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Home My WebLink AboutApplications, WC and Licenses • �5 c ��. '�"��s_ TOWN OF YARMOUTH BOARD OF HEALTH �1 S APPLICATION FOR LICENSE/PERMIT-200 A ��'i h + C;;�t� * Please complete form and attach all necessary documents by Il�e ei 31; 2007. Failure to do so will result in the return of your=apphc'a'�id'n packet. , _s�� r ��;" ' NAME OF ESTABLISHME T: 4 � TEL. #e��77/;3�y LOCATION ADDRESS: U� �- MAILING ADDRESS: S�A1P_ OWNER NAME:�'ulr-e [�'4'S�a// TAX ID (FFIN or Nl•(ZC�`7��e CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIpNS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please Gst the designated Pool Operator(s) and attach a copy of the certificarion to tivs form. 1. 2. Pooi operators must list a minimum of two employees currently cenified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certiScarions to tlris form. The Health Departreent 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 cenified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certificacion to this appfication. 'i'he Health Departmeat will not nse pasi years'records. You must provide new copies and maintain a file at,your establishment. 1. �c3 ��.��k1�C�� 2. j P�R�9N IN CI3ARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of empioyee certifications to this form. The Health Departmeut will not use past years' records. You must provide new copies and roaintain a £ile at your place of business. 1. z. 3. q : RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGCVG: LICENSE REQUIRED FEE PERY9T� LICENSE REQL'IItFD FEE PERbIII # LICEA'SE REQL'IRED FEE PERYIIT= . _�B 5� _CABIN S50 _MOI'EL S50 � _INN 550 � _CA1�IP� S50 _S\17YL4fINC,pOOL S7iea. _L07XiE S50 _TRAILERPARK 5100 _R'HIRLpOOL S75ea. FOOD SERVICE: ��, LICENSE REQUlltED. FEE , PERMIT� LtCENSE REQUIRED FEE PERkIIT a LICENSE REQti1RED FEE PER�IIT= ! I 0.100 SEA'IS S75 �a�l7g � _CONTINENTAL S?0 _NON-PROFIT S2i i � >100SEATS Sli0 — _CO:�L4ION VIC. S50 _��I-IOLESALE 575 RETAQ.SER�'ICE: . —REStD.KI7'CHEN S7i j LICENSE REQUIRED FEE PERMI'I= LICENSE REQIIIRED FEE PER4D7'- LICENSE REQL7RED FEE PERMi- � _<50 sq.ft. S45 _>25,000 sq.ft. S?00 _VENDIiVG-FOOD 5_'0 _<25,000 sq.ti. S75 _FROZEN DESSER7 S35 _TOBACCO 550 �Ai�CHAVGE: 510 AMOU\T DUE _ $ ?s pp •"••'pLEASE TLR\O�'ER.1_\"D CO\iPLFTE OTHER S[DE OF FOR�i*•�•* ADMINISTRATION Under Chapter 152, Secrion 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insarance. THE A1"1'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 Yarmouth taices and liens must be paid prior to or issuance of your peanits. PL,EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transietrt 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 eL9ewh�e. Transie�rt occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shell not be considered uansient. Occupancy that is subject to the collecdon 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�iosed Motel Census must be completed and returned.�;tn th�s apP��on. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the sea.von must be ins ed by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys 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 CAT'ERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heakh Departmeeott by fiting the required Temporary Food Service Applicarion fonn 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit urnil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval&om the Board of Health. OUTDOOR COOKING: Outdoor cooking preparatioq or display of any food product by a retail or food service establishment is pro6ibited. NOTICE:Permits run ammally from January 1 to December 31. TP IS YOUR RESPONSIBILPfY TO RETURN TFIE COMPLETED APPLICATION(S)AND REQUIItED 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 Tf�BOARD OF HEALTfi PRIOR TO COMME_VCEME�IT. REVOVATIOVS MAY REQUT A SITE PLAN. DATE:___s� I b/C�� _ SIGNATURE: �-� PRINT NAME&TITLE: �' b io so„� ^ �' � The Cominonwewlth ofMassachusetts Departmest of Indtts[rial Accidents NAfesa� 600 R'ashington Streey 7t°Floor Boston,Masc 02111 Worlcers'Compensatios Iasm�arce Affidavit Bnildiog/Plumbieg/Etectrical Contnetors . t. :. . .. � � � � � . . . � �. �a// a�s: CiIY �L�/�,�� SMdtC' �' Zt8' t Y'1�n / D�I�t�6��s�-/ � I work site locatim�(fiill addressl: - � I ag�o�imer performing all work myaelf. Project Type: ❑New Canstcucdam�Remodel �1'am a sole propaietor aad have no ame woxking in any capcity. ❑Bwlding Addition ❑ I am an employer providing waakeis'compensazim f�my�ployees wodcing on this job. . �m �ane: / � . �,,: (�a I �:-��' ��1� �� , ��- ` -�?� ��l�� . p�n�,x � _ � f: � .-. � � . , , ,_ >�: .u.>. .z,<< ❑ I am a sole proprietor,g�ml eodtractor,or homeaw.er(drdt oiu)and have hired 1Le conhactots listed beluw wLo have the following workers'compensahion polices: s�ouv�aee- . ad�ess: citv: �q. iesaraxeca� � . ��p . eommsr s�me: ad�vs• ellv:� � � � �p. . i�emaseed. -� _. . .:. �g , . , ,. .. . Faiore0�f[emt � , •; :. ,. , . -' • � ,� , . . .. o�e Ynn'IePri�ueat n wd n dN�tler 9cetlo�2SAd MGL 152 n�Wd b IYe i�itlu dvlsWal pea�ltln da Soe a�b t13M.M udx��. pmaltln io t6e brm Ka 31OT WORK ORDBA a.d a eee dS1M.W a dar apimt.e. I odnapad tLN a a�py ottlb sfahseW vay he fa*waNed ro Ne Omce�lavntlgatlsm e[the DIA bor cevenge veri9ntlse. - �hdeby cerfify xnder tLe perjxry tl�at(�r7nfornrmion pro�ided aboae is�$rn U � �Sy B"a�"re Dste �O Ptint name . U , -�J P6one# � official ox oery ao ea..r:re�ute.re,a ae mmqetea uy dly er rwu.�� . . . . . . . cilyarfawo: Pe�ficeme# �Boidin6DePar�ent ❑ehedc H�medi�le rcqieme k reqmred �Bmrd �n'a O�ce eodsctpen�o: �p� ��[ l.�.i.ea s�.iom) TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-179 FEE: $75.00 In acwrdance with regulations promulgated imder autharity of Chapter 94,Section 305A aad Chapter 111,Secrion 5 of the General Laws,a permit is hereby gtanted to: I j Julie Driscoll, 600 Route 28, West Yarmouth, MA i Whose place of business is: Cape Cod Cakes Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 BOARD oF HEnLIH: 3felen SHal�, `J2.JV., �'/tai�unart C�ax[ee .�.9Ce�fiR�ex `llice '(.ffa"vwna�rc ; `JtaBext s. `.�iawn, � ; Qeae C�xees6aunc, `J2..N'. F,uefi/n�-.�fa�ea May 13.2008 'I Bruc G.Mi phy, ,R.S.,CHO 'I . Director of Healt ` � . � C� D ?�F�"R.ya TOWN OF YARMOUTH BOARD •' � � APPLICATION FOR LICENSE/PE ,� MAY 1 '] 2006 ��s ; � �4��1 � • Please complete form and attach all necessary documents by December 31, ALTH DEPT. Failure to do so will result in the retum of yow application packet. NAME OF ESTABLISHNIENT:�l �.�o ��yy, �'Q�` TEL. # �7�G/y� LOCATION ADDRESS: �nC� ��i��,� l,uPc-� �/�,s�z-nr�h �/�-�� ?�� Mau.