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Home My WebLink AboutApplications, WC and Licenses Prior to 2010 — � e �'o ' �, �� TOWN OF YARMOIITH BOARD OF '� ? �' � '� ' � APPLICATION FOR LICENSE/P�:�II '�.' p i� � NOV � � `LQ08 J �, A� a � * Please complete form and attach all necessary�d�cum�t§ yDece 8,�p.i_ Failure to do so will result in the retum of ybur application pa . ' NAMEOFESTABLISHMENT: �q�t�4��n i��r �s �v+3, ��. TEL. #��71 �' �LaCI LOCATION ADDRESS: (�6£ r�'F- a �r MAILING ADDRESS: �vr sf rt�t ros�7x q ��6 7 3 OWNER NAME: �,c.aic� �ah� , � c� TAX ID (FEIN or SSNI• CORPORATION NAME (IF APPLICABLE). ' MANAGER'S NAME: G��er,f d F'(�4�a,�a TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the cei7ification 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 Cardiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies o£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: Ali food service estabiishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitazy 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 �le at your establishment. 1. Z PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Z HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all tnnes. Please list your employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your piace of business. 1. Z 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI�G: LICENSE REQUIRED FEP PERNIIT# LICENSE REQUIRED FEE PERMII# LICENSE REQUIRED FEE PERNIII# _B&B S55 _CABIN S55 _MOTEL S55 _1NN S�5 _CAM� 5�5 _SWTivtiiINGPOGL a&Oza. _LODGE S55 _TRAILERPARK 5105 _Wf�IIRLpOOL 580ea. FOOD SERVICE: LICENSE REQiJIRED FEE PERMII'# LICENSE REQUIRED FEE PERbIIT# LICENSE REQUIRED FEE PERMIl"# _0-100 SEA'IS S85 _CONTINEN'IpL S35 _NON-PROFIT S30 1>100SEAIS 5160 ��p-6�/ / COMMONVIC. S60 �6y_n1/ _WHOLESALE S80 RETAIL SERVICE: —RESID.ffiICHEN S80 LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<SOsq.ft. S50 _>25,OOOsq.fr. 5225 _VENDING-FOOD S25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 _IOBACCO $55 \A:1�IE CHA\GE: S10 AMOUNT DUE _ $ 2 Zo . 00 "*"**PLEASE TUR\OVER A�D CO.�IPLE'IE OTHER SIDE OF FOR�I""••* ADMINI5TRATION Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISffiVIENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vc(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. 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(S�days prior to opening. PLEASE NOTE:People aze NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yazmouth 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 monttily 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 Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approvai fromthe Board ofHealth. OUTDOOR COOKING: Outdoor cooking preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IMENT, 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: �' I U�� SIGNATURE: ��'�`� �� PRINTNAME&TITLE: Ve�Cwld. ��nn �n; �l�'5��-.l —f�a'"',y�R , ioizvos NOU-13-2008 16:25 From:MCSHER 5084209a11 To:15083980836 P.1�1 �Og� CERTIFICATE OF LIABILITY INSURANCE oArc�M�� PROGUCUt TNIS CERTIFICATE IS l8SUED AS A MATTER OF INFORMATION MC9h0d Tnsurance Ag9IICy, IIIC. ONLY AND CONFER8 NO R16HTS UPON TNE CERTIFICA7E HOIDER. THI8 CERTIFICATE OOES NOT AMEND, EXTEND OR 749 Main StrOet, 8uite#H ALTER THE COVERAGE wFFOR�ED BY THE POLICIES BELOW. oscez,.�iie, Ma. 02655 508-420-9011 �NSURERB AFFORDING COVERAGE NAICi! msur�u Captain Pg�=ker6 Pilb, IaC_ irvauRtr.n. Natioasl F1ood Iuauranca Prag IN°.URCR 0: 668 Maia 8treet iwur+aRc: W• Yarmouth� �SB 02673 INR�IIiERD. 8-7`/ - wyURER E: COVERAGES THE POLICIF_5 Of INSURANGE LISTED BELO`N FiAVt BEEN 16SUED TO TFIE INSUREO NAMED ABOVE FOR THF POLICY PEHIOO INDICATFO NOTNITNSTM101N6 ANY REOUIREMEN7,l"eHm OR GONDITION UF ANr CUNTRAGT OR OTHER DOCUMF_NT WItN RES�'ECT TO WHICH TFIIS CER71FICqTE MpY BE ISSUFO OR AMY PERTAIN,THE INSURANCE AFFONDED BY TIiE POLIGES pESCRIBEO MEREIN IS SUBJECT TO ALL iHE TERME,EXCLLISION3 AND GONDITIONS OF SUCH POLIdES.AGGftECSA7E LIMITS SH�WN MAVHAVEBEtN RGDUCED9V PAIDCU11M5. . �..... ... _ .__ . .... ILT1 NlAO 7y 1'OLICYNUMOER LI Y � TNE Y(ILICYF%Plq N � DA M OATF MrnNO UMI78 C�ENERnL Lua�UTY EACM OGCURRENL't S 1,OOO.00O ][ C.�1.WFnGULCCNCfLyLUh5lLllY �REMI Ecocdllenmj S Q�Q ICUIMSMA�F. �p�CUR MF,I}FJ(f'(MrqqpynOnJ i 5 0� A . . PAC3139486 4/5/2008 4/5/2009 �tRSONN..BADVINJURY f 1 000 00 X �Sql10T Llil]. �EutHp� nGGREGATE 8 Z OOO OO GEN'LApQHfiGA7ElIMRqpp��GSPCR: pp(]OIICT6-CAMP/pVMHO 9 Q�QQQ QQQ POUCY jFC LOC .. .. AUTOMpp11,FLUBILITY ANVAUTO 1 aeBI�NFxOI'SINGLELIMIT f AI_�OWNEO AIJrOS � BODILYInJURY 5 SCntouLEo nurns tF^�ce�e�N HIRCD AUTpS BO�I�VINJl1RY ` NOMOWNtUAUT�R (WfiLGUenI� . . PFOPFRTY pAMNGC a . (CN�CG0en1) GMAf;F.I.Iqq�LITV LUTOONLY-FAAfi;illtNT 5 aavAUtO .. . OTI�I[RTHAN ��'� $ A(ffOONI,V� �i; % E1(CCSSNM�RELL4 LI�IBILRY EwCn fn,'(:UiiRENGC 5 IOCCUR �I CAnim�NnOE AOCiNtc;aTE S S oE�l If,TIRLE � S RPIfNf10N i . ... g .. M�ORNER9CUMPENRATIONqND XYLIMR EA kMPLOYERS'LIABILM �- ��+v NiUVR�rOWVMTNlNLxlLUTNc E I,EACH ACCIDEN I' E �FicFnndcYelll tkCWoco� 4,�.pgEA$E.G CMFLOYE 5 '�y� dei��W� E.L.OIFfnlit-POLIGY��MIT S �PEGIAL Y12UVI'JIONF lrA�w OTNFR Buildinq - 750�Q� B Property PaC3139486 04/05/08 04l05/09 Contenta - 100, 000 $1, 000. deduatible �ESCRIP710N OF OFFHnrwN9/LOCATIpN6l VLHILL[S/Fk�I.U&UNSADO[D DY ENDOR3EMFNT��NtGIAL PROVISIONS GERTIFICATE HOLOER C4NCELLATION TOFRl o f Yarmauth �PIO{1LU FWY UF TXF ARpVE DG`GRI�ED YOLIdE3 RF CANGELLCD OCFORE fHE E%PIRATIOH ❑ATE n1Cfi[pF,7H[IRtlUIN6 IN(UqER WILL ENtJFAVOR TOlMI�� AVS WNnTEN HUl S(ilAg Department NpTICE TO TVIE CERTIFICATF MOLOER NAMED 7G Y'HE LEFT,RUT FAILUR[70 UU 9b SXAI..I Yarmouthi � IMPOSE Np qBLIGATION Ok LIAHILT'!1F ANY KIN�UPON IME INSIIHFP,RS ACGNT;Ok RCPRESENIA7IVER pUT1�InRii'V WEPREbENTATIVC FAAt 508-398-0836 ACORC25{2007IOBj ' mACO CORPORATION198B TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-021 FEE: $160.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chep[er (l 1, Section 5 of the General Laws,a pertnit is hereby granted to: Gerald Manning 668 Route 28 West Yazmouth, MA Whose place ofbusiness is: Captain Pazker's Pub Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit exp'ves: December 31. 2009 BOARD OF HEALTH: .`JE¢L¢n, SI�IR., J2.rY, C'hauunan SEAnxG: 130 e�� .�- � �� JrtoBr,ct s. `.�3uausc, (.� a,uc (�'neee8a.a►c, ✓2.✓v. F.uePyn `J'• .�Ea�e.e November l9 2005 Bruce G.Miuphy ,R.S.,CHO Director of Heal[h THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-011 FEE: $60.00 This is to Certify that Gerald Manning d/b/a Captain Parker's Pub, Inc. 668 Route 28, West Yam�outh, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violanon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority gsanted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: q.�QEe-P�e�en_.SlrklaLh�2y."`J�,,2Q.�N� ., C'l�abtmqan SEAIING: 130 � �-��!`�'^�!�� `'�'an' ✓WI�YJfI� J{l7.0�{F!L Q�trt (�xeertdautnr., :JZ.✓Y. �l*�J• .`�ECulc° Novemberl9 2008 Bruce G. urphy, ,R.S., CHO Director of Health - ' (�L�12`{8a _ r o °`;:''"� TOWN OF YARMOUTH BOARD OF HEALTH�� "' s � `' � 3�� APPLICATION FOR LICENSElPER�IIT-2007 N O V 2 7 2006 o� ,i � * Please complete form and attach all necessary documents by Decem r��,�OQ� pEPT. Failure to do so will result in the return of your application pac e . NAME OF ESTABLISf�fENT: CiiP�'9i ^ � q�t�n �S /- v/S �tiC - TEL. # �g'771��G LOCATION ADDRESS: �6� �29-� r38' 1,,,,tsf y,v,e�+o�t4, ,y,! c�aG -7 3 MAILING ADDRESS: OWNERNAME: ��cR�d f�(ntin ,hq TAXID (FEINorSSNI CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �`-t,�.t�{ �q„ „ �n � TEL. #SUS-SL 4-$7ao ME111,��'7l�D�S$:�(Z�� ' LvY ST SfArth � N� G1G 7 �S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 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 will not use past years' records. You must provide new copies and maintain a file at your place oi 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 Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies ofcertification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a Tle at your establishment l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: I,ICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT ti LICENSE REQUIItED FEE PERMI'I'# B&B S50 CABIN $50 MOTEL $50 _.._INN $50 CAMP $50 SWIIvIIvIING POOL$75ea. LODGE $50 _TRAII,ERPARK $100 WIIIRI,POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PF.RMIT# LICINSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $75 _CON1'INENTAL $30 NON-PROFIT $2S ( >t00SEAT5 $150 -t'�7-6 0 � COMMONVIC. $50 �J07-0� WHOLESALE $75 RETAIL SERV[CE: —RESID.KTTCIIEN S75 LICENSE REQiRRF;D FEE PERMIT# LICENSE REQiJII2ED FEE PERMIT tk LICENSE REQiJIRF.D FEE PERMIT# _<50 sq.ft. $45 >25,000 sq.ft. $200 VENDING-FOOD $20 __Q5,000 sq.ft. $75 _FROZIN DESSERT S35 TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE _ $ ��D U � •'•••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM`•"• ADIVIINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INS�CE ATTACHED �� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED r �� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any 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 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 Department to schedule the inspection five(5�days pnor to opening. POOL WATER TE5TING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certiSed lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failwe to do so will result in the suspension or revocation 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 from the Boazd ofHealth. OUTDOOR COOKIlVG: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET'[JRN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CO1�Il�IENCEMENT. RENOVATIONS MAY REQLJIRE A SITE PLAN. DATE: � I � � /I � o� SIGNATURE: �0,-,�t�(.�— ✓hJ�� / PRINT NAME&TITLE: GeYFq/l /��a r„9 PR`S��P�� iomios � 11!27/2006 13:44 FAn t5084209010+ McShea Insurance �001!001 �� CERTIFICATE OF LIABILITY INSURANCE °"'�'"`"'°°^'��, PRO➢UCER 1 ' MeShea Ineuraace Agency, iao, ON YCANbFCONFER9SNOR IG TSMUPONR iHENCERTIFICATE 749 Main 9tr0Bt, SuitO#H A�TER7HEHCOVERA ECp QRpED BYTTHE O�ICESEBELpW. Oaterville, b]a, 02655 508-420-9011 INSIIRERS AFFORDING COVERqGE � IN$ppEo Captain Parkexa Pub, Inc. NaCx INSURER a �J!rdVgjB=e Zn6 CO. u+sunerr a: AIM Mutual Inaurance 668 Main 3treet INSURERC: H. Yarmouth, Ma 02673 INBIIRERO: 5 —7 1— covEwacEs INSURER E: THE POLICIES DFINSURANCE LISTEo BELOW hWVE BEEN ISSUEC7oTNE IN$�REO NAMEO ABOVE FOR TTi@ PO�ICY PERIOO INDICAiED.NOTlMTH57ANDING ANV REpUIREMENT,TERM OR CONdITION OF qNY CONTRAC7 OR OTHER �OCUMENT WITM RESPEGT 70 WMICH TMIS CERiIFIcnTE ivtaV BE ISSUED pq MAr PERTAIN,7HE IN5URANCE AFFORDW 8Y T}{E POLIdES DESCRIBEo HEREIN I5 SUBJEGT To qLL THE TEftMS, EXCLu610N5 qNC CONDI71pN5 oF SUCF{ POUCIES.AGGREGqTE LIMITS SHOWN MAYHqVEBEEN REOUCFD BY PAID CLAIMS, LTn N0110 TV OF ❑ E POLICYNUMBEp P �Y FECT E p��CY Rq � N OENERqL LIABILITY �A MM/ LIMITS X GOMMERC�ALGENERA��pgI117V �CH OCWRRENf� $ '1 OO OOO I CLAIMSMADE �i occuR ""�"^'� �•�,� 6 100 000 A �- NE�EkP�Myon<vaeon) g QO .. i— 16607907A505 8/1/2006 6/1/2007 r�r+sowasnoviwunv s 1 000 000 I G@kL p�pRE�qTE UNITAPP�IES PER; GENEFq� qGGREGATE S '1 OO O POII[Y r� j"� �o� �i0011�T$-COMP/OPpQG a 2 D00 000 � AUTdApg��IqBILITV � ' ��aNvq;np cOM&NED9mGLEUMIT AUOWNeo�UTos fEeealdeni) 5 i ; �SCMEpULE0AUT05 �oRYINJURY � MIREoo1�Me �'� ' NON�OWrveoq�ToS BOOILYIMJ�RV (P�nxy�l) � l�em�pMMAOE $ GApACE��q81L1Ty ANYAI/TO AUfoONLY•EqpCC10ENf E CTNERTHAN EAFCC 8 ' AUiC10NlY. A00 S ' i EXCE59M11MBRELL��V�BILITy I I , ��R ��GLAIMSMA�E �CH 6C�URREryCE g � AOOREM�E g DEWCTIOLE S RETENTqN 6 S I IWORKER&COMPENgpTIONqNp S �flMPtoyER9iNlIL11Y � � (+m'PRDPweiW�yqqnyEp�EXECUirvE e0D3661012006 04/Dl/06 �4�Q1�Q'7 EL.EiCHACQ�OENT �.