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Home My WebLink AboutApplicaitons, WC and Licenses . �.. � � �� TOWN OF YARMOUTH BOr1RD OF HEALT� � APPLICATION FOR LICENSE/PERNIIT- 0 '� y � � �'� � `� � * Please complete form and attach all necessary d ,. ��j �� p��008 Failure to do so will result in the return o p�licdt�on A�Th Q��-f. NAME OF ESTABLISHMENT: t, TEL. # � �-3��-�vGu LOCATION ADDRESS: .S' ��-,� a t, ��_ /�ra„�, So;.l'�, Vi�.,,.-,,, �l, va�Ic,� �,�j�Gy MAILING ADDRESS OWNER NAME: �,/a„n r_ ,9-v�3 TAX ID (FEIN or SSNI:� CORFORATION NAME (IF APPLIC�BLE): MANAGER'SNAME:��,�, ��/�-�n3 TEL. # MAILING ADDRESS:_j/,/ i�/v,..-. S% i,u�sT � e � v�'r� �� /�G � 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 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 ofexnployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manaeer, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l._ 'f�/� �>a-4!s 2. CYI,/).-.'r>c..u�ti. i��riie-✓c.� PERSON iN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. /{�/,�n �/�vl'3 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich 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 # OFFIGE USE ONLY LODGING: LICENSE REQUIRED FEE PERMI"1'# UCENSE RFQUIFtED FEE PERMff# LICENSE REQUIRED FEE PERM[T# _B&B S55 _CABIN S55 _MOIEL $55 _INN S55 _CAMP S55 _SVCIVIMINGPOOL 580ea. _LODGE S55 _TRAILERPARK 5105 _WHIRLPOOL S80ea. FOOD SERVICE: LICENSE REQLIIRED FEE PERMI'I# LICENSE REQUIRED FEE PERMI'I# LICENSE REQUIltED FEE PERMI'I# LO-100 SEArS SSS 'If"D — ��7 _CONTINENTAL S35 NON-PROFIT S30 _>700 SEATS SI60 I COMMON VIC. $60 �0 —O7d _WHOLESALE SSO RETAIL SERVICE: —RESID.KITCHEN 580 LICENSE REQUIRED FEE PERMIT£? LICENSE REQU[RED FEE PERMIT# LICENSE REQUIItED FEE PERMIT ik _<SOsq.&. �50 >25,OOOsq.R. 5225 _VENDING-FOOD S25 Q5,000 sq.ft. S80 LFROZEN DESSER'I S40 *!��'S� I'OBACCO S55 ��E cxA�cE: sio AMOIJNT DiTE _ $ l85. �� """*"PLEASE TUR\OVER A1�"D COD9PLETE 07'HER SIDE OF FORVI"*•* ADMIlVIS'IRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiJPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy 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 siac(6)momh period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Deparhnent to schedule the inspection five(5�days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and 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 CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered evetrt. 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 revocarion of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromthe Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQi1IItED FEE(S)BY DECEMBER 15, 2008. 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: /�- ��- U C/ SIGNATURE: ,s��'�—. �� ,� PRINT NAME&TITLE: ��✓�-i �- �-�/�3 - o�.,.,., .�� imzvos � Client#:46785 CCCRE ' ACORD,� CERTIFICATE OF LIABILITY INSURANCE 11/12/08D,�� PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis ONLY AND CONPERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: CNA/COfIL1fIBf1�8I Ca5U0I�1 COfilPBlly Cape Cod Creamery, LLC iNsuaea B: National Fire Insurence Co.of Hartf 5 Theater Colony Way South Yarmouth, MA 02664 INSIIRER C: INSURER D: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWI7HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRAC7 OR OTHER DOCUMENT WI7H RESPECT TO WHICH THIS CERTIFICATE MAY eE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. � POLICYEFFECTIVE POLICYEXPIRATION LTR NSR n'PE OF INSURANCE POLICV NUMBER DATE MMIDDM' UATE MM/DU LIMRS /� GENERAL LIABILITV B2077173822 ��J/0�/�$ OS/01/09 E4CH OCCURRENCE � S'I OOO OOO J( COMMERCIAL GENERAL LIABILITV P�M SES Ea occu an $SOO OOO CLAIMS MADE �OCCUR . � MED EXP(My one persm) $�Q QQQ PERSONALBADVINJURY $� OOOOOO GENERALAGGREGATE E�IOOOOOO GEN'LAGGREGATELIMITAPPLIESPER: . PRODUCTS-COMP/OPAGG $ZOOOOOO POLICV jEa LOC B AUTOMOBILELIABILITV SAP2095490286 OSIO�/OH OS/O'IIO9 COMBINEDSINGLELIMIT ANV AUTO (Ea accitlenl) a ALL OWNED AUTOS � BODILVINJURV $��OOO�OOO X SCHEDULE�AUTOS (Perperson) X HIREDAUTOS BODILVINJIIRV $��OOO�OOO X NON-OWNEDAUTOS (Peracdtlent) PROPERTYDAMAGE §��OOO�OOO (Per acciden�) GARAGELIABILITY AUTOONLY-EAACCIDENT $ ANVAUTO EAACC $ OTHERTHlW AUTOONLV: qGG $ B EXGESS/UMBRELLALIABILITY B2097307367 �rJ�0��0$ OS/01/09 EACHOGCIIRRENCE $� ��OQQQ X OCCUR �CIAIMS MADE AGGREGATE $'I OOO OOO $ DEOUCTIBLE $ X RETENTION $'IOOOO $ A WORKERSGOMPENSAiIONAND WC2077173819 OSIO�/OH OS/O�/O9 X WCSTATU- OTH- EMPLOYERS'LIABI�RY ANY PROPRIETOfLPARTNER/EXECUTIVE E.L EACH ACCIDENT $SOO�OOO OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EAEMPLOVEE ESOO�OOO If yes,tlescnbe untler SPECIALPROVISIONSbelow E.L.DISEASE-POLiCVLIMIT $SOO�OOO OTHER OESCRIPTION OF OPERATIONS/LOCAT10N5/VEHICLES/E%GLUSIONS AODE�BV ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SXOULD ANV OF THE ABOVE DESCRIBED POLIGIES BE CANCELLED BEFORE THE EXPIRATION Town of Yarmouth UATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �jL DAVS WRITfEN Health Dept NOTICE TO THE CERTFICATE HOLDER NAMED TO THE LEFf,BUT FAILIIRE TO DO 50 SHALL 1146 Rte 28 IMPOSE NO OBLIGATION OR LIABILITY OF ANV KIND UPON THE INSURER,ITS AGENTS OR South Yarmouth, MA 02664 REPRESENTAiNES. AUTHORIZED REPRESENTATIVE s ACORD 25(2001I08)1 of 2 #S40031/M36620 pp O ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGAT�ON IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S(2001I08) 2 of 2 #540031/M36620 � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-107 FEE: S85.00 In accordance a-ith regulations promulgated under authoriR�of Chapter 94, Section 30�A and Chaprer i l I,Section�of the General Laws,a permit is hereby granted to: Alan M. Davis, 5 Theatre Colony Lane, South Yarmouth, MA Whose place of business is: Cape Cod Creamery Type of business: Food Service To operate a food establishment in: Town of Yarmouth . Permit expires: December 31. 