�rrG ann�ss: ow�R rraME: �,�;�, ��;�� TAX ID(FEIN or SSN);�=/c1-�l�-�aati CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAII,ING ADDRESS: � POOL CERTIFICATIONS: � T6e pool supervisor roust be certified as a Pool Operator,as required by State law. Please list the designated � - —�eel-0�erater(s}artd attach a copy ofthe certification tothisfarm. - --- - 1. 2. Pool operators must list a rr,;,,;roum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of empioyce i certificauons to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4. 'I � 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 Pood Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The He91th Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 3VLi E D i?)5[�C.L_ 2. I PERSON IN CHARGE: - _ -- _ _ - Each food establishment must have at least one Person Tn Charge(PIC) on site during hours of operation. 1. 2. HEIlb�ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and � attae}i eopies of employee certifications to this form. The Health Department wdl not use past years' records. i You must provide new copies and maintain a file at your place of business. I 1. 2. � 3. 4. � RESTAURANT SEATING: TOTAL# OF`FICE USE ONLY LODGING: LICENSE REQIlII2ID FEE PERMIT# LICINSE REQIJIItED FEE PERMI"I'I! LICINSE REQiJIl2ED FEE PF12MI1'# _B&B S50 CABIN $50 MOTEL $50 _INN $50 � CAMP $50 SWA�IIvIINGPOOLS75ea. � _LODGE $50 'I'RAIC,ERPARK $50 WHatLPOOL S75ea. FOOD 5ERVICE: - LICENSE REQUIl2ED FEE PERMIT p LICENSE REQUIltED FEE PERM[1'# LICENSE REQiJIRED FEE PERMIT# � ( 0.100 SEATS $75 �Ob�I�7 CON1'INENTAL $30 NON-PROFIT $25 >100 SEATS $150 _COMMON VIC. S50 WHOLESALE S75 RETAIL SERV[CE: LICENSE R&QUIItED FEE PERMTI'q LICINSE REQtJIItF,D FEE PF.RMI1'# LICENSE REQIJIItED FEE PERMiT# _<50 sq.ft. $45 _>25,000 sq.ft. 5200 VINDING-FOOD S20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: E10 AMOUNT DUE _ $ 7S•OO ••"""pLEASE TURN OVER AND COMPLETE OTHER SmE OF FORM•*""• , ADA�NISTRATION ' Under Chapter 152, Secdon 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a CertiScate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFNIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth t�es and liens must be paid p�to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pernuts run aonually from January 1 to December 3 L IT IS YOUR RESPONSIBIIITI'TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO t1NY FOOD ESTABLISf�1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: FFozeff de�sert�mesf�tesie�-en�Fnon�gbasis-by�Statg eertified lab_ Test results�ust�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 ofHeahh. OUTDOOR COOHING: ' Outdoor cooking,prepazatioq or display of any food product by a retail or food service establishmeirt is prohibited. DATE: �v � SIGNATURE: �l�"`'�-C/�%'�'�� PRINT NAME&TITLE: U ,� r' �O/( L�.A� 09/28/OS f � —� Tke Cannwnwealth ofMassachusdts Deparf�rent ofiadrsdia/Accidentc �+ - N�aNil�s __ 60B Woshiag�vn Stirey �'Floor _ � Bostae,Mess. 011ll i. I'' � Worlcas'Compe�aatioe I�sva�ce A�d�vit B�fl " kelrical Co�dactars �,. �.. . =a�"�.-s *� ,. , �. . � . .. . ,.