�eby granted to: Memory Lane, Inc., 928 Route 28, South Yarmouth, MA Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food establishment in: Town of Yazmouth Pemut expires: December 31. 2005 BOARD oF HEALTH: Beisjrs�ri�c `�. (�'atdar, ��. ' �.N�� v:�e�K �g_ �z R�t�. a�, e�,� � Sl�, R.N. +��, R.N. April]4,2005 �� ruce mP , , Director of Health THE CONIl�IONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-104 FEE: 50.00 This is to Certify that Memory Lane, Inc. d/b/a Blondie's Ice Cream 928 Route 28, South Yazmouth, MA IS I IEREBY GRAN1'ED A COMNION VICTITALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomuty with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed Yheir o.fficial signatures. BOARD OF HEALTH: Be�xi.�2. � M.$. ' 5�� z p�.a� v�ef� ��R.N.� �4.,.a��, R.N. Apri114.2005 Bmce G.Miuphy R ., H D'uector of H r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMl'T NUMBER: #OS-013 FEE: $35.00 IThis is tD Certify that Memrnv i ane Tnc d/h/a Rlcmdie'c irP('ream ; 928 Route 28,Souih Yannouth,MA � IS HEREBY(iRANTF.D A LICEidSE ' FOR THE MANUFACPURING OF FROZEN DESSERTS ' AND/OR ICE CREAM MIX ' For the year commencing with March first 2005 ; This License is subject to the Rules and Re�u1ations of the Massachusetts Deparlment of Public Heahh Reletive � to the Manufactunng of FROZEN DESS�RTS and ICE CREAM MIX,to the Rules and Regulations of the Board of Health granting tlus License, and to the pravision of the Ge�eral Laws Chapt�94 as amended by ; CLapter 373 ofthe Acts of 1934,and may be revoked or suspended in accordance with the provisions of Section � 65J said Chapter. i BOARD OF HEALTH:B 2.�M.�C� *Regulation 105 CME2 561.009 requites paa�/Hc� �/it� Imon8ily plate count and colifomi tests. Qo�ieht�. B4orwsy �e3�ro ' d�S/�1,� R.N. � ��j�, R.N. � I Arn�il 14.2005 .Murp ,MPH, , i Director of Health �;' "� ��'��bp � ';< I� ��i`�'st� D° 3��``R�c TOWN OF YARMOUTH BOARD OF HF,�� ,rjtC 0 S 2003 i �C�s APPLICATION FOR LICENSE/PER1�1T-2�4 ` HEALTH DEPT. ' * Please complete form and attach all necessa� u�,�etrts hy December 31, 2003. I Failure to do so will result in the returri��u�application packet. � �.� � ' ��(� L T N RE • 6 i a i T N � C ER' E: - 6 RE Ol M � i j POOL CERTLk'ICATIONS: i The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � PooT dperator(s j and atiach a copy of the certification to th�s form. � 1. 2. j Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopuimonary Resuscitation (CPR). Please list these employees befow and aitach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maiutain a file at your place of 6usiness. 1. 2. i 3. 4. � �OD PROTECTION MANAGERS - C�RTIFICATIONS: ' All food service establishments are reyuired 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 copies of certification to this application. The Health Department will not use past years' records. Yo mu t provide new copies and maintain a file at your establishmenL 1. ��'�s�.i,s1p !' 1ah61'1 2. - -- — _ _ _ , _ _. _ _ _ _. _- __-- _.- -- __ PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. �.�� v� I�a�;oc,�o, z...��A�'�eb�i�� /�1Q��r� 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-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide ew copies and maintain a file at your place of business. i n , ) ' i. �os L �e�� a. l"a��el��ti�F r�a l,Gh 3. 