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Project Type: ❑New Conshuction�Remadel L(v 1 am a sole�proprietor and have no one wodcing in any�ca�city. ❑Birilding Addition � ❑ I am an employer providing work�as'compensation for my employees working of��this job. . camm.vme: �FDSS J`S ��f)L"l� � l /1�l� � 1r�1 / .�'I C� � 7 � � � )� x: _SZ��'"��'J'B�� C 1 �. ` �I L & z J�O� •.:... �- � .`A!a� .s x l :%b ,.�.#.wK—�a'54+�'. Eas s� ❑ I am a sole propri y Se�eral ewtraetor,or bomeow�er(cirde owe)and Lave hired ihe contiac[as listed below wla have � the following waakecs'comp�,�nsation polices: � �wav aane• � . � . ad�ns•. . . � . � . . . � . eiL9• . . . � � � oianeN• � � . . � . . ieea�ce co. _� . �� . � . . � . . . . . . . _ . . _.. ... . _ . .- . . �n�:� x�,,•, meor��me• . #�f• �9: �' . . � . . . ��. . , � � . . . ._ __ .. __ . . . . _ ..__ -. ___ _ _ __ _.— __.____ . ��l1ll�r,� . ._. . . - �olk�M _. . - _ _. . .. ,� � _ . .. .�, � . � c ��,r3„ • Fdve Y xece c�a�e o�eqdrid odv Satlw 1SA d'MGL 1S2 m kW b IYe�M'aiWY pmNin�f a�e�bS1,3M.M aiAart�� aoe ynn'fepNwawt n we9 n dN pwltln lo the for'ota 31�WORK ORDEA ud�Bu df10�.N i day a�Wt� 1�M tht• npyKWa�tatmatdy6efeew�M[dbtleO�edlaieWpW�sKMeDlAterewmgeverNntl�e. � � . I b Aercby cer6fy rnler t ptns and pepe7d�oj 'rry tltat Me inforvnmion proviAed absve h eve eed�rmt- . . .. / e // sigoatu�c 00/yL� E��+'Cl ��o �`��D� Ptint name /YJP`1'�l��_�(�Y"�}Yl � Phone#, ��'��//J"��'� r . . effieial ose ouly do nat wtke Y Ws�rea to be comPktm 69 dlY xlawa a�dal . . . city or tawn: . . pemiN�A Rxoant..pep�p�ot ne ❑ehe�K�meB�Be rea�wme y rtqd`ed . .. ❑�� ❑Sdxfum't O�cc . nahe[pvew: � �y. �� t�s�mrcfl r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF H�ALTH PERMIT NUMBER: #09-001 FEE: 5105.00 This�s�o cznifi ihat Kathleen Watson d/b/a Bass River Trader Pazk Inc. ' 698 Willow Street. Bass River, MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS � This License is issued in confonnity with the authority eranted to tl�e Board ofHealth,b}'Cl�apter 14Q Sections 3?A,32$, 32C,32D and 32E as amended,and is subjzct ro the pro�'ision�ofthe Laws ofthe Common�iealth ofMassachusetts relating thereto,and upon such terms and conditions,and to the mles and regulations in regard ro said Cabins so licensed as adopted by the Board of Health,and expires December 31,2009 unless sooner suspended or revoked. Nocember 14.Z008 BOARD OF HEALTH: .�¢�RIL S�17P6� �..lY.� �QUMf►t(pE �tRX.�20 .�. `.1{�.¢�I�fPJL �lC¢ �[YUltitlllt �?J[t `.�. �KOILlfL� � Qftft �lPR.17��7[{l,l,l�l�l�t��.Jv. �(IC�ft �• """�^' Bruce G.M y, S., CHO Director of Hea(th ` `�,� t� '73.�. %2Ar� °' """ TOWN OF YARMOUI'H BOARD OF �� j� ` ��y; APPLICATION FOR LICENSE/PER1N1�'P"= � C� byr .� c�,l� ,�QV `L 7 ?n07 * Please complete form and attach all necessary docu'inents by December 31, 2007. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: � "' '�e�''/ ;� �r �,_- TEL. #,��3`�t��l/ LOCATION ADD�tESS: ./0 9� G✓'//�c% .� �/�C� SS �' P v� �c7L�(c�� MAILING ADDRESS: ' ` ' OWNER NAME: '� �E Di� X r N • - (� � — CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: � ,I —�-„ � POOL CERTIFICATIONS: The pool supervisor must be certitied as $Pool Operator,as required by State law. Please Gst the designated i Pool rator(s) and attach a co of the certiScation to this form. � / PY 1• �/� 2. Pool operators must list a minimum of iwo 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 eertifications to tivs form. The Health Department will not use past years' records. 1'ou must provide ne�• copies and maintain a tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS All food service establishments are required to have at least one fizll-tune employee who is cenified as a Food Protection Manager, as deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �/ 2, PERSQN�N��-I��'r�: -- - Each food establishment must have at least one Person In Charge (PIC) on site during hom•s of operation. 1. ,�j�/�4 z. HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to tlus 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. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PER197# LICENSE REQDIRED FEE PER4fIT= LICENSE REQti IRED FEE PERbfIT s _B&B S50 _CABIN S50 MOTEL S50 _INN S50 _Ch'bfP S50 _Sk7�Lbt[NG POOL S7iea. _LODGE y50 �TRAILERPARK 5100 � O -'OOI _R7-IIRLPOOL S75ea. FOOD SERVICE: UCENSE REQITQtED FEE PERMIT v LICENSE REQUIRED FEE PER'NIT s LtCENSE REQtiIRED FEE PER�IIT= _0.100 SEA'IS S75 � _CON7'RVENI'AL S30 NON-PROFIT S2i _>IOOSEATS S1i0 _CO:�L'�fONVIC. S50 l�1-IOLESALE 57> RETAIL SERVICE: —RESID.KIICHEN S7i LICENSEREQUIRED FEE PERMIT= LICEIQSEREQUIRED FEE PERVIIT= LICENSEREQtiIItED FEE PER�317- _<50 sq.R. S45 _>25,000 sq.8. 5200 VENDING-FOOD S20 _Q5,000 sq.tt. $75 _FROZEN DESSERT S35 TOBACCO Si0 vn:�c�►vcE: sio AMOUI�TDUE _ $ l00.00 ="•**pLEASE TL'R.Y O�'ERA\D CO}iPLE'fE OI'HER SIDE OF FOR�f***** 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 A1"I'ACHED 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 taxes and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCC[TPANCY: For purposes ofthe limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence eL9ewhere. Transient occupancy shall generaliy 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)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. * NOTE: En�to�Motel Census must be completed and returned witn t�is app�icarion. rooLs POOL OPENING: All swimming,wading and whirlpools which have been closed for the sea.4on must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coGform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CI.OSING: 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 Yazmouth 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 resutts must be sent to the Health Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Pemut uMil 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: _ Oattloorr,aokingPreparation,ordisplayvfairyfoodprvdnctbyarctailorfov&serviceEstabtishme�isprohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETtJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�ICEMEVT. REVOVATIO'VS MAY REQUIRE A SITE PLAN. i� .{- DATE: l 7 � SIGNATURE: � 2��C/ � �L'.�n� x� PRINT NAME&TITLE: (k��F[t I��2 7`��/% ✓�✓'�� io;u o� . . , � The Commonwealth of Massachuset[s DepaNmeat of Industria/Accidencs M�YN� 600 R'oshiagton Streey �"'F[oor Bostox,Masc. 02111 VI'orlcers'Compeeaatioe I�sera�ce AfSdavk:B�ildiog/Plambi�g/Eketrical Co�tractors �: r�-f1��F��f�✓��'��n add�ess: E�� /E.�/��" ! /��-�.,L� " � . ciry r� f� 1 L'��".� smte� /7f�' zi�'a��G'!C� ah�e# � '�� 1/ work site location(full�d`essl: O�mm a homeow�r performing alt wak myself. Project Type: ❑New Caa�stmctim❑Remadel �"I am a sole proprietor aad have no one wodciug in any capacity. ❑B�rild'mg Addition ❑ I am an employer providing watk�s'wmpe.�asati�f�my�ployees wod�cin�g on-iyL�i-s�'ob. commnv me: -�f�.�S � ��'Y� �,r� � �rc� ��^K l , /' - �-,�` . i �.,: ��9s G✓,� �/�� X . �- �s� �; ��r- ��,� �a�� l �� 39�� r, �,��.`�7.'�z+ �P�prs i�i^r�,t,r��'�/�sua/�4/ ��f l/�f.�,.��3�� T�"�l ��,�„ ❑ I am a sole propridor,ge�eral e�trxMr,or Yomeow�v(drde�J and have hiied the coahactois listad below wlw have � t�following wakets'compensa[ion polices: a000rv me• - � ad�resa• dn" � n4ere#: �.4a� �y M . , . . .. ,. . . . . � . . .. . . ..... . � ., . �� N aaanuv�se• +�'e�r• e[tr: � orre d• .. _ __ __ -- - --_ _. ._-- � -- - --_- .. _ _ _.--- ----- ----�-------. _..._--— ie�ea�ee co. naL+�k . MYI�i��liY�rry�-:' . . . .�. . .. .. . �:; . Faive r aecme a�vaaae a rtqdrad odv 3atlr 2SA NMC.L 152 m Wd b He�i1W�f v1�YY peafl6o�f a me�p bf1,3N.M aM/w�. a�e yan'Ispe6w�est ae we8 as dvi peultln 61he 6r�af a 370T WORK ORDER ud�Oae dS1M.M a dry qdW�e. I odew�d Wt a upy�[tlb thle-eel my be[erwardrd b the Omee s[t�et16e DIA fir ewerage veNBea1M. /do hercbq ceraFfy re r Me pdns aed yendtiea ojperJ o a�Me ufennallow provl/elrhone 6 erre a�Acormt �/ a S�BnNum � 6�-"/��E£�-. '_6 � �GFSB�'7 � Ihte �1�� /�� / Pri�namc ��I�('�ir')� l'V/,��1 PhoceB ��C' .� C-' �� I� .�d.�ex ewy ao em.vrwe ia re6 are,a ae m�Weta1 er dlr er wm.miiai eityartawn: �p ^- - p�� ❑�eek Name�le rtap^me b re9� ❑Sdecdm Omce ❑HeMh D�nt ceafaQ penoc P�g X: �e cM1+:m s p.mm� i ., THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-001 FEE: $50.00 This is co Certify thac Kathleen Watson d/b/a Bass River Trailer Park, Inc 698 Willow Street. Bass River.MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS This License is issued in confoimity with ffie authority ganted to the Boazd of Health,by Chapter 140,Sections 32A,32B, r 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws of the Commonwealtq ofMassacLusetts relating thereto,and upon such tecros aad conditioos,and to ffie rules and regulations in regard to said Cabins so licensed as adopted by the Board of Health,and expires December 31,2008 unless sooner suspended or revoked. November 28_2007 BOARD OF HEALTH: .