�„ro'�a"g P`"�'a_. i�t., . , � i �S C � �: ��_��n�e, ��' ci4v ( Q,[(✓Cc�- �,�/p(�� slm' �^3' zio• b�j��l �e# b '�7�y,"L,`�� v work site locatim(foll add�e�SsT. I wner perl'mning all wa�C myaelf. Project Type: ❑New Cmsa�ao�Ranadel �a sole and have no aee in . Addition ❑ I am ao m�PbY�P�'��B watkas'compeasati�f�my employces wo�cing a�t6is joh �' _— -- - — ---- - �z�s. �s. s�f- . or+.e/� g ❑ I mm a sole prop�iUor,gwa�al ee�trxtor,or homcewaer(arde owe)�d Lave Irinod the co�actas lis[ed bdow wlw Lave the folbwing wot�Cas'comPense4on Polices: c�ar r�e: � �: ohre�{- N �ar w� �• titt: oi�e/� � FaYve 10 aee.e svasje n ieyid oAv BaYu 2SA d1MGL l�oe kW M IYe h�p�itlw daW W pmMnKa ie y b Q3KM aMla e�e yan'�t a�wel n eM peWtla h Ne 6�r�af a STO?WORIC ORIISR ud�me Kf1M.N�dry apiat�a I ode�ud tYN• apy�IW��q he tuwu�AeA ee 10�Omee d I�N I�DIA Ar aw�v�ge wmntlw. !b henby ceia(jy r 'er dY� olD�Y Md Me luforareoabu provided ebnre 6 tar a�d osrr�et �� _ l� —n.� _�lr�,�[J b Printname U� / �d / PhoneN_.�J�O-�7�'�7'1y e�ddoseWy daeatw�keYtWurab6en�plMed9Ydl7arinros�id dty or ts�rn; P�F ^- __ p�t ❑eY[ek if ima�!ia�eeee h teq�ed �� 4dee�s's O�ae uelxt pvesa: �y� �"��t��, lM1.me s�mm� - TOWN OF YARMOUTH - BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-177 FEE: 150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a pemut is he�eby granted to: _ Julie Driscoll 600 Route 28 West Yarmout MA Whose place ofbusiness is: Cane Cvd Cakes Type of business: Food Service ! To operate a food establishment in: Town of Yarmouth Pemut eacpires: December 31,2006 soARD oF HEnLTH: !� i�$. �,iGJ,$,, • �s�, .�v., v�e�.� j p��a� � �0+��j� R.N. � May 18_2006 Bmce G. Murp H,RS.,CHO I Director of H I � i � I '� oF.YA��p TOWN OF YARMOUTH � � � y 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 026644451 N MFTTACHCES � �^+�„o,,,�o,�*�d' Telephone (508) 39&2231, Ext. 241 — Fax (50S) 760-3472 B O A R D O F H E A L T H �ia �. _ � � - � --J. To: All 2005 Yazmouth Board of Health License/Permit Holders q I� � 5 ��05�S f � , k.�ri ��€'-� . From: Yarmouth Health Department ' '�� Re: T�Identification Numbers Date: July 27, 2005 The Massachusetts Department of Revenue is now requiring that the Health Department fiunish to them detailed information regarding all permifs and licenses that we issue. One of the required detaiis is to provide a tax identification number, whether it be an establishment's Federal Employer ldentification Number (FEII� or, in the case of an individuaPs license, a Social Security Number (SSI�. This information will be used by the Health Department purely for administrative purposes only. Would you please fill ouY the fields below and return this letter to: Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 Thank you for your anticipated compliance. If you have any questions regazding this matter, please do not hesitate to ca11. The office hours are Monday to Friday, 8:30 a.m. to 4:30 p.m. The telephone number is(508) 398-2231, e�ct. 241. Establishmert: .�,(�g, l..[X 1 l-�L�� FEIN�r SSN: v�y 76 �I'a 6 __ Location Address: �� I�. �,� ��L/�0�/+"1 Signature: - 1 ��v� Print: U�'�. 'J��S�D�, Title: Q wl 'c-1 � Printed on Recyded :'��Z � Paper � � � ` C11��49 1� c� � � �� _ �� 3°Fs'p1� TOWN OF YARMOUTH BOARD � TH o��= APPI.ICATION FOR I�f3$�t5�E ; .'