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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 : . , � ��r� c �:1 p TOWN OF YARMOUTH BOAR]�A�$EA�.T.� ' �� APPLICATION FOR LICENSE�$N�-2��'V ? NOV 1 O 2UU8 , � � ~. * Please complete form and attach all necess `a�iocu n ts by Decemb 1 .H DEPT. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: ,��+ S' �`U�JQ �Do�9'� TEL. # oR=3 .O.SS/O LocaTioN aDD�ss:ag�l�_s1A•�,�T- s-o��,��`e�/'N,�ra�. �a.�� y MAILING ADDRESS: OWNER NAME: TAX ID FEIN or SSN • CORPORATION NAME (IF APPLICABLE): N1/�S ✓. Dc NtTif�P�/iei�r'/C � MANAGER'SNAME:�/��cliiYB,�, E" —TEL. #�l.se" MAILING ADDRESS: S�¢!ne POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. /u�/¢ 2 � Pool operatars must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopuimonary Resuscitation(CPR). Please list these employees below and attach copies ofempioyee 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 fixll-time employee who is cei�tified 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 �ile at your establishment. i. N/� z.�T/�- PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. 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 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. �. �v/� 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQTJQtED FEE PERM[T# LICENSE REQUIRED FEE PERMIT� _B&B S55 _CABIN S55 _MOTEL S55 _INN S55 _CAMP S55 _SWIIvIMINGPOOL S80ea. � 1LODGE S55 �Qy��L _TRAILERPARK 5105 _WHIRLPOOL S80ea. FOOD 5ERVICE: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED fEE PERMIT# LICENSE REQUIItED FEE PERMIT# 0.100 SEATS 585 _CONTINENTAL 335 NON-PROF[T 530 _>I00 SEA'IS 5160 _COMMON VIC. $60 _WHOLESALE 580 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQLnRED FEE PERMCL# LICENSE REQUIILED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k _<SOsq.ft. SSO .. >25,OOOsq.$,. . 5225 _VENDING-FOOD 525 a25,000 sq.ft. S80 _FROZEN DESSERT 540 _TOBACCO 555 �a:�zE c�:�cE: sio AMOIJNT DLTE _ $ SS.oa •*•'"PLEASE TURV OVER eL1'D C0IVIPLETE OTHER SIDE OF FOILVI**••• . � ADMINI5TRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth tazces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES // NO MOTELS AND UTHER LODGING ESTABLISHNIENTS 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. 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 s'uc(6)momh period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Deparhnent to schedule the inspection five(5�days pnor to opening. PLEASE NO'I'E: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MIJST BE REPORTED TO t1ND APPROVED BY THE BOt1RD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:�/— �o,Y SIGNATURE: �„�,� p� � PRINT NAME&TITLE: Cr�it��/oL�sK�lQ �DC f�� io%u%os T �\ The Cominonweatth of MassachusetLc DepaRment of Indusdiwl Accidentc �N� 600 R'ashington Streey �"'Floor Boston,Mass. 011ll Workers'Compeasatioa iosm�snee.4�dsvit:Baiidiog/Plumbieg/Electrical Cootractors �P�MM�ir�tfu�: F�u Pl�i�iq'le�lv ��/1-/-��f�l��la� r�� dr��'s-�i?'�� /ad4 � add�ess. s�9 / !�•�l+-�'�+ti'/ ' � . ��/��K�v�� siate� LN(¢ zio�0�� ohace# So� tOS�D wotk site locafion ffvll addressl: �. ❑ I am a homeowcer perfotming all work myselL Projec[Type: ❑New Canstcucti��Remodel . �I am a sole�pa�oprietor and have no one working in�y�ca�city. ❑Bwlding Addition .. ❑ I am an anployer providing workets'compensation fa my employces wodcing on t6is job. . � . . _.-' -- - - -- � - . � -- �_._._. . _ . comwnv�ane• . . . . . . . . .. . _ _ ad�'as• . . . . . �- �x• �..��. �a ,�� . .�a,_:. ,�>p��.�v ❑ I am a sole propriefor,gweral eahacMr,or 6omeow��(cirde one)and Lave hiced We contractors Iisled below wla have� the following wockeis'compeatiation polices: � somwav�ane• . . . addroa: . . . � . . � . . � ci�" . . . . . � �p- . . � � . . � . . i��ee ea � . . �ky q � . - . . .. �� . .. �. ... ... . .. _ . . .. . .;=�'. .�'�.�. �ar me- d�dreg' . � : . . � � � � � oYwe#• . _. — -- —. _ . . __ ._ __.-- -� . . . _ . -- ---- _.__ _.. . _ .___. ie�p�ce eo. � �g . . Faive b ueme wvua6e o rtqd�d eedQ See1Nn 2SA e[MGL 132 ne lad b IYe .. � `� . ,., n.,,.>,:;�„ , x,_.w..:; . �S«�'dP��f a wd n d�i ��Cai�Yal pefaMka efa me ip b A.3M.M aaNer �,�.m u��.r,sror woe�c oanea m.e.�wsieaee.e.y.g.i..��. �mn.u.a mu, eapy�HhMalewente�y4focwWedlolSeOmce�laveMi�WaesNt�DlAtscwe�age�tlsa . . I b henbq n�lify rnlnWe pdna owdP�■Q«olP�7+�3't6a the Infwvnadou prod6e[ebave ia arve m.l camct- . � � �8�� •�� Date ��7�O� .. Ptint name��/¢�(]L(K .� /�� F�Y�� Phoce# So� 7i ^t1SY4� . e�cw ax owy ao eat..rae fa lhh,rea[o ae ceuWefeA Dr.dlr.r en.a o�thl . . � cily ar tewa: . ..p�rmif�A ❑BoOdio6�P�� ❑eheh H�ie 6 . � . ❑,�� '�P°B� RQe� �'a O�ce . . � ❑1kaMY ORa��/ crwct Peaa�e: PAeae N; � l�e s�mml THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-001 FEE: S55.00 LODGING HOUSE LICENSE Ihis is to Certifp that a Lodgine House License is hereby granted to Ihomas J.Roche Realrv Inc. at Rasc River Lodge 28 Plea�ant Street Couth Varmonth MA in said Town of Yarmouth and at that place only and expires December thim�-first,2009 unless sooner suspended or recoked for �'iolation of the laws of the Cotnntonwealth relating to the licensing of Lodging Houses. This license is issued in confoanih� with the authoriri granted to th2 licensing authorities under section twenn'-three,of chapter one hundred fortl',of the Grneral Laws,and is subject ro the provisions of sections n;•rnty-t�i�o to thirty-one inclusive of said chapter. In Tesrimony�'Vhereof,the undersigned have hereto affixed their official simatutes,this Fourteenth day of Noaember A.D. 2008. BOARD OF HEALTH: .`�E¢P,¢JL SI�QIR� JrL.JY.� C�PK7%XffUUt e�QAfeCb .`�. .�2�(�PJC �lC¢ �QGI�N►tQIL JZodexE s. `.�nawn., C�eieP� Uni[s: � Q��t�t,K,��„lC?.ft�t�lY,U,�f�),t,��..lv. `'""^'� ` `�• "`�`y"" Bruce G.Murphy Ivt H,R.S., CHO D'uector of Health i3. ,�. LoD�rc � "k�y TOWN OF YARMOUTH BOARD OF ALTH ;�� s� � ' APPLICATTON FOR LICENS�-20D$ ��L�� -i .. � . ; , ,�� r�V?;n�� 9 , �nr� . N- y� ,.;e ... . e �_. * Please complete form and attach all n�,doa�rneats'�by ecember 31, 2007. Failwe to do so will result in the returh of your application packet. NAME OF ESTABLISHMENT: ' TEL. #SOS��S/p LOCATION ADDRESS: — p� MAILING ADD�S: OWNER NAMg: c. T IN r N : CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: i � TEL. �8=3 -�?.SS�l� MAILINGADDRESS: �e�� POOL CERTIFICATIONS: The pool supervisor must be certitied 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 Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to tMs form. The Health Depertment will not use past years' records. You must provide ne�� copies and maintain a file at your place of business. I. �� 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 deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to thu application. 3'he Health Department wi}I not use past years'records. You must provide new copies and maintain a 61e at your establishment 1. �/�� 2. , � PERS9N IN C�AI2CiE: — _------ ------. _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. /�(�l� 2. . �� HEIMLICH CERTIFICATIONS: All food service establislvnents with 25 seats or more must have at least one employee nained in the Heitnlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of empioyee 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. 1. �!/� 2. 3. T 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PER'bf1T# LICENSE REQtiIRED FEE PER4iIT� LICENSE REQti IRED FEE PERLIIT a _B&B S50 _CABIN S50 _MOTEL �� S50 INN S50 CA.�iP S50 � SNLVS.vIING POOL S75ea. I LOIXiE S50 �QQ�O��' _IRAILERPARK 5100 _R'HIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT� LICENSE REQLIRED FEE PER1fIT¢ LICENSE REQL'IRED FEE PER�ilT= _0.100 SEA'IS S75 _CONTINENTAL S?0 NON-PROFI? S?5 _>100SEATS 5150 _CO;bLbIONVIG S50 _��Z-IOLESALE S7i REiAIL SERVICE: —RESID.KtTCHEN S7i LICENSE REQUIRED FEE PERMII= LICENSE REQL7RED FEE PER�IIT� LICENSE REQL7RED FEE PER�i1I- _<50 sq.R. S45 >25.000 sq.8. 5200 �'ENDING-FOOD S20 _<25,000 sq.@. S75 _FROZEN DESSERi S35 TOBACCO� S50 �tAA�CHA�iGE: SIO AMOUnTDUE _ $ vo.00 "**"*pLEASE'IL'R.Y OVER A�D CO\iPLE7E O'fHER SIDE OF FOR�i*""•* ,� . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISIIMENTS TRANSIENT OCCUPANCl': For purposes of the limitations of Motel or Hotel use,Transiem 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 thal they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirly (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shail 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 Transiern. * NOTE: Enctos�d Motel Census must be comDleted and returned wrth ttvs�ti�ation. POOLS POOL OPENING: All swimming,wading and whiripools which have been closed for the season must be ins ected by the Health Department prior to openuig. Contact the Health Department to schedule the inspection five(�days pnor to opemng. POOL WATER TES1'ING: 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 Health Departme�by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Percnit urnil 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 Heakh. OUTDOOR COOKING: - -- OutdoeFsoelung;�reparation,�r�isplay of�ny food�roduct by a r . -- NOTICE:Pernuts run arumally from January I to December 31. TI'IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S)AND REQUIIiED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�vv1EE1VT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMME_VCEMEVT. REVOVATIO:VS MAY REQUIRE A SITE PLA�I. DATE: �/ 'o�G 07 SIG�IATURE:��k�„��('...-r ,�/ ,,� -- PRI�IT:VAME&TITLE:��I�L�K� �� C11� L��?'�� io,o n- : � The Commonwealth of Massachusetts Departmeat of Industrial Accidents N<eeN�s 600 Washington SYreet, �'Floor Boston,Moxc. 011ll R'orkera'Compeeaatioe Iesea�ce Affidavk:Baildiog/Plambiag/Eketrical Co�tractora wa.x...r�.�• Please FRINT I�r �� 4SS /Pr'vLr/'� lD c�9'� addiess� p2 0 � �� .�l/ • 'N�� iL�A�/ slate� L!