�¢It S�� ✓2..1v.� �A[iXtttpat @Puv[eed .�.�CeP�iRxn `viCe @8a"vultan � .� �xau,��c,�� , ruce G.Murphy,T , S.,CHO t _ . :-. — . __ : Director of Health . _ . �b�o /� F YA nS r �_O �r i� �.1'' 3?° v R1C TOWN OF YARMOUTH BQ,g,�p O�-H�-r�I.�,�' "`�� ,�., APPLICATION FOR LICENSF.�PERMTIt-2�07 : N O V 2 8 2006 r'\,� -'s .�•�- F� � . � ' * Please complete form and attach all necessary documents by Dece e�{�Q►2UJJ8fiDEPT. Failure to do so wiil result in the return of your application pac NAME OF ESTABLISHI�IENT: ��r�5 �'��Fr- �2�i le^i� ��i�: /1 C_ TEL. #Sc�1.�`��-.�C,// LOCATIONADDRESS: �� 'lllvta )� � � i'�t�t� dti�� C'?.` lnln� MAILING ADDRESS: ' � OWNERNAME: �/)'f/i/�e�. I�a ��C�� AX fFEINorSSI� " �� CORPORATION NAME (IF APPLICABLE): � � MANAGER'S NAME: � � ,- l 7 �-� TEL. # MAII,ING ADDRESS: ' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. ,�� 2. Pool operators must list a minnnum of two employees currently 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. T6e Health Depardnent will not use past years' records. You must provide oew copies and maintain a£de at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 540.000. Please attach copies of certificarion to this application. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. L �� //� 2. � — PERSON IN C�IARGE: _ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. /C�� 2. � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must haue at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. � :� 1. /(/�i� 2. 3. ` 4. RESTALJRANT SEATING: TOTAL# OFFICE USE ONLY LODGINC: LICENSE REQUIItED FEE PERMIT# LICINSE REQUII2ED FEE PF.RMI'C# LICENSE REQUII2ED FEE PERMIT# _B&B S50 CABIN S50 MOTEL $50 _INN $50 CAMP $50 SWIIvfIvllDIG POOL$75ea. � _LODGE $50 / 1RAII,ERPARK $100 ��I��Q3 WI�RI.pOOL S75ea. FOOD SERVICE: LICENSE REQUIItED FEE PF,RMIT# LICENSE REQUII2F.D FEE PERMI1'# LICINSE REQUIl2ED FEE PII2MIT# _0-100 SEATS $75 _CONTINENTAL $30 NON-PROFIT $25 _>]00SEATS 5150 _COMMONVIC. S50 WHOLESALE E75 RETAII,SERViCE: —RESID.HITCIIEN $75 LICENSE REQUIl2ID FEE pF,Rlvi►T g LICINSE REQUIRED FEE PERMIT# LICENSE REQiJIItED FEE pERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. 5200 _VENDING-FOOD $20 � _QS,OW sq.ft. $75 _FROZINDESSERT S35 TOBACCO S50 NAME CHANGE: SIO AMOUNT DUE = S�f3'0.00 � •=•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""•• � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a 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. PI,EASE CHECK APPROPRIATELY IF PAID: YES V/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations of Motei or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence eLsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggre�ate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be wnsidered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Aealth Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,totai coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool}nust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must�otify the Yarmouth Health Departine�t 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 resuk in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heahh. OUTDOOR COOKING: Outdaor_cnnking,_preparntion,or tlisplay ofany fond product by a retail or food service establishment is prohi�ited. NO'I'ICE:Pernrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIL.ITY TO RETURN Tf�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2006. i,i• RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TE�BOARD OF HEALTH PRIOR TO COD�iENCEMENT. RENOVATIONS MAY REQLJIItE A SITE PLAN. DATE: ; �D SIGNATURE: PRINT'NAME&TITLE: � iomioc � Tke Coramomvealtk of Massochusetls Depart�xent ofindwshial Accideets NbN� 6�w�h;��A� f"F�. Bostan,Masc 02111 -_ _. Worlcas'Cem do�Invaeee A�dfvU: ' 63�glEkNrial Co�trxlars . .:;,.. _ . �v...... �.�,3.:y.? „3s — ..y� � n.� �...�vdy�.�: �: �)l5`��1��Y1 l G�`'�C�17 �: (�98 I�,�; l lrn� �� S4U—�S`_] ��AJ�'.� Sm[C: 4`I � LID:t ��Uhaot#��—��/C)—�L.�� work si1F locffiim(full add�ssl: ❑ I am a homoowner performing all wodc myself. Project Type: ❑New Cm�uc4on�Ra�nadel �a sole and have�a�e w m an B ' ' Addition ❑ I am an employer�oriding w�cas'compensatian f�my�ploy�.s wo�cing m this job.. . �s.�: ��4 �S �� ]��'P Y` � � Y� i:�FY` �� ''7��—�iC-. _ __ _ — /, � �. �:�a� i JF r. t�l��. 6.=�?Cc�l�� r: -��-�l�i- �C`) l� l ��.`T��le�� F��t�r�v ��«�I��,�. !-��o -i9.�x �a�'�=7��-ot ❑ I mm a so(e pmpcidoy gea�ral eo�lrxtor,or Iwmeow�er(cor/e owe)�d have hicad ihc conhactas listed below wlw have the following workas'compensatioa polices: ao�sa�r�e: . �� 5�4: � aYseR: � M 1� s�rv rsec ad3r�a: ekv: �e t FaYne b�eene eem�n'eq�had udv B�sYN 2SA dAlC.L l32 m kW b He i�p�dlW�fai�Yd psfllin�f�4e�p bfl SKM aeihr we ynn'dptbadt a wd o dH pwltlo 6 tYe f�Ka SIOt WORK 08DBY atl�Qae df1M.M a dq apdM�e. 1 odew�tl tYN a app�1i6 Maaae�l my be Newardd 1�1le Omce dl�vM�Wr Ntlr DIA/rewnage vaientlN. /lo henby eertJ'y �M/e�painn a�d pswaMiea�rjperJwry tAu dYe iwje'webn provldd obnwe fa awe m�d arme sip,nn�ue C Cf.fl•!/P,[rn c� ✓7�C�/�ti i n.re _ /��/C''�- Printname �� '1�1� ��C1�7�"� Phone# � ,SQ� �.�� „�� .ma.�.xswy a..«w.�rcrm�.,rnmee.�e�anr�r.rww..ma� d�r or mm: pemw.a,.�r nRad.eat ❑eYtekHim�t 1� �� apee�e +eqe�d . ❑Sdxf�a's O�ce ❑deMh Dep��9�eat oMact P�' Pdxe Y; ❑p1� tm�a smc mm) THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NLJMBER: #07-003 FEE: $50.00 Tlils is co Certify that Kathleen Watson d/b/a Bass River Trailer Park, Inc. 698 Willow Street, Bass River, MA HAS BEEN GRANTED A LICENSE TO � OPERATE TRATi_RR COACH PARKS � This License is issued in conformity wiih the authoriTy granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of fhe Laws of the Commonwealth of Massachasetts relsting ' thereto,and upon such terms and condilions,and to the rules and regulations in regard to said Cabins so licenged as ad�ted by the Board of HealtY�,and expires December 31,2007 unless sooner suspended or revoked .r�u�y za.aoo� soa.�v oF�.s�,�: B �5. M.�i., ' e%r��'l.al., .N., ?/ic�s C� nr.�ilc.�C Mo� fQ�c�s�j'�i�eerc�rswg /2./�. Bruce G. Murphy,MP , S.,CHO Director of Health ' : �S� ✓ .R.TRa�� o��a,y � TOWN OF YARMOIITH BOt�R,D ��EA�1 � � � � '� M I�s DD 2 � APPLICATION FOR IsICE�1VSE%PE�Tl'-2b06 ,°�� ,�� , . DEC 1 2 2005 * Please complete form and attach aIl necessaty''�documents by ,�40 T Failure to do so will resuit in tihe retum of your applicat P NAME OF ESTABLISFIMENT: h � CL�� GZ: �' iC°_ TEL. # _��c��I� LOCATION ADDRESS: (� L 1��.i Q c�t.f.l' MAILING ADDRESS: OWNERNAME: �`�� T ID IN r ✓� ` CORPORATION N (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS:��!1-� POOL CERTIFICATIONS: The pooi�upervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Oper tor(s)an�attaeh a copy of the certifieation to this fo�n. 1. � 2. Pool op�tors 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 employce certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You m4s pmvide new copies and maintain a fde at your establishment. �// 1. / �' 2. ,�� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlbg:FCH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attae}i 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. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT N LICINSE REQUII2ED FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT# B&B $50 _CABIN $50 _MOTEL $50 _INN S50 CAMP $50 _SWA�A9INGPOOL$75ea. _IADGE $50 I TRAII..ERPARK $50 �o6-m3 _WHQtLPOOL S75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQi7II2ED FEE PERMIT# 0.100 SEATS $75 CONTINENTAL $30 NON-PROFIT $25 >I00 SEATS 5150 COMMON VIC. S50 WHOLESALE S75 RETAIL SERVICE: LICENSE R&QiIIItED FEE PERMIT k LICINSE REQiJIItED FEE PERMI1'ik LICENSE REQLJIRED FEE PERMIT# _d0 sq.ft. $45 _>25,000 sq.ft. $200 _VF.'NDING-FOOD $20 _QS,OOOsq.R. 575 _FROZENDESSERT $35 _TOBACCO S25 NAME CAANGE: S10 AMOUNT DUE _ $ 5� .00 "•"•"pLEASE TURIY OVER AND COMPLETE OTHER SIDE OF FORM•*""" r AD1�IIl�iISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hoid issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STA7'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiTRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PI.EASE CHECK APPROPRIATELY IF PAID: YES ✓ NO NOTICE:Permits run annuaily from January i to December 31. TT IS YOUR RESPONSIBILdTY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�iING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO CONINIENCF..MENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTfIONAL REGULATIONS POOLS POOL OPENING:All swimming wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening. POOL WA'I'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swirruning pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yannouth Health Departmem 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: Frozerr desserts must�etested vn a monthly basis by a Statecertifred lab. 