� 8 �FICEPMBMfA�(QwEoi` a 500 000 pye�tlesenbeunaar E.LdSERSE.�qEM{LOYE � 500 QOQ Sf'EC�IAI PROVISIOws beiaw OTH9j E.L,0�8Fa$E•POLICYLfMIT � OO OOD DESCRIP710N OF ppER4TI0N5/Lo�qTIONS 1 VBiI�Eg i E%CLu510.N9 4 W E�eY ENOp�GFMEryT/9PECIAL P�2py�gpNg CERTIFICATE HO�OER � CANCELLATION TOWIl O� Ydi'IDOUC11 3HOpLOPNYO�TNEABaVECESCq�B�iq��CIE$BECANCglE�9EFOFE7HEFXPIMTiON Licenaing Soaxd ��THEREOF,THE ISSUINO MSURER wILL EN�EAVOR To MP,LL10 op}g WRIT7EN NOTICE TO THE CERTIciCAiE NOLOEp NqMEo TO 7FIe�B:T,B�7'FAILURE TO DL SO BHAL� �O6E NO OeuC�TION OR LIqBILIT✓OF ANY Wryp UPON TNE INSUPER ITS�IGENTe pq �F'AIC: 50 6-3 98-0 83 6 RERiE8EN7'ATNES, FU7HORIZEo R TATIVE �CpRD23�2007109) m ACORD CORP01iAT10N 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NIJMBER: #07-030 FEE: $150.00 In acco[dance with regulalions promulgated under authority of Chapter 94,Section 305A and Chaptet 111,Section 5 of the General Laws,a pernut is hereby granted to: Gerald Manning, 668 Route 28, West Yarmouth, MA Whose place of business is: Captain Parker's Pub, Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pemvt expires: December 31. 2007 BOARD oF HEALTH: B�� $. as�ok, �95., senrtivG: 130 dfeLerc ��i�i, �./�., 7/lce e�i�iu�n lla4wlc14. 83kuwi, G�lrlu(t a� st.�, Rrv. A...� �j�, R.N. Januarv 23.2007 Bmce G. Murphy, H, S.,CHO Director of Health T� COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERNIIT NLJMBER: #07-020 FEE: $50.00 This is to Certify that Gerald Manning d/b/a Captain Parker's Pub, Inc. 668 Route 28, West Yannouth, MA IS HEREBY GRAN1'ED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2007 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confomvty with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: /� �5.�, i19.�5., . sEAT,�G: �30 ��s�`�, .�., v� e�� Roa�t�. a�, et�.� n�Mo�� A.��j.�.�.,�, R.N. Janua�y 23.2007 � �J � Bruce G. Murphy, S.,CHO Director of Health " „ ..� cs+vr Prherc�z's ;�°` Y"��s TOWN OF YARMOUTH BOARD OF H�.4L ,� �a� �rJ� � 5 APPLICATION FOR LICENSE/PER]�T1'-�2f� '�}� �� r * Please complete form and attach all necessary ddcuments by ec mber 31, 2007. Failure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: � /°I7�rh /a�c ll�,e 'S Ul� �+�- TEL. # ��7�-�/'��6 LOCATION ADDRESS: h 6 � �t, �� c-(�g�h S�- MAILINGADDRESS: r- icHo �7�, . 7 OWNER NAME: _ TAX ID (FFIN or N) CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: G�r�c.+lC� {�/�s.�-ri�s TEL. # ST� �- 77/- '/��G MAILINGADDRESS: [��Sr Mt. a� GvrS�' c/ ,r,�a✓f4 �,�} o3G 7y} POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required b��State law. Please list the designated Pool Operator(s) and attach a copy of the cenification to tivs form. 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past �ears' records. 1'ou must provide neK• copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Saiutary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department witi not use past years'records. You must provide new copies and maintain a file at your establishment. 1. Z. P_E__R�9N�N CI-(ARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Deparfinent will not use past years' records. You must provide new copies and maintain a Tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LqDGING: LICENSE REQUIRED FEE PER'�fIT* LICENSE REQtiIRED FEE PER�III= LICENSE REQL'IRED FEE PER4IIT= _B&8 S50 _CABIN S50 _MOTEL S50 _INN S50 _CA:�1P S�0 _S\i'IVI��I[D�G POOL S75ea. _LODGE S50 _TRAILERPARK 5100 ti7-IIRLPOOL S75za. FOOD SER�7CE: LICENSE REQUll2ED FEE PERMIT� LICENSE REQI IRED FEE PER�4IT= LICE�SE REQl1RED FEE PERbDT= _0.100 SEA'IS S75 _CONTINEN'IAL S30 NON-PROF17 S25 �>100 SEA]�S 5150 D��(�(o /COD�LVION VIC. S50 �OS'O�5/ _N7-IOLESALE 575 RE'IAIL SERVICE: —RESID.KITCHEN 57i LICENSE REQUIRED FEE PE&'4fIT= LICENSE REQL7RED FEE PER\qII'= LICENSE REQU[RED FEE PERbiIT= _<SOsq.B. S45 _>35.00Osq.ft. 5200 VENDIIG-FOOD 520 _Q5,000 sq.ft. S75 _FROZEN DESSERT 53i TOBACCO 550 \iAMECHAVGE: S10 AMOUITDUE _ $ o20a. 0o **•**PLEASE 1'L'R.\O\'ER A\D CO�iPLETE OTHER SIDE OF FOR�i`"*�• , : . ' ADAIINISTRATION Under Chapter 152, Section 25C, Subsecrion 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 dces not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDA�'IT 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 pernrits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCP: For pwposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhe,re. Transient occupancy shall generally refer to conrinuous 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 collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transiem. * NOTE: En�tosea Motel Census must be completed and returned W;cn tvis app>>�az�on. 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 opecung. Contact the Health Department to schedule the inspection five(�days prior to opening. POOL WAT'ER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Permit umil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdooe cookiag prepxratioq or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISf�vvIEEIVT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMME�ICEME�IT. RE:VOVATIO'�tS MAY REQUIRE A SITE PLAN. DATE: � �" a '� G� SIGNATURE: ��^�' 1 -Z PRI�IT:VAME&TITLE: Gf�A�J �9��inY /�/��'Sid�^� / �o su o- NOU-29-2007 16:14 From:MCSHER 5084209011 To:15083980836 P.1�1 AC_ORQ„ CERTIFICATE OF LIABILITY INSURANCE °""`"'"�°°"""' li o� iR0IX10ER TXIB CERTIFICATE IS ISSUED AS A MATTER OF INFOftMAT10N MCShAd znaurance Ag6ACy, IIIC. ON�Y pN0 GONFERS NO RIGHTS UPON TME CERTIFICA7E NOLOER. TXIS CERTIFICA7E DOES NOT AMEND EXTENO OR 749 Main 9traet, 6t11te#H . AL7ER 7ME GOVERApE AFFOR�ED BY THE POLICIHS BELOW. Oaterville, Ma. OZ655 � 508-420-9011 INSURERS AFFORDING GOVERA6E NAIC# '"'y""'A Captain Parkers Pub, II1C. �NSIWFRp Gleat ]!1}AaT1CdI1 IN'3URER B. . . . 668 Maiil SCL'e9t , IN911RF.kC � i �P. XdrinOuth, Ma OZE�I3 INSUNtKU. ' �7 � INSURCR C � COV@RAGE9 � 7HE POLICIES OF INSURANCE lISTED BELOW H/�VE BEEN I$3VED'TO TNE INSURCD NAPAED ABOVE FOR?ME POLICY OERId]INDICATED.NQPNITN6TANOING nraY REQUIREMErri.1ERM OR COnl0lTOta pF ewV CONI'kqC! UH UTNER DOCUMENT WITH RESPEl:7 TO WMICH THIS CERTIFICATE MnV sE 19gUeD OR . MAY GERTAIN,TMF INSUNANGE AFFOROED UV TI1E POLICIES OESCR19E0 MEREIN IS SUBJECT TO All hIE TERMS, kxCLUYP]NS AND CONDITIONS OF 3UCH � POUCIES.AGGRFGATELIMIT55HOWNMAYhiAVEBEFju1{tDUGCDBYPAIDCLAIMS �� POLICY F LI YC%M ION �� F FIN 1 l•' PQI,If�V NUMBEIi Ulilh M4ww1Nv pTC M LIMITS GENCML LYp1�IT/ [pCFI UCCURNlNCF E 1 ,OOO.OOO f,qYMEALIQGENCRALU�ORITY OREM16G5 CeeEwmnu) 1 ], Q pQ� x �c�niM.sunnc �or,cun M[o[xP(Myonepenm) x 5 00 P+ _ PAC3139486 4/5/2007 4/5/2008 PFASpNA�dADVINJURV 5 1,000 OOD — (i1-NtNAI AGGAEGAi'� S '1 QQ��Q00 Gen'�nGcrt�cn�ubiTnvw,itereK wNaWCTS•fAMGrovAGG S 000 OOO ruucr j�c°r i Oc Z-'. .. aiff0rA0U4ElIM1UTY COMBINEDSIN��IMR = •NYAUTO lEaaviCnn) ALL OWNCD AUTO$ .. �CHELRILEDMIT OOOILIINIIIHY s OS �Perp�rypp) nu�on�rtnx � � BODILVINJURY j NON-0WNEGAulU9 (Perawaniq PROPFRTVpAMAGC � .. .... ` (PO4GGCenp (.4MGE LIMII ITV ° AUTOONLY-EAALCIOFNr 5 �NY<lllf,l '.. OriIFk1w�N �ACC S AIJIOONLVI ��. _ EYCFSCn�tiNwr'��LIABILITV EAGH p�qJpp�NCt j I UCCUR �I n AIN6NA[�E AgGpEGATE f f OEDUGnBIC � f RE?ENTIOIV i �- s. NNkI{HtYCUMPEN3�Tnl1Nl� A U- EMPLOVFRS'LIABILIT' 7'UNVLIMITF Efl .rvrrrtuAURpwv�pm�xlWT�V[ ELUCIIAGGIUENT = O'�IRWYCMBFX F10U[COi � p��Q� E.L UISFJ�$E�G CMPLOYE f .. Cia�4fa)1nV1()NY44w Et �i$FpyE.�OLICY�IMR S O*NER Suiidiag - 5 ,000 B Froperty PAC3139ge6 04/OS/07 04/OS/OB Contents - 100,000 $1,000_ deductible UE.Sf.HIF I IqN VF ql'ERAiION$/�p(',q}pN5lVEMICLE9 i EXf:I uxKIN�1'P[1pEDBYCN Wfj�"EAIEN I lSYtCIPL GROVIfJqNf.. CERTFICA7E HOLOER � ciNCELLA710N TOWIS of Yarmouch +f�VLUNNYUFTMFAP011EDFNCRIUCOGp��pE9tltGNCFLLFp�PORETIi[[)Ip��+qIIUN Licensing Of�ice �TC TH[REOF, 'IXh 153111NA IN�IRpq W�� CNDEAVqw lU�NL1� DqyS WRfT7EN MA 0 2 6 64 NOTI�C TO THE CERTIFIfJi I}M(p_�/y ry/�[D TO THt LtFT,91R FAlI.1.ItiE TO 00 00 SNPLL South Yazmcuth� IMPOSE NO ODLIGATION GH LIAaR1TV QG ANV NIN�UPON TME IIV`3111TER.ITS 4CENT5 OR PAX: 5 0 8-3 9 8-0 83 6 rtevr�.aerarnrnrEs >UTIOR2 0 R Pq[SCNUTNE / /�\. ACORO35(]001108) OACORD CORPORaTION 1 g88 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #08-046 FEE: $150.00 In accordance with regularions promulgated iwder authority of Chapter 94,Section 305A and Chapter 1 I 1, Secdon 5 of the General Laws,a pemut is hereby granted[o: Gerald Manning, 668 Route 28, West Yarmouth, MA Whose place of business is: Captain Parker's Pub, Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2008 BOARD oF HEALTH: .`�feP.ert SPtal�, `J2.JV., C'.�abrnuut SEAr[DrG: 130 � �.�[pXe¢d .`�..`�¢�lR'PX �lC¢ �lAlptlift ✓2a�ent s.J`3aauen., ('.�exk Clrua�8cuun, J2..N. November30 2007 ruce G. Mucphy, P , .5., CHO Director of Health THE COMNIONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #08-035 FEE: $50.00 This is to Certify that Gerald Manning d/b/a Captain Parker's Pub, Inc. 668 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violarion of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing authoriries by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: .�Eeee�t S� `J2..N., C'f�aixman SEArtrrG: 130 � �p�[�R-6 .`�. .�F.�l�4JL, �lCC �.�ilXlfilttt J2a6ent 3.f�l3Kawft, C'.PenPt Qrtn , J2..N. November 30.2007 Bruce G.Murphy, . .,CHO Director of Health � �f�AR� V"'r (7i1� �'�, �f 1 . fA��S z TOWN OF YARMOUTH BOARD OF H�1L�'$`t � ' _o . i . .� �--__.._ _ ._._... o `� APPLICATION FOR LICENSE/P.�+R�T,��'�0 �6�, � i ��!i ` . � � -� ( , * Please complete form and attach a11 necessaryty3acu�t by Decembet 31, 2005. Failwe to do so wiil result in the return o�%bur application packqt. � __ ,.,,.� - ', NAME OF ESTABLISHMENT: C/-�/'tW�� i4r4�vr S �u/� �C_ TEL. #SU�'77�-�L� LOCATION ADDRESS: ��- ,�Fr �H,ti St L PSfi � 5/.e v�a � ti/�¢ c�67j' MAILIAIG ADDRESS: OWNERNAME: (�c�dGd .�� iti� TAX ID (FEIN or SSIVI� / CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: �i2�Nla l`'la.,n �.