2009 BOARD OF HEALiH: ,�fee¢n S�alE, JZ.✓Y., C'l{aixrnan (.lfax�ea ,�. 9CeP�i/ie�r.�tce C'�aiauruuc *RESTRICrION: Fo�(4)seats. ./ZUBCIIlt 3.�M4lUfL� ��..,��1L llfl`✓Z..IY. \A/f.{r�1.�4 �/t{L�l O December 31.2008 Bruce G. Miuphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-070 FEE: 560.00 This is to Certify that Alan M. Davis d/b/a Caue Cod Creamerv 5 Theatre Colonv Lane, South Yarmouth MA IS HEREBY GRAN7ED A COMMON VICTUALLER'S LICENSE In said Town of Yannouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respectine the licensing of common victuallers. This Gcense is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersiened have hereunto affixed theu official signatures. BOARD OF HEALTH: 3Ee�r SRc►l£, `JZ.N., CPiavunan C'&a�eeea .f�. .9Ce�iRen `Uice C'flaixnuYn *RES7RICIIOI�i: Four(4)seats. f�y� �.�,�� e�q�{ �P�c�r:6cu�u�n, .%Z..N. December3l ?008 Bruce G. Murphy, M S., CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIr NUMBER: #09-006 FEE: 540.00 This is to Certify Ihat Alan M_Davis cUh/a('ane Cnd(�reamer; 5 Theatre Colony Lane, South Yarmouth, MA IS HEREBY GRANI ED A LICENSE FOR THE VIA\tiFACTtiRI�G OF FROZE\DESSERTS A_\D/OR ICE CREA.�i�IIX For the yeaz commencing with March first 2009 This License is subject to the Rules and Regulations of the Massachusetts Department of Public Health Relative to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regulations of the Board of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with the provisions of Section 65J said Chapter. BOARD OF HEALTH: ,�E¢f¢rt SP�aB., 9L.✓V, CFiAuxttuut *Regutation l05 CMR 561.009 requires eptq�Ce¢0 ,�. ,�P.�[�IPX., �"[C¢. �.QIXNtR/i montUl}�plate count and colifonu tests. ,I�q.�y!/l .�. �XO(IlIL� C�R![(� Q�'�f�t�fpt��,,KCC/t�liltlil� .�..lv. """'�" �. December 31.2008 Bruce . Murp ry,M , CFI6— Director of Health " - C'.C. CREX1ME7eY �°` """�s TOWN OF YARMOUTH BOARD OF H�ALT$ � � .,� � �A �� `� �o s APPLICATION FOR LICENSE/P'£1tMTl'-20U& � �-i � � r� , c� *Please complete form and attach all necessary documenfs'by ISec�� 31,2007. , Failure to do so will result in the retum of your application pac t. � "_ � NAME OF ESTABLISHMENT:� G,q-w,u TEL. ('/D LOCATION ADDRESS: �. ,s- � MAILING ADDRESS� /.�-w.� OWNER NAME: ,�„ '7�-,,,3 TAX ID (FFIN or Nl- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiTed 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 minimum of two employees currently certified in basic water safety, standard First Aid and Communiry Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You mast provide new� copies and maintain a tde 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 applieation. 'i'he Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. l. /d!/�i11 l./i'a-✓Y3 2. S/�w �G�.SS�'os ', PER�QNIN C�3ARGE: - - -_____-- - -- -- -- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �✓�. /.�/9�1/✓.S 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-chokuig procedures below and attach copies of empioyee 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. �/�9v� �.9�✓i� 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQU11tED FEE PER'�i]I ¢ LICENSE REQL'IRED FEE PER�IIT= LICErSE REQtiIRED FEE PER�t17= _B&B S50 _CABRv S50 _MOTEL � � S50 � _(NN S50 _CA.'�iP S50 _Slk'[�L�IING POOL S75ea. _LODGE S50 _TRAQ.ERPARK 5100 «7-IIRLPOOL S75ea. FOOD SERV/CE: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER\41T s LICE?i�SE REQti1RED FEE PER�StT= �0.t00 SEATS 575 �'O$-[� _CONTINENTAL S?0 _NON-PROF17 S2i _>100 SEATS 5150 1CO:bLbION VIC. S50 �1'O�O _N'FiOLESALE 575 RETAIL SERVICE: —RESID.KITCHEN S73 LICENSE REQUIItED FEE PERMIT= LICENSE REQL7RED FEE PERWT= LICENSE REQUIRED FEE PERMT r _<SOsq.ft. $45 _>25,OOOsq.ft. 5200 VENDING-FOOD S?0 _<25,000 sq.8. S75 LFROZEN DESSERT S35 �'l'J$^60S TOBACCO S50 va�cxnv�e: sio AMOUnTDUE _ $/60.00 •w*"'pLE9$E TLR_V O�'ER�\D CO\1PLETE OTHER SIDE OF FOR\f�*'"'* J � ADNIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or compaay 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 INSiJRANCE 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 of the limitations of Motel or Hotel use,Transient ocwpancy 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 principa(place ofresidence elsewheae. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s�(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. a 64G or 830 CMR 64G, as amended, shall generally be wnsidered Transient. * NOTE: Ea�iosea Motel Census must be completed and returned.�tt►tn�s aPptioatio,,. POOLS POOL OPENING:Ali swimming,wading and whirlpools which have been closed for the sea.son must be' ed by the Hea(th 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 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 CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Deparnnent by filing the required Temporary Food Service Application 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 until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval&om the Board ofHealth. OUTDOOR COOKING: Outdoar coafidmg;pceparation, or disptay of any food product by a retail or€ood serviee establishmenE is prohibite�. N01TCE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�vvIEEN'T, MOTEL OR POOL (i.e., PAIN'PING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMME?10EME?IT. RE�IOVATIONS MAY REQUIRE A SITE PLAN. DATE: �� I"7i� SIG�IATURE: ,(�� -i_ r/ ..�t � PRI:�IT:VAME&TITLE: �.a�.