4. RESTAURANT SEATING: TOTAL#� ' OFFICE USE ONLY ' LODGWG LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S50 _CABM 550 _MOTEL S50 _INN $50 _CAMP S50 _SWIMMING POOL S75ea _LODGE E50 _TRAILER PARK S50 _WHIRLPOOL S75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FGE PERMIT# LICENSE REQl11RED FEE PERMIT H � I 0-100 SEATS $75 ��0 _CONTINENTAI. S30 _NON-PROFIT S25 _>I00 SEATS $150 I COMMON VICT. S50 #O�'��O _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMIT tl LICENSE REQUIRGD FEE `PERMIT q LICBNSE REQUIRED FEE PERMIT# _60 sq.ft. S45 >25.U00 sq.R. 5200 _VBNDiNG-FOOD S20 _<25,000 sq.ft. $75 1 FROZEN DESSERT S35 TOBACCO S25 dnMe cxnNCE: S�o AMOUNT DUE _ $ I ��. p0 '••'•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*••• .' .' � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES,� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENIAIG FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINITNG, NEW EQUIPMENT, ETC.), MIJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEHtING: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,totai 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 Heaith Depaitment 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. �i101.Pi1�TL�e�__^Cr_�T,nT(�. _ ._.____- ._.. .. __ _. _ -_. _ ___. _.. __"_"__ _.__- _ _. . _- - . . Z�� Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establislunent is prohibited. DATE: I O SIGNATURE: PRINT NAME&TITLE• 10/22/03 I � xx INFORMAT�N PAGE wsc WORI�RS COLAPENSATION AND EIAALOYERS LIABILRY POI.ICY N�: m�n� cz� �� ntsu�cs coa�aNr HP,RTFORD PLAZA, HARTFORD, CCIA7NSCTICUT 06215 ��,"�: � THE �'� ' HARTFORD � �, � a 0 � o uns ne�wu o POl�1f N1lYB@i: � � Prwiou�Polf�y I�Nwib�t: M HQUSING CODE: DI�i p�''� 1. t�Md ifwtld iN11A�Ig Addnst: �RY I,i4N8 IIdC DBA JQ&'S DINBR & N Mo•.saset.taMm,8�te,Zfp Code) sr.a�mxss xcs cxsar� 0 � 9aa r� s�r. Rx� 2e x �III/eb�f: SOUTH YARMOUTx, DD► 02664 e .91��Ife�Uoe+Numba(�k � � _ � � �1MsNM�d iliM1l�d Ir. CORPORATION � Otl�IMid NMNd kMlAd: RBSTAURANT � i�l/f�iaitlRl/o�tnoRaUoYlMiabovY: 928 ffiAIN ST:RTE 28 5 YARMOUTH. MA. 02664 '�"` 2, P�r� From Q5112/43 To OSl12/04 �� . 42t01 a.m.�Standud iime at Uie ineurods meNing address. lhodu�mrr'stir�: cxac� n+istrxaxcs accr atc/sczc 9402 MIDDLE SSTTLffidffi�'P ROAD NBW HARTFORD, NY 13413 IA0�0�!'i CaM: 08T027 bM#1�t!lIICl: TE� HARTFORD 4401 ASIDDLS SETTLffi+lEN'P ROAD, 2ND F'LAOR NfiSV HARTF'ORD NY 13413 (866) 467-8730 T411�l�Iftleh�l�d Atnud Praniun: $1,541 D�ponit PnrttMan: P�lqr111Noww�f�wmiwe: $zi9 au� At�t Pael� lUr�lAL kp�Nm�nR T�na: 17»�is not b�np unlass cam�rai9�bY wu autlwtlzed representativa. _ �� ,��,. For��WC 90 CO 01 A (t) Printed in U.SA Ppr 1 (Continued on next Pa9a) Peao�pDMk 04/06/03 PaicYFxpY�lonD�b: OS/12/04 ORIGZNAL i TOWN OF YARMOIITH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLIS�NT PERNIIT NLTMBER: #04-100 FEE: 75.00 In accordance with re ations promulgated under authority of Chapter 94,Section 305A and Chapter I I 1,Section 5 of the eral Laws,a pennit is hereby ganted to: Jim Magliocca's Memory Lane, Inc., 928 Route 28, South Yazmouth, MA Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2004 BOARD oF HEALTH: B�$. C�'o�ars, M.�. ' n�,aa� v� ef.�.� ��,s: �2 a�t� a� e�c � s�, a.n� Jffivary 29.2004 B e . u ry, > Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04072 FEE: $50.00 This is to Certify that Jim Maeliocca's Memory Lane Inc d/b/a Blondie'e Ice Cream 928 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This Gcense is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affviced their official signatures. BOARD OF HEALTH: Baslaarlw�. �j'o+tdan, M.2. ' SEA,�,,a_ �2 p�t�6,N�.S.�,� v:a� �S��`R.N� January 29_2004 ruce G. M hy,MP S.,CHO Director of Health THE COMMONR'EALTH OF MASSACHUSETTS � TOWN OF YARMOUTH PERMIT NUMBER: #04-007 FEE: 35.00 iT71ts ls[O Certify thAt iim l�fagliacc;a'e Memnrv i.ane inc d/h/a Rlorulie'c Ice('ream i 928 Route 28,South Yazmouth,MA ( IS I IEREBY GRANTED A LICENSE FOR THE MANUFACl'URING OF FROZEN DESSERTS j AND/OR ICE CREAM MII� ' For the year commeocing with March first 2004 This License is subject to the Rules and Re�u1ations of tbe Massachusetts Depmtment of Public Health Relarive to the Manufachmng of FROZEN DESS�RTS and ICE CREAM MIX,to the Rutes and Regulations of the Board of Health ganling this License, and to the provision of the General Laws Chapter 94 as amended by I Chapt�373 of the Acts of 1934,and may be revoked or suspended in accordance with tfie provisians of Sectio� 65J sa�d Chapter. isonxn oF�ni,�: B 2. Cf�do.