'Festresutts must�e�ent to the�Ieahh 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 approvai from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmem is prohibited. DATE:� j� SIGNATLJRE: � �, � � � PRINT NAME&TITLE: � 09/28/OS r -=�== The Caxnwnwewlth ojMassachusutc - — Departwiea:ojrndxsdial Accidentc - = Nfa/N� _- 600 Washingtoe SYree; 7"'F/oor -'-,,, Bostwe,Mass. 02111 " worlcers'Compwaatio■Lsva�ee Affiid�vid Bdl 6ug/Eketrical Cwtrxrors - ` ' +3,ir -� +,�� , ,az� � �,-.. ., . . f u �a»;n' ..�t 'w- . . -w, _ n3me: ��1 �� '� . � ` . ,. . ��_� , �lEBS: cflv�CL.S-� � . 1 l�# srate� �� zio• �� dace# "J��-.��R ��t � work sih locatim(foll addresst . ❑ I am a homaowner perfo�iug all w�c myself. Project Type: ❑New Cmat�ucriao ORmiodd am a sole 'dor and have no me w in� Buil ' Addition �Q I mm an�ployer pnviding waaic�s'compensation fac my�pbyce.s w.. . on t6is job. sJ-�/ , �` �� f0�..�Is; � � 1 \�� /Ts—.�"''�2.—��''z'.;��L.s"� _ . /� lY� l- � Yi , � .� r� �� - - C%�� - �' �� `�� ❑ I mm a sole prop�ictor,8e�a'al to�iraetor,or�� (cvele owe)aed Lave hrtod the cavt�actas liated bclow who have the folbwin8 workeas'wmp�sation Po�ices: �/ ��: �; dtv: oire k B�6ev N as�nrc�e: ai�: 4�Y• §� __ _ ... . _. . _. _ _ —_ . . _-._ ._- . _ _ _ _ � _. ._. . ..__. -. ._ . . . _ .___ F�Yve Y aaae w�enae a�rtqiN udQ 8[aYr 2SA dlllGL LSt m Iei b IYe`p�i1M�f aiNd pa�Me ta�e�b AqM.M aW�r .�r�+'��..�,.a.��eu�6...r,srorwowcoenBe,r,ae.tu�.a.y.�.e.e. ��..aur. npy KtYi+lahae�t sq he t�rwnMed b Ne Omee oflaPntl�tlw NHe DIA hrewa+ge vermntlw /b harby ■ Cer dlepdea m�d�penahlea ojp . r UYat Me fefenwwlon�reride!abevr h sve� si�ture `Y ,/ , .L�% _Date /,�/,��`J Print name ,�L 1� � Pho�#,�� 1C �� .ffiiw.xe.y ao.awrker[Ys,reaBaeen�WMNbsdh.rrw..mdd �YA*�= per�Nlic�eA - -" p�� ❑ehak KiwmaWle�eapsne 6`e.qired �Heud �7 ❑Stlx�'s Omm mmaetpasu: PM�eB: f101A� �t t�n��1 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #06-003 FEE: $50.00 �rh;s�to Certify�nat Kaihleen Watcc�n d/b/a Bass River Trailer Park; Inc. 698 Willow Street Bass River MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS This License is issued in conformity with the authority ganted to the Board ofHealth,by Chapter 140,Sectio�s 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofthe Laws ofthe Commonweallfi ofMassachusetts relatii�g thereto,and upon such terms and conditions,and to the rules and regulations in regazd to said Cabins so licensed as adopted by the Boazd of Health,and e�ires December 31,2006 unless sooner suspended or revoked. January 30,2006 BOARD OF HEALTH: B �• � �$•. ��s�`�, ��e�.� aod�t 4. a�, e� P�k M�� A.� �j�. R . ruce G.Mwph R.S.,CHO Director of Health ��.P�,.R-- �'� oFYq��p TOWN OF YARMOUTH � y 1146 ROUTE 28 SOUTH YARMOUTH MASSACFIUSETTS 026644451 ' � MI�TTACMEES � ,��a,.�,,,�„�� Telephone (508) 398-2231, Ext. 241 — Fax (508) 760.3472 B O A R D O F H E A L T H G�s' iSC� i; �7C'�7i� 1 To: Yannouth Board of Health Permit Holders !v1AR 2 �, 2005 From: David D. Flaherty h.,RS. � HealthInspector �Dr HEALTH DEPT. Town of Yarmouth Re: Federal T�ID Number i i Date: Mazch 22,2005 The Massachusetts Departuient of Revenue is imw requiring that we fiunish detailed infomation to them regarding all permits and licenses that we issue. Ocre of the details that they require we send to them is every establishmenYs Federal Employer ldentification Number(FEIIV)otherwise known as your"Tax ID Number". This is purely for adminishative purposes only. So� businesses use the owner's Social Security Number (SSl� for this purpose. If this is the � case for your establishment, be assured that we will not allow tkvs informarion to be public record. Please fill out the fields below and retum this letter to Yazmouth Heakh Departmeut 1146 Route 28 South Yannouth, MA 02664 Thank ou for our antici ted co liance. If ou have an ue i y y pa mp y y q st ons regardu�g this matter, please do not hesitate to cali. The office hours are�fomiay to Friday, 830 a.m to 430 p.m. The telepho�number is(508)398-2231,ext. 241. � ` Location Address: �� ' `� � �`�� S S��JE Y` �I¢� �o�(�� 1 Signature: Print: �GC` V�\l�� Vt �' �K:C�l �1� Title: ! 1 C'.`� . �� Printed or},y Recycl Pape r . _ � �ASSRrvF2TRRrcCY Pf1R� �R�s TOWN OF YARMOUTH BOARD OF HEA'LT$�(9�� + o o - °� APPLICATION FOR LICE�/P�RMI'[' 200,� k ., ,,s '' ` > C� _. � � * Please complete form and attach all neces�h�o " s y Decemb r 31, 200�. ' '� - I� Failure to do so will result in the r yow application pac et. NO V 1 6 2004 NAME OF ESTABLISFIMENT: Y' LOCATIONADDRESS: 6T8W�(fouJS�. %�i5s�'j�� MAILING ADDRESS: OWNER/CORPORATION NAME: MANAGER'S NAME� �' TEL #SO S'o�0/� MAILING ADDRESS: POOL CER'I'IF'ICATIONS: The pool supervisor must be certified as s Pool Operator,as required by State law. Please list the desigaated Pool Operator(s) and attach a copy of the certification to this form. 1. �� 2. l Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please list these employees below and attach copies of employee certifications to this form. 1'he 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 PRO'IBCTION MANAGERS - CERTIFICATIONS: All food service establistunents 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 ttus application. The Healt6 Department will not use past yeais' records. You must provide new copies and maintain a fde at your establishment. l. /v�� 2. �^�� F�RSOAi IN G�-Ir�t&E: _ Each food establishmem must have at least one Person In Charge(PIC) on site during hours of operation. 1. �� 2. HEIMLICH CER'TIF'ICATIONS: 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 LODGING: LICENSE REQUIl2ED FEE PERMI1'# LICENSE REQUIItED FEE PERMI7'# LICENSE REQUII2F.D FEE PERMIT# _B&B $50 _CABIN �50 MOTEL $50 _INN $50 CAMP $50 SWIIvII�9NGPOOL$75ea. _LODGE $50 �T'RAILER PARK $50 �S�OOI WHQ2LPOOL $75ea. FOOD SERV[CE: � LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMI'C# LICENSE REQi7Il2ED FEE PERMIT# _0-100 SEATS S75 _CONIINENTAL $30 NON-PROFIT $25 _>100 SEATS 5150 _COMMON VICT. SSO WHOLESALE $75 RETAIL SERVICE: � LICENSE REQUIItED FEE PERMI'f# LICENSE REQiJIItED FEE PF.RMIT# LICENSE REQUIItED FEE PERMIT p _<SOsq.R S4S >25,OOOsq.ft. 5200 VENDING-FOOD $20 _QS,OOOsq.ft. $75 _FROZENDESSERT S35 TOBACCO $25 raMecx.uvcE: aio AMOiTNTDUE _ $ �.pp ••*••PLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM••••• ADMINISI'RATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth tarces 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 ItESPONSIBILTTY'FO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(5)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENTS ARE TO CONTACT TF�HEALTHDEPARTMENTFORINSPECTION 7-10 DAYS PRIOR TO OPENING FOR TEIE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COD�IlI�NCEMENT. RENOVATIONS MAY REQUIRE 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 opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('7)days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food estab 'shment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FR��N DESSEBTS: Frozen esserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. DATE: (� SIGNATURE: � PRINT NAME& TITLE: �� r��_t� ��i' 10/22l04 - ' ,�, The Co�nnnwnwealth of MassachusetGs _ \ �� -3 Department of Indaslrial Accidentc — �.i�N� _' a 60B R'ashingtoe Street, 7ib Floor , Boslon,Maxs. OIIII � Wo�es'Cooposatio�I��Affid�rN:Bdl ' 6i��/Eketricsl Co�trxtors ._ _.. _ � ,.� . �. � �: �/reK �� ` �s: 8/'� � e�� , J ��S T � v` 1 S�IC: U tA 1 ZlIX� ObO�E� WOIk SiIC.lOC8h0��8�9): ❑ I am a 6omaowra perl'o�ing ell waak myaelf. Projad Type: ❑New Caostcw�tim�Raaodel am a sole aod Lave no me w in� &ril ' Addition � ❑ I am an�P�Ya PD�idinS w�ceis'cqm 'on far my empb wmlcing an tLie job. �.....�: �� P.r �Y1� �,�Y' 1"a r�I-�e� ; �q ��s �?��/��4 D�f�(� �� =,�9 �- �o �/ -��n- �a�r�-o, ❑ I�a sole propcidor,8Aa�1 co�traetor,or bmeow�er(cbde awe)a�have mnod tbe con4act«s lis[ed bedow who have t6e following wa�keas'compensation polices: uoo�t we: �dm� �s: oMe s: � ��: addevr eilv: aie�e t . . _- ___ ._ __ _..- . _._--------- ---�- - - - - __._ ___---�--- - ------ . . . .. � FaYve e�aeeae ewer�e s nq�trN oAv BaW�2SA�IIIGL Iffi m kad b 1Ye i�piliw de�iW psWes da O�e�btt,3KM Whr .�r�*'��..•a,.a.��der�w..t,srorwox�cosoee..aa�ru�.e,y.�.r. �oenww�. eepy Ktlb Male�at oy he hrwaMd M Ne Om[c afl�KUe DIA frew+ge ve�Nntlr. ��sy��Ir�+��eP��/M�n�+-oI/-P-eH-�Y tA�Me i+rfonrrtoa proridd abone 6 tre a�d orrrrct si�atom '71GGf�LLf'annc . ( }�'A/E�O-tn � nm �� —_ Print name��'E�LL[ . ��Q� Phoce# ��O �� .