�5 TEL. # SzB- 7Jl- /�d66 MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safery, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to ttus form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is ceRified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of ceRification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. G-��A�d l�lpn� ;,,y 2. �� M�s Gp,�d,,;�.� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. i. �oyTrt G�+,�d ��e Z. /l'� i Ke I�aC/Je HEHlg,fCH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attael5 copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �� / — OFFICE USE ONLY LODGING: LICENSE REQUII2ED PEF. PERMIT N LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# BBcB $50 _ CABIN $50 MOTEL $50 __INN $50 __ .___CAMP $50 _SWIMMIINGPOOL$75ea. _ LODGE $50 TRAII,ER PARK $50 _ WHIIZI,POOL $75ea. FOOD SERVICE: LICENSE R&QiJIItED FEE PERMI1'# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _,0-100 SEATS $75 __ CON1'ININTAL $30 _ NON-PROFIT $25 �>IOOSEATS $150 �lb'6f9 � COMMONVIC. $50 �O(�� / _4VHOLESALE $75 RETAIL SERVICE: LICENSE REQUIIZED FEE PERMIT'k LICENSE REQUIItED FEE PERMIT# LiCENSE REQUII2ED FEE pERMIT# _dOsq.R. $45 >25,OOOsq.ft. $200 ___ VENDING-FOOD $20 _<25,000 sq.ft. $75 _ _FROZEN DESSERT $35 TOBACCO $25 NAME CHANGE: $10 AMOUNT DUE _ $ 2Ao .00 "•""•pLEASE TURN OVER AND COMPLETE OTHER 5mE OF FORM•"""" ADMIlVISTRATION , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED t�ND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2005. SEASONAL ESTABLISffivIENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPEI�IING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQIJIRE 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 establishment which serves or sells ready-to-eat, raw or undercooked animal products are required to post Consumer Advisories. CAT`ERING 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 b�tested on a-monthly basis by a State certified lab. Test results musfi be sent to�he 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 haue prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking preparation, or display of any food product by a retail or food service establishment is prohibited. a _ �� —7 DATE: �� SIGNATURE: � � / PRINT NAME&TITLE: GCiertC d /t'�`�'"" •"f�j�s;d P"� 09@8/05 . No�-28-05 03: 35P P.O1 CERTIFICATE OF LIABILITY INSURANCE '°"'E,"""°"", vaooucp�ry THIS CERTIFICA7E 15 I�SUED AS A MATTER OF IN��ORIW\TI()N ONLY AND CONFERS 'NO RIGHT$ UPON TNE tERTIFiG>TE MC$hBa InaUianCe AgBriCy, InC. HOLDER. THIS CERTIFCATE DOES NOT AMEND,-E7RENU OR 749 Main Straet, SuitB#H ALTER THE COVERAG 'FFO �E '-0t Ti�2 OL(CIES BEIOW. Oaterville, Ma_ 02655 INSURERSAFFORDINGCOVEr1AGE -420-�911 �wsurteo Ca tain Parkers Pub IIIC. INSURFFq; P , _ �ravglQrs._inaur�nce comnany, _ wFuuer+e: �geiated =ndvstiies of .Mnea Mut.. 668 Main Sti'eet INSVRERC: W. Yarmouth, Ma 02673 �NSI1REAq' __ �NSUREFi[: COVERAGES THE POLICILS OF INSURANCE USTED BELOW HAVE 9EEN ISSUEO TO THE INSURED NAME6 AdOVE FOR TH�Vp�ICY PERIOU IND�CATED.NOI WITHSTANDING ANY REOUIREMENT, TEftM OR CONUITION OF ANY CONTRACT OR O7MER DOCUMENT wITH RESPEC7 70 WHICH f1115 CERTIFI�,qTE MAY BE ISSUED OR M4Y PEftTAIN,THF�NSUHANCE AFFpHpED BV THE pOLICIES OESCRIALD HEREIN IS SU6JECT TO AL�Tt1E TERMS,E%CLUSIONS ANU CONDITIONS OF SUC:H POLICIES.�GGREGATE LIMiI$SIIOWN MAV HnVE BEEN REDUCED BY PAIO CLAIM�. N1SA �ypEO�IN9UfLWCE. .. �'OLKYNUMBEF ��IIC�'FF TIVE YOLICY i%FA�E TION ,.. .. .. ...-- tR I OAT M NWD LIMrtS GENERALLIABILITV FPCMUGGU2RENCF bl �4l4QVY_ _ � GUMMERCIFLGENFfuiLIFBIIRY YIFEDAMnGE(Anyq�¢pre) E100_�p CIAINSMWE �(X:CUR ,MEOF,.%PN�y�eyersm) S OQQ_ r A _ _ I660-7907A505TIA04 08/O1/OS 08/O1/06 ,YERSON�L6ADVIWURY s ,� r , 'GENEHAL AGGREG4TF. S'1,Q Q Q"�'�Q '�, GEN'IqGCfiE6�T[LIMITwPYLIESfCR: PRODUCTS-�MPNPAGG F � �1 �.' NOLICY P� lOp . . .. _ �4UTOM0911E UA&Un' COMUINFD SIN4LE LIMIT nr�.auro [G��u S1,OOO,�J00 ALLOWN[DAUTOS raui�rw+duar . . _ SCIIEO�iI.EUAUfOS I�.��'�^) S A MIREDRUTOS I-H10-9179W495-IND OS/Ol/D5 OB/Ol/06 opa�viwursr ��. NON-0WNEDAUIOY IPe�eodGent) s � -� �OPEktrwuncE S IPo.ameenq GARAGELWBILITY AUTOONIY•Fp�CIDENT E ANVqV'10 EA<CC S - O�HtftTN0.N . __. � AVIOONLT: qCG�..,S EllCEA4LIA9141Y tM;MOCCUFRFH(;E '�51"0QQ"I�� OCCUR C�CL41M$lIHUE AGGRE(i44TF S �i,S ISF-CUP-9417W14004 108/O1/05 OB/01/06 5 ___ p otu�cna�e �.., s RRENTION S . . . . S . ._ MiOflKEAS COMPEN�IT�ON I1ND ' EMYLOYER9'L1�Bil11V TnRy��MITS _I FR wMZ8003661012D05 04/Ol/OS 04/01/06 ��F4CHACC�OENT 5560.00C7 B E.L.OISF.FSE-FAEMGLpYE6 f OQ,00ci E.I.D�$pq9E-RAI(;V�IMIT i OTMER �� ClFlood Ins 3000274203 10/09/OS 1D/09/06 Huilding SSOO,ODO DESLRIFTION OF OVER4TDN3ILOCAtION9NEXICLES1ExClUS�OM3 AOD€o BY ENpOqgEMEMl9VEC41l CROVISIONS CERTIFICATE HOLDER ADDRiONq��N9URED:INbUREH lE1TER: CANCELWTION 6HOULD ANVOF rryE ABOVE DESGRIBED YOUGE5 BE CANCELLEU BEFORE TNE EIIRMTqN Yarsouth Health Department �TE TXEREOF,THE 19SUINC�NSURER WILL ErapFNVDR TO NniL 1�Df.Y6 WRITlEN NOTICE TD1NQ pERTIFICATE MOIDER N4YED 10 TNE LFfT,6UT FAILURETOOOSO:iNALL IMPDSE NO OBLIGIITON OR LI�&UT'OF I1NY qND UPCN THE INSUpER,�TS AGEMS�F REPNESENTqnVES. 5 0 8-7 6 0-3 4 7 2 FaX aUT110X1ZED RpPRESENt1TryE L. ACORD 258(7197) 0 ACORD CORPORATION 1 � �G • ,�� oF �q� � o T � WN OF XARI�IOUTH � y 1196 ROUTE 28 SOUTII YARMOUTII MASSACHUSETTS OY6644451 H MATTqC�� j '+�oq>o,,,ro,s'^��d Telephone (508) 39�2231, Ext 241 — Faac (508) 760-3492 B O A R D O F H E A L T H ,__. To: Yarmouth Boazd ofHeaith Pernut Holders � From: David D. Flaherry Jr., R.S. � Heakh Inspector � D� j H EA� i H J c P"l. Town of Yarmouth Re: Federal Tax ID Number Date: March 22, 2005 The Massachusetts Department of Revenue is now requiring that we fumish detailed information to them regarding all permits and licenses that we issue. One of the details that they require we send to them is every establishment's Federal Employer ldentification Number(FEIl�otherwise known as your"Tax ID Number". This is purely for administrative ptuposes only. Some businesses use the owner's Social Security Number (SSl� for this putpose. If this is the case for yow establishment, be assured that we will not allow this information to be public record. Please fill out the fields below and return this letter to Yarmouth Heal[h Department 1146 Route 28 South Yarmouth, MA 02664 Tl�ank you for your anticipated compliance. If you have any questions regarding this matter, please do not hesitate to call. The office hours arP Monday to Friday, &30 a.m to 430 p.m. The telephone number is(508) 398-2231, ext. 241. ' fiiPCP�B�C ,. ..� � � �.:b q �/ Establishment: ; �tn pj�� F�(N or SSN: �� d 7/ �5 3/ —�'j'�Npi$7LA�678 ,�, _ :.�' Location Address _,�� ,�r�� "' '� ""c,;,;1� Signature: x,.��- ��`h`''^ ~ � Prirn: �j f',�,1(C� �l9�ni� " Title: ��'J��"/ - � Printed on �( Retycled L _s Paper �. � ��4 �231� T pa�,� 2°=;""�s TOWN OF YARMOUTH BOARD OF HEALTH �� C� iSC� [� I� �Y? f� D o ,s APPLICATTON FOR LICENSE/PE ��2005 � 3 0 2004 �:. � , ,� � �8X * Please complete form and attach all necessary docu�ient�by December 1, 2 Failure to do so will result in the return pfyou�"Xpplication packet. HEAL T H UEPT, � NAME OF ESTABLISF�viENT: ` f'i74,„ ' ,c ' ul'�^�.,r. TEL. #SD �71/� -�E� LOCATION ADDRESS: �,C, fr ik'-F 1 S�'` �tr� S'f � MAILING ADDRESS: i_,�5 f',fA�/'�o�-1`d, �/ff � 3�. 7� OWNER/CORPORATION NAME✓ MANAGER'S NAME: �t�,d ic� �isn �n g TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (yCPR). Please Gst these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2. 3. 4. FOOD PRO'I`ECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a Tile at your establishment. 1. � �'v��4 l �� Y (a4-�n i'�f 2. J�}� �' S L:<4� cic �� PERSON IN CF3AI�GE: Each food establislunent must have at least one Person In Chazge(PIC) on site during hours of operation. 1. �C L'rf'�� h'1 l h( 2. / `V��/� ��K �f q C/� � HEIMLICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedwes below and attach copies of employee certifications to this form. The Health DepaMment will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. t ,c,C�ld /`«h� ��S 2. 3. 4. RESTAURANT' SEATING: TOTAL#�j OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIIZED FEE PERMTL# _B&B $50 _CABIN $50 _MOTEL $50 _INN E50 _CAMP S50 _SWIIvIIvfII1G POOL S75ea. _LODGE $50 _ _1'RAII.ER PARK $50 WIIIRI.POOL $75ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT N LICENSE REQUIItED FEE PERMIT tk LICENSE REQUIItED FEE PERMI1'# 0-]00 SEATS $75 CON1"INENTAL $30 NON-PROFTT $25 I >100 SEATS $150 �Q�_y_�'}� I COMMON VICT. $50 O �O � _WHOLESALE $75 RETAIL SERVICE: LICENSE REQUIl2ED -FEE PERMIT ti LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIRE;D FEE PERM[T# _<50 sq.ft. � $45 _.>25,000 sq.8. $200 VENDING-FOOp $20 _Q5,000 sq.ft. S75 _FROZEN DESSERT $35 ;�"��TOBACCO $25 ' NAME CHANCE: $10 AMO UE _ $•�-�:oo� '"•""pLEA5E TURN OVER AIHD COMPLETE OTHER SIDE OF FORM^"`•" �.� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. 'I'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTTCE:Pemrits run annually from January i to December 3 L IT IS YOUR RESPONSIBILITI'TO RETIJRN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2004. SEASONAL ESTABLISHI�fENTS ARE TO CONTACT TI�HEALTH DEPARTMENT FORINSPECTION?-10 DAYS PRIOR TO OPENII�TG FOR TI� SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMEN'T, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDTTIONAL 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 T'ESTING: 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 orundercooked animal products are 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. 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 searing with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display ofany food product by a retail or food service establishment is prohibited. � , DATE: ��- �U I SIGNATURE: ' r��'— PRINT Nt1ME& TITLE: �/�/�� l4�h ��r y ��rSj t y / 10/22/04 Nov-30-04 03- 35P P_O1 �Q- CERTIFICATE OF LIABILlTY INSURANCE °�""'�'°°"" mocuceR . TMIS CERT�ICATE IS ISSUED AS A NATiER OF INFOpMATIOPI ItCShea Ia$tirdnCt AgsnCy, IitC. ��Y AND CONPERS NO RKiMTS �UPON TNE CERTIflCATE MOLOER. THp� CERTIFICATE DOla NOT AMENO. EXiEND OR 749 DS3.'LA SC2'eot, Stiite#R ALTER THE COVERA6E AFFORpEp BY TNE POLICIEB BELOW. Oaterville, 1la. 09655 plguRERSAFFORDINOCOVERAGE 509-s2n-gnil �xsuxEn Captain Parkara Pub. Zric. ��R�' ASUTR6� �"�flQ OOCist�d Znduatri�a ef..j�gsg _ 668 D[ain Street �� _. . W. Yasmouth. Ma 02673 n+su¢no: -- -- —. _ _ M5URER t �COVERAG88 � THE POLICIES�OFINSURANCE LISTED BELOW HAVE BEEN I$$UEO TO TME INSUREO NAMED ABOVE FOR THE PpUCy VERIOp INOICATED.NOTWi7M5TAN01NG Mri REOUIREMENT, TERM OR CONDRION OF ANY CONTRAGT OR OTHER DOCUMENT WITFI RESPECT TO WHICH TFMS CERTIFICq7E MAY BE ISSUW OR MAV PER7AIel,iriE IN6UHAN(:E AFFOIiDEO BY TNE OO�ICIES DE8(Fi1BED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND Cp�ITI0N6 OF SUCH POLICIE9.ACaORHiATE UMITS SHOWN MqY W1VE BEEN REDUCED BV PAI�GA�IAAS,y . ._ . . W � ..._.. � . N5R TY►EOF1NAlPANCi WIYYNIMOER � 68N611ALI.uWtrtv � [KMoeW0.NENCE i �QQ. LOMU!'RCIIIL GEIKRAL LIApq ITV FIi�(yy�y�(�(/N q1!