�, M.�., . I *Regulation 105 CMR 561.009 reqiures pa��/He.�ol�xo�, �/ic+� �toi3wta�s monthty plate count and coliform tests. Ro6s+�1�. B�+�wc, �4 dkl�.�Sl.�i, R.N. i Januacy 29.2004 . wp MP , Director of Health � � o�^'+.y TOWN OF YARMOUTH BOAR F � (r� (� (� f� � N/ [� �p + = o ' APPLICATION FOR LI ° _� ' � qpR 3 0 2003 3 -1c F �,�1 , . I * Please complete form and atEach all necessar�#,docUinents by Dece r 1��H ��PT. Failure to do so will result in the retum of your applicat�on packet. i =: I�IAME OF ESTABLISHMENT: /:� �r�,�J�F� TEL. # I I�OCATIONADDRESS: �� l��lii�r> � 31, MAILING ADDRESS: ,3'c'� �''/9.�/�J�Iac/� � �� OWNER/CORPORATION NAi�1E: .��sr-�'I�.G��1/ .�d.��- /•C/l'_ MAN�GE�t�$�': _6s'�� oc�'� ` TEL. # ��/�dd MAILING ADDRESS: `�S�-�� QOL CERTIFICATIONS: The pooi 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 thts form: L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies aod maintain a file at your place of business. 1.< 2. 3. ' 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• Atl food service establishmetrts 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 Fpod 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 aad maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food estabiishment must have at least one Person In Chazge`(PIC)on site during hours of operation. L 2. � HEIMLICH CERTIFICATIONS: All food servi�e establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all 6mes. Please list your employees trained in aciti-choking procedures below and attach copies of employee certifications to this form. The Health Departtnent will not use past years' records. You must provide new copies and maintain a file at your place of business. 1 2• 3. 4. RFSTAUR ANT SEATING: TOTAL# OFFICE USE ONLY � wncmc: � � � � i � LICENSE REQUIRED FEE PERMIT# � � � LICENSE RBQUIRED� FEE PERMiT#� LICENSE REQUIRED FEE PERMIT# _BBcB S50 _CABM S50 _MOTEL S50 INN S50 CAMP � 550� _SWIMMMGPOOL$75ea. LODGE S50 _TRAILERPARK� $50 _WHIRLPOOL S75ea �'OODSERVICE: � � LICENSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# �0-100 SEATS S75 . � � . _CONTINENTA(. ..S30 _NON-PROFIT S25 >100SEATS SI50 �COMMONVICT. $50 _WHOLESALE $75 � RETAIL SERVICE: � � � � . � � � . . LICENSE REQUIRED FEE PERMIT# ' UCEMSE RGQUIRF.D FGG PERMIT# . LICENSE REQUIRED FEE PERMIT# _G50 sq.ft. S45 >25.000 sq.R �� 5200 � _VENDING-FOOD 520 <25,000-sq.ft. . S15 � �FROZF•.N DFSSERT S35 � 03—D��F _TOf3ACC0 525 rrnntecxnNCE: sto AMOUNTDUE _ $ .3vC-. 00 ""**"PLEASE TURN OVER AND COMPLETE OTHER S1DE OF FORM*•*"* Ib . . . . . . - �� . .,_ ._�...,.. . . . �, : 1 � ADMINISTI2ATION i Under Chaptef 152, ,�'section 23C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal '"" of any license oi�permit to operate a business if a person or �ampany does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ; AFFIDAVIT MUST BE @OMPLETED AND SIGNED, OR ``CERT. OF'INSURANCE ATTACHED 9� 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 APPROPRIA'CELY IF PAID: YES NO NOTICE:Permits run annually from Jarivary 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABi,ISHMEN'E'S ARE T0 CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-]0 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLJIPMENT, ETC.j,MUST$E REPORTED TO