�{/1� • ziel��lo[O,� o6one#_S�n '3��j yQ work 'te locati� foll ad&ess: I am a homeowner performing all woik myself. Project Type: ❑New Constcuc4on QR�adel ❑ I mn a sole pro�xie[or and Lave uo�e wo�cing in any capecity. ❑Building Addition ❑ I am ao einployer}xoviding workecs'compeacati�for my�ployees working on this job. . . . _ .__.. .__ _ ... . _. . _ . . __ —�- - _ _ ._. ..._ .. com me. �as' eity � DYO�e�' . id..�.e�ea uBNev$ .. .. .. . _. . . . . . .. .;.. . .. .c.:�r,.N .,. ._.. ❑ I am a sole proprietoy geaeral co�trxtor,or�omeow�er(cuicli ont)and have hired the co�actois lis[od below who have the following workers'compentation polices: add'w• city: oAare M' iuogaa�ee ca � oelicv N addrna- etN: olw�e#: � --� -- - -.__. . - _ ._ .-- -.-_-- - ---- --- �- � -- - �-- -- i�eg�eew. ---- - ppl�q# . �YdL�Y�7rGt��'�,r.. � .. . .. ... � .. .. . . . . � .. Faive b�xve cweade n'eqJuad udv Saile�2SA dMC.L 1Sf n�Wd b IYe Irp�ilir daL�YY pd6n d��e R bfl,SM.M a�dNr.. e�e ynn'Isptb�srst a wd u dN pwltln h t6e tw�d a 31YN WORK 06DBR ud�6e d T1Bl.N a dry a�t�e. 1 odnshod 1dt a cepy NIYb Aaie�eM my 6e HnurdM 6e We Omce ofl�we�m e116e D1A tar avenee ver�ratla. /!o Mneby ce rnler tAepaGu onrpenahfea/j .r.��r�� t Mt tefenndlon previded o6nve la trre o�f conrct � Sigoa[um/�i/t.U��.s�-t /!/ • }��E'zL.C:- Date �� /2-ls ' �/ Print name��'�d/ai6� r Phoce# �,t�t�r'3��5�� o�cLiexoaly MnNwAfe4thbarcabbeco�plefsdpydl3'erYwue�eW . . � cily ar fawe: pvmMltlame# t Q�JeeeY�R Beard . ❑eheek if i�me�te Rapeme b ra��N �Sdx�s's O�oe ra . �HnMY D�rdnl ' nani[Pvaso: Phwe41; O� tti+��l THE COD�IIVIONWEALTH OF MASSACHITSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-002 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby granted to Thomas 7.Roche Realri Inc. �� at Rass River I n�ine_2R Plea�ant Street_South YmmoLth_MA � � in said Town of Yarmouth and at tl�at plece only and expires December thiny-first,2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the Gcensing of Lodging Houses. 1Lis license is issued in conformity with the authority granted to the licensing authorities under secrion hventy-three,of chapter one hundred forty,of the General Laws,and is subject to the provisions of sections twenry-two to thirty-one inciusive of said chapter. In Testimony Whereo�the undersigned heve hereto aflixed their official signatures,this 1Lirtieth day of November A_D. 2007. BOARD OF HEALTH: .�EeP¢It S�ICI� �JZ.JV., �Xnta�t �6�P![t 3��.�AldQlll� �tC¢�QIXIttIYIt Units: 5 Q/tIt CjxeertBal�m, J`t..N' ' Bmce G.Murphy ,R.S.,CHO D'uector of Heal � . �-�2�wyS}./��inI` �I I �r� f Y'� G V W l� � I-� IJ \�� L.� V�. ?° e "�so TOWN OF YARMOUTH BOARD OF HEA,LTH .. ��= APPLICATION FOR LICENSE�KIR'TT 6 2Q07 `r NOV 2 O 2OOG �`y * Please com lete form and attach all neces � � p s�ry'dqcuments by Dece b� ��CpEPT. Failure to do so will result in the retuttil of your application p . NAMEOFESTABLISHIvIENT: ��SS f��`//F �FJ�qr� TEL. #SoS�3 -f>Syp LOCATION ADDRESS: ��P/Ei¢S�iNT�T, Sov��i�l�spvT(�usaQ� 0��/ MAILING ADDRESS: OWNER NAME: � T r CORPORATION NAME(IF APPLICABLE): ' � G, MANAGER'S NAME:�I �`^�g �lI,��Ng TEL. # �l.y�" �,rtvG nnD�ss: ��,� POOL CERTIFICATIONS: The pool 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 ttus form. 1. /�i� 2. N�i4 Pool operators must list a minimum oftwo employees currentiy certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Healt6 Deparlment will not use past years' records. You must provide new copies and maintain a t"de at your place of business. i. 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 'u+the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Piease attach copies of certification to this application. The Health Departmeot will not use past years' rewrds. You must provide new copies and maintain a Tde at your establishmen� i. iV/�.� a. �/.r� PERSON IN CHARGE: _ _ ---- - - -----_ - -__ . -- -- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1._�O Na�S�aP�iE �o� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-cholung 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. i. /�� Z. J1��i.4- 3. 4. 7 RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIltED FEE PERMI1'# LICENSE REQUIItED FEE pERMIT# LICENSE REQUIl2ED FEE PERMIT# _B.@B �50 _CABIN S50 MOTEL $50 INN $50 _CAMP $50 _SWIIoIIvflNG POOL$75ea. �LODGE $50 �97-00 � _TRAII,ERpARK $100 WfIIRI,POOL S75ea. FOOD SERVICE: LICENSE REQi)IltF,D FEE pF.RM[T# LICENSE REQIJIItED FEE PERMIT# LICINSE REQi7IRED FEE PERMIT# _0-100 SEATS $75 _CON1'INENfAL S30 NON-PROFIT S25 _>]00 SEATS SI50 _COMMON VIC. S50 WHOLESALE S75 RETAII,SERVIGE: —RESID.KITCHEN $75 LICENSE REQiJIItF,D FEE PF,RMIT# LICINSE REQUIRED FEE PERMIT N LICENSE REQiJIRED FEE PII2MIT# _<SO sq.ft. $45 � _>25,W0 sq.ft. $200 VINDING-FOOD $20 _QS,OOOaq.R. $75 _FROZENDESSERT S35 TOBACCO S50 NAME CHANGE: $]0 AMOUNT DUE _ �$ ��0 ••••"PLEASE TURN OVER MID COMPLETE OTHER SIDE OF FORM"••• ADMINISTRAITON Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pem�it 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 AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': 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 hotei use. Transiert occuparns must have and be able to demonstrate that they maintain a principal piace of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dweiling unit shali 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, shali generally be considered Transient. POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been closed for the season must be ins ed by the Health Department prior to opening. Contact the Health Department to schedu(e the inspection five(�ys pnor 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 CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Heaith Department. Failure to do so will resutt 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 ofHeakh. OUTDOOR COOKING: - Outcioer ceeki�g,preparation,or display of any food product by a r�ail or foad service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATION5 TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��Q� SIGNATURE: ,�� PRINT NAME&TTIZE: GLRfy/O�i`NC F�� G�ff� �onva � The Comisonwealth of Massachusetts Deparlxeent oflndusdial Accidcnts NMeIM�w�r�s 60o w�;,�� f'F�. Boston,Mess. 02111 ��,, --- Worlurs':.Com�as�tioe Lsvaeee A�davit b�g/Ekrtrical Cs�hxtvrs .. . ... . �-:-. _ _. , ,,.. . ,.. .... . . , .. �� . . _ . - . .. *� a� `,�,.^� �: ✓�ss �P�'v� /a c�(v�� s'�- �— �: /� ,�i 5._ � cih+ �'-s/J��l�G/.lL�)u/�'� s�ce: ��. zio•��y Dhme# �� q�-{� YO � wo[k site locatim lfnit addRasl: ❑ I wra performiog a11 wak myself. Project Type: ❑New Cons�r.tim OR�adel mm a sole and have no one w ' in an B�ril ' Addition ❑ I am an employer provicling w�keca'compeagation far my�pbyees wodciog�tLis job. ��e: . . . _ _ _... . .. _ . _ . . . . _._.�..-_ _ . . . .__ .. ._ �rau• elh- � nYreAF � . eeYer/ ❑ I am a sole propridot,ge�val�h�actor,or komeowoer(rneie owt)a�Lave l�rted the co�ctas liated below who have tLe following wakas'compensation polices: �t u� � rlGr �� ew p �4�� Y� FaYo+e b areae overye n reqbd oAQ 8[etlr 2SA NMGI.LSf m Ind 6�IYe�tlW�dviJW paYb d�ie+i�lI.SMM dl�r we yean'ImptYsweat n wd n dH pwNin la t�e br��[a Sl'OP WORK ORIISR arl�B�e dS1M.M a dry�t ee. I ode�M Idt a ay ef1W MaaaeW ry he hrwaMN b IYe O�c dl�n d He DIA Are�serqe wMnW�. I�Aere6y ce e pfna rwd p /da�np�,�-,-,•,t�—.+,,M�Me isfonwlJan previld ebnro 6 erre ad cermt S�Soatum � s� ' i( />> a DaM ��—/ 7 ��,� Ptintname�_f�l�S V . OCi/� P6one# SO�-,39��SS�tJ .mad.sewy a.eatwAteruha.umeeaorplMedprdlrarrw.amdd dry or t.wnc per�i�e g 1-1��..D�� ❑tic�V�Be rapne b r�q�M ��6 B�W �Sdeem90�ee ta�Mlpnawc �yy�g, �� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NUMBER: #07-001 FEE: $50.00 LODGING HOUSE LICENSE This is to Ceitify that a I.odging House Licen.se is h�eby granted to Thomas J.Roche Realtv Inc. � at Rac�River I.cxlge 28 pi acan[Sffeet o�h Yanno� h MA in said Town of Yazmouth and at that place only mmd expires December thirty-first,2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of Lodging Houses. This licen.se is issued in conformity with the authority granted to the licensing authorities under section hventy-three,of chapter one ihundred forry,of the General Laws,and is subject to the provisio�vs of sections twenry-two to thirty-one inclusive of said i chapter. In Tes[nnony Whereof,the undersigned have hereto aflixed their official signahires,Ihis Twentvcighth day of November A.D. 2006. sonan oF��.�: B .c 95. ,M.11., • i R��, ��e�� units: s /�a�icc�(c Mc.�e3awk` �1.��.,.d�.,�, R.N. Bruce G. Murphy, S.,CHO Director of Health Z� . � cp.�lb �fe q.y TOWN OF YARMOUTH BOARD,.A�$�;ALT�� ' � � " o��y APPLICAITON FOR LICE'1�SE��ItMrT-2006, p E C 0 7 2005 p • �'I' F. •- *. �. � ` � * Please complete form and attach all nec�esSary�documents by D 1 Failure to do so wi(I resuit in the retum of your application . ��'�T' NAME OF ESTABLISfIMENT: TEL. # Sc.B=.�'8'�S`!/p LOCATION ADDRESS: —' ; MAII,ING ADDRESS: OWNERNAME: T ID r CORPORATIONNAME(IF APPLICABLE)'� � � C� MANAGER'S NAME: ' � TEL. #�� MAILING ADDRESS: ,�'',L- '�t�l� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P�el-0�erater{s)-anc�attaeh a cepy of the ceRificat�on te-�his ferm----_ _ 1. /1(�j� 2. Pool ope�st list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employce certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��f¢ 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 de5ned in the State Sanitary Code for Food Service Establishments, 105 CNIR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' reeords. You must provide new copies and maiutain a file at your establishment 1. �� 2. P�RSON 1N-CHARGE_ _ _ _ _ _ _ Each food establishment must have at least one Person In Chazge(PIC) on site during hows of operation. 