&e) i ElAM�SM�VG �Ol:CiAt MIDOP((N�ymeVMaclll" .S O A � .. 1660-7907A505TIA04 08/Ol/04 08/Ol/OS �"��a"��+� +1,. GE1lkHlll AC6PEOATfi � GEN'4pUG�+tOATlIIMRMi'LKSP6R: Pf�7WCB-COMI+AP�CiG f POIiCY 7 IOC _. .-., AUTOIYONLi lJluqfR �NYAU10 ��,NGL6LIMR f � �L�� BODILYpuUtV � SCHEOUL��Vf05 IPc+R�) � ia�suros xOr+-0wNEDAUTos ��Y� i �_'. ..- PR01'qITY DARNGE s .. . 0'M emaem) �E�U04(fY AUTDOMLY�61.1C,�I�pf S , ��NV�UfO - .. - . ... , OTHtN�WW GACG i AUTO dilY: �GG f �- UCHOCCWkENCE i . OCCUR n CIAMISMAOE �Cat�iECH1TE i. . S �UCWCTI6tE f- . RE7[NfqM i . .... s .. wanc�xs co�n,iox um x i crt �oveRr uunnr )iNZ8003661012004 04/41/44 04/Ol/OS �� N�+� + p B E.LW9FASC-FJ�ENP�O f 0 EI.UISFABE-YpUCYLMIR 6 Gf1�R xrcmmw ar orr�unora�.ocarrowwiwaEvexc�usiow amEe w woo�sc�x►�wau wror�oxs :ERTIF�A7E NOLDER �oomwu uAw�m,�ute urnn: C�NCELLA110N . allow.e unnr nE��►a.�es�c�uo�ervxe nEocnnr�nax� ToMa of Yarawuth � . nare n�enew.n�e asuwe rawa�wn��wwa w��wra wxmr�+ Health DepartmeAt �omeron�cc�nsiur��o�ewrrnron�t.�rr,61RFYJM[�OOOWSIMIL At�a: David Ra!lerty wwse xo aa�rrnou oa�ua�rtr�un wno urow r�e nauwe,�rs�uerrts oR �aeKum�s. 508-398-0836 Fax �'R'��Di�"�'R�TM` acaeo za.s�re� e�caen r.npw,Q. . TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHM�NT PERMIT NUMBER: #OS-041 FEE: $150 00 In accordance with reaulations promulgatad under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the Zieneral Laws,a pemu[is hereby granted to: Captain Parker's Pub Inc. 668 Route 28 West Yazmouth, MA Whose place of business is: Captain Pazker's Pub Inc. Type of business: Food Service To operate a food establishmecrt in: Town of Yarmouth Pernrit e�[pires: December 31_ 2005 BOAIZD oF HEALTH: Ba ya�i�c$, (�'o3dora,/yJ,�1y, • SEA'rwG: 130 �Jd��J� v�,� ��./V�i.� R�� R.h. raa,�y>>.zoos Bruce G. Miuphy, ,RS.,CHO Dir�tor of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #OS-031 FEE: $50.00 , This is to Certify that Captain Pazker's Pub Inc. 668 Route 28 West Yarmouth, MA IS HEREBY GRAN1'ED A COMNION VICT[JALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirry-first 2005 unless sooner suspended or revoked for violahon of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity wit6 the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: Bessfa«rin. `.�. /H�`y. ' s��: �3o A�Ma��:�e!� Ro6eot 4.Buuwc, 1�+t�(a �S!� R.N. Q+�y'� R.N. J�a,�y i i.zoos Bruce G.M hy,MI' , .,CHO Director of Health � � � � �d . �.;, _. _ ?�^"�. TOWN OF YARMOUTH BOARD ��Ai;TH � - � NOV 2 6 2003 3 ° APPLICATION FOR LICENS�.E�I�T.�-(�200� � I� � 2 'R� � * Please complete form and attach all necess�t�`'dc�curtients b Decem r E , �ENT. Failure to do so will result in the retuat nf your applicadon packet. NAME OF ESTABLISHMENT• iaP7' q.e 14,c 's uR � c TFt # �fr ��/S�a6G , LOCATION ADDRESS: b�� K't,��- MAii.IN D F�: �„Pzfi y,,,ei�a�Tt, N�} ca� �3 OWNER/CORPORATION NAME: `Cnnt�-,,; %�.r,�IrK 'S P�R , ;1-�c . MAIIAGER'S NAME: G-�,ew�d M�4r a �`�,,j TEL. # SL�S�S�=iobi MAII,ING ADDRESS: 6 i Cn-�'1`_ L.rH�t p KD , rx l�,f.,s,M9 ca6 s3 POOL CERTIFICATIONS: The pool supervisor must be certitied 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. L 2. Pool operators must Iist a minimum of two emp(oyees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department will aot use past years' records. You must provide new copies and maintain a Tile at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establishments are required to have at least one fuli-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 maiutain a file at your establishment. /^` (/� o ` ]. l� �FW�� I ��N �n 'l.�}�'�K �A-�d r.re� P�RSON IN CI-LARG'�: Each food establishme�t must have at least one Person In Charge(PIC)on site during hours of operation. 1. � /1 M� S V ��CG�i'I C!L 2. ��`h S r L CJI v} l HFIMLICH CERTLFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich-= Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifica6ons to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1. ctKwLc� �t�9�h,n 2. ��tK G�4Kd� ;�.� 3. r�-ril�e �7wc�-L 4. Ch.cis I��v,oti'�' , itF.STAt�ANT SEATING: TOTAL#�a `I OFFICE USE ONLY LODGING: LICEMSEREQUIRED FEE PERMIT# UCENSEREQUBED FEE PERMIT# LICENSEREQUfRED FEE PERMIT# ' B&B S50 _CABM S50 _MOTEL S50 INN S50 _CAMP S50 _SWIMMINGPOOL$75ea � IADGE S50 _TRAILER PARK S50 _WHIRLPOOL S75ea FOOD SERVICE: . � UCENSE REQl3IRED FEE PERMIT q UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k _0.100 SEATS S75 CONTINENTAL S30 NON-PROFIT S25 I >I00 SEATS 5150 �.7 �WMMON VICT. SSO �� _��LESALE S75 RRTA t1.�CF�.RVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. S45 >25,000 sq.ft S2W _VENDING-FOOD S20 O _QS,OOO sq.ft. S75 _�ROZEN DBSSC:RT S35 _TOBACCO S25 �,p� NAMR AN F: Sio AMOUNT DUE = S o200 .00 ,��,o •••«*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••"" ADMINISTRATION Under Chaptet 152, Section 25C, Subsec6on 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's CompensaUon lnsurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT'MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED 6J iL� � �X WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and tiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO NOTTCE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILI'I'Y TO RETLTRN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEAI,TH DEPARTIv1ENT FOR INSPECTION 7-10 DAYS PRIOR'I'O OPEIVING FOR THE SEASON. ALL RENOVATTONS 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. ADDITIONA F .ATION POOLS POOL OPENING:All swimming,waciing 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 CON$irMFR ADVISORY• Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATE iN PO iL'y- Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained at the Health Department. �O .FN D �,R RTS• Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OiJ7'4IDF.[`ATi�i.C• Outside cafes(i.e.,outdoor seating with waitedwaitress service),g�have ptiot appmvai from the Board of Health. OU'!'DOOR GOOKIN[`• Outdoor cookin8,prepaistion,or display of any food product by a retail or food service establishment is prohibited. DATE:�f-a 3 - °3 SIGNATURE: -,-��u�"`--2 � PRINT NAME & TITLE: G��d �-/�r,,,,:,,y �,�o„�� -- 10/22/03 D�c-01=03 01 : 58P p.pZ �� CERTIFICATE OF LIABILITY INSURANCE °4r��Mr'v°om� raooucen � THI$ CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McShed IneuianCe Agency, Inc. ONLY fWD CONFERS NO RIGHTS UPON THE CERTIFICATE 749 Main Street, Suite#H AL R TMEHCOVER4GE AFFORDED BYTTHE pNpLICIE$EBELOW_ Osterville, Ma. 02655 54�42Q_g011 INSURERS AFFORUING COVERAGE n+suaeo � � � . . Captain Parkers Pub, InC. irvsunER�. Travgl•Qr8 i*+ffurancg � wsuasae: Aasociatod .jpdyStriae of Mnss ld�t 668 Main 9Lreat iNs�xc: W. YaxmOuth, Ma 02673 INSUftCRD: � -' INSURFR t: _ �� . .. .. coveRq�es THE POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABpVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANV REQUIREMENT.TERM OR CON�ITION OF ANV CONTRACT OR OT1{ER DOCUMEN7 WITH RESPECT 70 WHICH TFqS CER7IFlCATE MAV BE ISSUED OR MAY PERT4IN,THE INSUR4NCE AFFOROEO BV THE PpLIC1E5 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS ANO CONOIilONS OF SUCM POLICIES.AGGREGqTE LIMITS SHOWN MAY MAVE BEEN REDUCED BY PAID CLAIM$, INSRI.. T•pEOFINS11F4NCE ��'E TVE PDL ' . . iOLM1'NUMBER �0 MI�IN�Y� 11Mlf3 GENERRL L�q9��y EPCN OCCURRENCE i]. OOO_OO.O R CpMMGFiCW�GFNERAI IIANILITY FIREOAIAAGE(A�Y�fiie) y CUIMSMA� �OCCUk - ' 90, MED EXP�My one peraon� 3 QOO A ' . I660-7907A505TIA03 06/Ol/03 08/Ol/04 �RsoN^�g^��n�u�' s p — GENER4LAGGRCGAIE S �OOO .00O GEN1Af,GREGNTEP�APM.IFSYEK PRODUCTS-GqM%OPqGG S'j OOO_OO POUCY EC7 � O. �UTOMOBILE LMBIIm COMBINED$INGLE IIMIT AfiYAUTO (Eaardtlanp S /LLLOWNEDnUfU9 ' ' � � BODILYIWURY S SOIEM1lEU AUi03 (�� IIIRFDqUTOS - � NONANMEDAUTQS B��ILYINJ�qy f (Pn actlper�p �— PROPER7Y pqMqGE f � . (�a acaEantl CA�GE u�un AUTO ONLY- E�ICCIOENf S ANY AUfO orHeR rnnN ��cc s . A1fTOONLV: AGG ( .. . EXCE93 WIBILIIV GCN p�CURRFNCE f .]qCCUR �CUIMSMA�E aGGNEGAT[ g OEWGTI�LE � s . . RCTENTqN 5 ' f , S WORNEflSCOMVEN$ATONAND EAMLOYERS'1IR61LRY TOqY LIMRS ER �Z8��3661�1?'�02 04��-�03 04/Ol/04 E.L.EqCHACCIOEM E Q/� nnn B ' ' Y-I-+�-r— E.l.DISEASE�F4 EWPLOYEE i Q OTHER GL.DISEASE-FOLICVIIMIT S �ESCRIPIION OF OPER4TONSILpWTONSNEXICLE$IfiXCLWIONS GppED BY ENDOR$EMENdSPECI4L►ROVI910NS � [. iC� '_� ,� Q? '.� D DEC 0 2 2003 HEALTH DEPT. CERTIFICATE HOLDER nnumowu vuurt¢0{IN9URER llrTEq; CANCELIJ�TION bHOULO ANY OF THE ABOyE DFypq�gEp pOLJC1Ed BE CANCFLI.ED BEFORE TXE EXPIRNTION rOWll of Yarmouth GATE iXEREpF,T„E ISSUING IN9URER WILL pipFJlypp 7pl�q��_pqr6 WRIITEN Health Department NOTCE�OTNEGER7IFICATEHOIDERNAMEOTOTMELPFT,9�FAILURETOD0903XALL Y8L1l1011tty, Ma. 02673 IMPOSE Np pgLIGATION pq Uq&LfIY pF ANY I(IND UO�N THE INSURER,li9 AGENTB OR REPRESENTqT1VES. AUTHOR2E011EPRE9ENTATIVE ACORD 253(7/97) I C m ACORo CORPORnnON 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLLSHMENT PERMIT NUMBER: #04-043 FEE: $150.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chepter ]11,Sec[ion 5 of the C�eneral I,ews,a permrt is hereby granted to: Captain Parker's Pub, Inc., 668 Route 28, West Yazmouth, MA Whose place of business is:___Captain Parker's Pub, Inc. Type of business: Food Service To operate a food estabGshment in: Town of Yarmouth Permit expires: December 31 2004 BOARD OF F�ALTH: Be�ami�s$. � M.�. san�rwc: t3o PaL+tcLi Ma.�`le�xoll, ?/ic+o C�ai�tw�a�c �5�� December 2 2003 ruce G. Miuphy, , S,CHO Director of Healih THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #04-033 F'EE: 50.00 This is to Certify that Captain Parker's Pub, Inc. 668 Route 28, West Yarmouth, MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and e�cpires December thirty-first 2004 unless sooner suspended or revoked for violation of the laws of the Commonweakh respecting the licensing of common victualler's. This license is issued in conformity with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. soaRv oF�ai.�: B�$. l3�,M.$. sEq�rw�: 130 /�atifc�6 M�o.$ fi/ios G�ltoi�n �o. �n Roda�t 4. B�� R.N. December 2.2003 iuce G.Murphy, ,R.S.,CHO IJirector of Health Ca�- Rv,eK�s • o��a,y TOWN OF YARMOUTH BOARD F r � � ., 3 � APPLICAT[ON FOR LICEN 20 '�� "3 I� (t� '._ ( ��J/ [s' � rC�i � ,' � v - * Please complete form and attach all necessa , c�ents by IJecem�er l, �� 2 � ZQQZ Failure to do so will result in the return o . our application packet • HEA�Ti-i U T. NAME OF ESTABLISHMGNT: W�4 ` � [ [. TEL. # 77/- a7L6 i QCATION ADDRESS: 6L � /C-f� .�J3' MAtLII�IG ADDRESS: vtST J�i+�C /9u/�� /NA o.TL �3 R/ RP N ME• 1�ANAGER'SNAME: „o.t�.rd NHAw�Mf TEL # 77�''�9�G M�II�INGADDRESS: G68 R't• �8' 4.