AND'APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. REN�OVATIONS MAY REQUIRE A SITE PLAN. ADD1T10NAL REGULATIONS POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openin�. POOL WATER TESTING: 'Fhe water must be'tested for pseudomonas,total eo(iform and standazd plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL�LOSIIVG:'Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing. , : FOOD SERVICE MNSt�FR A1�VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Adxisories.' CATERING POLICY: Anyone who caters within the Town of Yazmouth:must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �gOZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certiFied lab. Test results must be sent to the Health Department. Faiture to do so will result in the suspension or revocation of your Feozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i:e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. QUTDOOR COOKING: ', Outdoorcooking,preparation,or display of any food prod�ct�y a r '1 service e 'shment is prohibited. ' DATE: �'7`�_,�'J —/,2� SIGNATU • � PRINT NAME&TITT,E: 1' � ,' � . . Y ��_'� .a'$'4 . �Q�18��2 .. �{y, , . I " � �. . s.�s.suf� � � , � i THE COMMONR'EALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER:#03-014 FEE: $35.00 , This is to Certify that Memorv lane Inc d/b/a Blondie's Ice Cream 928 Route 28,South Yarmouth,MA IS HEREBY GRANTED A LICENSE FOR THE MAN[JFACI'URING OF FROZEN DE5SERTS AND/OR ICE CREAM MIX iFor the year comme�ing with March fust 2003 This Lic�se is subject to the Rules and Regulations of the MMasssachusetts Depaztrne�rt of Public Health Relative to the Manufachvuig of FROZEN DESSERTS and ICE CREAM MIIC, to the Rules and Regulations of the Board of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended:in accordance with the provision4 of Sedion i 65J said Chapter. � BOARD OF HEALTH:eka�lis�, zdllkei. �a:n�s.s ( 'Regulation 105 CMR 561.009 requires D. C�e�doK. �Jl.D., vlee monthly plate count and coliform tests. ��• �wawc, � � �s0ife4'�lc�er�xatt i ,fl. A�ril 30.2003 • �n'p Y,MP , DirecKor of Health � � — .��F�R.�c TOWN OF YARMOU �� ✓��Ny �OF HEALTH ,,�ao (� � (� (� � 1� � � APPLICATION FOR�IC�+NSE/PF1�NfI1`-2003%i1�`, �-�.�..�_ �� --° ��j� oEc � � 2nn2 * Please compiete form and attach all nec,�'sary documents by Decemt�er ,��LTH t�EPT. I Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT• niuJ�,��, _,�',�Vi9'f # -.9�1�3� LOCATION ADDRESS• � /�jiViGU �S/.�G �SD Y.A�.Y1 d6�6� i MAILING ADDRESS: � T��rsAF .9+3 A�Sii.� � OWNER/CORPORATION NAME: /'�'fi�'l�9Q�l9Y �i� /.e� MAI�AGER'SNAME• �/�9 /'J'l.qs't��G.St TEL #.S�1�.�9l�'�T�' MAILING ADDRESS: � �3'.�ar�.� /ocs .�7�u�, � I � POOL CERTIFICATIONS: �' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opetater{sj ae�-at�ach a eepy-ef the certification to tlus orm. 1. Pool operators must list a minimum of two employ c y rtified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation( . list these employees below and attach copies of employee certifications to this form. The Health a e will not use past years' records. You must provide new copies and maintain a file at your o b s�ness. 1. 2. 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments are required to have at least one full-time emgloyee 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 establishmenk 1. �i�/.�y /�ifGif�i�iC� 2. , _ _P .RS L�LII�I CHAR(',R� _ _ _ _ . __ _ _ _- Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Ci/f�i� �f/�/�' 2. � H�F ��ICH CERTIFICATIONS: All food service establishments with 25 seats or more mus have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your em oyees trained in anri-chokmg pmcedures below and ' attach copies of employee certifica6ons to this form. Th e th Department will not use past years' records. � You must provide new copies and maintain a Fle at lace of business. � l. 2. 