-. //�'I- 7.4-,A? �o t�-�+-�/ �o so nz r • � The Cominonwealth ofMassacausetts Departmeat of IndustriaJ Accidenu NfaN� 600 Woshiagton Street, 7`"Floor Boston,Masc. 02111 � Workeaa'Compeesatioe I�am�a�ee Affidavk:Baildiug/Plambieg/Ekctricil Coah'actors �4�atla: C)eue FRiKP le�lv nazne: address: siN � staM• zio� oh�.M# wark site location(fnll addressl: ❑ I am a homeowner perfoiming all woik myself. Pcojec[Type: ❑New Cm�mction QRemodel ❑ I am a sole proprietor and have no one wodcing in mry capacity. ❑B�ulding Addition ❑ I am an employer pmviding workecs'compensati�for my�ployees wodcing on fhis job. . . __ _.. __ ._. .. _ _ . comoav me• addreas- dls'- oYaee M- IasefKe ca. ooliev A � . . ' '--"_,,, . .. .. . .. ..��.. . .. „_ . . ... :. -; ,n �,,.� ��, � �` ❑ I am a sole proprietor,ge�eral eeetraetor,or iomeowea(drde ont)and have hired the con4acWis li�ed below who have the following wotkers'compen4ation polices: . ��m�r nas• . ad�pf: �' oY�elt- Iesea�ce e0. pp�y . . ��e' �' �' orre#• . . . _. . _ ._.... _. _---_ . . . _ _ . __._. - - -- -.. ___.__.. _— - --- - - -- - - ._ ir�e ea oaticv 8 r�ri�rlaiftl�lrw�Y< ' ...� ^.._._,_ Faive Y xt�e a�era<e n�eqd�M odv SMM�2SA NMGL 152 n�kad b tYe dpr�itlr�f a4�YY paaNin�fa Le�M S1,3N.M+�N�r�: °�Ynn'Wi��nt as we9 n dM pe�es in the f�r�af a STOT WORK ORDEA tad t 60e dS1M.M a dry api�et we. I mdnahW fW a upy K We ahte�t vy be farwarded M Ne Omce Kleve�tloti of IYe DIA far e�vmge vai6ntl�e. !Ao hereby cer�ify te.d�e�.,dse„�rn�o perjury tAat Bie infonueNoe providal above @ crve m�d canect �� .4 �, �� n ,,�- a i-d � p�� ... � �,� p��# sz� -as�- s�s3 e�d.�as owy a.nM.r.ite r tN,,.e.to ee carp�+M 6r�*r or rwu.mcw ekyor/ewv: P�� ❑�dmB�Pv�� ❑check iCf�me�!�apeme b re�drN ��6 Bmrd �dx�se�Y Omee �tlnMY Deprdvt mahct pe'aon: pYaae#; �Q tm�d s p.mm� �if�A CNA Plaza .. Chicego,lAirrolaH0685 STANDARD WORRERS COMPENSATION AND EMpLOYERS LIABILITY POLICY � INFORMATION PAGE - RENEWAL OF WC 2 77173819 P+��YHumbl� ,; F�r+; PoGr.X Reriatl T's�j Car�►�S t6Pt+�xlsla�Sy � 1 WC 2 77173819 � OS/O1/07 OS/01/08 I CONTINENTAL CASUALTY CO �Q03863120 �G'Yxle�ld hhd�Ir�s ; ' �L ITEM CAPE COD CREAMERY, LLC �� OGER5 & GRAY IDU^ , AGCY. , SNC -� � -- - 1. 5 Theater Colony Way 434 ROUTE 134 SOUTH YARMOUTH, MA P 0 BOX 1601 SOUTH DENNIS ;4A 02660 02664 FEIN NUMBER: NCCI CARRIER CODE '.i0: 10243 OTHER WORIC PLACES NOT SHOWN i�BOVE: SEE ATTACHED SCHEDULE (S) YOU ARE A - LIMITED LIABILITY COMPANY 2. POLICY PERIOD- OS/O1/07 TO OS/O1/08 12 :01 AM STANDARD TIME AT THE INSUREDS MAILING ADDRESS . 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS COMPENSATION LAW AND ANY UCCUPATZONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE: MA. 3B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED 2N ITEM 3A: THE LIMITS OF LIAPILITY ARE: RODILY INJURY By ACCIDEIdT $500,000 EACH ACCIIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $500,000 EACH FISpLO`fEE 3C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AK, ND, OH, WA, WV AND STATES DESIGNATED IN ITEM 3A OE THE INFORMATION PAGE. 3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULE^u: SEE ATTACHSD SCFdSDULES ------------------------- '---------------------------------- 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE: AT POLICY EXpIgATION CLASSIFICATION OF OPERATIONS EST ANNUAL SEE ATTACHED PR�IUM $1,900 PREMIUM DISCOUNT p EXPENSE CONSTANT Zg4 FOREIGN TERftORISM PREMIUM 38 MINIMIJM PREMIUM $264 TOTAL ESTIMATED ANNUAL 'PREMIUM $2,222 TOTAL STATE TAXES/ASSESSMENTSJSURCHARGES $80 �.. DEPOSST PREMItJM TOTAL ESTIMATED COST $2,302 � �� 52,222 ACCOUNT NUMgER: 3006581756 DATE OF ISSUE: 03/15/07 �,;;E,rq� � f` Ayy IN3UR./A/^,�CE GENCY�iNC. POLICY ISSUING OFFICE: NEW ENGLAND / J '/, �y� COUNTERSIGNED ��+¢__�/� i� DATE AUTHORIZED AGENT WC000001 P-•33398-E (ED. 6/87) 0 , TOWN OF YARMOUTH BOARD OF HEALTfI PERMIT TO APERATE A FOOD ESTABLISI�MENT PERMIT NUMBER: #08-113 FEE: 75.00 In accordance with regulations ptamulgated wder authority of C6apter 94,Secrion 305A and Chapter 111,Section 5 of the General Laws,a pennit is hereby granted to: Alan M. Davis, 5 Theatre Colony Lane, South Yarmouth, MA Whose place of business is: Cape Cod Creamery Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 3 l. 2008 BonRD oF HEALTH: .�fefe�c SRaR�, �.JV., C/iaixinan C,Rrtu�Lee .�.��efPi�e�C `�Jice C'�a'vanan 'RESTRICTION: Four(4)sea[s. �A8411t 3.��IOWIt� � . . � �/it� �..lv. � 7anuary 17.2008 Bmce G.Mucphy, .,CHO D'uector of Health THE,COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTT3 PERMIT NUMBER: #08-070 FEE: $50.00 Tlris is to Certify that Alan M. Dauis d/b/a Cane Cod Creamerv 5 Theatre Colony Lane, South Yarmouth, MA IS HEREBY GRANTED A COD�ION VICTUALLER'S LICENSE In said Town of Yarmouth and at that piace only and expires December thirty-fust 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .�Eefert SRtal�, J2.JV., C'F�ainmtut CR�ax�ea 3E,:ICePliPee,x,l `U,i,ce C'P�aixrnaa •RESTRICTION: Four(4)seats. ✓�O�lLE�. �KOIUfy� l.[¢YR . Qf't,t�fL,�'NAle¢It8(YU.Nt� JZ.,IV_ . �` January 17.2008 Bruce G.Murphy, , . .,CHO Dicector of Health , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER:#08-005 FEE: $35.00 111is is to Certify that Alan M navic d/h/a�yge('od('reamer; 5 Theatre Colony Lane,South Yarmouth,MA IS HEREBY GRANTED A LICENSE FOR THE MANUFACTURING'OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the yeaz commencing with March fust 2008 This License is subject to tlie Rules and Regularions of the Massachusetts Department of Public Health RelaUve to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and Regulations of the Boazd of Health granting this License, and to the pmvision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with the provisions of Section 65J said Chapter. BOARD OF HEALTH: .�EePe�t S�aIF., JZ..N., C'l�atvrnta�t "Regulation 105 CMR 561.009 requires �.�AX�¢o .�. `.r��,,} �,l,C¢ ��.�U[Xfttplt monthly plate count and coliform tesu. ✓�o�4![t�.�7!