�a.�axo.ry MretwrlfelalWamb6ee��fdDYdtYrinrua�l ary°r�.w.: p�s ' p�� ❑AecY H�se�1e�psde 6�MM�'� ❑Sdx�a's O�m QRnM�Dqs�� whet Pmac PM�e N; flOUe lmsa S¢IDtt11 THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #OS-001 FEE: $50.00 This is to Certify that Kathleen Watson d/b/a Ba Riv Tr�ler Park Inc 698 Willow Street, Bass River. MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAII,ER COACH PARKS This License is issued in conformity with the aufhority granted to the Boazd of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth ofMsssachusettsrelating ihereto,and upon such tcims and conditions,and to the rules and regulations in regard w said Cabins so licensed as adopted by the Boazd of Healtl�,and eatpires December 31,2005 unless sooner suspended or revoked n�,n�i Zooa son�oF�.�: B�95. �joado.�M.`n. • P��r� v:�ef� , R�t4. a� et� � � R.�v. � �a.� a.n�. , � ruce G. MurPhy,MP , . .,CHO Director of Health i i . L'�--h�"�BL�f { � B.e.Teqi� �`e q� TOWN OF YARMOUTH BOARD AL�H ' �rC�$ APPLICATION FOR LICENSE/�1�I =2004 ` c �� , f`r '`� o ` ��i�i � 3 2003 * Please complete form and attach all necessary docurr�ents by Decemb r 3 0 . Failure to do so will result in the return of your application pac t.HEALTH DEPT. l � L T N �v e.✓ c ER' N 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 certification to this form. 1.��/`f 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fite at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must rovide new copies and maintain a file at your establishment. 1. /V�� 2. PER�ON IN CFIAIFGE:_ _____ _ -- --- _ _ Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. !Y/� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee Uained 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 LODGING: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRGD FEE PERMIT ll LICENSE REQUIRED FEE PERMIT N _BBcB S50 CABIN S50 _MOTEL S50 _INN S50 _CAMP S50 _SWIMMING POOL S75ea _LODGE S50 I TRAILER PARK S50 ��(Y _WHIRLPOOL S75ea FOOD SERVICE: UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PCRMIT# LICENSE REQNRED FEE PERMIT# _0-100 SEATS 575 _CONTMENTAL S30 NON-PROFIT S25 >(00 SEATS $I50 COMMON VICT. S50 WHOLESALE $75 RETAIL SERVICE: LICENSEREQUIRED FEE PERMIT# LICENSBREQUIRED FHE PF.RMIT# LICBNSEREQIJIRED FEE PERMITA _<50 sq.ft. S45 . _>25,000 sq.Il. � E200 _VENDING-FOOD S20 _<25,000 sq.ft. S75 � _�ROZEN DBSSIiRT S35 _TOBACCO 525 NAMECHANGE: $10 AMOUNTDUE = S SO•00 •*"'*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'*"•" ADMINISTRATION Under Chapter 152, Sec6on 25C, Subsecrion 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A'I"CACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓� NO NOTICE: Permits run anttually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CON'I'ACT THE HEALTH DEPAR"1MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A 3ITE PLAN. ADDITIONAL �GULATIONS POOLS POOL OPE1vINIG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Heaith Department prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standazd plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATEIZiNG POL•ICY: 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. Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health DepaRment. Failure to do so will result in the suspension or revocation of your Frozen DesseR Permit until the above terms have been met. OUTSIDE G FF:C: Outside cafes(i.e.,outdoor seating with waitedwaitress service),�have prior appmvai from the Board of Health. QUTDOOR COO iN • Outdoor cooking,preparation,oc display of any food product by a retail or food service establishment is prohibited. DATE:_�Q_� SIGNATURE: PRINT NAME & TITLE:_�{'�l� � 'TS pyi �j-C S 10/22/03 : : � The Commonweallh ojMassachusetls = Depnrlment ojlndustria/.-iccidents ; 011/ceal/erestlOsdiis 600 Washington Slreel ' Bnston.Mass. 02111 "' Workers' Comprnsation Insuranct Affidavit Anolica�n/t�inf�o"rmallon: P►e••ePR(NT7erGi�a n�m��—�K /(2��^L��' M� J L�tc�tie2 / !t'1.(7 �� •�im��Q�191' � �� ' � ��Q� ehonep��DU� JL !/ �( � � I am a homecµner pzrturmin�all work myself. � �am a sole proprietor r..,', ha�e no one uorkin� in am capaein• � I am an employer pro�idin� uorkers' compensation for my employees workine on this job. comnanrname• / L('s.5 ��l��J�(�d�� / j7 � � J d ress• " � D � - y D� / ; ��,�� r� � „ -!9 .X � - �-o/ � I am a solz proprietor. general contractor, or homeowner(circle onel and hace hired the contrattors listed below «ho ha�e thr follo�cfn_ ��orker ;ompensation polices: companv name: address• c�,y: . . �hone M• insurancc co. nelie��q tompanv nrme: _. .___._. _- - -- ----- - ------ - . _ ._ --- —__ ------- - addrns• titv: � ehoee M• insaraneeeo. � eeRevM F�ilure to seeurt coverqe as required under Seenoo 2SA of MGL 152 n�ind to tYe iepaiBoe o(eridW peWtln of�O�e ap m f1300.00 a�d/or aae ynrs'imprisonmmt ia w�ell u civil pendHa io thc form of i STOP WORK ORDER�W a flae ofS100.00�dfr q�iest ma [�benh�d tYat a copy of tAn statemem may be forwyrded to the ORee ot lavee[ig�tlom otthe DIA tor eoven{e veeilleitlo�, . � 1 do-hrreby ceni •u r rhr pains and pmaf ' s o r'ury that tht injonnation provided abavt ia dut and rnrrceY. Signamrc ��d � Print name !�. �(� Phone M �� ] .� oRci�l use only do not.rite in this�rea to be tompleted by cily or Imro oflltial eiry or town: Y�MODT� _ permiNieenee M nBuildin`Dep�rtmeot � QLiteesioe Bo�rd �chtek if immcdia�t response i�required Z61 �Stlettmtn'f Oflfet contact person: Phpp�p._ (SOH� 398—?231 eat. �Othere Depanmmt � THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #04-002 FEE: $50.00 This is w certify that Kathleen Watson d/bJa Bass River Trailer Pazk. Inc. 698 Willow Street Bass River. MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS Tlus License is issued in conformity with the sut6ority grantod to the Board of Healtty by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisioas of the Laws of the Commonwealt6 ofMassachusetls retatmg thereto,and upon such terms aod conditions,and ro the rules and regulations m regard to said Cabins so Gcensed as adopted by the Board of Health,and expires December 31,2004 unless sooner suspended or rewked. November 4.2003 BOARD OF HEALTH: �ciaNria'�. Cjatdrmc. '�.�. �aGuxsx �ateic�&7XCDeurwA[. ?/iee �stn�a� __ _ Re�rt`�. �aaewc,�— __--_ . �[�ea ,SiEa+�. �� ruce G.Mwphy,MP .,CHO Director of Health r . _ _ 6 R•TRq��£R.Qq¢k_ ' o ''Aa TOWN OF YARMOUTA BOARD OF HEt� ,, — -� , • r % '�' � � %� � �� L� f', L� o �� APPLICATION FOR LICENSE/PERN,� ��3, � .= �� NOV 2 2 20�2 �>. • * Please complete form and attach all necessary do�ents byDecemb r 31,2002. Failure to do so will result in the return of y application pac .NFALl;y DEPT. NAM OF .ST R .IS F.NT: � C� T_F.i,. # i0 : — 0(� I � , RESS• TI ' # MAiT.iNC, AnDRFSS: POOL CERTIFICATIONS: T6e pool supervisor mast be certified as a Pool Operator,as required by State law. Please list the designated Pool Operato (s) and attach a copy of the certification to this form. 1.�/V/ T� 2. / Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitadon (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Departmeot will not use past years' records. You must provide new copies and maintain a £ile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MA7vAGE� - CERTIFICATIONS: All food service establishments are required to have at least one full-time emgloyee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Estabiishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must pr ide new copies and maintain a fde at your establishment l. 2. PERSON R�I CH�R('.F• 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 anri-chokmg procedures below and attach copies of employee certifica6ons to this form. The Health Departmeet will not use past years' records. You must provide new copies and maintain a tile at your place of business. 1. 2. 3. 