- j OS JAN 0 5 2005 • Please complete form and attach all n �ssary document's by Decem D E PT. Failure to do so will result in the�re'Cum of your applicarion packet. NAME OF ESTABLISHMENT: I TEL. # -7 /- y LOCATIONADDRESS� �O m)� �F� /��vSf G,iirr �h /}�f! aal7� MAII.ING ADDRESS: OWNER/CORPORATIONNAME: �UHY ! �SCo// MANAGER'S NAME: TEL #�a��/7as— MAILING ADDRESS: -fab U �o �� 9� i?,��s � rn� a�� POOL CERTIFICATIONS: TLe 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. Pooi operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary ResuscitaUon �CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service EstabGshments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years' records. You must provide new copies and maintain a fde at your establishment 1. 2. PERSON IN CHARGE: Each food estabGshment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIlbiL,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maiutain a file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQI)IltF.D FEE PERMIT# LICINSE REQiJIltHD FEE PERM[T# LICENSE REQiJIRF,D FEE PERMI1'# _B&B $50 _CABIN $50 _MOTEL S50 _INN $50 _CAMI' S50 _SWIIvII�fIN(3POOLS75ea _LODGE $50 _TRAII,ER PARK $50 WHQ2I.POOL S75ea. FOOD SERVICE: � � LICINSE REQiJIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQt71RED FEE PERMI1'# LO-100 SEATS S75 1�'05� y _CON1'INENTAL S30 _NON-PROFIT $25 >100 SEATS SI50 _COMMON VICT. $50 WHOLESALE S75 RETAIL SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICINSE REQIJIItED FEE PERMIT tl ISCENSE REQUIItED FEE PERMIT# _<SOsq.R $4S >25,OOOsq.ft. 5200 VENDINO-FOOD E20 _QS,OOOsq.ft. $75 _FROZENDESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ �' """'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•^ r ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any lice»se 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 Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN TI�COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTADEPARTME1dTFORINSPECTION7-10 DAYS PRIOR TO OPENING FOR THE SEASON. I ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONINIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTITONAL REGULATIONS POOLS POOL OPENING:All swinvning,wading and whirlpools which have been closed for the season must be inspected by the Health Departmeat 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 establishmem which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERING POLICY: Anyone w o caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior ta the catered event. Thses forms can be obtained at the Health Department. F1tOZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food prod ct by a retail or food service establishment is pro6ibited. DATE: SIGNATURE: lc-� PRINT NAME& TITLE: � i D 10/22/04 r _ � The Cowimonwealtk ojMassackusdts - __,� - _ - _ DepartMertt of Iadwshiul Accrdents _ — �1�//� _ = 60o woshu,gtoe sn,eeg f"'Ftoo. �,� Bo�,Mesc. 0211I � Wor�vs'Com�opdo�Leeaece A��vk: bi�g/Eketrieal Ca�tractors _ �, � _ ._ , ,, , _ . � , xr ;��' :� �: ��,�e C� C'a I�eS' �� r�� `�� a� �.��5� l,ll'um� �.. YY1� �o� o�T�, �� .77i 3yyy work sih locati�(foll addressk ❑ I a homeow�perfo�iog all wak mys�f. Project Type: ❑New Caoe�ucum❑Ranadel mm a sole aad have�me w in� B�ril ' pdditipn ❑ I am an employer providing warke.