@U�ft� ll� . Q��f�t�f�L��„AfC¢ft�Qllflt, ✓�..lv. """"�T" January 17,2008 B ce . mp y, H, D'uector of Heakh , . , �-Fr214 2,'�os"e.c. c2�n,Fa.ti � ?°`s"o TOWN OF YARMOUTH BOARD OF HE.AI.� �� , APPLICATION FOR LICENSEIPEItMIT-2007 � ��n� o�� 2007 * Please complete form and attach all necessary documents by December , 0 Failure to do so will result in the return of your application packet. NAME OF ESTABLISffiVIENT: � TEL. #�'6dr 3 9X'-S�Y�D LOCATIONADDRESS:S ��,o,/vc �'�/�n !�,-�e� a �� G�lt- o�(.�Y' MAILING ADDRE S: OWNER NAME:�fl�,-. � ,9-✓i? TAX ID (FEIN or SS CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Poo!Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum 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. The Healt6 Department wiil not use past years' records. You must provide new copies and maintaiu 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 fiill-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establistunents, 105 CMR 540.000. Please attach copies of certification to this applicatioa The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment 1. �/�_I�,CYl�1.3 2. ,Si'�✓'u.- �Gt SCr"nt PERSON IIaI CI�ARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. ��i-�,� ��4-u�3 2. HEIlVII,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t'de at your place of business. 1. �1i9+'� �i$✓�3 2. 3. 4. RESTAURANT' SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQT.TIRED FEE PERMIT# _B�B S50 _CABIN $50 MOTEL $50 _INN $50 _CAMP $50 _SWIIoII�fII1G POOL$75ee. _LODGE $50 _'1'RAII,ERpARK $100 WHII2I,POOL $75ea FOOD SERV[CE: LICENSE REQUIRF,D FEE PF.RMI'C# LTCENSE REQIJIRF.,D FEE PF.RMII'# LICENSE REQiJIItED FEE PERMI'I# I 0.100 SEATS $75 �O��a"� _CON1'INENTAL $30 / NON-PROFIT $2S _>100 SEATS 5150 �COMMON VIC. S50 �J _WHOLESAI,E S�5 RETAII.SERVICE: —RESID.KTTCHEN $75 LICINSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _<50 sq.ft. S45 _>25,000 sq.ft. $200 VENDING-FOOD $20 . _Q5,000 sq.ft S75 �FROZEN DESSERT 535 0��1 TOBACCO E50 NAME CHANGE: S10 AMOUNT DUE _ $ /Go•00 •`•••PGEASE TURN OVER A1VD COMPLETE OTHER SIDE OF RORM'••^* 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 Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFI�IDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitazions 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 ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(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 collectio� of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(5�days pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a mont}ily basis by a State certified lab. Test results must be sent to the Heatth 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 waitedwaitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. N01TCE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATION5 TO ANY FOOD ESTABLISI-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��-��7- />C4 SIGNAI2JRE: ^�_��.� ��,,,,rs PRINT NAME&TTTLE: �N.v�.. /�I• r �A-r^S v iomiac �\ The Commonwcaltk ofMassachuset�s . Departmertr ojlndrstrialAccidentc �a� 600 R'os6iagtoe Stree; 7'"F[oor Boston,Masc. 02111 -- Works�s'ComRnsatioe I�sQa�ee ASd�vlt. ' b�JEleetrkal Co�hxton ,....� .- .. .. �....-. ;ff.�.._�:« , .�-�� .x�� - �r ,�,�Z„��- a' �� . » ,z. .v: name: address: � S1N 3181C: ZID: �G/R WOijC S12C�OC8II0�(�eddlC'SS} ❑ I am a homaowar perFo�ing all w�k myaelf. Projxt Type: ❑New Cma�ructim ORemodel I�a sole and have no aoe w in� B ' ' Addition � I am an�pbyer providing workas'compensatian for my�ployees wa�ciug on this job. �v�me: �I�P �DOC- c�'�y.�P��/ . . . Wi�as: � ` /Ilc, o v///ry�� f/J�1i"!Qi � . �: s6� ii,�,..��t. �►F-- �.: S�Y 3 g�-e-y�� .�j�n a �.. c�� 7�i73819 ❑ I am a sole pro�ictor,geaersl ewtrxter,or Lomeoverer(cude awe)a�Lave hired the co�cactas listed below wLo have tLe following w�kes'compensazion polioes: tldt� cLLve ehre M: � M ae�v r�c ad8rao: � �r: o1i.�e/: � _ _ .__—_.. ._.__. _- . 8 Faive Os+xee osenye n�eq�4d udv SuNN 2SA d MC.L LSS w kW M tlie IspNIM daLiW p�We d a de�0�51.3�LM aW�r e�e 7en+'IsPtYa�t n wd n dM pwltln h t�e f�Ka 37'Ot WORIC OBDSR aed a�af S1M.N�day apieN� I adnehW 1YN a apy N1iY Maa.wt my he�va�d�d M We Omro dL�r sttYe DIA M eaerqe ver�ntlx. l b 6enby certJy rnler NYe pdnx ad peea(Bes oJperJrry bl�u[is iwfensedon ssevidel a6eve k dxe iw�cenect Sig��to¢ Date Print neme Phoce p e�lmemly deutw�keYth6amN6ear�NdbYdl7xWwn�1 dlyarfawn: pvmklYome• 1-lmiJurlkpu�mt �� ❑ehat Hi�tB�le�e�eae 6 re9ahed �'s O�ce ❑NnMb Oept�nt meMt Pe+aon: Phae g; OqYv c.�.a sri mm� '�i�A CNA Raze . . . Chrca9°��Nuwre60685 STANDARD WORKERS COMPETISATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - RENEWAL OF WC 2 77173819 P41tc�r tlut+�` �� Z3(:Fer�atl ?'s� � �is Praivided 8y : /�6en�Y WC 2 77173819 OS/O1/06 OS/O1/07 CONTINENTAL CASUALTY CO ��003863120 t1'fdlflad�r�r�hAd A�a6 ' qgc� ITEM CAPE� COD CREAMERY, LLC OGERS & GRAY�� INS . AGCY. , INC � � 1 . 5 Theater Colony Way 434 ROUTE 134 � SOUTH YARMOUTH, MA P 0 BOX 1601 OUTH DII�NIS MA 02660 02664 � FEIN NUMBER: NCCI CARRIER CODE N0: 10243 OTHER WORK PLACES NOT SHOWN ABOVE: SEE ATTACHED SCAEDULE(SJ YOU ARE A - LIMITED LIABILITY COMPANY 2 . POLICY PERIOD- OS/O1/06 TO OS/01/07 12 :01 AM STANDARD TIME AT THE INSUREDS MAILING ADDRESS. . � 3A. PART-ONE� OF THIS POLICY APPLIES TO THE WORKERS COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE: MA. � 3B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: THE LIMITS OF LIABILITY ARE: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT � BODILY INJURY BY DISEASE $500,000 POLICY LIMIT � B6DILY INJSTRY BY DISEASE $500,000 EACH EMPLOYEE 3C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AK, ND, OH, WA, WV AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE. � . 