�s1' yiq�cHoc.l�s� �c�ls) a�L7S POOL CERTIFICATIONS: The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated Pool OperaYor(s) and attach a copy cf the certification to this ferm. 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 of employee certifications to this form. The Nealth Department will not use past years' records. You must provide new copies and maintain a 51e 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 wiil not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON II`r CH�SRGE: - _ Each food establishment must have at least one Person In Charge(PIC) on site during h�urs of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies aod maintain a file at your place of business. I. 2. 3• 4. RRSTA A T ATIN : TOTAL# ►.onciNc: OFFI . ON .Y � LICENSE REQUIRED FEE PERMIT# � LICENSE RGQUIRBD FGB PERMIT# LICENSE REQUIRf D FEE PERMIT fl ._H&B $SO _CABIN S50 _ _MOTEL S50 _1NN S50 _CAMP $50 _SWIMMING POOL$75ea _LODGE $50 _TRAILER PARK $50 _WHIRLPOOL $75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _0-100 SEATS $75 _CONTINENTAL S30 NON-PROFIT S25 I >IOOSEATS SI50 1�0.3- (J3/ / COMMON VICT. $50 #a -dZl _WHOLESALE E75 RETAIL SERVIfE• � LICENSE REQUIRED FEE �PERMIT# LICF.NSG REQUIRED FEE P6RMIT# LICENSE RBQUIRED FEE PERMIT# _�50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDMG-FOOD �20 , _<Z5,000 sq.ft. S75 � _F'RO'1..8N D6SSF,RT�575 I T013ACC0 �/ , �=83-ooY � NAMECHAN('F• $�0 AMOUNTDUF = $ ��$'.00 , *"•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*••+� - - -- ---'^^--� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license ot permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pnor renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO N01'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILI'I'Y TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 2002. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVAT[ONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depaztment 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 Ai�VISORY: Each food establishment which serves or selis ready-to-eat, raw or undercooked animal products aze required to post Consumer Advisories. ('AT RING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtamed at the Health Department. �]tOZFN DESCERTS•___ -- - - - - - - —. ---- � Frozen desserts must be tested on a monthly basis by a State cert�fied lab. Test results must be sent fo the Healt Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until tkie above terms have been met. OtiTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING• Outdoor cooking,preparahon,or display of any food product by a retail or food service establishment is prohibited. DATE: I I" l �� o z SIGNATURE:'�CJ�^ """ /��/ PRINT NAME&1'ITLE: GCRA�l� �pw^ /n �KfJ�IdO�� 10/18/02 . � , —_�� i - . � The Commonwealth ojM¢ssachusetls = Deparrment ojlnduslria/,-fccidexa o amceo�iiresaosw.s 600 Washington Slreel ' Bnston,Mass. 02111 �� '` W'orkers' Campensation Insurance Affidavit nam��. l v9� I� �/��d. ,S 6�1! � �dC• � r Lucation� `�7 � 1�f• e�� rit� �vfST `�'�q�yoli�f'�� l'�� O)G 9 ehon a S�a ' �l/� tr766 � I am a homecwner pzrtormmg alI work myself. � I am a sole proprietor _r.� ha�e no one ��orking in anc capacin� � I am an emplo�er pro�iding workers' compensation for mv employees workine on this job. T 8�� comnana name: aJ A ress• �5�� ehon p• insurance co. eolicv M � I am a sole proprietor. general contractor, or homeowner(circle onel and ha�e hired the contractors listed beloK «ho ha�e the follo�cin; �corker, ,ompensation polices: �moanv name• ad d ress: tin'• Ahone tl• irsurancc co. neliev p tomoanv name: __- ---- ----- �- � - ----_ . . ...-- --- _ _ addresr. . . . _ -_. . . . . _ . — _ __ .._ �__ ._ _.__ .. ttri: - � phoee�• � insurnnee co. p��n,p t Failurc ro ucure covenge u requircd uader Secnoe 25A of MGL 152 n�Ind w He iepaiow o(erid�l peadtles of a Ou ap to 51�00.00 a�d/or ooe yean'imprisoamrnt u w�dl��eivil pendtlea io the torm of a STOP WORK ORDER��d a li�e of SI00.0!t d�r q�io�t me. 1 ndenta�d that� eopy of thy sutement may be for.r�rded to the Olree of Inr�fNe�tiom otMe DIA tar eovera�e reriflotlo�. . /do-hrreby cenij}• der,/��re pernt artd penaUia o pepury thm tbt injormadnn providtd abov[ir put and enr►tet Signaturc_7_�C/LA�— ��A�� /�-/ /� �� . Print name V��C} ��q / q �e N .56�'7�/' f�.4L� .. oRcial use onh do no��rite in this trea to be comp�eted by cih or towo ollltial ciry ar town: yARMODTH _ permiNiceex M n8uilding Dep�rtmeet pLteemieg Board �check if immedia�e response ie required 261 �Selettmen'e ORee contact person: (S�8 3 QHnItE Departmeat � phone M:_ __� 98—?231 eat. nOtAer ��TM CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDD/YV) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MCShed Insurance A enc IaC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE . 4 Y� HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 749 Mdin Street, Suite#H ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. � Osterville, Md. 02655 INSURERSAFFORDINGCOVERAGE INSURED Captain Parkers Pub� II1C. INSURERA: INSURER B: 668 Main Street �NSURERC: W. Yarmouth, Ma 02673 INSURERD: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTNITHSTANDING ANV REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSUR4NCE 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 CLAIMS. INSR rypEOFINSURANCE POLICVNUMBER Po�VEFFECTNE POLICYEXPIRATION LTR UATE MMIDD/W DATE MMID lJMR3 GENERAL LIABILITV EACH OCCURRENCE $ CAMMERCIALGENERALLIABILI7Y FIREDAMAGE(Anyo�fire) E CLAIMShLI�E �OCCUR MEDEXP(Myoneperson)� E A PAC5656766 08�O1�Q'Z Q8�01��3 PERSONALBADVINJURV E GENERALAGGREGATE $ GEN'LAGCaREGATELIMRAPPLIESPER: PRODUCTS-CAMP/OPAGG $ POLICV PRO- JECT LOC AIJfOMOBILE LIA&LIT' COMBINED SINGLE LIMR ANV AUTO (��tlent) E ALL OWNED AUTOS BODILV INJURY $ SCHEDULED AUTOS (Per pet5on) HIRED AUTOS BODILYINJURV S NON-OWNED AUTOS (Per acdtlent) PROPERT'DAMAGE t (Per attidmQ GARAGELIABILI7Y AUTOONLV-EAACCIDENT $ ANYAUTO OTHERTHAN �ACC S � A1f�00NLV: pGG S E%CESSLIABILT' EACHOCCURRENCE S OCCUR �CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION ANO TA - EMPLOVERS'LIABILIiY TORV LIMITS ER WMZ8003661012002 08/01/02 04/O1/03 E.L.EACHACCIDENT s 8 E.L.DISEASE-EAEMPLOYEE $ E.L.DISEASE-POLICVlIM1T S OTHER DESCRIPTION OP OPERATIONSILOCATIONSNEHIGLES/EXCLUSIONS ADDED 8Y ENOORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LEfTE/t: CANCELLATION SHOULD ANY OP THE ABOVE OESGRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOF/Il OP Yarmouth DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL� UAY$WRRTEN Health Dept NOTIGETOTHECENT7FlCATEHOLDERNAMEDTOTXELEFf,BUTFAILURETODOSOSHALL Yarmouth, Ma. 02664 IMPOSENOOBLIGATIONORLIqBILIiYOFANVqNDUPONTXEINSURER,ITSAGENTSOR 5 0 8-3 9 8-0 8 3 6 1''dX REPRESENTATIVES. AVfHORIZEDREPRESENTA7IVE ) /' rtI ,,C e � �Wv�^— �Y ^�j�,y� ACORD 25S(7/97) 0 ACORD CORPORATION 1988 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #03-031 FEE: $150.00 In accordance with re ations promulgated under authoriry of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eral Laws,a permrt is hereby ganted to: Captain Pazker's Pub, Inc., 668 Route 28, West Yaruwuth, MA VJhose place of busmess is: Cautain Pazker's Pub.I�. Type ofbusiness: Food Service To operate a food establishment m: Town of Yarmouth Pern�it expires: December 31. 2003 Boaxn oF HEnI,TH: �a�s� ZdlGfec, �aor�a,c sEwru�rc: �30 � D. Cjezdac �J1,!D.. ?/Eee ,�a�. S"�eas�. �lerk �a�iu6'�Dauxaft �e�c S�fak, 2?Z. Nwember 29 ,2002 � ruce G.Mwp y, .,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER #03-021 FEE: $50.00 This is 10 Certify that Captain Pazker's Pub Inc. 668 Route 28, West Yazmouth,MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2003 unless soo suspe ded or revoked-fai-violatian af the-lxws of the Gon�monwealth resPge�ing th�-- licenns3ng of c,nommon victualler's. This license is issued 'm ebnformity with the suthority granted to the licencin�u authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereo�the undersigned have hereurno affiaced their official signatures. BOARD OF HEALTH: Qlraalea ii�. Zelll�ai. �ka�carc sen�rn�c: lso �i.�Ja.�rt.s D. Cjmrda.�, �1C.D., ?/[ee Radect�. Sua�c. �k �a0aiak'jX.dDauxett :� S�fa . ,��Z. � November29 ,2002 ruce ut Y, •, Director of Hea(th � . . . r,. � . . .. s: � I THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER #03-004 FEE: $25.00 Th;s is to certiry t6at Captain Parker's Pub. Inc. — 668 Route 28. West Yarmouth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This�em'�t is�nte�lia��'ormitv with Article VI o�e Sanit�Code of The Commonweaith of Massachusetts,and e�cp es ec er uol8ss sooner suspen or revo November 29 ,2002 BOARD OF HEALTH: �adte�, i�elll.(oc, J(�tbryrs� �ucja�c 9. C�iride,c, 'I�D., ?/iee �(�ata.xa« �a6art`�. $�. � �a�[ek'�XCDauxott :�' S�Fa.E .�Z. --- — __ ruce G. Y, •> . — _— Director of�s- .. ,� � r.,. as CAPT.PAQKE2s - ` TOWN OF YARMOUTH BOARD OF,,�IE` 'A r � ,;; j� `�� ;�'"';�' APPLICATION FOR LICENSE/PFi�� ry'� JAN 0 8 2002 • Please complete form and attach all necessary documents by Decemb ' 1, 2001. Fai re to do so will result in the retum of your application packet. HEALTH DEPT. NAME OF ESTABLISH NT• �}K .c S v 1h c, TEL. #Sa ' � ��fa i n�ATinN A1�l�RF.SS� 6 ��• $� MAI DRE S: 6 t- �Sf t S� i9�lHa �} aab 7� OWN .R/CORPORATIONN[LME• C/tpr� p�� 'S ✓�v�,, Tn�. MANAGER'SNtLME: C. cRal d /`-t�*�� %�f TEL. #�fr��6� MAILING ADDRF_SS• /o6Fr iCf- d� L✓PS�' YlfFfHa✓�"�i� G�1r� adc 7 3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �hw,rS G�a.c�inu2 2 �'v� h .�r1L (J�rt PERSON IN CFIAKZ'iE: _ _--- __ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. GL�c �d v`-( ` � �+ . 1. �t l9nn� ny 2. .�� C9/+r�dr�reK 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 Umes. 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. �. � � �,�a ��.,��a�. 2. r�K; H `G,�,�� 3.�tAiY.G..cC ��FC�C 4. �An ,�,ch�y RESTAURANT SEATING: TOTAL#� OFFICE USE ONLY Loncmc: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT# B&B S50 CABIN $50 _MOTEL $50 INN $50 CAMP $50 _SWIMMING POOL$SOea LODGE $50 TRAILERPARK $50 WHIRLPOOL $25ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-t00 SEATS $75 _CONTINENTAL $30 _NON-PROFIT $25 �>I00 SEATS . $150 I COMMON VICT. $50 _WHOLESALE $75 RFTA�I��.RyI . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# _TOBACCO S20 _<25,000 sq.ft. $75 � TOBACCO $20 _<50 sq.ft. ' $45 _>25,000 sq.R. $200 _FROZEN DESSERT$35 NAME CHANGE: $10 ' AMOUNT DUE _ $ LZO•OO ..