1. /�1�� 2. HEIA��CH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please Gst your employees trained in anti-choking procedures below and attaeti eopies 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. �T 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PF,RMI1'# LICINSE REQiIltED FEE PERMI1'# LICENSE REQUII2ED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL $50 _INN S50 _CAMP S50 _SWIIvI[�4INGPOOL$75ea. �LODGE $50 � _TRAII,ER PARK $50 _WHQtLPOOL $75ea. FOOD SERV[CE: LICENSE REQUIRED FEE PERMIT N LICENSE REQiJIRED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT fl Od00 SEATS $75 CON1'INENTAL $30 NON-PROFIT $25 >I00 SEATS St50 COMMON VIC. $50 WHOLESALE S75 RETA[L SERVICE: . LICINSE R&QUIItED FEE PERMI7'�# LICENSE REQUIl2ED FEE PERMII'N LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft.. $200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERP$35 TOBACCO - $25 IYAME CHANGE: E10 AMOi7NT DUE _ $ 50 •OO "•"""pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•••"• ADMINLSTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Perntits run aonually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RET[.1RN THE COMPLETED APPLICATION(S) AND REQiJIltED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT'I'HE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVF.D BY TI�BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQLJIRE 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 prior to operung. 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 Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hows prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Fro�ect desserts m�tst-be-testeEl-0n�-n�entlaly basishy a State ccrtified lab. Test results must-h�sent tathe_HPA�}h Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemvt 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 ofHeahh. OUTDOOR GOOKING: Outdoor cooking preparatioq or display of any food product by a retail or food service estabiishmern is prohibited. DATE:�'��—p� SIGNATIJRE: ' PRINT NAME&TITLE: � � i{� � � � 09l28/OS �� T/ee Cwninonwealth of Massachusetts �� _ DeparMreet ojlndesfrial Aecidenls � __ �IN� = 600 R'ashisgton Strcey �'F[oor - Boston,Mass. 82111 ..- Worlcen'Compnsatioe Iasvaeee A�d�vik Baa ' Mq,lEkelneal Cwtrxtars �. . � ._ .. ,*�„x, r �..:`"ao-z , .`tS,. ... . .. _. .."F.�r��,'� `�[:.+•,.� s*t-�_'�„'s' _.. .,., ., . �: ,Q�ss' �?��a� lad�� : �P��-i s�- �.�.�N-7�rb�� : �� ao:.2�y �#.SQ4=39�-os�o �,t�m i«ar��rrnu�8t ❑ I am a homeowner performing atl wadc myself. Project Type: ❑New Cma�ucum DRemodel �a sole and have m�e w in� B ' ' Addition ❑ I mm an�ployer pmviding wadcess'compensatim far my empbyces wodcing�this job. _ cenerv ree• ai�e�s• ekv: . eYa�e 6: ❑ I am a sole proprietot,geoersl eo�trxtor,�6omeowoc(are%oweJ�Lave Lired U�e comtrx[as liated below who Lave the following workers'compe�afion PuHces: �[aue:_ ae�ess: dlr• oY�e#: M �rv me: � �v: orre t: � _- - - - .___ .- - - - � -- — -- . ___. _ _- _— �-- -- --- -_. .. --- .—._- _. . _ _ ._. . - - - - - - _ It FaYve r fe[ae ewR�e n�eqyd de SeetlM 2SA dMGL 1ffi m lead b IYe i�polly do1�iW pWb da 6e�bA.'iM.M aW�r ..�y..�+•�rr....n,.�.a..a.��..rwdu��..t,smrwowcoaosem.�.rue�.M.a.y.�.e. �oa�.wur. dpy d1i6+hieseat ry 6e fiewatded!�Ne Omee dl�atHe DIA 6r owv�ge verqlnlM. /l0 6enby ce�oJ'y rnAer H�e pdas rw1P��olPad�'Y rA�Me 7�fonr�nbn provlld abone ia rxe a�d csrrect Si�aattarc I)ate Priet name .`r E/�/�/eY i e�� ,�� X�FJG � ehone#,SG��O�O � a�rLlaxaWy dsutwAfeYtWarnb�e�d69d19ar4w�a�cW dyortewu: pQoMlgemeN I�BaY�ap�t ❑eYed Hfms�b reapem 6 rtqWN ❑5�h O�ce ❑HnIIY Dept�nl m��P�� P�N; 1-IOlhv (.�.:a sy�.loml THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NLJMBER: #06-003 FEE: $50.00 LODGING HOUSE LICENSE This is to Ceitify tF�t a I.odging House License is hereby ganted to Thomas J.Roche Realty Inc. at Racc River T �*e_28 Plea�ant Street SouLh Yar�nonth. MA in said Town of Yazmouth and at that place only and expires December thirty-first,2006 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the licensing of I.odging Houses. This license is issued in conformity with the authority granted to the licensing authorities under section twenty-thcee,of chapter one hundred forty,of the General Laws,and is subject to the provisions of sections twenty-hvo to thirtyone inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed their official signatures,this Twenty-seventh day of January AD. 2006. BOARD OF HEALTH: B fst $. M.�S., . �� ., v:�e� a�t�. a�, e�,� U��: 5 p�M�� A.�lf�, R.N. Bruce G. 1'Viwphy ,RS.,CHO I?irector of Health , � ��FY9��o TOWN OF YARMOUTH �� 0 �"3 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 H MAtTACMEES � �xo„�p,�„�P� Telephone (508) 398-2231,Ex� 241 — Fa�c (50S) 760.3472 B O A R D O F H E A L T H � To: Yarmouth Board of Health Permit Holders � '� �� n m � DD � From. DavidD. FlabertyJr., RS. ;�� R <`� � 2005 i Health Inspector � TownofYarmouth � HEALTH DEPT. Re: Federal Taa:ID Number � Date: March 22, 2005 � I The Massachusetts Department of Revenue is now requiring that we furnish detailed information to them regarding all permits and licenses that we issue. O� of the detaiLs that they require we ; send to them is every establishmenYs Federal Employer ldernification Number(FEII�otherwise lrnown as your"Ta�c ID Number". This is purely for administrative purposes only. � So� businesses use the owner's Social Security Number (SSI� for this purpose. If Uvs is the �' case for yow establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to ' Yazmouth Health Department 1146 Route 28 ' South Yarniouth, MA 02664 Thank you for your anticipated eompli3nce. If y�u have any questions regazding this matter, please do not hesitate to call. The office hours are Monday to Friday, 830 a.m to 430 p.m 1'he � telepho�ber is(508) 398-2231,ext. 241. , ��s ,�. ��iTs� y.,rc . n � rf � ��. Establishment D/��1'" or SSN: � . ._. , Location Address: _p�/�l�,�S,�/S/ � Signature: Tl.d � Print:�'1-zs��"�i`N��OG�� Title: �� ,�� Printed oe� Recy , Z. � Pa � _ �y67�5 °' s e,�a�c�oc� o �ay TOWN OF YARMOIITH BOARD OF � �'�� ` s �� "� � J o -, APPLICATION FOR LICE � s AS ; N 0 V 3 0 2004 3��a '��,? ,��.� � � � �� * Please complete form and attach all necessary��ocurt��y Decemb r��[J�{ DEPT. Failure to do so will result in the return your application pack . NAME OF ESTABLISHMENT: TEL. # - - p LOCATIONADDRESS:�� /�/¢S�/sT, �/ a,�f.io�x.�t�, �+„�, O�LGv MAILING ADDRESS: � OWNER/CORPORATION NAME:�t¢ y� �?�/Tr, �r*G. MANAGER'S NAME� C'...�,�/.li r+� ,� ,�cff� —T� TEL # t',�rq� MAII,ING ADDRESS: S��y� POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. T�i'T 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation �CPR). Please list these 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 maiutain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIkTCATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. �� 2. PERSOI�IAIG3�ARGE: __ _ - _ - _— _. - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 employees trained in anti-choking procedwes 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 LODGIlVG: LICENSE REQUIl2ED FEE PERMI7'# LICINSE REQUIItED FEE PERMIT'N LICENSE REQUIltED FEE PERMI'P# _B&B S50 CABIN $50 MOTEL S50 _INN $50 CAMP $50 SWIMhIING POOL$7Sea. �LODGE $50 �s�� 'PRAII.ERPARK $50 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMI'C# _0.100 SEATS S75 _CONI'INENTAL $30 NON-PROFIT S25 _>100 SEATS 5150 _COMMON VICT. $50 WHOLESALE $75 RETAII.SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICINSE REQUIItED FEE PERM[1'# LICENSE REQUIRF,D FEE PERMIT# _<SOsq.ft. $45 >25,OWsq.ft. S200 VHNDING-FOOD $20 _QS,OOOsq.ft. S75 _FROZENDESSERT S35 TOBACCO $25 NAME CHANGE: $10 AMOiJNT DUE _ $ SO.00 •=•""pLEASE TURN OVER AIYD COMPLETE OTHBR 5IDE OF FORM""••• ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requ'ved to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and Gens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO NOTICE:Perntits run annually from Januazy 1 to December 31. TT IS YOUR RESPONSlBII.1T'Y TO RETURN TF� COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISFIMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENTFOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR TI-IE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfA9ENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTI'IONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food estab ishment which 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 prior to the catered event. Thses forms can be obtained at the Health Department. �R6�EN DESS�`R3'S: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service estabtislunent is prohibited. nA�: I/ - 2 q • py sIGNA�; s�.��.-f �� PRINT NAME& TITLE:_ C'��'N� r� /�O�r�I� q'� 10/22/04 —� T/ie Commonweahh of MwssachusetGs �--_� Depart�reet of Industrial Accidexts — NIi�rI1i� � - 600 R'oshington StreeK �'Floor ��, Bostay Mass. 0211I � Woricers'C��satio�I�sea�ce AS�v� " kehieat CoetraeMrs �,-._, ... x . ss.,.*:e �+n ,.,-.:n�mw ;�.:z�'-�. . _ ., ., _... .. ,. - . . . � namc: �3: �� /LJ"i�S�N/ S% r1lV�(��I�F�Bv� Sph: !�� ZIO:��# S!'JO �7!() �SI� VVO SILC IOCBh fOII 8m 8�OOWIICI PCIfOlmlllg 8d Wq�C 1Ly8P.�. P[OJBd T�E: �NCW(�.�1'IIChO�� I am a sok and]mve�aoe w m an B ' ' Addiaon ❑ I mm an e.�loyer providit�warke[s'compensatim far my empbyees wodcing a�n this job. amor�rer � _ - . . _. _ . . .. addrmr ehv: . � ol�a�N: � �u. oaicv ❑ I am a sok propiiUor,ge�aal ceotractor,or homeowrer(cwde owe)�d have hired�e co�ctas liatad below wln Lave the following wadcas'compensation polices: nodar r�e: �� v: oi�re/: 8 aa�rv re: add�ep• S.�Y• d�re�: � � - -_ —_ Faive Y aeeue eraf¢o nqiN dQ See1M�2SA dMC.L 152 m Wd b IYe i�pd1Y�daidW�sWn d�6e�p bA.MM atllr a�e ynn'I�prM�rnt e wd n eM penitln�tYe 6�da 3T(Ir WORK 08DER ud�me atSIMM a Ary aplM�e. 1 odnaWd Hu a apy NNb W�t dy be hrwrtlm M Ne O�eotl�NNe DIA hrowe�e vteNntlN. /do henby certi rw rr die pa8�a�wd pena/dea ojperjn tAd dYe Isfwwdlon prerlded ebew ls twe o�Adrmt pa8 a sss�R n.k �//' � g. �% Print name r Phoce#_.�OR��z!�"�C2.S YA .�CLI.x«ry a.wtwrkerw.,.no.SewplNedbsdly.re.ws.