�s'conup�tian f�mY�PbY�W'��on tLis job. ��e: ■ddEss. ehv: . � eYr�e AF �� k.e1k.._._ ❑ I mm a sole propridoy�1 mtracMr,ot Yameow�e.r(cirde owe)and have ltirod ffie cwNcactas lis[ed below who have I the following wa3cas'compensation potices: o�uwe: � �' �e 6- nNcv N ��e: �• �b;_ g. Faiee i�aeene sverqe u nqhN odv SceYw 2SA dMGL 19 m Wd b Me ip�WY��fa4dW pedfe da ie�b f1„SN.M aW�r eee Ynn'��prYwat aa wd n cM pmltle 1�Oe br�Na 5f01 WOFK OBDER ad�6e d91M.M a dq a�et�e. 1 adenOW Wt• npy KUb�hlewt my be tsnurdN rn Ne Omee�Ie�eYipWw etlYe DIA RreN+erqe wNnW�. �la MArey rnfyy te.Ma pe�. �olre�j+Rr aia xu afo...aoA pravttar.eone 6 sve m�t a�ret � , � �� ( �Q Y Prim ISl6�� PLone# �C,1� -�77�- ��/U� .�d.�.x..ry a..r.Mle r tY..re,b ae nrplMed pr dlr.r rw.amrL� dty'�bwu: P�nW�ewe! ^- --• Ilepaumt ❑tYat Hi�b�eeqese b nqeN ��[BpN �eep� �,a O�ee nMact@vaea: �� d�� ln d9#mm1 , . . . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERI�IITNUMBER: #OS-134 FEE: $150.00 I°acc°rdance withre�u1ations Promulgaled imder authority of Chapter 94,Section 305A and Chapter i l l,Section 5 of the�'ieneral Laws,a peimit is hereby ganted to: Julie Driscoll 600 Route 28 West Yazmout MA Whose place ofbusiness is:_ Cane Cod Cakes Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth i Permit e�cpires: December 31_ 2005 BOA1zD oF HEAt,�rH: Bea�c$. (�'o�dory,�J„$, • ' P�� v:�ef�,,� ; Ro6e�t� B�e�,�� j �S!� R.N. I ��.td�.�,�y, R.N. I _ Febcuary 3_2�5 Bruce G.Murph , RS.,CHO I Director of Hea1Hi i . , ' L3C� C� GOM [� D = s'p o TOWN OF YARMOUTH BOARD QF Fj�ALT �,��;= APPLICATION FOR LICEI�i��(i�o��y JAN 2 2 2004 \ � �h. q, * Please complete form and attach all necessar}�cuRfnts by Decet3tber 1 �TH DEPT. Failure to do so will result in the return bf your application packet. S E . # - Z T N SS: � �. ADD (7 OWN R/ RPORAT N E: �U � i o/ MANAGER'S NAME: — TE # M�IILING ADDRESS: — i POOL CERTIFICATIONS: ! T6e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ' Pool Operator(s)and attach a copy of the certification to this form. i 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS• All food service establishments aze required to have at least one full-time employee who is certified as a Food I Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. iPlease attach copies of certification to this application. The Health Department will not use past years' records. i You must provide new copies and maintain a file at your establishment. 1.��1� ��o // 2. j PERSON IN CFLAR iEach food establishment must have at least one Person In Charge(PIC)on site during hours of opera6on. ; t. �� I i. ',�a// 2. iHEIMLICH CERTIFICATIONS: Ali 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 this form. The Health Department will not use past years' records. You must provide new copies and maiatain a£�le at your place of business. 1. 2. 3. 4, $ESTAURANT SEATING: TOTAL# OFFI wnc�xc: E USE �NLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $50 _CABIN $50 _MOTEL a50 _INN $50 _CAMP $50 _SWIMMING POOL$75ea. _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL S'75ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS S75 . �Q��(�� _CONTINENTAL $30 _NON-PROFIT �23 >I00 SEATS 5150 � _WMMON VICT, a50 _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20 _<25,000 sq.ft. $75 _FROZEN DESSERT $35 _TOBACCO $25 1VAME CHANG ; $(0 AMOUNT DUE _ $ J •� *""**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**•* ADMINISTRATION ,Utxier�haptef i52, Secuon 25C, Subsection 6,the Town of Yannouth is now required to hold 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 Compensarion 