3. 4. IF TA TR A T ATIN : TOTAL# IO I OFFICE USE ONLY LQDGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _BBcB $50 _CABIN a50 _MOTEL $50 _IA1N . S50 _CAMP $SO _SWID�A4ING POOL SSOea _LODGE a50 _TRAILER PARK S50 WHtRLPOOL S25ea � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# 1 0-100 SEATS $75 6 �( (7 _CONTINENTAL $30 _NON-PROFIT S25 _>I00 SEATS $150 I COMMON VICT. S50 �`-a3�ag� _WHOLESALE S75 RFTAI_I ,�.RVI F LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICEN$E IjEQ�UIItED F$E PERMIT# _TOBACCO S20 _<25,000 sq.ft. $75 _TOBACCO E20 _<SO sq.ft. S45 _>25,000 sq.ft. 5200 _FROZEN DESSERT S35 NAMECHANGE: $t0 AMOUNTDUE _ $ 12S•00 "****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** _ ,� � , �+---- . . I ' � � ADMIlYISTRATION i ;��Js�er�ktapikl�il�, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit ta operate a business if a person or company does not have a Certificate of Worker's CompensaUon Insurance. TFIE ATTACHED STA�'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE,�'OMPLETED AND SIGNED, OR ' CERT:OF INSLJRANCE ATTACHED , � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be pazd prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January I to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN T D REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISFIMENTS ARE TO C ACT TI�HEALTH DEPARTMENT FOR INSPECTION 7-10 YS PRIOR TO OPENRVG ASON. 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. �nnTTioNAL 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 animal products are required to post Consumer Advisories. CATERING POLICY• Anyone who caters within the Town of Yannouth 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 Departxnent. FROZEN DESSERTS: - . Frozeri desserts mustbe iested on a monthIy basis tiy a State certified Iab:Test results must be sent to ffie Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food pm y retail or ood service establishment is prohibited. ; DATE: /a "3 J' Do�SIGNATU : PRINT NAME & TITLE: ♦ / � 10/18/02 �_ , (PolicyProvisions: W�, �0 CO 00 A; � c=: INFORMATION PAGE ,_� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: mwlN ��my �TRE �NcURANCE CGM?.�ry HARTFOBD ?�AZA, HARTFORD, CONNECTICUT 06ll5 NCCI Company Number: � i �� o a [�,�I�j: Company Code: 7 I 1 /�.R 7��'nT��) � c - Suttix � LARS RENEWAL ; POLICY NUMBER: � � Previous Policy Number: =; HOUSING CODE: DW 1. Named Insured and Mailing Address: MEMORY LANE INC DBA JOE ' S DINER & x v (NO., Street, TOWn. State, Zlp COde) BL,ONCTES ;CE CREAM v ' �� 92o MAIN ST, RTE 28 ; FEIN Number. SCUTH YARMOUTH, t�iA 02664 _ State Identification Number(s): _ The Named Insured is: CORPORATION = Business of Named Insured: RESTAURAtvT Other worlq�laces not shown above: 9 Z g Ma:N S7';RTE 2 B = S YARMOUTH, MA O�b69 = 2. PolicyPeriod: From OS/12/02 To OS/12/0? ' 1201 a.m., Standard time at the insured's mailing address. _ ProduceYsName: �HAGNON INSURANCE AGCY INC/SCIC �4C1 MICDLE SETTLEMENT KOAD � = NEW HARTFORD, NY 13413 - Producer's Code: C�C 7 0 2? Issuing Office: mF.E HARTFORD 44J1 MSDDLE SE'PTLEMENT KOAD, 2ND FLOOR NEW HARTFORD NY 1391? • ---�---. `gOL" =44-81�9 , ._. _ ._ ... ------- Total Estimated Annual Premium: — -- — — - _ — -- - So06 _ Deposit Premium: Policy Minimum Premium: $�i 9 �yp, Audit Period: �JpL Installment Term: — "—— The policy is not binding unless countersigned by our authonz��presentative CouMersigned by ��:%'��, i� � �� . � . Authon ed Repre "ntative � ��'� — � � ' � � � ; paet ` / Form WC 00 00 01 A (1) Printed in U.SA Page 1 (Continued on next page) Process Date: 06;'0 c,�� Policy Expiration Date: O S/12/03 JRIG_'_VAL TOWN OF YARMOUTH BOARD OF HEALTH PERMTT TO OPERATE A FOOD ESTABLISHMENT i PERMIT NUMBER: #03-132 FEE: $75.00 � In accordance wiih reeulations pmmulgated under authority of Chapter 94,Section 305A and Chapter � 11 I,Section 5 ofthe�ieneral Laws,a permrt is 6ereby grented to: Memory Lane, Inc., 928 Route 28, South Yarmouth,MA i ' Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food establishment in: Town of Yarmouth ! Permit expires: December 31. 