4. BESTAURANT SEATIlVG: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# _B&B S50 _CABIN S50 _MOTEL � S50 _1NN $50 _CAMP $50 _SWA�ffoIING POOL$SOea _LODGE $50 I TRAILER PARK S50 Q -UQ3 _WHIItLPOOL S25ea FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0.100 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 _>100 SEATS $150 _COMMON VICT. S50 _WHOLESALE S75 RETAIL SERVICE: LICENSE REQiJIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACCO S20 <25,000 sq.ft. $75 _TOBACCO $20 _<50 sq.ft. S45 _>25,000 sq.ft. 5200 _FROZEN DESSERT$35 NAMECHANGE: $10 AMOUNTDUE _ $ 50.00 *"**"PLEASE TURN OVER AND COMPLETE OTliER SIDE OF FORM*«*•* ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSUR[1NCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taates and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE: Permits run aanually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2002. SEASONAL ESTABLISHIv1ENTS ARE TO CONTACT TE�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEIVING:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparfinent prior to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICYc Anyone who caters within the Town of Yannouth must notify the Yarmouth Heakh 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. �07.EDI-DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to fhe 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 preparation,or display of any food product b retail or food service establishment is prohibited. DATE: / `J � � SIGNATURE: PRINT NAME & TITLE: � � 10/18/02 ✓' ' �\ The Commonwealth ojMassachusetls = Department ajlndustria/.-lccidexts ; omceo/Ieresuyswis 600 Washington Slreet Bnstort.Mass. 02111 �" �� `` W'orkers' Compensation Insurance Affidavit namc� `�;G�a � � on [ � s ` �a �� a e �- 9�`�o c� � 1 am a homecwner pznorming all work myself. �m a solz propriecor �-,', ha�t no one �rorkin_ in am capacin� � I am an employer pro�+din� workers' compensation For my employees working on thisjob. comPanv namr �IJS �1 ��✓ � ✓L�11 �lE'�' �r� )A�' . . .. 5 : YG ( VV ` • � �` _ lJ �O�O ( / • ��,�� V � � c5 er � -� - lL-o/ � I am a sole proprietor. _eneral contractor, or homeowner(eircle onU and hace hired the contractors listed below ��ho ha�e che follu��in_ ��orkzrs .ompensation policas: cumoanv aame: address: cin': nhone p• insurancc co. nelier N eomoanv name: --- -- - . . . _ ___. _- _._.--_ __. ._ - - - - . __ _ .._—� - - -- . . .. . . ... addres3: f�h-.— � nhoee N• � insuronee co. ��K � • F�ilure m seture covenge u required uader Seenoo 25A o(MGL 152 u�lad to t�s i�paidw of eri�i�fl peultla oh O�e ap ro Sl¢00.00��d/or one ye�n'imprisonment u w�ell a�civil pendNn io tht form o!�STOP WORK ORDER ted i flee of SI00.00 a dq qaiwt sa 1��denta�d H�t■ eopy of thy sn�ement may be fonv�rded to the 011fee of Iave�tiQ�tiom of tEe DIA for emen�e veri8n�. �. /dn hrreby cenij• er t paint and penal�ies oj ry'u thm�ht injorrnation providtd abovt fs we end rnr►td Signaturc ��/��U � Print name p��N �j VC,J ��L /J oC�� ., olTicial use onl� do no�rritt in thi�area to be eompleted by eity or tmva oflltial city or town: Y�ODTR _ permiNieeme N nBuildiag Departmmt � pLieeosios Bo�rd � eheck i!immediate response i�required 261 �Stltetmen'e Oflite (508) 398-2231 p�t_ �Hu1t6Depanmmt . ronuct person: phone M:_ _ _ nOther THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #03-003 FEE: $50.00 This is to Certify that Kathleen Watson d/b/a Bass River Trailer Pazk. Inc 698 Willow Street. Bass River.MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS This License is issued in confomtity with the suthority graated to the Board of HealttS by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,ffid is subjec[to the pmvisions ofthe Laws of�e CommonweaWi ofMassac6use�ls retating ; th�xeto,and upoa such tertns and conditions,and�the rules and r�ulationg in regard�said Cabins so Gcensed as a�pted : by the Board of Health,and eacpires December 31,2003 unless sooner suspended or revoked. December 5 ,2002 BOARD OF HEAI.TH: �(,�a�lta�. i�alltkai. (�GadrNra.s �D.��.?J.. `Liu �a�lek'�IleD�att � S �+ ,��l. '� mce G.Murphy,� .5.,CHO i Director of Health -y � a. rz. -rQaic,� Pn2K �,, • ' � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMIT-2002 � .:�; ;: � * C��plet�rm and attach all necessary documents by December 31 2001. Pail�r� o(}o s4•W#1,1 result in � the return of your application packet. ' U�� 1 4 C�`� � I .• �JAME OF ESTABLISI IMENT: ;T��S i � �� zE% �i' cn ' ��C_: TE - # v�-:39�-: � / c ��' i�� Y � MAILING ADDRESS: /o �.S' /�/' ��/ u�J . � S .' ic��r CJ,� (� OWNER/CORPORATION NAME: �G�� / .a2 ��"i� ��c'7'�-- ER'S N EL. # 0 ` ` fN`�� / MAILINGADDRESS: ��/l/I�SL� POOL CERTIFICATIONS: ��/� The pool supervisor must be ce ' ed as a Pool Operator,as required by State law. Please list the designated _ �oa1 f�ratdr(s�a�d at[a��o�y o�tY�certificafian to"t�is form.- --- ---- -- 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a£de at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: f�,/� All food service establishxnents are required to have at least one 11-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. PER�flN inI EHARGE: Each food establishment must have at least one Person In Chazge(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 tlus form. The Healt6 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. RESTAiJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN a50 _MOTEL $50 _INN S50 _CAMP $50 _SWIMMINGPOOL$SOea _LODGE $50 �TRAILER PA2K $50 O �AD� _WHIRLPOOL $25ea FOOD SEYVICE� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-]00 SEATS S75 _CONTINENTAL $30 NON-PROFtT $25 _>I00 SEATS � S150 _COMMON VICT. $50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE �PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _TOBACW $20 ��:,y,. _<Z5,000 sq.ft. $75 _TOBACCO $20 <50 sq.ft. $45 � � _>25,000 sq.ft. $200 FROZEN DESSERT S35 xnmE c�xcE: Sio AMOUNT DUE _ $ 50 .Oo *****PLEASE TiIRN OVER AND COMPLETE OTHER SIDE OF FORM**•** i`� ,.�� ADMINISTRATION i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certifica:e of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Q$ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO NOTICE:Peimits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISI IMENTS ARE TO CONTACT'I'f�HEALTH DEPAR'I'MENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINT'ING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. A1�DITIONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and wturlpools 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 C�Nci1MFR A�VISORY: Each food establishment wtuch serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATF.RING POLICY: Anyone who caters wrthin the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Deparhnent. FROZFN DF.SSF.RTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFFS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),m�S haue prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. / � �� a DATE: �� SIGNATURE:� �� , ��` / � �� . PRINT NAME &TITLE:� ' <=��11 09/11/O1 ": ` � The Commonwea/th ojMassachusetts + ` Deparlment ojlndustrial.-lccidenrs ; �/1/Cd O//OYESII�!!1//f . 600 Washington Srreet Bnston. Mass. 01111 ` Wbrkers' Compensation Insunnce Affidavit n�m��. �!J-6E �� '-'/ l � �! � �' �SL� � � . ES� � / G�� c� � a � �� O � � I am a homeoµner pzn�rming a I work myself. [�/I am a sole propriemr �r.� ha�z no one ��orkin_ in am capacin• 1-amaa-erse �nrkers' ��•��^ f�m4 em losees ti.orkine o�this job.-- O PlesEa-ar�i-�i�s �vmasn�..-.F . P . — comran�� name• �1�� i/ 1�/�/"S� ��"7`�.C1 /F�✓- i��1C _I�L�C� tJAress: ,�� /' �"I' ", ///�r(.1/ �� ' citr�: �l� C�� l(J�'-D`_ �� lf-c -. /�'r��(�'�i.'�� ehene q: ��%/� " �1�(l � `�ti� �� _l �-/ 2 y insurance co �r/A L�l� ��`r� oolicv a � � G� � r J�\ �� I am a sole proprietor. general eontractor. or homeowner(eircle onel and hace hired the contractors listed beloK ��ho ha�e the follo�cin_ uorker_ ,ompensation polices: companv name• � addres�• �h�' ehone M• - insur�ncc co oolitv# eomoanv name• ---- -. . - . _ . . -- - � - - _ _ __ . ._- --� - --- a�drees . . ._ __. ... - - � � - - - - - . .. --. titv• � phaee M• � incnr�n�w�n IM�[11� ___ ' " "' Failure to�ecure aovenee as«quired uoder Setnoo 25A of MGL 152 n�lad to t!e i�priOoa of cri�f�l pedtla oh Ou ap to SI�00.00 nd/or one ye�n'imprisoement u w�ell u eiril penaltlef io the form of�STOP WORK ORDER aed�Ilae o(f100.00�d�y q�ioq mn 1 udenta�d tlat a copy of thh satemrn�may be fonvvded to the Olfiee of Inva�iptlom of tAe DtA for eoven�e veri6atlo�. 1 do htreby ctrfijp un rhe pains artd pertatti�s ajperjury�ha�1he injornmtion provided abovt is nue wd ro c � Signaturc---f��Lil%il'( . //!��'�jb�„-' Date G i �-/ 7 ��,. Print name ��t��1��ti� ��) PhoneM � �� /// � �� .. oR�i�l use onlc do not�rite in thie aro ro be compleled by tily or tmvn ollleial eity or town: Y�M�DTQ _ permiNiteex M nBuildiog Dep�rtmeot �Licemioe Bo�rd p cheek if immediaa response ie required 261 QSdectmrn'e ORcr �Health Departmenl - connct person: phont N:_ �508) 398--2231 eat. nOther __ THE COMMONWEAL`I'H OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #02-001 FEE: $50.00 This is to Certify that K�thleen Watson d/b/a Bass River Trailer Pazk Inc 698 Willow Street Bass River MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS This License is issued in confonnity with the auYhority ganted to the Board of HealYh,by Chapter 140,Sections 32A, 32B, 32C, 32D and 32E as aznended, and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating thereto,and upon such te�ms and conditions,and to the niles and regulations in regazd to said Cabins so licensed as adopted by the Board of Health,and expires Deceuiber 31,2002 unless sooner suspended or revoked. February 20 ,20(12 BOARD OF HEALTH: ��Z�zCJmrdoa .