«:«pLEASE T[JRN OVER AND COMPLETE OTHER SIDE OF FORM****" _ � _ _ ADMINISTRATION ` Under Chapter 152; Segtidn 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � �/ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED/� Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2001. SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL 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 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 ('QNSUMER A1�VISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked az�iinal products are 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. FROZFN DF.SSERTS: 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/waih�ess service),must haue prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepaza6on,or display of any food product by a retail or food service establishment is prohibited. DATE: I" 7 �� SIGNATURE: PRINT NAME & TITLE: G�� 4"'� �h �""�K g+K 1 % 09/11/O1 Nov-27-01 04;32P . P.O1 ACORD CERTIFICATE OF LIABILITY INSt1RANCE °"'�`"'"°°"" ii a� zooi ��i^ THtS CERTIF ATE IS �SU�AS MATTER� NIFqRNATION MeShea Zneuraace Agency, Il]C. �Y AND CONFERB NO RIGFtTB UPON THE CERTIFICATE NOLDER. TMIS CER7IFICATE DOES NOT AMEND, EXTEN� OR 749 Main Street, Suite#H ALTFR THE COVERAGE AiFORDED BY TH5 POLICIES BELOW. Oeterville, Ma. 02655 508-420-9011 1l18URER3 AFFOROWCa CQYER/1GE mau� CBptain PdYkE1rH fhi2!> IAC. " msur�r+w SASTERN CASUAi,TY IN9lNER B: 668 Main Street �nsur�nc: W. Yazmouth, MA 02673 pJSURERD. i508-771-4266 mru,�ree.. COVERA6ES � 7HE AOLlCIES OF INSURANCE Lb7c0 BEIOW HAYE BEEN�SUED TO THE INSURED NAMEDABOVE FOR THE POLICV PEW00INOICATFA.NCTWITM97ANGtNG ANV REQUIREMENT, TERM pq CpN01T10N OF ANY COMRACf OR OTHER DOCUMENT WI�H RESPECT TO WHk',H THI6 CERTffICqTE MAV BE 16SUE0 OR MAV PERTAIN,7HE INSUFiqNCE AFFORDED BV TME POLICIES OESCRIBED HE9EIN IS 5UBJECT TO ML THE TERMS,EXCLUSIONS AND C9NOITIONS OF SUCH POL1qES.AGGREGATE LMITS 9HOW N MAY FWVE BEEN RFpUCED 9Y PAID CUIM3. maawuwwec roucvwr� �ecrne roucr rwnox �r� 0lI�RLL UABLRT FACX OCCURRENCE 6 S� �UQ��O U X ca.+uerscw�c,�nenuiwawrv Raeoan+u�ianrmew.� s100,000 � c�ae.uu,noe ❑X occua nEocxv�,xyw�.�,,,� s5,000 A CP-0000075 08/Ol/Ol 09/Ol/02 cEassaru�anoviwunr s1�000 000 :.er+ena�nccaewre s2,000,000 GENLA6GREG4TELMRAWllESPtTl PRO�UCTR-Cql.pppl�6 $1�000 D/�Q N POLICY �� !p� MITOAIOlIL!YMNT'! ANVAUlO �WRINEDS'.NOtEIIMff = IC��q MLOrvxEDAUtos B000.Y1NJWY ' SCXEDU�ED AUT� (Pai pssp�) HPEDAVfQS � BODiIYINRFY = NON�QWMEDMfipS {Parep,qrml wonenmou.uce S tr�.�mmv;. �E�V� Alf10WlY.FA0.;,G0ENT S '�'N�A� ENACC S OTXERlINf: WTOONIY: p� : Fkt¢tf waurv E4GM OGGUPAENCC 5 � �OCGJR ��WAaKµop¢ nGGREGAIE `S DEDtiCT6LE � T 5 �RElENTroN E S wp�lilRS CorvlNlllTqn�vN FMPLOYFR4'I.W4Rv X RY WCOOC13004 OB/O1/Ol OB/Ol/02 EL.FApiAtC10ENi ESOO 000 �. A e�oissnsE-E.ewi.wee =500,000 � e�.ms��ro�,cvunxr s500 000 or!�e arscArnow os wm�noxs+�oc�rrowr�xwtestzaiaa�e�ooeo er eNoan�ernrtnreew�eansww CERTIFICATE IqLDER novmoru�wsur�; uuune��erreR; CAYiCELLATION 1M[I:1LD 0NY 9i TME 1Y04Ti lYitRiFD iOLICJii BE CANCfC1E0 CEFORE:X!EW9fAilaN TpWa Of ?d�'6Routh owre rnerteoF,me�sswr��xs:�w mu e+ueawH+ro ru '�p a.rs v+rsmr�� TowLl F711 xonce To rxe:srce�ute xotnen n�x�o ro rne�sr,eur eaw.�e ro ao se sHuu � Licenai.ag Lept IIA^OSE MG OpUC�TIOry pR L A611T`�f uyy qM��PpN TNE:N9URER ITf AGiNTS CR YaYmauth, Ma. 02673 ,�,,,�,,,�� urtHon�tRvrsxnr.r� �. ACORD 25•S;7i97) A� �p ACORD RPORATI6N 1888 TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: #02-096 FEE: $150.00 In accordance with re ations promulgated imder autho�rity of Chapter 94,Section 305A and Chapter 111,Section�f the General I.aws,a permit is hereby ganted to: Cant�in Parker'c Pub��, �d+R Rrnrtr�R Wect YarmnLrth_ MA Whose place of business is: Cantain Pazker's Pub_Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2002 BOARD OF HEALTH: �:�. zd[i.�rea. (�,�xa,c sear¢�G: lso D. Cjmrdas, 771.D.. 2/iee �� . Ll�erk �aSrEe��arixotl �de«Skak. �'!Z. March 26 ,2002 ruce G.Mwphy, .,CHO D'uector of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #02-064 FEE: $50.00 Tlus is to Certify that Cantain Parker's Pub. Inc. 6fiR Rnute 2R West Yarmauth_ MA IS HEREBY GRANTED A COMMON VICT[JALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2002 unless sooner suspended or revoked for violation of tlie laws of the Commonwealth respecting the licensing of common victualler's. T}ris license is issued in conformity wrth the authonty granted to the licensing authorities by General Laws, Chapter 140,and amendments thereto. In Testimony Whereof,the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: �ifazlee� xdlfiFoa, � szarurG: lso �' rja«rui D. CJmido�e 711.D., ?/ree ,�adert`�. 'S'�aawic, (/�ezk �a�dek�Dor�ett '�ele�S�ak, ,�71. March 25 ,2002 G.Murphy, I� .,CHO Director of Heal THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTFI PERMIT NUMBER: #02-016 FEE: $20.00 1'his is to Certify that Cantain Pazker's Pub Inc. 668 Route 28. West YarmoutiL MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBLTI'ION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBAC O FGLTi TION This permit is ganted in conformity with Article VI of the Sanitary Code of Tl�e Commonwealth of Massachusetts,and eacp'ves Dec�ber 31_2002 imless sooner suspended or revoked. March 26 ,2002 BOARD OF HEALTH: �u�clia�s�, i�efll�et, �(/fabwiaK �rja+x�D. �josdar. �l.D., ?/�ee �iFat�,�a.c �e6ett'�. �Oavs, �lerk �a�lek�ee.xetL' '�efe�S .�1. Director of Heal� � c �� CH. . PH2K&R.S I�JB ., , ' ��2$ � � � d � � TOWN OF YARMOUT A H¢, APPLICATION FOR LICENSE/PERMIT-2001'[ D E C � �F YOOO • Please complete form and attach all necessary documents by December 31, 2000. Fail the return of your application packet. ----------------------------------------------QA�'Pr 'IIV�--------------------------------------------- NAME OF ESTABLISHMENT: �$lBYAIId . TEL. # 7��" �'�� LOCATION ADDRESS: MAII,ING ADDRESS: MANAGER'S NAME: �e�,�i ��n �n ti TEL. #S ' � 7�- KaLG MAiT.ING D F : �,k �'r�ay wPs1' � ,,..�� a6�3 --------------------------------------------------------�------------------------------------------------------------ POOL.CERTIFICATIONS: The pool aupervisor must be certified as a Pool Operator, as rec�uired by new State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tlus form. 1. 2. Pool operators must list a minimum of two employees currenUy certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. T6e Health Department will not use past yeara' records. You must provide new copies and maintain a file at your place of buainesa. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificaUons to this form. T6e Heatth Deparhnent will not use past years' records. You must provide new copies and maintain a fde at your place of business. 1. �T[�AGa�s 2. 3. 4. RESTAURANT SEATING: TOTAL# NON-SMOKING SEATS: TOTAL# _ -----------T��___..�...,�--__...__� s�__��_-----_-- L OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# B&B $50 CABIN $50 _INN $50 _CAMP $50 LODGE $50 TItAILER PARK $50 MOTEL $50 SWIMMING POOL $SOea. WHIRLPOOL $25ea. FOOD SERVICE: NO'I'E: Per the new 105 CMR 590.000 State Sanitary Code for Food Establishments,the effective date for food protection manager certification is October i,2001. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $75 CONTINENTAI, $30 I >100 SEATS $150 �� NON-PROFIT $25 I COMMONVICT. $50 ,#Q1��3G, _WHOLESALE $75 RETAIL SERVICE• LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $45 / TOBACCO $20 ��-0 2( _<25,000 sq.ft. $75 _FROZEN bESSERT $35 _>25,000 sq.ft. $200 NAME CHANGE: $10 AMOiJNT DUE _ $ 22A•00 *•*•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•""* _._._.. _. _ . , � ' ADMI1vISTRATION i�nder Chapter 152, Seclion 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of_�:.�i�e�i�?ct�e�lit 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 A1VD SICtil'YTtiil;A1[ *..`s:' ::�� CERT. OF INSURAN'C��.�#��H�D� � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31,2000. SEASONAL ESTABLISHIv1EN'CS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPErTING:All swimming,wading and whirlpools which have been closed for the season must be inspected , by the Health Department,and the water tested for pseudomonas,total coliform and 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 withirt seven(7)days of closing. FOOD SERVICE NEW STATE SANITARY CODE FOR FOOD ESTABLISHMENTS: The effective date for food protection manager certification is October 1, 2001. As stated in 105 CMR 590.003(A)(2), food estabiishments must have at least one person-in-charge who is a certified food protection manager. T'fus provision is effective one yeaz from the date of promulgation of 105 CMR 590.000. The effective date for wnsumer advisory is January 1,2001. As stated in 105 CMR 590.000(K), enforcement of Consumer advisory, Food Code 3-603.11,will be implemented January 1,2001. Only establishments which sell or serve ready-to-eat, raw or undercooked animai products are required to have consumer advisories. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be obtained_at the Health DeQartment.____ FROZEN DESSEI�TS: Fmzen desserts must be tested on a monthiy 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 un61 the above terms have been met. QUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. QUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. 9 DATE: I�J i�– GV SIGNATURE: ��-' PRINT NAME& TITLE: �f�'�+lc� V I�"° H f �'?y.ri r.-r � 11/16/00 � otiye�L — ...., ,,,'--`-�--:r_!�s ��&��"� ��#✓�,a 2.... ... s;t" 1], .2�0 ...: a '"""3 vxOuuCEx THIS CFATIFlCATE IS ISSUED AS A MATTEN OF INFOAMATION BENSON YOUNG & DOWNS INS AGNCY ONLY AND CONFERS NO AI6HT8 UPON THE CERTIFlCAIE HOLDEIL THIS CEATIFICATE DOES NOT AAAEND, EXTEND OH 15 BRIAR LANE ALTEH THE COVERAOE AFFOHDED BY THE POLICIES BELOW. PO BOX 717 COMPANIES AFFORDINO COVEWIGE WELLFLEET MA 02667-0717 �„P,,,,,. � EASTERN CASUALTY INSURANCE CO �"m caMvun CAPTAIN PARKERS PUB INC. B & GERALD A MANNING �P�. 688 MAIN STREET � W YARMOUTH MA 02673 �Pury O D ;::�..� .:::<::..:::„.. . :c:a:�o.:sa:c..,.. .� a.'i';b,`�;.,E,'�..�,.,..:p.:;:.:`.:',:xs:S':�£Y"<�5;�¢i2x.;a.., i. �� :C:,;:;:� 'ylk. ......,.o .::.,,.o.e,.., o .. o.....,.,. .o.o............ ...'...':�:.;.,,,.. .,,?3.��F ;.?.� �. 'o.;:^o'gE;,o.o�.. ...., , , , ...o.>..:..., .�....�.,o, ....<..>. o . � ' ..;.....,..2...,'c, a. . . . ,..., ....,.,.............. .. .... . .. .> ..�...c.,....�..,. .. ....,. .. .�. !';..>:...�..,c><....::;.,..,..,...,... 7XIS IS TO CER7IFY THAT 7}IE POLIGES OF INSURANCE LISTED BEIOW NAVE BEEN ISSUED TO TNE IN6URED NAMEO VE FOR T}IE POLICY PERIOD INDICA7ED, NO'IWfT}1STANqNG AM' REQUIREMENf.7ERM QR CONDIiION OF ANY CONTMCT OR 07HER DOCUMENT WfTFI RESPECT TO WHICM 7HIS CERTIFlCATE MAV BE 46SUED OR MAV PEHTAIN,7ME INSURANCE-AFF6RDE6 BY 7HE POLIqES�DESCRIBE�MEREMI I6 &U&IECT TO ALL TlIE 7ERMS, E7(CLUSIONS AND CANDff10NS OF SUCH POLICIES. LIMffS SFIOWN MAY F1AVE BEEN REDUCED�BV PAW CUIMS. � ine OF MBIIxu�Ce �OUCv MM�6Ex p�/��r�pyypnn �n ry�,n ��/ng m�seu �y GENENAL AGGNEWTE 3 COWAEfiCIK GBIERAL tIABILRV PRODlMTB-COMP/OP A6G f CLAY6 MAOE �OCCUR PENSONAL 1 ADV MUUfiV i ..ON77ER'8 l CONRiACTOfY6 PROT EACN OCCUNRENCE i FlRE DAM�6E(Any oro M) i M�IXP(My ons psRon) i MlfOYOBLE ll�BLIfY ANY AUTO � � . C066Nm SINOIE LIMR i N10WN�AUf08 .. .. . . . .. _. . . .. . BODILV�.WUNY - �� ... . Sd1�UL�AUTOS (�PM�1 = HIPED AUfOS BODILV NlJURV Na+owri�wros rv«.cueem • � PPOPERfY DAMAGE j OYIAOE tMl�IfY AUTO ONLV-EA ACCIDBJ7 i �A� OTiER 7HMl AUTO Of�V: E�CN ACCiOENT f AGGRECa�7E i ��Y EACN OCCUflNBiCE S UMBRELLA PoflM AGGREG�7E f 07NER 711�N UG6PEl1A PDMI j won�meorvom�nowun WCOOA2011 8/O1/00 8/O1/O1 X ��.