2003 Boa�tn oF�Ai.'rl-i: eifa�dss?� xdlt�4a�, (�Fa:+�uu — -- _ _ . . ___ – D. ClstdoK._�D.-�2/iee � Seatmg:l2 . . ,. i� �. �teara. � .. � �el.,� S�R n 7anuazy 24.2003 ce G.Murphy,MPH,R.�,C� � _' Director of Heahh G THE GOMMONWEALTH 0F MASSACHidSET1'S TOWN OF YARMOUTH - ,.. ,., PERMIT NUMBER #03-081 FEE: $50.00 , 1'his is to Certify that Memorv La�. Inc. d/b/a Blondie's Ice Cream 928 Route 28, South Yarmouth, MA IS HEREBY GRANTED A COI�IMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�p�ires December thirty-first 2003 unless soo�r suspe or rev--oked�or vio��on 6fth�1$�vs isfYk��ooffitaonw�kkresp ' licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thexeto. In Testimony Whereof, the undersigned have hereunto affixed their vfficial signatures. BOARD OF HEALTH: �(ra�lea�, xdUGGoc. �a.c SEATMG: 12 . pc �, C�p/w��'�� ,�,, ?/� 1G�. �70pMc, [isns�e �at�r[e�d�mnratt ��Sk � ,�7P. January 24.2003 '" Bruce G.Miuphy, .S.,CHO Director of Health al.oND1ES ICE�EqM � �` OWN OF YARMOUTH BOARD OF HEALTH j �.� �, k; PLICATION FOR LICENSE/PERMIT-2002 �'i��o /a��o•ab> ° * Please com ple�e form an d a tt a c h a l l n e ce s s a r y d o c u m e n t s b y D e c e m b e r 3 1, 2 0 0 1. F a i l u r e t o�@�'p�v i�1 �t i n the return of your application packet. N.�ME OF ESTABLISHMENT• ��1�� —' TEL # - �� LOCATION D FS • /y�q,r�.� ��i�T � y��j� �� MAILING ADD FSS: � Sa..�S ' O O ,q �" MANAGER'S NAMF• i� /!�l.iP�t io�,riv TE # � SA.b MAILING ADDRF • 9d?�' /7'l•Kt�.V cTT.cd U, Yq,o�„�jk ,j� �j,yr �--- POOT RTIFI ATION • The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated , Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimutn of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitafion (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 busiuess. I• � � 2. 3• 4. FOOD PROTECTION MANA RS ERTIFI ATION • All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. C�+i'R�/.Y� ��i� 2_ � --_ PEKS(�1�TI1�CH E ---- ---- - _ -- - - _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �A.BP.y� ]O.oW�li/O 2. HELMi ICH CERTTFICATION • All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedwes below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. iYou must provide new copies and maintain a file at your place of business. 1. �� 2. 3. 4. RESTAURAN'T SEATIN : TOTAL# OFFI ON Y LODGING: � L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _B�B $50 � � _CABIN S50 _MOTEL $50 " �� _1NN S50 _CAMP $50 _SWIMMING POOL$SOea _LODGE $50 _TRAILERPARK $50 _WHIRLPOOL $25ea � FOOD SERVI('E: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H �0-100 SEATS E75 �� _CONTINENTAL $30 _NON-PROFIT $25 _>I00 SEATS $150 �COMMON VICT. $50 0 �Q _WqOLESALE $75 RETAi► RVIC • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO E20 _Q5,000 sq.ft. � �75 _TOBACCO � $20 _�50 sq.ft: $45 _>25,000 sq.R. $2Q0 _FROZEN DESSERT$35 NAME CAeNGE: $10 AMOiJNT DUE _ $ /aS pa - ***`"PLEASE T[JRN OVER AND COMPLETE OTHER SIDE OF FORM**•*' � . . �«.