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 k�ixes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPItIATELY IF PAID: YES�� NO NOTICE:Perrnits run annually&om January 1 to December 31. IT IS YOUR RESPONSIBII.ITI'TO RETtJRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT T'HE HEALTH DEPAR'TMEN'T 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. Ai>DITIONAL REGULATIONS POOLS POOL OPEPIING: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 CONS iMFR ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post Consumer Advisories. CATERNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above tetms have been met. OUTSIDE C?�FF'S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),�.t have prior approval from the Board of Health. i � OtiTDOOR COOKING• ', Outdoor cooking,preparation,or display of any food product by a retail or food service establislunent is prohibited. DATE: I a d SIGNATURE: ^ ��lJ�-U�U-c�t PRINT NAME& TITLE: �)I�� iYc�/l 10/22/03 . � � The Commonwealrh ojMassachusetls � Department ajlndustrial.-lccidenu ; Omeeo�/ar�sa►yswis 600 Washington S�reet Bnston.Mass. 02111 " Workers' Compensation Insurance Atfidavit Anolicant informaHon: PleasePRIPTTel�'idt � nam� �� C .6LY ( U.f�p li�citinn: ��(i�i�-I"f'�/�^)YLY17� � . �� I lJ. �Pl rrra' ehone a �� '� am a h eowner pznorming all work myselE � I am a solz proprieror �r.� ha�e no one��orking in am capaein� � I am an employer pro�iding workers' compensation for my employees workine on this job. � +dArecs• Sjij�• ohone N• . . � insur�nce co oolity N � I am a sole proprietor. qeneral contractor. or homeowner(circle onel and ha�e hired the conttactors listed below ��ho tia�e thz follu�cin_ �corkzr ,ompensation polices: vn address• titr' ' o6one p• � - � � insur�nceco D��'� -adr • - titr� el�oee M: � . . insuraneeeo � �RnM � F�ilure m seeure covente as requirsd uoder Seeno�2SA of MGL 132 n�lad w the i�paitlw of cri�iW pndtle of�O�e�p to Sl¢00.00��d/or � oee yean'imprisonmeet u w�Nl a tiril ptadtln ia tAe form oh STOP WORK ORDER aW�If�e of SIOO.M�d�y q�iott me. 1 ndmh�d tLt t � eopy of thy eta�emm�m�y be fonvvded to�he ORiee o(levntia�tlom otthe DIA tx eeven�e vedlleatha 1 da�hrreby ctrti •under thr pains and pennl�i[s ol ptry'ury thN the injornu8on provid�d abovt isWe and eomet Signaturc � �� /� � _T ^ . Print name ��il° 1 1/��i)�� Phone K ��- �7�=6 3y� _ a oRcial use onh do not write in thia�rea ro be tompleted by eily or towe ollltial �� eity or rown• Y�M�DT$ _ .permiNieeex M nBuildin�Dep�rtmcet �Lietosio�Bo�rd i �check if immediatt respome ie«quired Z61 OSdeumen'e Offltt � (508} 396-2231 eat. �Hnim uep�nmeee , i vontaat person: phone M;_ , _ nOt6er � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #04-149 FEE: 150.00 In accordance with reRulations pr�ulgated under autharity of Chapter 94,Section 305A and Chap[er 11(,Section 5 of the�'ieneral Laws,a peimii is hereby granted to: Julie Driscoll, at Terra Cotta Restaurant, 518 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Cakes Type of business: Food Service � i To operate a food establishmem in: Town of Yazmouth � � Permit expires: December 31. 2004 soARD oF HEaI.TH: Be�sjr.�!«� �. �fo+�oK, M.`.?!. ; n�M�� v:� e��. ; a�r�. a� et� ; � s�., a.�v. i � i — February 10.2004 " Bruce G. Murphy,Iv3 H� S.,CHO Director of Health I I � i � I �