3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES : SEE ATTACHED SCHEDULES -------------------------------------------------------------------------------- � 4. .TAE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES, . CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS � SIIBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE: AT POLICY EXPIRATION � CLASSIFICATION OF OPERATIONS � EST ANNUAL � PREMIUM SEE ATTACHED $1,900 . PREMIUM DISCOUNT 0 EXPENSE CONSTANT 284 FOREIGN TERRORISM PREMIUM 38 � MINIM[7M PRII2IUM $264 TOTAL ESTIMFITED ANNUAL PREMIUM $2,222 � . TOTAL STATE TAXES/ASSESSMENTS/SURCHARGES $84 = TOTAL ESTIMATED COST $2,306 � DEPOSIT PREMIUM $2,222 S s ACCOUNT NUMBER: 3006581756 .''�"US�ERS dc � iNSUR CS GENCY� iNC. � DATE OF ISSUE: 03/13/06 � = POLICY ISSUING OFFICE: NEW LAND $y= � COUNTERSIGNED .��OG� gy , � DATE AUTHORIZED AGENT � � WC000001 P-33398-E (ED. 6/87) � � l,a,,,,r,��./ �L'F" ciw�an.m.o 'I INSURED TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISffi1�NT PERMIT NLTMBER: #07-129 FEE: $75.00 In accordance with regulations prqmulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the General Laws,a peimit is hereby granted to: Alan M Davis 5 Theatre Colony Lane South Yarmouth, MA Whose piace of business is: Cape Cod Creamerv Type of business: Food Service To operate a food establislunent in: Town of Yarmouth Pernut expires: December 31. 2007 BonRD oF HEALTH: B `�. �o�r, �1•$•, ' dk�Sk�k. R.�., v�e�� *RESTRICTION: Four(4)seats. �� A��j� R.N. March 30.2007 iuce G. Murphy, RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #07-085 FEE: $50.00 This is to Certify that Alan M. Davis d/b/a Cape Cod Creamerv 5 Theatre Colony Lane, South Yarmouth, MA IS HEREBY GRAN7'ED A COMMON VICTUALLER'S LICENSE In said Town of Yazmoutli and at that piace only and expires Decexnber thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common nctuallers. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereo� the undersigned have hereunto affiaced their officiai signatures. BOARD OF HEALTH: B $. GiHdo�, �l/.`�., . �� .�`st�, ltrv., v;�e� gRESTRICTION: Four(4)�ats. RodeJtt�. B�io[ws, � P��t9�# �� R.n�. March 30 2007 Bruce G. Miuphy, S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NIJMBER:#07-008 FEE: 35.00 This is to Certify that Alan M.Davis d/bla Caue('.ocl rreamer; 5 Theaire Colony Lane,Soirth Yarmouth,MA IS IIEI2EBY GRAN'I'ED A LICENSE FOR THE MANUFACI'URING`OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with March first 2007 T7�is License is subject to the Rules and Regulations of the MassachusettsDeu artment of Public Health Relative to the Manufacturing of FROZEN DESSERTS and ICE CREAM MIX,to the l�ules and Regulations of the Board of Healthgranting tlus License,and to the provision of the General Laws Chapter 94 as au�dadby Chapt�373 oftbe Acts of 1934,and may be revoked or suspended in accordance with the provisions of Section 65J said Chapter. BOARD OF HEALTH: B ' ' $. M.$., ' *Regulation 105 CMR 561.009 requires ��ta�s, ./V., ice e� monflily plate count and coliform tests. Robs?t�. BRoaws, �e3� P�io�Mc9,e+uru,tt A.�.��j� R.M. March 30_2007 Bruce .Murp , H , H Director of Health t� C.C , C2EAMERTf . °`�Ryo TOWN OF YARMOUTH BOARD OF HE.� ,�/ 3�� APPLICATION FOR LICENSE/P�R��1�I�1'�,- �006��p r�'� * Please compiete form and attach all �ecessary docu�n�s�by Dec,�'em` ber�}��0�5� Z�05 Failwe to do so wiil resuk in the retum df yow application packet. NAME OF ESTABLISHIvIENT: � � G�. �`,�G,v.,,,,t,-� TEL. # S"L 1t - 39�-$Y Ub LOCATION ADDRESS: � -1�,�� r�.,� �-,��. „ �,q,, ,,r, yv�w d MAILING ADDRESS: C�,,,,� OWNER NAME: �//#�, ivl. i7 fhi��3 TAX ID(FEIN or SSI�� - CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pooi supervisor must be certified ae a Pool Operator,as required by State law. Please list the designated - Pool Op�rateF(s)azic}attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currendy certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. 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 must provide new copies and maintain a t"ile at your establis6ment. 1. S/}�a. ,�RSS�'uS 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2. 1 HEIll�,ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimtich Maneuver on the premises at all times. Please Gst your employees trained in anti-choking procedures below and atfaeti eopies of employee certifications to this form. The Health Department wilt not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. �/� /�.9+�'t 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODCWG: LICENSE REQUIl2ED FEE PERMIT# ISCENSE REQi7IRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# BBcB $50 _CABIN $50 _MOTEL $50 _INN S50 CAMP $50 _SWA�IIvfING POOL S75ea. _LODGE $50 TRAII,ER PARK S50 WI-IIRI,POOL $75ea. ROOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT N LICENSE REQUIl2ED FEE PERMPP# 10-]OOSEATS $75 �IZiZ CON1"INEN1'AL S30 _NON-PROFIT $25 >IOOSEATS $1S0 I COMMONVIC. $50 O� G�( _WHOLESALE $75 RETA[L SERVICE: LICENSE REQiJIItED FEE PERMIT# LICENSE REQiJIItED FEE PF.RMI1'N LICENSE REQUII2F.D FEE PERM11'# _60sq.ft. $45 � _>25,OOOsq.ft. $200 VE,NDING-FOOD $20 _Q5,000 sq.ft. $75 LFROZEN DESSERT $35 �S TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ /�e O. O O "•"""pLEASE TURIY OVER AND COMPLETE OTHER SmE 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 CeRificate of Worker's Compensatioa Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLEI'ED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemvts. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN TF�COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2005. SEASONAL ESTABLISHIVIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEIVING FOR TIIE 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 COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. POOL 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 establistunent 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 Heakh 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: Frozent#esserts mxs�be tested oir a moathly basis by a-State cert��ieck�ab. Test resuks mcest be sen�to the�Iealt6 Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishme�is prohibited. DATE:� � •�,�- d S� SIGNATURE: �� yj-� �_,.,,,�;� � PRINT NAME&TITLE: ��✓�,-, �A7n3 /�w.�e� 09/28/OS 1 CNA CNA� Chicago,Illinois80685 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE - NEW POLICY Fol�y NWqbe►'; ��rom P��Y�pd To � ; C�'a�9�P�rJvit�tad Fly �I Ag�y WC 2 77173819 OS/O1/OS O5/O1/06 CONTINENTAL CASUALTY CO 003863120 ` _N�If1�41T1s1�AkfEl�tidA4(1SAfE'SS .. :�,.Ay.g� ITEM CAPE �COD CREIiMERY, LLC � � OGERS� E GRAY �INS . AGCY. , INC-� �� - �� 1 . 5 THEATER COLONY WAY 434 ROUTE 134 SOUTH YARMOUTH, MA P 0 BOX 1601 OUTH DENNIS MA 02660 02664 FEIN NUMBER: NCCI CARRIER CODE N0: 10243 OTHER WORK PLACES NOT SHOWN ABOVE: SEE ATTACHED SCHEDULE(S) YOU ARE A - CORPORATION/S 2 . POLICY PERIOD- OS/O1/05 TO OS/O1/06 12 :01 AM STANDARD TIME AT THE INSUREDS MAILING ADDRESS. 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE: MA. 3B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: THE LIMITS �OF LIABILITY ARE: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE 3C. PART THREE OF TI-IIS POLICY APPLIES TO OTHER STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AR, ND, OH, WA, WV AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE. 3D. TH25 POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES : SEE ATTACHED SCHEDULES ------------------------------------'--------------------------------------'-- 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS � SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE: AT POLICY EXPIRATION � CLASSIFICATION OF OPERATIONS EST ANNUAL N SEE ATTACHED FREMIUM $1,604 � PREMIUM DISCOUNT 0 EXPENSE CONSTANT 264 TERRORISM RIS% INSURANCE ACT PREMIUM 38 MINIMUM PREMIUM $228 TOTAL ESTIMATED ANNUAL PREMIUM $1,906 TOTAL STATE TAXES/ASSESSMINTS/SURCHARGES $79 � TOTAL ESTIMATED COST $1,985 � DEPOSIT PREMIUM $1,906 � = ACCOUNT NUMBER: 0000335171 ` � DATE OF ISSUE: 04/12/OS t';.�"y"LSQ�Pd`jiElSUYa"C2�gL'��j•��„' � POLICY ISSUING OFFIC : N W �NGLAND r��J Yf tr�� C COUNTERSIGNED '� BY�3, f xa�,,.�� i�v„-,-�a=-y = DATE ..a_;..�K{3'f'H'0R'IZE�p-`-}CG'EtST c = WC000001 P-33398-E (ED. 6/87 ) l,a.,,�r'�{ 0'��.� aei.�,mx.eo a "I Age�Y t�[era4�ls l�v�ded 69 ' g�ytfUf�iper � p�� o :'�: . �003863120 WC 2 77173819 � OS/O1/05 OS/O1/06 � CONTINENTAL CASUALTY CO ��e�t ._ �(pEd Iil�I![�KF�� ' � �pGERS &��GRAY INS . AGCY . , INC �-�CAPE COD CREAMERY� LLC 434 ROUTE 134 5 THEATER COLONY W11Y p p BOX 1601 � p2660 SOUTH YARMOUTH, � OUTH DENNIS 02664 �. SCHEDULE ** NAME A N D A D D R E S S S C H E D U L E pAGE 1 ENTITY NAME AND ADDRESS LOCATION ENTITY 001 001 CAPE COD CREAMERY � LLC FEIN=000887333 5 THEATER COLONY �02664 SOUTH YARMOUTH S � � 8 � � _ � - � � DATE OF ISSUE: 04/12/OS � POLICY ISSUING OFFICE: NEW INGLAND � WC000001 P-33396-E (ED• 6�8�� s � INSURED , INFORMATION PAGE — NEW POLICY Ac�&yl�umber rmm p,�t�yr;Peel4d ?o � , t�er8ge Is PraVl€1eC[�!y I; Agenc� WC 2 77173819 I OS/O1/OS OS/O1/06 CONTINENTAL CASUALTY CO � 003863120 �.�IMIEd I1i31u�dlVftt[A}�@#y ::AyEl�t CAPE �COD CREAMERY, LLC �� OGERS�� & GRAY �-INS . AGCY. , INC�� 5 THEATER COLONY WAY 434 ROUTE 134 SOUTH YARMOUTH, MA P O BOX 1601 SOUTH DENNIS MA 02660 02664 ** E N D O R S E M E N T S C H E D U L E ** SCHEDULE PAGE 1 NUMBER DESCRIPTION EDITION DATE G15388C20 MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT 07/99 G35224B COVERAGE B — INCREASED LIMIT OF LIABILITY 03/84 WCOOOOOOA COVERAGE PART 04/92 WC000112 NOTICE OF PENDING LAW CHANGE TO TRIA OF 2002 09/04 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMINT 07/90 WC000420 TERRORISM RISR INSURANCE ACT ENDORSEMENT 12/02 WC200301 MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT 04/64 WC200302 MASSACHUSETTS — ASSESSMENT CHARGE OS/86 WC200401 MASSACHUSETTS PENDING PREMIUM CHANGE INDORSEMENT 11/90 WC200405 MASSACHUSETTS PREMIUM DUE DATE IIdDORSEMENT 06/O1 WC200601 MASSACHUSETTS CANCELATION ENDORSEMENT 06/92 PLEASE READ THE ENCLOSED IMPORTANT NOTICES CONCERNING YOUR POLICY G140370B CNA PRIVACY NOTICE FOR WC POLICYHOLDERS 02/OS � G145759A IMP INFO DOMESTIC TERRORISM, EQ & CAT 10/04 � � � � � � - DATE OF ISSUE: 04/12/OS = POLICY ISSUING OFFICE: NEW ENGLAND = WC000001 P-33398—E (ED. 6/87) INSURED , INFORMATION PAGE - NEW POLICY Pa�IiFY Nu�nbel' Fr«n P�ttc�y Pet94d To CGvrtra�F{3 Pmad#!e�By , R�'ktGY WC 2 77173819 � OS/O1/OS OS/O1/06 � CONTINENTAL CASUALTY CO ��003863120 . �Q�Ii�1i13Wed1VEldAi��298 - r,. � �. CAPE COD CREAMERY, LLC OGERS & GRAY -INS . AGCY. , INC � � � 5 THEATER COLONY WAY 434 ROUTE 134 . SOUTH YARMOUTH, MA P O BOX 1601 SOUTH DENNIS MA 02660 02664 '* S C H E D U L E 0 F O P E R A T 2 0 N S ** SCHEDULE STATE: MASSACHUSETTS PAGE 1 4 . LOC CLASS CLASSIFICATION OF OPERATIONS EST TOTAL RATE PER EST ANNUAL N0. CODE ANN REMUN $100 REMCTN PREMIUM 001 8017 STORE: RETAIL NOC 125,000 1 .31 1,638 SUBTOTAL FOR LOCATION 001 $1,638 9807 EMpLOYERS LIABILITY INCREASED LIMITS .0100 16 9848 INC. LIM. BALApCE TO MINIMiJM PREMIUM 34 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 1,688 9885 MERIT RATING MOD. , EFF OS/O1/O5, USING FACTOR .0500 84- TOTAL ESTIMATED STANDARD PREMIUM $1,604 0900 EXPENSE CONSTANT NCCI REVISED PROGRAM 264 9740 TERRORISM RISK INSURANCE ACT PREMIUM 125,000 .0300 38 TOTAL ESTIMl1TED PREFIIUM $1,906 0988 MASSACHUSETTS ASSESSMENT � 79 TOTAL ESTIMATED COST $1,985 � � '�"*** POLICY TOTALS ***** � ESTIMATED CLASS PREMIUM $1,638 ESTIMATED STANDARD PREMIUM $1,604 PREMIUM DISCOUNT $0 � � EXPENSE CONSTANT � $264 TERRORISM RISK INSURANCE ACT PREMIIIM $38 g ESTIMATED PREMIUM $1,906 STATE TAXES/ASSESSMENTS/SURCHARGES $�y _ ESTIMATED COST $1,985 � = = DATE OF ISSUE: 04/12/OS- _ POLICY ISSUING OFFICE: NEW INGLAND = WC000001 P-33398-E (ED. 6/87) INSURED r TOWN OF YARMOiJTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #06-122 FEE: 75.00 .