�a. . , 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 Compansation'Insurance. THE ATTACHED. STATE WORKER'S COMPENSATION INSURANCE AFFIDA�'IT MiJST EE COMPLETED AN�SIGNED,OR . CERT. OF IAISURANCE iATTAGHED „ � WORKEI2'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to ewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: yEs NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILI'TY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHIVg'sNTS ARE TO CONTACT THE HEALTH DEPARTMF,NT FOR INSPECTION 7-10 DAYS PRIOR TO OPENRVG 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 OPE1�iING: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 quar[erly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. ' FOOD SERVICE rnrrcirn-rFR ADVISORY: Each food establishment wluch serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATF.RiNG 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 Department. FRO N DESSFRTS• --- _ _ -- — __ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter�waiuess service),m�t have prior approvat from the Board of Health. niT'�'nOOR COOHING• Outdoor cooking,preparatron,or display of any food prod y food service establishment is pmhibited. DATE: /L— /D "D I SIGNATU • PRINT NAME&TITLE• iK� 09/I 1/01 1 � 34 (PolicyProvisions: WC 00 00 00 A) � � xx INFORMATION PAGE � wec WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY � INSURER: TIqIN CITY F2RE INSURANCE COMPI�NY ��'� HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115 - m � NCCI Company Number: �� 1 H� ic�,�nyc«ie: , HARTFORD I 'i � �, � � 0 �, s�mx � LARS�� o POLICY NUMBER: ,d„' Previous Poliey Number: "' HOUSING CODE: �W � 7. Named Insured snd Mailing pddrosg• C�B JOE'S DINER & Ci � m (No., Street,Town,State, Zip Code) �� BLONDIES ICE CREAM� 0 N i 0 0 � � 928 MAIN ST, RTE 28 ' ; FEIN Number: : . = The Named Insured is: CORPORATION = Businesa of Named Insured: RESTAultataT � ��WO�1e��s��e�� 926 MAIN ST;RTE 28 S YARMOUTH, MA 02664 — 2• PO��P�Od� F� OS/12/02 To OS/12/03 � 12:01 a.m., Standard time at The insured's mailing addrass. � = ProduceYs Nmno: CHAGNON INSURANCE AGCY INC/SCIC � 4401 MIDDLE SETTLEMIIVT ROAD � � D1EW NARTFORD, NY 13413 — Producar's Code: 087027 � �s��9�� THE HARTFORD � 4401 MIDDLE SETTLEMENT ROAD, 2ND FLOOR � . NEW HARTFORD NY 13413 � � 0 94- � Total Estimated Annual Premium: $606 � Daposit Premium: � Policy Minimum Premium: $219 MA '� , � A�� ANN[JAL Installment Te : = The policy is not binding unless countersigned by our authoria tl presentative. — Countersigned by � ' .;� r;," l'�/!--'�/Li��,.^._ utho ed Repre ntative Date ' ✓ Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Proeess Date: 0 6/0 4/02 Policy Expiration Date: 0 5/12/0 3 ORIGINAL , TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISFIM�NT PERMIT NUMBER: #02-080 FEE: $75.00 In accordance with regulationspromulgated under authority of Chapter 94,Section 305A and Chapter 111,Seckion 5 of the C�eral L.aws,a permit is hereby grented to: Memorv Tane, inc., 92R Main Street/Rnute 2R South Yarmnuth_ MA � Whose place of business is: Blondie's Ice Cream Type of business: Food Service To operate a food establishment in: Town of Yarmouth i � Permit eacpires: December 31_2002 BOARD OF HEAL'I'[-I: eka�alea r?�. xcUt�fai. (�aduxa.a ' � a. � �x.a., v� � �� , l� s�: �z Parrk6l�ev+�rea S�F ,��l. , �ia ,zooz ! ruce G.M hy, .,CHO i Director of Heal i � 1 j i ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH I i PERMIT NUMBER: #02-053 FEE: $50.00 � This is to Certify that Memorv Lane.Inc. d/b/a Blondie's Ice Cream 92R Main Street/Rnute 2R South�h_ MA IS HEREBY GRANTED A COMMON VICTQALLER'S LICENSE In said Town of Yarmouth and at thai place only and etcpires December thirty-first 2002 unless sooner suspended ar revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing suthorities by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: �'ri� 'XdUlkec, � sennrwc: 12 �ui D. C�d� �1lC.D.. ?/ree ��• � S�FaE, � ia ,zoo2 • ruce G.Murphy,MP .S. HO Direc,Kor of Health