�ehl dryartswa: p�tlixes! -" Dep�t�t ❑eYeek if i�! �Bavd rz�eme b'eqah'ed �'s O�ce �tlnitl�Le�a�l�! caWcl Pn*sa: �xe a; (�101� lmiee S�t mm) THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-001 FEE: $50.00 LODGING HOUSE LICENSE Tlus is to Ceitify thet a Lodging House License is hereby granted to Thomas J.Roche Realtv Inc. at Rasa River i ndoe_2A Pleasant SL�cet SoLnh YarmnLnh MA " in said Town of Yarmouth and at that place only and expires December thirty-first,2005 imless sooner suspended or revoked for violation of the laws of the Commonweakh relating to the licensing of Lalging Houses. This license is issued in confomuty with the authority granted to the licensing authorities under sec,tion hventy-thrce,of chapter one hundred forty,of the Gener�l Laws,and is subject to the provisions of sections twenty-two to tLirty-one inclusive of said chapter. In Testimo�Whereof,the undersigned have hereto affixed their official signatures,this Eleventh day of January A.D. 2005. � BOARD OF I�AI.TH: Beir�wnis��5. y'm!c%sty, iN�5. ' � n�.wa�� v�e� a�t� a�, er� U��: 5 � s� Rrv. ,v.�g� a.n�. in�e G.lvimphy, 5.,Cxo i Director of Health i . . ��.{�'�� ; � � � �9B'.�c.�'o � _�`�'+o TOWN OF YARMOUTH BOARD EALTH �V 1 3 Z003 �C�S APPLICATION FOR LICENS�fP�RMl�' -2004 �c`�', �: ��'' EPT. * Please complete form and attach all nec�a'r�d nts by Decemh ` , . Failure to do so will result in the ret �of��pPlication packet. NfrME OF ESTABLISHMENT• ' a T # -��,�,ya LOCATION ADDRES�_ �B' �/€i4S�i�� SO�%,F��,��,��m2�ti�/ R/ T N N �� R'S NAME• T MAILING ADDRESS: �'�i.e� 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 ccrtif cation to th�s form. l. /✓o ,�Ao / 2. Pool operatots 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 and maintain a file at your place of business. 1. r�,�- 2. 3. 7 4. �'OOD 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, ]OS CMR 590.000. Please attach copies ofcertification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your estab►ishment. l. � 2. PER50iQ IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT H LICENSE REQU(RED FEE PERMIT# _B&B S50 _CABIN 550 � _MOTEL S50 _INN S50 CAMP S50 _SWIMMMGPOOLS75ea I LODGE E50 �� _TRAILER PARK S50 _WHIRLPOOL S75ea EOOD SERVICE: LICENSE REQUIRED FEE PERMIT# UCBNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H _0.100 SEATS $75 _CONTINENTAL S30 NON-PROFIT S25 >(00 SEATS $150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERV(CE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FGE PERMIT# LICENSE RHQUIRED FEE PERMIT# _<50 sq.ft. S45 _>25.000 sq.R. S200 _VENDING-fOOD S20 _<25,000 sq.ft. S75 FR07.EN DESSIiR"f $�5 TODACCO S25 NAMECHANGE: SIO AMOUNT DUE _ $ SO.00 "•«"*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 CompensaUon Insurance. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR _ CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH�D Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �/ NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISI IMENTS ARE TO CONTACT THE HEALTH DEPARI'MENT 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. ADDITIONAL F U ATION POOLS POOL OPEINING: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 CONSU F.R VI ORY: Each food esstablishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATE IN PO .I Y: 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 obtamed at the Health Department. TiDA7L'N TL'CCTi nma_ ___ __ .. _ _.—_. _._'_._ __— _ . _ . __. ._ _ _. . _ _. __. 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 tem�s have been met. O TSID • �4• Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board of Health. OUTDOOR COO iN : Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. r DATE://' ��S� � Q�3 SIGNATUR�: F £ PRINT NAME& TITLE: g �/��.v� � �' 10/22/03 ' ' � The Commonwealth ojMassachesetts : Departmenr ojfndustria/.-lccidents ; OI!/eeol/er�sUys/His 600 Washington Slreet Boston,Mass. 02111 ' ` Wbrkers' Compensa[ion Insurance Aftidavit Aoolicant information: Pfe*sePRINTT�w'i.ik aim� ./��/�� !D OLOfr loc�ti�n �.��/�I'�� - � �/f��st ��, �,y , ��f aho��a c od=3�"-�SYa �1 m a homecµner pen rmmg all work myse m a sole proprie�or=r.,�. ha�z no one ��orkine in am capacin• � I am an employer pro�idino uo�kers' compensa[ion for my employees workine on this jab. comnanv name: address: litv: ehone N• insurence eo. noliev# � I am a sole proprieror. general contractor, or hameowner(cirde onel and hace hired the contractors lisced below �.ho ha�e the follu��in_ ��orker; ,ompensation polices: comoanv name: - � address: cin�: phone q: in�r�ncc co. Deliev# eomeanv name: . .-- - _ . ____. __– ----_ .. . . . .._ ------------ -- ._. ._ .. addresr . . __ _ ._ ._ __ . —.. . [1LY' pAoee N• iniut�nce eo. neRn M - � Failure to seeure covenee�s requlrcd under Scenoo 25A of MGL IS2 w iad to�Ye i�pailio�Merid�l pndtln o(�p�e op w Sl¢00.00�W/or oee yean'imprisoamrnt u w�Nl u eivil penalHe�io the form of a SI'OP WORK ORDER a�d a 6�e of 5100.M�d�r q�iert m� 1��dmta�d ehat� topy of thy sutemem may br(onnrdM to the OII{ee of Inveuiptlonf of Me DIA tor eoven�t vedlfutlw. � � !do�hrreby certijp und r rhe pains and penal�ies ojp cry'ury that� jo on provided above is trrm and correet ,// 1 Signature�� G-- tL�e �/ 'Q�� Print name , �,�N �08=3 p'�=o5yo . olTrial use only do not nri�r in this�rca to be eompleted by cily w fmvo ollleial ciry or town: Y�M�DTQ _ permitAiteeae M nBuitdiog Departmea� �Ueeesio`Bo�rd p eheck if immediate response ie required 261 OSdectmen'e Ofliee (508} 398�?231 pst, OHeaItE Departmeat contac�penan: pAo�e M;_ __ _ nOther r I ACORD CERTIFICATE OF LIABILITY INSURANCE DAIE�MM/D0/YYYY) --r—^^ 11��5�2��3 PROpY ER �508)473-0556 F� (508)478-6709 THI CERTIFfCATEISISSUEDASAMATTER�OFINF RMATIQN . Karl A. Bright Ins. Agency, Inc. ONLYANDCONFERSNORIGHTSUPONTHECERTIFICATE . HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 6 Congress St. ALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW. P.O. Box 424 Milford, Mn 01757 INSURERSAFFORDINGCOVERAGE NAIC# IN5URED Thomas 7 Hoche Realty Inc INSURERA: Merrimack Mutual Fire Ins. Co. 19I98 � DBA Ba55 R1V21' Lodge INSURERB: 28 Plei52nt $t�eet INSURERC: Yarmouth, MA 02664-4543 INSURERD'. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NO'RMTHSTANDIN i ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH - POLICIES.AGGREGATE LIM�TS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS � - � - - L7Ft NSR TYPE OF INSURANCE POLICV NUMBER DA7E MM/DD OATE MM/D LIMITS GENERnLunBlurr SBP 2206840 O1/O1/2003 OS/O1/2004 �CHOCCURRENCE 5 1,000,000 X COMMERCIAL GENERAL LIABILITV $ PREMISES Eaoccurerica 50�000 � CLAIMS MA�E O OCCUR MED E%P(My orre person) � $ 5,000 i p PERSONAL&ADVINJURV E 1,000,000 GENERALAGGREGATE 5 2�000�000 GEN'LAGGREGATELIMITAPPLIESPER' PRODUCTS-COMP/OPAGG $ z�000�000 X POLICV jE� LOC AUTOMOBILE LIqBILIiV �' COMBINED SINGLE LIMIT $ ANYAUTO �� (EaacGdent) . . .ALLOWNEtlAUTOS . . .. .... . . .. ... .. . . BODILV INJURV ... . . $ ,. . .. SCHEDULED AUTOS (Per person) i � HIREO AUTO$ BODILV INJURV a NON-OVJNED AUTOS (Per accident) PROPERTVOAMAGE $ (Peraccitlenq GARAGELIABILITY AUTOONLV-EAACCIDENT $ I MIVAUTO OTHERTHAN �ACC $ i AUTOONLV: qGG $ I EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ �. OCCUR O CLAIMSMADE AGGREGATE $ $ DEDUCTIBLE $ � RETENTION $ $ WORKERSGOMPENSATONAND TORYLIMITS ER � EMPLOVERS'LIA&LIIY ' ANYPROPRIETORIPARTNER/EXECUTNE E.L.EACHACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EAEMPLOVE $ H yes,descnbe untler SPECIALPROVISIONSbeIow E.L.DISEASE-POLICYLIMIT $ OTHER DESCRIPiION OF OPERAiIONS/LOCATIONS/VEHIC�ES/EXCLUSIONS ADDED BV ENDORSEMENT/SPECIAL PROVISIONS � � � � .. . .... ' � CERTIFICATE HOLDER CANCELLATION � � � ' . .__ . .. .. . . .. .. . .__ . . SHOULD ANV OF iHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE iHE ' EXPIRATION DATE TXEREOF,THE ISSUING INSUftER WILL ENDEAVOR TO MAIL �_DAYS WRITTEN NOTCE TO THE CERTIFICA7E HOLDER NAMED TO THE LEPT, Town of Yarmouth Hea1Lh Department BUTFAILURETOMAILSUGHNO7ICESHALLIMPOSENOOBLIGATONOR�IA&LITV 1146 ROYSE 28 OFANVqNDUPONTXEINSURER,ITSAGENTSORREPRESENTATIVES. $outh VaF'InOYth� MA 02664 AUTHORIZEDREPRESENTATIVE /_:]eE-`Is�.t/*�"w Peter Ellis/CHRIS t � ACORD 25(2007/O8) �OACORD CORPORATION 1988 FGn A.�1'19f1t Insurance Agency, Inc. 6 Congresa St. P.O. Box 424, Milford� Ma 01757 (508)473-0556 (800) 287-9191 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-001 FEE: $50.00 LODGING HOUSE LICENSE T1us is to Certify that a I.odging Hwse License is hereby granted to Thomss J.Roche Realtv Inc. � � at RaQ¢RiverT.ni�e_2RPleasmrtCtrer.t SruithYarmnnth MA in said Town of Yarmwrth and at that place only and e�cpires Decembet thirly-first,2004 imless sooner suspended or revoked for violation of the laws of tbe Commonwealth relating to the licensing of Lodging Houses. This license is issued in confoimity with the authoriry grmmted to 8be licensing authorities under sectian twenry-three,of chapter one hundrad forty,af the General Laws,and is subject to the provisions of sections twenty-two to thirty-o�inclusive of said chapter. Tn Testimo�Whereof,the imdersigned have here[o affixed their official signat�ses,Uus Second day of December A.D. 2003. BOARD OF HEALTH: Bucfa�xfit�S. Cjdt�, M.�,S,.f ' /�attic�INo�e4nro�fos l:liaLt�xa�s /1o1�+et�. Baoewr,. ' —_ e�f�/ais S�ra�. IQ./V. Bnue G. Murphy, R HO Director of Health . ,� t��''� B K LoDQE � e qwr TOWN OF YARMOUTH BOARD OF HEALT�I _ _ � G�3C �c� �, r ,� �' D 3 � APPLICATION FOR LICENSE/PERNIIT-Z00 � � ' ? � ,/? p ` `�'y'D �I� � 'r . , * Please com lete form and attach all necess docutti�t b ec 31, 002 j 3 Tt{�f� Failure to do so will result in the return our application packe . �-{��LTF# bEP7', NAME OF ESTABLISHMENT: � i%/E dF TEL. #.s�P?9%9S'S/o LOCATION ADDRESS: �/��,��f��,f�ur . 0�/06 fi 5 T � � � � '�vE � MAILING ADDRESS: S�irr� I POOL CERTIFICATIONS: The pool supervisor mast 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. /11�G� 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 certifica6ons to this form. The Health Department will not use past years' records. You must provide new copies and maintaie a file at your place of busiaess. 1. 2. 3. 