�lee �a�t`�. S�raawc, efezk �aauek'�� S � ce G. M rphy, R.S., CHO Director of Health BH,,5�5 RiJERTRAILE'IZ�PAR.� �,. —, . �� a� � �r,, �� Q `� �i (� IiC`� � 1� TOWN OF YARMOUTH BOARD OF HE ��'� DEC O S ZOOO APPLICATION FOR LICENSE/PERMIT-2001 HEALTH DEP . . + Piease complete form and attach all necessazy documents by December 31, 2000. Failure o o so the retum of your application packet. ---------------------------------------��---� ��r T'va ler 1'�.- r�,=Ne ----------�rF,L #Sr�B'39g a4�i -��----- ------ -- - ��renn.TrADD FS • (9 g � 9k7 �]� 5$ `a�V"' - d (¢ ♦Til11T 1T 111r �+U� ��p�• �_ /� ��}]/� ' . l 1�1 d�JG\(I 6� J�c - f M.41'1 I IV lT HLLiCr,Jj� �, '�.'""'�"'"""�'"""_""�""""""""W """""'�""_'��"""""'_��"�'�'�""""'�'"""'�'��'""�"'�' � PnOT ['FRTIFICATIONS: /�j�Yw The pool aupervisor muat be cerhfied as a Pool Operator, as reyuired by new Stete law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. i. 2• Pool operators must list a minimum of two employees cwTently certified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will not use past years' records. You must �,, provide new copies and maintain a file at yoar place of bueinesa. 0 1. 2• 3. 4• HEIMLICH ERTIFICATIONS• 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 hained 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 pmvide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# _._, _ �_� �__,__._�__-_ ----=- -----T-�— �—_ — —, ------ -------_--.------- �-��.__- -- —= — — OFFI_CE LTSF ONLY LO�GING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B&B $50 _CABIN $50 � $50 _CAMP $50 LODGE $50 I TRAILER PARK $50 �� MOTEL $50 _SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE• N01'E: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October 1,20111. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 _CONTINENTAI, $30 >100 SEATS $I50 NON-PROFIT S25 COMMON VICT. $50 _WHOLESALE $75 RFT ii. SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _TOBACCO $20 4,5,000 sq.ft. $75 _FROZEN DESSERT $35 >25,000 sg.ft. $200 NAMF. f'HANGE: $l0 AMOUNT DUE _ $ S�►�00 ••'•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""* ,_ _._ _ .,. . .. __ _ .._ , - , , � . ' ADMINISTRATION I Under Ghapter i,52„y�ection 25C, Subsection 6,the Town of Yatmouth is now required to hold issuance or renewal e€any-�icense'or perinit to operate a business if a person or company dces not have a Certificate of Worker's CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RETURN � THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2000. I SEASONAL ESTABLISHIvIENTS ARE TO CONTACT TE�HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION i F Ui ATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depar�ent,and the water tested for pseudomonas,total colifonn and standard plate count by a State i cerhfied lab,prior to opening, and quarteriy thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of ; closing. I � FOOD SERVICE NEW STATE SANIT Ry C�nF F� FOOD ESTaRt ISHM nrr� '� The effectfve date for food protecrion manager certificaHon is October 1, 2001. As stated in 105 CMR 590.003(A) 2), food establishments must have at least one person-in-chazge who is a certified food protection manager. �s 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 implemented January 1,2001. Only establishments which sell or serve ready-to-eat,raw or undercooked animal products are required to have consumer advisories. CATE iN PO ICY• Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the reqwred Temporary Food Service Applica6on form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. __ _ __ _ FRO .FN D . 5 RTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUT ID � C FFS• Outside cafes(i.e.,outdoor seating with waiter/wairi�ess service),must have prior appmval from the Boazd of Health. OUTDOOR COOKIN • Outdoor cooking,prepardtion,or display of any food product by a retail or food service establishment is prohibited. DATE: I�/ � � SIGNATURE: . PR1NT NAME & TITLE:��I�-rs I�t�Q�O'i� //7� �et!e 1^ 1 I/16/00 ��S � � � The Commonwea/[h ojMassachusetls : W Department ojlndustria/.4ccidents o /lllcsol/rrest/osUiis 600 Washington S►reef Boston, Mass. 01111 W'orkers' Compensation Insurance Affidavit Aoolicant informaHon: P►eatrPR[fl1"itM�'LTa namc: ��1�1�.V1 �('1l l5�{� location: IQ9 D w 1 l `�� • cin� J )Q�JS 1 �\. 17L� . �f� . o«KJ�Q7 phonek ��`�� ( !� ' �J �� I am a homeowner pzrtortning all work myself. �am a sole propriecor�r.d ha�z no one �corkine in am capacity � I am an employer pro�iding workers' compensation for my employees workin¢on this job. com�an?� name: �CC. �SS �i J�Y j �0.i �L'_,1�� Y' � , �H.�� add s 10 ; .. � �e.Y' . SoS- q F-� � insur�nce co. Y Y� � # l� o �4 -� x3 ��? � � I am a sole proprietor. general contracmr, or homeowner(circle onel and hace hired the contractors listed below �cho ha�e thz follo«in_ �corker ,ompensation polices: companv name• addresr citv• phone M: insur�nce co poli�7;# comnTnv name• - -- -- ._ _ . . . _ _- - -- � - .. . . -- — . _._ - -- - —. ___ .. __ .--- --_.___. _ addresa: .. .. -.. - .. . .. citv phoee N• insurance co. eoliev N Failure to sceurc covenge as required uuder Seedon 25A o(MGL 152 ne lad Po t0e inpaitloe of erisi�fl peWtin ot�B�e op to f1,500.00��d/or oae ye�n'imprisonment u w�ell af civil peodMn io the(orm oh STOP WORK ORDER�od a Oet of SI00.00 i dry tpimt me 1 a�dent��d H�t t topy of thN sbtement m�y be fonv�rded to the ORce of lava�ia�tiom of the DIA for emenge veri6utio�. /do�hrreby cenijp er the pains and penal ies o perjury�hm thr injormation provided above is we md corrccY. Signaturc__��/ �� Dy� �d/!�/�� Print name f�0.��`��1 WOL�� l� Phone# 5�� "�7�—�� ., olTirial use onh do not w rite in this arn m be tompleted by ciry or towo oflicial ciry or rown: Y�M�DT$ _ permiNieeme M nBuildiog Departmee� � �Lieeosiog Board p check if immediau response is required Z61 �SelectmenS Oflfee (508} 398--2231 ¢at. �Hcalth Departmmt con�ac�person: phone M;_ __ _ nOther bm�isN i;a5 PIA1 � r � � I co � o � �-,�, ° a o 3 �' (J o ,� Q o � � �' � J� � � vi � � � •c o ��. a o �o y W �g� � � • � � W .2 ,,., � ?: � w � o � �3 >;Y h � � t � ', � y 3 0 �� .y� � �'a� w a � o �`,�' �x � O � � � v `� �� o 'x F" � ,,� � 2 `^ �i � C7 0 V � o ° �S � �iC� o 0 y v d' ►7 F ~ W a' � o .d � W �� R`7 L1 a� ,� "�� ' �` E-� V x o •y �� .., (� W ' � y� ►'`,��':� �y�� fJi O � � � '� a'Y ,� F 7 g `� ' r � ' ��.�' � � � A C� « a> ' X a � � t �'r��` �� v� t 1`s,�'��,. .o ra 'v � . a W CL a� e .o W � "�' � �� F w Q z a�''�f �y ,e � w ��°, � �+��'j� �� #��s Q Q� Q m � � �� '� {�l a � �'�' i � �" � � ai f� � �" � '3 ,k�� 3 °5�r��.. � ��9kx �, . d c7 F+ o h � � � � �°'�:�� , � z�,� �,�;t � � }, , O � � � � �., o ..r� �.d€ ,�,� r , 3��_ zO0.1 � W FW-� m .vs ° a1 `s ,"a � e,'��}� �a�'e''� �,�`' O F W � $ � v ' � '. 'r 3�`2 �� ' ��'� �. �` �, � � g �.I W O p p..�. � s. C. f"' • V1 W � y p m '� << �� $ d .'�{ r � � ,�'�. � � � 0.. Q a� f � .� m 'Op � ' s' �'� •� i Y� �'� x 1�4' . . y' a`. � � W .O �� .a [ �r. • ::re � � � N � � ' ' .. -� t W �y � • F 6 -. � ` .r ' . � W a`i O � W .5 N m� o LLl $ '$ � •� � c�v � .� °N—' Ca .°'. � _ ' . F" o .°y U `� o N . � Y U N � N m j 'n � m � d N N 'C O a �` � m � U '� � � , � ;;..g'f��?` . ___ _ .Y�1=� °1?s-..::4 -, i � _ .� ,� :, - . ' _. _._ _ ___' '+ " � 5 �ti,s k;��;� T ,i �a�.� ' �- (� f�� 11N/ f�DD ' TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT- 2000 NOY 1 7 1999 q TH DEPT. * Please complete form and attach all necessary documents by D�mt`ie�31, 1�9�.�'f'a w� result in the return ofyour application packet. ��j7�3 ��= ------------------------------------- -- ----- -- -�7-� - - - -- ------ NAME OF ESTABLISfIMENT � i uL'Y'T��TL'✓" N tS � TEL # ��0 l/ LOCATION ADDRESS: S2 l.� t 1 I Ru��o�s�P�Y� Y � ' L OWNER/CORPORATION NAME: ' N # MAILING ADDRESS: L ---------------------------__—______—_----------------------------------------��_. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s)and attach a copy of the certiScation to this form. l.�j,�/� 2. Pool operators must list a minimum of two employees cunendy certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of empioyee certifications to this form. The Health Depardment wiit not use past years' records. You must provide new cop es and maintain a file at your place of business. 