� In accordance with reg�ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Ueneral Laws,a peimit is hereby ganted to: Alan M. Davis, 5 Theatre Colony Lane, South Yazmouth, MA Whose place of business is: Cape Cod Creamerv Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2006 BOARD OF HEALTH: ,6 ic�5 M.9l. ' ��"`st.� .%, v� e��. •RESIRICTION: Four(4)seats. Qode��. Bdou�, � P��i1� �4.�.� �� R.N. J�U�s i.zoo6 � ruce G.Murp , H,RS.,CHO Director of Heakh THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-081 FEE: $50.00 This is to Certify that Alan M. Davis d/b/a Cane Cod Creamerv 5 Theatre Colony Lane, South Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2006 uniess sooner suspended or revoked for violat�on of the laws of the Commonwealth respecting the licensing of common victuallers. This Gcense is issued in confomuty with the authority granted to the licensing authoriries by General L,aws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: B $. � �$., ' dfe��Sk�li, ./K, ?/ice G��i�iw�C *RESTRICTION: Four(4)seats. /�ode3t 4.BRotwg � P��fa�� .�br�� R. . Januarv31.2006 Bruce G. Murp , H,RS.,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #06-008 FEE: $35.00 This is to Certify that Alan M Davic d/h/a('aT('nrl ('reamerv 5 Theatre Colony Lane,South Yarmouth,MA IS HEREBY GRANTED A LICENSE FOR THE MANUFACi'URING'OF FROZEN DESSERTS ANDlOR ICE CREAM MII� For the year commencing with March first 2006 This License is subject to the Rules and Regulations of the Massachusetts Deparl�nent of Public Aealth Relative to the Manufactw�ng of FROZEN DESSERTS and ICE CREAM MA,to the R�iles and Regulations of the Board of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with the provisions of Sechion 65J sa�d Chapter. BOARD OF HEALTH: B $. M.$., ' *Regulation 105 CMK 561.009 requires a�44��Ii�'.�iy��lce e�.l�l� monthly plate count and coliform tests. Rode3t 4. Bhoiiat� � A�:k Ma��«�tt A.r.i Cj�ree�td�t�, R✓V. January 31.2006 iuce G. �P Y, � Director of Heai , � , • �lo�b� �) � _ 2�7�770 , ?��s R� TOWN OF YARMOUTH BOARD OF�'AL 0� o�y APPLICATION FOR LICENSE/P `200'5--.— r a A,,,a `�1�T-� � � I o� * Please complete form and attach all necessa jr�flo , s'by Dece ber 2p04. f Failure to do so will result in the return o��+o�`p�plication p ke�kY U 9 2005 NAME OF ESTABLISHMENT: � C - - Op LOCATION ADDRESS: � -7/n�✓�l.i e ��e�� /w-.� MAILING ADDRESS: c,a-,..,� OWNER/CORPORATION NAME: �/A,,, �,4� 3 MANAGER'S NAME: TEL. # Sr- " a3 MAILING ADDRESS� /� / ' f lv:.. � �✓ . 2 �S �c Llil� r�A �a/a k v POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation �CPR). Piease list these employees below and attach copies of employee certifications to this foim. The Health Department will not use past yesrs' records. You must provide new copies and maintain a t'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 certiSed as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Departmeut will uot use past years' records. You must provide new copies and maintain a t'de at your establishment. i. (,�/,II-�� -Iv Z.��P�iRi�� s�mc,�s �,�.�o vr ��i�A PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. l. �I/-�,� I/��? 2. /��n sa� �r/i� HEIMLICH CERTIk'ICATIONS: All food service establishments with 25 seats or more must have at least one employe� e trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Tde at your place of business. 1. �/-l;v� '�lF1'v�3 2. (J��n��Q / >�)a� 3.r� P,.� c" S �w,Q��P s 4. �'�..��:��,5<�S RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICINSE REQiJIItED FEE PERMIT# LICINSE REQUIItED FEE PERMIT# _B&B $50 CABIN $50 _MOTII. $50 _INN S50 CAMP S50 SWIIvIIvIIIQGPOOLS75ea. LODGE $50 T'RAII,ER PARK $50 WIIIRI,POOL $75ea. FOOD SERVlCE: � . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERM[1'# LICENSE REQUIIZED FEE PF.,RMIT k ✓-100 SEATS $95 ��r!$O CONI7NENTAL $30 NON-PROFiT $25 _>100 SEATS $150 �OMMON VICT. S50 S�IIO _WHOLESALE $75 RETAIL SERV[CE: LICENSE REQUIl2ID FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICINSE REQiTIl2F..D FEE PERM[T# _<50 sq.ft. $45 >25,000 sq.ft. S200 VINDING-FOOD $20 _QS,OOOsq.ft. $75 '/FROZENDESSERT $35 �d5-OL� _TOBACCO S25 NAME CHANGE: S10 AMOUNT DUE _ $ „••"pLEASE TURN OVER AIYD 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 Cenificate of Worker's Compensation Inswance. 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 pemtits. PLEASE CHECK APPROPRIATELY IF PAID: YES '� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISfIMENT5 ARE TO CONTACT THE HEALTHDEPARTMENTFOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIl�1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COl�Ilv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTI'IONAL REGULATIONS POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to 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 estabGshment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by 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. Failwe to do so will result in the suspension or revocation of your Frozen Dessert Pernrit 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 product by a retail or food service establishment is prohibited. DATE: 5�f ro/o5'^ SIGNATURE:�/� �iL �r PRINT NAME& TITLE:�,�., ylii / >,9v;S l� l.