4. i �OD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one fuil-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 establishmen� 1. �� 2. I PEI�SON IN CHARGE: _ Each food establishment must haue at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. F.I IICH RTIFI ATION : All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anri-choking procedures below and attach copies of employee certifications to this form. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a fde at your place of business. l. 2. 3. 4. RF.STA TRA1.1T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT i! LICENSE REQUIRED FEE PERMIT H _B�B SSO _CABIN S50 _MOTEL . _. .-550 _INN $50 _CAMP $SO _SWDvIIvfINGPOOL$SOea �LODGE $50 a3�� _'['Rp[LERPARK $50 _WFI[RLpppL $25ea � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQ[JIl2ED FEE PERMTT# LICENSE REQIJIRED FEE PERMIT# _0-t00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT S25 >10(1 SEATS $150 _COMMON VICT. $50 WHOLESALE $75 RFTAri SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO $20 _Q5,000 sq.R. S75 _TOBACCO $20 _<50 sq.ft. $45 _>25,000 sq.ft. 5200 _FROZEN DESSERT S35 NAME C ANGE: $IO AMOUNT DUE = S SO. �o •*•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••:** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarxnouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHIvfENTS ARE TO CONTACT TI�HEALTH DEPAR'TMENT 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 THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIO AY REQUIRE A SITE PLAN. — __ \ ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WAT'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consuxner 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. _ FRn7.F.N DF.. SERTS• - Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: ' Outdoor cooking,preparaUon,or display of any food product by a retail or food service establishment is prohibited. DATE: /��/O — �e2 SIGNA �` �---- PRINT NAME&TITLE: CY�/�if/�l-i�� /Q ,�F�� St� 10/18/02 _ , � The Commonweolth ojMassachusetts � Departmen!ajlndustria/.-1 ccidexts ; omceoJ/aresd�stlus 600 Washington Slreet ' Bnston, Mass. 01111 " °� •` w'orkers' Compensation Insurance Affidavit nam�� i%/�6� �OlLO� � loc�ti�n� s�� //�,/��9Y�S%— cm S�� 5� o"_U+—'fr—�� Qe�lOF9 y ohone q SF�3�-�SYO � I a ho ecwner penorming all kork myself. am a solz proprieror =r..'. ha�e no one �corking in am capatin• � i am an emplocer pro��dine workers' compensa[ion for my employees workine on this job. eomnanv name• addresr titr: phene N• insur�nce co, policv p � I am a sole proprietor. qenerai con[ractor, or homeowner(circle onel and hace hired the contractors listed 6elow ��ho ha�e the follo�cin_ «arker> ;ompensation polices: companv name: address• cin�: nhone M• insurancc co poli�r# tomoanv name: � � . .. _ _ - -- - � . _ . _ . ._._ _ _. . ___- — - - � -- addresr � � - t�: phoee Ih. insuronee eo. � peRn M F�ilure m seture coverqe�s required under Secnoe 2SA o(MGL IS3 n�lad M tAe i�poriliw Merid�l peadtln of�O�e op to SI�00.00 a�dlor � one yean'imprisonment u w�ell a�eiril penaltln io tAe form of�STOP WORK ORDER a�d�li�e of 5100.M�d�r K�imt s� f��denta�d mat a eopy of thy sutemrnt mar br for.r�rded m the 011iee of lovntlptiom efthe DIA far eoverqe verillatla. . � !do�hrreby ctnijp un •rhe pains arte perta!lier a�m tht ' maY n provided abavt is Wt and rnnttt Signaturc t;[ �� Dme ��/,r9 '"�� Print namc �Y��OG i�� .f�G � � Phpne N 5'u�398"-oSy� ., aRci�l use onh do nat.ri�e in�Ais ana m be completed by eiN w tmva ollltid city or rown: Y�M�DT$ _ periaiNieeme M nBuilding Departmeut . ❑Lieeasine Bovd � check i!immediatt response ie required Z61 ❑Seleetmen'�ORee �Health Dep�rtmtat , contac�person: pAone M:_ �508) 398�Z231 eat. nOther THE COMMONWEALTH OF MASSACHUSETT5 TOWN OF YARMOUTH PERMIT NUMBER: #03-002 FEE: $50.00 LODGING HOUSE LICENSE � This is to Certify that a Lodging House Liceuse is hereby granted to Thomas J.Rcehe Realty Inc. i at Bass River Lodge.28 Pleaswt Street South Yarmouth.MA in said Town of Yazmouth and at that place only and e�cpires December thirty-Srst,2003 uotess sooner suspended ' or revoked for violation ofthe laws ofthe Commonwealth relating to the licensing ofLodging Houses. This license is ' issued in conformiry with the authority granted to the Gcensing authorities uoder section twenty-tluee,of chaptcr one hundred forty,of the General Laws,and is subject to the provisions of sections twenty-two to ihirty-one inclusive of said chapter. ' In Testimony Whereo�the undersigned have hereto affuced their official sigoamres,this Sixth day of December A.D. 2002. BOARD OF HEALTH: �ranlea'r�. .'�e!llkot. �alirwra/a �II . _ �ua�t.s D. Cjmrdak. %�,D.. ?�iee _ ,�o6oet?. �oar�. �a�E �asilr,E'1�Daurretr r'�du Skak. ,�7Z. Bnrce G.Murphy, R.S.,CHO D'vector of Health _ . : ri ":: W � � LS � V IS � TOWN OF YARMOUTH BOARD OF HEALTEI�� qUG 2 6 2002 APPLICATION FOR LICENSE/PERMIT-2��Y:�" sy � �� HF ALTt;�.'7 F� * Please complete form and attach all necessary documents by December 31, 2001. Fail �e-se-wiIl �st�bin the return of your application packet. NAME OF ESTABLISHMENT: sl SS .'!�r /o E TEL. #SoS 39$�fio in('ATION�� cz�S' � �/fll.�rA.�j�[,�.� a�6�i ,�MAILING ADDIZFS�• s'r�G✓.� ' � � � MANAGER'S N.�ME• �E,�✓ / ' �.,_ oc,�� TEL. # ��i� MAILING ADDRFSS• ��ir� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ___,_Pool Operatorjsland attach a co�y of the certific�tion to tkus fQrm. . _ L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Communiry 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 uew copies and maintain a fde at your place of business. 1. 2. 3. 4. F_QOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will oot use past years' records. You must provide new copies and maintain a File at your establishment. 1. 2. PERSOi� IN CH 1RGE: Each food establishment musi have at least one Person In Charge (PIC)on site during hours of operaUon. 1. 2• HF_IlvILICH 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. L 2• - 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $50 CABIN E50 _M07EL b50 _INN S50 _CAMP S50 _SWIMMING POOL SSOea I LODGE S50 �6�—DI� _TRAILER PARK $50 _WHIRLPOOL S25ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 >I00 SEATS 5150 COMMON VICT. $50 WHOLESALE S75 AETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT k _TOBACCO $20 _<25,000 sq.R. $75 _TOBACCO S20 _<50 sq.ft. S45 � _>25,000 sq.ft. $200 _FROZEN DESSERT$35 0 v�nME caaNce: $�o AMOiJNT DUE _ $ O, � **••*PLEASE TURN OVER AIYll 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 pernvt to operate a business if a person or company does not have a Certificate of Worker's Cornpensation Insurance. THE ATTACHED STATE WORKER'S CQMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR '�� CERT. OF INSURANCE ATTACHED_�� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: �y�� YES � NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISfIMENT5 ARE TO CONTACT Tf�HEALTH DEP.�,itTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL C3tt FOOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY T#�IE BOARD OF HEALTH PRIOR TO COM1�tENCEMENT. R�NOVATIONS MAY REQUIRE A SITE PLAPI. Al>DITIONAL IZF.GULATIONS _ _POOLS_ _ . _ _ _ POOL OPENING: All swimming,wading and whirlpools which have been cloyed 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 Al)VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. ('AT . iNG POL•ICY: Anyone who caters within the Town of Yarmouth must noUfy 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 Heaith Department. _ �R9��N n�s.�FIt1'S: Frozen desserts must be tested on a monthly basis by a State cenified lab. i est resuhs must be ser.t�o 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. QUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparauon,or display of any food product by a retail or food service establishment is prohibited. �"�� //-� C�d // '�;� DATE: �`a3 �p� SIGNATURE:E�rs��,p `� PRINT NAME &TITLE: QGI��j�� . iLoc�� ,Q",r� 09/11/01 O�'�Y`�R �� ,'�� TOWN OF YARMOUTH 0 - y 1146 ROCPE 2S SOUTH YARMOOTH b�IASSACHliSETTS 02664�451 H MTTTACHEES � C�. q�o,o� �o,bt+� "Ccicphone(508) 398-2231, Ex[. 241 — Faz(SOS) 395-2365 =`a BOARD OF HEALTH August 16,2002 To: Tom Roche c% Bass River I,odge 28 Pleasant Street South Yazmouth MA 02664 From: David D.Flaherty Jr. Health Inspec[or Town of Yarmouth Health Deparhnent Subject: 2002 Lodging Permit Dear Mr.Roche, Please find your 2002 Board of Healih Lodging Application and Worker's Compensation I��snrance Affidavit enclosed.Please fill out the fields that I Lave highlighted and return them to the Health Department either in person or via U.S.Mail.Please make sure to sign and date both papers;please make yow check out to"Town af YazmoutH'. Thank you in advance for your prompt attention.If you Lave any questions regarding Utis matter or any Health Department related issue please do not hesifate to contact this office Monday tLrough Friday, 8:30 am.to 4:30 p.m.at(508)398-2231 ext 242. �� Printed on Recycled L P3per _ �\ � The C'ornmonwealth ojMassachuseKs Deparrmen�ajlndrestria/�ccidents > OMes�/�y��s 6b0 Was/�ington Slree� Boston.Mass 021I1 W'orkers' Compensation losunnee Aflidavit Annlicaaiieformation: PlemeYR ,,�,m�: G.s�ss A�'r.�.�P la�o� �"� �o�� /�l�lfSr�-ri� [�+ �11- � _ _ _ �_y. � . _. ..�—cin�--- 'V--�6��1/��tl`� � ��(0 6 � . . . _- ohone MSW:�ro—Q5'�OJ �,,�� I a homa w�ner pertortning atl wo mysdf. � am a sole proprietor:r.d ha�e no one��orkinc in an}•capaciR• f � I am an employer pro�idins wodcers' compensation for my employ�ees working on this job. eomnany namr � � � � � .