1. �j/"� 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 premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Heelth Department will not use past years' records. You must provide new copies and maintain a file at your place of busiaess. �. N z. 3 4. RESTAURANT SEATII�IG: TOTAL# NOAT-SMOKING SEATS: TOTAL# --- - - -_------------------------------------------------------------------------------_—______------- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# B&B $50 _CABIN $50 _INN $50 _CAMP $50 LODGE $50 �TRAII..ER PARK $50 K� MOTEL $50 _SWIl��IING POOL $SOea. _WHIRLPOOL $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 RETAII. SERVICE: LICENSE REQUIltED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $45 _TOBACCO $20 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>25,000 sq.ft. 5200 NAME CHANGE: $10 AMOtTNT DUE _ $ �J(J ` •••"•pLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM""•"• ADMINISTRATION ' UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSiJANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON'�OR COA'Il�A�IY 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 � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MIJST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES .l NO NOTICE: PERMITS RUN ANNUALLY FROM JANCJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHMENTS ARE TO CONTACT Tf�HEALTH DEPARTMENf FOR INSPECTION�-10 DAYS PRIOR TO OPENIlVG FOR THE SEASON: ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE TtEPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. Ai�DITIONAi RF_GUi ATIONS POOLS POOL OPENING: ALL SWIMIVIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR TI� SEASON MUST BE INSPECTED BY Tf�HEALTH DEPARTMENT, AND TI-IE WATER TESTED FOR PSEUDOMONAS, TOTAL COLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENII�TG, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIlviN�IING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE �ATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY Tf�YARMOUTH HEALTH DEPARTMENT BY FILING TF� REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO Tf� CATERED EVENT. THESE FORMS CAN BE OBTAINED AT TI� HEALTEI DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO Tf�HEALTH DEPARTMENT. FAILURE TO DO SO WII.L RESULT IN TI� SUSPENSION ORREVOCATIONOF YOURFROZENDESSERT PERMIT UNTII,TI-IEABOVE TERMS HAVE BEEN MET. - . OUTSIDE CAFES: OiTTSIDE CAF'ES(i.e., OUTDOOR SEAT'ING WITH WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM TI�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE: ( /6 SIGNA PRINT NAME& TITLE: (\CC7�tI��'L � �✓t%S 11/12/99 i r . � The Commonweallh ojMassachusetls = � Departmen! ojlndustrial.-Iccidents _ a OlAee el/�rest/Osaliis 600 Washington Slreet ' Basrort.Mass. 02111 �� '` W'orkers' Compensation Insurance Affidavit n m• � V ��, ��—�� ,ho� w 57� — � �-�2D( ( � I am a homeouner pen�rmmg all work myself. (�.I am a sole proprieror _r.,'. ha�z no one norkine in an} capacin• ❑ 1 am an emplo�er pro�idin� workers' compensation for my emplocees uorkin¢on this job. _ cmm�am name• 1�Lt.._'S`i �K\ l�` ��'�� Jll fl°�V��Q�(`�� Arcs : F�-�.�—�I � �3� �;r��GLS.�� `� �(� • pno� a• � �' � 7 O `oG� � � insurance co. policv a � I am a sole proprietor. _eneral contrac[or, or homeowner(cirde onel and ha�•e hired the contractors listed below �iho ha�e the follo«in_ �corAcr, compensation polices: wmoanv name: - ad d ress: [ih�' nhen e• � insurance co poliev# eomoanv name: addresr. ��h'� phoes�+' in�uranee ce. �� Failure to seeure corenee u required uoder Secnoe 25A o(MGL 153 n�Ind to lYe ieporiao�p(cridW pe�dtles oh��e ap to 51300.00�W/or oae yean'imprisonment i�wxll u tivii penaltla io the form ot�SfOP WORK ORDER�ad�O�t otS100.00�dy q�iost mt 1�Wenta�d tl�t a eopy of tAy statement m�y be fonv�rded to the Oliite of Inve�tl`�tlom of Me DIA tor eovera�e verilfatlw. !do-hrreby ce i under br parns and ptnel�i J o pe 'ury a!he injonnalion prorided abovt it nr�t and corred Signaturc �T�9� � Print name pM K �v$`��.`�/'� / / d�•=� .. oliicial use onl. do no�wri�e in this area m�eompleled by eity or town ollltial eity or rown: YA��DTQ _ permiNiceaee r nBuildiog Departmeet � pLieensioE Bovd ❑cheek if immediate response ie required Z61 �Seleetmen'�ORce �Nea1tA Departmeet conuct person: Pho��p�_ (SOB� 398-7231 eat. �OtAer , ' THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMITNUMBER: Y2K-1 FEE: $50.00 This is[o Certify that Kathleen Watson d/b/a Bass River Trailer Pazk __ 69A Willow Street B s River MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS This License is issued in confortnity with the authority ganted to ihe Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions ofUie Laws ofthe Commonwealth of Massachusetts relating thereto,and upon such tertns and condi[ions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31,2000 unless sooner suspended or revoked. November 23 , 1999 BOARD OF HEALTH: �/�/P. yede�e/, C,�iayi�rmya/n �oan C�. �ulCuran� K.//.� �ics ��irman �o6e,r� f3„�„�, C�.� a6.is�a S'a�o��y-✓�onpea ' �lOo('o�y�Lrt Bruce G. Murphy, MPH,R ., O D'vector of Health � , s ��S2��'I� r D�ri� ' � Towrr oF YA�au�� A�'TH G3 I� 6 � 0 d C� D APPLICATION FOR LIC��?� /��- 1999 DEC 0 2 1998 * Please complete form and attach all necessary documerrts by December 31, 1998. Fail E LTH EPT . the return of your application packet. —_---------------------------------------- -------- --------- ------ --- --------------------------------------- TAB I # l A I N D S: u RAT N . # MAiT ING ADDRFSS� 1 -------------------------------------------------------------------------------------- - ------ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as rec�uired by new State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certificarion to ttus form. 1. /Y/� 2. Pool operators must list a minimum of twoemp loyees currendy certified in basic water safety, standard First Aid and Commumty Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificat�ons to t}us form. The Health Department will not use past years' records. You must provide new copies and maintain a t'de at your place of business. 1. 2. 3. 4. 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 f�e at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# — ----______--_____—__�_______�w�------------ ------ --------------------- ------------ _ — - — _ - - --- —�F�fE�US�4�NL� . _ _ LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERNIIT# B&B $50 CABIN $50 INN $50 CAMP $50 _LODGE $50 I TRAII,ER PARK $50 ��_ MOT'EL $50 SWIlvIlvIING POOL $SOea. _WHIRI.POOL $25ea. FOOD SERVICE• LICENSE REQUIltED FEE PERMIT # LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAL y f $30 >100 SEATS $150 NON-PROFIT $25 COMMON VICT. $50 WHOLESALE $75 RETAII.SERVICE: LICENSE REQUIltED 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 �AME CHANGE: $10 AMOUNT DUE _ $ � � ••"""PLEASE TURPI OVER AND COMPLETE OTHER SIDE OF FORM"""*` f ; ADMINISTRATION tJNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, TI-IE TOWN OF YARMOUTH IS NOW REQUIItED TO HOLD ISSUANGE 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 ✓ � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIlZED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISFIMENTS ARE TO CONTACT T'I-1E HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIvIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING: ALL SWIlVIMING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf� SEASON MUST BE INSPECTED BY TI-IE HEALTH DEPARTMENf,AND Tf�WATER TESTED FOR PSEUDOMONUS, TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY THEREAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWI1vIIvIlNG POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7) DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN THE TOWN OF YARMOiITH NNST NOTIFY Tf� YARMOUTH HEALTH DEPARTMENT BY FII,ING Tf� 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 MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TF�HEALTH DEPARTMENT. FAII,URE TO DO SO WII,L RESULT IN ___—THE Si JSPENSIONQR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL Tf�ABOVE TERMS HAVE BEEN MET - __ _ -- _ OUTSIDE CAFES: OLI'I'SIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE),MLJST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAII,OR FOOD SERVICE ESTABLISf�1ENT IS PROHIBITED. DATE: � � SIGNATURE: PRINT NAME& TITLE:�,�►'1A,1�PiY1 ��, ��_ . ' �\ The Commonwealth ojMassachusetts � Deparlment ojlndustria/.-iccidexts ; Omce o/%resd'sa►in 600 Washington Street Bosron, Mass. 01111 Wbrkers' Compensation Insurance Affidavit Annlitant information: PfeasePRINTTedGi�Te name: ��L.P/� YUQ,.� , � l �;�"��a..5 ;v ex— , ��.. pho��D Ff �9��.o-i 1 � 1 am a homeowner ptrtortning all work myselE �1 am a sole propriecor�-d hace no one �corkin¢ in an} capacih• � I am an employer pro�idine workers' compensa[ion for my emplo s uorkine1 o'n this job. comnancname: �JC�75��,� 1"\ QL �� Q;`( � �� '� ,��«t5: I�a� � �; lL� �� tity: � �Q —1-\l v�� -. ��' ohone M:��V �)/ 0 �V Z ! ipsurance co. Y l�C°�,'e!