�,�-e� 10/22/04 —� T/re Commonwealth o Massachus�s � � � nepmt�,a,:ofredw�Acddei,tc �� -= 600 R'askiagmn Stree� f"'F/oor ` ,,. Bostae,Mass. 02111 � Worlcers'Com�aho�I�sva�ce Affid�vik Bo7 ' leelneal Co�tractors ,�..<.- . ....... �,., . _ „ � , - . ., ....> , . .., .. �. <.-..�. t� "�s:,,r _ ��: »k:�,g"?�� .*��n, f�.; . w..,. ,t...�,..� .�.:;e � �: ,�l.4,., rh `�,a,3 � �: / a/ �/��.. s T citv ijv� /`7/1c7.�5{vX��e. �m {7/( w. �`��n��/ ohaoe M <2�Y 7� !J ��G3 work sih locati�(foll addressl: � ❑ I am a homoowner yerfonning all wa�1c myself. Project Type: ❑New Cma�ruaiao�Rwnadel I mm a sole 'dor aod have��w in any B�ril ' Addition � . ._ . . ,: . . . ❑�I�an emPloyer providing wakas'wmpeasatian far mY�P�Y�wo�cio8 on t6is job. . . C. � 3�'Cq• � '71�1 C/�Y-✓l C /J/d✓1 (�'�i�^ 9�. �1,: . s,,. U�., ,,..,,�k. //�w ..�s- �-v 4 � 7�0 0 -�ao3 �i 11/ f}' ,�O l 7 :,Z ❑ I am a sole propridor,gwenl eo�trxtor,or 4ome•woer(rnclt owt)�d Lave haed the conhac Wrs listed be(ow wlw have the following worke�s'comPemsation Polices: �[�• �Gres� �' oiur 6 N �r x�e: �s' dSf• p. Fa�el�+aae cvreade n�eqWaA odQ Sed�2SA NMGL l52 en kW b Ne h4dIW�f ea1�Yd psdlb da Oa�p b f1.3MM aWa �YpR'dP�a�a wd as dN pmitln h tYe 6ra eta 31'Or WORK OADBH atl a eae dS1M.N�my a�t�e. 1 odenhW tW a app�Hb Mai�eet my 4 hrwaM[d b t0e Omoe o[LvatlhW�e NIYe DIA Rrpver�ge wNpW�. I do 6a�say md�jy/.,n,�le.µsveiwa.wt pen.rua ofperj..y tMd ue i�fer.rlon p.oviaat.eove 6 ewe a�a c.rmt s;gaazom /-LC-r ��-. ��..r— p� S-- /O- D� P�D� �� - �� 3 P6oM# S7�k-`394- 4 �/oo .�cW�seea�y M.xw.uert�areab6en�aplbedbyd(yerywn.�Ll dly ar fewA: �� r-._ _._ �� ❑ehetk iff�g�pssae b r�yabad �� '�O�ce t�.+'soa s��moo�� p�e 8; ��t .�, . CNA NEW BUSINESS ACCOUNT PACKAGE POLICY �2�� '��'��s` :� - SPECIAL FORM _.._ �_; . _"l.1 ✓.� � ,: �Pe Cod Creamery. L�' OS/Ol/200��/Ol/2006' 5 Theater Colony Way . � � SOIITH yARMpp� �p Oa664 ;: ,:, . � " �Jlk'� -...:<�>� .,. : ;_. 003863120 ROGERS � GRAY INS_ AGCY'�.. INC��`� -- �� ::- '�... .. 43q ROQTE 134 Continental Casualty Company �� P O BO% 1601 CNA Plaza SOUTH pg�=g �p py660 �icago, Illinois 60685 TI'iis Aolicy becomes effective �g � addres's on the dates show� ��e �lres at 1a=01 A.M. standard time at � your mailing The Named Insured is a Li.mited Liability Corp, Y�ur policy is composed of t1�i8 Declarations, with the attached C Coverage Forms, and g3dorsements, if any. The Poli shows all forms a �on Policy Conditions, pplicable to this poli � FO�B �d �dorsement Schedule �Y at the tiee of policy issuaxyce. - The Policy Premium is . . $3,019.00 Total Policy C1�arqea Terrori� Riak Insurance Act $3.019.00 ��1� 510.00 For your loc�tions in the states of IL, yA� N,7� �y �yd Og Terrorism Sndorsement G-144225-A and Terrori� policyholder Notice G-144233-g applies: in all other states � DC, Terrorism Endors��t G-144234-8 applies Cn return for the payment of the � :ontained herein, we aqree to Br�l�' and �Ject to all the te Provide the insnra�ce as stated. �s �d conditions `hi$ section st�8rizes the itycluded limits aad coverages on IISIl1g8g L�g�y� Your policy. . . iability and Medical � L�ts of• $�� edical Penses Expenses (per Person) � ire Legal Liability (p�y pne Fire or $Z.�00,000 -oducts/Coy�pleted pperations p� �losion) $10,000 aneral Aggiegate (Other ggregate $100,000 Than Products/ 52,000,000 ��pleted pper8tions) �. red and Non-Owned Auto Liabilit $2.000,000 Y i8ach occuxrence) ��5 1,000,000 =h Incident L�tB Ot Iaeuraaca Jregate $1,000,000 zined Limit $10,000 51,000,000 �rella Coverage does not apply to Hired Aato Physical Damaqe Coverage � � - TOWN OF YARMOUTH BOARD OF HEALTH PERMTI'TO OPERATE A FOOD ESTABLISHMENT PERMIT NLJMBER: #OS-180 FEE: $75.00 In accordance with re�(ations pmmulgated under authoriry of Chapter 94,Section 305A and Chapter I 11,Section S of the�ieneral Laws,a peiinit is hereby granted to: _ Alan Davis 5 Theatre Colony Lane South Yarmou MA Whose place ofbusiness is: Cape Cod Creamerv Type ofbusiness: Food Service To operate a food establishment in: Town of Yazmouth Permit expires: December 31. 2005 aoARD oF HEALTH: Bea�xiuc$. (�'mtd,o�ry/��y, • P�� v:�ef� *RESTRICTION: Four(4)seats. Ro��s. B3orwa, � � � R.N. ��i� R.N. �y i i.ioos Bruce G. Murphy,l I� S.,CHO Director of Health THE COMAZONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-110 FEE: 50.00 This is to Certify that Alan Davis d/b/a Caue Cod Creamerv _ 5 Theatre Colonv Lane South Yazmou MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2005 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornvty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo� the undersigned have hereunto affuced their official signatures. BOARD OF HEALTH: Borc�si�c$. (�'med�ws,M.`.b. ' /��.�iid�Ma`.�5e�rrol�, ?/ice��cin�x��c *RESTRICTION: Fout(4)seats. /jp/�G� B�y� � d�.� Sl� R.N. �4.�l�'�d�,,, R./K Ntay i i.2oos Bruce G. Murphy,� ,RS.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-015 FEE: $33.00 ThiS i5 to Certify that AI»n navic d/h/a('zne C'cxl('rramgrv 5 Theatre Colon Lane South Yarmouth,MA ' IS IIQ2EBY GRAN'I'ED A LICENSE � FOR THE MANUFACI'URIPiG OF FROZEN DESSERTS AND/OR ICE CREAM MIX For the year commencing with March first 2005 This License is subject to the Rules and Regulations of the Massachusetts Deptuiruent of Public Health Relative to the Manufactunng of FROZEN DESSERTS and ICE CREAM MD{, to the Rules and RegulaUions of the Board of Health granting tlris License, and to the provision of the General Laws Chapter 94 as amended by Chapter 373 of the Acts of 1934,and may be revoked or suspended in accordance with the provisions of Saction 65J said Chapter. BOARD OF HEALTH:B g �5. y'dtc�on, iN.�., ' *Regulation 105 CMR 561.009 requires pcw�ltio�/�o�xa�� /i� e�blinwc monthly plate count and coliform tests. Roddtt�.Bsauwg � � S!� R.N. �� R.N. May 11_2005 � .M�p Y> , Director of Health