� address � � � - � � cih• ohonelF. � � �� - ��'�taA'l� insuran[e co. ooliev M � � "'�Y 0 1 am a sole proprietor. �eneral contractor,or homeowner(cire%onU and hace hired the contractors listed below who ha�� the follu�sin� ��orkers' .ompensation polices: eompsnv eame• � �ddr�er - • ein• � ehoneN• insuranee ro. eeliev N mmeanv nnmr � iddre�s• � tihr: nAe�eN: � . .. . ... . .. _. . . . .. . . iesunnee co. eeRn M � � e � � Failun ro uenrc toren�t u reqvired o�der Satiw 25A of MC61S2 n�le�i N IYe i�il[s�af eri�iW peWqa of�6K q to f1.S0�.00 a�dlw . o�e yean'tspri�o�ne�t a�w�eq a dv�l pnddd�Ne fons of�STOI WORY�tDER qi tllie�f SIMO�i Ny q�idt�e 1 pknfaN tYat� � rnpy of thN suument m�r be forwfrdM to Me OOin of lave�iptlom ef Me DIA�eererqe reriOnYa�. �. . . .. . � - /do be�eby reni •under tae pains ond pm rra ol � ,y r ��rAfo.�noR p„o.�saeo.e ts n�e o„r�o.,ra ��s��u�.e t— . $�3 O� Print name • M SD��qt��✓�'Y/� oRicial use oay� do not.rite in tlis ana to De rnmplead by ciry a Uw�o11kW eily or towa: Y�� _ peroNMaa�e M nBuiWlo`Departmeat DUteesiK Band ❑eheek if imraMi�u.rnpoase ia required . 261 O��mea'�OINee pNedtA Dep�rnnem con�ae�penoc aqK M;_ �508� 398�Y231 ezt. �p�per i.rnn:o�PIM � . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-014 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a Lodging House License is hereby ganted to Thomas J.Roche ReaITy Inc. at Bass River Lodge.28 Pleasant StreeL South Yarmouth.MA in said Town of Yarmouth and at that place only and expues December thirly-£ust,2002 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to the lice�sing of Lodging Houses. 'I7iis license is issued in confomvty with the authority ganted to the licensing authorities under section twenty-three,of chapter one huridred forty,of the General Laws,and is subject to the provisions of sections twenty-two to tUirtyone inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed the'v official signsnues,this Twentv-seventh day of Aueust A.D. 2002. BOARD OF HEALTH: eka3(ad�f. .�etliket. (�,lataasa�c ��a. �, �e.a., v� �� , � Patr�ek'�eDeu�wtt '�fefe�c Skak. ,�'yl. i Bruce G. Murphy, .5., CHO Director of Health ;s -'� k .V . .-� ^ - - � . ,�,,� f , . - g R . , . � ��: - �b G� G, ,�, c_=. n �7r� D TOWN OF YARMOUTH BOARD OF HEALTH �k`�' �� '�C O 5 POOO APPLICATION FOR LICENSE/PERMIT-2001�� HEALTH DEPT. ' Please complete form and attach all necessary documents by December 31, 2000. Failure to do so will result in the return of your application packet. ----------------------------------------------------- -------------------------------------------------------------------------- /o -p — � � � � , < <.r� MAILING ADDRESS: S�� ------------------------------------------------------------------------------------------------------------________ POOL CER'TIFICATIONS: , The pool supervisor muat be certified as a Pool Operator, as reyuired by new State law. Please list the designated Pool Operator(s)and attach a copy of the cert�fica6on to tlus form. � i. � 2. �— Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscita6on(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. Yon must provide new copies and maintain a fde at your place of businesa. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the ptemises at all times. Please list your employees trained in anri-choking procedures below and attach copies of employee certifications to this form. The Healt6 Department wiil not uae past years' records. You must provide new copies and maintain a fde at your place of business. 1. ��o �L 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# --- ------------------------------- ------ --------------- ---------------------------------- ------------ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $50 _CABIN $50 INN $50 CAMI' $50 I LODGE $50 �I-OOd" TRAILER PARK $50 _MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: NOTE: Per the new 105 CMIt 590.000 State Sanitary Code for Food Establishments,the effective date for food pmtection manager certification is OMober i,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL, $30 >100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQIIIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _>25,OOOsq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ 5� •Oa ***•"PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM*«*"* R 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 haue a Certificate of Worker's Compensa6on Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLJRANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taaces and liens must be pai or to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31,2000. SEASONAL ESTABLISH1vf�NTS ARE TO CONTACT TEIE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL 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. AI?DITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department,and the water tested for pseudomonas,total coliform and siandard plate count by a State cerhfied lab, prior to operung,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be dra.ined or covered within seven(7)days of closing. FOOD 5ERVICE NF:W STATE SrLNITARY CODE FOR FOOD ESTABLISHMENTS: T6e effective date for food protecNon manager certificarion is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food establishments must have at least one person-in-charge who is a certified food protec6on manager. This provision 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 inplemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATERING POLICY: Anyone who caters witlun the Town of Yarmouth must nodfy 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. 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 CAF�`S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�S have prior approval from the Board of Health. OUTDOOR COOKLNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. DATE: /02-v2—�� SIGNATURE: PRINT NAME & TITLE: �u. c S, 11/16/00 _ __ -,_ �. _ _ _ � The Commonwealth ojMassachusetLs : Department ojlndustrial.4cciden�s ; 9111ceo1/srestlDstliis � 600 Washington Street Boston, Mass. 02111 "� '` W'orkers' Compensation Insurance Affidavit A�jjcant informaHon: � PlessePRllaTTedGhTi�. S� ,�L�� /J� location� 2rP� /�/�.,fe�/"� � .��- S'/J �� Ges�. /��y ehone M So�^3��5�0 � 1 a �'ner pzrtortning al�k myself. am a sole propriecor ard have no one��orking in am capaciry � I am an employer pro�idine µorkers' compensation for my employees workine on this job. com�n�• name• — �ddress �� ohone M• — insur�nce co policv k — � I am a solz proprieror. general contracror. or homeowner(ci�cle onel and have hired the contractors listed belou ��ho ha�e thz follu��in_ «orl:zr_' .ompensation polices: m nv n address• cin phone k• . insurance co Doliev M n e: . _ . . _ _ .___ . _ _ -� ----__ . __._- -- address• ��h, phoee IE• insuronte to R°�n'� F�ilure to s�curt coverage�s required uoder Secrioo 25A otMGL►53 u�Ipd to the iopaitloe of erisiul pe�dtle ot��e op to f1�00.00�W/or one yan'imprisonment�e w�tll ae tivil peodtla io the torm of a STOP WORK ORDER�ed�6ne of f100.00�d�y a{tiort se. t ndenta�d that a copy of thh sutement m�y be fonvvded b the Olifee of/nveatig�tlom of t6e DU(or eoveraee veri6t�tlw. 1 do hrreby certijy unde��he pains artd pena!lies ojperjury lha��he injormallon providtd abovt ls We and ron[et Signaturc �� Print name Phone N . oRcial use only do not writt in this area to be tompleted by eity or towo oflftial � city or[own: Y��DTR _ permiNicenu N nBuildiog Depirtmeut — - � OLitensiog Board p check if immediate response is required � � 261 QSdretmen'f ORte �Hcalth Departmml tontactpvson: Dho��K�_ �508� 398=7231 eat. nOther i,�,.�e i;0i p1A1 b'qo� a a aCi �o y'�� > L. G � o�o� A � o s �y - o d a Say, o � � �+' - � o mv� ,�. x w o'm� o « �/ (.WL, `V o o p L/ \s Y .r�•- �"F" w o y � �a ��y(j d �x � �ca � ��0 �s�o , x � � � - � o _� U W �.."^.. _ o �L � , c°�iy .� � L. � � ,,q� � i � x z °�`'�'o � � �� C'A �Ll � y<t��1 �,�'� �; .�*<�� d � U s Q ��o 8 ` t,��' , � ;�"r: �°c: �y � Z y mm �: �� # �a � a s �•5 eo � ° F �_ r� �`�'�'t�`: �+ � w 3 �x 4 =,Vi N � �;g �� 4 O rri � � „ S � a , z.�3 � d' p �o r,�= o .d Wx �St c � •� �,� x [.'T"i � O � i� �3� y � wO ,�;a�� r�� $�.�¢ s� : {:_��'< a � G7 s ° � " 8 W �: ` _s,�l�` • t��i �#a`r�: � ^ � °,d 8 � - *; � ` c�. ��tg ?� # �`:`.� � '�';� + m d ' r�• F m�'� r :�" a.-*' R�"�` Y , . 1: � � N y � ""� � � .. x �^ � �r..�� a� � + . Z Q A � �y� �y � ( ' .� t y�a y t.t�r��s f w°��i� ; „ � ,, 0'�" "a ja �" ` s�' i� E"� � � .�5 r ,x� � � ";T�` 3 ` 34� •�t�i -� ►� � ,��'�� t, � -y.�� r'v�YY,� 1 � � p G r . , ,P .. . . bq V ' x °' �� w3ty ,�,N I' 3�* • e'� ` ' I � N L � N n..l � �;. . . ., £ . . M 7k .� � �+o,r� �Q � r . � Fa $ � y¢ i F a � � € 0•3 � � s . , C7 W s,`°' •- o o�p ,a � . '-� �', �' p >�"C�" ° j � . � 3 i„ z � � F w o � >, F V � Vw ° i-+ O Y.G � 5 � :C > °� }`�, m W N N � 7� �F Q..i � � C O•�t U� O � . . . . �. . _. :.. ' - . . . . . '.._ . � . . . . .i _ .. T. -..-.�'. ..�'.. i :.-�l. . >. i �', E'�:� R� �� .ic�� ` -ck-� �af� �s�= TOWN OF YARMOUTH BOARD OF HEALTH p [� (� f� � M C� D . APPLICATION FOR LICENSElFERMIT-2000 D E C 0 1 1999 �, t-' ' Please complete form and attach all necessary documerns by December 31, 1999. Fail re}��b�h�1ER�uit the return of yow application packet. —' ------------------- --------------------------------------------------------------------------------------- NAME OF ESTABLISfIMENT: ,�i��c c�,�//�,� /�0,� TEL. # 3 p'8"-�5�/o LOCATION ADDRESS ,�R" /�i�r%s'T. LIN WNER/CORPORATION N • i f��,�c v. OcN� .eav�s� Z.�+c . MANA . ' N MF: ,� 'f* c TF.T. # �8=of�/o MAn ING ADDRESS: �.tu.6 � �__��---_�.._----------------------------�_�__�_---_�___r___M_----------M______ POOL CERTIFICATIONS: The pool supe►visor must be certified as a Pool Operator, as ret�uired by new State taw. Please list the designated Pool Operator(s) an�attach scopy ofthe cenification to tlus form. 1. ��l�" 2. N1�4 Pool operators must list a minimum of two employees cunently 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 $file at your place oi business. 1. 2. 3. 4. FIEIIvfI.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 file at your place of business. 1. ,�/�/� 2. �///� , 3. 4. RESTAURANT SEATING; TOTAL# — NON-SIv10KI�+I�SEA�:TOTAI�#- -- - -----______________---------------------------------___�___------------------------------_.__�� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _B&B $50 _CABIN $50 _INN $50 _CAMP $50 I LODGE $50 Y21�-5 _TRAILERPARK $50 MOTEL $50 _SWIlVIl�IING POOL $SOea. _WHIItLPOOL $25ea. FQOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIlLED FEE PERMIT# 0-]00 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 _COMMON VICT. $50 WHOLESALE $75 R�TAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICEN3E REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ �� •••"•pLEASE TUR1V OVER AND COMPLETE OTAER SIDE OF FORM•••"• ADMINISTRATION IJNDER 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 PERSOI�T OR GOMPANY 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 Q8 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTI� TA7�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES !/� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPART'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE 1tEPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MtYY REQUIltE A SITE PLAN. Ai)DITION i F 1i ATION POOLS POOL OPENIIIG: ALL SWIlvIlvIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY THE HEALTH DEPARTMENT, AND TI3E WATER TESTED FOR ESEUDOMONAS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENR�IG, AND QUARTERLY Tf�REAFTER. POOL CLOSING:EVERY OUTDOOR IN GROUND SWARvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING TI� REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. TI-IESE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI-IE HEALTH DEPARTMENT. FAII.URE TO DO SO WII.L RESULT IN TI� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET. . . OUTSIDE CAFES: OLTTSIDE CAFES (i.e., OiTTDOOR SEATING WITH WAITER/WAITRESS SERVICE), �T$.�HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OIJTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBIT'ED. DATE: SIGNATURE: PRINT NAME& TITLE: I 1/12/99 � '� The Commonwea/th ojMassachusetts s = Department ojlnduslrial.-lccidents " _ b 011/C001//1'CStlyldllf 600 Washington Street Bnston.Mass. 02111 ` '� '` wbrkers' Compensation Insurance Affidavit ARplicant information: PI n. � n�m �� [�SS ��//�� CJ Ki 6 on: f 'un__�tL_ ��9�LszOv%� LN� 2� e /� phone p �f7R= .�q�'O$��/O � I am a ho eoµner pzrt�rming all work myself. �m a solt proprieror r..� ha�r no one ��orkin� in an} capacin� � I am an employer pro�iding workers' compensacion for my employees workine on this job. comnanv name: aJdress: ��'� pAene e• insur�nce co. ooliey q � I �m a sole proprietor. _eneral contractor, or homeowner(circle onel and ha�e hired the contractors listed beloµ ��ho ha�e the follu��in; ��orkrr_ ,ompensation polices: comoanv name: � address• zin�: nhone k• insurancc co. Delie�•# somoany name: .__ . ._ -- - - - ._--.._-----� - . . .___... - ----------- -- _- -- ----- ---- � iddrese: — - tiri: pheee M• insur�nce co. portev M ■ F�ilure to secure coveraet as required uuder Seenoo 25A of MGL ISI n�lad to t!e iepaitlo�oteri�i�l pe�tltles of�O�e ap ro SI�00.00�W/ot oae yean'imprisonmcot as w�di a�eivii peadHa io�he form of a STOP WORK ORDER�ed�6�e of 5100.00�d�y K�io�t sa 1��denu�d Hat a eopy of tAy sta[emen�m�r be forw�rded to�he 011ie�of Invertig�uoe�of IEt OIA for eovera�e veriflntlo�. 1 do hrreby ce jp a •�hr pains a d penaf!' ajper' ry thm the injonnatinn provid[d abovt is bne and rnrrcet Signaturc i //-�.�[— 9� Printname �li-rF¢S � �GOGf�� Php�eN ,?-��Q - ��S�O .. oRcial use onl�� do no��rite in this arra m bt tomplettd by eih or tmve o01tia1 city or mwn: Y�D�T$ _ � permiNieeme M nBuiidio`Departmee� pl.ieemio6 Board � check if immediate response i�required 261 �Selectmen'�Oflicr �Health Dep�nmenf �o��a«P«�o�: P�o„�p;_ (508} 398-7231 eat. �Other 1 THE COMMONWEALTH OF MASSACHUSETTS • TOWN OF YARMOUTH PERMIT NUMBER: Y2K-5 FEE: $50.00 LODGING HOUSE LICENSE 'fhis is to Certify tha[a Lodging House License is hereby granted to Thomas l.Roche Realtv Inc. at Basc River Lodge 28 Pleasant Street Souih y�outh MA in said Town of Yarmou�h and az thaz place only and expires December thirty-first,2000 unless sooner suspended or revoked for violazion of the laws of the Commonwealth relating to the licensing of Lodging Houses. This license is issued in confom�iry with the au[hority granted to the licensing authorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections twenty-hvo to thirty-one inclusive of said chapter. In Testimony Whereof,the undersigned have hereto affixed ifie'v official signatures,this Sixth day of December A.D. 19�Q_. BOARD OF HEALTH: �t��n.�r�ll7eag�g C�iairmaq/a� � � /� �oan C�.c 7Ju/�llivan, �//., Vics (,�irman �o�ert J. 9�rown a6rie��ap�a�ro�a�y/-p.�oopse ic�L Q u�rh[in ruce G. Murphy, MPH, O Director of Health •�� _��_ _„_.+_�� ,,, a�omc cnrerpnse. and including the Ie¢al representatives ofa deceased employer, or the recei�er or tnistee of an indi�idual . partnership, associa[ion or other lega! entity, employing emplo�ees. Ho��ever the u��ner of a d«el lin�_ liouse ha� in� not more than three apartments and who resides therein, or the occupant of the d��ellin_ house �f another��ho emplo}s persons to do maintenance , construction or rcpair work on such dwellin¢ house or un dia _round; or buildinu sppurtenant thereto shall nut because uf such emplo�ment be deemed to be an emplo}er. \1GL �hapter I_� ;ect{on :: also swtes th�t e�en� state or local licensing agencc shall ��•ithhoid the issuance or rene��al of a license nr permit to operate a business or to construct buildings in the commonwealth for an�• applicant ��ho has not produced accept�ble e�idence of compiiance with the insurance cor•errge required. Addiiion�ll�. neither the common��ealth nor an} of its political subdi�•isions shall enter into am contract for the pertbrmance of public «ork witil acceptable e�•idence of compliance with thz insurance requirements of this chapter ha�e bcen presznted to the contractinc authurin. Appli�.:nts Please fill in the �vorkers' compensation affida�•it completely, by checking the box that applies to cour situation and supph ing comp�m names, address and phone numbers as all affidavits ma�• be submitted to the Department of Induserial ,�ccidents for contirmation uf insurance coverage. Also be sure to sign and date t6e afiidaciG The affida�it should be retumed to the cit} or to�vn that the application for the permit or license is being rcquested. not the Deparnnent of lndustrial .accidents. Should you have any questions rceardin¢the "1aw"or if you are required to obtain a �wrkers' compensation polic�. please call the Department at the number listed belou•. City or Towns Please be sure chat the affidavit is complete and printed legibly. The Departrnent has provided a space at the bottom of the affidavit for vou to fill out in the event the Office of lnvesti¢ations has m cnnracr�� -,..,-..:;,.� .L. ___;:___. ' �xss rnver L�icj� ., , TOWN OF YARMOUTH BOARD OF HEALTH 'S�b p � � � � d � D APPLICATIONFORLICENSE/PERMIT-`i9�9, c9� DEC Q 4 �gg8 Y * Please complete form and attach all necessary documents by December 31, 1998. Failu M8AIs3kbiD�711 � the return of your application packet. ------------------------------------- __ _-- -- +---- -- --- ---- ----- -------------------- ------- TAB I — Q O I D RATIO N MF� .i� �sf uvC. MANArF.R' NA1�iF' � �jK� � T'EL. # �� Y� MATT TN(s Ai)DRESS� ,��-k!Lr _---------------------------------------------------------------------------------------------------------�--- POOL CERTIFICATIONS: /'l/� 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 certification to ttus form. 1. 2. Pool operators must list a minimum of two employees cwrently certified in basic water safety, standard First Aid and Community Cazdiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1, 2. 3. 4. HEIMLICH CERTIFICATIONS: N�� All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a f�e at your place ot business. 1. z. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIItED FEE PERMIT # B&B $50 CABIN $50 INN $50 CAMP $50 � LODGE $50 qR-� _TRAILERPARK $50 MOTEL $50 _SWINIlvIING POOL $SOea. _WHIItLPOOL $25ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RFT ii SERVICE: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $25 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOUNT DUE _ $ `JO`- "••""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•"""" � _. ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6,Tf�TOWN OF YARMOUTH IS NOW REQUIRED TO HOi,D 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 COMI'ENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSIJRANCE AFFIDAVTl' MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLTRANCE ATTACHED � 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 APPROPRIATELY IF PAID: YES !/� NO NOTICE: PERMITS RUN ANNUALLY FROM J.ANUARY 1 TO DECEMBER 31. Tl' IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLIS��fEEN'TS ARE TO CONTACT TI�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 EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMIvfENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIMMING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR TFIE SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENT,AND Tf�WATER TESTED FOR PSE{JDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEI�TING, AND QUARTERLY TI-IEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIT�IIvIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf� TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FII,ING THE REQUIRED TEMl'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TF�SE FORMS CAN BE OBTAINED AT TI� HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO'TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN _ TH�SUSPENSION OR REVOCATION OF YOUR FROZEN DES5ERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET. -- OUTSIDE CAFES: OLITSIDE CAFES(i.e.,OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM Tf�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�IENT IS PROHIBITED. , �� DATE: /�—/— � SIGNATURE: � � PRINT NAME& TITLE: �S �/. �/x�f ar , �+P�S. f ; � � The Commonwealth ojMassachusetls : Deparlmen!of Industria/.4ccidents • s = �llflCe 0//OYOSII/O�//i b 600 Washington Street Bnston, Mass. 02111 W'orkers' Compensatian insurance Affidavit �L.os�S �/. /�DG f�� T�. 