�Rs ER' �orEne•u�aurr ri�a+�ccnv+r s 500 000 TME°rrorni�row X � ao�s�-roucvuMn t 500 000 PARINER$�E7(H'.IRNE OFfICEN3ME: IXCL aoisFwsE.Ewo.�r�ovEe = 500 000 or�En nFscnvnow os orcn�no�oc�no�r�a.ca�av[a�t�re RESTAURANT FAX: 508-398-2365 ...,.�.�. ,�:.�.:;c;:.;:::s::;>:::...:.:.:.:.:.�;:'�<;,:;�,.;s.:,;;.: .. +��{� .: .,. ,.:.... . CERg1. .............FI.Cr.Al:: �:::. �- .::g..,x.�:�aa>:i.::�:::<:.:.:.::r:,:>...,,.,...,.........::..:..:.,:,.::.:.>,�....:.,,r.,.,..,.. ::>:;..:.,:::.:<';;:;,'::,:s?,:::::::i:<.::.;sor.�e,:.:>'::,::;:.::>:;;:;,":;;:,.i':::::�i::i>:.z!�:�>g.:��:�::;:;:;>:��g ......... .� � n........... ..:...c......2 a c L .�..... . .... .......':'::n�,�»Yr� E n... ..... . ... ..w............. . ..�...r.... . � .. ... .. . .. .. . . .... ::.. BXOIMD�AM'! GF ilE�AlOYE OESCPlFD PCLIqE6!6 CAfICE11EU 5FFOPE TF TOWN OF YARMOUTH evw�nor o�� ,�or, TE 1$$IIWp CpYPANY WLL EIOE�Vpi TO Y�L LICENSE DEPT — TOWN HALL ,��onre rrnrrta Monce ro nE c�ns�re xo�oeen wu�Eo ro nE�r, MAIN STREET eur Fwa�ro r�wa�rane� rvos�no o�c��p�u�surr SO YARMOUTH MA oF un wn iwow nE v , irs waexn �xr�rnee. wmon�o nEvnEs�r�rn i Elaine F. .,;>..:>:::<,..:.:_ ,... ..; ... .... .:.... ... ....... AbQRD.�...:i:.... . .. . .... . . ; ...; , . .. .....,.,.... . . . ' >:�::.: .. . .:. . ..,. . .......... .... >..... .:.: ........: ...:. .. ....:.:�:.;:: :�:�:::�.:.: �A�.�.'.A1f,:.CQRRONATION 7989: r THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH ' PERMIT NUMBER: #O1-036 FEE: $50.00 This is to Certify that Captain Pazker's Pub Inc 66R Rnnte 2R, West Yarmnnth_ MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2001 unless sooner suspended or revoked for viola6on of the laws of the Commonweatth respecting the licensing of common victualler's. This license is issued in confomuty with the authonty granted to the licensing authorities by General Laws, Chapter 14Q and amendments thereto. In Testimony Whereof, the undersigned have hereunto �xed their official signatures. BOARD OF HEALTH: L�d'�?l. '�et7`es, �iaGaarak s��,�: ►3o e��. z�, v� e�� 3. �: ee� �� o :� �� . .a. Februarv 9 ,2001 ruce G. Mwp ry, ,R CHO Director of Healt6� TOWN OF YARMOUTH BOARD OF HEALTH ' PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #01-059 FEE: $I 50.00 In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter 1 I 1,Section 5 of the General Laws,a permit is hereby granted to: ��p ain Park r'c Pi�, Tnc" fi6R Ro � . R Wect Yarmrnith 1��A Whose place of business is: C�ptain Parker's Pub_ Inc. Type of business:__ Food Service To operate a food establishment in: Town of Yazmouth Pernut expires: December 31. 2001 BOARD OF HEALTH: �d� �etlea, (�a� SEATQ�]G: 130 �-A--�J .� z�, v� �� W � �. � �tQFI d .L�O![ �G�t fa D. o�c JC.D. February 9 ,2001 ruce G. Murp y,MP ,R. , CHO . Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #01-021 FEE: $20.00 1'his is to Certify that Cantain Pazker's Pub Inc 668 Route 28 West Yazmouth MA IS HEREBY GRANTED A LICENSE ', For T E ND DIST UTION OF TOBACCO PRODUCTS � AS PER THE YARMO TH BOARD OF HEAi TH TOBACCO REGULATION This permi[is g�att[ed in wnfotmity with Article V[of the Sanitary Code of The Commonwealth of Massachusetts,and I� expires December 31.2001 unless sooner suspended or revoked. February 9 ,2001 BOARD OF HEALTT-I: �� dted. �savt�� QXfed�. /��C. �/fCe �Urnt[1K l�a�u �. �i40tvK. �tl� . �Kukael d :L�«�q�c ?a�x Cfoz 'f'K.�. ruce . p� , . ., Director of He , Ca��tzt� n I�r kF r s R�i� (,� ^ � TOWN OF YARMOUTH BOARD UF HEALTH � � �' � 0 M l2s DD , APPLICAITON FOR LICENSE(PERMI'F- 2000 $a � D E C 0 3 1999 `�., ' �,.� lll�4�ao * Please complete form and attach all necessary documents by Deceinber 31, 1999. Failure the retum of your application packet. ------------------------------ ---- ----------- - ---- -------------------------------------------------------- N� OFESTasLIS�rrT� �i+r°t�+�%, A�� 'S /J�✓S :iKc, �L # 7Jl-��6� LOCATIONADDRESS v6B �`r- �� /-tn�=� st. MAILING ADDRESS: k,e s 7 �,a,er e�Y-h� K�4 oa� �3 1vIANAGER'S NAME: ��t.v i cf �+�•,�s TET # MAILING ADDRESS: � —_----------------------------------------__---_—_----------------------------_��_��_. POOL CERTIFICATIONS� The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy ofthe certification to this form. 1. 2, Pool operators must fist a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Healt6 Department wilt not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. 1-iFi_Mi I H RTIFI ATION All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anfi-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1._c..�`� AZrY3c.tt�D L[�S1 2. 3. 4. RESTAURANf SEA'F�NG: TOTAL# NON-SMOKING SEATS: TOTAL#- - - -- ------------------------____�__ _---__M_______�M________________� OFFICE USE ONLY � �� ~ �� ADGING: LICENSE REQUIItED FEE PERMIT # LICENSE REQUIItED FEE PERMIT# _B&B $50 CABIN $50 _INN $50 CAMP $50 _LODGE $50 TRAII�ER PARK $50 _MOTEL $50 SWIlVIlVIING POOL $SOea. WHIltLPOOL $25ea. FOOD SERVICE• LICENSE REQUIItED FEE PERMIT # LICENSE REQUIILED FEE PERMIT # _0-100 SEATS $75 CONTINENTAL $30 �>100 SEATS $150 2 -3 _NON-PROFIT $25 �COMMON VICT. $50 y2K.2,s _WHOLESALE $75 RET ii ERVI E: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _<50 sq.ft. $45 � TOBACCO $20 Y2K-12 _<25,000 sq.ft. $75 FROZEN DESSERT $35 _>Z5,000 sq.ft. $200 NAME CgANGE: $10 AMO[7NT DUE _ $ `Z ZL�- •'•"`pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•^••• � . ADMINISTRATION UNDER CHAPTER'152, SECTION 25C, SUBSECTION 6, 1T�TOWN OF YARMOUTH IS NOW REQUIRED TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A RER�OI�.(�It -COMPANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSURANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVII' MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED W' C � g� � F�4x�D `To D FFI C,� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TA3�S AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERNIITS. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE: PERMITS RUN ANNLJALLY FROM JANLJARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISHIV�NTS ARE TO CONTACT Tf�HEALTH DEPARTMINT FOR INSPECTION 7-10 DAYS PRIOR TO OPENING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ADDITIONAL REGULATIONS POOLS POOL OPEMNG: ALL SWIMNIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR THE SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENT, AND Tf�WATER TESTED FOR PSEUDOMONAS, TQTAL eOLIFORM AND 3TANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPEIVING, AND QUARTERLY TI�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIIvINIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN(7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN Tf�TOWN OF YARMOUTH MUST NOTIFY TI-IE YARMOUTH HEALTH DEPARTMENT BY FII,ING Tf� REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO TI� CATERED EVENT. Tf�SE FORMS CAN BE OBTAINED AT TI-IE HEALTfI DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI.Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO TI�HEALTH DEPARTMENT. FAILURE TO DO SO WII.,L RESULT IN Tf� SUSPENSION ORREVOCATION OF YOURFROZEN DESSERT PERMIT UNTIL TF�ABOVE TERMS HAVE _ _ ___ _ _ _ _ _ BEEN MET. �1TSIDE CtLFFS: OiTTSIDE CAF'ES(i.e., OLTI'DOOR SEATING WITA WAITER/WAITRESS SERVICE), MLTST HAVE PRIOR APPROVAL FROM Tf�BOARD OF HEALTH. OiJT'DOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISHMENT IS PROHIBITED. DATE:�� 3 �/ SIGNATURE: ''� �- PRINT NAME& TITLE: �C rc'y`1�cl ��fa�G�� owh e,�/�.l,f,,.r y v�c I1/12/99 12/06/99 MON 16:99 FA% 5089497894 B &D - WE FLEET � 1�002/002 .............. �� ACORD 12 06 99 r�waicw � TMIB i1TIF7G► IS ISSUED A$ A O N�IFO � BENSON YOUNG & DOOPNS INS AGNCY �'r � �� NO �0►rts uvON n�e �cp� . HOLGE0. 1M18 CEWi1FiCA7E DOES NOT AYFJID, 67[iEND OR • 32 HOWLAND STREET M.n+ n� eov�u►oe �onoeo er Txe nour.�sa�ow. PO HOX 559 COIO�ANIES APioeul�w COVEiu►a8 PROVINCETOWN MA 02657 m...nr • FAIRMON'P INSUItANCE COMPANY � CAPTAIN PARKER PUB INC � o � l� r`'., (�N S,� � s6s aG�,Eix s��=�G `°c""" DEC 0 6 1999 WEST YARMOUTH MA 0.2673 p°'�"Y HEAi : :� UEPT. 7N81i TO CERTIFY T1AT Tf�POIJCIBS OF W6U�MCE USTED BELOW INVE BEEN BSUFD TO Ti�MIBUim NANED ABOVE WH TIE POIJCY vEiilOD MlDICATm.N011NIM6TANOI�Ki ANY I�Ol1�iENEMf�TEAY Oli QONDRION OF MIY CONi1YC�OR OiNER DOCIIMENT WRN�SPELT TO WHICH 7X6 E7fCUI610N6�Al�q CCNDI710NI8 GF Btlqi FOLICEB..l11ff8 BMOM�M AIA�BEEN RECIICm B1'G�BE�f7.AM16. �8lIB.IFC�TO M7.711E 7ER116� � e�re o��y11MI1C[ . /01lCT 1�11�t�. � � � � �� l�llls �EUL W W11/ � C�UL L9BREO1�tE i MI�eR{iYL OBIEML 1UIBWIT . . . . . a PRO�UC�S•COWIOP 11Ci6 i CJJYB WO! �OCCIIR _ i9ROMIL f ADV wWIP i „o OYYNEM'8�CONIR�GIGR'B PROT EAW OCCURRBiCE i . .. . .. . . . .. wxCDAW9EWyarW) i .. . � M�FYP Wy dr prwN { tlR0Y0YaE W1e�dt . _ . �wv�um cae�a�ta�uar s �ui oMM��urOs - .�. . .. . moLr rulnv s BCII��IR08 (�� fW�W108 . . . . . .. . 60CRY�LMIV , u011.we�µ1�G6 ��'� GROPERn ovuGE t wn.oe weanr �uro owr.u e �wrwro o+N iww�uro aar '^�"«rp''='�°`:�: ��ccoexr s re s oc�,�aa wn+er oeeupae� s Uene�.�iuwi � �c�te 07M8R TWl ti6RHl�rpf� i •onimxaeerom+wr�ro 80646844 1/Ol/99 1/01/OU X '�m��-u3�:�3 o��o�r wrun a�ec �+r s 100 000 TME°R°""tTO11' X Na ae�s run 5U0 000 �� eoa " aom�.eiw,ov� 100 000 ona oEsa�nta�os oraunoMrtoranae�pa�awa��mr wome w�a n��sovc o�asauem vaueEs��•--•••-evon�ne TOWN OF YARIYIOUTH ouw�na pr��. � �p e�� ra� �,�p�p� HEALTH DBPARTMENT 1SL wn wwr�rons»na wn�+e Na�rwE.o ro ne�or, FAX: 508-398-2365 �� YARMOUTH, MA 02644 ar �rr m wor �e,ons e� �onqo�r��arp, AY111011� 11WNpBRMME Elaine F. H . TOWN OF YARMOUTH BOARD OF HEALTH � PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMITNUMBER: Y2K-39 FEE: $150.00 In accordance with regulations promulgated under authoriry of Chapter 94,Section 305A and Chapter I 1 I, Section 5 of the General Laws,a permit is hereby granted to: C�}tain Parker's Pub inc_ 6fiR Route 2R West Yarmrnrth MA Whose place of business is: Captain Pazker's Pub. Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2000 BOARD OF HEALTH:��n/. �.t�g0,, C'�ay��.,q,,�an.7 � /� SEATING: 130 �y�oa/n Gc.7�/ic�lCuran�nKg.///.� Vica C.