�� oolicv q �� o i9 3x �a��cor � I am a sole proprietor. _eneral contractor, or homeowner(circfe onel and have hired[he contractors listed below �cho hace thz follu�cin� «arker ,ompensation polices: company name: address: c�: � �hone k• insurancc co. pelicy p eom a�ny namr � _.__ _ .._.------. _.--.. . _ _ ___ ___ _ __. _----- _ . ___. addrcss: . -_ . _. ------ ------- ---- -- c�: phoee M• insurance co. ppj�y M Failurc to xcure coverage�s requirrd uoder Setaoo 25A af MGL IS3 n�lad to IYe i�paitloa ottri�i�l peultln ot�B�e op to f1�00.00��d/or ooe ye�rs'imprimnmrnt n w�ell�s tivil ptoaltln io tAe form of�STOP WORK ORDER nd�Ilu of f100A0 a dry qdmt m� 1 a�denb�d N�t a topy of thy sntement may bt fonv�rdM to the 011fee ot Invertigadooe of tht DIA for toven�t verilitatlw. /do�hrreby cenij}•un r rhe pains and pena!lies ojperjury that�he injormallon provided abovt is trut and eorrea. s,g��D,�.� 1,�� ,��/q�-- Print name��PM Y Va.��l PhotrcM y�0 -�95� ao� r ., oR�i�l use onl�� do no�w rite in this are�to be completed by eity or lorrn olfltial eiry or town: Y�DTQ _ permiNieeex B nBuilding Dep�rtmeet � � ❑Lfteesiog Bovd �eheck if immrdiate response i�required Z61 QSeleetmen'�OOfee �Health Dep�rtm�ot contactperson: pAoneN:_ �508} 398-2231 eat. nOther ve„srd bo5 FIAI THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT NiJMBER: 99-3 FEE: $50.00 This is to Cettify�hat Kathleen Watson d/b/a Bass River Trailer Pazk Route 28 Bass River MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS 'I'his License is icsued in conformity with the authoriry granted to the Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of Ute Laws of the Commonwealth of Massachusetts relating tLereto,and upon such terms and conditions,and to the rules and regulations in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires December 31, 1999 unless sooner suspended or revoked. December I S , 1998 BOARD OF HEALTH: �i� ��+-1a�lee� ��ia(�irmq/aJnq � /� �/�oan G. �u/��an�/KJ0.//l.� Vice C,�irman Ko�/ort Q�� //�Jr/au�n� l.[erk . a�irie��BA Ja/1/0lL��tj/-a�oo�ie9 � �Bl Od h[{ri ruce G.Murphy,MPH,RS., HO Director of Health r C p � L� �!� � ' �I:,. ��_1� TOWN OF YARMOUTH BOARD OF HEALTH FEB 0 2 1998 APPLICATION FOR LICENSE / PERMIT - 1998 � � �i�At i� ��:F �. � �,��, � / � �� " Please Complete form and attach all necessary documents by December 31, 1�7 l�il�w$t��,,�„� � so will resuh in the return of your application packet. Jr- , ------------------------•---------------------------- --------------- ------ -- ------------- ------------ �e # 9 ' o�a! / ` � ING i �Y' le�t.c ' � ; _ , , "ac 1 '� MAILING ADDRESS: � � ti ------------------------------------------------------------------------------------------------------------------ P90L 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 these employees below and attach copies of employee certiScations to this form. Tde Health Department will not use past years records. You muat provide new copies and maintain a file at your place of business. �//-� 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 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 wiil not use past years records. You must provide oew copies and maintain a file at your place of business. 1. /I�/,� 2. 3�� 4. RESAURANT SEATING: TOTAL # NON SMOKING SEATS: TOTAL#_ ' -------------------------------------------------------------------------------------------------------------�---- OFFICE USE ONLY LODGING: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _INN �50 �CAMP $50 _LODGE $50 �TRAILER PARK $50 �4, _MOTEL $50 _ SWIM POOL $SOea. _WHIRLPOOL $25ea. FOOD SERVICE: LIC. REQUIRED FEE PERMIT# LIC. REQLTIRED FEE PERNIIT# _0-100 SEATS $75 _CONTINENTAL $30 _>100 SEATS $150 �NON-PROFIT $25 _COM. VICT. $50 _WHOLESALE $75 BETAti. SEBYL�E: LIC. REQUIRED FEE PERMIT# LIC. REQUIRED FEE PERMIT# _<50 sq. ft. $45 _TOBACCO $20 _<25,000 sq. R. $75 _FROZ. DESSERT $35 _>25,000 sq. ft. $200 AMOUNT DUE _ � � � � ADMINISTRATION LRVDER CHAPTER 152, SECTION 25C, SUBSECTION 6, THE TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMPANY DOE3 NOT HAVE A CERTLFICATE OF WORKER'S COMPENSATION INS[JRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. 'TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMTTS. PJ�EASE CHECK APPROPRIATELY IF PAID: YES_�_ NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RE'fURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 31, 1997 SEASONAL ESTABLISHIvfENT5 ARE TO CONTACT TI-IE HEALTH DEPARTMEN'P FOR INSPECTION 7-10 DAYS PRIOR TO OPBI�IING FOR'Tf� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHNIENT,MOTEL OR POOL (i.e. , PAINTING,NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEI�TING: A1.L SWTMMING, WADING AND WHIRLPOOLS WHICH HAVE$EEN CLOSED FOR 1'HE SEASON MUST BE INSPECTED BY TF�HEALTH DEPARTMENT, AND THE WATER TESTBD FOR BACTERIA BY A STATE CERTIFIED LAB,PRIOR TO OPEI�tING. POOL CLOSING: EVERY OUTDOOR IN GROiJND SWIMMING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7) DAYS OF CLOSING. FOOD 5ERVICE C'A 1NG POLICY: ANYONE WHO CATERS WITHIN T'HE TOWN OF YARMOi7TH MUST NOTIFY THE YARMOUTH HEALTH DEPARTMENT $Y FILING"I'I�REQUIRED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. 'IT�SE FORMS CAN BE OBTAINED AT TI-IE HEALTH DEPARTMENT. FROZEN D�S�ERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHLY BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SEN'F TO TI� HEALTH DEPARTMENT. FAILURB TO DO SO WILL RESULT IN THE SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT UNTIL 'TI� ABOVE TERMS HAVE BEEN MET. OT_JTSID� C��: OUTSIDE CAFES (i.e. , OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MUST HAVE PRIOR APPROVAL FROM TT-IE BOARD OF HEAI,TH. O TTnOOR COOKING: OUTDOOR COOKING,PREPARATION,OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHIvvIEE1VT IS PROHIBITED. � DATE: o� ��I 9� SIGNAT[JRE: ` PRINT NAME & TITLE:1`GL G �L�LYt .�F � , ' � S 10/97 page 2 of 2 � The Commonwealth ojMassachusetls = � Deparlment ojlndustria/.-lccidents ; 9/llceol/�st/OslJiis 600 Washington Slreet Baston, Mass. OZlll Workers' Compensation Insurance Affidavit n m• b�1Yl i-s�e4 ^l�� - . O LL� �C�[v-,�fl��.� '� l.�'E �� phone p ��c� /CJ "oL d�� 1 am a homeowner pzrtorming all wo�k myself. [�I am a sole proprieror acd hace no one��orkin� in am capacity � I am an em—ploy�er pro�idine workers' compensation for mv empl workine on this job. comRany name� l'�x-C�S �1J�1� /��Q / /L� �" / Q �"(� ��° , addr s : � i U� ipsurance co, policv M � 1 am a sole proprietor. general contractor, or homeowner(circle onel and have hired the conaactors listed below �cho ha�e the follo�tin_ «orker ,ompensation polices: s9m{Laqv name: addresr. titv: ohone M: insuranceco. � ooliev# compg,p,y�ame: address• � [�: nhoee N• insuranee co. eoRev M Failure to securc aovenge as required uoder Seeaon 25A o(MGL 152 n�lad to the inpaido�o(erisivl pt�Utln of�O�e op to 51.500.00�W/or ooe ynn'imprisonmrnt u a�AI a�tivii pendNea io the form ot�STOP WORK ORDER tod t Iloe of SI00.00�d�y qdott sa 1 ndenn�d H�e� eopy of thia sntement may br(onv�rded lo the 011iee of lovatlg�tlom of the DIA for eoven{e verillutlw. !do hrreby cer�rj•un r rhe pains and penotries o trb �hat�he injormation provided abave Ls hut and rorrtet Signamrc � ,�l�/�� .�_ Printname ��I`� ,(�� onep ,�7�y <�U �l .• olTicial use anly do not write in�his arta to be tompleted by eity or to�vn oflleial city or rown: Y��DTQ _ permiNiccox N nBuildiog Dep�rtment �Lieeesing Board ❑ check if immadia�t response ia required . 261 �Seleetmen4 Ofifte �Health Departmeet conlact person: pAone N:_ �SOH� 398-2231 eat. �Other va isxa;,05 v1M , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: 98-9 FEE: $50.00 Tlus is to Certify that Kathleen Watson d/b/a Bass Rver Traiier Park Route 28 Bass River MA HAS BEEN GRANTED A LICENSE TO OPERATE TRAILER COACH PARKS T7tis License is issned'm conformity with the authority granted to We Board of Health,by Chapter 140,Sections 32A,32B, 32C,32D and 32E as amended,and is subject to the provisions of the Laws of the Commonwealth of Massachusetts relating iheieto.and upon such teims and conditions,and to tlie rules and regulatioas in regard to said Cabins so licensed as adopted by the Boazd of Health,and expires Decembec 31, 1998 unless sooner suspended or revoked. Februar,L3 , 1998 BOARD OF HEALTH: Gd ///n. �e�teQs�, l.�ia/�irmq/a�an / /�/ � �(�oan G.c�7u{�Clivan�/K�a.�1.� Vice l.hairman Ko�/ert QJe . 9�rowen� l,le/r/� � a6riel[ea�a�ia/e�ry��/daoPed . �' el0 u��Cin � Bruce G. Murphy,MPH,R .,CHO. Director of Health