7,�i1�l��2�rl� lv fE— Ls�cation� f—(P�(� ��5�"�� cih� J�� y /,�LB��i LH� ��0�4 �� phoneM �/n � O�J 70 � I a a ho eowner pzrforming all work myself. am a sole propriemr a::d h�cz no one norkin_ in anc capaeih � I am an employer pro�iding workers' compensation for my empioyees workine on this job. comnanv name: �ddress: tity: �hone p: �surance co. poficy fJ � 1 am a sole proprietor. _eneral contractor. or homeowner(circle onel and ha�e hired the contractors listed below «ho ha�e the follo��in_ �corkzr_' aompensation polices: comoanv nome: addrcss. � - � cih�: ohone R: insurancc co. poliev p tom a�ny namr. � addresr � � � titv: phoee 8: insuranee co, poRev M Faiiure�o seeure covenge a required under Secnoe 25A of MGL IS2 n�leid lo tYe iepaiUoe oterid�fl peultln oh Os op m f1�00.00��d/or oae ye�n'imprisonmrnt n w�AI a tivii pentlHa iu tht form ota STOP WORK ORDER�ad�Ibe of SI00.00 a d�y apinst st I��dentaW th�l a eopy of ihy satement may be fonvarded to tde 011iet o(lovntig�tloo�of the DIA for eoven�e veri6uUa. . /do�hrreby ceri' �rhe pains and pen lies aj jury 1ha1�he injonnation provided a6ovt is nut and conect i Signaturc �� / � ��,p�� Printname � " .i Phone# �3,7Q��J�y� ., oRcial use onl�� do not.rik in ihie�ra to be tompleted by ciry or lown oifleial ciy or rown: YA�ODT$ _ permiNiceex N nBuildioe Dep�rtmmt � ❑Llteesiot Board p eheck if immediate response i�required Z61 �Seleetmen'e Oflfer ❑Hcalth Depinment conroct person: pM1one a:_ �508} 398�2231 eat. nOther Ue�uM i,o5 p1A1 � THE COMMONWEALTH OF MASSACHUSETTS ; TOR'N OF YARMOIITH � PERMIT NUMBER: 99-4 FEE: $50.00 LODGING HOUSE LICENSE i � This is to Certify that a Lodging House License is hereby ganted to 1'homas J.Roche Realtv Inc. I � at _ Bass River Lodge,28 Pleasant Street South Yarmou[h.MA in said Town of Yazmouth and at that place ouly and expires December thuty-fust, 19 99 unless sooner suspended or revoked for violation of the laws of the Commonwealth relating to ihe liceasing of Lodging Houses. This license is issued in conformity with the authority ganted to the liceusing anthorities under section twenty-three,of chapter one hundred and Forty,of the General Laws,and is subject to the provisions of sections hventy-two to Uwiy-one inclusive of said chapter. In Testimony Whereof,the undersigued have hereto affixed theu official signafires,this Fifteenth day of December A.D. 19 98 . �j BOARD OF HEALTH: �d///• .�a1l�� C�ia[i�rmQa/n/ � / /J �[�oan ��7un�an� K.//.� Vice C,�irman Ko�rt�}. O�rown a6.;��e s�,G/�� y-e_.U�Pes ic�el Odnay�G:n ruce G. Murphy,MPH,RS C Director of Health � �r•�@fla �. C:•a..� n B' l� J �, , `�SS II.IYT��,�"C�c��✓ . ` � �� . f �� ._� � �� f_.,r- � Q `r � �!_', � "j _ !� TOWN OF YARMOUTH $OARD OF HEALTH �' � APPLICATION FOR LICENSE / PERMIT - 1998 � NOV 2 1 1Q°� HEALT�' � -'.� � " Please Complete form and attach all necessary documents by December 31, 1997. Failure to do ' so will resuh in the return of yout application packet. ------------------------------------------------------------------------ ---------------------------------------- F o # —D �T S: �� 11�G � O , KG. ' - /-S ----------------------------------------------------------------------------- ------------------------------------ POOL CERTIFICATIONS: 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 thesc------ employees below and attach copies of employee certi&cations to this form. Tde Health Department will not use past years records. You must provide new copies and maintain a File at your place of business. I. � 2. 3. � � � 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich 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 recorda. You must provide new copies and maintain a file at yoer place of business. 1. ,�/� 2. 3. � 4. I2ESALJRANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL#_ --------------------------------------------------�----------------------------------------------------------�---- OFFICE USE ONLY LODGING: LIC. REQLTIRED FEE PERMIT# LIC. REQITIRED FEE PERMIT# _B&B $50 _ CABIN $50 _INN $50 „CAMP $50 i LODGE $50 �� _TRAILER PARK $50 _M01'EL $50 _ SWIM POOL $50ea. _WHiRLPOOL $25ea. FOOD SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERNIIT# u 0-100 SEATS $75 T CONITNENTAL $30 _>100SEATS $150 _NON-PROFIT $25 _COM. VICT. $50 r.WHOLESALE $75 BETAII� SEB�E: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq, ft. $75 _FROZ. DESSERT $35 ._>25,000 sq. ft. $200 AMOUNT DUE _ � ,��' �. , ADMINISTRATION UNDER CIIAPTER 152, SECTION 25C, SLJBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCB OR RENEWAL OF ANY LICENSE OR PERNIIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. 'TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANC$ OF YOUR PERMTTS. P ASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE: PERMITS RUN ANNUALI,Y FROM JANIJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATIOI3(S) AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL BSTABLISI-IMENTS ARE TO CONTACT THE HEALTH DEPARTMEN'I'FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT,MOTEL OR POOL (i.e. , PAIN'ITNG,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PffiOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAT R�',GLTi ATIONS POOLS POOL OPENIAIG: ALL SWIMIvIING, WADING AND WHIRLPOOL5 WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTEb BY Tf� HEAL'FH DEPARTMENT> AND THE WATER TESTED FOR BACTERIA BY A STATE CERTIFIED LAB, PRIOR TO OPENI2�1G. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMMING POOL MUST BE —--- -DR�D O�CC3V�D-Vi�I'I'I-IIN S�VEAT�?)DAYS!1F CLQSIbiG. _ _ - - FOOD 5ERVICE �;ATERiNG POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOUTH MUST NOTIFY TI� YARMOUTH HEALTH DEPARTMENT BY FILING"I'HE REQUIRED TEMI'ORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. TI-IESE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FR02.EN D�SSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�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. OITT IDE C�FF.S: OUTSIDE CAFES (i.e. , OU'TDOOR SEATING WITH WAITER/WAITRESS SERVICE), MLJST HAVE PRIOR APPROVAL FROM THE BOARD OF HEALTH. ni T't'I�OOR COOKING: - - OUTDOOR COOKING, PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIv1ENT IS PROHIBITED. DATE: /�' /9 �� SIGNATURE: • PRINT NAME dc TITLE�M/,�S J. /�v c��/, 10/97 page 2 of 2 • � � The Commonweo/th ojMassachusetls = Deparlment ojlndustria/,-�ccidents ' ; Of!/ce o/%rsstlDsWis 600 Washington Slreel Boslon, Mass. 02I11 ` Wbrkers' Compensation Insurance AfTidavit Aoolicant informallon: P1e+�uPIt1NTT�sSdt '�7 C / / m•� vfi O � � � . � !'r v , ��, oho��a 39R=�Syo � 1 a homeowner pzrtortning all work myself. I am a solz proprieror��d hace no one «orkin� in am capacity � I am an employer pro�idin� workers' compensation for my employees workine on this job. comnanv name: address: tit}': ,�hone p• insurnnce ca. po�i�y p � I am a sole proprieror. general contractor, or homeowner(cire(e onel and hace hired the contractors lisred below �cho hace thz follu�cin_ ��arkzrs' tompensation polices: companv namr. � ad d ress: cin�: nhone M• i�u ra n cc co. poliev# � tsmnany namr. iddress• ��h' nhoee 1!• insunnee eo. - � polfev M Failurc m seturt covenge as required uoder&cnoe 25A o(MGL 152 u�Ipd to t6e iepaidos of erisiW pe�dtla oh Ou op to 51.500.00��d/or one yean'imprisonmmt af w�ell u civil pendNn io Me form ot�STOP WORK ORDER ied a 6et of SI00.00�day qdott sa 1 udmta�d N�t t rnpy of thif ehtement m�y be fonv�rded to the 011iee of InvnNe�tlom of the DIA for eoven�e veriRutlw. /do�hrreby ce ' r rhr parns an penalfi jperju hat.the injormallon providtd above ia but and rnrrret � r Signaturc /� /q�� Print name / ' one M .lo�y�3�l0 f�.f . oRci�l use onl� do no�r rite in this are�to be completed by tiry or Imvn ollltial eiry or town: Y��T$ _ permifAitemt M nBuildiog Departmeet � OLicensiog Bo�rd �check if immediale response is required Z61 �Seleetmeo'�ORitt (508) 398--2231 0at. �HealtA Dep�rtmaet conroct person: phone p;_ __ _ nOther I�misN i,ac Plnl ' . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 98-4 FEE: $50.00 LODGING HOUSE LICENSE This is to Certify that a I.odging House License is Lereby granted to 1'homas J Roche RealN Inc at Bass River Lodge 28 Pleasant Street Soukh Yazmou -MA — in said Town of Yarmouth and at that place only and e7cpires December Wirty-Stst, 19 9$unless sooner suspended or revoked for violation of the laws of We Commo¢wealth relating to ihe licensing of Lodging Houses. This license�s issaed in conformity with the authority ganted to the licensing authorities wder section lwenty-three>of chapter one hundred and FoAy,of the General Laws,and is sabject to the provisions of sections twenly-two to thiAy-one inclusive of said chapter. In Testimony Whereof,the undersigned have herero aflixed their official signatures,tLis twelve day of December A.D. 192. c7 BOARD OF IIE.4I.17I: �i��PJeltw� ��ea(i�rmqa/n� � / /�/ �aa/n G.c'�7u�/�n� K.1/.� Vice l,.hairman .,:...:CRIC170NS IF ANY: None �abert ,}. /)rown .. /-//��aj6.:of�/saL/�1 �y�QlooPa� ///ic�el Odoug�lin B�. urphy,MPH,RS,CHO Director of Health ,�:�.:. � _ �na L�:��oiv� ,� �o S� ---- — ooz� �u �h� �,uu�5z� ss� iztas� �n �mb � -- s« �u �� ,��r;� . _ -- oz$ O:)Jvflo_L �— —�---� � ,r,, ;� n, i,� - t? .I.II'�2I3d 33� 432iI[1�32I 'Ji"i # S.6ti � ' ! � i (; i,! �� R, >I I "�I ', , N�S 'ti '� 1 � — sL$ 3"3d'S , IOIi.M — -- Usb L, �� b��>_) ��w il�?� �N�I `.: ,�, _ _ �� i .. � �. �. -�.�� . . _ c5 .t V��hl,l `:� � i - � - _ - , � � t � �„�, = I [t'c �. ;,, � , � ; i?II IO{N .1�. : .- l iivH-I,i i ' _ � ' i ��' ii� J?I i� �'�.)I �?I�1� Ul��l:f _---- ;a5�c, 1(�Od12i1}111 __ e.�n.k !(l�)d [ti� ��.�. -- _. . . . � If � 'r1 1 71?i`.d ?Iri ill.�t? l �'--j_b �r,� ,; , � . ... 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