�zairma KobarE J. /�rown, C�[ark a6,��S'a�oG�y-JJao�s �� Oo('e,��ln December 15 , 19� Bruce G.Mwphy, MPH,R. ., C Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: Y2K-25 FEE: $50.00 This is to Certify that Captain Pazker's Pub Inc 6hR RnntP�R Wect Yarmonth R�A IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE In said Town of Yazmouth and at that place only and expires December thirty-first 2000 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victualler's. This license is issued in conformity wrth the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testnnony Whereof, the undersigned have hereunto affixed their official signahues. BOARD OF HEALTH: �' �Y�+`�neffige/� C�ia[t��qa//n q � /�/ SEATING: 130 oan C��.7Jna[Gvan�/KJ@.///•, Vica l.hairmaa o�ar[p.�1. k�rotuan� C.lerk a6.:o[[e/�a�m/a�y-�oope� ' �C o irt December 15 , 19 99 ruce G.Murphy,MPH, .S. O Director of Health , THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � BOARD OF HEALTH PERMIT NUMBER: Y2KI2 FEE: $20.00 This is to Certify chac Captain Pazker's Pub. Inc. 668 Route 28. West Yazmouth. MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION. EFFECTNE NLY 1. 1996. This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2000 unless sooner suspended or revoked. �j December 15 , 19�Q BOARD OF HEALTT-I: Gd///. .lnedse, l��airman � �oan G. Jnullivan� K.//.� Vice C..�irman Ko�ert.p.t. /�ioton � �a6risCle�a�ole�y�Jdoopaa �l ' ouy�f ruce . urn Y, • •, Director of Health q _ _ eup� I-�.rLYr-�s Rcb 1r,G . , ��p53�o p [� � � I� ��I � l� • TOWN OF YARMOUTH BOARD OF,HEAEU�'II-�•-,. APPLICATION FOR LICENSE%PERMIT- 1999 N:�`_ � � i�SB a * Please complete form and attach all necessary documents by December 31 1998.� Fail HE LTH Q PT. the retum of your application packet. --------------------------------------- -- f� - ---- ------------------------------ NAMF OF ESTABLISFIMENT �/}��9+� � iqn 1�.� S / �� -1•,C- TEi_,. # 77/ 'CL v'6l,_ - ---- -- - -------- �--- . r------ �nrATION D F, f��, f'r ��,,? .4� .Ll.a;� c�- ,., oa e: 7 rn�n.rcui�rJRPORATION NA1�''�,�pf.} .a��c 't �-�S 1� r jt> j�j � j � ri,on� # c7�s"1=io G r,rerr rT.1G DRF : ! / Cvro? L ��f// /P • U /r � H.a oa�.8' z ------------------------------------------------ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by new State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. 1. 2. Pool operators must list a minimum of twoemp loyees cwrendy certified in basic water safety, standazd First Aid and Community Cazdio�ulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificatrons to ttus form. The Heaith Department will uot use past years' records. You must provide new copies and maintain a file at your place ot business. 1. 2. 3. 4. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all rimes. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a file at your place ot business. 1. �/"� , / e q / C/�Cn /� /v,�n/, .n( 2. c/ � f�c �j/�.lCi�n! 3. �'N C c (,�.c � �L',:, 4. .� [ � ! � RESTAURANT SEATING: TOTAL# I °? I NON-SMOKING SEATS: TOTAL# g ----------------__—_____-------------------------------------------------------------------------- - - OF`FICE U�E ONE,Y LODGING: LICENSE REQUIltED FEE PERMIT # LICENSE REQUIItED FEE PERNIIT # B&B $50 _CABIN $50 INN $50 CAMP $50 LODGE $50 TRAILER PARK $50 MOTEL $50 SWIlv1A�IING POOL $SOea. _WHIltLPOOL $25ea. FOOD SERVICE: LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $75 CON'TINENTAL $30 I >I00 SEATS $150 �_ NON-PROFTI' $25 I COMMONVICT. $50 Q9-I _WHOLESALE $75 RFT iL S_F,�tVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIltED FEE PERMIT# _<50 sq.ft. $45 �TOBACCO $20 �_ _<25,000 sq.ft. $'75 FROZEN DESSERT $25 _>25,000 sq.R. $200 NAME CHANGE: $10 AMOUNT DUE _ $ ZZb` •*"""PLEASE TURNI OVER AND COMPLETE OTHER SIDE OF FORM•"•"" � t. . ADMINISTRATION UNDER CHAPTER 152, SECTION 25C, SUBSECTION 6, Tf�TOWN OF YARMOLJTH IS NOW REQUIRED , TO HOLD ISSUANCE OR RENEWAL OF ANY LICENSE OR PERMIT TO OPERATE A BUSINESS IF A PERSON OR COMI'ANY DOES NOT HAVE A CERTIFICATE OF WORKER'S COMPENSATION INSIJRANCE. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS: PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO NOTICE: PERMITS RUN ANNUALLY FROM JANUARY 1 TO DECEMBER 31. IT IS YOUR RESPONSIBILITY TO RETURN TI� COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 31, 1998. SEASONAL ESTABLISF�NTS ARE TO CONTACT TI-IE HEALTH DEPARTMENT FOR INSPECTION 7-10 DAYS PRIOR TO OPEIVING FOR THE SEASON. ALL RENOVATIONS TO ANY FOOD ESTABLISf�fENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIIv1ENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ADDITION T F TI ATION POOLS POOL OPENING: ALL SWIMbIING, WADING AND WHIItLPOOLS WHICH HAVE BEEN CLOSED FOR Tf�SEASON MUST BE INSPECTED BY TI�HEALTH DEPARTMENf,AND THE WATER TESTED FOR PSEUDOMONUS,TOTAL COLIFORM AND STANDARD PLATE COUNT BY A STATE CERTIFIED LAB, PRIOR TO OPENING, AND QUARTERLY Tf�REAFTER. POOL CLOSING: EVERY OUTDOOR IN GROUND SWIMNIING POOL MUST BE DRAINED OR COVERED WITHIN SEVEN (7)DAYS OF CLOSING. FOOD SERVICE CATERING POLICY: ANYONE WHO CATERS WITHIN TI� TOWN OF YARMOUTH MUST NOTIFY TE� YARMOUTH HEALTH DEPARTMENT BY FILING TF� REQUIItED TEMPORARY FOOD SERVICE APPLICATION FORM 72 HOURS PRIOR TO THE CATERED EVENT. THESE FORMS CAN BE OBTAINED AT THE HEALTH DEPARTMENT. FROZEN DESSERTS: FROZEN DESSERTS MUST BE TESTED ON A MONTHI,Y BASIS BY A STATE CERTIFIED LAB. TEST RESULTS MUST BE SENT TO THE HEALTH DEPARTMENT. FAILURE TO DO SO WII,L RESULT IN Tf�SUSPENSION OR REVOCATION OF YOUR FROZEN DESSERT PERMIT LTNTIL'fF�ABOVE TERMS —- __ __ _ — _ — _ __--- _ _ ------ - — -- - HAVE SEEN MET- _ — OUTSIDE CAFES: OUTSIDE CAFES(i.e., OUTDOOR SEATING WITH WAITER/WAITRESS SERVICE), MIJST HAVE PRIOR APPROVAL FROM TF�BOARD OF HEALTH. OUTDOOR COOKING: OUTDOOR COOKING,PREPARATION, OR DISPLAY OF ANY FOOD PRODUCT BY A RETAIL OR FOOD SERVICE ESTABLISF�vvIEE1VT IS PROHIBITED. DATE: �I" � 7 � � SIGNATURE: L.%� � c PRINT NAME & TITLE:��i{ /C( rlyn i n �wnc�,� �q�� _ 0 ACORD,�'`CERTIFI�AT �flF��. ABII�1fi1f�1N;SURA,� ,C� � � . �� °"�'"�°°;;";. �« ,,y� �,� � r�r, 06 19/1998 � r.�,��. .,�,� .,.W � �� . PRODUCER ��SOB�395�6033 � � FAX (508)760-1667 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 11 i ed Ameri can Insurance Agency, InC. ONLY AND CONPERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIPICATE DOES NOT AMEND,EXTEND OR One� Atl dnti C Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. YdfmOUth, MA 02664 . ��:. COMPANIESAFFORDINGCOVERAGE . .. .. �Mpµy Public Service Mutual� �-�� Attn: FAX 398-2365 �� ' A _.. _ _ __ , _ _ _ __ _. . ��'�� Captain Parker's Pub Inc ' 00 g""" c/o Gerald A Manning -------------- —'---- 668 Main St ' �MPµv i � West Yarmouth, MA 02673 - - . . -_ � COMPANY I D .�i3OVERACaEB�,h'`_�'``Y;".. � ,� :... .. . ., . , ,.. - . . . . � �,. ' „�. '.� � THIS IS TO CERTIFY THAT THE POIIGES\OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TFIIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS Of SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CW MS _ . .. . . ___. . . CO ',. TYPEOFNI8UflANCE .._.. __.POLICYNUNBER .'..... POLICYEFFEC77VE POLICYFJ�IRATION;. LIWTS LTII I , , OAiE(MM'DDM') .. WTE(M�Y) ':. OENEML LIAOILRY .� � ; 6ENERAL AOGREGAiE �S ...... I CAYMERCLLLGENERALLU8ILT' ( i ;PROOUCf3-CAYPoOPA66 .i ._. _ I cwMs rMoe ^i occua l I j I rensorui a�av uuuar _ s , � i - —. _ ......... . EACXOCCURRENCE Ai � I ,-. ... . .._ _.. . ..OWNER'86CONTRACTOR8PR0T i : � FIREDAMAGE(Myanske)�I—S , . . _ ' ' I �E7�(MY Me Pram) I S '— I II .��&�� ' '.. I�I COMBINED SwGIE LWR j S L �'��.ALLOWNFDAUTOS �� .. IBOD0.VIWURY '!S ` '��. SGiEWLEDAUT08 ! � ,. (Px0�) � �, � '�,. .._...... ....�._ ___._ .......... ' XIREDAUfOS ' � ' �� BODILV INJURY ; _ . I �,, I(Peracdtlan) � . _ � . - . .._.... ..�.__ ...:_.. .......... i.... . � NON�ONMEDAUTOS .._. I . i � I PROPERfYDANAGE �i � � 6ARAGE W1BIUiY ��'�, I ' �AUTOONLY-EAACCIDEM ��'S � ANY AUTO � I..OTiER 7F4W AUfO ONLY:.... � FACMACCroENT i -- � '�—�ccr�c��s ' ezcEas w�eiurr ; i�cH occuw�ce s � .,.. _.. ..'��. UMBRELLA FORY I: I ; I AfiGRECa�TE I. i '__' "'_'_____'._._."—.—" . ,,,O7HEftiWW UMBRELUFORM � � ..,' ' ;'s i .....YYORKEWC0IMENS�TIONANU '� ''.. ;_. TORVLIGIf8J , �. �o��'��TM i ' ��cc�r s 100 000 A ' ;--� �0 32 5 14 8 6-98 ! Ol/Ol/1998 : Ol/Ol/1999 '-- — , i_— i� � -- asFwsE-Pa�cv uwrr ;t 500�000 ' rwrr�i�xEctwirrve I _-i _.__ oFv�nsu�: � i�ca' i� � i e�asewse-r�euxor��s 100 000 or�a i ' 'i ' � I � � , � ' I ; DESCPoPiION OF OPEM710NSM1OEATIONSNENCLESISPECULL IfEMS � CERTIFICATEHOLDER .'` °j � . , _..�._...b..�».,� sxou�o nxr oF n�e neove oescaeeo rouaEs ee cuiceueo e�oae n� ownnrwN on�rn�,n+e ieauno cowan wiuerroFwvoa m wu� Town of Yarmouth 10 onrswwrrewr�onc�roniEcerm��nrurEoron��cr. Building Department surcawneTowu�aucxamiceaww.irrosEnoaeuwna+a+un�urv Rt 28;Mai n St reet oc THE COMPANY,ITS AGENTS OR REPIiESENTATYES. South Yarmouth, MA 02664 E �"T"'� .-� ,, . r_ _ �, ACORD 28-5(1�95),r��at ex�� n�f�� ..:' v� , ,. ,< � � '%€`� , .��fi"` ' � _ r,w�� SIRPORA7"b�l` � TOWN OF YARMOUTH BOARD OF HEALTH ,� PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: 99-1 • FEE: $150.00 In accordance with regula[ions promulgated under authoriTy of Chapter 94,Section 305A and Chapter 11 I,Section 5 of[he General Laws,a permit is hereby gan[ed to: ('�,tain Parker's Pnb Tns, 668 Rnu e 28 West Yarmonth MA Whose place of business is: Captain Parker's Pub Inc. Type of business: Food Service To operate a food establishment in: Town of Yarmouth Pernut expires: December 31 1999 BOARD OF HEALTH:��f. �pett0a0e, C�...q.taq� q � /�/ sEATINc: 130(69 non-Smoking) � - �/�oan �c 7J/u�llivaa,/��p//(., Vice (..hairmart Ko�ert�Jp .p0_>rowpn� l,Lerh ��/J/��a/�r/ielle Ja�ol��x�aooPed ///icha O au��lin` December 3 , 19 98 ff f�t'' ruce G. Murphy,MP ,RL_;CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: 99-1 FEE: $50.00 This is to Certify that Captain Parker's Pub_ Inc. 66R Rnute 28, West 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 1999 unless sooner suspended or revoked for violahon of the laws of the Commonweakh respecting the licensing of common victualler's. This license is issued in confomuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: L��l.+Jetlee, C'�ia(�irnQu//can / /� 3EATING: 130(69 noII-Smoldng) � �oan G. �a�an� K.�1.� Vica l,�irman ,�o�,�Q�� ,�/weR, c�/./� a�rie��ee�akno/O�[j/-,Q.J�{ooPa9 iC�l oCoa. hlin December 3 , 19 98 ce G.Murphy,MPH, . .,CH Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH � BOARD OF HEALTH PERNIIT NUMBER: 99-1 FEE: $20.00 This is to Certify that Captain Pazker's Pub_ Inc. 668 Route 28 West Yatmouth_ MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOiJTH BOARD OF HEALTH TOBACCO REGULATION EFFECTIVE JiJLY 1 1996. TLis permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and e7tpires December 31. 1999 unless sooner saspended or revoked. y�j� c7 December 3 , 19 98 BOARD OF HEALTH: �cI///P. J�affee, ��eairman �oart G. Jullivan��//.� Vica l,hairman Ka�r� �� nO�rowan � �a6rie[[e Ja�roG��ooPed �84 O[ b� �� . "rn r Director of Healih� � ,/